First Principles

I started my career in management consulting at McKinsey, where I predominantly focused on the NHS. That was where I really got a taste for the inefficiencies and all the difficulties the NHS has been grappling with since its inception. I wanted to have an impact on the healthcare system, but felt that my role in doing that wasn't going to be in advisory. I'm just much more of an operator, much more of a hands-on person. So I decided I would leave McKinsey and start a company.

All I knew was that the company was going to have a huge impact on the healthcare system at large — but I didn't know what I wanted to focus on. So I actually took a job in NHS London. This was in 2011, when Andrew Lansley's reforms came in and there was this huge reorganisation of the NHS. I joined a team that essentially aimed at designing NHS London out of the future, which was quite a strange project to work on. I did that for about a year and a half, and all the time I was thinking: what are the different pain points I'm experiencing here? What are the really big problems to tackle? And I just kept coming back to the workforce.

For me, the biggest issue facing healthcare systems — not just the NHS, but globally — is around the organisation of the workforce. Every single healthcare system has its entire operating budget nearly almost dedicated to the workforce; it takes about 60 to 70% of operating budgets. So I decided, if I want to solve a big problem, I may as well start where most of the spend is. And looking at other stats — the NHS being the fifth largest employer in the world — all of these things pointed to the workforce being the big problem.

So I decided to start a platform that tackled, first and foremost, agency spend. That was, and still is, a very popular hot topic across the NHS — how much money is being spent on agency. I think it was almost £5 billion every year at the time I started Lantum, and I decided that's where we'd focus. We started a marketplace: essentially a way to bypass agencies, for clinicians to set themselves up and book shifts directly. We started niche, in primary care, and built a marketplace for GPs. And we've evolved from there — over time we've built out software tools that let people manage all of their workforce, salaried and freelance, as well as connect with locums. All along the same lines: helping people organise their workforce better and more efficiently.

That's a bit of a whistle-stop tour of my journey so far. We've done quite a few funding rounds, we're now over 60 people, we've worked in the UK and the US. It's been a really exciting and action-packed journey — probably the only way to describe it.

Oh, it was the best thing I ever did. Honestly. It gave me such an amazing grounding — I learned skills under such a pressured environment, and that's where I tend to thrive, so my learning just accelerated. I don't think I ever learned so much. You learn PowerPoint skills, and those are extremely important: how to communicate succinctly to busy CEOs or world leaders. Often you're thrown in at the deep end, having to communicate really complex problems in a visual, simple way. That's a skill that should be more highly valued, generally.

But more than that, the best thing was being around people who are just so intelligent. Everyone who works at McKinsey has imposter syndrome, because you're constantly comparing yourself to everyone else that's there. Being around people like that makes you strive to be better, and you learn so much.

So many founders have come out of McKinsey. My cohort of analysts especially — you've got the founder of GoCardless, the founder of ClassDojo, the founder of allplants. The list is as long as my arm. I think the reason is that when we left, the deal was you'd leave, go get some experience in the "real world," quote unquote, and then come back. But it was the time of the financial crisis, and there really weren't very many interesting jobs around. So a lot of people thought, well, I'm just going to go and start a company. It was the very beginning of when startups were becoming a thing.

None of us quite realised we'd succeed. A lot of us just tried it, thinking: if we fail, we've got an offer to go back to McKinsey. So you may as well take a big risk — it didn't really feel like too big a risk. And everyone I left with and started a company is still doing it today. So obviously it was a good thing to do. The network, too — all the people in my year and the partners who were there, I'm still very much in touch with all of them. So many have gone on to do amazing things.

The problem is huge. It's an unsolved problem, still to this day, and there are so many different facets to it. It can be extremely overwhelming. If you decide you want to tackle a really big world problem, you have to be prepared for many feelings of just being overwhelmed. The key is really just to start small — start somewhere. But try to start in a place where there's some ease of adoption.

We could have gone off and built an entire new operating system, turned up at Barts and the Royal London Trust and said, "give us a chance, why don't you use this?" But we would have failed. So you have to really think: what's the least risky area I can start in? What's a problem a lot of people have, but something that can be adopted quite quickly? That's where we started, and you build out from there.

The other point is knowing the journey is long. When you try to do everything all at once, you spread yourself too thin. Once you've made peace with the fact that if you want to be an entrepreneur in healthcare, chances are it's going to be a long journey — you need to build that into your strategy, factor it into the amount of capital you raise, and take things step by step. Don't try to bite everything off, because you might burn out, and you also might just die trying. So that would be my tip.

It's a good question. I suppose the question is really about getting adopted. There are so many barriers to being adopted in healthcare, and I come back to that same thing: identify the areas where you could be adopted easily and quickly. We started in primary care, where you don't have to contend with frameworks or government tenders, and you don't have to integrate with a whole suite of other software. That let us get our foot in the door and prove we could do what we said we were going to do. Off the back of that, we could then start signing larger contracts.

But in healthcare, the barriers aren't just government tenders. There's also a real trust barrier. You're often dealing with clinical information, or you could affect patient safety, or it's to do with the clinical workforce — all high-risk areas. The only way we've learned to build that trust is step by step: keep adding clients, and demonstrate that you've done it before and have a track record. It's a long game, but it's really about getting credibility. If you sign a customer, you'd better do a good job for them, because the NHS is such a small, close-knit community. It's very easy to get references — our customers are constantly being called by future customers asking, "what's it like to work with Lantum?" So it's really important that you deliver what you said you would, and try to go over and above, because your main mouthpiece is your existing customer base.

I think the former is more important. ROI calculations can be quite subjective, and quite difficult when you're trying to establish a baseline. And ROI data can take a while to collect — there are real lagging indicators; you might need to be implemented for two years before you can actually see it. So it's really about the relationships. But you only build relationships when you're doing a good job — and often that isn't measurable. So you have to think about how you can speed up the time to value, how you can deliver value very quickly to customers, because as we all know, healthcare is slower to adopt.

You need to think about how to shorten the time between signing your first customer and your next one, and your next one. You want to get customers to a point where they can be referenced as early as possible. So the most important one is the former. This is all about people at the end of the day. The closed network can be a strategic advantage and a strategic disadvantage, so you need to really think about how you're going to cultivate that network of people you're working with. The people part, the subjective part, is quite important.

What we've found is that not having formal structures or forcing mechanisms around it makes it more genuine. In the past we'd tried to create communities and almost control a community to help grow the business, and it just wasn't authentic. Genuine excitement around your product — if people are going to refer you, they're going to refer you anyway. They don't need an incentive, they don't need to be measured on it or told to do it. So you've just got to think about how you can deliver value for your customers, how you can genuinely have empathy for what they need and deliver it. And then the community just comes.

That's what we've learned. Focus on what you said you're going to do, do a really good job, and don't try to force a sense of community. It will come naturally if you're really delivering what you said.

The phases of a company are just so different. Of course there are benefits to being a small team, all on the same page. But Lantum's product is really complex, and our end-to-end offer has so much to it. Even 60 isn't enough — we need to double the team size this year so people can focus on each part of our machine. Some parts are scaling really quickly, and we need to specialise more, so different people take care of each different part.

In the beginning it was so difficult. It's like your right arm's doing something, your left arm's doing something, and your foot's pedalling — extremely difficult to coordinate. You end up having to drop the ball, and it's a very painful feeling when you know you have to drop something to save some other part. So honestly, it's so much better when your company gets larger, because you can attract people who've not only managed this part of the machine before but have radically improved it somewhere else. They come in and dramatically improve it. I've always really enjoyed the specialisation part — building a more repeatable engine, rather than that beginning part, which I personally found remarkably difficult. That's just because our ambitions are so big and it's hard to do things with a smaller team.

I definitely don't miss the days when I was getting on my push bike and signing up GP practices one by one. Long gone, those days, and I wouldn't want to go back to them. Everyone's different — everyone has their niche of where they like to operate — but this stage is definitely my favourite so far.

I think medics are perfectly suited to founding a company, just because of the level of resilience they have — the ability to manage emotions and deal with things in a very analytical way is exactly what you need as a founder. There are so many ups and downs, and being able to deal with whatever life throws at you is really important. The critical thinking that's taught to medics right from the start is extremely valuable. And the ability to have empathy — for the people you employ, for your customers — is what helps you create a product that people love. So from my perspective, medics are ideally suited to being founders.

But the thing that gets in their way is that they get too scared. All the founders I've talked to who are medics won't give up their day job. They're trying to do it on the side, and that just doesn't work — it's impossible. You've got to take the leap, and it's a lot easier to take a leap when you've got nothing to lose. The medics I know who've gone down this road really struggle to give up the idea of the security and the structure that being a medic brings. So it's really just a case of taking the leap and being brave. But all the skills and personality traits you see in the medical community make them ideally suited to building very successful businesses, in my view.

Any big problem is worth solving, and you're not going to be the only person. I'd be pretty worried if we were the only people trying to solve this problem, because it would probably indicate it wasn't that important. Of course it's important, and everybody just wants it solved. So the first thing to understand is that if it's worth doing, there's going to be more people trying.

It's still very fragmented. There are a lot of people trying to solve the problem, but no one's really done it. Even Lantum — we're still a small company. When you look in aggregate at the number of people doing it, it's just a lot of quite small organisations trying to do the same thing. So there's so much to go after, so much to play for still. It's a really interesting time, particularly in healthcare, where leaders of healthcare organisations really want to do things differently now. We'll really see what happens in the coming five years, because it's a critical time. There's no point trying to build something where you're the only one and no one else cares about it — I don't think that's going to happen in the information age we're in today.

For us, we just try to focus on adding value to customers. I'm not really looking over my shoulder seeing what other people have built and copying them. People copy us all the time, and I just think, well, I feel sorry for you, because you're always going to be the second person to launch that. So really, go back to first principles, talk to your customers, understand what they want, and go from there. That's always been the way we innovate and operate.

It's an interesting one. I'm so used to it, because I've been doing this for nine years now, and before that I worked at McKinsey, and before that in investment banking. So I've just been comfortable with this base level of anxiety that I've come to live with — I just don't know any different.

It's high pressure. I don't know what to do with myself if I'm bored. I do struggle on holiday, or times when you're supposed to switch off — I really struggle, and try to find things to fill my days. So it definitely suits a certain type of person. It comes in waves. There's always this base level of stress, but you can't let it overcome you, because you wouldn't get anything done. It's all about having perspective. And the more difficulties you go through, the more resilient you become.

There were times when I'd have to fire someone and I'd be up all night, unable to sleep, feeling awful. That's still a terrible thing to have to do, and in some ways it never gets any easier — but the stress you associate with it, once you've done it before, greatly reduces. This is why a lot of second- and third-time founders are often very successful: there's not really anything they haven't seen or done. Over time, your benchmark of what's a stressful situation really changes. We've been through all sorts of crazy times building Lantum, so now a lot of things just don't faze me anymore.

It does come in waves, though — particularly when you're doing things like fundraising, because most startups aren't profitable; they rely on the lifeblood of investors. That's always a very fraught time: if I don't get any investment, are we going to have to turn the company off, and what's going to happen? That can be a very real stress. It normally comes around every 18 months or so, every year. So it's about being prepared for that and planning as much as you can to try to ensure it's not as stressful as it could be. But yes, there are definitely waves.

Over time, fundraising does get easier. One, because you've got numbers you can reference — it's not just an idea you're pitching. And two, you've got more people to help you. In the beginning, I'm trying to grow the business and raise money at the same time. You not only need to show you've been growing over the last year, you also need to show you're growing during the time you're talking to investors. So when you're a two-, three-, four-person band and you have to stop growing the business in order to talk to investors, suddenly growth slows — and investors see that, and they don't understand it's because you're talking to them. They have no sympathy for that, by the way. So it can be a really tricky situation.

Later in life, when you've got more people around you — people who can help on the finance side, with due diligence requests, a repeatable go-to-market strategy and sales team that can grow the business — it gets a lot easier, because really you're just coordinating and keeping on top of things. You're only doing the value-added activities: pitching, building relationships with VCs, coming in at the last minute to help close an important deal.

All of this, though, with the caveat that you have good product-market fit, you're growing, and customers like your product. Otherwise, no matter how many people you've got, if people don't want to use your product or you're not growing, at some point you'll stop being able to convince venture capital companies to invest. So you have to assume those things are true, and then what I just said makes sense.

Oh my gosh, that's really hard. I'm trying to think of good advice... You know what, I'd just say: take all advice with a massive pinch of salt. If you start a company, you're basically inviting the whole world to comment on whether they think what you're doing is a good idea. And people are very liberal with their opinions. That's great — but a lot of the time, the people talking to you either haven't thought heavily through the problem, or they're not qualified to give you an opinion that could be considered expert. So I'd really scrutinise whether you should take an opinion on board.

When I first started, I had much lower confidence. You generally look at anybody a bit older than you, or anyone senior at a bank or McKinsey or wherever, and you automatically think their advice is good, and you go ahead and start implementing it. Or you see another company implement something and you decide you want to do it too. I'd really caution against that. Go back to first principles and understand what's right for you, what's right for your customers, what's right for your business — otherwise you can end up going down the wrong path. Really evaluate the advice you're getting: is this person actually an expert in the particular thing they're telling you about? Because if they're not, consider whether it's valuable advice. So — think hard about whether it makes sense for you.

I don't think that's true. Firstly, I don't even remember having a locker. And secondly — no. But Myers-Briggs is really central to McKinsey's ethos and way of working. People mistake this; they think Myers-Briggs is a way to judge other people, and it's really not. It's a way to understand why other people act in a certain way, so you can be more accommodating to them. As an extrovert, knowing that someone's introverted — that they don't want to talk through a problem every five minutes like I do — is really valuable, because it means I know how to better cooperate and interact with them.

At McKinsey, when you work on projects, you're on them for maybe three months and then you go to another. So it's important to form strong bonds with people on a new project quickly, so you can all start adding value. It's really a tool used so people can see where their points of difference are, rather than a way to judge or brag about your personality. So no, I don't think people stuck it on their lockers — but it is central, as a point of principle, at McKinsey.

Habits? Oh, God. I don't really have any, to be honest. I probably should. I tend not to make too many plans at the weekends or in the evenings, just because I like the ability to work if I want to. I don't have any hobbies as such — I don't really want to do anything that consumes my time, because there's one really important thing that needs to consume my time, and it's this. The only thing I do make time for is exercise. I need to exercise, and it helps manage some of the stress you talked about. But no, I don't really have any. I feel bad now — I feel like I should have some. Maybe next time I'll talk to you and I'll have some rituals.

Yeah.

Oh, so many. I've got loads of books. I'm listening to one at the moment — I always listen to audiobooks, because I can listen when I go on a walk or a run. There's a good one, Never Split the Difference. It's actually written by a hostage negotiator, but it's really about how to negotiate difficult situations with people. Another one I love is Radical Candor, which is about how to deliver feedback in a way that's empathetic and caring. Feedback's so important, but delivered badly it can have the opposite effect. So that's also a really good book. I've got so many that have helped me in different ways. But I only read business books — I don't read any fiction or anything like that.