Episode 10: RESEARCH with Professor Nick Bishop

In this podcast you can expect to learn about:

1. The importance of research in children’s health.
2. The Academic Toolkit that helps students and other health professionals get into research.
3. Some of the challenges students face pursuing a career in paediatrics and during their training .
4. Some of the struggles students, trainees and other health professionals face while trying to get into research.

We would really appreciate it if you would complete this short survey (6 questions) after listening. 

"Without research and without data you cannot make decisions that are in the best interests of the patient.  It's as simple as that......."

This week we speak with the wonderful Professor Nick Bishop about the importance of ‘Research’ for children’s health. The conversation was educational and inspirational, and we hope that you enjoy listening to Nick as much as we did.

Nick is Vice President for Science and Research at the Royal College of Paediatrics and Child Health in the UK and also Professor of Paediatric Bone Disease and Head of the Academic Unit of Child Health in the Department of Oncology and Metabolism at the University of Sheffield.  He is also an honorary consultant at Sheffield Children’s NHS Foundation Trust. He graduated in medicine from Manchester University in 1982 and trained as a paediatrician in Manchester, Cambridge and Canada before moving to Sheffield and establishing the Children’s Metabolic Bone Disease Service, now the largest service of its kind in Western Europe.

He is Director of the Sheffield Children’s Clinical Research Facility, Associate Director of the Experimental Arthritis Treatment Centre for Children, co-lead of the Clinical Trials Working Group of the European Reference Network for Rare Bone Diseases, and the immediate past-President of the Academic Paediatric Association of Great Britain and Ireland.

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Written & performed by Lisa Fitzgibbon,
Violin Jane Griffiths

Podcast artwork thanks to The Podcast Design Experts

Transcript

Professor Nick Bishop: 0:00

Without research and without robust data, you can't make decisions that are in the best interest of the patient. It's as simple as that.

David: 0:20

Welcome to episode 10 of the Not Mini Adults Podcast Pioneers for Children's Healthcare and Wellbeing. My name is David Cole and, together with my wife Hannah, we are the co founders of UK children's charity Thinking of Oscar. This week on the podcast we speak to Professor Nick Bishop. Nick is the Vice President of science and research at the Royal College of Paediatrics and Child Health in the UK and also professor of paediatric bone disease and head of the cademic unit of child health in he department of Oncology and etabolism at the University of heffield. As you will have just heard, this week's topic of conversation is all about the importance of research for children's health. Our conversation was both educational and inspirational. Professor Bishop shares his story of how he came to be working in the field of paediatrics, which is really a tale of honesty and serendipity. We hope that you enjoy listening to Nick's story and wisdom as much as we did. Hello, thank you so much for joining us on the Not Mini Adults Podcast.

Professor Nick Bishop: 1:32

Nice to be here. Thanks for having me, David.

David: 1:35

So, if we could start, I think your journey to where you are now and certainly into how you got into paediatrics is just a fascinating one would you mind, you know, giving us an overview, please?

Professor Nick Bishop: 1:49

Sure. So I started off life wanting to do paediatrics from the time I was a medical student. But I didn't think I was good enough. So having done my house jobs in a district general hospital, which I really enjoyed, I got a job doing combined adult and paediatric neurosurgery. I thought, yeah, I can do this. But if I'm going to do it, then I really need to get a broader range of experience. So the next job that I went for and in those days, things were very much more ad hoc, you had to apply every six months for your specialist training jobs. I went off to an interview at St. Mary's Hospital in Manchester, to do neonates, special care baby unit work. The interview didn't go particularly well. I could see that they weren't very impressed with my performance and got to the end of the interview. They said, as you do in interviews, "well, is there anything you'd like to say to the panel?" And I said, "Yes, there is actually, I think I really want to do paediatrics. I know that this job will be six months out of my life, because it's a very intense rotor, but it's what I want to do". I could actually see their faces change when I said that and I think that's what actually made me an acceptable candidate for that job. I have to say it was like jumping into the deep end of a swimming pool off a five metre board, though, the first day. Trying to take blood from extremely small babies who had had lots of intensive care already and whose veins were, well, they'd all disappeared, basically. It was quite an education. For the first couple of months, it was really tough going. But I had a very supportive team. The consultants were great. So were the more senior doctors who were still, junior doctors, if you like. I made some great friends there. It was really important, I think, formative experience for me and made me think that probably I wanted to do that kind of work for the rest of my life. I then went through a number of other jobs and ended up on another special care baby unit. In another part of Manchester in Salford, in fact, about two years later, where I met a little baby, who changed my life and he again had been born very prematurely and been through an awful lot. But he'd survived all of that. We'd got him into the what we call the feeding and growing end of the baby unit. So we all expected that he was going to graduate and go home and everything was going to be fine. Very sadly, when he was about 14 weeks old, he suddenly had a series of convulsions, one day, and two days later, he passed away. Which was an enormous shock to all of us, and people had got to love him and care very much about him. He was special. In as much as any baby is special, he was particularly special to those of us looking after him. People were really, I suppose, distressed, angry, you know, grieved for him. All of those things. In the same way, not as deeply, obviously, as a parent would. But nevertheless, it was, it was pretty tough. The consultant, who was there had recently been to a lecture about children who were on dialysis because of kidney failure, and whilst he was there, they've been talking about the problems with aluminium contamination of dialysis solutions and it causing a number of different side effects. Particularly anaemia and bone disease, but also, encephalopathy and encephalopathy is manifested in babies by convulsions. He said, I think he's died from aluminium poisoning. We all went, really? Then he explained that he'd been off to this lecture, and we still thought he was a bit crazy, suggesting that. But I was tasked with finding out whether that was the case or not. That involved looking at the levels of aluminium, in the little ones, brain tissue, which, obviously, we talked to the parents, and they agreed that we could do that. In fact, we found that he had a very high level of aluminium in his brain unexpectedly. From my perspective, certainly. That's where my time in research started, because to be clear that his was different to other babies, we had to look at some other babies as well. His was way higher, 20 times higher than other babies, who'd also passed away but hadn't been in similar situation to him. It turned out eventually, that the aluminium had come from his intravenous feeding solutions, specifically, from the solutions that have calcium and phosphate in them. Which are put into the intravenous feeding, to give babies enough mineral for their bones to grow. It looks likely, even now, you know, 30 odd years later, it's still absolutely certainly looks likely that the aluminium isn't there as a result of the manufacturing process, it's actually being sucked out of the glass that the solutions are stored in. So there's been moves to try and make sure that those solutions are now stored in plastic to reduce that risk.So that was where things started. And eventually, after a couple of years, trying to work out how we could stop this happening to other babies I approached a couple of groups, one in Cambridge and one in London, about doing a fellowship to look at the problem. Studying the long term outcome for babies who had had intravenous feeding solutions where we knew there was a lot of aluminium in those solutions. These were the standard solutions, everybody was using them compared with solutions where we had tried to remove as much aluminium as possible. So I ended up working in Cambridge at the Medical Research Council Unit and we studied over 200 babies in a clinical trial, where we either gave them the standard solutions, or we gave them solutions where we had adjusted things. After a long time, because in terms of doing the neurodevelopmental follow up that goes through until you're 18 months old. With a lot of support from colleagues working in a statistical part of the MRC unit and so on. Eventually, we were able to demonstrate that for babies who received more than the average length of feeding, which was 10 days, for every day of intravenous feeding beyond that, that they received with the standard solutions, they lost one IQ point. The result of that, combined with other data, was that in the, think it was about 2009, the medicines and health regulatory agency changed their guidance on how much aluminium you could have been intravenous feeding solutions and reduced it to the level that we were able to achieve in our clinical trial. So that was my entry into research if you'd like. I mentioned that part of the aluminium toxicity profile is bone disease. Whilst I was working in Cambridge, my boss was Alan Lucas, whose main interest was feeding premature babies. Working closely with him and with the others at the unit. I got more interested as time went by in the bone outcomes from those babies and we had, what at the time was state of the art equipment to measure bone mass in babies. It's obviously long gone and thoroughly superseded by other things now, but in those days, single photon absorptiometry, as it was called, was the bee's knees in terms of working out how much bone the baby had got. We were able to look at babies who were fed different diets after discharge from hospital, babies who'd been fed different things whilst they were in hospital, followed up for up to five years, and all sorts of things. We realised fairly quickly that we were going to need to generate some standards for kids who are normal. So we set up some studies in local Cambridge schools, we took the machine out to the schools and studied I think, about 420 children in two separate studies, two years apart. Firstly, to see how much bone they'd got and then see how it developed over time. We found some interesting things about differences between boys and girls and how things change with age and publish the data. Then, sort of in this early 1990s, I started getting letters from people saying. I'm really interested to read your stuff. I've got this child who seems to have osteoporosis. What can we do? You know, can you tell us what we should do about it? My response was, no. But I realised that there was if you like a gap in our provision for children, that we, we really needed to be able to understand what pathological processes might affect children's bones, as well as just studying normal children and the other things I talked about. So I looked around to see where in the UK I could go to get trained to do bone disease, because it was becoming my all consuming passion, if you like. There wasn't anywhere really. There were a few places where you could go to get trained up if you were interested in adults. So, as you probably know, as we get older, once we get to our mid 40s, and I have to confess to being somewhat beyond that now, your bones start to disappear. You gradually lose bone tissue. That's sort of the process of ageing of bone. Particularly in older women after they've gone through the menopause that process accelerates in quite a number of cases. Osteoporosis in adults is a big problem. Particularly if you end up with a hip fracture. So there's training around that sort of thing. But not if you're interested in children or there wasn't then in the UK and I found that I could go, or I found a lot that I could go. But there was somebody who was interested in bones in children, and that was Professor Francis Glorieux in Montreal. So I made contact with him, asked if I could go up and visit, which I did. I don't know if you've been to Canada in the winter. But there's a lot of snow. I went in a week when it was relatively overcast. Although there was a lot of snow wasn't that cold, until the last day, when clouds disappear, the sky was a lovely blue colour and temperature dropped like a stone. I was in typical English winter wear, which was totally inadequate. I was so cold, but I thought, well, you know, it's still a great opportunity and I came home. After a lot of discussions with the family, we said, okay, if we can get the money we will go to Montreal, which we did for two years. Again, it was another sort of seminal experience, really. So I came back from spending two years with Francis having had the experience then of managing a whole group, whole load of different bone diseases, particularly inherited forms of rickets, and the brittle bone disease osteogenesis imperfecta, which then meant that when I came back, that's what I could do. There were relatively few other people around who could say that they could do that at that time. So I then got further funding from the Arthritis research campaign, as it then was, it's now Versus Arthritis. Initially to spend a year back in a lab in the UK. Then subsequently, I got a senior fellowship with them and went to Sheffield, to be the first professor of paediatric bone disease, which is where I still am. I set up the metabolic bone disease unit for children there, which has, over time, grown to be the largest of its type in Western Europe.We are the lead designated centre for the highly specialised service for children with brittle bones, who have severe complex or unusual forms of that disease. Recently, over recent years, we've started to see a lot more children who've got bones which are called dysplastic, or strangely shaped if you like. That would be children of our conditions that make them very short and bend the bones but don't necessarily make the bones more brittle, or easy to break. So that's how I got to where I am if you see what I mean. In that time, we've done a lot of work, trying to do research in the areas particularly around brittle bone disease and inherited forms of mineralization defects, rickets and a rare disease called hypophosphatasia, where you have too much of an inhibitor of bone mineralization. We've been lucky to, I guess, be in the right position at the right time to take on new treatments and to be able to offer those initially in research studies and then as standard of care. I guess it's also brought home to me, all of that time and all of those things, how difficult it is sometimes for people to access the training that they need to get, to follow their dreams, which is what with the support of my family. I would emphasise that very strongly because without my wife's support, we would not be where we are now at all. I think it's difficult sometimes to find your way through all of the morass of information and to some extent barriers that now exist. A lot of the things I did early in my career just not possible to do now. Because of the amount of, the way in which the regulation of the environment around research has changed, it would take so much longer, unless you're working in a very, very large research unit that had everything set up and running for you straightaway. I think that's one of the things that young paediatricians particularly and I'm sure it's true for actually if you do paediatrics, adult medicine or whatever the young trainees struggle with, they find it difficult to find the entry point and get into it. It's also dispiriting when 80% of the time your grant applications are rejected. You have a limited amount of time to do that kind of stuff alongside all of the clinical work, the expectations that you have, and the intensity of the work for junior doctors is much higher now than it ever was. So their free time, so called, is much more limited, I think. Yeah. So one of the things, I was previously President of the Academic Paediatric Association of Great Britain and Ireland, and when I was doing that role, one of the things I thought was important to do was to try and improve the opportunities for trainees to get into research. So we set up a group to look at creating something and we created a thing called the academic toolkit. That is available through a web website to anybody who wants to use it, it's freely available. It basically brings together all of the resources that we can find that enable you to get started in research with the aim of getting an externally funded fellowship. So being able to do a PhD or an MD. We're aiming now, through my role with the Royal College of Paediatrics and Child Health, because I was, seems ages ago, Im nearly halfway through being Vice President for science and research, I can barely believe that. We've brought the toolkit with us effectively to the college and the college are now going to provide some specific support for that. So the resource will grow and develop further. We'll try and make it try and broaden the scope of it so that anyone from a medical student, to a junior doctor who doesn't necessarily want to do a fellowship, all the way through to a consultant who might have done research in the past and is now struggling to get back into it, because of, you know, all of the regulatory hurdles that you need to go through now. We want to make it available for everybody to be able to do something of that nature.I think that's probably enough of me talk for quite a while. Hannah, and David, whether you've got any questions?

David: 23:20

So first of all, thank you so much for sharing, you know, especially at the beginning, the the motivation, I guess, in terms of why you are doing what you're doing and how that came to be. I think it always fascinates or fascinate might be the wrong word. I think it's still a motivating factor. Let's put it this way that, you know, your consultant at the time had happened to have been at a lecture or happened to read a paper and that had helped to form his view as to what had happened to the baby. You know, I think we've said a few times, we found the same thing with Oscar when he was in hospital, we couldn't believe that it was as a result of, you know, people just trying to speak to other professionals or try and get information from others to try and help them to form their opinions. I guess, when you're a parent in a situation you think, you know, this person knows everything they know, you know, they should know exactly what's wrong with my child, they should know exactly what to do all the rest of it. You know, in a lot of cases, it's just luck or experience or whatever it might be. So that you know, that part, I'm sure resonated, you know, with Hannah as well. You're the best guest we've ever had, because all the questions I've had, you've answered.You've pre determined a lot of the stuff you know, in terms of your background, so which is great. So thank you so much.

Hannah: 25:13

Well before we move away from the story that you told us, which is has been so engaging, because we've been so quiet for the last 15, 20 minutes, it's a very remarkable story for lots of reasons. But I had a, almost a personal question about the beginning part of your story and the baby boy that had such a fundamental, such an important impact on you. I know that families such as his parents, or us and so many others around all deal with experiences of losing a child in different ways. But I have a curiosity that's not leaving me. So I'm asking you. Whether any yourself or any of the team stayed in contact with his parents and how the work that you went on to do impacted them. Because if it happened to me, it would have been amazing that, that there was this legacy that was created. But I absolutely respect that for another family they wouldn't choose to stay too close, because it would be too difficult. So I'm curious.

Professor Nick Bishop: 26:26

So we stayed in touch up to the point of his funeral. Quite a number of us went to his funeral. Beyond that, no, we did not. As you say, I think it's a two way process. I think at that stage, it was, it was probably two years after he passed away that we published the first paper. I had moved hospitals by then. I was actually going by then, I was actually down in Cambridge, it's more than two years, it was actually nearly 5 years, because there was a problem. We sent the paper into a journal and in those days, it wasn't electronic submission. It was all paper submission. They sent it out to the reviewers. One of the reviewers lost the paper didn't tell the journal. So after about six months, we inquired, well, what's going on? He said, oh, let us check. Let's check and get back to you in about. I don't know, a few weeks after that. I came back said I'm very, very sorry. This is what's happened and we've sent it out again. So there were delays and so on, I think. I think also at that stage in my career, I'm not sure I would have had the confidence to stay in touch with the family. Which might have? I don't know, I think at that stage, you might say that at the stage in my career I think I would have found that quite difficult in some ways. I think less so now. Now, I think it's different. It's also the case now that most of the families that I deal with, I know them extremely well. They've been with us for a very long time. Whilst he was with us for 14 weeks, just over the families I'm looking after now, I'll do this for often more than 10 years, then so we know, I know that it's a much easier thing to do to talk to them when this sort of things happened. I suppose the most recent similar experience was a young lady who very sadly passed away just after she'd turned 18. She'd had a lot of different problems. She had a complex disability and had been ill on a number of occasions previously, to such a degree that we thought that she might go then, but it's still a shock. Again, I I am still in touch with that family. Although there's no research associated with it, but no, just occasionally we'll touch base and see how they are.

Hannah: 29:47

That's good to understand. Thank you. I have a second question about the very earliest times and it kind of ties into some of our later questions around research and your desire to support others coming into the profession to be able to find it to find an easier path and find the resources that they need. This other questions to do with right at the very beginning when you said you were interested in paediatrics, but you didn't think that you were good enough, you would be good enough. Then you kind of alluded to the responsibility that is inferred on you by you know, these tiny, tiny beings in your hands. Do you have a point of view on attracting medical students into paediatrics because I can imagine it would be an extremely intimidating area to get into because of the magnitude of responsibility of a sparrow like life.

Professor Nick Bishop: 30:50

So when we have medical students coming through in Sheffield we give them a couple of days on the neonatal intensive care unit and ask them basically to spend time with the nurses and chatting to parents. As well as understanding the very basic, the range of issues that a premature baby might have because neonatology has become such a sub specialised area in its own right, that paediatricians neonatologist have really gone separate ways. Whilst they speak the same language, today, the patients they are looking after are very, very different in terms of the range of problems that they have. So the students are very variable in their response to that. There are some who absolutely love the fact that they have time to sit and talk to parents, and if you like, understand the sort of holistic family dynamic aspect of things. There are others who I think, just feel the pressure of the need to accumulate knowledge and they spend their time desperately cramming more and more knowledge in. I think, for them, it's stressful, because there's just too much for them to take it in. Our expectation of them as students is that they will not learn everything. We want them to have an understanding of some very basic things. We want them to understand the effect of a child's illness, whether they are a premature baby or an older child on the family. The impact that that has on a day to day, week to week, month to month, year to year basis and that's something I actually I think we struggled to do within the relatively short period of time that they're with us, we only have them for seven weeks. I think actually know, even a lot of our junior doctors, because their time is focused into care hospital, they struggle with that aspect. Our systems are less well integrated in terms of the interface between hospital and primary care than they should be. My wife is a GP. I get a certain amount of feedback from her about the suggestions that are made by consultants in hospital about how much the GP could do for the care of their patient in the community, which basically means devolving a lot of tests and so on. I think in paediatrics we're better than that, if you like I think we do try to make sure that there is a continuum of care. That is reflected in the fact that we have a very large number of community paediatricians in the workforce as well. So there is that sort of spreading out. But yeah, I think it's hard for the students to get their heads around paediatrics and I think emotionally it can be difficult too. It's interesting. Some of the feedback I've had over the years from when we've done the introductory lectures is that they are scared rigid, actually, some of them about going to see children. The trouble is I look at them fresh faced and you know, shiny, all these young medical students and think you're barely out of an egg. How can you not remember what it was like to be a child?

David: 35:27

So I think certainly that the, I've seen, I've seen statistics, you know, across the world where we are struggling to or the Royal we are struggling to get people into paediatrics. I think, you know, that's, that's something that needs to be looked at, getting more and more junior doctors to really specialise in the paediatric community. If we if we come back to the research side of things. What are the lessons that you've learned over over the over the years in terms of, you know, where you started from with research and the importance of it that we can that we can share?

Professor Nick Bishop: 36:06

Without research and without robust data, you can't make decisions that are in the best interest of the patient. So as simple as that. Research is needed, where there is uncertainty and there's an awful lot of uncertainty in almost everything that we do. So then you have to try and make sure that whatever the answer to your research question, it matters either way. So if you ask a question, for instance going back to the original studies that we did, is the aluminium contamination of intravenous feeding solutions important or not. The fact that that little one ended up with a very high concentration of aluminium in his brain was not proof that it had killed him. Could have been an incidental finding that had no relevance. But the fact that you can demonstrate in a randomised control trial, that prolonged intravenous feeding reduces your IQ by one point a day. That's evidence and that changes what people do. So you need evidence. The evidence has to be sufficiently robust that people will apply it. So it then has impact. I think doing research in order to get a publication in The Lancet is not the right reason for doing research, the reason for doing research is to make a difference. But if you're going to make a difference, the evidence has to be strong enough that people will believe it and act on it. You have to be able to show causation, rather than just association, in order for people really to change what they're doing. So I think that's the most important lesson I've learned about research, if you like, over the years, that's the thing that makes a difference to people's lives.

David: 38:22

I think, in in a previous conversation, and it's funny, we hear this in a couple of different walks of life that by moving into research, if you're doing a patient, if you're working with a patient, it's kind of a one to one, or maybe you can see, you know, maybe 10 patients in a day, or whatever it might be, or depending on your clinic, or your rounds, or whatever it is, with research, you've got the opportunity to affect 1000s, if not more patients at a time. I think we've seen, you know, clinicians that have moved into innovation that have moved into different areas for exactly the same reason, the opportunity to impact a much larger body of people that is there. I think that you've you feel the same way.

Professor Nick Bishop: 39:10

Yeah, very much. I think it's, it's the opportunity to do more than you can with one pair of hands. It as simple as that. I think, the hope, because it's not a given, but the hopes that you will do some good. Yeah, it's the hope for something better. Improvement. A step forwards.

David: 39:42

I'm interested in where do you think some of the best research is happening today? Where do you kind of feel the gold standard is or where would you look?

Professor Nick Bishop: 39:55

I guess it depends what you mean by the best. I mean, in the current climate, the current situation we find ourselves in with COVID-19. You might say, well, it's when you get agreement between lots of different places that they will do the same thing, collect the same information and study patients in such a way that you achieve the scale of study that you need to produce a result. The clear result about dexamethasone, in COVID-19, affecting adults with pneumonia. The review of the two thirds reduction in mortality associated with the use of dexamethasone is probably the best example of that. I would say, that's come along in the last two or three months. That's the sort of thing where you can see the importance and the value of collaboration. People saying, Yeah, this is really important, we all need to work together to do this uniting to have a common approach, and doing it and getting the results back quickly. Then looking at them critically, not just accepting them at face value, but critically appraising them, and then introducing that as a change. So now, any further studies that need to be done will be done on the background of an altered standard of care for those patients. What's important from a patient point of view is that their chances of survival have just gone up. So at my age Im at significantly more risk from COVID-19 than you guys are, and so I'm quite pleased about this. But there's some reliable information that might if I get that horrible thing, improve my chances of survival. So, yeah, that's the kind of thing I think, where you can say where you know, what research is important. In paediatrics. again, thinking about the COVID side of things. We have been incredibly fortunate that in contrast to most respiratory virus type infections, children have been less severely affected than adults. I think the current situation with the uncertainty around children returning to school is one that hopefully, if studies that are in the wings are put in place in a timely fashion, we hopefully will have data in the not too distant future about the risks of transmission, and what makes a difference there. So again, it's collaboration. People need to work together to achieve those things. Sometimes that's very complicated. When you say the best research, I think the best research is the research that adapts to the needs of the moment, in that way. Because there is a great need to get your children back to school, they need their education, and their parents need to go to work. But if you were to send them back to school and the result of that was to lead to a second wave from the community with a lot more adult deaths, that would not be a good result.So yeah,

David: 43:40

Absolutely. Thank you. I think we've been, you know, reading extracts or comments from Russell Viner, the president of the RCPCH over the weekend, and I think we're looking forward to that study, you know, coming out. I'm sure all parents are at this point at this point in time, you know, just trying to understand what's going to happen in September and the importance of that. Nick, we're so grateful for your time and with every with every podcast, we kind of close on a question, which is, if you could change anything, if you had a, you know, kind of utopia, or whatever it might be a magic wand. If you could change anything within paediatric healthcare. What would it be?

Professor Nick Bishop: 44:32

Are we talking about within paediatric healthcare or paediatric research?

David: 44:37

Up to you, given that we're talking about research today you can chose.

Professor Nick Bishop: 44:42

If I was to choose anything in relation to paediatric research, it would be that we had a more level playing field for funding because 20% of the population are children,paediatric Health Care Research gets 4% of the funding pot. If we're being asked to improve outcomes in children, then we need a level playing field in terms of how the funding is allocated. I appreciate all of the caveats that go along with that in terms of quality of research, and so on. But I think there was a systematic bias that we struggle to overcome at times. With healthcare, I think that some of the changes that are currently in progress with the integrated care systems will have an impact if they're properly resourced. The things that we could do to improve children's health, most clearly, would be to invest more in things like preventing obesity, and the things that will contribute to lifelong ill health, to look after children's mental health, as much as possible. To properly support the provision for children with learning disability and to invest in understanding more clearly, and acting upon or developing the evidence base around vulnerable children and safeguarding. You might wonder why I've picked all those areas out, it's because they're so intractable. They're so difficult to do research in. It's been, it's a, it's a struggle to get the money, and to draw things together to do work in those areas. I think those are the ones that actually for the population of children as a whole, are really, really important. So the specialist societies will, and the charities and so on, will all shout for their own corner. I think it's much more difficult to shout for those who don't really have a proper voice. That would be those areas that mentioned. A lot of them are not purely medical problems. That's part of the reason they're so intractable, they are bound up with poverty, disadvantage, and societal inequity. That's part of the reason they're so difficult to sort out. But if we're, if we're going to move forward as a society, I think those are the things I would want to see move forward at pace.

Hannah: 47:54

This might be too long for the podcast, in which case chop me out. But do you see some countries handling those intractable type challenges more effectively than others?

Professor Nick Bishop: 48:08

I think that countries that have health care and social care systems that are better integrated, tend to do better with some of those issues. Honestly, I think childhood obesity is a plague, which affects pretty much every nation on Earth. Mental health is coming up the agenda, but is difficult. Learning disability is better in those countries that have better integrated systems. Safeguarding is a very mixed bag. Again, it's about trying to ensure that the configuration of services is effective. I think often it's so many different moving parts to bring together in one place to deal with these situations. It's really difficult to do that if the systems aren't properly lined up.

David: 49:18

Nick, thank you so much. There's three things that created this podcast to do. The first one was to educate ourselves a little bit, selfishly, and I think we've definitely learned a lot from this conversation with you today. The second one was to share stories of the pioneers that are out there trying to do things differently within within paediatric health care and well being. You know, your, your story, I think has really resonated with Hannah and I in a lot of ways and we're so pleased and honoured to share your story. The third one is to inspire and i and i really hope that people will listen to this and will be inspired by A what you're doing but also by, you know what you've just said in terms of the things that we need to change and hopefully, you know, people will help or think of different ways in which they can, you know, they can do that. Even if we get one person that is not a paediatrician, but decides that they want to move into paeds, then then to me that's kind of successfully. So, so thank you so much for your time.

Professor Nick Bishop: 50:22

Thank you very much for asking me to be part of this. I wish you both well.

David: 50:32

Thank you to Professor Bishop for joining us on this week's Not Mini Adults Podcast. Thank you, also to you, and for everybody else who continues to listen and subscribe to our podcast week on week. If there is someone that you think that we should be speaking to or a topic that you would like us to cover on the podcast then please do get in touch. All our details can be found in our show notes. Next week, we'll be speaking to Professor Paul Dimitri. Paul amongst other things, is professor of Endocrinology a the Sheffield Children' Hospital, but he's als pioneering to bring the world' first Centre for Child Healt Technology to the UK. We reall hope you can join us the