Deliveroo for Drugs

Sure. I have no real background in health. I don't come from a family of medics or pharmacists, and I never really had any interest in working in healthcare as a kid or a teenager. At university I signed up to study economics and philosophy — I just wasn't pulled towards health.

Ironically, or paradoxically, I've been taking medicine every day of my life for the last 38 years. Since I was a very young kid I had pretty bad asthma and pneumonia, and then in my teens I developed clinical depression, which morphed in my mid-20s into generalised anxiety and panic disorder. So I've been a regular user of healthcare systems — a daily user, a pretty typical user — and I never gave it much thought. It was just a cost of doing business. I've also had quite a lot of relative success in the system: the treatment I've had over the years has worked quite well. My mental health is really well managed by medicine, a mixture of that and talk therapy. So I was just kind of plowing on, relatively in a slumber about the opportunity and the challenges. I got on with stuff — or, as I'll tell you in a second, other people managed it for me.

I was working for a large corporate, making slides for a living — PowerPoint decks for meetings I'd never attend, without getting any feedback on my output. And I saw a job pop up on the jobs board Movemeon, which is targeted at consultants looking to escape classical corporate roles and go into something a bit more dynamic. The role was director of international expansion at a practice called Dr Thom.

Thom is an obstetrician who, in the early noughties, decided that healthcare could be done better online. He's very much the pioneer of what we now take for granted. He started with home chlamydia tests, which he ran from his house — famously, I think, aided by his child's nanny. From there he broke into sexual health and erectile dysfunction, which is now a mainstay of the online-doctor world. He really did pioneer and challenge a lot of the status quo. In fact, he launched, I believe, the first Skype-based consultation. He had the conversations with the regulators, with his peers — he was a big pioneer.

So there was an opportunity to join, and it sounded so fascinating. It also sounded really scary. I remember thinking, oh goodness, I'm not a doctor. Is this safe? Is this legit? Is this the right thing to do? Which is funny when you look back — in a time of Babylon and Push Doctor and Accurx all doing incredible things, we were really nervous back then about pushing the status quo.

So I joined Dr Thom. They'd been acquired by Lloyds Pharmacy, and my mission was to expand the service to other markets. The first place I went was the Republic of Ireland, where we completely pivoted the service away from erectile dysfunction towards female hormonal contraception. And it just took off — it was like boom. It was a really exciting time, because I was running my own little unit within a little unit within a very, very large business. It was like having training wheels: I got my salary at the end of the month, but got that exciting startup feeling. And I had a fantastic manager there, Rachel, who gave me lots of autonomy to get stuff done. Then I tried to do the same thing in Australia, and it was a massive disaster.

Australia, it turns out, is on the other side of the world, whereas Dublin is an hour away. It was really hard to do anything out there being based in London. So if you take anything away from this: you need to be on the ground. You need to be where your patients are if you're going to do digital health — you need to know what's going on, what people are reading about, what the temperature is. When a package of Viagra gets lost in the Northern Territory and you're in London and it's 3am, it's very hard to get any sleep.

It demystified a lot of health for me. Before Dr Thom, healthcare was a black box — doctors were weird magicians who studied for decades and were always right. Being a non-clinician in that world, pushing the boundaries, I got to see a little bit behind the curtain: how it's a lot of training, but also a lot of instinct, a lot of judgment calls, some right, some wrong. Suddenly doctors and clinicians became mortals in my mind rather than white-coated gods.

During this time we were having lots of success doing private medicine — Viagra, the pill, a bit of statins, relatively low-risk stuff. But I kept asking myself: why is it so easy for us to get this to patients, but me getting my antidepressant every month is like running a gauntlet? What can go wrong does go wrong. The systems are not quite broken, but they don't talk to each other. It's all paper, all admin — calling up receptions, trying to get prescriptions, "no, you need to see the doctor," "I can't see the doctor," "okay, we'll write you a prescription," going into the pharmacy and them not having enough medicine, getting an owing slip, going back to the pharmacy — and just repeating this every single month.

So I met a guy who was in a very similar position, and we decided to quit our jobs and build something different — not with an emphasis on healthcare, but with an emphasis on convenience for people like us, as opposed to saving the world and transforming digital health. It was really straight from the Deliveroo/Uber playbook: how do I make my life easy? This is a pain in the backside. In 2015 — I remember I was on the Eurostar coming back from my parents — I thought, yeah, the time is now. Handed in my notice the next day and took the leap. It's hard to know whether that was the right choice; you never know the true cost of things. But today Echo, the pharmacy we created, is the second largest pharmacy in England and the fastest growing. So it's been an adventure.

Through this adventure we've moved on from that pure proposition of convenience to understanding the role we play within a healthcare context. I've gone very deep into medicines adherence and compliance — it's sort of become my mastermind topic of choice. Particularly during COVID, we've seen how vital what we're doing is. We're not selling pizzas here. We're not an e-commerce company. We are an NHS pharmacy helping 250,000 people stay healthy and out of hospital. That's very different from when we started, which was "how do I make my life easy?" But the two are entwined, because one begets the other: make it easy for people to get their meds, and hey presto, they're more likely to take them; more likely to take them, it reduces the burden on the NHS, and so forth. But we always approach things, still to this day, from that question — what does the patient want? Not what the doctor wants, not necessarily what the pharmacist wants. What does the patient want, as a customer who can choose to go anywhere and do anything at any time?

For me it boils down to two things: get medicine and take medicine. "Get medicine" is the act of going and obtaining that packet of pills every month, every two months. And you'd be really surprised how many people just cannot be arsed.

You might be familiar with the team at the Hurley Clinic — a large GP practice in London. Ross and Murray there tell a really interesting story. They have a practice near me in South London with huge hedges in front of it. One day they decided it was time to cut the hedges back — for a practice that's a bit of an investment, beyond the day-to-day expenditure. So the gardener came in, and what did they find in the hedge? Tens — in my mind it's hundreds, but I'm sure it was only tens — of discarded prescriptions. FP10s. Someone had gone to the GP, said "yes, doctor," been handed a piece of paper, walked out, thought "nah," and thrown it into the hedge. Bear in mind there's a pharmacy directly across the way from that hedge.

So getting medicines into people's hands is really important, and there are lots of reasons people don't do it. There's inertia — can't be bothered. There's lack of understanding: why am I taking this thing? What's the difference between this pill and the next? There's a scare story in the Daily Mail — suddenly I should take statins, I shouldn't take statins. There's a complete lack of patient information. And there's also this existential dread every time you take a medicine: it's a reminder of your own mortality, that you have a fixed number of days on earth, that yes, I should be watching my diet and exercising and laying off the booze. No one wants to take medicine. It's just not a fun thing. So people find any excuse not to get the medicines.

Step one in adherence is get medicine — put it in their hands, remove all the admin so that physically obtaining the medicine is the path of least resistance. That's what we do at Echo: you click a button, we send the order in. It's always patient-led, but we reduce the barriers.

The second thing is trickier: take medicine. Once they have it, how do you get them to actually be compliant? This involves psychology, patient understanding, any number of things. Perceived side effects crop up a lot — you take a medicine, you believe it's causing XYZ, and you stop. Not understanding the risk-reward. A good example is the antidepressant I take. A couple of days ago I forgot to take it — I know the irony of that statement, but Echo is not a silver bullet yet — and I was climbing the walls because of the withdrawal effects. That's a real trade-off I have to make, but I understand it: taking this medicine means I can sit here with you and not cower under my bed afraid of the world. So it's one I'm willing to take.

There's lots of information asymmetry between what a doctor knows and what a patient knows. If we can use the smartphone to bridge that gap and drive understanding, we can help people decide, "yeah, I'm going to take this." And if they decide not to, that's up to them too — voluntary non-compliance is brilliant, as long as you're armed with the facts. But it's just not that common.

Then there's behavioural psychology — nudge. When you sign up for Echo, we remind you when to reorder, but we also tell you when to take your medicine every day. I get an automatic reminder every morning. It just creates habit. I can turn it off, but something like 97% of Echo patients leave it turned on, because it's just a notification for your health. So "take medicine" is the next part of what we're doing, but it has to be built on "get medicine." There are loads of brilliant apps out there that patients can download to manage their medicine from a compliance perspective. But unless they link into the pharmacy and the GP, you may as well use Siri or Google Reminders — they're pretty good too. We go on the basis that people are generally pretty disengaged about their health, because it's just depressing. It's not fun taking medicine. So how do we remove all the barriers around that, make it a bit more interesting, and expose some of the workings of the decisions that have been taken?

Yeah, we're trying. Echo is 1% complete — every day we learn more. Particularly as our patient base grows: what started as an app for 33-year-olds — the age of me and my co-founder — now has an average age of about 55. The use cases are really different. There are significantly more women than men, so you get different sets of medicines. We have a lot more carers on the app now, people using it to manage someone else, and a lot more complex patients. I'm always fascinated by our cystic fibrosis population, because their needs are really complex and they're on so many different medicines.

We take inspiration from one app in particular that I love, and it's for the most boring thing — Trainline. They've taken the most pedestrian thing — for me it's usually going up to Leeds to see someone at NHS Digital — and made it fun. It's a fun platform to use. We're trying to do something similar in medicine, without dressing it up as anything it's not. Let's not pretend with cartoons that "hey, it's fun, it's time to take your metformin." But at the same time, make it so easy that it's easier to take your medicine and be compliant than to break the cycle. That's what we're aiming for.

Yeah, absolutely. A perfect example is using an app — something you and I take for granted, but it's quite fiddly if you have arthritis or any motor-skills issues with your hands. Even on a relatively big smartphone the text is quite small, so accessibility becomes a big issue. We see a greater proportion of our older patients using the web interface. And with a web interface, reminders don't work the same way — even with notifications on Chrome, you have to be logged in and live to get them — so you have to think about reminders differently. We see a lot of our oldest cohorts still using feature phones, so text messaging is huge in that population. Text messaging is also huge in younger populations when you need to get something done now.

Coming from that convenience background, we tried to make something very, very cool. And by trying to make something cool, you don't necessarily make it as accessible as it should be. So the challenge for our design and product team now is how to make something that's still cool, still awesome to use, but can be read by someone with serious accessibility needs. That's a design challenge, and a really exciting one for all technology companies as populations grow older. The small fiddly text and tiny buttons have got to change if we want people to use our products.

Let's break down how a pharmacy makes money. A pharmacy gets paid to exist — something called the establishment fee. Then it gets paid an activity fee for every medicine item, loosely a packet of pills, that goes out the door. And it makes a buying margin: you buy medicine from a wholesaler and get reimbursed by the NHS through something called the drug tariff. We wear the postage costs, which is the big difference between us and a high-street pharmacy, and that has a serious impact on our bottom line. Where we make up the difference is scale — volume. It's having a large warehouse with a bunch of automation and processes that let us do things more efficiently than a community pharmacy, where you're manning the till and someone's in the back going to and fro.

So the summary is volume. You cannot do this at small scale — you need tens of thousands of patients if you're going to do NHS scripts. The other thing is that the margin available has remained flat for years, so there's an awful lot of pressure in pharmacy at large. While the margin stays flat, demand keeps going up — we're getting older, and even parking COVID for a minute, it's just going up and up. So you need these efficiencies at scale, which is why you'll hear the term "hub and spoke" used a lot in pharmacy. It's an interesting time. It's hard. But we make our money just like any other pharmacy — we just have to do it at massive scale.

I think there are probably three buckets that interest me the most. One is alternative treatments — be it cannabis or magic mushrooms, DMT — understanding what we can do to harness those for more effective treatments. There's lots of interesting research that you and your listeners will be more familiar with than me, but there's a very real need to look at these alternatives now. Piling people with benzos and opioids is not a good look. There's will in the system to try new stuff, but it's not going fast enough. We now have a situation where, yes, it's legal for a doctor to prescribe cannabis, for instance, but there's no infrastructure around it — people don't know what they can do, or whether it's legal. We need NHS and Department of Health help to make this more widely known and culturally accepted. That said, every Tom, Dick and Harry is running into this very fast, so I'd urge caution: it's a land of cowboys and fast money, and we have to remember we're here to deliver clinical services.

The second is secondary care. There's nothing that exists for secondary care the way it does for primary care. Think about the delineation between the medicine a patient is given by their consultant and the medicine they're given by their GP — they don't make that distinction. They don't know what secondary, primary and tertiary care is; they just see a doctor who gives them a prescription. So if we want to be smart about how we use hospitals and manage outpatients in particular, we have to find a better way to manage their medicines — to air-traffic-control what the GP is doing, what the consultant is doing, what's happening between departments — to eradicate the paperwork and admin, and bring it into, for want of a better phrase, a single patient view. We have things like the summary care record, but that has no record of what secondary-care medicines you're on. So there's a big opportunity for someone to come in and do an Echo on secondary care. It's going to be hard, but the good news is there's a lot more margin and money there, because it doesn't have the same flat margins. It's super fragmented, though — every hospital, every department seemingly has its own way of dealing with medicines management.

The third is really embracing our ageing population, and what that's going to mean — not just for healthcare, for anything. We still don't have a strong cohort of brands that truly represent what these patients want. Here's an example: I'm 38 right now. Google is 20 years old, so if Google turned up today I'd be a heavy user, an early adopter. Twenty years down the line, I'm 60 — am I going to stop using Google? No. Am I going to stop using technology? No. So we have a generation of 60-year-olds for whom Google is theirs — it's from their generation — and a lot of the internet we take for granted is theirs; they're native to it. And yet the brands and services that talk to them can be patronising. They're not optimised for their changing needs — for arthritis, say — and they tend to be quite alienating. So there's a big opportunity for teams to go hard into this market, regardless of sector.

The challenge is that entrepreneurs tend to be younger, startup people tend to be younger, product teams younger still — I'd guess the average age at Echo is 30, whereas our patients are 55. When you have 30-year-olds trying to build stuff for 55-year-olds, you have a gap that needs to be filled with research. And frankly, you're a good example — I'm going to guess you're in your mid-to-early 20s, and you're just not thinking about these things. That's why we have so many dating apps for people trying to meet partners, and so few decent ways to, I don't know, manage diabetes.

The second thing is we just don't have enough doctors or nurses to continue with the status quo. We can't keep pulling people in for face-to-face consultations — we don't have the staff, we don't have the money. So technology has to solve this problem for us. I'd just get freshly minted MBAs and engineers to go and spend a week in a care home and see what they find out, because I can guarantee that's not going to be wasted time. Whereas you think about some of the brands out there, like Saga — Saga magazine, this typical thing when you hit 50 you get sent Saga magazine, cruises and pensions. That's in 12 years' time for me, and I don't want a fucking Saga magazine when I'm 50. Stop it. I want something that's going to inspire me and keep me young, but that will also adapt to what will no doubt be my changing needs. So finding that match is a huge opportunity.

Yes, there's definitely one. Taking a step back, research is absolutely fundamental — to understand your customer, your patient, what you're doing. But sometimes you just need to take a leap. Everyone, when I told them I was going to start Echo, resoundingly told me it was a bad idea. It was a mix of "this is pretty high risk" and "you're solving a problem that's already been solved" — because when we started Echo there were already online pharmacies. On paper they do exactly what we do today, in the same way that before Uber there were minicab apps that did exactly what Uber does, and before minicab apps you could call a minicab company and they'd send someone round. So I got a strong sense from friends, colleagues and really knowledgeable people that we were solving a non-problem.

It's particularly difficult when someone you really respect and trust, who you think is super smart, tells you this. You have to just say, "okay, but I'm going to do it anyway. Thank you for your feedback — thank you, all hundred of you, for your feedback — I'm going to do it anyway." Believing what I thought was true, and what my co-founder thought was true, in our stomachs: this problem isn't fixed, because we use it and it sucks, so we need to build something better. So there's a time when you need to be bloody-minded and say, "we're going to do this," and that comes from having an intimate understanding of what you're trying to solve.

I approach this as a patient who's taken medicine for 38 years. One thing I see a lot in digital health is doctors and entrepreneurs trying to solve problems for other people — it could be a male obstetrician trying to solve a problem for a female patient. There's no reason that can't be done, but you have to have a really strong sense of what you're trying to solve. So whenever I meet a clinician trying to solve something from their own day-to-day — task management, paperwork, admin — I gravitate towards that far quicker than someone trying to solve a problem for someone else, because deep down they'll have a strong sense that this is a problem worth solving. They'll know what the problem is, rather than something that might not be the most pressing issue. So: know yourself, know your problem, get the research — but when you need to, push forward anyway.

The only book I'll recommend is A Confederacy of Dunces by John Kennedy Toole. It was his only book, and it keeps me sane when I read it and have to deal with some of the paradoxes of our healthcare system. I'll let your listeners find out more about it — it's not related to business or anything else, it's just a fantastic book that helps me laugh. Catch-22 would be another one — a lot of what we deal with day to day in an NHS context feels Catch-22, and it just helps you laugh, and helps you get mentally tough, get tenacious and keep going.

In terms of business books, none of them are really screaming at me. Lost and Founder is really good — it was actually given to me in the post one day, out of the blue, by Hamish from Thriva. It's by Rand Fishkin, the guy who founded Moz, which is a search engine. If you want a real insight into just how hard it is to get a startup off the ground — he's super honest, super direct, and frankly, if you still want to start a company after reading it, then you're nuts.

There's one other I really recommend, and it's on strategy — a Harvard Business Review compendium. "Strategy" is a word that gets bandied around a lot and becomes quite meaningless. Understanding what strategy is and isn't is really important — that it involves trade-offs, and understanding what you're not going to do as much as what you are. When we started Echo, our ambition was to do everything — we were going to do AI, the absolute lot. A turning point was when we decided to stop doing everything and get laser-focused on becoming the best pharmacy we possibly could. We weren't making enough trade-offs at the start; we were trying to keep everything alive just in case. Doing it all again, I'd laser-focus on doing one thing and owning it end to end. Most business books are absolute bullshit — an idea that probably merits 300 words expanded into 100,000. So beware.

Honestly. But you don't get a publishing deal for a blog post. There's one really interesting thing: Paul Graham, one of the guys from Y Combinator, has a blog, and there's a post he wrote that has always inspired me called Do Things That Don't Scale. Don't worry about how you're going to operationalise things — just do it. That's always been a go-to for me when I'm thinking about what we should be doing at Echo, because once you figure out product-market fit, you can theoretically back-solve a lot of the unscalability. So I'd really check it out — throw it into Google, it's a fascinating read. What I would have loved to read, though, is part two: right, now you've done that — what happens next? That's the bit I've struggled with. But thankfully I have an amazing CEO and COO who deal with that stuff. I'm like the kid who takes the toys out of the toy box, and at some point you need to tidy it up — thankfully I've got a team of adults who do that for Echo.

Oh wow, thanks. Though — Eric Topol beat that.