About this episode
Think of life like a grand pyramid scheme, where each generation relies on the next. But what happens when the growth of this pyramid stalls? Welcome to today's world. There simply aren't enough young people or resources to care for older people properly. We've got some band-aid solutions — you can increase immigration, or maybe ban contraception, joking — but eventually you'll get stuck again.
If you can make care at home more efficient — and hence cheaper — that's interesting. Or what if you could even use predictive AI to prevent older adults from becoming sick and ending up in hospital? That's basically what Birdie do: a Series B age tech company who have raised $52 million from the likes of Sofina, OMERS Ventures and Index Ventures, and captured 10% of the UK market whilst currently expanding into Europe. I started off by criticising Birdie — asking whether you can really tackle such a fundamental problem by building software. Don't you need to actually, you know, deliver care?
In this conversation
- Max frames the entire age tech market as two archetypes — the capital-hungry "Amazon" roll-up that buys and runs care providers, versus Birdie's "Shopify" model that only ever spends money building software to empower the providers who already exist. A clean mental model for anyone choosing between owning operations and enabling them.
- Birdie started B2C — Max literally handed out leaflets in King's Cross Station trying to sign families up — and it was a total failure. The pivot to selling B2B software to care agencies is the story of how the company actually found product-market fit.
- The concrete product wedge: care workers were still using pen and paper, typed back into Word docs and audited by hand. Digitizing that one workflow unlocked earlier detection of falls, UTIs and deterioration — the expensive, preventable events that put older adults in hospital.
- His honest founder playbook, extracted over a hypothetical pub chat: stick to the vision through two or three pivots, pay above market and treat sourcing as a growth engine, and accept that resilience — not strategy — is what actually prevails.
- A guest who turned down the McKinsey-partner track to do "the hardest thing I've ever done," and talks candidly about opportunity cost, the social contract, and why you should never start a company for the money.
Transcript AI-generated
So, Max, I mean this with the greatest of respect, but to me it seems that in the age tech space, to win, you need some kind of physical presence. You can't be a pure software player. We've seen examples of, say, Honor's acquisition of Home Instead. And in the UK scene, we see Cera acquiring a lot of physical presence as well. Do they know something that you don't?
“We see ourselves more as a Shopify, and these guys more as an Amazon-esque model — where it's winner-takes-all. Whereas we see ourselves more as an empowering tool.”
Max
“There are two models, two archetypes, and I really don't know which one is better than the other. Theirs seems to work. Ours is working very well.”
Max
It's a great question — one I get asked very often, including by advisors and friends. But you've got two examples. For me, that's not enough as a data point to define a trajectory that's working or not working. And I have a lot of respect for these two. I think there are other ways as well, so I stay firmly convinced about the model we have, which is, in my view, a much more scalable fashion. There have been other examples that have failed — in Germany and a couple of other countries where they've tried this kind of physical-presence scaling.
There are two models, two archetypes, and I really don't know which one is better than the other. Theirs seems to work. Ours is working very well. So I really hope both can be successful.
Archetype one is the roll-up. It's more of a private equity play — quite capital intensive. You buy different providers, and the thesis is that you'll realise economies of scale and synergies by aggregating them, including through the injection of technology, to make them more efficient, so the margins improve. It's a very nice play. But it requires a lot of capital, so it's not so scalable unless you have a lot of money that you need to either raise or borrow.
Archetype two is the one we follow, where we say: we are a technology company. We're empowering existing care providers. And we believe that's more scalable, because we spend every single pound we've got on building technology. We're not distracted by the operations. We really want to empower the people delivering care to do a better job — particularly in a world where care providers are quite decentralised. Community care is very local, and there's an army of people doing that already. So we have a strong conviction that we don't want to repeat what they do, and we have no arrogance whatsoever that we could do it better. We want to empower them.
Because we invest only in technology, we can actually scale fast. That's how we have 10% of the market share in the UK and are expanding into other countries — probably at a capital efficiency that's higher than theirs. I think there's no winner or loser. It's also a philosophy. We see ourselves more as a Shopify, and these guys more as an Amazon-esque model — where it's winner-takes-all, where you need volume and mass to succeed and bring the benefits to patients. Whereas we see ourselves more as an empowering tool. So I don't think they're winning or we're losing. Both models are working, but they're very different.
Just to steal a march on the acquisition play — there are two plays. There's the software play you're going for, the Shopify approach. And then there's the PE, private equity approach of acquiring the physical presences. Is the assumption of companies doing that PE approach basically that they can acquire a lot of physical presences and run them more efficiently than they're currently being run? Is that essentially where the benefit comes from?
The good thing to say is: we can get to much higher efficiency by acquiring these different providers, which are often, because of their size, not equipped as much as they'd like with the right tools, systems and guidance to be more efficient operationally — but also to improve the quality of care delivered. So the thesis, you're right, is that by size you can invest in more efficiency gains, particularly through technology.
Now, the other question is the licensing of the technology to third parties. That's why I'm saying it takes quite a lot of money to build the technology in the first place. You need a lot of money if you want to do the physical-presence acquisition and the tech. So we said we'll just do the tech. If you want to do both, you'd better have a lot of money.
I wanted to ask about the Birdie product and how it's developed over time. I'd love to hear your initial MVP, or the initial product, and then how it's changed throughout its development. In particular, I'd love to hear if there were any red herrings — any areas you went down that didn't end up panning out, and how you adjusted.
From the beginning, we wanted to be a technology partner. But we started B2C — with a consumer proposition for families. I remember vividly, I was in King's Cross Station here in London, handing out leaflets to family members to try to convince them to sign up for free on the Birdie Care Companion app. We had miserable results. It was really hard, and we learned so much from it.
Every situation is different — number one, because it's a quite intimate and sensitive topic for families. There's no way they're going to talk to someone in a station about their mum's health condition and how hard it is. And number two, we were very unclear about the value proposition we were offering, which was: "we'll support you." What does that mean? The great learning is that you've got to be very specific and understand inside out the experience and the pain point of the customers you'd like to sell to.
So we started B2C, it was a failure, and then we realised the people closest to the patients and the families were these care providers. We also realised, as I said, that they will become the future healthcare workforce. So we pivoted to these folks and said: how could we help them become better and really do a better job?
And that's where the B2B SaaS proposition began. We started with a piece that for us is key: care management. We realised these providers were using pen and paper. The care workers, or healthcare assistants, going into patients' homes were using pen and paper to check in and check out, but also to report on the medication they were giving, on the tasks they did, on the clinical observations they made. All of that paperwork was brought back to the office, typed into a Word document, printed, and there were two people auditing the archives of these printouts. So it was not only utterly inefficient, but also really compromising the quality of care delivered.
So we started with that module. Let's build an app for the care workers and a web app for the agencies employing them, to manage care better — assess better, in a much deeper way, using a few different clinical assessment frameworks that are much more comprehensive. Then we help them plan the care better. And during the visits, the care workers were actually recording them on the Birdie app, so that whenever there was a concern — a wrong medication given, and so on — it was immediately flagged to the agencies, to the employers, and treated on time.
That was a huge win, because this industry is regulated and these agencies are inspected by the regulator. But also because these guys realised they were suddenly saving a lot of time, and they could see things much earlier. That opened up a world of opportunities in terms of more preventive care — whether the medications are compatible or not, all sorts of things you can do once you've digitised data that previously only existed on paper.
From there, because these providers were asking for more, we moved towards more of a full operating system model. We built module after module to give them a full experience with Birdie — from rostering and scheduling to part of the invoicing and payroll, the analytics, and so on. It really covers all of the operations, digitising as much as possible, with one single aim: save time, so they do what they do best, which is care, and we take care of all the rest.
With all the data points you have, what are some of the interesting things you can do? In my mind it would mainly be predictive stuff — trying to predict deteriorations and hospital admissions before they happen, because those are the expensive part of care. Is that the interesting bit with the data? Are there other things, or is that the big opportunity?
That's the opportunity. There are two things. There's the immediate opportunity, which is avoiding hospital admission, broken down into the classic use cases — falls, so identifying the risk of falls and acting on it much earlier. There are different types of infection, but one is urinary tract infection, a classic one with older adults. Can you detect it much earlier? You can treat it quite fast with antibiotics, but if you let it deteriorate it can significantly worsen, and you could stay easily three or four weeks in hospital. These are use cases we know we're trying to address, and we're working with the data to address them.
But then there's a wider set for us: the wider set of health determinants, which isn't all about hospital admission, but about how we could ensure a patient is happier and feels healthier. So it's not about actual health measured by hospital admission — can we go even earlier and ask: would a patient feel better? Health determinants could be risks of depression. Do we see mood signs? This is not something we're running at scale, but we would love at some point to try to identify mental health signals, because that is an incredibly strong signal of health eventually. And physical health is a lagging indicator of mental health, as we know. So there are a couple of things where we'd like to use the data to identify things upstream to avoid the problems downstream. But essentially, you're right — it's prevention.
Can I pitch you an idea in the D2C age tech scene, and then you critique it? Maybe say what you like about it first — because I suspect that's going to be a short list — and then why it wouldn't work, based on your knowledge and experience. Is that all right?
Sure.
The caveat is that this isn't my idea. It's my friend Chris Lovejoy's idea, but I thought it was amazing. The problem is essentially that a lot of people have come from less economically developed countries to places like the UK, the US — more prosperous places. They might have family back home, and they are not confident their relatives are being looked after well. That might be because the health systems aren't very good, or because of a lack of communication. But here you are, 2,000 miles away, and even if you want to do things, you can't really care for them properly.
There's an interesting opportunity there: take a service that charges in the UK, the US, more prosperous countries — so there's a bit of a currency arbitrage — and take money from people here, through a platform very similar to Birdie but more on the B2C side, to make sure your relatives are being cared for back home. It'd look like a dashboard where you could see: this is my relative, my parent, this was their last check-up, these are their health concerns. Someone organises all of this, someone monitors it, here are their investigation results, and so on. It'd be based on a subscription model, say monthly, and you might be linked to good providers over there — so you're confident the people caring for them, whether care workers, doctors or nurses, are decent and not cowboys.
When you hear an idea like that — and I appreciate it's not very fleshed out, it's more a problem and a solution — why do you think it's a good idea, and why do you think it's a bad idea?
Can I clarify the idea? Back in the country where the older person lives, are you including physical services as well?
Yes — physical services, involved care, nurses and doctors and the like. And maybe you'd have some regular cadence of check-ups, say a monthly primary care check-up.
I think it's an excellent idea. The thesis of "I live far from my loved one" — wherever they live, and particularly if it's in countries where the healthcare system isn't good enough to give me reassurance — that feeling of guilt and worry is very, very present. The informal caregivers, as we call them: it's a pervasive issue across countries. I've explored that at length, and I've been in situations where families struggle incredibly. It can be really heavy, emotionally draining. It can hamper your career, damage your family relationships. So the trigger and the pull, I recognise fully. Great idea. I could totally imagine people in the UK paying for that for their parents back home.
I'd just call two things into question: the economics, and the logistics on site.
Let's start with the logistics. If you have nurses and a check every month, you need to find these people. If there's not enough concentration, you need to call upon third-party providers, private providers, and it becomes complex — so the quality of the service is often limited. You need a physical presence in that country to make sure the quality is good. You need volume so they take you seriously and are happy to work with you. So you probably need to start with cities — one city, then another. And how do you ensure you have enough people in the UK with parents in that specific city? I really wonder whether there's a bottleneck there. But that could be waived, or simplified to the extent of a telemedicine call, a few sensors, and maybe an informal model like Papa in the US, where you have caregivers going to see the patients.
The second one: how much does it cost? It's always the same. In countries where healthcare hasn't stepped up, families living remotely often struggle to pay the full cost of healthcare, so it becomes only a premium system where only the wealthiest can pay. Even in countries where there's not much healthcare delivery, paying for private healthcare is often quite a premium, quite expensive. So I'd really love to look at the business plan and ask: can I, as a second-generation immigrant in the UK, afford to pay for my mother or grandmother who lives in that country, and am I ready to pay a monthly fee that could be substantial? I don't know. That's my hypothesis.
That's really interesting. Max, if you had to condense down the smart things you've done building and scaling Birdie — if someone came to you about to start a very similar company, and you were giving them a really honest talk over dinner, or at the pub, and you said, "look, these are the ways you're going to fuck up, and this is what you should do instead" — what tips would you give them?
There are three things, really.
One: we stuck to the vision, and it's still there. We've basically pivoted two or three times, as I said, and we failed so many times in the things we tried. But that vision stayed there — it was a North Star, a goalpost. And we stuck together, and our investors stuck with us, because we were saying: we're going to approach it from different angles, and we're going to try. And if it doesn't work, we'll start again. But that's the plan. And the plan is to fundamentally transform the way we age, and to use technology to empower better ageing.
The second one — and I know it's cheesy — is that it's all about the people.
Max, can I interrupt on the people point? I always believe values only mean something if you talk about what you'd sacrifice to achieve them. So when you say people are really important, does that mean you'll pay 50% above market rate? Does it mean spending triple the time to find and hire people? Does it mean, if someone wants to leave, giving them whatever they want to keep them? What's the sacrifice you make to achieve that?
All of that. Number one, of course, you need to pay above market — and that's a sacrifice, believe me. We benchmark ourselves continuously, and our principle is we always pay above average, and we try to be largely above average, because that's how you get the best talent. Otherwise the equation doesn't work.
Second, you come with a wider range of benefits that make it attractive to work at your company. You need to make sure people are satisfied and happy — so there are ways of working, governance, values in the company. And the mission, which for us is really important, and people are attached to that.
And sourcing — you're absolutely right — requires an incredible amount of effort. You need to look at sourcing as the growth engine. We dedicate a lot of time and effort to finding the best people and convincing them to come and work at Birdie. I'm not saying we have the best in the world, but I'm saying we spend an incredible amount of effort to get there. We have to reinvent ourselves continuously to speak to the best and try to convince them to come and work with us.
Sorry, I interrupted you. So you're talking about having an overarching vision — and presumably that means not getting distracted, that's the downside. You can't boil the ocean; you need an overall trajectory. The second point was around hiring and having the best people, and the sacrifice was pay and being a bit more selective. And then you had a third point I interrupted.
Again, it's very cheesy — I'm so sorry about that. Resilience and optimism. It's the hardest thing I've ever done in my life, because you're facing a mountain. There's no guidance or direction — you're in unknown territory, and it's an adventure, a very exciting adventure. But you need to believe every day in this adventure. And whenever there's an issue — and there are a lot, a lot of hurdles — you have to have the resilience to carry on. It's worth the journey. Everybody says resilience is the single determinant, and we've heard that again recently from a few top leaders. But it's true. Determination prevails and trumps any sort of strategy.
If I could colour in that resilience piece — your alternative right now, and let me speculate, feel free to correct me: you were at McKinsey, so theoretically some of your peers have gone on to become McKinsey partners, or other high-profile, high-earning jobs. They're on a lot of money, they've got a guaranteed paycheck, and it will continue to rise. And you're taking this huge risk. It could all not work out, and in five or ten years you've had so much opportunity cost. So I think that's where the resilience comes in — you really have to believe in what you're doing, because you had a very comfortable alternative.
“To anyone willing to start a company: do not do it for the money, because there's very little money and only a very, very few happy winners.”
Max
Yeah. I had a conversation with my partner two days ago, and we were talking about exactly that. I'm a firm believer that if you're not happy where you are, you have to change — but you cannot whine and complain too often, too long, particularly in the privileged situation I'm in, where I had a good education and optionality. When I look at care workers — and I know many of them — it's a different ballgame, because many of them don't have any choice. I have the luxury of choice, so I don't allow myself to complain if I'm not happy.
I'm very happy in what I do. And I agree — the opportunity cost is huge, but I believe the reward is extraordinary. The mere satisfaction of building something with value to society is incredibly rewarding for me. Serving a wider mission energises me incredibly. And I do believe firmly — and this might be very tainted by my values and cultural background — that with the kind of background I had, where I could study and work in good places, I absolutely have an obligation to at least try to contribute to the wider societal benefit. If it's all about me and my money, then I'm breaching the social contract.
Of course I'm building a startup, and of course there might be a financial upside. But as you said, the risk is incredibly high. To anyone willing to start a company: do not do it for the money, because there's very little money and only a very, very few happy winners. This idea of the social contract, of setting a societal mission and working towards it, is deeply ingrained in my values. And beyond that, trying to build a company where we do our best to treat people well, to operate with excellence but also with integrity — and to hopefully convey these behaviours to the younger employees who've just started their first job, so that in turn they go to another company and call out behaviours that, for them, are not acceptable. For me, that's incredibly rewarding as well. So for these reasons, I'm super happy in what I do. The opportunity cost is higher, but if I'm not happy I should leave — and I'm very happy for now.
The last question I wanted to ask: have there been any books, resources, anything that's been useful or helpful along the journey?
Plenty. I'll spare you all the business books on scaling startups — there are plenty and everybody knows them — but there are a few that have been very helpful. If we go a little more niche: the latest book by Peter Attia, Outlive, is for me excellent, kind of the Bible for prevention and longevity, which I find fascinating in terms of depth and concrete tips. I highly recommend it for any geek who'd like to live longer, or at least feel healthier.
Then, on the more exotic side, there's a book by Professor Mazzucato called Mission Economy, which I really like. She says we should organise our economy towards a single societal objective, and calls on the example of the mission to the moon — where the US government and Kennedy said, "we're going to go to the moon," and rallied up NASA, but then thousands of private companies worked towards that effort. She says it's time to set a societal goal again — whether that's climate change or healthcare — and have the government not just regulating but being at the forefront of the initiative, rallying up the economy. It's true that in liberal societies, the UK or the US or others, it's great to let the system manage by itself, but sometimes we lose sight of what matters. I'm often frustrated to see the amount of capital and intellectual resources deployed in things that are probably less important than healthcare, education or climate change.
And there's War and Peace by Tolstoy, which for me is an incredible example of where I think the existential essence of living lies — in the feeling of belonging and working for a greater good. I think that's one of the sources of happiness. But I have another list, and I'm going to stop here.
I hope you enjoyed the podcast. You can find all my links by going to bigpicturemedicine.co.uk. And if you've been enjoying the podcast, please consider leaving a review and telling a friend about it — maybe send them an episode you think they'll like. All right. See you next time. Thanks for listening.