In February 2022 Francesca founded Nen Health, a purpose driven organisation built to help children with cancer manage their pain. As someone with experience caring for a child in severe long term pain it is difficult to overstate the importance of this work and how honoured I was to speak to Francesca about her incredible story and achievements to date.

Liv:  Francesca, am desperate to get into talking about your business, , and the work that you are doing at the moment. But before we do all of that, , I’d like to find out first a little bit more about Francesca away from work?

Francesca: Sure. I’m a mom of three teenage boys, so Max is 17. Charlie’s almost 16 and Simon’s 13. So that certainly keeps me very busy as a taxi driver when I’m not working. They’re a great source of humor and joy and inspiration. 

Liv: So what are the things outside of ferrying your boys around, what sort of things interest you outside work?

Francesca: We’re, we really are very focused on our family. We are quite busy during the week. Both my husband and I are both digital, pediatric digital therapeutic CEOs so we are quite busy during the week. They’re quite busy, the boys with their sports during the week. So on the weekends we really like to relax when we can, when we’re not driving them to their various sports games and practices. As a family we love traveling and going out to eat and, exploring new things and getting fresh memories.

Liv: Perfect. So let’s talk about your work then. Because this is so fabulous what you’re doing. You’ve worked at some huge organisations and then in February 22, you came away from all of that to set up Nen. So tell us about that?

Francesca: Yeah, so you know my career over the past 30 years now has been really focused on drug development, but it hasn’t been a linear route. I started in managing clinical trials, then I went on to get my PhD and change as a scientist and then went into biotech private equity then, strategic management consulting and then have been in pharma for quite some time.
The red line has always been trying to accelerate product development to get to patients who really can stand to benefit from it. And about nearly eight years ago, I got into the digital health. First as a digital health venture capital investor with Merck, and then as Chief Digital Officer, where we were operationalising digital solutions in house at Almirall.
We also started a digital health Startup Accelerator there, which was great. We incubated a total of 10 companies and helped them with their business models and with their market plan. I’m happyto say they are still around, and that’s been great news. We’ve had two exits, which is unusual and quite nice. But it really got us very close to the startup world and thinking about, not just creating solutions, but really solving problems within healthcare startups. Startups come up with really cool tech that isn’t really keeping anyone up at night.
We always try to focus on solution seeking for real world problems, either within the industry or within healthcare. When I was thinking about what my next steps would be, I knew I wanted to do something that was very mission driven, that had patients truly at the core and can really benefit patients lives in a meaningful way.
So I put my consulting hat back on. I did a scan of the whole of the digital health landscape and was really surprised to see there were so few innovations within pediatrics in terms of digital health. The venn diagram was, where are the gaps, where are the needs? Can those gaps or needs be filled with a digital solution, but specifically with a digital therapeutic? Because I feel strongly that’s the fourth wave of medicine. We’ve had small molecules. Then biologics, then cell and gene therapy. I’ve been lucky enough to work across all of those areas, but now I really see digital therapeutics as the wave of the future, particularly when our healthcare systems are so taxed after Covid, there’s tremendous healthcare provider attrition.
So how do we solve real world problems using digital therapeutics? And then the last piece of that Venn diagram is, do I care? Is this something that I can be really passionate about. And that was the genesis of Nen. We had looked at digital therapeutic solutions for adults to help adults management manage the pain via cognitive behavioral therapy, and I thought why not apply and adapt that for children? Pain is such a huge issue in pediatrics and is really not an area of a tremendous amount of research. And there is a W H O mandate that came out that said,  managing pain for kids is a fundamental human right.
I thought why not apply gamification and leverage play in children? To to find a way to get them the therapy that they need and then democratise that therapy to make sure that kids all over the world, regardless of their economic situation of their access to healthcare, could benefit from it.

Liv: So why do you think that it was an area of so little research, now you’ve come some way down the line, what have you learned?

Francesca: It’s not entirely clear. I think pediatrics is viewed as a very niche market. I don’t think it’s so niche, a quarter of our population or kids so it’s really quite large. They’re probably the predominant users of digital technology. My children are constantly showing me new things on my phone, and on the computer. And they’ve grown. They’ve never lived without technology. And for them it’s perfectly normal. If you ask them how they’d like to get therapy, and there was a study about this recently. I think it was something like 75% of them would rather get therapy on a digital platform versus in person. , something they’re familiar with and, we’re trying to create and gamify therapy for kids so that it’s fun and they don’t even really realise that they’re getting therapy or they’re learning these skills along the way. But, it is in fact delivering what we think will be the same level of effectiveness and efficacy that, that we’re seeing, in person setting. Part of the problem with pediatrics is, within the mental health space, there are very few pediatric psychologists, even fewer, that are trained in pain management.
So it really becomes an access issue. We have a collaboration with the largest pediatric oncology centre in Europe and they expect to see 2000 kids with cancer this year. And there’s one pain psychologist that’s managing all of those patients 
Currently,  kids are triaged based on whether or not they have preexisting mental health conditions. And within the course of that therapy, if their therapist happens to be trained management, they get some management. CBT is great in that it can really be applied to kids across different conditions, different types of cancer, different stages of cancer and can be modified across different ages as well.
We’re focusing on kids with cancer between 7 to 12. , but then we’re going to quickly expand to the littles, which is where there’s a huge area of unmet need. The scientific comparators aren’t as robust as that mid age range, which is why we’re starting there. Then we’ll go into the adolescence.
Then beyond pain cancer, we’re going to look to do smaller studies in different areas of chronic pain for kids like, irritable bowel disease, migraine, aplastic anemia, sickle cell, orthopedic issues neurodegenerative conditions. So our goal is to really treat kids with pain across the continuum and wherever.

Liv: Wow. Talk to me more about the gamification bit? I’ve got a nearly nine year old and a nearly 10 year old,  they’re on Minecraft and Roblox all the time. They know so much about coding etc. Is that what you’re bringing out of them when they’re doing this? 

Francesca:  That’s exactly right. So we’re creating a bit of a fantasy world for them. We have three virtual companions who look like these sort of forest fairy creatures that are very gender neutral.  They’re not bound by ethnic norms.
Initially we had a bunch of virtual companions that we thought we would create to look like the children, but because we want a global footprint, it’s really hard to do, so we’ve created these sort of non-human creatures that guide them through their journey. For kids, particularly with small kids, it’s very difficult for them to distinguish mood from pain. So you can have a very happy child who’s in a tremendous amount of pain, or a very sad child who isn’t in pain at all or two year old. And as you know, What do you even do to manage them? ? So,  Dolores is our virtual companion that deals with CBT directed at pain. So her activities and her games will always be associated with pain, but in a way that doesn’t make the children really focus on their pain and catastrophize about their pain.
A bit of pain education, some CBT techniques that we know work in the pain setting, some distraction techniques, some belly breathing and cognitive skills that help them put their pain into the right context. These skills we expect the children to take with them beyond the gaming experience so that they can pull from their armamentarium and their toolbox. It’ll be a literal toolbox within the game and they’ll be collecting all these skills.  Then we have Sarah and Tony that are more focused on the sero receptor pathways. So Sarah focuses on anxiety and asking questions about the procedures. Or, for different things that they’re going to face within their illness. Then Tony will focus on depression. So he’ll ask questions, are you sad? Let’s talk about that. The goal is to provide C B T for pain, but also for anxiety and depression, but also give children the appropriate lexicon that they can start talking to about their issues with parents, with healthcare providers, with their therapists. Because many of these children are also receiving therapy outside of the hospital setting. The C B T is gold standard. We know that it works. We know that it works in kids of this age.
We know it works across indications. Again, we’re starting with oncology. Because from a clinical experimentation perspective, it’s where we think we have the highest probability of getting our clinical validation, but then we’ll expand more broadly. So the gamification piece is a tool that we can use to use positive psychology and rewards based psychology in order to get the children to complete their modules and, unlock different worlds and different rewards along the way.
Altruism is also something that, as a mom is really important for me to introduce to the kids. I think the whole world can do with a bit more kindness so children can share their points and their rewards, either with actual children or with virtual children. We’re trying to work through the implications there.
We don’t want to pair children up directly who are experiencing the same condition. If one has a poorer prognosis, it can be distressing  for the child, but we encourage siblings and cousins to play in with them to give bit sense of community. 

Liv: So you’re a year in now, it must have been a rollercoaster for you?

Francesca: Yeah it’s definitely been a rollercoaster, but it’s certainly the best thing that I’ve ever done professionally or personally. As a family, we’re all really bought in, we’re early investors.
We’ve also brought on angel investors, and I’ve been really humbled by help, both financially and strategically that we’ve received from our advisory boards. We have an amazing clinical advisory board that is comprised of worldwide experts in pediatric pain. Then our business advisory board, which are top digital health venture capitalists pediatric innovators, social impact drivers, and some names some would know within the digital health community. Both these boards have been absolutely critical in unlocking doors and unlocking things for us, and I think is really responsible for our momentum and the speed with which we’ve been able to tackle our milestones.
We set out milestones for two years at the very beginning, and by six months we had reached all of them. So we’re moving fast, which is fantastic. It’s a bit of a rollercoaster during a tornado sometimes, but it’s great fun. We did our first patient testing with our product this weekend actually, where we were able to pilot directly with kids to get their views on the platform we use in CBT modules for them to try out. We’re really excited to see it developing into a product. It’s been great fun. We’re in the process now of our series A 10 million round of fundraising which is going well, and hopefully we’ll close that in the first half of this year.
 
Liv: Have you had any feedback yet from this weekend? From the kids that have seen it?

Francesca: I haven’t yet. In fact, I have a call right after this, so I’m really looking forward to hearing that. 

Liv: So what has been the biggest challenge for you personally? 
You’ve come away from working as an employee in these large organisations to setting this fabulous business up. It’s quite a journey.

Francesca: It is. And I think the biggest difference is the speed that we’re able to to achieve our goals. I think what’s been most surprising is how kind people are and how willing to help they are, that’s been it’s been such a lovely and pleasant surprise.
We’ve had people, opening up their brains to us, their wallets to us. And the money that we’ve raised so far has been people investing personally. Because they are really aligned with our mission and vision. That’s a tremendous responsibility. We want to make sure we do right by them.
The biggest pressure I would say is making sure that we have a product that’s clinically validated, that’s always based in science to make sure that we’re getting something that really works for kids and families and that physicians will feel comfortable prescribing. Because our goal is to have this as a prescribed digital therapeutic.
That’s something that we take very seriously. The very first thing that we did was to form a clinical advisory board to make sure that we were staying true to what the clinical research is, what the clinical practice is, and making sure that we incorporate all of that into the product from the very beginning.
Also working with parents and kids from the very beginning to make sure that they’re helping us co-develop the product in a way that’s meaningful and useful and for the kids fund for them.

Liv: I imagine the engagement that you’ve had from some parents must have been fairly overwhelming?

Francesca: Really overwhelming yes, and we always make a point of, securing some time in our agendas after a call with parents or with kids because their stories are so difficult and the strength that they have is just amazing. We’ve also had some parents reach out to us who have lost children, but they really want to help other kids with their experience and across the board. What we’ve heard from parents is, Beyond the initial diagnosis of cancer, which is obviously devastating for these families, managing their pain is the second most difficult part of this journey for them. Parents feel helpless in terms of not really having much to do to help their kids during this time. So we thought of it initially as a nice to have set of parent services, for development of parents. To make sure that we can give them the tools that they need to help their kids get the best outcomes from CBT. We’re not going to be delivering CBT to the parents directly, though that was a discussion that we had as well. But we really want the patient, the child, to be our focus. But we want to give the parents the tools. Things like parental modeling social learning. Even scripts to show how to respond in a way that is supportive of the CBT that they’re getting and that doesn’t augment the catastrophization that the kids are feeling sometimes that the parents, of course every parent wants to do what’s best for their child, but these are very visceral responses sometimes. Making sure that they are saying things to the child that are supportive and helpful rather than, potentially negative or causing some untoward responses.

Liv: It’s giving them a feeling of control back at a time when they feel completely helpless.  I have some personal experience with that and I can tell you as a parent, just being told that there is something you can do, and feeling that you can make the tiniest bit of difference at any time, it goes a long way. 

Francesca: Yeah. That’s exactly what we’ve heard from other parents and we’re giving the parents some homework as well. Some of the parental assessments are going to be done by the parents rather than by the physicians. Because if we rely on the physicians, again, we’re confronted with this access issue.
So we want to empower the parents who know the child better than anyone. Of course these are all parent reported outcomes that have been co-developed between parents and physicians, so they’re easy for a lay person to understand.
It’s just a series of dropdowns in the platform that the parents have access to.   The two apps are connected so the parents can see the progression that the child is having within the game and can understand some of the modules that they’re completing.

Liv:  Has it changed you, do you think this last year?

Francesca: Yeah. In so many ways. I think my understanding of what a patient-centric solution is was I would say, much more superficial than it is now. I think that’s a buzzword that, that pharma throws around with all the best intentions. But really having that contact with parents, with providers, with kids directly. This week I’m going to be performing a series of of interviews with kids as well, to have them look at the platform.
Having that one-to-one interaction, really trying to solve real problems that they have,  has been for me, really life-changing. I think from all of my different career career spots or stops I would say, along my career path being an entrepreneur, being responsible for for the company, for the team that we’ve grown now to nine people, we’re looking to hire two more in the middle of the year after our funding round closes.
That’s been really eye-opening. I think as as an investor, you realise that it’s tough and it’s stressful, but I don’t think I appreciated to what extent that’s true. So I applaud all the entrepreneurs out there . Because it really is hard work.
It’s very gratifying work, professionally, this is by far the best thing I’ve ever done. But personally as well. 

Liv:  I can imagine. So what’s next for you then?

Francesca: I’m hoping over the next five years we’ll go through all of our clinical trials for cancer, for the different age ranges, for the different pain indications. We’ll have a product on the market that’s that’s been through regulatory clearance, that’s reimbursed and that we can get into the hands of kids and families.
But we’re very much a profit for purpose company. So my goal is not just to to have this return on investment for our venture capital investors, but really to get them to kids all over the world where, wherever they might need it. Soon we’re going to be bringing on a very senior exec onto the team to help us with the social impact democratisation of the platform , that’s really key to to who we are as a company with the idea that we’ll start partnering with NGOs and organisations once we’ve clinically validated to make sure that we get them either into hospitals or just into neighbourhoods where kids can access it regardless of whether their parents have the ability to pay, whether they have any sort of health insurance or there’s any sort of structured health system that that they can access. So that that democratisation piece, I think will be very difficult, but also incredibly satisfying. Even in places like the US where we’ll have a B2C channel directly to parents. We’ll also be going directly to hospitals with our our b2b version of the business. And then of course our prescribed digital therapeutic through payers and and insurance providers and corporations health insurance plans.
If you look at who is covered with all three of those areas, there are still a lot of kids that don’t have health insurance. I think in the US children are the largest proportion of uninsured, and so we want to make sure we work with grassroots organisations in the US to make sure that those children have access to Nen as well as in, the southern global where the healthcare systems have a huge access problem and children don’t have access to things like CBT. Then hopefully beyond the next five years, we try to expand on that and just work on expanding healthcare to children beyond beyond the platform. 

Liv: Francesca, we’ve talked a lot about your business . Normally it is more about you as an individual, but I make no apologies for the fact that we’ve talked so much about what you’re doing because it needs that time. So I’m glad to have done that and I’m fascinated by it. But I do want to get a little bit more into you, and I’m really curious as I’m talking to you, you’re so passionate about what you do.  What did you want to be when you grew up? Have you been consistently driven to this world, do you think?

Francesca: It’s an interesting question. I would say nothing about my career journey and career plans from a young age have been consistent. But I, from a very early age, I did want to be a pediatrician and I was always interested in children’s health that may be the only sort of wisp of what I’m doing now from my childhood, but I was always really interested in drug development and how we can get the best products to patients as quickly and as safely as possible.
My first job after university was managing clinical trials for an HIV aids clinic, and we had about 50 studies, loads and loads of patients. It was at the time where protease inhibitors were being tested in the clinic and they were the real hope for patients with HIV.
Because I had a lot of interaction with the patients, I saw how transformative these products were. And, there were many people who thought they were gonna die and had given up hope. And then after being on these therapies, they were reestablishing relationships and they were going back to school and looking for jobs and starting to live their lives again. That was probably the most mind-changing part of my journey. It’s what made me want to get my PhD in pharmacology initially to create more HIV drugs. That was my focus of my thesis. But then I realised in academia, though they’re doing amazing work in academia and in clinical research and basic research, I’m not a super patient person, and the pace of research was much slower than than  I was comfortable with, which is actually why I went into private equity, because you can put money behind really good products, accelerate their clinical development and get them to market sooner, safer.
That was really compelling to me. So I think that acceleration of access to healthcare was was really the red line. I think if you would’ve asked my much younger self my career path would’ve been expected, probably not because , I don’t know that I would’ve expected to have lived in different countries and worked in different countries on different therapeutic areas.
I don’t know that there’s a therapeutic area that I haven’t touched in some way. But it’s been really fun. I think my advice to people who are starting to forge their career is try it. Don’t worry about your choices. When you’re younger and when you’re older as well. It doesn’t need to be permanent and forever. You’ll start finding things that you’re passionate about and that those tend to be the things also that you’re probably pretty good at. So keep at it and just discover what’s exciting to you and and then hopefully that can have a nice impact on the world as well.

Liv: You preempted one of my questions!  You’ve got three teenage boys. Is that your advice to them too as they start to enter adulthood?

Francesca: It is, and I hope that they choose careers without any pressure, without any any expectations from society from us as parents.
 Just find whatever it is that they really like and that they think they can do well. And and hopefully, at the same time they can also do good . All three kids are very much involved with with the company. My oldest is interning. He’s actually changing his thoughts on his career based on some of the things that he’s learned while working with us.
He was initially going to focus on biomedical engineering, I can’t imagine that most 16 year olds know that they wanna become a biomedical engineer. But he did. And now he’s shifting more into psychology and neuroscience. He’s interested in how things like neuro behavioral change can actually impact the brain and the chemical makeup and the structures of the brain.
So that’s been a little bit of a shift since he’s been working with us. My, my middle guy, Charlie, is very into graphic design. He’s very artistic and he did our logo. And and then the little guy’s a gamer , so he’s just been designated as one of our testers, which made him extraordinarily happy!
I think, even within this silly example of how they’ve been adding value to the business, it’s finding what’s great about each of them and what they’re curious about and kinda re reinforcing that and encouraging that and making sure that they find their own way. That their path isn’t predetermined for them.

Liv: I love that they’re so involved in it and it’s such a family thing. When you had your boys, how was your return to work after your maternity leave? How did you find that period of time?

Francesca: It’s it was very different with each of them. When Max was born, my oldest, I was in a private equity firm. There was lots of travel throughout a lot of my pregnancy. I would leave for California on Monday or on Sunday night, then we had an investment near near Washington so we’d fly into Washington, then had another one in Boston. We’d take the train up to Boston. I was based in New York at the time, so there was a lot of travel. It was a lot of late nights. So as soon as Max was born, I very quickly realised I loved the work, but the pace of the work just wasn’t consistent with how I wanted to be a mom. It’s not to say that other people couldn’t or shouldn’t do it, it’s just it wasn’t consistent with how I wanted to do it. So I actually went back to academia and and worked with the scientists to think through how they can commercialise some of their technology.
I was using different pieces of my experience to help in a different way. Then when my second and third were born my husband Mark and I had a boutique consultancy based in New York where we were helping pharma companies and biotech companies thinking through their portfolio prioritisation, their market optimisation.
That was really born out of the fact that we wanted to spend more time with our family and we wanted to have more flexibility. So while it was stressful because we told our parents, look, we’re quitting our jobs that are relatively okay, I’m pregnant with our second, we have a one-year-old at home, and we’re gonna go it alone! They thought we’d lost our minds, but that was stressful in the sense that we needed to make sure that we got clients to feed our children , literally. But it was also wonderful because we can take breaks right after their afternoon naps and go to the playground with them.  I joked that I had a proper a proper maternity leave when I was with the private equity firm, although I had to go back about, I think three weeks after the baby was born to go to a conference. So my husband and the baby had to come along with me. It was a little bit of a different kinda maternity leave and it was in the US.
Then with the second and third it was our own business. So we worked, I was on a call in the taxi on the way to the hospital. I was having a conference call when I was getting my epidural. So it was very different! We went right back into work as soon as we brought the babies home. But then when we moved to Switzerland, we were actually pitching work to to Novartis at the time as part of our business. They wanted to hire one or both of us to do the role that we were pitching on as a more permanent employee in Switzerland.
So at this point, I think I was eight months pregnant with our last, and I said, you know what? I said to my husband, why don’t you go for this , and I’m gonna take some time off , accumulate all of my maternity leaves and I stayed home with the kids for just under a year. It was wonderful. So my return back to work after having the kids was was more immediate. But then I was lucky enough to have time to spend with them when they were all still really little. The youngest was five months and then I had a two year old and our oldest turned four on the plane on the way over, so really little ones. That was really nice.

Liv: It’s lovely that you and your husband were doing that together.

Francesca: Yeah. I have to say, without his support, I  certainly wouldn’t be able to do this, but probably wouldn’t have been able to do most of the roles I’ve taken on.
We were business partners, but we’re very much partners as well and view our roles with the kids as completely joint. So I think we’ve both made choices and in some cases sacrifices for the family because that’s what’s most important to us. 

Liv:What do you think you’d be doing if it wasn’t this? Do you ever think about  a different route you might have taken?

Francesca: I honestly have no idea because I didn’t think I would be doing this,
so I’m not really sure how to answer that. I wish I had a wonderful answer that would be a completely different, based on a hobby of mine! I really love what I’m doing. I’ve really loved what I’ve done. I love learning, that’s been a really important aspect of every new role I take.
My favorite day is the first day of a new job when I have absolutely no idea what I’m doing. I love that and I have to figure it out.  I think the detective work is something that drew me to academia. It drew me to strategic and management consulting. I think being an entrepreneur now, every day I wake up and there’s at least 10 things that I don’t know, that I have to figure out.So maybe I would be a detective or something?!

Liv: Detective. That’d be amazing! Fantastic. It’s been so lovely to talk to you. If anybody wants to know more about your business, can we send them to your website? Can we get them to get in touch with you via email? 

Francesca: Absolutely. Thank you so much for having me. 

If you would like to contact Francesca directly or find out more about Nen’s mission, you can email her on [email protected], or visit the website nen.health.