Raising $139M, Biotech, Introversion and Happiness

Sure, thanks for having me. It always sounds very well planned in retrospect — like there was some grand red thread and I knew it was all going to happen. Ultimately it never is that way. Your career progression is usually you making the best decision you can with the information you have, trying to make it work, and if it doesn't, going off to do something else. That's the truth, though when I tell it it'll sound quite polished and professional.

I really started out when I graduated undergrad and went to work in Washington DC in healthcare policy. I went as a starry-eyed 20-year-old to change the world — that's where you go, right? You go to the halls of power to make big changes. What I quickly learned was that politicians and policymakers are more reactive than proactive. They respond to the market, they respond to constituents; they weren't really driving change, they were on the back foot. So I got disillusioned very quickly in DC. This is the late 90s, early 2000s — I'm dating myself — but I was right in the middle of the dot-com boom, and everybody was joining a startup. So I joined my first startup as the second employee, in something totally unrelated to health, and it fantastically blew up in 10 months, as they tend to do. I was young enough that it wasn't terminal, and I learned a ton.

Then I decided I wanted to get into the business side of healthcare, so I went back to business school at Columbia, in New York, and came out working for Merck — the big pharma company — who had a managed care division called Medco that ran pharmacy benefits. That was my first true healthcare job. Then I became a consultant in the healthcare industry, working with pharma on market access.

Then I moved to my hometown. I'd been in New York City that whole time, for five years; I got married, and my wife and I decided to move out of the city and think about having a child. So we moved to my hometown of Richmond, Virginia, and I joined a startup pharmaceutical company as one of the first five members of the management team. The business was focused on addiction medicine — a very underserved area of medicine. We built that over 10 years to 1,100 people in 37 countries, eventually carved it out of its parent company and listed it on the LSE in 2014.

So — as you can tell by my funny accent — I'm an American who's lived in the UK for 12 years. My wife and I are both American and sound like this; my kids are both basically British, with very posh accents, and play strange sports like cricket that I don't really understand. The way we ended up in the UK was that halfway through that journey the company sent me to London to start the European operation. And as you'll appreciate, working in a startup or scale-up is very different from working in a mature, publicly listed company that's in 37 countries with a thousand employees.

So at that point I decided to go back to my roots and work with startups again, really start to build things. In 2016 I left that business we'd built over ten and a half years and started working with startups as an advisor and consultant, working with private equity and venture capital, and investing a bit as an angel. I have a portfolio of 13 companies I've invested in, and I sit on the board of four of them, including Ori. So I get a fairly unique perspective — as an operator, CEO of a Series B venture-backed company; as a director for other health tech companies; and as an investor and advisor to PE and VC. Seeing it from multiple angles is a good perspective from which to add value.

I met the team at Ori Biotech in 2018 as a potential investor. Ori works in the cell and gene therapy space — a super exciting area of medicine where we take personalized, tailored medicines for an individual, often made of living cells. They're living medicines that we somehow have to figure out how to manufacture and deliver back to the patient, but they have incredible potential to cure cancer and rare disease. I decided to join full-time in 2019, and we've been growing the business ever since. So that's a little bit of the journey over the last 20-odd years.

I got into healthcare because I figured if I was going to expend my effort in a direction, I should do it in a way that had some value beyond just making money. Of course we all have to make money — it's part of the gig, part of the way we keep score and provide for our futures. But I'd had the opportunity to go and sell toilet cleaner within the same business where I built that pharmaceutical company, and I decided toilet cleaner wasn't nearly as exciting as healthcare and medicine. So I've been in healthcare since business school, for 20-odd years. And the impact is palpable — in addiction medicine, and in some of these other businesses. I work with a neuro-rehabilitation business called GripAble doing exciting stuff in stroke rehab, and companies like Ori. It's easy to get out of bed in the morning and go work in these companies that are trying to make a difference for patients.

The success we had with what's now Indivior — the business I started that we grew to a thousand people — was really an inflection point, seeing a business go from essentially a startup into a successful going concern. The red thread for success, in my view, is taking risks: not being afraid to try something new or go to a young company. When my wife and I were deciding whether to move to London, we'd just bought a house, my wife was five months pregnant, we had a two-year-old, living half a mile from my parents down the street in Richmond. It was all very comfortable. But we asked ourselves: are we ever going to regret moving to London for two or three years, or however long it is? And we decided no, we wouldn't. You always regret the things you don't do much more than the leaps you actually take.

So a willingness to take risk, to try to capture an opportunity and make it happen. And when I left that business in 2016, it was a little nerve-racking — I had two young children, living in London, a very expensive place, and I didn't have a guaranteed income. But I bet on myself. I got a little severance from my employer and said, well, if being an independent consultant doesn't work out, I'll go find a job in the salt mines and do what I have to do to earn money. Ultimately, betting on myself, taking a bit of risk, going after your passion — these are the recipe that's worked for me over the last 25 years.

It's an interesting insight, and you're right — you're taking calculated bets, not just going and playing in traffic. Take Ori as an example. I had seen maybe 3,000 health tech opportunities over two and a half or three years. I'd invested in some of them — 10 or 12; my portfolio's 13 now. But I hadn't ever thought about going back into an operational role. It wasn't what I was looking for. But when I met the Ori team and saw the opportunity — the incredible science happening in cell and gene, cures for cancer and rare diseases — I just said, what the heck. If I can bet on myself again and say I think we can raise money based on the story, the data and the opportunity... I said to Farlan, the co-founder of Ori, I'll help you raise money, and if we raise it, we'll figure out what happens next.

I just went at risk. I saw an opportunity, and the downside was basically capped — I had other consulting jobs keeping the lights on and food on the table. If it works, we'll do something great; if it doesn't, I'll do something else. So it's picking your spots, not taking crazy risks, but trying to mitigate the downside and look for opportunities that could have big potential and be very satisfying. It's not always "what can you make the most money doing?" — it's potentially what can you get the most gratification out of. I've been very lucky in general: born in the western world, my parents paid for my education. All those things started me on good footing, and I've tried to maximize from there.

I don't think I've ever made a change, taken a role, just for the money. There was an inflection point in business school — I went to Columbia, and there were a lot of investment bankers and consultants taking a two-year hiatus before going back to Wall Street. That path was open to me. I was 28. You sacrifice 10 or 12 years of your life working like a dog, but you come out with tens of millions in the bank. I had friends who went down that path and now they're basically retired, doing whatever they want. But I wasn't willing to sacrifice those 10 years — I figured I'd be missing some of my kids' early years.

It's not always a binary decision. Hopefully you can find a way to earn a good living and support your family doing something you love, and I've been fortunate to do that, taking some of those calculated risks along the way.

Great question. There's an old adage: if you want something done, give it to someone who's busy. I don't believe productivity is a fixed pie. Time is a fixed pie, obviously, but you can be very productive in the hours you choose to work if you keep a cadence, keep yourself busy, and don't get sucked into scrolling TikTok or whatever people do these days — I sound like an old man.

I've tried to be very selective about what I dedicate my time to. I sit on the board of four companies: Ori; Credentially, in the clinician-credentialing space, trying to solve staffing challenges in the UK and elsewhere; GripAble; and Auxita, whose operations are based in Canada. Those were all portfolio companies where I really hit it off with the founders and thought I could help. I've turned down a number of board roles — and there was one board I actually stepped off, because it just wasn't working; I wasn't adding value, and they were better off with somebody else in the chair. So good self-awareness helps: what am I good at, what am I not, am I making headway, am I adding value?

I don't do a lot of things. I've got my two kids and my wife, so family time. I try to work out in the mornings or it doesn't happen. And then I've got work. I don't have a long list of hobbies. For me, work-life balance is a misnomer — it's about work-life integration: how do you put all the pieces together in a way that makes sense for you? Generally I get up around 6:30, help the kids get out the door to school, go to the gym eight to nine, be back at the desk by 9:30 or 10, run till 5 or 5:30, take a couple of hours for dinner and family, and then maybe do a bit more between nine and midnight if it needs to be done. But if there's a football match or a netball match at three o'clock on a Wednesday, I just schedule it in — I'm not going to be available then, I'm going to go do that instead.

It's about being ruthless with your prioritization and not allowing other people to dictate where you spend your time. We actually just went through this — my daughter's going through GCSEs, and there's a time-management hack the tutors give them: you schedule all the things you have to do into the week first — those are your blocks — and then schedule everything else around them. That way you don't find yourself blown in the wind, and the things that are critical get done. That's a hack I've adopted recently. But I still say yes to too many things — I'm not faultless. I love to help, so I mentor companies when I can; if a founder reaches out, I'll read their deck and give feedback. It eats into the sleep a little, but it's all about priorities and how you want to spend your time.

Great question — I'd love to read that article, actually, if you'd send it to me.

The analogy I often use is that coaching is about performance, and a coach has a position of trust with the person they're coaching. If someone's coaching me and I know they have my best interests in mind — we have a relationship of trust — then I'm much more open to the feedback and challenges. If I'm concerned their motives are other than pure, I'm much more guarded in how I accept feedback. So first of all, feedback is built on trust, and coaching is fundamentally about trust and feedback. I work very hard on those relationships, to be worthy of being trusted, and to build rapport.

And as someone being coached, you need to be open to taking it on board. Think about Tiger Woods — best golfer ever — he had a coach, Butch Harmon, who helped him get to peak performance. No matter how good you are at something, there are always people with alternative perspectives or experiences to add. So being open to coaching and seeking out those people is a two-way street.

We're working very hard at Ori to build a culture around feedback and trust. These things have cultural differences too. I always joke that the US and the UK are two countries separated by a common language. Having lived here 12 years, I've seen both cultures in action — I have both passports, so I'm sort of neither nor rather than both. As an American you can get away with being a bit more straightforward, a bit more blunt — you're known for telling it like it is. My British friends and colleagues can be a bit more circumspect, shall we say. So knowing those cultural differences helps open up the lines of communication. At Ori I say: I'm the CEO, and I want feedback from you — the good, the bad and the ugly. Put your hand up and say, "Jason, I don't agree," or "Jason, I don't think we're doing the right thing," or "Jason, I don't understand." Usually in an organization feedback flows one direction — down, your boss telling you all the things you did wrong. That is not the kind of feedback we're open to. It's built on trust and a desire to help everybody improve.

LinkedIn is my social media of choice professionally — and I'm old enough to think Facebook is okay too, so I see friends' pictures of their kids from college. But on a professional basis, it's building and investing in your network. Often someone will reach out — this happened just this morning — "Do you mind talking to this person? She's looking to switch careers." And I'll say sure, I'll spend 10 minutes, and if I can help I will. Being known as someone who adds value and is willing to connect is the start.

One of the analogs I think is appropriate for what we're trying to do at Ori is Illumina, and what they did in the sequencing market — a fantastically successful company; at one point it was worth $50 billion, doing amazing things in DNA sequencing, building whole new use cases for biopharma. I wanted to chat with Jay Flatley — I thought he'd be a super interesting person to introduce myself to. Someone I know knew him and introduced us, and Jay and I had a nice chat. I wanted to get him involved in Ori; he politely declined because he was too busy. But it was a great conversation, hearing about the early days of Illumina and what he as a CEO really focused on. I learned a lot in an hour.

So for the most part, asking for help is a great way to build rapport. Saying, "I'd really value your expertise on this issue — would you spend half an hour just having a conversation about it?" People most often want to help. I've very rarely had people just say no, I don't want to connect, I'm not willing to help. It almost never happens. You just have to be brave enough to ask, and for the most part people will try to help if they can. And if I can return the favour karmically out to the universe, I'll do that too, if I can squeeze it into the schedule.

No one wants to just say hi, no. I do get frustrated with the cold outreach selling me software, offshoring services, R&D tax credits — all this stuff. It's funny: for branding purposes I put "Jason C Foster" on LinkedIn, because there are way too many boring Jason Fosters out there. And in the box where you put your name, there was no middle-initial box, so I put "Jason C" and then "Foster." So if it's a bot reaching out, it'll be like, "Hello Jason C, how are you today?" — and it's an easy way to go, delete. I actually responded to one person who kept not getting it: I don't want to talk to your bot, please leave me alone.

For genuine outreach, this is why people advise founders to get a warm intro. If you want to talk to investors, find someone they know and get them to introduce you — it cuts through all the noise and clutter. It's probably not fair to first-time founders who don't have as big a network, but it's a way to cut through. There's so much noise out there. I don't know how many emails you get a day — I get hundreds, and maybe only 20 or 30 are worth engaging with. You have to be disciplined about what you respond to. So the hack is: reach out, find a warm intro if you actually want a response. But don't be afraid to ask for help. Don't be afraid to say, "Can I buy you a coffee? I'd love to pick your brain."

When I left Indivior — that company I built over 10 years — I really knew no one in the startup ecosystem, because I'd been heads down building a business, six years of it in the UK, and didn't have a clue what was happening. So I said, how am I going to get out there and meet people? I started with a few people I knew, took them for coffee, and asked, "Who should I go chat with next?" They'd say, talk to these two people, and I'd call them and say let's have coffee, and then ask who the next two people were. That's how I met James Somauroo — that's most of my network, it came through that outreach. I got involved with an organization called Tech London Advocates, a non-profit supporting the London tech ecosystem, and started volunteering with an early-stage accelerator called Deep Science Ventures. Just getting out there, trying to add value, and building that network. Every one of the opportunities I've had in the almost seven years since I left that company came out of my network — people saying, "You should meet this person," and an opportunity arises. So put yourself out there — generally people are nice and receptive and want to help.

I studied marketing in business school, and I love the psychology of marketing — why people make the decisions they make, whether it's a buying decision or whether they partner with this organization. The psychology behind human decisions is super interesting, so marketing was a very strategic and interesting area for me. When I graduated I went to work as a marketer at Merck/Medco, and ultimately when I signed on with Indivior I was a brand manager, running marketing for that organization. In pharma it's not unusual for people to come up through the commercial track and end up in senior leadership — you go through marketing or sales. Our CEO at the time was the former VP of marketing. So it seemed a reasonable approach to get to an executive role, and I really enjoyed marketing. I did that from when I graduated business school in '03; I got my first general-management role in 2012, so it was nine years of pure marketing and marketing-leadership roles.

It's great training — very strategic, very people-oriented. A lot of people want to be CEOs for all kinds of reasons, but what you don't realize is that most of your day is spent on people. You're recruiting, you've got people issues, policies around people, and you're communicating constantly. We've come to default to written communication as the primary means of conveying information — a text, a WhatsApp, an email. I bet 70 or 80% of our communication is written rather than verbal, which is different from years ago. Being able to communicate clearly, concisely and compellingly is something you learn as a marketer — you have to write compelling copy, you're communicating with the world. That skill set is absolutely transferable to any leadership role.

But I also wanted general-management experience — managing a P&L, looking at operations and finance, some of the pieces I hadn't done before. So in 2012, when I got that opportunity, it was great: I managed a team of 40 people all over Europe — the UK, Ireland, the Nordics and the Baltics. And, going back to culture, the culture in the Nordics is extremely flat, extremely open — people will hit you between the eyes, much more American in the way they operate compared to more hierarchical cultures across Europe. Great education for an American who'd come over to live in London: one week you're in Copenhagen, then Helsinki, then Dublin, then Munich or Milan, seeing all those cultures in action.

There's a great book called The Culture Map by Erin Meyer — she co-wrote No Rules Rules with Reed Hastings, which is a great book about Netflix's unique culture. In The Culture Map she writes about six or eight domains in which culture is measured — how you influence in different countries. Some of it's obvious, like Germany having more structured processes than Spain, to generalize, but there's so much nuance. It's a great read if you're working across cultures. These are the lessons you learn as a marketer and then as a manager: it's all about people — how do you relate, how do you motivate, how do you communicate. Doing those things well has been a secret of success.

I do have some thoughts. What do you think I am?

The only measurement I've ever done is Myers-Briggs, and I'm an introvert, actually — just close to the line. My understanding is that introverts get their energy from being by themselves, and extroverts get theirs from being in crowds or with people. You can often tell — if I'm at an event and I've been talking to a lot of people, my energy starts to wane as the day goes on, and then I need to go meditate and read a book to fill the cup back up. But I'm easily able to flex into extroversion, maybe because I'm American, maybe because of the roles I've been in. Being able to flex your style, get away from your comfort zone, is an asset. If you're horribly shy and introverted it's going to be extremely difficult to flex to a gregarious, out-there person — but using those muscles, stretching within the range where you're comfortable, is hugely beneficial.

Sometimes at the end of a long week you're like, I really don't want to go to that event, I've been out all week, I'm tired. And then you say okay, I'll just go, it'll be fine, and you meet someone great and have a great conversation and think, I'm glad I did that. It's easy to sit at home on the couch and watch TV — you can do that anytime. But it's the people that matter; meeting interesting people and having interesting conversations is what gives you the juice, the energy. We spend way too much time sucked into the matrix, as I call it — walking down the street, people staring at their phones on a bench. The whole world is in our pocket, which is not a good thing; it's incredibly distracting from the things that matter, which are human relationships. It's human relationships that make the difference in our quality of life, and there are lots of studies to prove it — the number one predictor of happiness, or longevity, or both, for men is the quality of their marital relationship. There's a 70-year Harvard study that followed a group of students, and that was the number one predictor. Human beings are social creatures; we're used to sitting around a campfire telling stories. So as much as you can do of that, or tolerate, while keeping your energy up, it's worth putting yourself out there.

Totally agree.

A friend and long-time mentor of mine, Adrian Norton — we worked together many years — is a student of NLP, neuro-linguistic programming. A lot of it is the study of human beings and why they do what they do. One of the shorthands he's taught me over the years is: people who are like each other, like each other. Have you ever met someone for the first time — "Oh, where are you from? Where'd you go to college? I know somebody who went there, do you know so-and-so?" You're seeking commonality, a shared experience, a shared bond. We're trying to increase sameness and decrease our differences. That's building rapport — the science behind building relationships.

I've also seen many studies that people will rate you as intelligent, interesting, wonderful, if you ask them a lot of questions about themselves, because people like to talk about themselves and it's easy. You can be a great date by asking your date a lot of questions about themselves — it's comfortable, and it's not controversial. So there are these tricks for us introverts to navigate social situations. I'm naturally curious and interested in people, and maintaining that interest, asking good questions, and active listening are all good skills to learn, both personally and professionally.

I do. Having lived through a couple of entrepreneurial boom times — where people could sell a sock-puppet company for two billion dollars, and there are these stories about really dynamic founders — there is a cult around entrepreneurship and founders, the sex appeal of starting a business and raising VC capital. I don't think it's well-founded, to be honest. Being a founder, or a startup CEO, is not for everyone, and it's really important to know there are many other valuable things you can do. Because you and I probably travel in the same circles, these are the people we meet, the lines we hear, the stories we get told. But when I was growing up, "founder" wasn't even a thing — people were lawyers, doctors, worked in companies for 20 years and got their gold pen at the end; that was success. So it's really how you frame what's successful. Having a successful podcast that entertains and educates people — that's a great success.

One of the many things I respect about Farlan, the founder of Ori: he's an academic — he was at UCL, a very deep expert in bioprocessing — an innovator by nature; he likes to create stuff. When we were going down the road of the financing for Ori's seed round in 2019, I said, I don't really care what role I have — this is where I think my skills are, this is where I think yours are, let's match them up and figure out what's got to get done. You tell me what you want. He went away, thought about it over the weekend, and came back and said, I want you to be the CEO. When you're a founder, there's quite a lot of ego tied up with the CEO title. But when you look at the day-to-day activities of a CEO, sometimes that's not best suited for your skill set as a founder or a scientist or a teacher. So it's really important to be honest and self-aware about what gets you excited, what you love doing — because if it's not making 150 cold calls to investors, dealing with HR issues and worrying about the balance sheet, then... that's a lot of what the CEO does. It sounds sexy, but it's not that sexy; a lot of it is just blocking and tackling — keeping the machine ticking over, putting the right structures in place, building a great culture. So be self-aware about what you love. If it is those things, great, go run after it. But for a lot of people it's not, and you can have a great career, be part of a great startup, and not be the CEO. That's the takeaway for me: finding the right spot for you, what you love and what you're good at.

It's an interesting one. Confidence and arrogance is a fine line. For me it's about who you focus on — am I focused on self, or on others? I really want the others I'm in touch with — the CEOs whose boards I'm on, the people I work with at Ori — I want to provide servant leadership. My goal is to help them be successful, and if they're successful, I know I'll be successful. Sometimes I've had to check my own ego at the door and say, I'm not the best person for that, or step back. You get a ping of jealousy if someone else gets the spotlight for a second — we're all human beings at our core, and we're not always going to have the intellectually right emotional response. I certainly struggle at times with the right balance of being out in front as a leader versus supporting the team. My more natural tendency is servant leadership.

I've been accused of being arrogant in the past, and you can have confidence mistaken for arrogance — it's a fine line. So it's important to have that EQ, that self-awareness: what you're really good at, what you really love, where those lines are drawn, and being very sensitive to the people around you. This is mixed up in communication, in good question-asking and good listening — do you really care about the people, or are you just asking the question because you're supposed to? These things get found out quite easily. So you have to be genuine, your genuine self. If you're genuinely interested in the people you work and partner with, that self-confidence to move the ball forward will be well received — as opposed to being seen to put yourself in front, wanting it to be all about me. It's a fine line, particularly for introverts — sometimes we aren't comfortable being out front, in the spotlight; we have to take ourselves out of our comfort zone and do that interview, have that conversation, go up to that person and say hello when we really don't feel like it, because it's good for us.

I like that. I like some of his stuff. I've read a couple of those books, but I haven't heard that framework — it's apropos, for sure.

When you and I met in Malta — you're friends with people I know and respect, like James and others — I'd never actually listened to your podcast before, but I got a couple of episodes under my belt, and you ask interesting, thoughtful questions. I do a lot of these things, and some I can do in my sleep because it's the same questions over and over. This one I haven't been able to do — I've had to really give it some thought. So it's entertaining, it's interesting, and I like meeting interesting people. I've enjoyed myself.

Thanks, guys. I think it came from a conversation he and I were having about the macro environment. We're in January 2023. Last year, 2022, was incredibly tough, coming off the highs of 2021 where — because of COVID and other things — health became an extremely popular thesis. Every generalist investor who wasn't focused on healthcare was like, oh, healthcare, we should look at that, let's run over there and deploy some capital. If you look at the numbers, 2020 was a record, 2021 was an anomaly, and 2022 actually wasn't that far off 2020 — they were pretty even. But there were a lot of tourists; general investors came into healthcare, valuations got pumped up, almost any idea could be funded, and lots of bad ones got funded. Last year we started to see the bubble deflating, and there's still a lot of pain out there. It's incredibly hard to raise. We were very lucky at Ori — we closed our Series B in January last year, right as the inflection point was reached.

Health tech in particular, in my view, is a specialist area. I don't think you should have generalists touring their way through healthcare; it's extremely difficult and unusual as a market, because the normal laws of supply and demand don't really apply. For 2023 it's going to continue to be tough, probably until the back half — hopefully. In an environment where interest rates are being raised, long-dated assets like biotech or healthcare are often seen as too risky. How do I value revenues that may come in 10 or 15 years? And discounted-cash-flow rates increase as interest rates go up, so investors say, that seems a bit too risky, maybe I'll go for something more near-term that I can value more easily. The hope is that interest rates start to stabilize, maybe the back half of '23 — if I knew the answer I'd be a hedge fund trader, not a startup CEO — and then public markets stabilize, and then private-market investing really comes back to full swing.

Ultimately, investors have lots of capital — they raised lots of money the last couple of years. Two weeks ago I was at the JP Morgan Healthcare Conference in San Francisco, and I talked to some investors who hadn't invested in any new companies in six months. They just said, we're not investing in anything new, because they can't price risk — they don't know where fair value is. For companies that raised in 2020 and 2021, valuations were maybe artificially inflated, and everyone's trying to figure out where the right value is now. Once that stabilization happens, it'll unlock some of that dry powder, and we'll get back to investing in and growing healthcare businesses. That's probably through the end of '24 before the IPO market opens up again for biotech and health tech.

Even so, there aren't that many examples of really successful health tech businesses. Biotech is its own animal — creating therapeutics, with a whole investment model around it. But everything else we lump into the health tech bucket — SaaS businesses, enabling technologies, platforms doing home monitoring, the Babylons of the world — there are a few you might consider successes, that got out on the public markets, maybe moved to the US. Every UK founder I've ever talked to wanted to go to the US and open their business there, because that's the biggest healthcare market in the world. But then they've suffered greatly in the public markets, and a lot of their stock prices are down 90%. So who do we point to and say, they did it right, I'm going to follow that lead? There are very few, even in the US. I don't really think we've figured out the business model for health tech — what does it really have to do, how do we really create value? There was a perception of value during the bubble, but that value proved fleeting. So I'm super interested to see how the next two years play out. There'll be a rationalization — a lot of companies will fail because they can't raise, even with good technology, just because of the environment. Survival is a strategy over the next two years — going turtle, pulling your head in and surviving. It'll be really interesting to see which companies survive, and you'll see new leaders emerge out of this downturn, maybe new models that work better than the old ones. It's a super interesting time to be here, and if we survive this, we'll come out stronger the other side.

The way I've thought about it — it may resonate — is that the receiver of the benefit and the payer for the service are often different people or organizations, or removed by several layers. Particularly in the UK and in socialized healthcare systems like Europe's, healthcare is a right, not a business — something the government owes us. The NHS is a highly politicized entity; it's paid for by our tax dollars, and we expect it to be free and unlimited. Coming from the US, where healthcare is a business, it's a very different perspective — you're used to paying for things. Every time you go to the doctor you pay a co-pay; it's part of the ethos of US healthcare to pay for things. So when you're bringing innovation in, you have to figure out who's going to pay for it, and it's extremely difficult, in the UK at least, to get the NHS to pay for anything. We always say doctors can say no but they can't say yes — they can say, great, I'd love to try your technology, let's do a pilot, here's some data. But then if you ask, will you buy this, will you be the customer? Oh, you've got to go talk to procurement, or whoever writes the checks. There's this disconnection between the people who enjoy the benefit and the people who pay for the service, and that makes it fundamentally different from more direct markets.

SaaS was, and still is, a big model — recurring revenue, proven to be one of the best business models out there. If you're selling software, it's relatively easy: take Microsoft, which turned its whole business from a one-off sale of a CD into a SaaS business — you have to pay every year now for Microsoft Office. What a giant pain in the butt, but what a great business for them. Salesforce invented that model. But it's a very direct transaction — they're selling me software, and I'm sending them money. In healthcare there are different incentives. What's the incentive of someone in the UK healthcare system to innovate? Better patient outcomes, great; efficiencies, great — but who pays for those things? Very few people. The NHS says it pays for those things, but it doesn't, really, because it has its priorities: "cardiovascular disease is our priority this year — does this help with that? No? Sorry, come back next year." So there are all these weird and perverse incentives — we just want to keep our jobs, keep our head down, keep the thing ticking over — and you have to create a value proposition compelling enough for someone to stick their head above the parapet and take a risk. That's not easy to do. So it's not just the clearing prices where supply and demand meet — it doesn't usually work that way in healthcare.

I've got two, actually — I'm excited about both, but I'm too old to do either. One is health insurance. Health insurance is an absolutely rubbish market: the quality is poor, the offerings are generic, and no one pays for prevention. No one actually pays for you to get healthy or be healthy — they just pay when you get sick, for you to go to the doctor or get your prescription. So could you provide — and there are a couple of companies on the fringes of this, Oscar in the US is one, and a company called YuLife here in the UK doing interesting things — how do you incentivize people to stay healthy? It's super hard. We all know you shouldn't eat 10 McDonald's cheeseburgers, but we do it anyway — we eat too much, drink too much, don't exercise enough, sit on the couch too long. We know those things aren't healthy, but we do them.

Essentially all insurance is a risk-sharing pool: we pool our premiums so that if this person gets sick, we pay for that, and we scrape some profit off the top and leave the capital alone. That's all insurance is. But if we could lower the incidence of those payout events by actually investing in health — motivating people to stay healthy, go to the gym, eat well, making it easy for them so they don't have to cook for themselves — if you could create, call it a wellness plan, that was essentially insurance but helped motivate people in all the ways possible: by making it easy, making it fun, lowering the cost of the good things and increasing the cost of the bad things — there's a business model there that could be really powerful. And insurance is the best business ever — that's how Warren Buffett made $120 billion or whatever he's made, because he's very good at investing the float of these insurance companies. So that's at least a ten-billion-dollar idea, I think.

That's probably a tactic that can help, because what you're trying to do with insurance is price risk — if you're riskier than I am, they'll charge you more. And you can do it dynamically. Life insurance is a great example of how ridiculous the current way is: when you buy it, they send someone to your house, give you a physical, ask if you have high blood pressure, how you eat — and when I was 35, buying life insurance, they priced me at the level of risk I was then, for a 20-year term. Wouldn't it be better to dynamically price, maybe once or multiple times a year, so if you're getting healthier you pay less, and if you're getting unhealthier you pay more? That seems an obvious use case for those sensors and technologies, but people don't really do it. You need the financial incentive aligned for both parties — the policyholder and the company. It would be a very good way to put a risk pool together, by dynamically monitoring the people involved. Although you might get selection bias — younger people more comfortable with technology are more willing to be monitored — but there's a business there somewhere. If you start it, I'll come join you and do my best to support you.

The second is a little more boring, but it just has to be done: we all know electronic medical records are a nightmare — antiquated, locally installed. The last statistic I saw, I don't know if it's still current, was that 60% of health records in the UK were still on paper. I find that extremely hard to believe, but I'm afraid it might be right. I also saw a statistic that the UK's National Health Service is the number one purchaser of a certain technology — do you know what that technology is?

Fax machines. So there's a ways to go in healthcare. We wasted a ton of money on an interoperability project in the UK — a big financial boondoggle — but no country's gotten this right; the US doesn't have it right either. There are some big players, but if we could actually link together the sources of data for an individual patient, so you can track them through their whole health journey, it would be incredible — the things we could do with that data, the wellness and information we could provide. But I think it would take ripping out the whole system and starting over, which no one's willing to do because it's too painful and expensive. Right now we just put patches on various pieces — data here and there, hooked together, sometimes bi-directional, sometimes one-way, sometimes you can see this one but not that one. It's a mess, because of these legacy systems. I think we're just going to have to rip it out and start over, but it's a massive opportunity — a hundred-billion-dollar idea if we could get it to work.

I'd read about an effort in Australia where they pulled all the patient health records together in one place, and you had to opt out if you didn't want it in the system. As we know, people are generally lazy, so only about 5% opted out — whereas if you asked people to opt in, it would have been 5% opting in. Now they have access to aggregated patient records over time, centrally controlled, in a secure government database. You could argue that's overreach by the government, but for it to happen, that's the kind of effort you need — you put that infrastructure in place, get people used to it, and show everybody it's safe, that you're not going to plaster their medical history on a billboard. I just can't see another way. This would never happen in the US — there'd be anarchy, people waving their guns from the tops of buildings. But in social economies with a national health service, where healthcare provision by the state is already expected, it's possible. It probably has to be government-led. Otherwise, how would I get into my Apple Health app the information from when I just went to the pharmacy, or the dock-in-a-box, or got my COVID jab? It seems incredibly hard to have those pieces work together unless they're operating off the same system. I can't really understand how it could be a patient-owned system — you can control access, you control the doorway, but you can't control the root database or the source. It doesn't really work from a crowdsourcing perspective.

I haven't reached it, whatever the number is. There's a fair amount of research on this, but for me personally, happiness is expectations minus reality. We have to keep our expectations in check. If we look at our next-door neighbor who owns a Tesla or has a massive house, that's a way to immediately breed dissatisfaction. So it is relative. Certainly people who don't have enough money for subsistence — a roof over their head, food — that's clearly not acceptable. But beyond that, how much is enough is relative to your expectations and what you need.

For me, I'm looking to no longer have to work within the next eight or nine years. I've just turned 48, so mid-50s would be ideal, because I've got other things I want to do besides work every day for a paycheck. That's my success, my criteria. There's a number my financial advisor tells me will be enough to last me till my 90s — and if I'm 95 and run out of money, then I'm screwed. For some people that's a million bucks or a million pounds; for others it's five million or 10 million. You need to get to a threshold where you can give to charity, travel, make sure your kids are put through college — but that number is different for everyone, so it's hard to put a single figure on it.

I've met a lot of people who don't have huge means but seem incredibly happy — their expectations were exceeded by reality, whatever that was. The numbers get in the way. The money people make being a YouTube influencer, I think, is obscene — but who am I to judge? Professional athletes make too much for what they do — but again, who am I to judge; that's what the market dictates. And teachers and nurses and doctors, certainly in the UK, don't make enough — but I don't make the rules. So it's how do we find enough for ourselves and our goals. I'm close — eight to ten years away — so that's exciting to think about. I don't have to work till I'm 69 and a half, or whatever the retirement age is in the US.

I'm generally a positive person. My old company had some great guiding principles, and one of them was: believe that others' actions are well-intended. I really like that as a principle for life. We've all received some short, terse email — usually without the accompanying body language or tonality, so you just get the words — and you think, well, that wasn't very nice. And then you realize the person was dashing for a bus, or had just found out someone was sick, or whatever. There are all kinds of extenuating circumstances. I try to believe that others' actions are well-intended. People are generally nice, generally helpful; I try to be those things. And if you look at life through that lens, oftentimes it will be true — though the contrary could also be true.

One of my favorite quotes is by a guy called Charles Swindoll, about attitude — paraphrasing: life is 10% what happens to me and 90% how I react to it. We're in control of our attitude. We can't control what happens to us all the time, but your attitude can make or break a family relationship, a home, a business — because what you bring is the attitude, not necessarily the situation. So those are some of the things I try to live by.