Why Your Degree Is Useless, Why The Company You Work For Is Full Of Idiots & Why Nothing Works!!!

It seems that further education is not producing productive graduates with a valuable skill set.  As a result, young graduates are not able to find jobs and a lot of them are having to do unpaid internships.

Just the other day when I was out for dinner I had a quick chat with a waitress.  She said that she had a degree in “Conservation Management” and that she was not able to find a job.  “The jobs are very competitive to get, because it’s such a needed skill set”, she said.  As a result she was doing an unpaid internship “to gain experience”, which would hopefully allow her to get a job.

I didn’t say anything at the time, but I couldn’t help but think that the skill set she had acquired really was not valuable or needed.  If your skill set is really needed by society then there would be plenty of jobs and you wouldn’t have to work for free – you’d be getting paid a premium!

For example, if you’re a doctor – you will never be out of a job in this current climate.  Your salary will also be in the upper percentiles of society.

Equally, people who are good at computer science and software engineering are very much-needed at present.  People can teach themselves Code online and after a few months they can get quite lucrative jobs – again this is a needed skill set.

So what’s going on here?  Why have people gotten into their mid 20’s only to realise that they haven’t got a skill set which can get them a job?  In short, I think it’s because education has been massively dumbed down in the last few decades.

When I was in Primary School, I used to make frequent trips to Bangladesh with my mother.  She was born and raised there.  I remember hanging out with my cousins while there.  I used to get amazed at how much maths they would know and how they had been taught to speak English at such a young age.

The maths I was taught in England was nothing in comparison.  In Primary school my cousins were already studying algebra which I would only encounter 5 years down the line in England.

Not only did this disparity in knowledge shock me, but the whole education system in Bangladesh was alien to me.  It turned out that you could fail a year!  In England, this never happens.  Everyone starts the year at the same time and they finish the year at the same time.  Sure there are tests, but these are more so for parents and teachers to be aware of.  There is no negative consequence in doing badly in a test in England.  And it certainly won’t result in you being held back a year.

This type of education – where you can’t fail – continues all the way up to people are eighteen years old in England – when they are then gently coerced into going to University.

In Bangladesh, if you fail, then you fail.  If you keep failing and end up being 18 years old in a class full of ten years old, then you are told that perhaps it’s best to give up on this education malarkey and go get a job instead of aspiring to be a University graduate.

What happened in England and the rest of the Western World is that society as a whole couldn’t tolerate people not being educated.  It seems that part of the reasoning was that if existing successful people and people who create wealth went to University, then surely the more people we get to go through the whole system, the more wealth and jobs we can create.

The problem is that “Conservation Management” and “Media Studies” are not the same as “Law” or “Medicine”.  This is very clear now.  If you don’t have a skill set that is valued by society then you won’t be able to get a job or generate wealth.

However, there is one more factor which has resulted in the education system being dumbed down and one that I have never heard mentioned.  This factor has not only destroyed the education system, but it affects all organisations and is the source of many inefficiencies and dysfunction.

Say for example we take a class full of Year 7’s (in England this is the 7th year of compulsory education).  At the end of the year we make them all sit an exam.  If they get above a certain percentage then they pass the year and get to progress up to Year 8.  Those that fail have to remain in the Year 7 class along with the people who passed their Year 6 end of year exam.

All sounds very good so far!  And in fact this is how things are ran in countries such as Bangladesh.

However if we let the system described above run for several years what will happen?  It’s likely you’ll end up with a Year 7 class full of people who can’t pass the end of year exam.  You will basically get a build up of people who have reached their educational limit.

This would have a very negative impact on the rest of the class.  The less smart pupils would negatively affect the bright students and you’ll end up with even more people failing.  The natural solution would be to reduce the pass mark and make the exam easier so that you don’t get a build up of incompetents in one class.

This seems to be what has happened in the education system in England.  And over the last few decades things have been continually dumbed down all the way up to the University level.  At the same time there was a push by the government to get more people into University.  This concoction of ensuring everyone passes all the time and getting everyone to go the whole way with education has resulted in worthless degrees and with degrees which necessitate supplantation with a PhD to mean anything.

The fact is that “unpaid internships” result in real world experience and skill sets.  For many this is the one that is needed.

So far we have established that people are allowed to progress even if they should not.  We have established that this doesn’t magically result in valuable skill sets being acquired or the wealth to be generated.

But what happens if we allow people to progress up until they reach their potential?  This is the system that is prevalent in most organisations and companies.

Say for example we take an administrative employee from a large organisation.  She works hard, she up-skills and gets valuable experience in the real world.  Over the years she moves up the ranks of the organisation.  She used to be very organised, she used to be able to deal with her tasks above and beyond that was required.  However, now that she has reached this high position she is finding it increasingly difficult to keep up with the work.  Her new job also requires that she gives speeches and talk to different clients.  The person in question has never been the extroverted type.  As a result she keeps making mistakes, she is late to meet her deadlines, a lot of clients don’t get on with her.  The person in this example has reached her “level of incompetence”.

This is what usually happens in all large organisations.  People keep getting promoted when they are doing well, but they stop being promoted when they are struggling in their current position.  What happens when you get an organisation full of people who have reached their level of incompetence?  Well you get scenarios like the following:

Me: “Hello, I would like to order a tuna pizza.”

Restaurant person: “I’m sorry, that only comes to £8.00.  We only deliver on orders over £10.00.”

Me: “Oh, that’s alright.  I really won’t be able to eat anything more, so I’ll pay £10.00 for the pizza.”

Restaurant person: “Oh…….Hmmmm….We can’t do that…”

Me: “What do you mean?  You’re still getting the required amount which I’m happy to pay”.

Restaurant person: “I don’t think we can do this.  Are you sure you don’t want something else?”

Me: “No thank you.  I don’t see why this isn’t possible….Do you think you can speak to your manager about this?”

Wait for three minutes

Manager: “I’m sorry we’ve kept you waiting.  This is absolutely fine.  We’ll get this delivered right away.”

Now in this example it may be that the first person on the phone that I spoke with was just new and learning on the job.  However, more often than not, these occurrences happen due to the person in question having reached their level of incompetence.

Clearly then the solution to a lot of societies problems is to not dumb things down and to stop people progressing before they have reached their level of incompetence.  I don’t see many people agreeing with this essay however, so I suppose we will continue to live in a society which gets dumber and retain its dysfunction.

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Build Something A Few People Love

 “It’s better to make a few people really happy than to make a lot of people semi-happy.” – Paul Buchheit

This is a common saying amongst tech entrepreneurs.  Successful tech entrepreneurs have noted that something which a few people really love is always better than something which only a few people merely like somewhat.

This has made sense to me ever since I heard it.  It seemed like common sense: If you make something people merely like a little bit then if your product or service dies or disappears then no one would really care that much.  And if you make something a few people really love then it is likely that more people will think it’s “really really good” or just “really good”.

But I’ve thought about this subject a lot deeper and after reading some of Nassim Taleb’s* essays and books, I think I was missing a key insight.  The insight is that minorities, if vocal enough, often win and impose their beliefs and wants on other people who remain indifferent.

Let’s take the example of GMOs and Non GMOs.  If we have a family (mother, father, son and daughter) and the daughter decides she is staunchly opposed to GMO foods.  It is likely that the rest of the family will cave in and everyone in this family will start to eat non-GMO foods to placate the daughter.

As there isn’t a massive price and taste discrepancy between GMO and non-GMO foods the family doesn’t mind eating non-GMOs.

Now let’s say that this same family attends a party.  The host of the party will be informed that the whole family doesn’t eat GMO foods.  The host decides that it would be easier to make all the food at the party Non-GMO, rather than making separate dishes for this one family.  After all the price is pretty similar so shouldn’t effect the budget of the party by very much.

All of a sudden this large party of say 50-100 people are all subject to eating Non-GMO foods without even noticing and more importantly this large group of people don’t even care!

As a result of this party, local vendors will start to realise that they can increase their profits by selling Non-GMO foods.  As a result, a large part of society is made to eat Non-GMOs despite not caring much about eating GMOs.

There are two things at play here.  First the cost different between GMOs and Non-GMOs is not that much.  Also, there is an asymmetry present in this example: The people who won’t eat GMOs will not eat GMOs under any circumstance – they are staunchly opposed to it.  However, the people who eat GMOs do not mind eating non-GMOs.  When this asymmetry is in place, the minority can overtake the majority and impose changes on everyone.

Halal (Muslim approved food) is another example of an asymmetry.  Apparently a large proportion of the meat imported to the UK is Halal.  The asymmetry is present – non-Muslims don’t really care what type of meat they eat, but Muslims won’t eat anything but Halal.  The price of buying Halal meat will also be pretty much the same as non-Halal meat.

McDonald’s is also an interesting example, which is relevant to business.  Everyone I know of has had some sort of McDonald’s food at some point in their lives.  In fact when I go on holiday these restaurants are often packed with foreigners as a respite from exotic food or the possibility of contracting some type of food poisoning.  The fact is that society is largely indifferent to McDonald’s – no one really hates McDonalds – whether upper or working class, no matter which country they are from.  So, we can all agree that McDonald’s doesn’t make the best burgers in the world, but no one really hates them either, which means that people still go.

Now to turn this conversation back to business.  I am wondering whether this effect is what plays out in successful startups and makes business spread.  1 – Do they have a core group of people who love the product, 2 – Is there an asymmetry where people adopt a certain technology/service, refuse to give it up and therefore force people to also use the product or service and 3 – are the rest of the people who end up using the startup indifferent to adopting the change.

Thinking about different startups, I really do believe this is closer to the truth than I had originally thought.

If we take Google as an example.  I cannot even remember when I made the switch between Yahoo! and Google.  It just seemed to happen and I became just another user – I was indifferent to the change.  It is likely that when Google first launched, there were a core group of users that loved it and refused to use Yahoo!.  There was an asymmetry here – Googler’s refused to use other search engines.  The rest were indifferent and the switch to a different search engine was easy to make.  As a result Google spread, when people started to simply set the homepage as Google, no one was staunchly opposed to using Google/in love with Yahoo!.  This is probably how I made the jump without even thinking.

Moral of the story?  Make something people love!  This way, to create a massive success you only need three or four percent of converts to start using your startup instead of penetrating the whole market.

Good advice after all it seems!

* However, Mr Taleb was mainly talking about how this insight effects society, rather than startups and entrepreneurs.

Healthcare & Volatility

Working At Scale

General Practice / Primary Care has been around for a long time in the UK (since 1911).  It is currently going through a massive transition due to funding cuts by the government, the pressures of having to deal with today’s needy patients and the increased work load being transferred from Secondary Care to Primary Care.

General Practice was traditionally provided by small Practices – often one or two doctors looking after the local community surrounding their surgery.  This model of care which has survived over 100 years, is now being radically changed.

To deal with the modern landscape there is a push by the government for general practice doctors to combine to create “MCPs” and “ACOs”.  These are large organisations  which have a very different way of providing healthcare.

Traditionally, patients would register with their local GP and over the ensuing years they would build up a real relationship with their Family Doctor.  This would allow GPs to provide a holistic approach to the care that was given.  Having this connection with patients of course made it a very cost efficient way to provide healthcare as patients could be managed in an appropriate way, rather than the secondary care approach which entails carrying out a barrage of investigations and providing a ton of treatment in a cookie cutter fashion.

This model of care is still proving to be very efficient today – over 90% of patient contact by the healthcare system is carried out by primary care and they are only provided with around 7% of the NHS budget.  That’s pretty good bang for your buck!

The new care organisations which are currently being created are turning GP surgeries into outpatient hospitals.  They will be staffed by “Salaried GPs” who will work in them on a rota basis (much like hospitals).  They will increasingly carry out the outpatient services traditionally ran by hospitals.

The hypothesis behind this shift is that “working at scale” will reduce costs for the healthcare service as a whole, as more conditions will be able to be looked after in the community.  Instead of being referred to the hospital for that cough, you will instead be seen by a GP with a special interest in respiratory medicine and instead of seeing the GP on your first consultation, you will be seen by an advanced nurse practitioner or a trained Pharmacist.

Sounds great!  Patients have more access to healthcare and more healthcare can be delivered at a lower cost.

However, the problem with this new model is that it is just a hypothesis, which is untested and since its inception has not provided the benefits that were promised.

The Lindy Effect

The reason healthcare is so hard to provide and also why it is so hard to change is because it is incredibly complex.

The NHS has to deal with the whole of the UK population and try to provide acceptable care to all people regardless of their backgrounds, it has to deal with the whole gamut of human diseases, psychological problems, social problems, economic problems, governmental initiatives and rules, different vested interests, market rules, changing demographics and so on.  It also has to provide an increasing amount of treatments, social care, investigations, operations etc.

The Lindy effect is the concept that the future life expectancy of a non-perishable technology or idea is proportional to their current age.

For example, the Bible has been around for 2000 years, it is likely – due to the Lindy Effect – that it will be around for another 2000 years.  It is not certain, but it is a statistical likelihood.

The reason the Lindy Effect is so potent is because it means that an idea or a technology has been put through the test of time and has had to have been through a whole host of iterations and complex challenges.  This increases and verifies its robustness.

One can think of it as a type of natural selection.  Put a piece of technology through a whole bunch of stressors, environmental changes, cultural changes, economic pressures and so on.  The technology that survives can continue to exist.

Time also allows us to be as sure as possible that the piece of technology in question works and is as devoid of as many side effects and adverse outcomes as possible in comparison to an alternative solution*.

Exposure To Volatility

Good systems are exposed to volatility and are allowed to thrive or die.  Primary care as we know it today has been exposed to a whole lot of volatility and as such it is a very robust and dependable system.

In the UK the government provides each GP Surgery with a certain sum of money each year.  This mainly depends on the number of patients that are registered at the practice.  With this sum of money the doctors in that surgery have to provide all the healthcare needed for their group of patients**, pay staff costs and run their business.

So in other words, for a limited amount of money, the NHS GP has to provide an unlimited number of appointments and services to meet their patients needs.  Any business-type would run away from this type of responsibility as unlimited supply is not logically possible.  However, this is the value that NHS patients are getting.

Each patient in the UK receives only around £90 of funding from the government.  This is generally less than people spend to insure their pet dog.

So in effect Primary Care has had to survive each year under very difficult conditions.  If demand and costs go up, GPs make less money.  If GPs can’t work efficiently, they lose their business and contract.

Currently, it is a robust system and works incredibly well – no one can deny this.

Denial of Statistics & the Removal of Volatility

The governments proposal to make general practice work at scales denies the existence of the Lindy effect (i.e. it dismisses statistics as a whole).

The fact is that statistically speaking, coming up with a whole new system of providing healthcare in a boardroom is incredibly naive and there will be a ton of unforeseen consequences.  I can guarantee that this will be at the detriment of patient care.

This type of “forward thinking” is a very “MBA type” of thinking.  It is all based on hypotheses  (aka guesses) by people in dark blue suits.  It ignores the existence of complex systems, second and third order effects which are not predictable no matter how smart you are.  It is the opposite approach to how successful businesses get created in the first place i.e. test a hypothesis and if it works then scale.

Not only is this new model of care worrying from this perspective, but it also removes the volatility faced by Primary Care currently.

As noted above, Primary care is exposed to the realities of having to provide care in a cost efficient manner.  Recently, as the potentially infinite workload is increasing alongside an increasingly finite remuneration, GPs are leaving the UK to work elsewhere, work in the private sector or retiring early.  In effect, the relatively reduced amount of funding is causing General Practice to fail.  This is volatility at work and indicates that something should be done to continue to provide good healthcare.

These MBA types have come up with a solution which they think avoids simply funding general practice adequately.  Their solution is to “work at scale” which involved GPs pooling resources together in the hope that this will somehow reduce costs.  A more logical process would have been to observe that General Practice is incredibly robust and cost efficient and simply increase funding.

These large “MCPs” and “ACOs” usually have over 70,000 patients on their registered lists.  These organisations if they fail economically and are not efficient will simply not be able to go out of business.  The government will have to intervene and bail them out as otherwise whole regions of the UK will not have healthcare provision.  Inevitably in the long run this will cost the tax payer/the government more than if they just persevered with the current system and funded it properly.

With these new systems as they will not go out of business, inefficiencies will increase.  Just think of the inefficiencies faced in large hospitals and it becomes clear that these large MCPs which resemble hospitals will face the same issues.

People In Blue Suits

This lack of understanding of the Lindy Effect, the lack of understanding of healthcare and its complexities by MBA types in their dark blue suits fares poorly for the future of the NHS.

It is astounding that such important issues are left in the hands of people who simply have no idea of what needs to be done.

In the mean time it is the front line staff – nurses, pharmacists, administrative staff and patients themselves – that will have to bare the brunt of increased risk, uncertainty and poorer healthcare outcomes.

*Thinking of religion in this way is quite an interesting thought experiment.  Could it possibly be that certain aspects of religion have benefits which we are unaware of, but due to the very fact that they have lasted for so long have untold benefits?

For example, many religions recommend fasting.  Only recently are the benefits of fasting being demonstrated in scientific research.

** In the UK, GPs are not able to close their patient list.  As a result anyone can go to a GP surgery in their region and register as a patient.  GPs are swamped with work and would rather close their lists, than to have more patients, more revenue, but not be able to provide good healthcare.

NHS Startup Part XVII – The End

Gosh, it’s been a long time since I posted about my startup.

I’ve decided that this will be the last blog post which talks about the minutiae of my startup and the challenges a new company in the healthcare scene has to face in the UK.

The reason this will be the last update is because the specifics of my startup are not helpful to other entrepreneurs / healthcare innovators out there.  The fact is that everyone will have to traverse a terrain which is different and face challenges which are different.  This I have come to realise is why so much advice surrounding entrepreneurship is so general.

“Solve a problem”

“Expect the unexpected”

“Provide value”

“Make connections”

These platitudes may seem clichéd and obvious, but they are cliched for a reason – it’s the truth and giving advice more specific is often not relevant or helpful.

Having said that here’s another update!

I Am a GP Partner Now

GP partners are owners of clinics in the UK.

This is a very privileged position I am in.  Basically I now have a test bed to test my application in.  I also have an allocation of money from the practice to keep building my app.  So, I am very lucky indeed to be have been given such a massive opportunity.

This is the best position a founder could be in!  Solving your own problem with outcomes which will be beneficial to yourself validates your idea for a business and ensures that at least one person will benefit from your product or service!

Keep in mind that 88% of founders fail because they fail to make something that people really want and will pay for.

To Spread or Not to Spread

The app is being used in a few test beds now.  As such I haven’t pushed for it to go into more and more healthcare settings.

The reasons for this is that the app has potential to become really killer.  But I need time to build the rest of the necessary features.  This will take 8 months or so.

It may seem risky to not keep pushing for it to go into more and more places, but there are a number of reasons why  think it’s a good idea to not spread to quickly in the healthcare space.

The first is that it’s very difficult to get into anywhere – but now that I am convinced that I will be able to get into more places, I need to make sure to not blow it by providing bad services or a crappy product.

The other reason is that when you’re creating enterprise software, the app itself is a small part of the whole business.  This is another reason why it’s a bad idea to learn to code just to make a business.  The fact is that people don’t just pay for an app (particularly in healthcare), but infrastructure, support, insurance, certification, governance etc etc.  Also, as you provide software to more settings and businesses, more code needs to be written to provide infrastructure for billing, handling new data and new protocols have to be written for implementation.  The legal implications and finances also becomes a whole lot more complicated.

Looking at it this way, I’ve figured that the best way to go forward is to really make an awesome product, get sales lined up and then launch in more places once we’re happy that we can deliver something remarkable.

The Future

The future looks good at this point.  I’m solving a real problem, we have customers, the scope of the app could make a really positive change for both patients and healthcare providers.

There will be plenty of challenges up ahead.  However, just because I’m not writing these in-depth updates doesn’t mean much for followers of the blog.

The fact is that anyone who really wants to do what I am doing can just read my blog and follow me.  As the whole blog is about entrepreneurship and healthcare, people will learn a lot more by reading and understanding the general view-point of an entrepreneur than to follow all the details closely.

Because let’s face it, how many other people out there are GP Partners and creating software for the NHS?

This Blog Post Was Written At 2.45AM

When I was at University I found that I studied best in the middle of the night.  I used to keep reading until my vision went blurry as a result of the small muscles in my eyes getting fatigued and slowly giving up.

Prior to medical school, the only other thing I dedicated my soul to was playing the guitar.  It was my first love.  Even then I noticed that I used to make the most progress in my abilities late at night.

Tonight reminded me of my younger days.  I’ve been up tying up some loose ends, sending some invoices for my startup and updating our upcoming workflow.  I think I’ve realised why I and so many others prefer to stay up late to do work.

It’s because there are no interruptions.

No phone calls.

No e-mails.

No one knocking on my door to distract me from what I am trying to accomplish.

I’ve realised that my whole day is full of interruptions.  Even when I am in clinic seeing patients, there is always someone who calls me while I am with a patient, or there is someone waiting outside of my office door, someone waiting for a patient to leave so that they can pounce on me for another request of some sort…

I think to get important work done, you need alone time to let your mind wander and to allow it to make those connections that can only be made during deep work.