Dr David Cox worked as an A&E registrar at Charing Cross, and was also at Beacon Health Strategies, trying to improve mental healthcare in the NHS, before becoming the Chief Medical Officer of the digital health platform Headspace. The guided meditation app has been downloaded 4 million times in more than 150 countries.
We interviewed David to find out more about his experiences transitioning from clinical training into digital health, and his advice for other budding doctor- entrepreneurs keen to do the same…
Hi David, great to talk with you today. Can you please start off by telling us about Headspace. What is it? Who uses it, and why?
Sure. Headspace is an app and a website that was founded by a monk and an adman, that aims to teach people the skill of mindfulness through daily practices in mindful meditation. You can use it offline, it’s bite size, and it’s just trying to get people to take 10 minutes out of their day, every day, to develop the skill, which helps in very many ways.
It’s been around about five years or so. We’ve got four million users and growing fast. It started off as a skills swap between Rich, the ad man, and Andy, the monk.
Rich was looking for ways to deal with the stress of the lifestyle involved in the ad industry that he was working in. He went to Andy and really thought it was incredible what Andy was teaching and how he was teaching it.
Andy was saying, “I want to get this to more people, but I’m finding it quite hard”, sat there with a company name over the door that was in Sanskrit, and Rich was like, “well, you my friend, have a brand image problem, so that’s something I know something about. Let’s talk about that”. And Headspace was born.
And they started off actually as an events company with Andy teaching a one-day course to a small group of people. Over time, the demand outstripped Andy's bandwidth to give courses, and what started off as take-home materials intended for people who attended the courses, actually ended up furnishing the material for the first version of the app. After about two and a half years, they had the idea, and they said, “well let's make an app”, and the app was a roaring success. So much so that they stopped doing the live events, and it's all just based around the app and the website now.
Amazing. And so what was it that led you to become involved in Headspace?
It’s one of those kind of random stories… I was working in a company called Beacon Health Strategies, which was trying to introduce a new model of mental healthcare into the NHS. My father had an accident and ended up dying in hospital, which was unexpected. I was doing all the things that I would have advised a patient to do, and nothing was really making much difference. I was looking for something to help support myself, and I read a magazine article about Headspace.
I had been aware that meditation was one of those things that supposedly has lots of benefits, but I had tried meditation a couple of times previously, and it was all a bit, sort of tree-huggy and crystal healing – not my kind of thing. The thing about this article was that it basically said Headspace is meditation for people who don’t do meditation.
And I thought, it’s only 10 minutes, and this is clearly aiming at people like me who are deeply skeptical. I tried it out, and actually found it palatable, so I kept doing it. After about four or six weeks, the change in me was night and day, and, literally my friends were saying ‘David, what are you taking?’ I wasn’t taking anything, and I was just meditating with this app.
I was like, “wow, they've found a way to present meditation in a way that doesn't, kind of, make your skin crawl, or activate all my mumbo jumbo senses”, coming from a medical background. There's quite a lot of scientific research and literature into the benefits of mindfulness meditation. The more I looked at that, the more I thought, “wow, there's something here that really has the power to help a lot of people”. And now it's been packaged in a way that actually is able to get it to a lot of people, so there's a huge potential there.
This is where fate took over. I was at a technology in mental health conference, in the audience, and somebody sat down next to me in an empty seat. We shook hands and exchanged business cards, and – it was Rich, the founder of Headspace. And I whipped out my phone and said, “what, this Headspace?” And he said, “yes, that Headspace”.
He introduced me to Andy, and so for a few months I just used to meet up socially with them, and chat. I was always getting really excited about the potential, and the science, and one day they turned round and said, “do you want to come and do all of that for us?”
That is an opportunity that doesn’t come along every day, and if I can play a small part in helping to deliver this potential that I have been so impressed by, I can’t turn that down. But it was really scary… it was not the plan. I had a plan, and this was not the plan…
Can you tell me more about the challenges that you’ve come up against, both personally and as a company? You were saying, from a personal point of view, it was quite different to the path that you thought you would take originally…
I had mapped out for myself a path that I thought I wanted to be a hospital chief executive, and I was trying to make career moves that were basically ticking the boxes to build a CV towards that.
Right, the medicine conveyor belt…
I always had an idea of what I thought the next job should be, and possibly even the job after that. It wasn’t set in stone, but I had an idea of how to navigate my way towards that goal. And this was a 90 degree left turn and straight off-piste.
The really scary question was, if it doesn’t work, what next? And until then, I’d always known what my next step would be, so that was really scary.
But I kept coming back to the same thought: “If I don’t give this a shot, I’m going to spend the rest of my life wondering what if”.
From the perspective of the challenges for the company, the challenge we face every day is trying to educate people about what meditation is, and actually, more importantly, what meditation isn’t, and you know, everybody… if I say the word meditation to you, you have an image in your mind of the kind of person that does it. What they’re wearing, what they look like, what kind of person they are…
Kind of trees they like…
Exactly, exactly. What kind of trees they like hugging. But the reality is that, you know, anybody can meditate. It is entirely secular. It’s just about training your mind in certain ways. And so, it’s just trying to get that point across to people, to get them to give it a go.
But I kept coming back to the same thought: “If I don’t give this a shot, I’m going to spend the rest of my life wondering what if”.
Right. Why do you think it is that Headspace has become so successful? I know you spoke about some of your personal experiences, but do you have any other ideas as to why it’s been so successful?
It’s the sort of perfect synthesis or perfect union between Andy, the monk who founded it, and Rich, the ad man.
Andy’s an English guy, who spent 10 years in monasteries learning meditation, and learning how to teach meditation. He has a depth of experience and authenticity that is impossible to rival – unless you yourself have spent 10 years in monasteries. And then Rich is a genius at the brand, the marketing. And so he’s able to package that authenticity and experience in a way that bypasses all of people’s tree hugging alarm bells.
It’s a very nice presentation of something that has a lot of authenticity and therefore actually just really works. So if you put it in a way that means people are willing to give it a go, and then when they give it a go, it starts working, it just takes off on its own. We’ve never had to pay for advertising, because people just talk about it.
And what’s the business model of Headspace?
It’s a freemium model. You can get access to the first 10 days of meditation for free, and actually you can just do those 10 days over and over and over again, if you wanted to, so there’s no instance in which people would ever be unable to have access to Headspace. And that was very important to Andy. He said, “look, this is not about making money out of meditation, this is about getting it to as many people as possible, and we’re only going to do that if we make sure that there isn’t a financial barrier to it”.
Headspace is a training in meditation, and so there are hundreds of meditations that are sequential, that Andy talks you through, so you're not repeating yourself, and actually every day he's introducing new concepts or new practices or new ideas, so it's literally like having a personal teacher that's in your pocket.
However, in order to pay the salaries of the genius designers and other staff that work at Headspace, there is a subscription that gives you access to the rest of the training system, which is like a kind of library of contents. The beginning few meditations teach you some basic techniques, but then the other stuff that’s in the library is about specifics on how to use those techniques to focus on particular problem areas you might have.
But, if you’re not willing to subscribe, you’re not done. You can actually just keep doing the 10 days over and over, it’s not a once only thing.
Ah, interesting. I didn’t know that. Are you able to tell me a little bit about the early funding for the app, what happened and how it was secured, between Andy and Rich?
It had been going for a couple of years before I joined. As I understand, there was seed funding from an early group of angel investors, who were particularly focused on making investments that were philanthropic.
Or trying to do, you know, good in the world, on a large scale. That was a long time ago, and since then we haven’t had any more funding.
what I would say to people is find ways to find out what else you’re interested in or what else you could be good at, and don’t undervalue the skills that you have, because they are valuable.
And do you have any advice for other medics that are keen to become entrepreneurs?
I had to make the decision that I wanted to be a medic when I was quite young, and I’m sure that’s true for most people, unless they’re coming as mature students. So for me, that meant choosing your GCSEs and then your A Levels in order to get into medical school, in order to become a doctor. So, I was 14 or 15 when I was having to make this kind of decision. And on reflection, at that point, you really haven’t got a clue what you’re going to be any good at.
But you get on the track, and then you go through… And so, if you get to a point where you’re thinking about doing something other than medicine, two things are true. One, you have a really good interesting skills set, and you’ve proven that you can do academic stuff, and you can do the tough slog, and pass all those exams and all that kind of stuff. And that’s valuable, and shouldn’t be undervalued. The other thing is that you probably don’t know what else you can be good at, because you’ve been on this road for such a long time.
So what I would say to people is find ways to find out what else you’re interested in or what else you could be good at, and don’t undervalue the skills that you have, because they are valuable.
First and foremost being the skill of being able to learn, which means that you can learn other skills, and you can learn new stuff, you can learn to do new things. Clearly, you’ve spent a decade or more proving you can learn. Then it’s just having the courage to leap off the cliff and actually do it, which is a big moment.
I think it’s harder these days. When I was getting into medical school, it was clear that the people ahead of me were able to take like a kind of career break for a couple of years and go and do something else, and it was easy enough to come back in.
Nowadays, my sense is that it is actually a bit harder to come back to it. It seems like more of a one-way ticket, if you’re going to leave medicine. It’s not impossible to come back, but, you know, there’s more competition for places, and you’re going to have to justify why did you leave, and that kind of stuff. So I think it takes quite a lot of courage to say, okay, this is what I’m going to do.
You might not know what your safety net is, or how to have one, but that’s when I come back to saying, “realise the value in the skills that you have, and your ability to acquire new skills”.
Regular meditation has been shown to reduce the amount of cortisol present in the brain thus leading to all kinds of beneficial effects, including an increase in libido.
You just touched on it lightly just now, but do you think that doctors should continue with clinical practice when they are involved in start-ups, particularly in the early stages?
I think it very much depends on the start-up. Certainly within medicine and within medically related start-ups, there is a huge amount of credibility. I thought there was a huge amount of credibility that came from saying, “yes, I am a doctor, and I have done what you do”. I found that actually there is definitely a distinction made about those who stop practising and can say, you know, yes I have done what you’ve done, to which people say, right, but do you really know what it’s like now? And that becomes more and more of a distinction the longer it’s been since you stopped practising.
Whereas if you could say, no, I still practice, that definitely buys you credibility with those within the profession. So, if that’s something that is necessary, depending on what the start-up is, if you’re going to be, you know, creating a new medical widget, and you can say, yes, and I still practice, I think that’s really important.
…from my perspective, I think the future of healthcare is going to be less and less about curing viruses and bacteria, and more and more about driving behaviour change in human beings.
Okay. Interesting. Thanks for that. Still in the clinical arena, do you see that Headspace might impact on clinical practice, and if so, how?
I hope so. NICE already recognises mindfulness therapy with respect to depression, and I think that’s going to expand. I would like to see if I can get us to a place where we could be prescribed for things. There’s lots of difficulty with that, just around the fact that (and this is something that’s true of a lot of apps), the speed with which apps develop, and technology develops is on a whole different cadence than the speed at which the system does things like regulatory authority approval.
And so this is becoming a real issue, both in the US, where they’re trying to get FDA approval for computer games that help with things like ADHD, and in the UK, where they’re still not entirely sure if an app is a medical device or not, and therefore does it go down that channel or this channel. Now they’re looking at changing the EU advice to the regulatory authorities, and the process to update the EU advice takes five years! But the phones are unrecognisable in two, so that’s kind of a tough thing to navigate.
But from my perspective, I think the future of healthcare is going to be less and less about curing viruses and bacteria, and more and more about driving behaviour change in human beings….
And where do you see Headspace in 5 years?
Hopefully, with, you know three hundred million users, or three billion users, or something like that! We are literally not going to stop until people think the same way about meditating as you do about brushing your teeth, or eating fruit and veg, or knowing you’re supposed to go the gym.
There’s nothing really on that list that’s about the health of your mind. So when people think in the same way about taking 10 minutes of your day to look after the health of your mind, as they do about brushing your teeth every day, that’s when we’ll be able to stop.
If you could change one thing about your career trajectory, or your move into this entrepreneurial area, what would it be?
I don’t know that I would change much, because, the thing that I finally ended up doing, that gives me more satisfaction than anything else I’ve ever done before, I didn’t plan for, it fell into my lap, and I was lucky enough to recognise the opportunity that it represented.
I think I was fortunate enough to have the confidence to grab the opportunity when I saw it. That is my kind of big message to people, is just, ‘go out there and do it’. You know, it’s scary as hell, but, you know, honestly, what’s the worst that can happen? You’re not going to end up becoming a street sweeper.