Democratising Blood Testing

Yes, and there are lots of examples of that. Our driving force as a business is improving people's healthspan. I think we're sadly having a lot of the wrong conversations about simply adding more years to life, and we don't spend enough time talking about how many years of our lives we spend in good health. So we focus very, very hard on that — it's integral to our vision and mission. And part of that is thinking about what isn't appropriate to do with people.

I think about the future of democratised healthcare in three buckets. There's responsibility — which I'll come back to, because it addresses your question directly — then bringing more data out more easily, and then better insights and more effective solutions.

To that first point, on responsibility: we haven't launched a test for prostate cancer. You can go and find it in the D2C market, but we've chosen not to do it. When we sat down with our clinical team and put it through the analysis matrix we use for any test we might provide, it unfortunately failed. First of all, the test itself isn't considered particularly sensitive — we look at sensitivity and specificity, so there was a question mark around the test itself. Then, and ultimately more importantly for us, the downstream consequences of finding an elevated result are very complex. You may have an elevated indication, but the reality is that might be driven by any one of a number of factors. And then you play forward the elevated PSA result — maybe they go and do a biopsy — well, the challenge is, so far as the data reveals, the biopsy may do more damage than the thing that was causing the problem in the first place. That was a no-go zone for us at the time. There are better prostate tests being developed, and we'd certainly like to offer that to our customers when the time's right, because clearly, if you can pick up a prostate issue early, that's a very, very good thing to be able to do.

So under that responsibility bucket, the broad canopy for me is: just because you can do something, just because you can create a technology or a solution — you do have to ask very, very carefully, what is the appropriate way to deliver it? And unfortunately, I don't think we ask that question enough as creators of technology.

Take the appropriate cadence for engaging with something like Thriva. There are lots of businesses coming out around CGM — continuous glucose monitoring — and I think it's fascinating; I love the way it has the power to indicate how you respond to different food groups. But you also need to be really careful. When we ran some internal trials with people to look at CGM, about four or five of them reported that they started getting really severe food anxiety while doing it. So responsibility is really key. You do need to think about whether you should do something simply because you can.

Treating people like adults, and having a very clear bedrock in the business about empowering the individual, means that tension does exist. But the reality is you also have to be mindful of the industry you're creating. We are creating a market here in the UK, because people don't do this stuff regularly at the moment — certainly not, in the main, as a proactive tenet of how they manage their health.

On the one hand, you have a very important stakeholder group in NHS primary care physicians, who quite rightly sit there saying, "Look, you can't just be throwing us the complexity and the false positives because your service isn't good enough. The NHS is struggling enough as it is." I've got a lot of sympathy for that. So it's good that the tension exists, because you always want to be willing to stand up and say to someone, "This is exactly what it can't do, but it can tell you these things." There's lots you can do under that banner — but you do have to be really careful not to take it too far. I think it's irresponsible to push it too far.

It's a good question. Ironically, it would probably be something out of our control. We're not vertically integrated — we plug into a network of five laboratory partners, but they're not our laboratories; they're the same labs that would run NHS testing, and they're accredited up to the hilt. But if something were to go wrong with a laboratory and they suddenly had to say, "For the last two years, this result data has been… really sorry, but we've had to row back from the results we provided" — I think that would cause a real problem.

I don't think it would be fatal, though, because everyone would probably have been experiencing something similar. The machinery and the reagents are highly commoditised, so it's unlikely you'd only see it in one small corner of the landscape — it would probably be a broader issue.

It would be having to say to people, "I'm sorry — we presented you with some information, and that information wasn't correct." That, I think, would be damaging.

First of all, I observe exactly the same thing, and I do it to myself as well. I'm trying to get really up the curve on some of the cold-water-exposure science, but the reality is I've been getting in a cold shower for years — I do it because I think I can piece together some of the clinical evidence, but it's a brute-force approach, not a scientific one.

I think there are two separate things there, though. There's the group of people who should just be left alone to take on the activities they think are right, and to experience them and either benefit or not. That doesn't need to be guided by a huge amount of tracking data — they'll feel it, because that's ultimately how many people choose to evaluate what's working and what isn't. That said, that group is probably okay because they're already immersed in it — or, to frame it better, they're okay because they're actually doing something already, and what they're experiencing is a quite high level of health confidence.

Where technology has a really important role to play is in helping people who have lower health confidence to increase it. And it could be that, in so doing, they come up and out of needing the technology and become self-sustaining without it. If that happens, amazing — that would be an amazing outcome.

To give you a practical example: someone shared a story with me that really resonated. It was an 18-month period where, like a lot of us in lockdown, they weren't eating quite as well as they'd have liked, were probably drinking a bit more alcohol, letting the exercise slip. We were wrestling with a global pandemic, right? So it's kind of okay that people let things slide a bit. Then they had Christmas — the season of excess — on top of an 18-month period of not being quite where they wanted to be. They just couldn't face the mountain to climb to get back into the groove.

But they took a Thriva blood test — they'd been tracking their biodata, using us for a little while, though they hadn't done one for six months or so. And what came back was that things were slightly worse, but not catastrophic. The consequence was that it boosted their health confidence, and they were down the gym straight away, because they realised that internally, "I'm okay. I'm not as screwed as I thought I was." That boost was enough to get them back in the groove. So that health-confidence lens is an important one to think about effectiveness through.

I'll give you the answer in two parts. Part one is simply acknowledging that we, as a society, have to be exposed to this stuff — through a number of different channels, providers, solutions and services. In the near term, we've effectively got two B2B2C products. We have a really easy-to-use portal where specialists and clinicians can organise remote diagnostics and get the results back — super easy, available literally from one day to the next, and it's how lots of our NHS partners work with us. But we're also making the remote-diagnostics capability available through an API call. So we're building Stripe for diagnostics for third-party partners. By doing that, you enable biodata insights to be available through third-party partners, and I think that's fundamental to how this industry grows up and ultimately does much more impactful things for us as individuals.

To the absolutely out-there, weird and wonderful ideas: I can share our 10-year, slightly crazy worldview of how this unfolds. Ultimately, there'll come a time — in the next five years, let's say — where Thriva will be able to say to you: "Good morning, Musty. We've noticed that you slept 25% less well last night than you have on average over the preceding 10 nights, and we think that might be associated with a change in your exercise regime. Did you realise poor sleep is correlated with lower vitamin D synthesis in the body? Don't forget to take your supplement this morning — 4,000 IU, which we recommended over the 1,000 IU baseline. If you continue to supplement, you should be back within the optimal range for someone like you within the next two months. Would you like to book a test to check whether that's the case in two months' time?"

That level of personalisation and effectiveness is there to be built. It would obviously be critical not to overstep the mark, become annoying and try to do too much. But if you think about where most healthcare is today, that's a huge step on — and for me a very exciting one.

Do you know, I think what happens first — though they could happen together, it depends how quickly they allow drones to fly the glasses — is point-of-care technology. Something sitting on your countertop at work that does some forms of analysis. We're not precious about how the analysis gets done. If we could magic it out of your body, spin it on a wizard's staff, and that was the cheapest, most convenient thing to do, we'd do that. But the reality is that today you have to take it out of your body using something like a pinprick and analyse it on a very large machine. As that technology miniaturises and becomes affordable, I think you might well find we have Nespresso-style capabilities for diagnostics. It seems like an odd comparison, but I think that's probably nearer-term than people realise, because it was propelled by COVID — there are businesses developing those technologies that now have big R&D budgets available to them, which is exciting.

Have you got another hour, Musty? There's been a ton. The big one is the difference between outside-in and inside-out realities. When we set out, we were probably under the impression that the underlying infrastructure we were going to sit on top of would be quite technology-first. We were a tech startup immersed in the tech world, and our assumption was that everyone's like us — which is probably a very stupid assumption to make. What we realised is that our partners were brilliant at the thing they were doing, but almost to the organisation, incapable of the sorts of technology developments we were looking to do with them. So we found ourselves having to integrate with a very capable but quite arcane group of infrastructure providers, figure out how to glue all of them together, and put processes, protocols and algorithms in place to ultimately provide a really slick, seamless and reliable service to our customers and now our partners. We hadn't seen that coming, and it slows you down — you've got to invest in more back-end engineers and do a lot of operational deep dives into how they work.

The other one — which might sound slightly random — is pricing, in terms of our cost of sales. When we started out, the big bet was that we could get our variable costs down, and we've done that by a big chunk. But the problem was we had no way of understanding how or why the labs priced the way they did. It was complete black-box pricing. The only real leverage we created was by building a network and playing them off against each other to some degree — and I'm sure they won't mind me saying that; I'm sure they appreciate we had to do that. We didn't want to squeeze all the value out for them, because then they wouldn't be motivated to work with us. But equally, we'd get some market intel suggesting this should just be a lot cheaper than it is, and then not be able to transact that with some suppliers, though we would with others. So black-box pricing has been a really interesting challenge to get around.

I do, yeah. I didn't share my thoughts on it at the time.

I'm fairly certain it's the latter, to be honest, Musty. And I say that because we have a small army of NHS-trained clinicians — our medical director and chief medical officer is a GP. Anyone who gets to talk to us from the medical community, and is open-minded to what the future may hold, comes to appreciate that we are not chasing the worried well and trying to sell them things they don't need. That's a really short-term, pretty indefensible business that ultimately blows up the trust of the medical community. That's just not what we're building.

If you look at what's propelling that heuristic in the medical community and their view of testing, you have to at some point look at the data and acknowledge that healthspan — the proportion of life we live well — has stalled and is in some cases declining in the UK. And the cost to serve, the healthcare cost per individual, whilst we should be very proud of what we have here relative to other markets, is still very, very high. The open question for everyone is how we improve on that. There's no silver bullet. But if you look at what's coming out of the political realm from some of the recent health secretaries, it's very clear that prevention — proactive, participative health — is going to be a fundamental cornerstone of how we turn the tide.

It goes back to the conversation we were having about what health actually is. Is health a state of wellness until such a time as you're sick, and therefore you enter the healthcare system, which finds out what's wrong and tries to fix you? Or is it something different? My belief is that it's something different, and we shouldn't be locked into that dynamic, because it's not actually what's best for individuals. There's a journey to go on as a country to get there, but I think it's incumbent on innovators like us to work with the establishment and say, "Look, we're all going for the same thing. We want more people getting more out of the years they're alive on earth. We think that's what you're going for as well. So let's work together." It's not combative — it can be highly complementary.

There's one habit I've tried to build — I didn't have it when I started, but I think I'm halfway decent at it now — and it's about reactivity. When you're coming up from being a very small business, the world is full of world-class distractions. As the CEO, I was probably prone to shiny-object chasing, as my co-founders used to call it, and it's actually very dangerous to get distracted. I'd like to think I'm now much better at absorbing really interesting information or opportunity and just sitting with it for 24 hours, figuring out what it means for us in a slightly more pragmatic and sensible way, rather than jumping straight back into the business going, "I've got this thing, we should go and do it right now." To take a beat and site it properly within your strategy is really important.

The only other one — we've been talking about it for an hour already — is doing what you need to build resilience. Startups are hard, and they're particularly hard in healthcare, where you do the sorts of things we're talking about and get a lot of no's. Being able to take it, come back, be willing to go again and keep pushing — investing in what it takes to maintain that resilience, and finding out what it is for you, because it'll be different for everyone, is really important.