Building a Mental Health Service from the Ground Up

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 organisations 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 bonds to respond to rising demand for mental health services. I'm curious to learn more about how his organisation operates at the intersection of public need and independent provision. Barney, welcome to the Purpose and Strategy.

Thanks, Bob, and thanks for having me.

Great to have you here. Could you just give us a picture of the organisation 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 doubled 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, so, Barney said 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 NHSE 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.”

So, we work for all the large health insurance. 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. Currently skew heavily towards neurodiversity services, but that's very much something that has a reason 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.

This is a really interesting, topical debate right now, about over diagnosis and rates of prevalence, all sorts of aspects of that. The NHS had built up a vast backlog of patients who were sitting on weight lists and NHS services weren't funded or scaled to deal with that demand, which was growing. But 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 weight list to having 70, 80,000 patients on our weight 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. But you're growing very quickly, that seems to be growing partly, I assume, to absorb some of that backlog and kind of clear that, but also sort of just a growth in a particular area of demand. Interesting to explore, you know, how where is 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 health care and ultimately into clinical partners.

I was 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.

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.

“I was very lucky that it was from quite a privilege background. And so my family could afford, 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 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 soundhouse 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. And 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. 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 are 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 there's 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. There are role models of regular decent people doing sensible things. Well, and that I'm extremely grateful for it. I couldn't have couldn't have asked for better. So being 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 it onto a clinical partner's 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 east. 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 asceteric 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?"”

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-imposed unit 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, 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 had to, because it's what I take out of anyways a message.

I try and share with our children, which is careers or not always straight. They're not always up every year.

You know, 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 probably learn something. You've probably met some people.

“I just think, 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 talked to me as somebody who is successful today, but I'm 57, and I've been relatively successful for about three years.

Well, the first, 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 have very blurry picture of. When you 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.

So that's our purpose, is to try and reduce human distress wherever we can.

Let's talk about the strategy, but 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? Because it sounds like it was a very effective, useful process to go on through.

“Just interested 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. The journey of our business, what happens, 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 patients, 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 specialise 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 a 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, you know, 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. 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 board from table, we added three new ones. We got the 60-side deck of a whole wide range of possibilities, and we then had some different management consultants come and facilitate a strategy offsite. They did a really nice job of that. They did very good.

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 was kind of a deceptively simple process. 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, you know, 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 this kind of margin and this kind of scale."

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 costs 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 the 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. To end 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 financial 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 without cold 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 as a whole range of factors.

And so what I'd take out of that is as a patient, or if somebody who's trying to help a patient, it's almost trying to find the match to the individual, not the organization, 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 organization, 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. The 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 organizations. 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, where healthcare organizations and this kind of links to the consumerization 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 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 California 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 mid-stage 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. The relation 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 NHS waiting lists, those two things are linked.

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 coarsund, and I think that's definitely a thing.”

The phrase that came to my mind is you were talking about that is sort of 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. The 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 healthcare may never get there, because it's messy human stuff.

So let me, if you don't mind, let me, I'm going to posit something, which I'm sure, you know, as an MBA, you can 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, that 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 started 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, when something doesn't work, you can ring up and apologise. 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 are 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 Deliveru. And he'd worked at Deliveru 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 health care business, but we are as techier health care businesses you can be.

“And I think this is part of our current competitive advantage against legacy health care providers in the UK who historically have been strictly bricks and mortar and not big investors in technology.”

We are very much a health care 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 scaling. So how do you balance that sort of scale, technology, et cetera, et cetera, and at the same time to still be delivering something that's incredibly human, you can't necessarily standardise it.

How do you get that to happen? We've found it really difficult for us. Our start point was not knowing anything about how to do proposition, product, technology, et cetera. 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.

Another is 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 a cross pilot page and you read it, a lot of the feedback is honestly extremely moving.

I couldn't 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 tend 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 ten 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 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 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.

“One of the things we haven't talked about, you've sort of talked, I think, very, you know, perceptively about what I might describe as the wrapper, all the customer interaction scheduling, etc, etc.”

But we haven't talked much about how you find the people who have both the skill, 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 as 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 a miss. In terms of recruiting clinicians, the CQC mandate 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 clinician's patient satisfaction scores, you have to be very careful around some of the signals which can be very misleading, so when we all did, are 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 haven't, and 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.

Anything that we haven't touched on that you'd like to share with our audience.

Well, I don't know that the Nest certainly 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 war, the second war, the Napoleonic war, 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 an interesting touch. We've got a lot of interesting societal challenges, young people not in not an 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 grownup 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 steer 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 inspiration. So 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.

Well, we'll organize as you know, organization and managerially in terms of leadership and all 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.

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