Creating Tension

Michael Schrage has written about what great organisations do.

And his term for it is:

“Who do you want your customers to become?”

I think this is similar to asking “what change do you want to make?”.

Harley Davidson is an amazing brand, worth billions of dollars.  Not because they make the best bikes in the world, but because they’ve turned a group of “outsiders” into “insiders”.  These outsiders used to be disrespected and frowned upon.  But when these people come together they feel something.  Harley Davidson made change happen.

Why is it that so many people line up outside the Apple Store for the newest phone?  It’s because Apple has made us into consumers that now have good taste in digital goods.

If we are going to make change.  You and I – what change are we going to make with our work?

I think doing important work means you have to be the one “in the spot”.  To do important work means you have to choose to be the one in the spot.

Being in the spot doesn’t mean it’s your “job” to do the work, or that the “dummies guide” told you to do the work.  It doesn’t mean you’re doing it because “everyone else is doing it”.

The work that matters, the work that we have the chance to create in our lives, is never work that other people could do.  It’s never the work being done by lots and lots of people.

The work that matters is the type of work where people would miss you if you were gone.  The work that matters is the type of work where people would be sad if you stopped.

Most of use work in organisations.  And most organisations are obsessed with authority.  “Can he do that?” “How come he didn’t ask me if he could do that?”  “Can I do that?”  “Who has the authority?”  “Who has the authority to spend for this?”  “Give me a raise so I can tell other people what to do.”

And this search for authority informs most of the bureaucracies in our life.  If you only had more authority, the thinking goes, then you could get “on the spot” and do the work that matters.

Well, no one’s giving you authority any time soon.  But there is something else you can take any time you want; responsibility.

People who take responsibility get responsibility.  No one gives it to you, you take it.  And what comes with it is the willingness to give away credit.  If you are giving away credit and taking responsibility when things go wrong, there is a looooong line of people out the door who want to work with you.

And this is super hard.  Because not only do you have to go “on the spot” and say; “I am going to do this”, but then you have to be responsible for what happens next.

Which leads to this huge idea about change.  Because when we do work that matters, we are changing other people.

There are two problems when creating change in other people: other people don’t want to change and we (ourselves) don’t want to be responsible for creating change.  Tension in us, tension in them.

Think of a great artist from centuries ago.  Got someone?  They created art that was universally hated by everyone!  Whether it’s Jackson Pollock or Elvis.  That person is hated.  But that person says “No!” and says “I’m making it anyway!”.

But it’s ok, because it was their responsibility and they wanted to create a change.

Are you willing to create this tension?

NHS Startup Part XVI – Thoughts On Integration

As integration with some of the large NHS IT suppliers comes closer and closer I am thinking more and more in-depth about what is the best way forward.

Integration when I first started my business seemed to be the holy grail!  It seemed to be the panacea to all of my problems.  However, as it was not feasible to integrate initially (most of the large IT suppliers don’t want to integrate as they want to own a monopoly, I didn’t have the contacts at that point to even begin discussions with the large suppliers to integrate and we still hadn’t tested out our assumptions / if our product would even work) I decided to take a massive leap of faith and build a stand alone system.

Being a stand alone system has loads of advantages.  The APIs for most of the legacy software in the NHS are hard to use, have poor functionality and limits what you can do.  It also locks you into a system which is inherently broken and can’t keep up with the demands of modern medicine – If the existing systems were so good, then my company wouldn’t exist!  It also prohibits you from using third-party apps which you want to incorporate into your service as they are not approved by the NHS.

Not being integrated allows you to be super lean, iterate, build new phases, do A/B testing and so on.  The flexibility and the speed simply wouldn’t be possible with integration.

This is the dilemma in my mind: We’ve managed to launch our product in several surgeries now and next month we’ll be launching our service to a massive 70,000 patient company.  This all occurred within a six month time period (our product first launched at the end of Dec 16/beginning of Jan 17).  This leads me to believe that it is possible to grow the business without integration.

So why integrate?  It will open up a massive distribution channel.  EMIS who are very keen to get integration going, own >50% of the primary care EPR market.  TPP who I should be able to integrate with as well own about 30% of the market.  This would mean that integration would allow us to scale enormously.  Integration also means that we wouldn’t need to worry about a lot of scaling issues which may arise otherwise.

Well this sounds amazing!  But what are the down sides?  The down sides is that you’ve essentially given over control of your whole company!!!!  Is that really the best way forward?


A graph showing what happened to many websites after Google’s search engine update (Panda Update)

Giving over control of distribution is a big risk.  It’s like relying on google to provide all your web traffic or depending on amazon to sell your products.  One rule break, one update of an algorithm and you’re dead!

In effect, one of these big IT companies may just decide to kill my company for the hell of it.

I don’t think a strong foundation of a company can be built on someone else selling for you.  Entrepreneurs take responsibility for their own success, I am not prepared to give that over.

The other thing I’ve realised is that being an integrated app in someone elses system will really reduce the amount of money we may possibly be able to make in the long run.  In the short run it will provide a big boost in revenue, but not so much in the long run.

“Back of the envelope” maths is important.  If I solely rely on integration for distribution, I realised that hypothetically we would be making in the tens of thousands of pounds a month.  However, without integration and with control of our own distribution, we could be making in the hundreds of thousands of pounds a month.  Theoretically an order of magnitude difference!  Too hard to ignore.

So, here is the new strategy for my startup!

We integrate.  But, we provide very limited functionality with the integrated version so that people can get a taste of what we can do.  Want the full version?  Then you’ll need to dump your existing system which is garbage anyway and switch over to ours instead if you want to really increase your revenue and improve inefficiencies!

This seems like the wise move for the time being and the definite way forward in my particular case.

Integration no longer seems like the panacea I once thought.

NHS Startup Part XV – “It’s Up To Us Now.”

We launched a new phase of our app for our patients and Primary Care services this week.  The build for this phase was huge and we have been steadily working on it for the previous four months (designing, building, testing, messing up ad nauseum).

I think we’ve really nailed what we intended to do.  As we collect more data, it should show that we’ve increased how efficient things are running at the practice, that more revenue is being made and that patients also prefer our new app to the existing means.

My main fear for this launch was actually the practice and the number of staff that work there.

As our app continues to expand and increase in its abilities it requires a concerted effort by everyone at the surgery for it to really work to its full potential.

I was initially worried about this.  Up to now, a small number of staff at the practice have been doing everything and they didn’t even need to do much to make the app as successful as it has been.  Now everyone in the practice has a small part to play to make it really grow and have a bigger impact.

Could they do it?  Would they do anything wrong?  What happens if they simply don’t want to?

These were the questions running through my head.  Although the launch itself went without a hitch, I was leaving the surgery still thinking that someone may mess something up.  That’s when someone from the team said:

“It’s up to us now”

At that point I just felt a massive sense of relief.  I truly do believe that the team are all bought in now.  I realised that giving people something to do with regards to my app isn’t bad.  It’s actually good, because now everyone is bought in and involved in the mission.

I guess being a leader is about leading from the front, aligning people and then creating change.  Maybe I was trying to create change from the back and by not leading all this time.

One thing’s for sure though – if someone does mess up.  I won’t be upset or angry.  I’ll be grateful they tried.

The Brick Walls Are There For A Reason

I recently came across a lecture by Randy Pausch, who was a Professor at Carnegie Mellon University.  At the age of 46 he was diagnosed with terminal pancreatic cancer when he gave his last lecture.   

There is a quote from the lecture that I just absolutely love:

“The brick walls are there for a reason.  The brick walls are not there to keep us out; the brick walls are there to give us a chance to show how badly we want something.  The brick walls are there to stop the people who don’t want it badly enough.  They are there to stop the other people.”

“Other people” are most people.  You better be damn sure you’re not the “other people”, because they’re the ones that just complain, play the victim and then give up!  

Three CEO’s Who “Rode The Tide”

** This post was written for another blog, so the style of writing is a little different from my usual **

“Startups” are a special type of business.  They’re designed to get big and get big fast.  If they don’t get big then startups are meant to die.

How do you know whether your startup may become as big as Uber or FaceBook?  I think there’s a common theme which is fundamental to any successful startup.  You have to “Ride the Tide”.

“Riding the Tide” means that you can see where the world is heading, whether that’s a technological breakthrough, the inevitable change of an industry or a change in human behaviour.  Paul Buchheit, the creator of Gmail, said it best: “Live in the future, then build what’s missing”.

Here are three CEO’s who successfully rode the tide.  However, any mega successful CEO will have a similar story.

1. Aaron Levie, CEO of Box, Net Worth $94 million


Aaron Levie had the idea of Box when he was in college.  He noticed that it was really difficult to share data with colleagues.  Surely, if he was having this problem then lots of others would as well?

He was right!  Turns out that most companies had to share a lot of data amongst themselves and there was no easy to use solution.  Aaron Levie realised that the cost of storing data would continue to fall and if he could create an easy to use solution for large businesses they would be happy to pay him.

Box “rode the tide” of an increasing number of businesses wanting to share more and more data and also the tide of decreasing costs of computer storage.  The company went public in 2015 and Box’s software now serves most of the Fortune 500 in America.

2. Max Levchin, Co-Founder / CTO of PayPal, Net Worth $300 million

Max Levchin was working on security gadgets for PDAs when he founded a security company.  Later on he started to focus on online payments.

At one point in PayPal’s history, millions of dollars were being lost to fraud every month.  Max Levchin and his team had to create a load of new technologies to prevent online fraud and customer money being lost.

All the hard work paid off when PayPal was acquired by eBay in 2002 for $1.5 billion.

PayPal “rode the tide” of consumers wanting to spend more of their money online.  PayPal offered the solution and the founders  were handsomely rewarded!

3. Bill Gates, Co-Founder of Microsoft, Net Worth $87.4 billion

The story of Microsoft is a great example of what happens if you already have a successful company and you’re not aware of the upcoming tide.

IBM was a hugely successful company, but they were mainly focused on large mainframe computers.  They didn’t realise that in the future practically every desk would have a small personal computer.

When IBM got into the personal computer game, they made a deal with Bill Gates and Microsoft.  Microsoft would make the operating system for all of their computers and they would get a loyalty for each computer IBM sold.

In the 1990’s Microsoft captured over 90% market share of the world’s personal computers.  I doubt IBM would have made the same deal if they knew personal computers would become such a big deal!

Microsoft “rode the tide” of the rise of the personal computer!

Epic Rant – The Maiden And The Hare

I was going through my subscribed list on WordPress the other day and noticed that most bloggers I followed have stopped blogging after only a few posts.

Three questions spring to mind:

  1. I wonder if these bloggers would quit if they had tens of thousands of followers and likes on their posts?
  2. I wonder if they would continue to blog if they could possibly be a successful blogger if they continued for 7 plus years.
  3. I wonder if they would continue to blog if I could guarantee that they’d be a successful blogger if they continued for 7 plus years.

I bet the answers to these questions would vary massively.  Most people want a guarantee.

This is why people fail.

They fail because they quit.

People fail because they want a guarantee of success.  If they don’t have that guarantee then they tend to not stick it out through the rough times.  They don’t stick around for the times when no one gives a damn about what they have to say and don’t give a damn about what they’ve done so far.  And why should others care?  People aren’t as special as they tend to think of themselves.

“At first, then, exhibit the coyness of a maiden, until the enemy gives you an opening; afterwards emulate the rapidity of a running hare, and it will be too late for the enemy to oppose you.” – Sun Tzu, The Art of War

In life there has to be a time when you keep your head down, obey orders and commands to learn your craft.  When I graduated from medical school, I accepted that I knew very little in comparison to other doctors who knew a lot more than me.  Voicing your opinion on how things should be run and organised as a nobody makes you come across as a douche bag.

I’ve spent over a decade involved in healthcare (from the time I started medical school up to this point in time) and before that, I was surrounded by medicine because so many of my relatives are doctors.

Only now am I writing a blog and starting a healthcare company.  Before this time, I kept my mouth shut and studied my craft.

It is shocking the number of people who don’t put in the grind and hustle and yet expect the world to take note of what they have to say.  Let me tell you something – the world doesn’t care unless you’ve provided something of actual value.  No one will listen to you unless you have credibility, which will be apparent in your actions, character, network and public standing.

Be the maiden and then the hare.

Rant over.


The decisions you’ve made so far have gotten you to where you are.  

However, the decisions that you make now, going forward, don’t need to be and in a lot of cases should not be influenced by what you’ve done in the past.  

Every decision is an opportunity to stand still for a second, look at where you are currently and decide “Right now, what’s the best way forward?”.