Building a Mental Health Service from the Ground Up

So I want to be reassured about the organization's motivations and ethics. And the other thing is I want to deal with an organization that knows how to do its job. And what I mean by that is an organization that can answer the phone, schedule an appointment, send me an invoice and do the basic mechanics well. And I think in healthcare we haven't traditionally been brilliant at that. And I think there's a lot of catching up going on right now. Hi, I'm Belded Mankers. Welcome to the Purposeful Strategist. The podcast that shifts the conversation about purpose and strategy from what organization should do, to what business leaders actually are doing, and what they've learned along the way. My guest today is Barney Guthrie, Chief Executive Officer of Clinical Partners, a large mental health provider. Since becoming CEO, Barney has guided clinical partners through a significant phase of strategic growth, expanding nationally, investing in digital delivery, and building new models to respond to rising demand for mental health services. I'm curious to learn more about how this organization operates at the intersection of public need and independent provision. Barney, welcome to the Purposeful Strategist. Thanks, Belded Mankers. Thanks for having me. That's really great to have you here. Could you just give us a picture of the organization today? It's scale geographic footprint, the areas of clinical specialism, and the kinds of patients and systems you support. So today we have around a thousand staff about 500 on payroll and 500 predominantly clinician contractors. We saw last year about 120,000 patients. We usually roughly double year on year. I think this year if we see 200,000 patients, I'd be delighted. We work all over the UK, we work for currently for all of the ICBs in the UK. That landscape's changing very fast. So, Sir, Barney, just for those of us myself included who aren't quite in ICB is. So the way that the NHS is structured is you have NHS in the middle and below that you currently have 42 integrated commissioning boards around the country who are purchasing services. So they're kind of your customer at one level. They are currently our main customer group. Okay. Our services today split into three main pathways which is NHS and then private self-referred self-pay customers and private medical insurance patients. So we work for all the large health insurers. So we work all over the UK. We provide services on and offline. We provide services to adults and children. So across the age range, although we skew towards younger people, we currently skew heavily towards neurodiversity services. But that's very much something that has arisen because that work has been sent to us rather than a particular strategy to go after that work. NHS England launched right to choose for neurodiversity services in 2022. And that coincided with a huge shift in awareness and demand for neurodiversity services which obviously is a really interesting topical debate right now about overdiagnosis and rates of prevalence and all sorts of aspects of that. The NHS had built up a vast backlog of patients who were sitting on wait lists and NHS services weren't funded or scaled to deal with that demand which was it was growing and at the same time, it had already accrued a huge backlog. And when right to choose was activated for that patient group, it's led to a vast surge in the amount of work being done in that area. And that works largely provided by the sort of top four or five independent sector providers of which we're one. That really changed our business hugely in 2022 because we went from having no patients on our wait list to having 70,000, 80,000 patients on our wait list. And so it forced us to make a lot of changes to how we operated, predominantly investing very heavily in operations, governance and technology. You're growing very quickly that seems to be growing partly as soon to absorb some of that backlog and kind of clear that but also sort of a growth in a particular area of demand. Interesting to explore, you know, how where's growth come after that? But let's get a little bit more background. It may be you could share a little bit about yourself and your background and what led you into healthcare and ultimately into clinical partners. I always like to think I've had literally the perfect preparation for my job and my job is my dream job of any job I could do in the world. My journey to do this job is that as a child, I had a very difficult time at school. I was expelled from every school I went to. I was in a psychiatric hospital by the time I was 15. I was in an adolescent unit when I was 16 for most of a year. And I didn't stay in secondary education for very long. My first 23 years were extremely troubled and then I got really throughout that time but especially towards the end of it when I was 23, 24 had just the most fantastic help. You know, I was very lucky that it was from quite a privileged background and so my family could afford that they could find out what kind of help would be helpful and they could afford to get it when I needed it. And those that was incredibly fortunate for me. And in the years since then, I've also been unbelievably fortunate in three main ways. So one was that I was an army officer and I think the sort of sandhurst training and army experiences is a wonderful learning opportunity for anybody and you learn so much about working with other people and leadership and so on. The next thing I was very fortunate to get encouraged by my family to go and do an MBA. I didn't know anything about business and how it worked. And the MBA that I did really demystified business because before I did it, I thought business sounded like this very complicated clever thing that only very clever people were doing. And I got to the end of the MBA and I was like, is that it? Is that all the magic there is? Yeah, yeah, we look behind the veil and like, hmm, it's really not that difficult. So that was incredibly helpful. But I've just been incredibly fortunate to be surrounded by some incredible role models. They're role models of regular decent people doing sensible things well. And that I'm extremely grateful for. I couldn't have asked for better. So been incredibly fortunate. And what that means I land up here today, somebody who from the army and business school I like things to be organized and to run well. And from my early life experience, what I know is that when humans are in trouble, it is possible for other humans to come along and help them. And that can work. And that the sort of single motivating factor in my life and in my experiences that I know that a lot of humans find life very hard. And I also know that it's possible to help them with that. Get the kind of personal connection to the purpose and we'll get on to clinical partners purpose in a minute. But just I've sort of got you in my mind somewhere in your kind of mid to late 20s, maybe even early these, but there must have been a couple of years between then and now. I don't quite have how you got from ex-centers MBA to CEO clinical partners. Well, that was pretty simple. I did business school. I came out of that. I met my co-founder of clinical partners there. I did that 30 years ago. And in the intervening 30 years, I spent 10 years blundering around with him starting unsuccessful businesses. And between us, we had plenty of unsuccessful ventures, including a cement mixing business we tried to buy. I mean, I can't even describe some very highly aceteric weird businesses that were definitely doomed to failure. We had any number of adventures, all of which were unsuccessful. And then we tried to buy a rehabilitation unit, which I was familiar with having been in it. And so I thought that would be a good idea. And we weren't successful in buying it. But one of the people who worked there who had been very influential in my sort of life's journey said, look, if you want to buy a rehabilitation unit, why don't you go and work in one and find out how they were. And so I did and I went and worked for another guy who was very influential and helpful to me. I spent five years working there in a 24 bed in patient units in Surrey, which was a fantastic learning experience. And then I've spent the last 15 years taking clinical partners from my spare single bedroom in West London through as we moved our family around the place, a succession of other spare bedrooms, until we eventually got an office and on the journey to what has become today. I'm so glad I asked that question. So glad you asked it because it's what I take out of anyway as a message. I try and share with our children, which is careers are not always straight. They're not always up every year. You know, that they're going to be times you do things. And if it doesn't work out, it's not the end of the world. You've probably learned something. You've probably met some people. I just say sorry. I just have to say thank you for sharing that. I think that's such a good point. People just right now today, I am from an external perspective quite successful. And a lot of people talk to me as somebody who is successful today. but I'm 57 and I've been relatively successful for about three years. So for about 54 years of which 34 years whereas a working adult was mostly notably unsuccessful. Or not successful yet. Well, let's say the first 34 years was a steep learning curve. But like you, when I talk to younger people, you know, there are so many young people today facing quite a difficult time getting off the launch pad, leaving university struggling to get those internships and first jobs. And I always really try and reassure them. I didn't even know what I wanted to do until I was about 34. It's a long game and they don't need to worry too much about not having the perfect CV and the perfect journeys. If we could come to clinical partners as a business, so if you had to describe its purpose, what would you say it is? I think the purpose of clinical partners is to try and reduce humans suffering and distress wherever we're able to and the way that we do that is by deploying safe, effective clinical expertise in ways that are proven to work. That is really our purpose. And this podcast is about strategy and strategy has been so helpful to us. We've just completed a big piece of work around strategy. And before we've done the strategy work, I had a very blurry picture of. If I knew that our purpose was that we were trying to help humans in distress, then the range of possibilities of where you might try and do that is too broad. And when I was speaking to colleagues internally or external advisors and they would ask what the strategy was, and I'd have a very blurry and wide-ranging picture of what we were trying to do. This is where strategy's biggest, the word that came out of our strategy worked stronger than any other word was focus. So that's our purpose is to try and reduce human distress wherever we can. Let's talk about the strategy bit. I'd like to almost sort of come at it from two angles. One is sort of the how. How did you go about that? 'Cause it sounds like it was a very effective, useful process to have gone through. So just interested in how you did that. And then the what? What did you get to? What is the strategy now? Of those various areas you talked about, what's the focus now? So in terms of the how, the first thing that was really surprising to me is that I realized that we didn't have a strategy and hadn't had one for like 15 years. And I didn't even know that because I sort of thought we had a strategy. But in fact, what we had was really a sort of one-year business plan. On the journey of our business, what happened was we opened our doors, we were selling six things, we sold them for eight, nine years. Then the NHS suddenly sent us an absolute wall of patience. So we had six years of scaling up for that. And at the end of that 15 years, we realized we'd never had a strategy. As I say, we had this very blurry, very wide scope of possibilities. The first thing we did was that we commissioned a project with some management consultants who specialize in healthcare. I'd never used management consultants before. And so I actually asked them the wrong question, but they nonetheless came back with a useful piece of work. And that gave us some market mapping and some market intelligence. And it gave us a lot of food for thought. But in a way, almost made the problem worse because if there was a sort of blurry, we could do something in one of these six, seven, eight big areas. The management consultants came back with a 60-page deck with lots of specific examples of things we could be doing. And so that just gave everyone more food for thought. At the same time, we had three new board members join us. And that was actually transformational in the process because the people that joined the board are more experienced than the rest of us. They're not more experienced than some of the existing board, but they're definitely more experienced than me and my co-founder. And so for us, it was incredibly helpful that in addition to the very experienced and knowledgeable people we already had around the boardroom table, we added three new ones. So they got the 60-slide deck of a whole wide range of possibilities. And we then had some different management consultants come and facilitate a strategy off-site. They did a really nice job of that. They did very good. Well, I hadn't really appreciated how much time and energy they would invest into the preparation phase for that. They really helped us to chew over the ideas. And then the work on the day, it was kind of a deceptively simple process. I think it was very skillfully managed by the consultants on the day. I'd really have to give them credit for that. They were facing into a room with a lot of brain power in it. And we discussed a whole range of possibilities and weighed up the pros and cons. And I was very conscious it was a very imperfect data set when we were evaluating some of the possibilities, where people were going probably more on gut than data because there was a lot of data that was missing. If you were considering, there'd be a segment you'd be looking at. And actually, we didn't have the unit economics data on that segment. So you could only say, yeah, I think we can make that work. You couldn't say, I know we can make that work and at this kind of margin and this kind of scale. So I was conscious that we didn't have the full set of information in front of us. But I think we had enough to make good decisions. Our board chair, he had strong views about focusing, which I have to say they were his strong views, but all of us could absolutely see the merit in that. He was very keen to say, look, let's do a few things well rather than a whole bunch of things not terribly well. So we came out of it with three areas that we planned to focus on. The biggest area of our business today is our NHS neurodiversity related work. In the core business, really, the focus is on driving down cost to serve to be able to still have a sustainable margin in a tariffed environment whilst driving up quality and effectiveness. So that's exciting. And then we have an existing private self-pay business and that we have neglected that for the last five years because we've been so busy scaling up. We're excited to invest in that and develop it. And I've been working in private outpatient mental health care for 20 plus years. So I know that area quite well. It's an interesting area where the prevalence statistics would lead you to think that there must be a massive amount of demand and there should be a really easy business to build there. And the reality is that it's not at all easy, but I have plans in that space. And the third area that we're focusing on is a range of new services for NHS funders. So and just back to the private self-pay, I would imagine naively that brand would be a key part of that. I mean, is that the case or is it like, no, you might think that, but it's just not. That's not how people make their buying decisions. That even how they decide they're in the market. So brand, I think in mental health care, I'm not sure how much for an asset that is. I'm looking to be persuaded that the person has the technical expertise that I'm looking for and the interpersonal qualities that I am likely to trust them and that the patient is likely to successfully engage with them. There's a big piece about matching. So if I'm trying to find someone to help a 55-year-old with alcohol dependence, I'm looking for a very different thing to a 18-year-old female with an eating disorder. And in both cases, I'm just looking for the right alignment around stage of life, gender, presenting conditions, a whole range of factors. And so what I take out of there is as a patient or somebody who's trying to help a patient, it's almost trying to find the match to the individual, not the organisation, the company. I think where the company comes into it is that if I'm dealing with any form of entity, whether it's a sole trader, psychiatrist on Harley Street or whether it's a large organisation, I'm looking for an entity that I can trust in terms of its ethics because for whatever reason, trust in providers, by-patients is very low. There seems to be a real expectation by-patients that entities are looking to exploit. And I hear a high level of distrust by-patients of organisations, so I want to be reassured about the organisation's motivations and ethics. And the other thing is I want to deal with an organisation that knows how to do its job. And what I mean by that is an organisation that can answer the phone, schedule an appointment, send me an invoice and do the basic mechanics well. And I think in healthcare, we haven't traditionally been brilliant at that. And I think there's a lot of catching up going on right now where healthcare organisations and this kind of links to the consumerisation of healthcare as it is of everything. So maybe we could press in just on that one particular sort of angle for a second and just see what are the big shifts you're seeing in terms of what patients or families or the commissioners expect. But take it around some of those issues, access, speed, continuity of care, customer service, how's that changing? I think there's some really fascinating changes going on and I'm sure you'll be aware amongst the sort of Californian billionaire types longevity is a big trend. And I think that trickles down to everybody because I think that wearables and data are giving us insights into our health that our parents didn't have. As a sort of middle-aged businessman, in my father's generation, you probably just would have high blood pressure and you'd have a much higher risk of stroke and heart disease and everything else. For our generation, we can get those insights, we can know what's happening with our sleep, with our weight, with our blood pressure in ways that they couldn't population growth has led to demand on services and we're trying to spread a finite amount of resources across a wider population and that means that everybody's going to get a smaller slice of the pie and everybody can feel that today if we've got 7 million people on an HS waiting list those two things are linked there are more people so more people are waiting there's not enough stuff to go around and I think the implication of that for individuals is well you better take charge of it yourself because it's not going to get done for you and and if healthcare services can kind of evolve and become more accessible and easier to use that facilitates that and what I hear from colleagues who work in health insurance is that the rate of claims has really skyrocketed since covid I think another thing that's happened which is really interesting is how society has become people talk about the sort of discourse being coarsened and I think that's that's definitely a thing the phrase that came to my mind as you were talking about that is so the expectation of perfection I think that says it very well and particularly in mental health care we do a very challenging job and I think you're exactly right that expectations are of perfection we are working all the time on quality of reports speed of report delivery reducing errors getting that prescription to you as fast as possible and minimum lost in transit etc so we're very much working on all of those fronts and I think there's an element of it which where mental health care may never get there because it's messy human stuff so let me if you know my limit I'm going to posit something which I'm sure you know as an MBA you could argue with but let me just posit that that sort of improvement tends to come from one of two things when I might describe is focus on process systems specific skill at sort of one angle and then the other angle is more culture awareness you know commitment where are you working both of those more focused on one than the other so we start in a spare bedroom when we were a little bunch of people who really didn't know anything about systems technology process governance etc when we started out so it's been a steep learning curve for us I would 100% agree with you that the systems and processes aspect of it what we found so we had a nice little business it was kind of when it was small the thing is that when something doesn't work you can ring up and apologize and you can and you can make that problem right because there's only one of them a week when you get bigger there are too many of them and you have to tackle those things in a systematic way and building continuous improvement and continuous learning what happened for us was that when we started growing very strongly we came to a point where our existing in-house colleagues ran out of expertise we were really drowning in work and we just didn't know what to do and what happened for us that was really transformational is that we hired an external chief operating officer who actually had come from Deliveroo and he'd worked at Deliveroo doing a phase of extraordinary tech enabled hyperscaling he brought the expertise and he hired the colleagues under him who had more of the expertise and we also at the same time we were sort of doubling our technology spend year on year for successive years bringing together proposition product technology and operational expertise we're moving from being a little small business from a spare bedroom into being like any other tech business now we're not a tech business we're a healthcare business but we're as techier healthcare business as you can be and I think this is part of our current competitive advantage against legacy healthcare providers in the UK who historically have been strictly bricks and mortar and not big investors in technology we are very much the healthcare provider of the future because we are 50% technology and we have the technology staffing and configuration that you would expect in a tech business you know you've touched on something in there that I'd really like to get a sense of we've talked about how what you're trying to do is it's human it's messy it's complex and yet you're you're scaling so how do you balance that sort of scale technology etc etc and at the same time to still be delivering something that's incredibly human you can't necessarily standardize it how do you how do you get that to happen we have found it really difficult for us our start point was not knowing anything about how to do proposition product technology etc and so we were on a very steep learning curve one of our friends in this situation has been trust pilot we survey patient satisfaction and we ask for feedback all over the place we get it to a greater or lesser extent but actually trust pilot has been a really helpful tool we were nervous about when we first signed up for it because we were thinking well we do this difficult work and what are people going to say about the work that we do and what we find is that if you go to our trust pilot page and you read it a lot of the feedback is honestly extremely moving because people write such nice things about what we've done for them that I could never never you know if I was trying to write a glowing reference for us I couldn't write anything as wonderful so a lot of it is really moving and incredibly thrilling to read but then people also you know they don't pull their punches and they will let you know exactly where you're getting it wrong and we've tended to get it wrong in things that look extremely simple but actually quite hard to fix at scale and I'm talking about things like you know you move from 10 calls a day to a thousand calls a day knowing how to handle a thousand calls a day and to answer them and we're really not there yet even now in year 16 we're not reliably answering 98% of calls within three rings and that's where I want to be I'm in awe of the knowledge and expertise of our ops colleagues and how they've worked with the data and technology team to to try and address some of these challenges but they really are hard I think this like a kind of middle ground which is the worst so when you're small you don't have too many problems because you don't have too many patients when you're big you have the money to invest in the tech and the expertise and everything to solve problems and I think almost the most painful period is being between those two points where you're overwhelmed with demand you don't have the financial or expertise resources to resolve the problems and that is really an uncomfortable period to be in so we're we're luckily kind of just coming out the other side of that we are currently doing it what is essentially a complete business transformation exercise but when I look back through the 15 years it's constant transformation and evolution growing a business it's really exhausting for everybody I mean I'm really conscious of the wear and tear on people at every level if you take a fundamentally quite challenging task that's hard to do at scale and while you're doing that double every year then you definitely have your hands full sure one of one of the things we haven't talked about you you've sort of talked I think very you know perceptively about what I might describe is the wrapper all the customer interaction scheduling etc etc etc but we haven't talked much about how you find the people who have both the skill that you know the background training all of that but also that interpersonal characteristic that sort of makes the service really make a difference how do you find those at scale when you're doubling every year I don't think you do when you're operating at scale is the truth what happens the way that an NHS service will source clinicians is that you set the specification you go to your talent people and you say get me 500 of these or whatever it is the examinational scrutiny of interpersonal qualities at scale the more people you're onboarding the less you're going to be able to do that I think if you operate in a well governed system the expectation is that your system will be sensitive to signals that there is something amiss in terms of recruiting clinicians the CQC mandates something called safer recruitment which requires a lot of checking of the clinician background and we see in the media you know when that goes wrong that appears in the media quite often and the regulator quite rightly is pushed providers to invest in making sure they've made every effort to be sure that the clinician they're bringing into the system is suitably qualified and is a suitable individual once they're in the system what you have to do is design and build the monitoring and governance that will allow you to pick up like right this clinician has got 20 late reports why what is happening here or this clinicians patients satisfaction scores you have to be very careful around some of the signals which can be very misleading so when we audit uh complaints what we find is they're skewed very heavily towards doctors trained abroad so there are other factors at play what might look like a quality indicator may not be so you might have a clinician who receives a number of complaints from patients and one of his colleagues who's not which one of them is doing the better job you can't tell from that signal because the one who's upsetting his patients or her patients maybe the one who is most rigorous in their diagnostic procedures because the thing is a private self-paying patient wants to be told the answer they've paid to come and get they are not happy when they don't get that answer and so you actually have to be quite a brave doctor to say to a potentially quite insistent and assertive patient who's quite determined that they have got a certain diagnosis that they happened and we're when you tell them that, you should brace yourself for a complaint. And the complaints, you know, as we said earlier, they seem to get less pleasant over time. And it's really, when you think about what motivates a doctor and they typically, their reward from their work is the pleasure of helping people. And to then receive what can be a really quite critical complaint when they have sincerely done their absolute best to apply the diagnostic criteria as they should be, is a difficult experience for clinicians. But for me, this has been, it's been interesting, both to learn a bit more about, you know, how mental health provision in the UK works, but also how you're wrestling with these really complicated issues. You know, you're sort of growing like a tech business. You've got this deep purpose. You've got a sort of a skill base that you need to attract that's very, I think, complex, difficult to sort of understand what you've quite got there and to manage. Anything that we haven't touched on that you'd like to share with our audience? Well, I don't know that the necessarily is. I was thinking about this and it's easy to say that we're living in quite challenging times. And I think that is part of the kind of narrative right now is these are quite challenging times. But when you look back through the last few hundred years, it usually is challenging times. Yeah, when hasn't there been? Yeah, I mean, was it the first wall, the second wall, the Napoleonic wall, it's always difficult. I think it's really difficult being a human being. I think the business of being a human being is a difficult task for anybody, whatever age you are, wherever you live. And I'm always amazed by people who say, no, I don't know what you mean. I'm like, this is an incredibly difficult task. So I think we do live in interesting times. We've got a lot of interesting societal challenges, young people not in employment or education. We've got all these questions about diagnosis. We've got lots of economic challenges. We've got a whole bunch of challenges. I think that it's really incumbent on sensible grownups to apply their force to the conversation, to try and steer it in the direction of sensible, grown up thinking and behavior. And it feels like society's going really in a different direction, where there seems to be some really polarized and unwise thinking and behavior. And I think all folks who are half sensible really need to help trans-deer the ship back towards the shore right now. - No, I think that's a great, absolutely great shout out. Barney, can I thank you again for joining us? For me, it's been both an education and an inspiration. So I really appreciate it. I look forward to hearing further as you continue to grow. If you can keep up that doubling every year, I really got to take off my hand to you. That's just organization. - Well, we'll-- - As you know, organization and managerially in terms of leadership and all of that, it's so difficult. - Yeah, yeah, it is quite difficult. - Thank you so much for having me. I really enjoyed it. - Likewise. - Likewise. - Thank you for joining us for this episode of the purposeful strategist. In addition to being available on our website, you can find us on Apple Podcasts, Spotify, and Google Podcasts. If you enjoyed this episode, please do follow us and leave us a five-star review. It helps others find the podcast. Thanks again and join us soon for the next episode of the purposeful strategist.