Dr Elliot Street: Reimagining surgical training

Matthew

Hello and welcome to the latest edition of Health Online. This week, we're focusing on innovation with a fascinating conversation with surgeon, inventor, and entrepreneur Elliot Street.

This week, we've seen the publication of the primary recovery plan. We at the Confed have broadly welcomed the plan, its measures on improving access, widening the role of community pharmacies, and improving the interface between secondary and primary care.

But the big workforce challenges are still there and await the promised workforce strategy. There's also some concerns about delivery. ICBs are expected to play a major role, but they're having to hugely reduce their head count at the same time. More broadly, and this is where we're doing a lot of our own thinking, we need a fuller and more rounded vision of the future of primary care within systems, places and neighbourhoods.

Also this week, Danny Mortimer from NHS Employers and I gave evidence to the House of Commons Health and Care Select Committee on the industrial disputes in the NHS. We talked about the impact the action has had and the work leaders and managers have had to do to minimise patient harm. We await the outcome of the new RCN ballot and talks between government and the BMA junior doctors.

We will at the Confed continue to press all sides to be pragmatic and creative so that we can avoid further disruption. Finally, next week I'll be delivering the annual Stephens Lecture to the Royal Society of Medicine, calling, among other things, for a new social contract for health. If you think that's of any interest, the text should be on our website in a few days’ time.

But now let's hear about innovation in the NHS and the barriers to it. From the very impressive Elliot Street.

Matthew

So, I'm excited to be talking to Dr. Elliot Street. So, Elliot Street is an award winning clinician and the co-founder and CEO of Innovus Medical, a multi-award winning designer and manufacturer of surgical training technology.

Elliot completed his medical training at University of Manchester and Oxford University Hospitals. He's an alumnus and mentor of the NHS Clinical Entrepreneur Programme, and he holds a position on the Liverpool City Region Innovation Board and is a strategic advisor to Liverpool Ventures and Liver Labs. So that's the basics about you. But let's start with your journey. So, I've kind of given the bare bones, but I'm interested in particularly the journey from clinician to entrepreneur.

Elliot

The journey really started back at medical school when I was training in Manchester and I was looking at my future career as a surgeon in the NHS and I was thinking about how we train surgeons, and this is coming from someone that's come from a relatively high sporting pedigree, playing tennis to a reasonable level. And I was looking at the pathway for training surgeons and how we did it day to day.

And I thought, hang on. We're not really training surgeons how I would expect us to train, which is more akin to elite athletes. That's the first thing. And the second thing I noticed whilst I was going this journey of exploring what a surgical career would look like was I thought we probably should be moving a little bit more of the early learning curve away from the patient bedside.

It strikes me that that was fine two or 300 years ago where early learning curve is very much at the patient bedside. But there's technology around now or could it be technology that could shift that early learning curve, as I say, away from the patient bedside and into what we would describe as a simulated environment. So, a very realistic environment for training.

So, I was exploring that whilst I was at medical school and then I got very, very lucky. And as per your opening piece there, around us meeting over drinks, I was lucky enough to meet my co-founder at a drinks party whilst we were at university together with a mutual friend and my co-founder, Jordan. He's a multifaceted engineer and he'd been looking at this from a different perspective.

He'd been doing research into predicting how good someone may be at surgery. And we both came to the same conclusion that some changes need to be made and that as a couple of 22-year-old students with no money, no contacts and no real knowledge, we were best placed to change the way in which we train surgeons.  So that's how we got started.

Matthew

So, the thing that's interesting to me about that, apart from the fact that it makes me feel inadequate in the sense that I can't believe really I would ever have taken such a leap into the unknown at any point in my life. But apart from that, you very much started with the problem.

I mean, I'm reading a book at the moment about cyber surveillance, and that's a book in which, as it were, the person starts with the product and then starts to think, oh, that's interesting. It kind of could apply this way. I could make money out of it that way. Some of them not, not particularly ethical, but for you, you didn't start with the solution. You started with the problem.

Elliot

Absolutely. And we talk about this a lot, which is this – problem-first innovation’s really important to us as innovators and business leaders. But we talk about lots of other people who are thinking about their own innovation journey, whether or not that so the clinical entrepreneurs or the people outside of the healthcare space, which is you, see it so often where there's this great piece of technology and virtual reality is a prime example of this, which is this exciting, very marketable piece of technology, which is searching for a home and a problem to solve.

And yeah, we've always taken this approach of let's look at the where the problem is, and let’s really delve deep into why that problem exists. What are the drivers of that problem? And therefore we'll use those drivers that are causing the problem, as are core values or our core focus to go and solve it and then we'll build the technology that's most appropriate for that.

So, what that does lead to is an 11-year journey where one could argue that we sort of completed our first decade of a multi-decade process, but it's a good job that we're enjoying it along the way. But yeah, I think that the summary there is a problem-first approach is absolutely key, but it's not an easy approach to take.

Matthew

I guess you had some notion at the outset of elements of the solution and as you say, you brought to it the kind of way in which elite sport was using technology and enabling people to simulate as closely as possible the kind of conditions of elite sport competition in their in their training. So, you brought that to it.

Then, my sense is what then happens is a fairly recognisable path. And I'm interested in, in the fact that I'm sure for you it didn't feel like a well-travelled path. It felt like a unique experience. But, you start off, you've got no money, you're working, I don't know, in a garage or somewhere.

You don't really have to raise much money initially, maybe you raise it from friends. I'm just I'm describing the classic account. And you can tell me how similar it was. You raise money from family and friends. That gets you going on your first stage. You get the breakthrough; you develop a kind of prototype. And at that point now you have to go and get some more serious money.

You get some more serious money at that stage. Interested about when the NHS plays into this process, then you get, my goodness, here is something, there is a product, it does work, and then you get into the kind of final stage which is which I guess you're still in now very much, which is, my God, we've got our product.

It really works. There's a huge market for it. How do we grow, how do we scale and does that involve for you the tragedy of the founder, which is suddenly the skills that you needed to grow the business to this point might not be the skills that are needed to grow the business to the next stage. So, there you have, Elliot, the kind of classic three minute account of the entrepreneur’s journey, how similar to that kind of ideal type was your experience?

Ellliot

Parts similar and parts very different. And I think it’s almost a generational thing. If we go back multiple generations - anyone that's not read it, a great book is Shoedog by Phil Knight and that gives that account that you've just described right there. That's an old-school built - a really, really successful business in an old-school way, didn't necessarily raise traditional venture capital, ground it out for a number of decades.

We've sort of done that in the first instance. And I'll share a few bits with you. And if it's okay, I'll maybe just give a little bit of context as to what we do so the listeners know what it is we do.

Matthew

We need to hear about the product. So, I was building up to that, but let's bring the product into the picture.

Elliot

I'm so sorry. I'll let the host do the hosting… this is a very, very brief overview and I'm sure we'll come back to it so as to touch on it properly. But the quick summary is we create solutions for training surgeons in the simulated environment and that includes hardware and a digital surgery platform. That's the summary and we'll go into a little bit more detail.

But when we started, we went even lower than the family and friends round, ie we didn't really have any family or friends that particularly had spare cash lying around and so the first product we ever created, we created with a heat gun and a sheet of plastic and a drill and we created it in my co-founder's grandparents’ garage.

And our first ever product we sold - this is a this is a box trainer for training people in minimally invasive surgery - first product we ever sold, our total startup capital I think amounted to £180 and we did it in the proper old school way for the first six years, which is every time we would sell something, we would take that money and we’d plough it back into the next piece of equipment to make the product better, the next piece of technology to make the website experience better, or the next piece of technology to add software solutions to that.

So, in a way, yes, that more traditional approach to building a business that you hear about in these stories and these movies of these big businesses and brands. I think that the Innovus of today, when you look at it, it's a digital surgery business first. From the outside in, that's what you'd see.

And if you looked at that, you'd expect me to be saying, look, we raised loads of venture capital really early, we're still burning loads and loads of cash, we're still having to raise loads of VC to stay alive. And actually I was having this conversation only yesterday that of the around £10 million that we've raised over the lifetime of the business, only around a million of that has been dilutive and again, hopefully for those listening that are interested in innovation, if you do find a solution to that problem, you'll be amazed that people are actually willing to part with their money to get hold of that solution.

And that's what I think we were very, very lucky and able to do in the early days, which is we found a really clever, really sort of elegant solution to this problem, because we went with the problem-first approach, people are willing to spend their budgets on it. And that allowed us in the early days to build the business with what we call ‘patient urgency’ but build it profitably and not have to dilute.

So, we've done all those things you mentioned, but we've done them in a roundabout way. And what it's meant is that we've built the business in the way we wanted to, which has been nice.

Matthew

So, let's go back to the product because when people talk to me about innovations, particularly technological innovations, there's a very clear divide for me between those things which I simply don't understand - it doesn't matter how many times someone explains it to me - and those where I think, oh yeah, I kind of get that. And I'm sure we have lots of surgeons who listen to Health on the Line, but help the non-surgeon understand what the kind of real physical problem was about people training other than on a human body and how it is you went about solving that.

Elliot

When we when we think about the traditional way in which we train, it's that at the patient bedside with a mentor mentee apprenticeship style and the classic adage of see one do on teach one. So very early you are learning your craft at the patient bedside. And that's the thing that we originally looked at and said, okay, we need to change that.

And then if we're going to change it, we should shift it towards training like athletes or elite athletes. And that would mean moving the early learning curve into a simulated environment - and bearing in mind simulators existed before we came along - so, we then looked at the current solutions, in inverted commas, to the problem. We said, well, why haven't those solutions been adopted at scale and shifted this paradigm where the early learning curve is done to a specific standard for surgery.

And we realised that really there were three main problems. So, existing technologies invariably were too expensive. They were not necessarily accessible or scalable. And the technology they tend to use, in this case, virtual reality, that uses software and motors to teach us how things should feel. So soft tissue should feel. And we were finding that that just wasn't realistic enough for surgeons to say, we can use that to replace the traditional approach.

So armed with that information, what we looked at is to say, well, what technology would solve those three issues? So how can we make a piece of technology that is more affordable, more accessible, and more scalable and ultimately more functional, so more realistic when it comes to how the surgery feels? And I realise what I've said there is we're saying we're going to make a technology that costs less and is better, which everyone says that can't possibly be the case. What's the catch here?

And the way we describe it, the adage we give is it's very similar to the computing industry and the shift that came with personal computing. So, fifties and sixties, it's mainframe computers, very expensive, large bits of kit, difficult to access in large buildings. And then along came the likes of Apple and Dell, etc., and they put more powerful systems in the hands of everyone in the world.

And that's how we see the world and the future of surgical training. For those that aren't surgeons, what is it that I'm actually talking about? Well, it's a simulator that you put real instruments that you'd use to operate into a box, and you operate on synthetic tissues. So, you're using the actual instruments you would use in real life, and you're operating on tissues that feel like real tissue.

But around those tissues are digital overlays. So, it's a digital environment that makes it look very immersive. It looks like you're actually operating. And then without going into too much detail, there's lots of other software and technology that allows us to objectively measure performance, trigger complications, allow people to understand the cognitive learning involved in surgery. So really what we did is with the benefit of hindsight, we looked at all of the things that came before us and we cherry picked all of the solutions that partly solved the problem.

And we like to think now we combine those into a solution that solves the whole problem in one go.

Matthew

Now, this is a technology that I guess is your customer primarily medical schools, universities? Explain all this to me because often, of course, innovators get very frustrated, feel very frustrated when it comes to interacting with the public sector and systems of public procurement, etc., etc.  What's been your experience?

Elliot

The first thing for anyone that is innovating and thinking about this, I think really important, and this will evolve, that it's really important too early on, try and segment your market for your customers so that you understand do I need to change parts of my offering for this particular customer, First of all, who are my customers? Who do I think they are? And let me go and acid test who they are.

So, to answer your question for us, yes, we do play in the undergraduate space, but the majority of surgical skills are acquired in the postgraduate space. So that's in the UK hospital systems where the registrars and the core surgical trainees are, in the USA it's the residency training program, so again, hospital systems. But what we also looked at when we were mapping that for ourselves personally is it just in the hospital systems and in the hospital where surgical training is going on? And we realised the answer to that was no. There was a massive amount of surgical training being delivered by industry.

So those are medical device companies who are delivering surgical training to teach people how to use their devices safely. But as a value add supporting and sponsoring surgical training to teach surgeons how to actually do the procedures, that's the difference between technical and clinical training. So, when we mapped that, we thought, oh, hang on, we can't just we can't just focus our offering just on one part of that and we'll talk about what our mission is as a business because it won't let us get to where our mission needs to be.

So again, when we're thinking about solving the problem, we were innovating our technology such that it could be used by anyone at any touchpoint within the continuum of delivering surgical training. And the example here is our technology is completely agnostic. So, I can put the instruments of one medical device company and then the next medical device company, and the next medical device company into the system and allow surgeons to use those instruments so they can get good at learning that specific instrument without having to make wholesale changes to the technology.

And I think that if any innovators are listening, first of all map your segmentation of your customers and then start testing your theories with them. And then very importantly, do not try and make a different product for every single one of those customers because it will be a complete it will be a nightmare, it will be a mess. Try and make a piece of technology, which is what we've tried to do, which is as agnostic as you can. That has a core piece of technology that can serve all the needs of these various customers and then make small changes to small additions if you need to.

Matthew

But the customers are public sector bodies, are they, on the whole? I'm interested in terms of the support you've had along the journey and in terms of the growth of the company, how has your experience of having a product which ultimately is not exclusively, but, but in large part, I guess being purchased by the public sector?

Elliot

I have to say overall our experience has been positive. And I think part of that is because we have very much engaged the concept of patient urgency, which is being incredibly patient over adoption. But every day I get up and go after things with urgency and I think let's take the NHS as an example.

A huge majority of our revenue still comes from the NHS. It was our primary focus because that's where I was working as a clinician, I previously as a medical student, then working anyway, and I wanted to solve this problem for this institution, which I loved then still love now. And so, it's been a major for us. And in terms of how we found addressing that, one thing I will say is, and this is what we counsel all of our team members on, you just have to keep turning up.

You cannot expect that there's going to be a silver bullet, even with central procurement towers or pathways or whatever. You still need to go and engage every single stakeholder at every single site to make sure that this product not only is going to get purchased, but going to actually be used, because there's a big difference between just selling lots of kits and actually moving the needle and making a difference.

So, if someone said to me, well, that you've got a majority of revenue going into the NHS, how on earth have you managed to do that? The very simple answer is we just kept turning up, enthusiastically turning up, and continuously putting the kit in front…the perseverance and resilience is really all that, all that I can give to anyone because I don't think there is any magic formula.

Overall, though, if you said to me, is that a positive or a negative experience? I think it's a positive experience because even when we go overseas to the US as a as a contrast and we're selling into these large hospital systems which can be seen as one huge single customer, they never are, these large hospital groups are again broken down and it's exactly the same process.

So I think when people get comfortable with that and think, okay, I've got my mind around the fact that this isn't going to be a piece of tech that I launch, I raise a couple of billion dollars for in venture capital, and I'm out in three years as a as a billionaire or a multi-millionaire, if they think I'm going to take a long-term patient view on this and enjoy the process, then you can be very successful selling into NHS and they can be a great partner.

Matthew

I've absolutely no problem about working with the private sector, with commercial partners, very important part of how we drive innovation in the NHS. But I do sometimes feel that our commercial partners, the way they talk with us and engage with us, does not fully understand the challenges that we face in the NHS and doesn't understand, for example, the public's view, which is when it comes to issues like profit or data, that the public attitude to these things is that they don't want that much money to be made in profit from something that's paid for by taxpayers.

They don't want private sector companies they don't completely trust have access to public sector data. And I sometimes think that commercial partners treat these things as kind of annoying interference with their big idea. And I'll say, no, this is part and parcel of working with the public sector, with its accountability, with its limited budgets, with the fact that it has to ration its resources.

Now that that that takes me to your business model because and I thought when you told me this, it was really impressive and I didn't think you were blowing smoke up my posterior when you told me about it, so you can share it with listeners, but you are absolutely driven by wanting to make a change.

You're absolutely driven by wanting to improve the quality of surgical education or education for surgeons. And what that means for you, particularly in the British context, is you're going to sell this as cheap as you can in order to make a reasonable profit. But actually, what you're driven by is the spread of your technology and the impact it will have.

Elliot

We believe in it so much that we've made affordability one of our three core values, and I'll take a step back if that's okay, because it helps, I have one way of answering pretty much every question anyone asks me about the business, either internally or externally, and I can answer it by our mission statement. So our mission is simply to become the world's partner for surgical training and what that actually looks like in practice is, whoever you may be, a loved one or yourself, if you're going for a surgical procedure wherever you are in the world, if we've achieved our mission, you'll be able to turn to the surgeon and say, how did you learn how to do this? And they'll say, well, I use the Innovus technology. But most importantly, I had to do it this many times in the safe simulated environment to this standard, objectively measured before I touched a patient.

And when you think about that as a mission statement that helps get everyone out of bed, across the business, and all our stakeholders get excited by it.

So how are we going to achieve that mission? We're not going to achieve that mission by price gouging people. It's just not going to work. And so, when we go back and look at that problem we were looking to solve, what were one of the problems we realised, well, simulators exist, People can use them, but there are £150,000 for a piece of kit, and you put one or two of those in the large training centres in the country, what about the people in in rural parts of the country who don't have access to that, that simulator? It’s not fair.

So, when we looked at that, we said, well, affordability must be a core value for us. And I wasn't blowing smoke and I'll share, I think the story I may have shared with you, which is our flagship product, which is we like to think and this good evidence for this has made a paradigm shift in the quality of training, we bring to the market for one fifth of the price of our nearest competitor.

And we do have venture capital investors that sit on the board and they say, well, could maybe we consider maybe doubling the price and you're still vastly more affordable than the competitors. And our answer is no, because it won't move the needle and it won't allow us to achieve our mission. So, we believe in that really heavily. And I'll just share this one last point.

The most difficult part for me of running the business is I've now stopped clinical practice for the time being. I miss that immensely. And the only thing that got me to stop that and that moved me out of clinical practice was the thought that we actually have a real chance of achieving that mission. And I need to be here at the helm to make sure that one of those very important core values of affordability we stay true to and so far we've managed to, which is great.

Matthew

And tell me also, Elliot, because we haven't mentioned this at all about your workforce, because that was another really fascinating thing you shared with me. You've brought some really great jobs to a part of the world that needs them.

Elliot

And I mean, when I'm describing the technology, some listeners may not expect for me to say that our headquarters are in St Helens in the northwest of the UK, famous for coal mining, glass manufacturing and a certain rugby league team and hopefully soon to be famous for surgical training technologies.

But and I'll take a step back. I grew up in a in South Wales. My co-founder grew up in the northwest in St Helens. We were both, and we know how lucky we were, incredibly lucky to meet the right people to mentor us at the right stages of our lives to get us to where we are.

We both talk about that all the time and so we take that process and that responsibility for ourselves very seriously now. So, in St Helens, there are some incredibly talented young people, and you find them in the strangest places. So hopefully this this will be an enjoyable story. We found one of our most talented products engineers in Maplin or the former Maplin Electronics store.

We like to joke that we nabbed him and then the whole the whole corporation came tumbling down. This is a young 19-year-old lad who's grown up in St Helens, doesn't particularly want to go to university and labour himself with student debts and starts talking to my co-founder about something that my co-founder didn't even understand - he was a very good engineer - and my co-founder had the foresight to say, hang on, who are you? What are you doing? And would you like to come potentially work for us?

And that was four or five years ago, and this guy hasn’t had to go to university. He's now operating as a mid to senior level engineer in his early twenties, earning great money, learning amazing skills, adding unbelievable value to us as an organisation.

And we've got that story over and over and over and over again. And so, what we've actually done, and we're really proud of this, is we've built a sort of career progression continuum so that we can think about that in a more long-standing and forward-looking view. So, we have the continuum where we know we can bring people in as apprentices, we can bring them in as interns and plug them into the various parts of the business and accelerate people through because as we move them up, we're going to need to backfill them.

And so yeah, we're really proud of that and, and that particular story is one that always brings a smile to people's faces.

Matthew

I mean, I could talk with you for hours, but we're running out of time.

So, the final question, I guess is, is what's next? Now, I know you're taking the product out to the rest of the world. I'm really interested in the challenges that that involves. Particularly, I think you're working in the States. I wonder whether you're resisting the opportunity to make a bigger profit in America, where they are arguably, they've got bigger budgets to spend on things.

But also, to what extent is the next stage for you all about widening the use of this technology, or do you have other ideas in the back of your mind, new products that you'd like to explore developing?

Elliot

A lot of people think, oh, you're probably just poised to double the price in the US, and it's not the case because we spent a lot of time again asking the questions of the end users.

What are your challenges and what are your problems? And alarmingly, I was sitting there going, oh my goodness, these are exactly the same as the problems they have in the NHS. There's not necessarily central funding or clear budgets for training because it's still technically a nice to have. It's a little bit more mature in the US in that there are certain benchmarks or objective standards you have to show to progress in your training. We're not quite there yet in the UK, but we're getting there.

So first of all, it's great because we can keep the same narrative and the same story going and over the other side of the pond, they love it, they’re like these guys are really thinking about the problems we have. So that's, that's been really refreshing.

To your point of do we look to new products? There are two answers to that: The first is focus is absolutely key. It's key for us to make sure that we deliver on that mission. And the first thing we need to do is get to a level of adoption in the United States that we have had here in the UK. And again, it goes back to that, the NHS has been a brilliant partner, we would not be in a position to be entering the US without the NHS as a customer because it's such a strong customer base for us. Our plan is to take the technology we have and get to the same level of sort of market penetration there in the US with exactly the same core values.

The other interesting thing with our current products is that part of our mission statement of being the world's partner. And I'll just share this, if I may, it’s a really proud moment for us, which is in December we announced that we're the official partner for the Association of American Gynaecological Laparoscopists, their flagship national training program. So now any gynaecologist being trained in minimally invasive surgery, laparoscopic or hysteroscopy, the technology to do that is our technology, and it's being made in St Helens in the northwest of England.

And that's an example of really where we're going with our strategy, which is not just trying to sell widgets to sites and make money. It's how do we actually come away from this, however many decades it takes us step back and go, wow, we've really made we've really made an impact here to patients’ lives.

And then the final piece very, very quickly, which is you have to be forward looking for the future and what technologies do you want to develop? Well, we're constantly developing our technology stack, but also, what are the parts of surgery do we need to address? We only address two very small parts of that right now, and our plan is, of course, to address all of it. So, lots to do. Very exciting times. And most importantly, we're really enjoying as we go along.

Mathew

It's been great to talk with you.  I'm glad that you've shared those experiences with us. And, you know, I wish you great luck as you go in the next stages of your journey.

Elliot

Thank you, Matthew. And as I say, it was lovely to meet you and thank you so much for having me on the podcast. Hopefully it's added some value to the listeners.

Matthew

For some people listening to Elliot's story, there might be a sense that there's kind of two separate parts to it.

There's this very clever entrepreneurial technological side to it, the business side to it, and then there's all the other things Elliot shared with us about the way he goes about this, about what motivated him. But I want to argue that those two sides absolutely go together and that the message I would have for any entrepreneur, innovator, wanting to work with the NHS is to apply the principles that shine out so much from Elliot's account.

So first of all, really focus on the problem. How often is it that I've spoken to people in the NHS and commercial partners and got the sense that the partners aren't really fully understanding the problem? They've got something to sell. And you know, as the old phrase goes, you know, to the person with a hammer, everything looks like a nail.

So, they've got a product and they need to make the problem fit the product. So first of all, make the product fit the problem. Don't try and force the problem to fit the product. And then secondly, ultimately, your aim when you're working with the public sector, with the NHS, has got to be impact. It's got to be making a difference to the world.

Profit is a means for you to do that, but if the aim is profit, an impact is secondary. Well, you know, you're not going to get the trust. And again, what shines out from earlier is what drives him is impact. And profit is a means to an end.

And then finally, if you're working with a public sector organisation, the NHS, based absolutely on a core set of ethical values, then you need yourself to be an organisation that takes ethics seriously in what you do.

So, I suppose I want to say to commercial partners, focus on the problem, aim for maximum impact, and recognise the ethical challenges of working with a not-for-profit organisation, a public sector organisation, and you're much more likely to succeed.