Just how hard is it to bring about transformation in healthcare? Magpie met with one of the UK’s leading start-ups in the sector to find out. Interview by Rishi Dastidar

This article is part of our feature on the future of healthcare, you can check out Issue 2 of Magpie here.

Stephen Bourke is a man in a hurry. What start-up founder isn’t, you might ask, but since he and co-founder Sai Lakshmi started Echo in 2016, the business has been moving at a rapid clip, to become the leading light of a cluster of healthcare focused startups based in London. Echo’s initial focus is on helping National Health Service (NHS) patients get their repeat prescriptions more easily through a mobile phone app. And while making repeat prescriptions work better might not sound sexy it’s important, as 40% of medication isn’t taken as directed, costing the UK’s healthcare system wasted billions every year.

£17bn is the UK yearly spend on medication,
half of which isn't taken as directed

It’s a task that Echo is succeeding at, so much so that it has attracted investment from leading venture capital firms such as White Star and Rocket Internet. The business was named Best British Mobile Startup at this year’s Mobile World Congress.

Magpie met Stephen at Echo’s modish offices in West London for a long conversation about the impulse behind the business, the role of customer experience in building the Echo brand, and how transforming a sector like healthcare is not always glamorous work. (Questions and Stephen’s answers have been lightly edited for clarity.) We began with the obvious:

MAGPIE: Why did you start Echo?

SB: To solve a very personal problem. Both Sai and I take repeat prescriptions and we have done our entire lives, and we felt that there was no solution for us on the market. Every month, it was a hassle to get my repeat prescription – the request to the GP, going to the pharmacy, them having the meds in stock. It was taking up too much head space.

Also, I’m pretty disengaged with my condition, and if you have someone who’s disengaged and it’s a hassle to get your meds, then guess what? They end up going in for emergency appointments to get a repeat prescription. That is certainly something I experienced – booking a last minute GP appointment, begging the pharmacist for an emergency script and even, in my case, going into A&E once to get a repeat prescription.

When we started we were very much about, ‘How do we make life as convenient as possible for us, as consumers?’ It was only later we realised that Echo’s impact, or potential impact on medication adherence. If you remove the barriers to people getting their meds, they’re more likely to take them. If you nudge people towards taking their meds, they’re more likely to take them. If you provide people with information explaining what the meds do, they’re more likely to take them.

“If you remove the barriers to people getting their meds, they’re more likely to take them”

We’re really trying to solve a problem that we understand, intimately. When we ask ourselves what we should do and what we should prioritise, we start with first principles: what do we, as professionals working full-time, need, and what do we value? We then focus on delivering that.

MAGPIE: This wasn’t necessarily about using the latest ‘hot’ or ‘sexy’ technology.

SB: Initially, we were a bit tempted by some of the more out there ideas, ranging from blockchain, to AI, but then we said, ‘No, let’s go back to first principles and build something that solves an immediate problem today.’ We’re using today’s technology, and that works. Mobile phone technologies, and also some backend technology developed by the NHS: those are the two factors that make Echo possible.

MAGPIE: And yet as Echo grows it’s become clear that this is a service being used by people who aren’t busy professionals.

SB: Yes, for Sai and me it was about convenience first and foremost, but actually a lot of our users value that we deliver to their homes, because they have mobility challenges, they can’t get to the pharmacy; they benefit from that and that’s not something we thought about or planned for.

We have customers with more complex cases and conditions than we’d expected. Sai and me, we take one, two items each day, but we have some patients who are on 30-plus items each day. Thinking about them makes us think harder about their experiences with the app: things like how the alerts appear, if you’ve got 30 items versus one, how do you build it? We’re learning all the time. The typical Echo user, if there is such a thing, is a 38-year-old working mum, which obviously I’m not, and hence why UX testing and user research has become such a huge thing for us.

MAGPIE: You’re rare in being a start-up founder whose title is ‘Chief Experience Officer’. How much has Echo’s customer experience informed the brand – or is it the other way round?

SB: One of the challenges I had using other services that existed before us was fragmentation, and a lack of communication, which just keeps you at this kind of low-simmering edge of anxiety – that’s what we want to eliminate, because really I need to know that my meds are going to arrive on time. If I need to see my GP, I want to know as early as possible. I need to know that there’s going to be sufficient stock; and I want someone to be accountable for that end-to-end experience. We don’t solve one thing: it’s a 100 little break points that all come into the patient experience.

“In terms of the brand everything we do, from the look and feel of the app through to
how we talk to patients, needs to be robust”

Then in terms of the brand everything we do, from the look and feel of the app, simple things like how the icons animate, right through to how we talk to patients, how we interact with the surgeries, to the packaging in which we send out the meds: all of that needs to be robust. It needs to feel solid.

MAGPIE: Are there any particular brands that inspire this approach to the way you deliver experience?

SB: We take a lot of inspiration from Apple, but more recently I’m taking cues from Fisher Price. I know that I can hand any Fisher Price toy to my daughter, and she won’t choke on it. There’s a clear kind of signal there. They might not have all the flashy features of some other toys, but there is a solidity to the product. You know what it stands for and there’s an accountability to the product, and that comes through every little touch point you have.

MAGPIE: Yours is a brand that’s being built experience first.

SB: For us, brand and experience are one and the same thing. The brand is what we do, day-in day-out. It’s everything from investing in our security to our backend infrastructure. It’s the work we do with the NHS. It’s not often anything to do with the logo or the colour scheme; it’s how we work; it’s how we operate; it’s who we recruit: that is the brand, and the brand is the experience, both for our users and the GPs, but also for our employees.

MAGPIE: How do you know what a good exployee fit looks like?

SB: Well you never really know until you start working with someone. One of the things we do, in our recruitment process, is that you will meet lots and lots ofEcho-ites, five or six people. In a very informal way, we’ll get someone in for a few hours and we’ll get staff to drop in. We take a temperature gauge, based on how people feel and whether or not they’re going to be a fit.

It’s a lot of hard work building a start-up. It’s a lot of dedication and you do need to believe in the mission and the goal, so I think it’s important that people see what we’re building. That doesn’t mean they have to have come from a healthcare background, it means they must see why it’s so important that we do the right thing.

MAGPIE: I’ve noticed in what you’ve said and the way that you’ve said it so far that you’re not using rhetoric around transforming the industry, transforming the sector, transforming the world. Is that deliberate?

SB: I think we have a big mission here and we have goals that extend far beyond pharmacy services. However, we do feel that we only get the right to unlock those next opportunities and have those conversations when we feel confident that we’ve solved the first thing that we’re working on.

‘Transforming’ is a good word, but ‘disrupting’ in the healthcare sector is a tricky word. We’re providing an essential healthcare service, and disruption, by its nature, doesn’t necessarily fit with providing a continuous care pathway. Healthcare is different and needs to be treated with a lot of respect. Doing an alpha release and seeing what happens is really tough in healthcare, because everything from data security to how things are handled, communication, all of that needs to be robust.

MAGPIE: How have you gone about getting the trust to do what you do in, what from an outside perspective appears a risk-averse sector?

SB: Making sure that we deliver the best possible patient experience and we let our patients and users do the talking for us. When I meet people in the NHS, and in government, quite often they’ll have already spoken to an Echo user about our service. And when that happens, it opens a lot of doors, because people can see that we strive to do our best and to provide utmost care and attention and respect, for our users.

The NHS does recognise the need for innovation and is working extremely hard to make innovation happen. Because, frankly, we’ve got an ageing population. We have to find some sort of new way of doing things, and technology is one of the tangible answers. The only way we’ll be able to provide universal healthcare, free at the point of care, is through technology: there is no other way.

MAGPIE: Are there parts of the NHS which are more open and receptive to innovation?

SB: Someone gave me a great analogy the other day: the NHS isn’t a massive whale but a shoal of fish. And within that shoal, there will be people keen on innovation and those concerned about something new coming along,disrupting the very, very tough job that they have to do.

If you imagine that you’re already working every hour in the day, you’re under huge amount of stress and then this new technology comes in. You feel the people behind it haven’t answered some of the key questions you’ve got and it’s just a rehashing of something you saw 18 months ago that didn’t work out… you’re going to get jaded. The onus is on the innovators and their supporters to make the case – and to ensure that there’s a continuity of care and systems.

If you think about something like a platform migration, that can be hugely disruptive. Even if the new platform offers long-term savings, who’s going to deal with the day-to-day impact? Who’s going to pay for it? Whose weekend is ruined by this? And so one of the principles we have at Echo is to minimise disruption. Use existing pathways, existing workflows, however that GP surgery works right now. And that involves understanding these systems, and adapting to them.

But it’s difficult and the shoal of fish isn’t always swimming in the same direction. And there’s some big questions, politically, about what’s the future of the NHS? Do you charge people for not attending GP surgeries? There’s lots of philosophical debates that we stay out of, but they’re happening, and they can dictate and determine what’s going to happen with innovation at large.

“One of the principles we have at Echo is to minimise disruption, use existing pathways, existing workflows”

You just have to keep turning up every day – tenacity has to be your watchword. And when I look at our peers in healthcare start-ups, the average age of an employee seems to be almost 10 years older than most tech startups, 35 versus 25. There’s a few different things going on there: it’s about, having the experience, know-how – and we have a huge responsibility, which is tough.

MAGPIE: This reinforces the idea that transformation is not about revolution, but is fundamentally a gritty, slow process.

SB: Going in with a transformation programme that is ‘revolutionary’ in healthcare is tough. We need to make sure that a GP on the other side of the country who’s never heard of Echo, doesn’t feel alienated, feels like we’re bringing them along on the journey. The onus is on us to do that, and that’s about turning up every day and taking the time to explain.

MAGPIE: How closely do you work with other start-ups in your sector? Are they competitors or something else?

SB: I look at some of the relationships that we’ve built with ostensibly competitors, and see that we have enough common challenges to pull together. There are companies that, where we overlap with, we work very closely together, and we help each out and we share information. We chat to each other almost every day. Again, that’s because we’re both working towards a bigger picture, and at some point in the future maybe we’ll be head-to-head competitors, but for now that we’ve got common goals.

Partnerships are really, really important. If you think about care pathways, it might be that, in the future Echo naturally will hand over to another partner, depending on the patient’s condition and life stage. I prefer being able to say to a patient ‘Here’s continuity of care’ and hand it to someone’s who’s ostensibly a competitor than leave that patient stranded.

MAGPIE: Right now it sounds like you’re not particularly worried that an Amazon or an Apple can come in and do what you do on a larger, more efficient scale?

SB: Anyone coming into this market has to realise that, no matter how big they are, or how much money they have, they’re still only going to be part of an ecosystem. They can’t compel a GP to issue a prescription on behalf of the patient. Every prescription that is dispensed by us, has to be authorised by the GP. And the GP may well have a good reason to refuse what the customer wants. So for one thing customer satisfaction is not in your control in the same way. If they come into this market the big e-commerce players will need to work with stakeholders and commissioners, which kind of goes against their operating models at the moment.

MAGPIE: What do you consider the biggest potential risk to Echo’s brand?

SB: Losing sight of why we started the company. I think we can weather an awful lot, as long as we remain true to our mission. We’re almost 40 people now, so we need to make sure that we hire people who share our values and who are on board with the mission, so that as we scale we continue to focus on the things that are important to us.

MAGPIE: And on the flip side, what’s the thing that people love about Echo?

SB: That it just works. A lot of the people I talk to are surprised when we tell them that you can get this service, and it’s free, and it works with your own NHS GP. Atthe start they can be quite sceptical. And then when it works they’re like ‘What!?’. The simplicity is what surprises and delights people, first and foremost.

And then the second thing is accountability. Because we’re working in a complex multi-faceted, many stakeholder market, things can go wrong and do go wrong and you know it’s easy to pass the buck in those situations. It’s much harder to say, ‘We’re going to try and get this sorted’ and to let people know exactly what to do and to be there. Frankly – giving a shit.

From clinicians’ perspective, I think they like that it reinforces a GP’s directions. We spend in the UK £17 billion a year on medication, and half of that isn’t taken as directed. It’s a huge issue. So, anything that nudges people towards better compliance, gives them the tools to understand why they’re taking meds, reduces barriers to compliance, helps keep people better for longer, and reduces strains on healthcare.

MAGPIE: It’s invidious to ask of a business that’s growing as fast as Echo but – what’s next?

SB: Unfortunately I’m going to be boring and saying ‘more of the same’. We have many, many, many things we need to fix and improve. We’re still trying to nail our core product. We think it’s the best on the market, but we instinctively know how many other things we need to do in order to make it the most frictionless app that it can be: and that remains our core focus as a team.

Because making hard things look simple is tough, and that remains our mission, to make it just work. That doesn’t just mean from a patient’s perspective, it means from a clinician’s perspective, and it means from our team’s perspective. And then, obviously, scaling that.

MAGPIE: This is a good story to tell; transformation is not this romantic thing. It’s the business of doing the same every day.

SB: 100%. There’s any number of different things that we could do in the app, and it’s Sai and my job to say, ‘No. It’s just going to do that.’ I mean – ‘map my genome, sure, but if I can’t get my pills I don’t care.’

Images courtesy of Echo