Why I've Got More Employees than WhatsApp

That's a great question — I love this question. Let me divide my answer into two parts. The first is that different kinds of businesses require different kinds of people and different sizes. The second is a genuine warning: be careful not to over-hire, and be very deliberate about how you build your teams.

Let me start with the first point. The reason a company like WhatsApp can be a much smaller team than a company like Patchwork comes down to two things. The first is what you're actually offering. WhatsApp is a single point of value: they offer a messaging platform, and messaging as a concept is now heavily commoditised. Lots of companies — Patchwork included — build messaging into their platforms as just a feature, not a product. WhatsApp is messaging as a product. The technology around end-to-end encrypted messaging isn't that complex anymore; the call you and I are on right now has a side messaging channel. It's in most products in the world.

What WhatsApp has to do is maintain that at scale — the sheer volume of messages — keep it secure, and protect against bad actors. And mind you, that quote you're referring to is about the engineering team. Once Facebook — Meta — acquired them, they had to add compliance and content-moderation layers, which is a whole different issue. But fundamentally, if you think about the value proposition, the engineering team's job is a single point of value maintained securely at scale.

We're the opposite. The surface area our products cover is huge. When you serve an enterprise — unlike a B2C consumer product — you end up owning an entire value chain. In our world that's workforce. We started with temporary staffing; today we do bank and collaborative bank, we manage some agency, and we do rostering for substantive, full-time clinicians. So we're a multi-product enterprise platform, and the service area is large.

That's actually quite normal, because enterprises like hospitals and the NHS don't want to buy a hundred different apps each doing one single thing — a hundred single points of value in a hundred different apps. They want a single platform that owns a vertical end to end. EPRs — electronic patient records — want to own the entirety of that. The PAS system, patient administration, owns the entirety of that. Radiology systems own everything from booking to scanning to reporting to discharge. Workforce is ours — the entirety of it: recruitment, onboarding, rostering permanent staff, filling vacant bank shifts, cascading to collaborative banks, timesheeting, payroll. Covering that much means your team naturally has to be bigger than a team building a single point of value focused on only one thing. I envy that sometimes, but it's just the world we're in. We're not in a B2C world, we're in an enterprise world. That's the first reason our team is bigger.

The second reason is that WhatsApp doesn't have a sales and marketing team. When you downloaded WhatsApp, you didn't have a call with a salesperson who did a demo and sent you a contract to sign — you heard about it word of mouth and just downloaded it. They probably have product and growth marketing, but not enterprise sales teams. And that's a big part of what makes our team the size it is: implementation and customer care. Enterprises don't just go on your website, punch in a credit card and buy the product. They go through a sales process, procurement, potentially a tender. Once you've landed the contract, then comes implementation, configuration, training the teams, going live, and ongoing customer care. These are large contracts with large organisations. So companies doing what we do — and we're not unique in that — will naturally have bigger teams than a single-point-of-value B2C product. That's the first half of my answer, and it explains why our team isn't like WhatsApp.

But there's a second, very valid point for this moment in the cycle — with the macroeconomics and the layoffs. Over the last ten years, money was cheap for a lot of startups; raising was cheap and easy. And when you raise a lot of money, you have to justify the valuation, so you start burning through cash. The fastest way to burn cash is to over-hire, way beyond what you need — and if you run out, there's always more cash out there. Somehow the incentives got skewed, and egos started being measured by the size of your team rather than the growth and the value you're adding to the world. A lot of companies that did that are now meeting the reality of 2022 as the bubble starts to burst — all that cheap money funded hyper-scaling that wasn't sustainable or really necessary, and now they're going through massive layoffs.

Now, to be clear, some businesses hired for the right reasons and at the right size, and the economy simply turned against them. That's the world of business — every ten years or so we go through these corrections, and there's some collateral damage. But I'm talking about the teams that shouldn't really have grown that fast, that spent all that cheap VC money to grow simply for the sake of growing — without being purposeful about the org chart, the purpose of each new joiner, whether they're creating value or bloating the system. It's really important for founders and management teams to challenge themselves on that, because, one, these are people's lives — hiring and then having to downsize puts people through a very stressful part of their careers. And two, bloating the company beyond your true needs just grinds the business into a slow-moving Titanic: more people, more communication load, more layers of management, all getting in the way of actually getting stuff done. So I remind myself and my team to always be very purposeful about every new hire — not just so you don't run out of cash from over-hiring, but because more headcount is counterintuitive to growth. It doesn't necessarily mean you grow faster; sometimes it means you grow slower. Of course, comparing an enterprise SaaS company to WhatsApp is its own leap too.

God, no — that should never be the case. Working with healthcare is really about being able to communicate the value and reduce the cost of change. The biggest barrier to adopting new technology is the hesitation to go through an expensive process of either replacing an incumbent or bringing you into a world they didn't have before. The cost of change is the area most people just do not want to go through — and there are often bad historic IT implementations that left a bad taste with clinicians and management. So every so often it's, here's another platform coming in, here's another piece of tech being sold to me — and you know what, I'd rather stick to my Excel sheets, it's just easier. Overcoming that is about communicating the value and your commitment to owning the cost of change. That's why we own the implementation, and why we built incredible customer success and customer care teams — we want to take away that friction and say, listen, we'll do the heavy lifting of moving you into the new world, so that's not the barrier.

The second one is building a reputation as a reliable partner to your NHS customers. Fundamentally the NHS is a small world — there are only about 240, 250 NHS trusts, including mental health, ambulance and community trusts, 42 ICSs in England, and then health boards in Scotland, Northern Ireland and Wales. In the grand scheme of things that's small, and your reputation becomes your biggest thing. Often, when we go into a conversation with a new organisation, what really smooths things is if suddenly someone there says, oh yeah, I know these guys — when I was at my other trust we used them and they were great; the tech was great, but the support was excellent too, and when things went wrong they fixed it fast, they were always responsive, they looked after us. Once someone says that, it makes our life ten times easier, because you've got all the social proof you need to separate the signal from the noise and amplify what you're trying to communicate. That's why the first few use cases are the hardest to win: land those and build the right reputation, and it makes your life easier, because the NHS loves tried and tested with a good reputation. So fundamentally it's value communication, doing the heavy lifting on change management, and building — and doing everything you can to protect — your reputation.

Interesting. I think there are a lot of players now working in home-based care, and there's still a lot to be done. It feels like we're getting some movement in home diagnostics, home tests, home monitoring — but I'm yet to see something that's truly end-to-end connected to the heart of healthcare, to hospital and GP systems. When you walk into a hospital, everyone knows who you are; you don't have to repeat your story ten times to the first nurse, the next nurse, the first doctor, the next doctor. That information is connected. But a lot of people talk about that being just hospital and GP information — whereas your wearables, your home diagnostics, your home care should be part of it too. A truly connected home-, community- and hospital-slash-primary-care-based model is a space where there's a lot to be done.

The challenge is there isn't an obvious way to make it a commercial success, because the money doesn't flow there. At the moment it still flows to transactional care — it's not value-based care, it's not outcomes-based population health as much as it could be. ICSs are hopefully bringing that promise, but until there's a commercial incentive for innovators to go into that space, I don't think it's obvious for people to move there yet. So they focus on the single point of value — a bit of home diagnostics, monitoring, testing. But connecting it all together and orchestrating it is definitely a missing space in healthcare.

The other thing — outside healthcare — I actually think the art industry. My wife is a fine artist, and it's an industry completely stuck in the old days, with a lot of entrenched interests keeping it very analogue and opaque, and artists getting the short end of the stick. I think there's a lot of disruption to be had there. Maybe future me looks into that one day. Who knows — someone hopefully should, because I think that space should be massively disrupted.

I'll tell you one I've learned in the last couple of years. When you're faced with a problem, I used to quickly try to jump to solutionising it. I've realised that very rarely do you need to have the answer right away. Taking space away from the problem — as immediate and urgent as it feels — almost always helps, because it's very rarely actually that urgent. For me that means literally leaving the building, getting into a different environment: a walk, a cycle, a swim, whatever physical activity. I find physical activity a good way to think, and I come back to it the next day.

When you try to solutionise in the immediate here and now — the problem lands, it feels so urgent, you ask everyone to drop tools and huddle — you're probably running on adrenaline. You probably don't have all the facts yet, you haven't reflected on the unintended consequences of your solution, and, especially as a CEO and leader, you're probably stressing the people around you into feeling they have to respond just as urgently. Taking a bit of a breather and stepping away is the best technique. You can still resolve it within 24 hours, but you come at it in a more holistic way, and your team has had some time to think with you too. So that's one tip that's definitely worked for me and has certainly improved my decision-making.

That's a great example. I've been in so many operating rooms where you feel exactly that — some operations run for 24 hours. If the patient is stable on the table and you can afford a fifteen-minute break, step out and think about it, rather than making the decision with a sharp knife in your hand. I completely get that. That's a very good reflection from that surgeon.

Honestly, there isn't a single one — but there are a few I'd recommend. My most recent favourite is Four Thousand Weeks, though that's more about understanding your relationship with time and our mortality, and how to make the most of the short lives we have. I read a lot, both fiction and non-fiction. The one I always recommend is The Hard Thing About Hard Things by Ben Horowitz — a great book for founders and CEOs. There are a few more in that genre, like The Lean Startup and Crossing the Chasm. But I'd almost always caveat: these books are really good at inspiring you to think differently and learn from other people's experiences, but be cautious about ever looking at them as the Bible of something, or the playbook for all your problems. Fundamentally, no two companies, no two startups and no two founders are the same. Draw inspiration from others, but find your own path.

There are quite a few podcasts I listen to as well — a16z, 20VC, a few more in that tech vein. They're all great, because they bring on amazing tech leaders and startup journeys we can all learn from. But, very importantly, assimilate all that information and then find your own playbook, because each company has its own story and its own journey, and each founder their own strengths and weaknesses.

More important than books and podcasts — and this is the one thing I wish I'd done earlier — is to get an executive coach as early as possible in your journey. Someone who can be a trusted individual, where you can be vulnerable and open about your challenges, but who can also hold you accountable to the things you're trying to improve and give you honest feedback on the sidelines. Unlike your co-founder, your investors or your life partner — who all have vested interests in your success, or a fear of your failure — you can be completely honest and open with a coach. It's important to have healthy, transparent relationships with all those stakeholders, but there's a level of honesty a true professional coach can hold that you can't always have with everyone else. And they're pattern recognisers — they've probably worked with many founders like you, so you can borrow their pattern recognition and expertise to think about the right problems and create your own journey, rather than just replaying someone else's journey you heard on a podcast or read in a book.

So I absolutely recommend reading these things and listening to podcasts — I enjoy them a lot and I've learned a lot from them. But the more important part is spending enough time to reflect. As doctors, we're trained on reflection, and I genuinely value that a lot. Be a reflective founder: reflect, learn, journal, improve, actively work on your leadership skills every single day — and find a good executive coach to support you on that journey.

A good executive coach should, first of all, be able to challenge you. It's a spectrum — from the very therapist end, where you can just offload and get something cathartic from sharing what you're going through, and they'll give you some ideas and feedback, all the way to the very business-oriented end, 'you should do this, you should do that.' Different coaches have different styles and sit at different points, and most I've worked with sit somewhere in the middle.

You need a bit of the therapy end — where you sit down, drop your shoulders, maybe start with a sigh: yeah, here's another tough week, I've got this and this going on, I'm worried about this, I'm scared about that, and I don't know how to deal with this issue. You need that, because the other stakeholders I mentioned — my wife, my co-founder, my investors — don't want me to sit down like that. They come to me for the answers; they expect me to have them all. So you need a relationship where you can be yourself, be vulnerable, and say, I don't know what the hell I'm doing today.

But the real value is when they give you the mental tools to think in certain ways — frameworks for how to prioritise, how to manage difficult conversations, how to take a step back and put things in perspective. And a good coach is great at the people challenges, because frankly about 90% of what founders and startups face are intra-team problems: how your senior leadership is working, whether they're aligned and rowing in the same direction, how you manage culture and difficult personalities, how you make sure the message is communicated and aligned, and whether you're driving the right outcomes and enabling the right people. As a CEO, I'm actually the coach of my team too — so as much as I'm being coached, my job is to coach the people who report to me. So you're constantly working on those leadership and people-management skills, and a good executive coach can give you either the right tools or the right perspective on how to work with other people.

So the value I've found sits in three domains: the therapeutic part of being able to be open and vulnerable and get some feedback on how to put things in perspective; the mental tools and frameworks to manage operational problems; and being able to talk through the people-management side — working with other people to become a better leader and a better coach of others yourself. I'd challenge anyone going to an executive coach to make sure you get as much of those three domains as possible.