The NHS Clinical Entrepreneur

It was about six years ago that one of my great career heroes and mentors, Sir Bruce Keogh, asked me if I'd take on the post of National Clinical Director for Innovation. It was a new post. We had about 15, maybe 20 National Clinical Directors — people leading on different areas in healthcare. We have a cancer tsar, a heart tsar, as they're often called in the media. But they were all very pathology-specific; no one really covered everything, the whole of healthcare and life science.

So he said, do you think you could do it? And I said, well, what does the job involve? And he said: we want you to address the inequality agenda, so the latest, greatest things get taken up across the National Health Service. We want you to grow the life-science economy in the UK — we have one of the leading life-science sectors on the planet, and that drives a lot of innovation and makes things available to patients much quicker in this country than people often have access to them elsewhere. We want you to advise different parts of government, arm's-length bodies, the public sector, companies and foreign governments that come and see us about healthcare innovation. And the last thing: we want you to make England the go-to place on the planet for medical innovation. But you have no money and no power. So go and see what you can do.

You might say that's the NHS way. And it sounds impossible, doesn't it? How can you take the world's largest unified healthcare system — 1.4 million employees, I think the largest employer of professionals on the planet — and help it become an innovative organisation and lead that? Of course it's an impossible job. But I was told it was impossible to build science parks in Essex and raise the money and have products that would change the world. I was told it was impossible to build a ray gun. Well, that was right — it wasn't possible to do that, although it was really exciting. I got to convert a magnetic missile-launching system into the largest magnetic stimulator ever built, and I think that was a pretty cool thing to do for a PhD.

So I've been at NHS England six years now, pitching lots of policy, coming up with new ideas and advising people about what's going on across technology — whether that's digital or electromechanical or other things in the life-science sector. I get to see things really early stage. I probably get more than 1,000 companies a year coming to pitch to me from right across the world, because the NHS is the largest purchaser of many things. We're the largest single purchaser of hearing aids in the world. Why do I know that? Because the speaker and audio-system manufacturers are getting into hearing aids and they want to come and find out — you're the biggest single buyer of hearing aids on the planet, what are you interested in, what problems are you facing, how can the products we design help? So you get to see lots of very early prototypes you won't find on Google or social media, and kind of horizon-scan and look at what's coming down the line.

That allows you, when government departments or ministers or senior NHS leaders want to know what's going on in a space... Recently I was asked about the latest advances in robotics, and there are some really interesting things going on — some in medicine, but actually lots in other sectors. We work collaboratively with a range of organisations. Recently I was working with Formula One teams during the Ventilator Challenge through the COVID-19 pandemic — they do lots of stuff in the robotics space. So some days I feel like a boy who's woken up in a toy shop, because I get to see the latest, greatest things and meet the people building them, designing them, thinking about them, and go: how might we use that in healthcare?

I don't think we need to be the next Silicon Valley. I've been there, I've spent quite a lot of time there, and we should just be ourselves and true to who we are. We don't have to be something or someone else. I once listened to a talk when I was in Silicon Valley, and the biggest secret at the time, they said, is that around half of entrepreneurs in the startups are burnt out and have a variety of mental-health conditions as a result. Is that really what I want for our nation — a load of bright, burnt-out people? I don't think that's what I'd encourage at all.

There's something about big industry that's really great and supportive and builds an ecosystem. Silicon Valley, when you look at it — people have written loads of books and histories on this — really came about from some big industries, some globally leading universities, and probably the right financial and regulatory environments in California in particular. But why can't we have something similar here? If you look at Cambridge, it's the life-science capital of the UK: a world-leading university, lots of industries grown up around it, and they do a fantastic job. There are a number of other places in the UK too. I definitely have an ambition for our nation to be the globally leading centre for life-science research and innovation — making the latest, greatest things available to our citizens and the patients of the NHS firsthand, so they're invented here and innovated here and don't have to go abroad to be tested and trialled while people somewhere else get the firsthand benefit.

If you look at the UK's history of invention, it's incredible. Incandescence — essentially the first light bulb — was demonstrated by Sir Humphry Davy at the Royal Institution in 1809, and it was 1879 that Thomas Edison, the American, developed the first commercial light bulb. I could add the CT scanner, the MRI scanner, the television, the computer — all invented in the United Kingdom, but all innovated and commercialised outside. We've got a great history of invention we should be really proud of, world-leading, more Nobel Prize winners per head of population than any other country. But our track record in building the large commercial organisations that then create economic growth is not as good as other countries'.

So I see what you're saying about Silicon Valley and their success — they have lots of multi-billion-dollar tech companies. But we have a great ambition in our country: something called the Industrial Life Sciences Strategy, led by Sir John Bell, the Regius Professor at Oxford, who's led lots of the COVID work, particularly around vaccine development. He's got an ambition for us to form four $20 billion valuation life-science companies over the next few years. It's a bold ambition. I think we can do it. And when you build companies that size, they grow into the tens, hundreds of billions, perhaps even trillion-dollar valuations over time. But we can build our own thing here — it doesn't have to be Silicon Valley.

Exploit your asset. Exploit your competitive advantage. Ours is the world's largest unified healthcare system. And boy, in the COVID pandemic, hasn't the NHS stepped forward. We've led the world in COVID-19 research, and the reason is that it doesn't matter whether you're in the highlands of Scotland or down in Truro — you can contribute to our nationally coordinated trials. We were the country that disproved some of the medications being suggested in COVID, and were able to prove that very simple things, like dexamethasone, made an absolutely massive difference. No other country in the world could do it. Separate private healthcare institutions competing against each other, unable to share data — but a unified, centrally funded national healthcare system stepped forward, and it's going to make a massive difference to people across the world. We should feel really proud of that. I'm really proud of what we do on our little island. And it's not so little, because we're contributing to and changing the world day in, day out.

First of all, that talk you heard was just before a general election — a period known as purdah, where people in the public sector aren't allowed to make new policy announcements, quite rightly, which is why I was so specific about any announcements when I spoke at Wired.

Getting involved in policy is a completely different world to anything you experience in healthcare. To be fair, I don't write the policies. I'm part of a team — I'm a clinical adviser to teams of people at NHS England, which is essentially the national commissioner for healthcare. All sorts of situations present themselves; you have to deal with issues that arise, and you need new policies and procedures — things that allow you to continue delivering high-quality healthcare for prolonged periods. You can't always do what you always did. That's not how it works.

When you first start, especially getting into the centre... I'm quite plain-speaking, and people who know me — certainly the entrepreneurs on our programme — know that if you come to a business-planning session with me, you're going to get some honest feedback. I love that Elon Musk has a saying about the essential qualities of startups. I can never remember the first two tips, but his third is: go to your friends and seek criticism regularly. Because your friends normally know what's wrong with your business idea, but they don't want to tell you — they're your friends. Yet they will really tell you what's going on, because they actually care about you, rather than others who often won't.

When I went to NHS England, I wasn't surprised to find there wasn't a lot of plain speaking going on, and there was lots of language so diplomatic that I met one or two people who'd mastered the art of speaking for five minutes without my being clear they'd actually said anything. They weren't unpleasant people — there were some wonderful people there — and I'd just be very open and honest. I learned from a few mentors that you depersonalise things: you don't talk about the individuals, you talk about the issues, and you stay focused on those. That's a really great tip for leadership generally. I stay away from individuals and personal criticism — I don't think that's helpful. It can be appropriate in a one-to-one coaching session, but in policy forums, giving an open, honest, polite but candid view of the situation — people find that quite refreshing. At least they know your opinion.

My job, as I see it, is to give advice to the executives at NHS England and across government. They weigh that against the other perspectives and evidence they've gathered, and they make a decision. It may not be what I suggested — that's fine, it doesn't matter. At least I've given them a very honest view, and then a decision is made, and we try to make it work.

I can remember occasions where I've said, I think that would be the wrong thing to do, I think we should do this — and the leader of that group would say, we're going to do this and we're going to make it work. A year down the line that individual had moved on, it hadn't worked, and we were back to reinventing it again. You see that a lot — across government, across different bits of the NHS and public sector. People keep retrying things.

It's one of the problems with medicine, isn't it: we don't publish the negative results. Science — and the business of science, and it is a business; the journals are businesses that serve a great function — but tell me where the journal of negative results is. I haven't seen it, because it's the big, positive, groundbreaking breakthrough results that get the most citations. There must be an order of magnitude more negative results, where things didn't work out, and people keep testing and trying them because we don't know about them. Some of the biggest failures I've had — no one needs to go and repeat that. Like the ray gun: I tried to convert a magnetic missile launcher into the biggest-ever magnetic stimulator, and it didn't do what it was meant to. Fine — we don't need to do that experiment again, we've learned.

But in policy, in the public sector, it hasn't got quite the same process as scientific and medical research, so you do lose system memory, because there's such a rapid turnover of people moving through different positions. Sometimes you quite quickly come round to somewhere you've been before. That's one of the benefits of having leaders in position for longer — they've got great connections, great system knowledge. And if I don't know the answer, I know networks of people who can say, oh, we tried that before and it didn't work for these reasons, so we don't need to do that again.

Policy is a great privilege to work in. There are lots of incredible people and great minds I've met in that space. If you look at where we started at NHS England when Simon Stevens came along — we had the Five Year Forward View, then the Long Term Plan. When I look across the world at what different healthcare systems are trying to do, what was distilled in those documents was a real crystallisation of what I saw going on in America, Asia, Europe — what healthcare systems were struggling with. It gave the narrative of how we have to embrace innovation and change healthcare in the future if we're going to make it sustainable. And that doesn't matter whether you're in a private insurance-payer system or a publicly funded national system — people still get sick, they still face the same problems, and giving the most high-quality, cost-effective healthcare is a problem everyone's grappling with.

There are a few misconceptions in your question. First of all, I'm not steering the ship — and I'm not sure any one person is. The NHS is really a movement. It consists of our whole population, and many people from across the world who stand up for universal healthcare. When the NHS was founded after the Second World War, it was the world's first-ever universal healthcare system. Before it, people had to decide whether to put dinner on the table or pay for a visit to the doctor. Imagine that choice — feed your family or get healthcare. We've forgotten in this generation; the NHS turned 70 a few years ago, and people have forgotten what it was like before it existed. We showed the rest of the world the way — nearly every modern country now has some form of universal healthcare coverage. I'd argue the NHS is one of the greatest innovations in the history of humankind, and we should be very proud of that.

It's very easy to stand on the sidelines and criticise — I get that a lot. It's far more difficult to get up out of your seat, roll your sleeves up, come into the arena and help us tackle the challenges. "Oh no thanks, I'll stay in my seat and tell you how to do it from here" — that's not helpful and it doesn't change things. I've been on the front line — a consultant surgeon in the NHS for 13 years, a qualified doctor for 26 years, on calls through the night. Now I have a chance to bring some of that frontline clinical knowledge to the centre.

It is a big organisation — the world's largest unified healthcare system — so it is a bit of a supertanker, I get that, and it can be seen as impenetrable and difficult to change. For all those people who stand on the sidelines and criticise, I'd ask them to come and take my job on: you're the national clinical lead for innovation, helping this supertanker become the most innovative healthcare system, making the latest, greatest treatments available to our population. Wow, what a challenge. But it's one of the most important jobs there is. People say it must be such a difficult place to innovate in because it's so large, and I say — on the other hand, if you want to innovate at scale in healthcare, the NHS is the place to do it. Just turn that around.

We've got lots of policies in place, and we're creating a culture around innovation and how we support our staff. We've just had the new NHS People Plan published, looking at how we support our workforce for their whole lives — so they not only have a fulfilling job but it's a great place to work, the best place for your health and wellbeing. Wouldn't that be an amazing thing to say: we work in the organisation that's the best place on the planet for your health and wellbeing? There's no one magic bullet. One of the things I've been involved in generating is the Clinical Entrepreneur Programme. We'd always supported people who wanted to be leaders or academics or teachers, but if you wanted to be an entrepreneur in healthcare, we did the opposite of support you, frankly. Five years ago we'd say, just get on with your clinical day job, what are you worrying about all this other stuff for? That was a common thing said to me when I was doing my startups as a junior doctor — and yet the latest, greatest things were often coming out of the startup world. So I pitched to Sir Bruce Keogh and Simon Stevens that we could learn from this really important sector.

Who would have believed it — we're in year four now. Within four years the NHS will have created the world's largest entrepreneurial training programme in healthcare: over 500 frontline clinicians. We're collating the year-four data now, but it's going to be around 250 startups, and I think well over £300 million raised by them in their first four years. I've only got year-three data, but I think 104 junior doctors who'd quit the NHS came back under the Clinical Entrepreneur scheme, because they could pursue their dual passions — being a clinician delivering healthcare, but also someone who could build a healthcare enterprise that could impact lots of patients' care rather than just the ones in front of them.

When people say the NHS doesn't do very innovative things, I think we do a number of really innovative things — access to all sorts of new treatments, and we've often been the first nation in the world to make them nationally available. Look at the genome — we discovered DNA in this country, we did the first human genome sequencing at the turn of the millennium, and in our 70th year we were the first country to nationally commission genome sequencing for cancer and rare diseases.

Take artificial intelligence — through the Accelerated Access Collaborative, which is part of the team I work in at NHS England, we've become the first nation to nationally adopt and roll out an AI system in a clinical pathway. I can't find another one — there may be one, but I can't find it. This is HeartFlow, which came out of Stanford University, using machine learning to predict whether a coronary stent will actually improve the blood flow and oxygenation of tissue beyond the stenosis. I'll get the exact percentages wrong, but with some coronary stents you might stent someone and it doesn't have the impact on perfusion you were hoping — and actually you'd have been better off not stenting them and just treating with medication. This HeartFlow algorithm helps you predict that. They've done brilliant trials over the last 10 years at Stanford, lots of randomised controlled trials, and NICE evaluated and approved it, so we funded it at NHS England and we're rolling it out nationally.

The last data I saw, we were doing around 5,000 cases a quarter — and that's from pre-COVID times. We went from zero of these analyses being done, ramping up into the thousands nationally. It took our elective chest-pain pathway from — I'm trying to remember the slide — I think 28 weeks from referral to getting through the whole pathway, down to seven weeks, and 17% of people were treated more rapidly right across the NHS. I've just given you a couple of great examples where we're beating it. Do we get it right all the time? No. Do we need to work harder and do more? Yep. Are we going to do that on our own? No — we need to bring our workforce with us, our patients, our citizens, to help us reimagine and redesign healthcare. No one country I can see anywhere across the planet — and I've visited many — has all the answers. Some do really well in certain things, and we learn from that. But overall we should be really proud of the achievements of the NHS. We have an amazing workforce — they're our most valuable asset.

If you want to understand how to change a tanker, you need to read the work of Robert Kegan, professor of organisational psychology at the Harvard Graduate School of Education — Immunity to Change. It's on the core reading list for the clinical entrepreneurs. Bob Kegan is probably the greatest living psychologist, one of them — he discovered a whole new field of psychology and has been developing it for the last 30-plus years. It talks about how individuals, groups and organisations actually develop an immune response against change and innovation, and goes through the fundamentals of how the brain is structured and how our psychology works. It builds on people like Daniel Kahneman, the Nobel prize winner, with his behavioural-economics work.

I also like Thomas Lewis, the psychologist who wrote A General Theory of Love — understanding the pathology around love. It's another book I recommend for our entrepreneurs, because people don't just fall in love with other people — they fall in love with products and services and processes, don't they? Everyone keeps their smartphone near them; I wouldn't say you love it, but you keep it very close all the time. Understanding the psychology of how groups of people and teams and organisations work together is a really great way to understand how to get system change.

We had a new commercial director, Emily Lawson, appointed at NHS England — I probably shouldn't say this, but I recall the first time I met her, we were both big fans of Bob Kegan. I thought, this is incredible — someone who's come from the commercial world, now come to the NHS, and she reads the same things I do, but she came at it from a commercial angle. She said, it's that kind of thinking that's going to help us change the National Health Service. And I went, wow.

There are lots and lots of people committed in the centre to doing that. And are our frontline staff committed? Wow — some of the most motivated, driven, committed people you could ever come across. It's one of the greatest privileges of my life to still work on the front line in the NHS — not just because of the patients, though that tangible difference you make to another human being is one thing that keeps most clinicians going. It's actually the other colleagues and members of staff, too, who are often so inspiring. So I think we can make this supertanker the most innovative organisation and the best place to work — if we embrace our most important asset, which is our workforce.

Oh, excellent.

The Clinical Entrepreneur Programme is a bit like a smorgasbord — a Scandinavian pick-and-mix lunch table with lots of different offerings, and you can choose what you like. We've got a whole range of things: commercial mentors on the programme; access to less-than-full-time training if you're a trainee, and we'll support your applications to HEE for that; a whole range of networking events, educational events, industry days; we can connect you with customers, signpost you to funding opportunities and help you apply.

But the most important thing has been bringing together like-minded individuals who want to create and innovate things together in one space — and then you realise you're not alone. Being an entrepreneur is tough on your own anyway, but in the NHS it's even tougher, because there are people saying, I'm getting on with the day job, what are you doing trying to do a startup, is there something wrong with you? When you join, you find a room of 100 or 200 people who are just like you. They don't look anything like you — no two are the same, different shapes and sizes and backgrounds and specialties — but they share core values around wanting to change healthcare, and this insatiable drive to do something different.

You don't have to have an incredible startup, some multi-million-pound-funded Silicon Valley type thing. You can just have a great idea. You can just be a clinician who says, I want to take the commercial skills, knowledge and experience you can gain from the commercial world to become a greater leader in healthcare. So we now take as many intrapreneurs on the programme as we do entrepreneurs, because it doesn't have to be a commercial entity — it could be a leader in the NHS. Some people think when they apply that you have to have a fully formed idea or created your startup already. That's not the case. We take some very early people — we've taken young medical students, I think still in their teens — and the most senior people we've had are in their late 50s and 60s. One was the director of Public Health England, who said, I want to come on the programme because I need some inspiration; I've got great ideas, but the day job is so tough going, I need a place where I can get that inspiration and insight.

When you come along to one of our pit stops — we call the educational days pit stops — you test and trial your ideas. You can speak to any of the entrepreneurs — I think you've spoken to some of them on your podcast — they'll tell you it's just meeting other people, it's so inspirational, that shared pathway and journey. We're in year four now, about to go out to advert for year five. It'll be on the NHS England website — if you Google "clinical entrepreneur" you'll see it. I'm expecting it's going to be completely digital this year; the portal will open late August, early September, be open for about four to six weeks, and you can fill in your applications. There'll be lots of video content — you can upload short video answers to some of the questions, as well as text, if you prefer. People should just be themselves — be open, honest, authentic and give it a shot. You've got nothing to lose. We've got, I think, about 500 people who've already approached us to express an interest.

There's no limit to the number of people we can appoint. We appoint really good people who we think can benefit from the amazing array — it's like a bite-sized boot camp. You get really distilled-down core knowledge on legal and regulatory, patenting advice, governance arrangements, sales and marketing, branding, selling into the NHS — anything needed to start a business, or a business unit within the NHS. And because it's the National Health Service, lots of incredible commercial mentors give their time freely, from a range of organisations, and we get exposed to some of the very best experts — some of our NHS leaders, some people from across government and other parts of the world.

It's an incredible journey for NHS staff, and it's free. We want people to be innovation-ready. It speaks for itself — we've roughly doubled numbers year on year. And the entrepreneurs from year one who started to build their businesses and are becoming successful now are coming back to become the leaders and mentors on the programme, to show other clinicians we can do this.

And not every idea worked. I am the king of failure. We do this thing on the programme — I'm not sure I should say it online, so I'll be careful what I say — we do this thing called the disaster-off. One year some of the clinical entrepreneurs came to me and said, it's so depressing, all we see is this great success all around, everyone tells us how successful they've been, how much money they've raised, and we've just had a string of disasters. And I said, those aren't disasters — that's learning. So some of our main commercial mentors go into a head-to-head pitching battle — we try to out-pitch each other for the worst disasters we've had in our careers. The rule is everyone turns their phones off; no tweeting, nothing leaves the room. We go from an incident involving a mafia shooting in New York as part of a commercial deal, to a really major issue in the public sector — one to stay in the room. 98 times out of 100 I fail. But I do hundreds and hundreds of tries, so you see the things that work out. That's the way it is.

It's one of the things I speak to our entrepreneurs about all the time: suspending self-judgment. You just said some very complimentary things, and there'd have been a point in my life where I'd have had to be very self-deprecating — oh no, no, it's very nice of you to say. Whether it's charisma or a particular style, I think that's in the eye of the beholder rather than the individual. But self-judgment is a really bad thing generally, in my view — people end up defeating themselves before they even walk out the door. There are enough people out there judging me, let me tell you; I don't need to judge myself. I'll take feedback and act on it, of course.

I try to make it engaging, but there's no plan of action behind it. There are some core values, driven by honesty, openness and authenticity. It was in Thomas Lewis's book, and some of his work, where he spoke about engaging with an audience — there are a number of psychological tools that help you engage with people when you're speaking. One is authenticity: really be who you are. One is humility: be humble. And the other is humour. If you use those three things... I don't have to do the science behind why — you told me you're a psychologist, so I'll take your word on it. But you tell people who you are — I'm a frontline clinician, a consultant in the NHS, I do the following jobs — and that's authentic; he is who he says he is. And you try to do it in a humble way.

When I describe myself — I don't know when I first did this, but it stuck — because I'm a urologist from Southend, I call myself a plumber from Essex. I think that's funny because it's a waterworks joke, isn't it: plumbers repair your pipes, and I repair your pipes. And Essex is known for really great high-quality tradespeople. In a format where someone's been talking about the latest AI algorithms and everyone's struggling to stay with them, it's actually quite easy to come on and just be honest and open, and people think that's authentic and humble. But the other thing I've learned is: don't ever deliberately tell a joke. Stand-up comedy is an amazing skill for people who get it right, but I have yet to meet a practising frontline clinician who can pull that off. If people find something amusing in what you're saying, great.

I recall I had to give a lecture — I think it was one of the annual awards days, the vice-chancellor's, somewhere, maybe Cambridge — and the lecture, 400 people, was packed. I had to talk about innovation across a whole range of things, and also in surgery. I was very proud that I'd learned to do HoLEP — laser prostate operations, which are quite difficult. I thought a way of settling myself down in this auditorium, in front of all these great academics — of which I didn't feel I was one, I was self-judging at that time — would be to show a bit of my surgery, because that would make me feel at home. I was in the operating theatre; to all the academics, they were squeamish, looking on in horror as this patient's prostate was enucleated with me lasering the bleeding with great excitement.

I explained that one reason I showed it was about innovation. And I said, the second thing is, to be honest, I've been a bit anxious about coming to give this talk, because I don't give talks to such academic, prestigious audiences — so what I thought I'd do is show a bit of my surgery, because that would make me feel more at home and settle me down. And of course they all roared with laughter, because it had made them feel anxious and uncomfortable, but for me I was at home, it was fine. We got on famously after that, and they were a really kind audience.

So be yourself, learn from others, and don't try to force it. I never told a joke. I recall one of the most eminent professors in this area went to speak at a big meeting in America — 5,000 of these surgical specialists crammed into a room, hearing this keynote from one of the world's leaders. He decided to tell a joke: the greatest changes that had happened in the specialty in the last decade — and he put up a blank slide, the joke being there were no great advances. He thought it was amusing. Have you ever heard tumbleweed? He waited for the laughter to come, and I wanted to jump in the hole he was opening up. I thought, I'm never going to do that.

Stand-up comedy — great respect. I had the privilege of sharing the stage at the Cheltenham Festival with Adam Kay, a doctor who does do stand-up, a doctor, comedian and writer — they just have an experience in a way. So humour is really important, and authenticity and humility, in giving a great talk. We've got fight-or-flight mode as human beings, our sympathetic response, and we've got a mode that makes us relax — our parasympathetic nervous system, so we feel safe. You don't want to put people in fight-or-flight mode; if you do, you're onto a loser. So humility, authenticity — and if it's possible to say something people might interpret as mildly amusing, then it helps: this isn't going to be such a dull way to spend half an hour, is it?