Dr Rupert Dunbar-Rees is founder and CEO of Outcomes Based Healthcare (OBH). He trained in Medicine at Imperial College, gaining a degree in Orthopaedics from University College London.
He became a Partner at a GP practice working as a GP for five years before branching out and also becoming involved in non-clinical activities.
Dr Nasrin Hafezparast is co-founder and chief technical officer at Outcomes Based Healthcare (OBH). She trained in both Computer Science and Medicine at University College London and also has experience working as a doctor in A&E, GP and General Medicine in London.
Juliana Bersani is co-founder and chief operating officer with a background in strategy consulting and M&As for a number of years. She also holds an MBA and has experience of working with some of the leading providers in healthcare globally.
How did your journey with OBH begin?
R: I started OBH 2 and a half years ago because I became pretty frustrated by the healthcare system. I was a GP partner for 5 years and I was frustrated because we were terrible at understanding whether we are making a difference to people’s lives in a systematic way. Of course we do make a difference, but we don’t know in any reliable way what type of impact we’re having. So I wanted to help the healthcare system measure this – whether that’s through measuring the avoidance of disease and complications, or through measuring good health.
N: My career had started in computer science, before retraining in medicine. When I started working as a junior doctor, the inefficiencies in the whole system were obvious. When thinking about it from a person-perspective, people were bouncing between doctors for different parts of their bodies, and none of the IT systems talked to each other about the same person. Most importantly though, I started to feel like we weren’t always doing the right thing for patients.
As doctors, we run around ticking lots of boxes, treating people using broad generic guidelines, doing as we’ve been trained at medical school. Great! But we aren’t trained to treat based on what the patient really wants, what really matters to them. When I met Rupert, I remember one of the first things he said being, “this is going to sound really crazy, but we don’t measure the things that matter to people. We don’t measure the outcomes of care.” Having spent 7 years in medicine, I found this hard to believe. We measure and pay for health based on activities and processes of care. It made no sense at all. We need to change the way the NHS measures success for patients. So I started to get involved with OBH.
ask [yourself] “what if?” and play really broad thought experiments, as it will allow you to innovate around things which haven’t occurred yet.
How many of your team are still practicing clinicians?
R: That’s an interesting question. A lot of us have been in that big dilemma around whether you leave medicine or not. I eventually did – after general practice I worked for the Department of Health and then did a finance MBA and carried on with sessional work in A&E as a GP. But then 3-4 years ago I stopped seeing patients. Would I say I’ve left medicine? Probably not. On the team I’m the only one who has got that far down the line to leave medicine. I’d argue that we are all still doing medicine, just of a different kind.
There are others in the team who are actively in their surgeries seeing patients 2 to 3 days a week. So we have a broad split of clinicians – from me, to those who are actively practicing, and a few recently graduated doctors. I would say we are two thirds clinical and one third technical – it depends on how you define that. What you will find throughout the team is an element of multiple backgrounds. What would have been regarded with suspicion a few years ago and still is, is a key attribute in our team.
Rupert, you completed a finance MBA, and you both attended the Value-Based Health Care Delivery programme at Harvard – how did these both help?
R: The MBA for me was about confidence and exposure to the world outside clinical medicine. In terms of technical skills, you can probably get those better through other routes, but it gives you this broader perspective and a bit of self-awareness. You learn what you’re good at and where your skill gaps are.
N: Learning cross-industry will often teach you different ways to solve the same problem, I think this is one of the most valuable lessons, and really helps you think innovatively.
R: It’s a bit like a language – if you learn a second language from an early age, it’s easier to pick up a third. I worked for the Department of Health, and for the first time in my career, I was working for someone who was non clinical. My boss was an accountant, I didn’t want to become a finance person, but I wanted to be able to speak that language.
OBH – tell us what you do as an organisation? Given that outcomes are so hard to measure, how are you doing it differently?
R: On the latter point, we get that question a lot. One of the top myths is that outcomes are hard to measure – and we believe that they’re not. Usually when we try and measure outcomes, we measure them through care settings, such as the outcomes of a hospital or a department. We need to stop and think for a minute: who are these people we are trying to measure outcomes for? What are their common characteristics? What do people want across all of their care, irrespective of whether it’s a hospital or general practice setting? Only then does it get easier, we start to get to the bottom of what people think is important in their lives rather than who is doing what in the healthcare system. In essence, once you start thinking across organisational boundaries, outcomes become a lot easier to measure.
Our job is to come up with metrics that help the health system know whether they are doing any good. But importantly we don’t come up with these; patients do. We just find ways of using data to accurately measure them. To begin with we had a business built on two things, educating the system that this is possible, and also offering advisory support to the NHS when they wanted to change the way they were paying for healthcare. Instead of paying healthcare providers for all the bad things that happen, like treating heart attacks and stroke, isn’t it better to pay for avoiding some of those things? This type of payment mechanism supports paying for the absence of ill health, which is a total mind shift. We help provide metrics for that. Now we have increasingly moved away from the advisory space and into measurement. Our digital products help the NHS measure outcomes and visualise them.
N: We also do a significant amount of research using the latest machine learning techniques on data that helps us understand people from all angles, and not just through data that sits in the electronic medical record. Last year we won 2 Innovate UK grants that are match funded. They fund 60% of the project cost. One is a £1million project to predict when somebody with diabetes is going to get a particular complication of diabetes, such as a heart attack or stroke.
We believe that diabetes type 2 is not just one disease. The disease and its progression clearly behaves in different ways. By looking at multiple different linked data sources and applying machine learning analysis, we are looking for insights that sub-segment diabetes, and show who and when someone will or will not benefit from a particular intervention or treatment, altering lifestyle, or a specific behaviour change. This could provide a radical change to the provision of healthcare to a more precise and personalised data-driven approach through better understanding people.
The second is a £100K research project to develop a smartphone app that can predict patient reported outcomes in people with diabetes through data collected from in-built sensors in a smartphone. Outcomes such as quality of life, feeling in control of your diabetes and levels of anxiety and depression, are typically measured through validated surveys. However, we believe people’s behaviour which can be captured through how they use their phones, can predict these outcomes – not just by asking people questions, but just by continuously and passively measuring it.
Focus on what you really like in life and you can really achieve great things.
Who are your most common clients, do you work more closely with the public or private sector?
R: The NHS is probably our most common client. We do also work with private sector providers but with those who are providing NHS care or NHS analytics. Certainly on the tech side, we collaborate heavily with organisations around the globe doing similar things. So we are sharing knowledge around the challenges that we are trying to address.
What difficulties do you face in the outcomes based healthcare market?
R: Outcomes is a hot buzzword at the moment. True outcomes, are those which matter to patients. Not because their doctor has told them its important, but its actually what they want. Barriers include people understanding what an outcome is and how that’s different to what we do right now.
N: Imagine making a cake for a birthday party. Your inputs are going to be your ingredients, your processes are going to be mixing and putting it in the oven, your output is going to be the cake, and your outcome is the child’s happy face eating the cake and for the child not to have food poisoning the next day. You can apply this exact thinking to healthcare and a care pathway to understand what a true outcome is the following:
Now you’ve moved to Old Street, termed the Silicon Valley of the UK, has it changed the dynamic with which your company operates?
R: I would go as far as to say we wouldn’t have won Innovate UK funding had we not moved here. It seemed a natural choice as we were very interested in collaborations with organisations outside of healthcare. These collaborations would not have come about had we not been in these premises. We’ve been able to take the discipline of healthcare and the discipline of another system, working across academic and operational silos to find insights we couldn’t see if we just looked in healthcare.
Would you describe yourself as a healthcare consultancy or is there a difference in what you do?
R: We started off doing advisory work, but increasingly we are now becoming a product company. The core product being our Digital Outcomes Platform, enabling health systems to visualise their outcomes data for specific population groups, set-up weights and thresholds for outcomes based contracts, and monitor their outcomes on a month by month, near real-time basis. No one has been able to achieve this yet.
How was self-funding, were you scared or nervous using your own money? What advice would you give to someone who wanted to self-fund?
R: It depends. I think there are some real advantages to self-funding, particularly if you have a mix of advisory and consultancy elements in there, because it allows you to product test as you go. We speculated that we would bring in enough money in the early days through advisory work to keep going, so we didn’t mind taking a big income hit, which we all did. That gave us enough to keep the mortgage paid and food on the table, and allowed us to invest in products development, and at the same time allow us to test products with advisory boards, clients, CCGs and hospitals.
In that respect it’s been very helpful. It’s quite hard though and it is a little bit scary. There is the other route, which is saying we’ve got a great idea, then convincing others it’s a great idea, so much so that they’ll reach into their pockets and fund you for a period of time. The advantage being you can focus solely on one project, the disadvantage is you often have a very short run time, and if you don’t take off, you crash. It’s OK to fail though!
What advice would you give to medics who want to innovate but feel guilty about leaving medicine?
R: This guilt feeling is very common. I got a long way down the track before I started dabbling in other things but I noticed that I was unhappy in my clinical medicine – I’ve done nearly every job in medicine. The thing that sustained me the longest was general practice, possibly because I was closest to the sort of entrepreneurial career that I have now. In terms of advice, I felt very guilty when I considered leaving, it took me about 2 years from thinking ‘right I’m going to do this’ to actually leaving. That was probably because I did it quite late – I was 37 and that’s quite late in someone’s career.
My biggest piece of advice is, that if you are having these feelings early, listen to them. There are lots of people who are very unhappy in medicine, and even though they are doing wonderful jobs, their skills could be very well deployed elsewhere. I personally would listen to those feelings, because at the end of the day, you are not doing you or your patients any good. Ultimately, we are all pulling in the same direction, we are all trying to do the very best for patients – its about seeing beyond the particular area of application that someone has trained themselves for. We couldn’t do what we do if we hadn’t got that clinical background or we wouldn’t be as efficient, so someone has got to do what we do.
N: For me, I had a career before so it’s not the first time I’ve done this. Having done something different before, I wasn’t scared to try something new. So if you’re not sure, try it, do something different and new in some free time you might have, do something you find interesting that’s not necessarily directly related to healthcare or medicine. Maybe a course in programming, or design. Often it’s that time away from your back-to-back daily shifts that gets you thinking, time to develop a vision and to think about what’s important about what you do everyday.
R: Focus on what you really like in life and you can really achieve great things.
There are lots of people who are very unhappy in medicine, and even though they are doing wonderful jobs, their skills could be very well deployed elsewhere. I personally would listen to those feelings, because at the end of the day, you are not doing you or your patients any good.
What would be your biggest piece of advice to Doctorpreneurs? Did you always know this was the direction you were going to take?
N: For doctors who are interested in doing other things, I would network through meetups you might be interested in, go to a workshop or talk, offer to do placements or internships at startups that interest you. Broaden your view beyond the hospital walls and the status quo. Explore other industries, which may enable you to bring ideas and innovation back into healthcare. Many solutions don’t lie within the status quo.
R: Building on that, my tip would be to ask “what if?” and play really broad thought experiments, as it will allow you to innovate around things which haven’t occurred yet.
And answering the other question, I never thought I would do this, I thought I was too old to run a startup, so no. However if you’d asked my friends at medical school what I would be doing, they’d probably say running a healthcare startup.