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.

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?”.  

How To Hack Motivation

Entrepreneurs are often described as being highly driven, relentlessly resourceful, focused and unstoppable.  It seems that a lot of entrepreneurs play up this image and talk about how they worked harder then their competitors to get to the top.

Will Smith encapsulated the entrepreneurial spirit perfectly in the following quote:

“The only thing that I see that is distinctly different about me is I’m not afraid to die on a treadmill. I will not be out-worked, period. You might have more talent than me, you might be smarter than me, you might be sexier than me, you might be all of those things you got it on me in nine categories. But if we get on the treadmill together, there’s two things: You’re getting off first, or I’m going to die. It’s really that simple, right?”

Determination and drive are clearly important, but how can “ordinary people” cultivate these characteristics in themselves?  How do ordinary folk with a 9-5 job, a family and rent to pay get started on their entrepreneurial journey.  There seems to be a big leap from just being a driven individual to being successful in life.

Well for those of you who are interested, I think I’ve found a hack!

I’ve been thinking more about this recently as my girlfriend has just passed one of her final exams, which means she is very close to becoming a senior physician now.  I have also now passed all of my exams and am a senior physician.  Interestingly enough, we both have startups as well.  I have an early stage health technology startup and my girlfriend has a non-profit startup which is launching a cancer screening programme in Africa.

So what’s the deal?  How come we are leading such fulfilling, exciting lives while a whole load of others out there want what we have, but never seem to quite get there?

(Just as an aside – I don’t think it’s because we’re particularly smart – I know loads of people who are smarter than us!)

I think that having “drive” and accomplishing things actually just comes down to organisation and prioritising what is really important to you.


How do you spend your time?

If you look at the above chart (credit to Stephen Covey who created it!), it shows that there are four “quadrants” where people spend their time.

  1. Quadrant I = Important & Urgent = The really important stuff you have to deal with immediately
  2. Quadrant II = Important & Not Urgent = Stuff that won’t have an immediate impact on your life right now
  3. Quadrant III = Not Important & Seems Important = that phone call you have to make, or getting down to the bank at some point….stuff that really isn’t that important, but which people generally prioritise higher than they should.
  4. Quadrant IV = Not Important & Not Urgent = Wasting time.  Most people spend most of their lives here

The fact is that most people spend most of their time in Quadrant III and Quadrant IV.  I’ve noticed that my girlfriend, myself and all the successful people we know spend as much time as possible in Quadrant II.

Working out, exercising, eating right, working on your dreams, dedicating yourself to an activity – these are the most important things you could do in life, yet most people choose to spend their time elsewhere.

Most people waste too much of their time on pointless activities such as watching TV or browsing FaceBook (Quadrant IV).

Most people fear things too much.  Therefore they dedicate a large amount of time to things which really aren’t important, but seem important (Quadrant III).

Quadrant III and Quadrant IV is where most people live life.

My girlfriend and I both passed our final exams by NOT going to study groups, by NOT wasting our weekends with other doctors preparing for their exams, I skipped my preparation courses for my final exams as I was meeting with important business leaders those evenings, I attended the minimum number of teaching sessions to pass my postgraduate training and so on.

In other words we didn’t let our fear of things which seemed important (but really weren’t) to get in the way of what’s actually important to us – our dreams and ambitions.

Of course this was a big gamble for me.  My exams cost £2,000 ($2,600) to sit.  If I failed one of my exams I think I would have had to take out a loan from the bank to sit the exam again as money was so tight when I launched my startup.

So that’s the hack!  

I honestly believe that we’ve gotten as far as we have, not because we’re exceptionally smart or “driven”, but because we prioritise what’s important to us.  We know exactly what we want out of our lives and we execute the plan on a daily basis.  Most successful people do the same.  They define their Quadrant II, they identify with it so strongly that they grind and hustle until they’ve accomplished what they want to.  They don’t just wake up one day as incredibly “driven” people.  They just know what they want and go after it – everyday.

The main obstacle for others out there is not that they don’t have drive but silencing the part of their brain that makes them preoccupied with Quadrant III and Quadrant IV activities.  They are a waste of time and although most don’t realise it, these are the activities that eat away at dreams…day…by…day…