Confessions of a healthtech entrepreneur 2020

3rd January 2021 by Chris Robson

Thank god we have left 2020. I thought it was never going end. On and bloody on.

So what was it like as a healthtech entrepreneur?

Having written a book 10 years ago called “Confessions of an entrepreneur”, I thought that I would now start confessing what it’s like to be a healthtech entrepreneur today. I am the founder of digital health company, Living With, and we are right in the think of this Covid pandemic

I am going keep it short and sweet. So to kick us off, here’s my top 3 loves and 3 hates of digital health in 2020.

2020 Top 3 loves

Finally remote monitoring became an everyday occurrence not an aspiration. Patients get treated when they need to be. Clinicians save time and cost on how they manage their patients. 2020 has kicked the healthtech industry into the future. It’s like the dotcom boom of the late 90’s. Anything is possible.
Everyone can see that rapid innovation is critical. Yes everything still needs to be evidence based for widespread adoption. But we’re all working together to implement solutions that will make a difference. Patients and clinicians have reframed their view of healthcare. This has enabled us at LivingWith to get new digital health products to market faster. And we can see the immediate positive impact that they can have on patients’s lives. My 2020 highlight is our Living With Covid Recovery product which is helping patients treat and improve their Long Covid symptoms. #livingwithcovidrecovery
The healthcare system has some truly amazing human beings working in it. The difference that they are making to the world and to patients through their clinical magic is awe inspiring. It makes most industries and most people in those industries look parochial and money grabbing.

2020 Top 3 hates

The deep bureaucracy that exists within the healthcare system. It makes it so damn hard for companies like ours to get digital products into use. We see this most frequently through Information Governance. We spend days every month trying to navigate the same Information Governance (IG) questions at every NHS Trust and private company we talk to. However hard we try, it doesn’t seem to get any easier.
Corporate decision making remains slow and tortured. Covid has made it much worse, even in areas where they want to implement something
Everyone expects a free trial for everything in healthtech. It doesn’t matter how much or how little the investment required. It has to start free until each new prospect feels the evidence works for them.

It’s going to be another rollercoaster of a year but it will be an exciting one for healthtech. Bring it on.

Retirement is an out of date concept

3rd May 2020 by Chris Robson

It may be heresy to say this, but retirement is an out of date concept, born of an earlier age.

For many people the onset of internet based technology and more recently discussions about AI are making them scared and more inclined to want to keep the world of work in a similar pattern to the past. This includes a view that the retirement age shouldn’t go up but in fact should go down, so that people have more time “post work”. But perhaps the reverse is true? Perhaps we need to refashion what work means and the idea that it starts and stops in the way it might once have in the 20^th Century? Now is the time to recognise that work is changing and we should proactively use this as an opportunity to re-imagine work.

Work is good for us. It gives us purpose and can be stimulating in a range of different ways. Purpose is so critical to living healthier and happier lives.

Technology overthrows past behaviours, activities and perceptions, but it also enables new ways of interacting with others and with the wider world that our predecessors could never have imagined. It makes it easier for people to monetise some of their skills and capabilities in other ways, including online. We can make technology work for the wider society.

If we re-imagine retirement then what are some guiding principles?

Work is a positive force for good. People should continue to work for as long as they can, but in very different ways and in order to be healthy and motivated and not just to make money.
The government should look at how it makes “education for life” a real option for everyone. In other words how government enables people to retrain in different ways to enable them to follow different types of work at different times in their lives
People are living much longer lives. The state shouldn’t be expected to pay pensions for 30 years for people if they don’t make any other form of contribution back to society.
However, the state should proactively look at how it facilitates older people finding new types of work and giving back to society for a wage.
Ageism is rife in society. It needs to be opposed as vigorously as any other form of prejudice.

We should use the COVID crisis to re-imagine our Society for the better and not feel the need to re-entrench past views and a mythical view of better times.

A lot of work will need to be done to create the right environment for this to happen, but we should start sooner rather than later, if we want to ensure that the UK continues to be productive and mould breaking.

Time for a UK Sovereign Fund in new technologies

28th May 2019 by Chris Robson

People have been talking about setting up a UK Sovereign Fund for years. However, there is still relatively little clamour to support this initiative and make it real.

Of course this is an old idea. Norway set up its Sovereign Wealth Fund back in 1969, with the aim of managing Norway’s oil resources over the long-term. Over the last ten years, the fund has delivered a return of 8.3%, or 36.5% in real terms after annual management charges and inflation. Source Forbes.

Much more recently in 2006, Australia set up a Future Fund which is performing well and is investing in a number of different areas including disability care, medical research and nation building.

The UK could very easily start a Sovereign Wealth Fund and it would be applauded by the majority of people in the country as long as its core principles were right and it was totally apolitical. It’s time we did. We are a small but highly inventive people. We shall become an increasingly small part of the future world and yet there is no reason for our creativity, originality and inspiration not to be captured, supported and indeed amplified through such a fund

We should set up our own “Future technology Fund”. It should invest in technologies that benefit large numbers of the future population. This should include the following:

Health
Energy
Agriculture, landscape and environment
Housing

Some of the amazing break throughs that are happening in health technology should be supported and ultimately be part of this Fund. There is too much incredible work that originates here in the UK but that is allowed to be commercialised elsewhere in the world. We need to ensure that the Fund can provide a commercially owned structure which ensures that value goes into future generations living in the UK.

The Fund should be controlled on the basis that no funds can be withdrawn for 10 years minimum and then only a maximum of 2.5% of the value of the fund in any one government as long as the total fund is still always higher than previously. It should be independently managed and separately monitored.

We should incentivise entrepreneurs to bequeath their companies and the assets of these companies to the state. We should do this by providing them with entrepreneurial tax relief on their output as long as at least 25% of the assets ultimately end up in the Fund. This would continue to build on the “innovation and entrepreneur friendly” tax structure that now exists in the UK and which is much envied across Europe.

We desperately need to rethink how we fund our future. This would be an important first step in that direction.

Should we clap, Labour keep telling us that they costed a budget!!?

3rd November 2018 by Chris Robson

John McDonnell, the Labour Party politician and Shadow Chancellor of the Exchequer, leads the pack in looking smug when he says that Labour had their budget costed at the last Election. Most of the rest of the Shadow Cabinet also laud this fact with great self-satisfaction.

Why?

As any business person and civil servant knows, business plans are not gospel. They are a point in time perspective on a business and a set of financials. They are generally inaccurate. Companies that repeatedly deliver what they forecast are rare. The idea that Labour have suddenly created a financial bible that will deliver exactly what they say, at the price they say, is ridiculous.

The Labour party numbers are dripping in caveats and abstract concepts. There is no certainty in them at all. No-one should believe for one moment that their policies are comprehensively costed. And this is not a party political message, I have no more faith in any of the other parties being able to budget their manifestos accurately.

But it is fair to say that many of the Labour policies are still un-costed including breaking down the cost of nationalising each industry, or putting a price tag on other major capital projects such as extending HS2 to Scotland.

In addition their plan is based on certain assumptions that are unlikely to happen, if history is any form of precedent:

For example they will not make Corporation tax deliver another £19.4bn by raising the headline rate to 21% from 2018-19, 24% from 2019-20 and £26% from 2020-21. It never does. In fact the correlation works the other way.
They have no actual plan to deliver the £6.5bn that they reference from tax avoidance.
They assume that they can raise another £6.4bn of income tax from increasing tax on the top 5% of earners, but quite often the very rich get mobile and avoid the tax.
Estimates that an “excessive pay levy” would raise £1.3bn or that introducing a new financial transactions tax would bring in £5.6bn are again speculative at best.

The really scary thing, is that in today’s politics, the idea that a major political party has a “costed” budget, is even news. Of course political parties should forecast what they are going to spend to achieve their aims. It is also scary that so many people believe their figures are the gospel truth. If anything what it demonstrates is how big a gap there is between most politicians and most business people. Let’s hope that the reality doesn’t end up being a big shock for everyone, if their budget is every tested properly in government.

Do politicians need to go to business school?

22nd July 2018 by Chris Robson

Channel 4’s breakdown of the careers of MP’s in June 2017 showed that 19% were career politicians, 14% were from business, 11% were lawyers, 8% finance and accounting and the rest were a very mixed set of occupations.

In fact more than a quarter of the candidates chosen by Britain’s political parties to fight in the 2010 general election had no experience of any career other than politics. And this was true in the 2015 general election when one in four (26 per cent) of new candidates contesting were political professionals source UCL and PCUK.

Going back to 1979, Nuffield election studies show no less than one in ten MPs from the three main parties have been barristers or solicitors. More recently research compiled by BPP University Law School has revealed that 119 of the 650 MPs in 2015 either studied or practised law before standing for election.

But it is clear that this isn’t what the electorate want.

A YouGov report in 2014 showed that voters would prefer if these trends were reversed. 57% wanted more factory workers elected to Parliament; 61% wanted more doctors (who made up only 1.4% of main-party MPs as of 2010) and 57% wanted more scientists.

Unsurprisingly, there is always a huge clamour for MP’s to come from less privileged backgrounds and indeed represent a wider societal view. However, there is way too little attention given to the need to have more people from business in Parliament.

A huge proportion of the issues that MP’s need to understand, debate and vote on relate to how organisations need to be run, how to improve efficiencies, leverage new ideas and technologies and motivate people. These issues are the bread and butter of business people.

So whilst the public may want more doctors and factory workers, actually we do need more business people before anything else, if we are going to solve the most pressing issues in our society.

Perhaps it’s time to train our MP’s to be better equipped to do their job. At least some of this training needs to be at a Business School or equivalent. Until then we shouldn’t be surprised if so many offices of state are poorly managed, and if too often politicians promise the earth and are unable to deliver it.

What is a human right and what is a societal benefit?

12th May 2018 by Chris Robson

There used to be a time when people were absolutely clear about what their human rights should be. It was about freedom of speech, a right to a fair trial, the right to vote, freedom from discrimination, freedom of religion, freedom of thought and freedom from enslavement. These are critical political rights that most right minded people believe in. It’s strange then, when so many people across the world are still fighting for these basic freedoms, that some developed countries are debating whether “paid leave for a bereaved parent” should be a human right.

We must differentiate between human rights that are fundamental to a fair existence and those that are really at the gift of a democratic society. People have fought and died for centuries for basic human rights. It dishonors their memories to claim that some freedoms or benefits enabled by the state should be classified in the same way. So whilst I feel tremendous sympathy for a parent who has lost a child or indeed a child who has lost a parent, i am not convinced that the state or an employer should be picking up the bill to give them paid leave. Either way this is a decision for the government of the day and not one for Parliament or the Judiciary to contemplate in the context of human rights.

Obviously the field of human rights grows ever more complicated and indeed larger, as people clamour for more rights. Sometimes this is reflective of the age, for example when the US set up their constitution and enabled people to bear arms. Equally we are now entering a time when sexual orientation, gender identity and the right to your own home are being talked about as Human rights.

It is interesting to see that people are increasingly relaxed about how others behave. This is a good thing. It is reflective of a more tolerant world. Long may this be the case, whether in terms of sexual orientation or anything else. However, we should be wary of passing endless new matters into legislation as Human Rights until we have genuinely built a Society that globally protects the basics. Until then we should treat many new issues and concepts as benefits but not as rights.

Certainly there must be more public debate on these issues. It is important to bring everybody together on these matters.

What are the sacred cows in the NHS and UK healthcare system?

3rd March 2018 by Chris Robson

At a time when the NHS is creaking under the strain of ever increasing costs there are a number of sacred cows that frequently get commented upon, but never get resolved and must eventually be key to a better solution. These scared cows graze happily in the grassy uplands of healthcare largesse, content in the knowledge that it is incredibly difficult to deal with them once and for all. Here are eight of these sacred cows:

1. The ever increasing number of NHS managers and administrative staff at the expense of frontline staff. In spite of years of cross party rhetoric about the need for more frontline staff and less admin staff, the reality doesn’t seem to get a lot better. In fact the number of NHS manager numbers has risen by a quarter in 5 years. More than 6000 managers have been hired since April 2013 taking the number from 26,051 to 32,133 in October 2017. Pay offs for managers have cost £2billion with at least £92million going to staff who were quickly rehired. Now of course this is consistent with other areas of government like the Ministry of Defence where frontline personnel numbers go down while the numbers of civil servants go up

2. The rising cost of negligence compensation and the role of lawyers in this cost. The total potential NHS negligence liability has risen from £29billion in 2014-15 to £65billion in 2017-18. Legal costs account for 37% of payouts for negligence, but somehow the lawyers are not being chastised.

3. The significant rises in the average level of GP pay. 15,190 GPs earned more than £100,000 in 2014/15. More than 200 ‘Super GPs’ in the NHS earned more than £200,000 a year in 2015/16. Some GP’s continue to do astonishingly well out of the system.

4. The cost of agency staff. The NHS spent £2.9 billion on agency staff in 2016/17 – down from £3.6 billion in 2015/16, but still £700 million more than in 2009/10. Source NHS improvement 2017. Even when employer costs are added, permanent staff working at plain-time rates are a much more cost-effective solution for employers source Royal College of Nursing 2015. Changes to the tax treatment of locum doctors were introduced in April 2017 with the intention of controlling costs further, but it appears that salaries have risen by an average of 6.3 per cent since these staff were moved from payment through personal service companies to PAYE source The Times 23/10/17

5. The inequality in female pay in the NHS. Full time female consultants earned £14000 less than their male equivalents source BBC 2018

6. The misuse of public sector time and resources by private consultants. Too many private consultants do use their public sector resources for personal gain. The British Medical Association said: “There should be no conflict of interest between NHS and private work, and this principle is contained in consultants’ employment contracts. Consultants who want to do private work must first offer to do extra work for the NHS, ensuring NHS work is the priority.” But the reality is that it is often hard for these 2 sides not to get blurred. As some have argued, time spent in the private sector deprives the NHS of consultants’ hours, and creates “a perverse incentive” to increase NHS waiting times to further private business. Either way this is a tough nut to crack and no Health Secretary seems to want to tackle it.

7. Waste. A 2014 year-long study by the Academy of Medical Royal Colleges, the professional body that represents the country’s 250,000 doctors, found that the health service wastes up to £2.3bn a year on a range of procedures and processes that could be done better, more cheaply or not at all. In August 2017 Professor Tim Briggs, national director of clinical quality and efficiency, said the NHS wasted too much money on poor care and “doesn’t deserve more money until it puts its house in order”. The review of NHS efficiency by Lord Carter of Coles estimated that reducing unwarranted variation in how the NHS procures supplies and delivers care could save £5 billion of the £55.6 billion spent by hospitals each year. There is a genuine recognition of the problem, but will anyone actually solve it?

8. Restructuring mania. Every government thinks that a “good restructuring” will sort out the NHS, but over the years the cold hard analysis would suggest that this is rarely the case. Certainly the Kings Fund concluded that “Politicians of all parties should be wary of ever again embarking on top-down restructuring of the NHS,” after the reforms of 2013.

If we are going to continue to improve the NHS and ensure that it is fit for purpose, then these issues need a resolution. The sacred cows can’t just be pushed into the long grass.

NHS commissioning of biologics

7th January 2018 by Chris Robson

Vedolizumab

I am on a biologic, vedolizumab, for my longterm condition.

I have been on it for 12 months.

I know that it is expensive but it has had an amazingly positive impact on the state of my condition and my health

But there is a crazy NHS commissioning issue for biologic users like myself.

If you do too well on them, then the NHS commissioners decide that you no longer need them and stop paying for them. As a patient this is madness. As a commissioner I understand the argument, but think it is a short-sighted one.

If I now come off my biologic, there are no other non biologic medication options available to me. I know this because I have discussed it at length with my consultant. I have had my condition for 30 years. Over time I have tried all the other medications and in the end they have all had severe side effects, including azathioprine giving me pancreatitis and asacol knocking out all my white blood cells. So if the financial argument wins, then i shall have no satisfactory medical options. Inevitably without medication, my condition will worsen and i shall end up back in hospital. This will cost more money than the medication would have.

The key learning for the NHS should be that now that biologics are becoming more established treatment options, the commissioning rules need adapting. The current guidelines for prescription are too inflexible.

Maybe commissioners need to talk more to patients like myself…?

Why don’t we focus harder on non-medical solutions to healthcare issues?

7th December 2017 by Chris Robson

In a recent study published in the Journal of Scientific Reports, it was demonstrated that for people living alone, having a dog can decrease your risk of death by 33 percent and reduce your risk of cardiovascular-related death by 36% -this is in contrast to people who live alone and don’t have a pet.

As a Medcity author commented, it is hard to find any drug or surgery that does the same without side effects and at a comparable cost.

Oh the magic of a pet!

The reality is that there is too little discussion about the unwritten pact between citizens and the state that the people need to take some responsibility for looking after themselves. Surely we should expect a minimum level of exercise from everyone who wants to use the NHS? Surely we should expect that people take some responsibility for their nutrition? In a world where, quite rightly, we all want the latest and most effective health technology, medicines, treatments and equipment, we must ask people to deliver their side of the bargain. It is time for this “pact” to be a mainstream part of the healthcare debate. It is time for the state to ask people to maintain a certain level of fitness, nutrition and self-preservation. This is not a discriminatory action. This is an example of normal everyday life, where people expect to make choices between different things that they do and don’t want.

It’s time I had a say in my medical treatment

16th September 2017 by Chris Robson

People have been talking about personalised medicine for ages. It’s all the rage in the NHS now with The 100,000 Genomes Project. This project is committed to sequencing 100,000 whole human genomes, from 70,000 patients, by the end of 2017 to help bring in better treatments.

This is because medical professionals are using genetic sequencing to enable them to separate people with similar symptoms into far narrower groups and target medicines at them. For example last year, researchers from the Wellcome Trust Sanger Institute determined that the most common and dangerous form of Leukaemia is actually eleven distinct diseases that respond differently to treatment. Now that the cost of analysing an individual’s DNA is significantly less expensive, it will become possible to link a person’s genes with specific medicines and even diets.

This is great news, in a world where, by way of example, less than 4% of cancer patients actually participate in a clinical trial. In other words fewer than one in twenty five patients contribute to developing the new knowledge about a condition that informs new treatment plans.

So the flaw in the personalised medicine plan is that the only person that the Government and the medical profession are not consulting is me – the patient!

Why not?

I am a patient living with a long-term condition, ulcerative colitis / crohns. I have had this for 30 years. I know a lot about my condition but I am never consulted on my treatment. I have had several different drugs over the years, from azathioprine – which gave me pancreatitis; asacol – which knocked out all my white blood cells, and salazopyrin, which never fully controlled my condition. Over the time my condition has gone up and down.

Now for many sensible reasons, drug dosage is very carefully controlled in any healthcare system and the drug companies are equally tightly regulated. But in a world of ever increasing healthcare problems and healthcare costs, it is time to relook at this approach.

I am on a biologic, vedolizumab, and it is working. I love it. However, it is working too well. I am classified to be in remission and so the NHS now wants to take it off me. If they do, then inevitably my condition will worsen. The NHS attitude is so binary. I am well or I am ill. I take the infusion or I don’t. Why can’t I have a smaller dose? It would cost less and it might work just as well. The answer is that the clinical trials have only led to approval for the drug based on a standard dose. This is therefore what NICE guidelines accept. But why shouldn’t I be allowed a say in this? It’s my body and I have been living with the condition, longer than any doctor treating me. In many ways I am an expert patient with living experience of the condition.

We need to change the approach. It’s time for the individualisation of drug dosage based on personal response patterns to drugs and not on old fashioned and out of date clinical trial methodologies. We need to bring in individual DNA based personalised medicine, and we need to drive active patient collaboration and participation in drug and treatment decisions. We can’t just leave this to the supposed professionals. We need to do 3 things:

Enable patients to have a say in their treatment and in the drug choices and doses
Enable different types of observational research study based on different levels of patient participation over different times.
Establish formal expert patient councils to advise the NHS based on patients living with conditions or disease for long periods of time.

It’s time to get truly personal.