Meritocracy

Well, it's quite a long story now that I've reached this advanced age. I grew up in the North East, in a little village called West Auckland in the west of Durham, which is a relatively poor area. For the first eight years of my life I lived in a four-roomed house with my two sisters and my parents, with an outside toilet and a single tap in the kitchen. My father then made money as a businessman and we bought the big house at the end of the street with a garden, which was a very exciting experience.

I went to grammar school in Barnard Castle — now very famous — and from there to medical school in Newcastle. I was going to be a chemical engineer, but at our small grammar school you had to choose between biology and maths, and I didn't realise I couldn't be an engineer if I hadn't done maths. So medicine was suggested quite late. To be honest, I didn't realise I could do medicine — I'd never thought about it, because I wasn't from a medical family, and back in the sixties and seventies it was a generational thing in many cases.

I came to Newcastle and qualified in '76. But along the way I'd become very interested in genetics. As a biology student I was taken with my classmates to hear a lecture on the genetic code at Lumley Castle, given by an Oxford academic. What captured me was, first of all, the wonderful simplicity of the fact that you could write the instruction book for a human being with an alphabet of only four letters. But also that my biology teacher, Mr Mason, didn't quite understand it, and asked me to explain it to him again on the way back to school. So that stuck with me.

And when I did surprisingly well in my first couple of years in medicine — partly, to be honest, because I felt slightly intimidated by all these people who seemed to know where everything was — I ended up being offered a year out to do a degree. I decided to do genetics, because it seemed like an interesting thing that no one else seemed to be interested in. There was nothing about it in our medical course: we learned a lot about the trapezius and the brachial plexus, which I memorised in three dimensions to the chagrin of my friends, but nothing about DNA. And of course, in the land of the blind, the one-eyed man is king. So when I returned to medicine a year later, I knew things that none of the consultants even vaguely understood. I ended up giving impromptu seminars on ward rounds.

Being a showman at heart, I announced in 1974 that I would be the North East's first consultant in clinical genetics — which was met with dismay by one or two senior colleagues who saw me as maybe being a proper doctor. They quietly forgot that when I came back to Newcastle years later. In those days there was no training programme in genetics; it wasn't even recognised as a specialty in 1976. Indeed, it was only when I was president of the European society that we got it recognised in Europe as a specialty. So I did general medicine and paediatrics, then went to Great Ormond Street for four years to learn my trade, and came back to Newcastle in 1984 as the first consultant in clinical genetics. I've been here ever since, and still have that job. I actually stopped being a consultant three years ago when I became chairman of the hospital, but I'm still recognised as a specialist. I got my chair in 1990 and helped build the Centre for Life, which became our Institute of Human Genetics in the early 2000s.

So that's my history. It's quite boring, really — I grew up and stayed in the North East, apart from a brief visit to London to prove I could.

Most of our leadership roles get thrust upon us, and we make it up as we go along. What I had to realise quite early on was that this is a team game. There's a constant desire to give credit to the individual — all the way up to the pinnacle of Nobel Prizes — but of course none of them actually do it on their own. Almost nothing in our world is achievable except as part of a team. So I had to learn how to work with a team, and I'm still learning; it's a never-ending process.

One of the things I learned that was most effective — I often say to people that in a forest, every tree has to be able to see the sky. If you want to be surrounded by really talented people, preferably people who are better than you — and that's always been my aspiration — then you've got to give them credit, you've got to give them space, you've got to support them. And they will in turn support you. That's why I continue to enjoy supervising PhD students and leading a research group: because I work alongside people. They don't work for me.

I've been asked that before, and again it isn't something I necessarily thought about — it just happened. I did once think that maybe the reason it happened was because I was the smallest member of my family. I had two older sisters, five and ten years older than me, in a family where they'd been waiting for a boy. All of my cousins were also much older than me. So everyone kind of loved me but ignored me in equal measure — at family gatherings they'd pat me on the head and then walk away. So I started telling them stories to catch their attention, like how far it was to the moon. I got one of these wonder books of knowledge and started divulging all this information, and if I could capture the attention of the group, that was appealing.

I think that's why I enjoy lecturing. It's probably built into me — not as a DNA thing, but as a long-standing cultural tradition. I had that desire for attention, but also that fundamental self-confidence that I was the chosen child. And from that came the idea of telling stories. When you're giving a lecture, you have to tell a story, you have to engage people. Doing medicine, and genetics especially, working with all these amazing people who've had to cope with different genetic diseases, gives you the vehicle for communicating a concept based on their story. A lot of the things that captured your imagination were me telling you about these wonderful rare diseases and disorders, where people had allowed me to tell their story as a means of explaining what had gone wrong with the biology.

But you also have to want to be a performer. Some people aren't — and if you're not a performer, don't do it. I guess you probably are. So the trick is: tell a story, and you'll keep people's attention.

QuantuMDx is something I'm deeply involved in. I spent ten years as its chairman; I've just stepped back to be vice chairman. The story there was that I helped win funding for a thing called a Genetic Knowledge Park, built on the Centre for Life in the early 2000s. One of the expectations of our development corporation in the North East, One NorthEast, was that we would support companies to develop. I'd already been active in that space, and I was asked to give advice to a young lady in London who was trying to set up a diagnostic service in the private sector. Having looked at her business plan, I advised her that I didn't think it was going to work — and it didn't.

But she came back and said she'd got another idea. This was Elaine Warburton, and she introduced me to Jonathan O'Halloran, a young scientist who'd been part of her diagnostic team but had actually been inventing things. He had the idea that maybe we could develop a DNA testing device you could carry — a portable, point-of-care bedside testing device. I thought, that's a whizzo idea; no one's tried to do that before. So I started to advise them. They got a grant in South Africa, but for complicated reasons, due to their strange civil service, they lost the funding even though they were making good progress. So I adopted them — I was the head of the research institute by then — and gave them a lab in a corner. The company started to flower, and it was established in 2008. I agreed to be the chairman and was given a few shares, and it's gone on from there. We moved into a separate building in the city in 2012.

After a few false starts — because discovery is an unpredictable process, you can't know for sure which way you should turn — we've now produced what was intended: a battery-operated PCR device, which has suddenly become very fashionable with COVID-19. But now we're in a different place, because there are all sorts of other devices hitting the market just as ours has arrived. So as we have this conversation, we're waiting for the government's assessment of our device compared to others. It's a multiplex PCR device, so it will do not just one virus but, for example, all fourteen variants of human papillomavirus that cause cervical cancer — which was our plan to roll out onto the street before COVID-19 struck.

What I've learned is that it's hard to start with a new invention and take it all the way through to production. I've learned a lot about things like CE marking, and about the investment community and its vagaries. To be honest, like most of these things, if I'd realised how hard it was going to be, I probably wouldn't have got into it in the first place. I wasn't expecting still to be here twelve years later explaining how we were almost there. But then Dyson took twelve years of battle before he suddenly broke through the clouds into the sunlight. It's a long process, and the investment community tend to have a short attention span.

The other thing is that the big organisations — the NHS, the Department of Health and Social Care — don't really understand how fragile small companies are. They're depending on the small amount of funding they've been given by investors, and they have to show progress, and sometimes the big organisations cripple them simply by not giving them enough speed of turnaround. That's something my dear friend Matt Ridley has drawn attention to in his book on how innovation works, which I'd recommend anyone planning to start a business should read. He shows the slightly random way in which discoveries are made, and how companies succeed or don't succeed even if they've got a good idea — and encourages greater support for that innovative structure, to allow people to take ideas to market. I don't think we're still good enough at that as a country, although we're better than most.

First of all, I didn't know much about the technicalities — but then, I didn't need to. Again, I was part of a team, and I was there, in a sense, as the older, credible clinical academic to give them street cred in the right places. So I didn't have to know everything. We're surrounded by some star performers, like Colin Toombs, who's in charge of the development work, and the executives who carry the thing forward. So the first thing, again, comes back to team building and understanding what skills you need in your team.

But in fact I was never not a businessman. Back in that village in West Auckland, in a little two-up two-down, my dad ran his own repair garage. He'd left school at fourteen, done his apprenticeship as a joiner, and then evolved into building ice cream vans, of all things — the Mr Whippy vans. We were modestly successful while I was nine, ten, eleven. Then they changed the tax on ice cream, his business suddenly lost turnover, and he had to stop and go to work for someone else. Then when I was sixteen, he had another bright idea, to my mother's dismay. He set up a business called Burnwright, recycling old pit heaps and old railway lines from the North East coalfield — closed railway lines that no one had noticed were actually full of coal and coking coal. So he made an enormous amount of money while I was in my late teens, reselling pit heaps back into the coal and back into the electricity board.

So I grew up at the knee of a businessman before I went into medicine. My dad was very happy I was going into medicine — a proper job, a career, a profession — although he was expecting I'd be a brain surgeon, and so was I, because as a working-class boy that seemed like the thing you had to be if you were going to make it to the top. I realised it wasn't quite like that once I got into medicine. Nothing negative about neurosurgery — it just clearly wasn't for me.

But I always had that eye to business, and I don't think there's any difference between that and being a clinical academic. In a sense, what you're doing is looking for gaps — looking for something other people haven't thought of. One of the attractions that took me to DNA was thinking in a businesslike way: I'm in this crowd of people who are all smart, most of them smarter than me — what do I do to stand out? I'll look for something they haven't spotted. And none of them seemed to respond to genetics. So it was a kind of businesslike thought that took me there. Similarly with writing research grants — I'm in the middle of writing another one now — it's about trying to see gaps in the system.

I was once asked to give a lecture in India on how to be an entrepreneur. I put up a picture of a picket fence and asked them to tell me what they were looking at. They said it was a fence. I asked what it was made of, and they said wood. And I said, no — it's made of gaps. You've got to see the gaps. Don't look at the wood, look at what's between. You could squeeze through that space. All of medicine and all of the business world — there are gaps everywhere, if you prepare yourself to see them. And when you see one that might work out, like QuantuMDx, you say: let's go for it.

We haven't got to the top of the hill yet. We've got a product, we've got a device, we've had a visit from the Prime Minister a month or so ago, which all looks good — but we could still end up crashing and burning if someone comes out with an even better idea to fill the gap. So far we think we've got something unique, and that's great. It's slightly scary, a little bit risky. Unlike living in the National Health Service and the university, if you run out of money, you're dead — you fall off the end. That brings a certain excitement, in stark contrast to the stability of being a thirty-plus-year professor and chairman of a hospital that's been here for two centuries. It's quite exciting to flip-flop between the two, though sometimes it gets in the way. Our hospital is leading the COVID-19 testing, so I have to keep stepping out of the room every time we talk about it, because I'm involved in a business that does COVID-19 testing. That creates a bit of a challenge for me and my colleagues, but it's worth it, because it means I can stay active on both sides of that fence.

I totally understand your perception, but I'm not sure they're that different. Once you get past that exciting opening bid — asking a rich person to give you some money to get going — you find you're then doing the same thing over and over again. In a business, you're applying for more funding, or trying to build an income that exceeds your outgoings. There's a long haul to create a successful entrepreneurial business.

Whereas in medicine, one of the great benefits you have as a doctor is that you can drop in and out of research. I feel enormously privileged to have been active in research all these years, but I never had to worry about paying the mortgage, because I had a job as a doctor. And the great thing about genetics is that it's been growing ever since I came into it. There's always been a growing edge, a developing concept you could pursue alongside the day job. We went through a golden era for clinicians in the 1980s and 90s, where our diagnostic ability — just looking at people — meant we could say, this person's probably got a mistake in that gene, except we haven't found that gene yet, but with this family's help we might. Being able to track down the Mendelian cause of a condition served your task as a doctor — looking after that family, giving them options like preventive strategies or prenatal testing — and at the same time you were making a significant contribution to basic biology.

So it's been a wonderful opportunity to sit on that cusp. I'd recommend all doctors of the same sort of biology as me to keep one foot in research, to continue to write and think about academic pursuit. But it's about personality. I work alongside colleagues who really don't want to do research, but take enormous pride in doing what they do well and never making a mistake. One of my former students, Sarah Mills, a consultant surgeon in Northumbria, has just retired, but we're still working together. She has a database of every patient who's had a colorectal cancer in Northumbria for decades, and last night she just answered a question for me, showing how many of them had had microsatellite instability testing, at the push of a button. I'd never have the patience to build that database. She's not a researcher at heart — she's a service-delivery person, someone who likes to finish things. Whereas I'm one of those people who biologically like starting new stuff, always looking for something a bit different. If you can harness in the same team the people who get stuff done and those who think of ways to do it differently, then you're successful. But it's very hard to be all of those people at once — which is why teamwork is so critically important.

As far as the nature–nurture debate is concerned, my simple explanation is: look at a bicycle. Which is the most important wheel? You need them both, and you can't really understand the problem unless you look at both.

There's no doubt I was lucky in terms of my genetic makeup and also my early upbringing. My mother didn't smoke, didn't drink; she was the daughter of a butcher, so she was well-fed. I started life a big bouncing baby that was breastfed and much loved. That, as much as my genetic makeup, gave me the best of starts. I was good at stuff — I could add things up in my head faster than the grocer's machine, which was one of my tricks as a kid; I'd tell him how much it was going to be before he pressed total. So I had some innate abilities, undoubtedly. But it was also that I had the good fortune to get sent to a grammar school, an academic environment where they encouraged us to go on and do O-levels and A-levels. That was a lucky break — without it, I wouldn't have made it.

I've just finished reading Hilary Mantel's trilogy on Thomas Cromwell and Henry VIII. I had this terrible sense of identity with Cromwell — growing up on the banks of the Thames in Putney, with an abusive father, in poverty, ending up becoming the second most powerful man in Britain before Henry decided to go a little crazy and execute him. You could identify with that rise. I was lucky in the sense that in the sixties and seventies we had this blossoming of a meritocracy in the positive sense — people who could pass the degrees and become doctors and academics were allowed forward in society in a way that hadn't been the case before.

I was once giving a lecture at the Royal College of Obstetricians and Gynaecologists, and there were two of us speaking. Mark Ferguson was a professor in Manchester — a brilliant guy who did a lot on cleft palates, and used to catch alligators to watch their palates close — and he had this intense Northern Irish accent. Then I stood up with my slight Northern accent, and as I was about to speak I looked at the row of people with fancy suits and dickie-bow ties in the front row — all Oxford, Cambridge academics. And I said, maybe this is a good example: Mark's got a bit of an accent, I've got a bit of an accent, and we've been allowed to stand here as your chosen speakers. Maybe the class barriers have dissolved. Or maybe it's just that I got the flip-over advantage, where people start saying, he must be really clever if he got this far with an accent like that.

So I still think there's a barrier for kids who come from places like I came from — people prejudge them because of their accent. And in parenthesis, that's one of the advantages I've had: just the fact I speak with an accent, people seem to trust it more than if I spoke with perfect English. I've never tried to lose it, although if you go back to where I come from, they think I speak in a very posh voice, because decades of having to repeat myself forces you to drop most of your dialect words.

So, yes — having a good deal of cards in terms of your genes is clearly an advantage; having a good early life is critically important; but then having a few breaks, and a social structure that allows people through. And yet, another book I recently read — Michael Sandel's The Tyranny of Merit — points out that the term "meritocracy" was originally invented as a dystopian term. If you come from the days of Thomas Cromwell, you're either high or low, and you don't get a choice — Cromwell was one of the very few who crossed from poverty into the highest echelons of aristocracy; you could count on one finger the people in Tudor England who did that. We've now moved to an era where you think, well, if you get really good exam results, they'll let you through all the way to the top.

Of course, that means the people who didn't make it — because they didn't get quite as good a deal of cards, in terms of being able to add up and subtract — before, they could blame their station in life on the aristocracy not letting them through. Now you've got no excuse: you could have got there if you'd just been brighter or tried harder. So in a sense it has a more negative impact on people who aren't promoted. If you over-reward those who are the brightest and best, and you don't think of the common good — and this is what Sandel, a philosopher at Harvard, is saying — you need to just throttle back a little, especially in American society, where you give vast rewards to the achievers, and those who don't achieve are told: you had the best chance, you should have done better. You create an underclass of underachievers who feel they're of less worth, and that becomes very destabilising to society.

So I've become far more interested in the levelling-up agenda, in a genuinely non-political sense — to make sure we're all in this together. One of the advantages of getting older, and there aren't many, is that you realise your own skills are fading, and you need to encourage your younger colleagues to think well of those who aren't quite as fast afoot as they are. Ultimately it's in all our interests to have a society that supports everyone, rather than just rewards the few.

Oh yeah, absolutely. I always think back — I've got terrible eyesight and I'm a bit of a nerd, so a thousand years ago I probably wouldn't have done very well.

Yeah. We were blessed to be born in this time.

I'm not sure you can be a good leader if you're a total dick. You have to earn the respect of the people who make you their leader, and you won't earn that respect purely on ability. They'll defer to you if you're rich, famous, and have lots of degrees, but they won't really consider you their leader — they'll simply consider you the person standing at the front. This probably reached its zenith in the First World War: the lieutenants who used to lead the men over the top, the ones who were dicks were as likely to get shot in the back as in the front. So there was a kind of Darwinian process there for leadership.

One of the people I'm learning a lot about leadership from now is Dame Jackie Daniel, the chief executive of Newcastle Hospitals, whom I helped appoint. She's a fantastic leader — she really thinks about caring for everybody in the team, rewarding and acknowledging those who succeed, but also making sure no one gets left behind. You have to be worthy if you're going to be a leader. That doesn't mean you can't get the top job being a dick — and I'm not going to make any political comments on that — but you probably won't be regarded by history as a true leader.

I don't think I made many sacrifices, to be honest. I think it was a slightly charmed life. Compared to some of my colleagues in the frontline disciplines — I lost some good friends who died young, trying to live up to the expectations of modern medicine. When we started as medical students, we were pitched straight into clinical practice. I actually went as a volunteer in the emergency room in my first year, and got given a patient to treat. I'd been taught in the afternoon how to sew, and by midnight, when it was getting busy on Good Friday — fifty years ago this year, in fact — I was asked to go and stitch up the chin of an old man who'd fallen over coming out of the pub in Elswick. He was very tolerant of the fact that it took me a hell of a long time to stitch up his chin. But the night sister was less tolerant of the fact that I'd run out of gauze — because I was so slow, and I'd opened another suture pack to get the gauze out of it, instead of getting some more off the shelf. I mean, who knew? So she was very cross.

When I was finally a medical student in Bishop Auckland, I delivered twenty-three babies and was given the job of sewing up episiotomies. When I started as a first-year houseman — as we'd now call an F1 — they'd moved the start date, and the other two didn't turn up. I was the only one ready to start, in the middle of July instead of the first of August, so they said, well, you're on until the others arrive. I was actually on call for four days before another doctor came to relieve me. I didn't have the heart to tell them I'd forgotten to send in my medical defence union forms — so I spent the first four days of my career working without sleep and without insurance. I can say that now, because I think it's too late for them to do anything about it. But we used to work ridiculous hours — hundred-hour shifts, it was just crazy.

The people in frontline medicine — one or two I really looked up to died young, like Mike Parkin, the paediatrician. When I was a registrar in neonatology at the Princess Mary Hospital, across from the RVI, I was on every other night, every day, and every other weekend. Nigel, the guy I was working with, was in his first year and wasn't very good at putting drips into little babies, and I was his second on call, so I effectively worked a one-in-one rota for four months. Mike Parkin was one of my consultants. He got angina, but was too busy to get it treated, and dropped down dead in his fifties. So when I look at people like that — immensely talented, far more committed than me as clinicians, who gave their lives literally to serving the job — I don't feel like I've had a hard ride. I'm very happy with the way things turned out.