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.

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.

Innovation With NHS Software

There are two ways in which Enterprises assess how valuable a piece of software could be to their organisation.

The first is whether it can save money.  Save on staff costs, inefficiencies, wastage etc.

The second is whether the software can make the organisation more money.  This is an order of magnitude better than saving money and you will face a lot less resistance if you can create something which can increase revenues.

I think that this is one of the reasons Primary Care in the UK has so much more technology and innovation than secondary care.  Surgeries in the UK are ran like small businesses and the better the health outcomes and indicators that a practice can achieve, the more money they receive for their business.  Hospitals get allocated money on an as needed basis.  They don’t get rewarded with money in the same way Primary Care Businesses do.

If this is the case then where is the incentive for companies to make innovative products that make things better?  Companies are only incentivised to make things cheaper in Secondary Care.  The way to make things cheaper is usually to keep doing what you’re doing at a cheaper price point.  Doing something new means large implementation costs.

Unless increasing efficiency is baked into your product / service then I would say that the best course of action may not be to go for a market where innovation and making things better is not rewarded.

Is there a market where there is money and an opportunity for your startup?  Then that’s the market you should go for.

If Marcus Aurelius Were A Doctor

When a man kisses his child, said Epictetus, he should whisper to himself, “To-morrow perchance thou wilt die.”- But those are words of bad omen.- “No word is a word of bad omen,” said Epictetus, “which expresses any work of nature; or if it is so, it is also a word of bad omen to speak of the ears of corn being reaped.”

The above is a meditation by Marcus Aurelius.  It’s not the most well known, but when I first read Meditations, this one really stayed with me.

Accepting that life is finite, although jarring is empowering because it allows you to focus your finite time on aspects which you do have under your control.

I’ve found that a lot of doctors cannot accept the fundamental truth that they cannot predict or control what will happen to their patient.  When a patient walks out of your room he or she may die.  It happens all the time and most often it’s the patients that you least suspect that get unwell.

What I find interesting is that a lot of doctors try to counter the inevitability of their patients dying by becoming emotionally involved.  I have seen some of my colleagues cry and go into depression because they get so involved.

Patients themselves may want their doctor to be more emotionally invested in them.  They may prefer and consider doctors who are more emotional to be the better doctor.  But just because they may prefer something doesn’t make it correct.

I find that a lot of people in the general population would prefer to not take responsibility for their health and outcomes in life.  If their doctor becomes invested in them, they feel that they are able to give the responsibility of their health over to their doctor.  This is patient disempowerment rather than empowerment in my opinion.

In 90% of cases a patient should not expect to give over complete responsibility of their health over to their doctor.  A lot of patients have actually tried and failed to sue their doctor because of this false expectation.  When a mother sees a GP about their baby and is told that the baby has a viral infection, but if things deteriorate to seek medical attention – we are telling that mother that nothing is certain in life and actually, there is a chance that this could turn out to be meningitis.  A doctor can only go by the clinical picture in front of them and come to a logical clinical decision.  It is up to the mother to act responsibly and do something if the child becomes more unwell.

Another sign of how dependant patients become / how unrealistic their expectations are is when patients complain about seeing several different doctors before getting to the correct diagnosis.  Patients don’t realise that if this is the case, it’s extremely likely that the way the patient presented was atypical as is evident by several different doctors coming to an incorrect conclusion.

Doctors should not become emotionally involved and accept full responsibility for their patients health.  Sure, we can empathise with our patients.  But what we mean by empathy is that we get where the patient is coming from, we try to understand the patients life circumstances and try to formulate a management plan which the patient can tolerate and live with.  Empathy does not mean becoming emotionally invested.  This is actually a very quick way to allow unknown biases to sway your medical judgement and provide poor care.

“All men are made one for another: either then teach them better or bear with them.”

I wonder what Marcus Aurelius would think about becoming emotionally attached and accepting full responsibility for their patients health.  I think the above quote sums up the correct attitude you should have as a doctor.  If the patient listens you can teach them about a healthy lifestyle, how to manage their medical problems as best as they can and so on.  (And always document what you have said!)

If patients do not like what I can do for them with the tools that I have available at my disposable then it is none of my concern.

Boss, Can I?

Here’s your typical employee mentality in a sentence:

“Boss I’ve got this great idea, please can I start a project?”

Often this question is followed by a quick “No”.

I’ve seen a lot doctors/nurses/admin staff etc rant and whine about being told “no” by their boss.  What I find baffling though is that I haven’t met a single one of them that really turns around and thinks about why they were told no.  They often go down the path of “blaming the system” or how their genius isn’t “appreciated”.

This is a classic case of Ignoratio Elenchi.

Here’s what your boss actually hears when you ask permission to do a project:

“Boss, I’ve got this great idea!  If it works then I get all the fame and glory.  If it doesn’t work then you’ll get all the blame for wasting time and money.”

Probably the main reason employees don’t ever come to realise that this is what their boss actually hears is because they can’t face the reality – that no one’s going to hold their hand.  After all, most employees have had their hand held through school, then university and then well into their professional lives.

The fact is that if you want to do something big in your life, then there has to be a moment where you take the leap and accept full responsibility for what happens.  You cannot demand authority, but you can accept responsibility.

If you’re in an organisation (not necessarily just healthcare) your options are to either just do your project and not let your boss know, or leave the organisation to do it.

Not willing to take the leap?  Then stop whining.

Being Young, Poor And Unkown

In large organisations and large businesses the state of technology is generally far behind the consumer world.  I think that in the next decade the enterprise world is going to be revolutionised with software in the same way that the consumer world has been.  Enterprise software is also a lot more lucrative than consumer software as companies are willing to pay a lot more than consumers for services.  Just to put this into context, people spend about $35 billion on consumer apps every year and about $135 billion on digital advertising.  This sounds like a lot until you realise that global enterprise software expenditure is $3.7 trillion.  It’s very likely that within the next decade we’re going to see lots of new billion dollar companies appearing in this space (and possibly  trillion-dollar companies!).

I have always been struck by how bad enterprise software in the NHS is.  So much of it is so obviously bad and painful to use that I am surprised a lot of it hasn’t been shelved for better products already.

There are the obvious reasons why this is the case – industries don’t like change and once software has been chosen and invested in, organisations want to build ecosystems around them rather than causing unnecessary disruption.

However, there’s another really overlooked reason why enterprise software is really really bad.  it’s because the majority of people involved in procuring enterprise software are so damn old!

I remember when I went to the NHS Innovation Expo earlier last year.  I must have been the only person at the whole expo with a full head of hair!  These were meant to be the movers and shakers of the NHS, the companies that were going to revolutionise healthcare in the UK and they were all 50+!  I’m not saying being old is bad or that older people lack insight, however if we look at history it’s generally younger people who can “live in the future and create what’s missing” (as Paul Buccheit once said).

A major reason for this is that young people have a naturally large advantage over older people just because of their age.  Being young allows people to intuitively envision the upcoming trends as they have grown up surrounded by the newest technologies.  What is painfully obvious to young people really is not obvious to older people.

I’ve noticed this with my own startup.  It’s so darn obvious to me that what I’m building should be how things are done.  But when I speak to older doctors and people involved in procurement they really don’t seem to get it until things are explained to them point by point, with plenty of data to back up my claims.  What seems blatantly obvious to me clearly is not blatantly obvious to them.

My experience kind of echos what Marc Andreessen said.  He said (to paraphrase) that most startups are not too late – they’re often too early for the times.  The reason entrepreneurs start a startup is because they have a clear vision of what the world should look like and so start a company to create that reality.  It seems so obvious to the founders that they are right that founders (including myself) feel like they started too late and that another company is going to come along and kill them.  However, in his experience this never happens.

Younger people who can see the trends and have a better idea of the what the future should look like can solve needs which no one is even thinking of yet, but which they intuitively know will occur in the not too distant future.  This is allows younger entrepreneurs to create startups which have no competition!

I’ve said it before, but it really does seem that being young, unknown and poor are some of the greatest things you can leverage in your start up.

Hating Groups of People

Because of the state of the NHS, doctors are often written about in the news.  It’s no secret that working conditions for doctors in the NHS (whether junior or senior) are really bad and seem to be deteriorating rapidly with time.

Shifts where you have to cover hundreds of sick patients by yourself is not and never will be justifiable.  Patients are at risk of serious harm and I’m sure many have died as a result.  When a patient does come to harm, that single doctor covering all those patients is the one that gets the blame, jeopardising his or her career.  A career that they’ve sacrificed a heck of a lot for and dedicated an enormous amount of time towards.  A similar picture is true of primary care physicians – they have to see a patient every ten minutes, which is a totally arbitrary amount of time and obviously isn’t enough for many patients.  The GP then has to make a choice between practicing dangerous medicine or letting their clinic run into their personal time.  All GPs I know do the latter as it’s better to let your clinic run late than to jeopordise your career.

What I find interesting is the public’s attitude towards doctors.  When doctors talk about how tough they have it and how it’s making them go abroad where working conditions and pay are better, a lot of people say that this is heresy.  A lot of people have similar attitudes towards GPs – calling them lazy and incompetent, whereas if this were even remotely true they’d be struck off or investigated.  Any patient can complain about their GP for any reason and it is always investigated by the practice or referred on to the local commissioning group.  If the patient is still unhappy they can complain to the national ombudsman.

Here is my argument: If a significant group of people  are being vilified, who are not intentionally causing any harm to their fellow humans, the people who are vilifying them are always wrong.

If we look at history this has always been the case.  Whether it be the Jews in Nazi Germany, African-Americans throughout American history, or the “Untouchables” in India.

I think that this is quite an important statement to always keep in mind when assessing how true a news story is or how valid a person’s opinion is.  Whenever I hear people make negative generalisations about doctors or GPs – who consist of a large group of people whose job it is to look after others – I know that that person is just plain wrong or trying to be controversial.