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.

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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?

Everyone Should Be On Statins!

This is the mantra of the medical profession.

When I am seeing patients basically every man over the age of 60 and every woman over the age of 75 is advised to be started on a statin.  The algorithms on my computer (anyone with a QRISK2 score over 10% is advised to start on a statin as per the national guidelines) tell me to give it to them.

It seems that every few weeks there is a news article singing the benefits of taking statins.

Just to step back for a moment.  Statins are a group of medications which lower cholesterol.  Lowering cholesterol, it seems is associated with lowering the risk of death from a heart attack or a stroke.  Statins have always been controversial as such a large number of people are advised to take these medications.

I think statins are a perfect example of a drug class which has a lot of evidence espousing its benefits but little evidence showing that it may be harmful.  As I wrote in my previous blog post, the absence of evidence is not the same as evidence of absence.

The fact is that studies will show that statins “cut the risk of having a heart attack by X%”, but the hidden side effects and long term health disadvantages are not measured and in a lot of cases cannot be measured.

For example are statins associated with breast cancer?  Are they associated with bowel cancer?  Does it increase the likelihood of other diseases such as diabetes?  How about if you’re already a diabetic, does it make your diabetic retinopathy worse than if you weren’t on a statin and cause earlier blindness?

None of these questions have answers and they never will have an answer until it becomes painfully obvious as drug companies and the scientific community will always go looking for evidence which should result in treatment.

What do I do with my patients?  I explain that guidelines advise that they should be on a statin as it may decrease their chances of a heart attack or a stroke.  But I also tell them of the possible listed side effects and also explain that “all medications have side effects and risks which vary from person to person” and that if he/ she doesn’t want to continue it then they are free to stop at any point”.

Why Your Family Doctor Tells You To Go Away And Take Paracetamol/Tylenol

This post may get a little heavy on theory and scientific jargon.  Possibly one of the reasons why there are often so many disagreements between patients and physicians.

Introduction

I was having dinner yesterday evening with some friends.  At the table there were a group of doctors, a computer scientist, a technical consultant and a health economist.

Discussion quickly turned to inconsistencies in healthcare between different countries and also amongst different physicians.  I am going to present my thoughts on giving any form of treatment to patients in this post and why it’s a good thing if your doctor tells you to go away and take paracetamol (aka Tylenol for all you Americans out there).

If current guidelines would permit and if medical committees would allow, I would be happy to give even less treatments to my patients than I do today.

Positive (Naive) Treatments

We have all heard anecdotes such as the following;

“I saw Dr X and she didn’t know anything!  She just told me to take Paracetamol!”

“Dr Y didn’t recommend a x-ray!  I know that Dr Z would have if I saw her!”

We are living in an interesting time.  We have an abundance of information*.  Medical technology and the choice of medications has increased into their hundreds in the last few decades.  There has also been an explosion in the number of procedures to choose from.

I want people – both clinicians and patients – to stop and consider whether this is a good thing.  Is it good that more and more people are on more and more medications?  Is it a good thing that so many people are having CT scans (and thus being exposed to so much radiation), invasive investigations and procedures?

Most of the public and indeed it seems, most of my patients seem to think so.  I say this in view of how often they are pushing me to give them antibiotics or send them for brain scans.

My argument is that although “positive evidence” exists for giving treatments, the antonym (“negative evidence”) doesn’t or is much harder to come by.  To compound the issue medical councils and regulators do not even recognise/are cognisant of such things.

What I mean by this is that most scientific/medical evidence study what effects an intervention has on patients with regards to a very specific outcome.  For example if a given drug is thought to lower the chances of getting bowel cancer, then the study will look at if the incidence in the cohort of people taking that drug is lower in comparison to a control group.  However it completely disregards unforeseen effects of the medication.  For example does the drug cause certain other types of cancer?  Does it cause bone degeneration?  Does it cause more heart disease?  The evidence doesn’t exist and pharmaceutical companies and physicians are unlikely to go looking for such findings as the scientific community in general, are so biased towards finding positive results and therefore more interventionism.

It is true that more evidence causes doctors to prescribe more and carry out more interventions than is needed.  The absence of evidence is not the same as evidence of absence.

Let us take the example of tonsillectomies.

In the 1930s tonsillectomies were very common.  The thresholds for operating on children were much lower than it is today.  There was a study carried out on just shy of 400 children in New York during this period.  In the study they took the children to a doctor and asked whether these children needed to have a tonsillectomy.  174 of them were recommended to have the operation.  The remaining children were then taken to another doctor and 99 of them were advised to have a tonsillectomy.  They took the remaining children to another doctor and another 52 were recommended to have an operation.

Consider that there is a 2-4% morbidity rate today (not back in the 1930s when rates were much much higher) and that 1 out of 15,000 children will die from the procedure or as a complication of the operation.

Obviously more children are alive today, simply by carrying out less treatments.  If the morbidity and mortality statistics were available in the 1930’s it is likely that less operations would have been performed.  More-so, I think the number of parents giving consent for such procedures would have fallen also.

I think it is easy to see why tonsillectomies are much less common nowadays.  No one would argue that we should go back to doing more of these operations today.  Can a similar thing be said about other treatments patients are given today?

Iatrogenics

Iatrogenics are the illnesses caused by physicians.  For example, if a patient is subject to certain procedures, such as radiotherapy or they have an adverse reaction to a medication they are said to have suffered from an Iatrogen**.

Although doctors are somewhat aware of iatrogens, medicine is still very naive when it comes to possible risks of different treatments – due to absence of evidence.

It would be foolish to think that doctors know what harmful effects there will be in the future for patients if they are given treatment today.

Medicine is littered with examples of absence of evidence (not evidence of absence!).  A famous example is that of Thalidomide.  Thalidomide was used during pregnancy as an anti-emetic.  It seemed like an obvious treatment to an obvious problem back when it was widely used.  Thalidomide helps pregnant women overcome nausea and eases their pain, therefore it is a good thing that they receive treatment it was thought.  Only after years did it become apparent that Thalidomide was teratogenic and as a result caused deformities in the foetus.

You see, lack of evidence (of harm), is not the same as absence of evidence (of harm).

Thalidomide is an interesting case study as the malformations caused by the drug were so obvious yet it took so many years for scientists to link thalidomide to the harm it caused.  It is very hard to extrapolate and find causality in such a complex world.

Think of all the treatments, medications and procedures we carry out today.  I wonder what side effects people are suffering from.  It is impossible to say right now, but I can guarantee that there are plenty out there.

The Medical System

This is the crux of the problem.  There may be short-term benefits with certain treatments.  However, with a lot of medications and treatments there is often very little or no evidence that such therapies are actually helping patients (for example, some studies have shown that water is just effective for treating depression as antidepressants are).  Not only this, but there is absence of evidence of the risks of treatments.

The reason people continue to get treatments from their physicians is because of presence of some information which could mean that some benefit may be gained by the patient.

This leaves doctors in a very difficult position.  We are continually forced by medical guidelines to carry out more and more investigations and treatments.  On the other hand, patients are also becoming more and more pushy demanding treatments they have heard of from the media or their friends or family.  The problem is that if no treatment is given and something goes wrong then the doctor is held liable for the “mistake” of not treating.  Doing something – any kind of treatment – seems to be recognised, but doing nothing is currently indefensible.

The case of Michael Jackson immediately springs to mind.  Conrad Murray was sentenced to four years of prison due to Involuntary Manslaughter.  However, would not treating Michael Jackson have been defensible in court?  This is the very real scenario that all practicing doctors face.

No one seems to have an understanding of the real risks of modern day medicine.

What I am suggesting in this blog post is that doctors, patients and medical guidelines are all blind to the harms of the medicine we practice today.  The side effects of the overuse of antibiotics, antidepressants unnecessary operations etc will not become fully apparent until many more years have passed.

Now, having realised that medical treatments today may be much more likely to harm you than you initially thought, would you still like that course of broad-spectrum antibiotics?  How about a nice MRI scan of your back so you can be considered for a spinal fusion and laminectomy?

Any takers?

Thalidomide…

Ps. A good question to ask your doctor is: “What would you do if you were in my position?”, instead of “What do you recommend I do?”.  You will be shocked to see the difference in recommendations as your doctor is much more aware of Iatrogenics (although they are probably greatly under estimating them).

*Interestingly this abundance of so much information will add to more and more un-informed treatments and long term morbidity.  As mentioned there isn’t enough data at all on negative information – only on positive intervention and medication.  “Big data” is all the rage in the tech scene right now, but actually this is a disaster in the making as more people will be diagnosed with dubious pathologies and have excessive treatments for such conditions.

** As an aside – it is interesting to note that medicine is pretty much the only field in the world where there is a study of iatrogenics and where iatrogenics are talked about.  If you speak with economists, politicians etc then you will not find a single person who is aware of what an iatrogen is or how to assess for them.  It’s just not in the common discourse.

This Is What Starting A Business Looks Like

Starting a startup is hard work.  It’s a very different kind of “hard” work than what most jobs require.  It’s not as difficult physically, as doing something like construction and it’s not as intellectually demanding as something like medical school.  However it is emotionally and psychologically draining as there is so much uncertainty involved.

Not only this, but there is added pressure on the founders of an early stage startup because it’s testing whether their “vision” is real or actually a hallucination.  This can make them feel very bare and vulnerable.

I think the best way to describe what it feels like to be a solo founder is via this video:

Visionary?  Or Just having a hallucination?

First you have to be willing to put yourself on the spot, be willing to be ridiculed and possibly laughed at.

Very few people are willing to be that first person dancing to their own tune though.  Most people never even get to this stage and they fail because they didn’t even get started.

Then when you’ve finally proved that you’re not insane and that there’s a party going on which is going to make an impact and a positive change, people will join you – these are your early adopters and your co-founders.

Then before you know it you’ve got a whole business dancing to the tune of common interests and values, working towards a common goal.

The Case For Private Businesses In The NHS

As a GP and entrepreneur, with my own software being used in the NHS, I have found that my opinion has continually changed with regards to businesses in the NHS.

I used to think as a junior doctor that a lot of the private companies dealing with the NHS were evil for two main reasons: overcharging the NHS for their services and the unethical use of patient data.

I think these two points are still valid for certain companies.  If you read some of the reviews of some of the NHS software suppliers then it’s patently obvious that certain organisations like TPP who provide the electronic health records for around 30% of NHS GP practices have stonewalled themselves from criticism.  Their software is also very dated and horrible to use as a result.

But, there are some great things about private enterprise.  One of the greatest differences between government ran organisations and private enterprises is accountability.

We live in an age where when there is outrage at a private company, real change can happen.  Just look at how the CEO of a multibillion dollar company was recently ousted for unethical behaviour.

I think that the world is changing.  People and consumers have a voice now, because of the Internet and how connected we are.  We can raise our concerns when we’re not happy and take our business elsewhere, or in my case start a business which is more ethically sound (I hope! :p ).

I feel that this is quite different from government organisations.  As private businesses become more transparent and ethical due to consumer pressures, large government organisations are appearing more and more opaque as time passes by.  Due to the lack of market place pressures they are also very inefficient and lack the focus that private enterprises need just to survive – but this is the subject of another blog post! 🙂

This Is Why We Can Change The NHS

The people at the top of the NHS, it is widely thought, have it so easy.  If they just had the sense to engage with the public and front line staff then they could make things better, cheaper and more efficient.

The people on the front lines of the NHS such as junior doctors, nurses and physiotherapists also have a widely held belief – that they can’t make change happen.  Patients are mostly the same as well.  “What can I do?”  they say.

If only patients and staff could yell at the people at the top and tell them how hard they have got it, the thinking goes, then maybe change would happen.

How can staff and patients possibly create change when no one listens to them?  When they don’t have any money?  When they’re just a tiny cog in the system?  When speak of innovation and creativity is often met with fear and disdain?

If this is the case then only the people at the top must be able to create change, they say.

The fact is that the people at the top realise that they have a budget where they have a whopping 1% devoted for software and 0% for innovation and creating change.  If the people at the top decide to innovate and blow some of their budget on something new, then it better have a big impact, it better be nationally scalable from the get-go and it better deliver on all the outcomes promised.  If they don’t deliver on this impossible promise then it’s their head on a pike!

You see, the people at the top are paralysed.  They can’t do anything because they know too much about the wrong kind of things and they are risking their livelihood if they put their name on something that doesn’t work.

The patients and front line staff, the ones that pick themselves to make meaningful work are the people who will create change.  The problems and barriers we face are not nearly as big as what the people at the top face.  This is a lie that front line staff and patients tell themselves, as taking responsibility for something much bigger than their role is a tough pill to swallow.

When I was a Junior Doctor at St James’ Hospital in Leeds, I had the great pleasure of working with the late Dr Kate Granger.  She started the “Hello My Name Is….” campaign.  The reason she started the campaign was because she had terrible experiences of doctors not introducing themselves during her illness.  On one occasion the doctor that told her that her cancer had spread left her “psychologically scarred”.

She went on to say at a speech:

“I had been moaning to Chris (Kate’s husband) about the lack of introductions from the healthcare staff looking after me. Being the practical optimist that Chris is, he simply told me to ‘stop whinging darling and if it is that important to you do something about it.’ So we did.”

It wasn’t Kate’s responsibility to do the campaign.  No one gave her authority to start a campaign.  She simply didn’t have to do it.  But at that moment, she picked herself and decided to make change happen.

She didn’t know that her campaign would end up being endorsed by the then Prime Minister, celebrities, about half a million NHS employees and result in her being awarded a MBE.

The reason why the NHS is so broken is because there aren’t enough people like Kate who pick themselves.  But anyone can pick themselves.  And it’s as simple as saying “I am going to make change happen”.