#447: Can you build europe's biggest clinic in just five years?

0:25Thank you. Hey everybody, delighted to be joined by Ranjan Singh, a co-founder and CEO of Health Hero, which is Europe's largest digital clinic. And very large it is, even much larger since we last spoke, Ranjan, on this podcast, where you gave us the whole background. But welcome back. How are you doing, sir? Very good, James. Great to be back on. And yes, time flies. I remember last when we spoke, we're still, I think, in the middle of COVID. It was not quite over yet at that time. Seems like... I think it was, yeah. I think it was. If it was later, it wasn't much later. But a lot has happened since then, Ranjan, and you guys have continued to scale.

1:12So I guess for people that might not know your whole story, they might not have listened to the previous episode, why don't you give us a little recap of Health Hero, but then let's dive into what's changed since 2021. on. Absolutely. Absolutely. So, look, a little recap. We founded Health Hero in late 2019, which was out a few months before COVID hit. Health Hero was founded on a basis that, like, there are some structural acute needs in healthcare that need solving, and we just don't have enough clinicians and enough money to meet the growing demand. So, we formed Health Hero to build a pan-European platform which solves experience for the patients, but efficiency.

1:58I've been using less clinician time and hence less money for the system. There was a lid of adoption. It was always a thing which is inevitable, but there wasn't digital adoption in the sector and COVID changed all that, right? So we really accelerated our plan And during that period, so we started with one company doing GP services, providing that to insurance clients in UK. So one service, one segment, one country. And our plan was to do holistic service, mind and body, and multiple segments, NHS, corporates, insurance, B2C, and multiple countries. So we then decided to put the building blocks for this.

2:53We needed to be in multiple countries. We needed to have multiple clinical expertise. And in several segments, we decided to put these building blocks to acquisitions, which we then completed all in 2020, which was a surreal time. I mean, buying six companies in nine months during a lockdown, all being done remotely, it was crazy. I mean, looking back at it, I think, how did we ever manage that? But we did. And since then, we've grown very nicely organically. As you said, we've scaled the business up significantly. We are now the largest digital health provider in Europe. We cover 35, 36 million patients in four countries, UK, Ireland, France and Germany.

3:45And we deliver just under 5 million consultations annually, which makes us not just the largest digital health provider, but the largest primary care provider in Europe. Wow. A number of consultations that are covered. So that's connecting to when we spoke, how we started to now. That's the journey we've been on. And I'll tell you going forward what we plan to do and how we're building it during the rest of the conversation, I'm sure. Amazing. Before we do, you used the phrase there, which is really interesting. and I think very different to how a lot of entrepreneurs think particularly in healthcare when they're starting out and starting maybe their first businesses like if someone's starting a first business might think okay I've got an idea for a clinic I'll start a clinic and I'll hire some clinicians and I'll market to try and get some patients and that's how a kind of a private clinic might go where you might link with the NHS and do something something different but you You mentioned the building blocks through acquisitions and very early on you said, you know, six companies in nine months that you bought.

5:02It's a very different mindset, isn't it? To kind of organically starting something, maybe pooch strapping even or a small raise to get something off the ground. It's a very different thing, isn't it? And so I think for a lot of people listening, it'd be good to kind of contextualize that a little bit and just kind of help us understand what your mindset is going to that. Was that always the plan? Was it always the plan to build a big business from day one? And that's how the strategy was set. And is there something in your background that allowed for that even? Are you trained to do that? Do you understand investment banking and all that kind of thing?

5:43and yeah, could you just talk to me a little bit about that? Absolutely, absolutely. Lots to unpack there. So first, yes, the ambition was always to build scale as soon as possible because look, in my previous life, I've done the classic entrepreneurship, as you'd say, from back of a napkin, build it brick by brick, you were designing your own business cards, setting up your own printers and scaling all of that good stuff, right? You just made that super relatable for every single person listening. That's the designer and business card, by the way. So we've done that. I had done that. And you have to go through.

6:32It's the rite of passage for any entrepreneur, right? You're not a real entrepreneur unless you've gone through that. So I've done that, right? And at this time, for two or three reasons, I was looking to create a high impact and make big scale. A, I think the need for healthcare was crying out, right? And, you know, we can't have a real societal impact by really doing things, you know, as I've done previously, and many entrepreneurs do bootstrap and stuff like that. I felt that there was a crying need to be solved kind of in near term rather than in 15 years time. OK, yeah. So that's that's number one.

7:20Number two, more on the business opportunity side of it itself. It's a massive opportunity. It's really big. Healthcare is the biggest sector. I mean, right now, with Trump and everything going on is come in focus. how much European countries spend on healthcare, 10 to 12 % versus say defense, which was one and a half to 2%. And people think defense is a big sector and they think of companies in that sector and so on. So just imagine how big healthcare is and how structural the challenges are. So the scale of opportunity itself was very big. So I wanted to do something, have that go-to-market, which was faster.

8:03Third, and most importantly, It was also the sector that we're in and the market that we're in. It was almost a necessity to do things in the way we've done it. OK, because in health care, for you to be credible, you need a certain track record, need to be at a certain quality threshold and credibility threshold. And it's possible to build that organically, but it just takes years and years and years for you to evidence that. OK, and given Europe, every market is different. Once you've cracked that, once you build that threshold and credibility in one market doesn't translate into another. There is only one NHS, for example.

8:46It's not there in France. It's not there in Germany. So as a combination, it was very clear from the beginning. So we built for a scale, we built for health care and we built for Europe. If you put those three things together, this is the only plausible way to build it. And we have ended up building a bigger and better business in one third the time and one fourth the cost compared to some of the competition. And there is no one, there are no examples today of having built a properly pan-European business holistic across as a platform without doing it the way that we've done it. So I'd like to believe that apart from healthcare innovation itself, we've been trailblazing on a business model innovation itself.

9:32nice so let's go into a bit of that then so pan-european that's really interesting different geographies different healthcare systems and even by the time we'd spoken last time you were in multiple geographies because i remember us talking about your approach in multiple geographies what's happened since 2021 then have you scaled into more geographies have you scaled deeper within current geographies? What's the scale looked like recently? And what's your approach to that multi-geography business model? Right. So short answer first, we are still in the same countries that we were back in 2021.

10:14So we've gone deeper in those countries and we are the dominant leader in those markets there where we operate in providing those online consultations. So that's how we've approached things over the last five years. And still, there is a lot of headroom. We are, thankfully, in the biggest markets in Europe. And if you think about Europe itself, there are about 5 billion consultations that happen yearly. We are doing 5 million. so if you do a quick math you might be better at this than I am is 0.1 % of the market as the market leader there's a huge headroom so our idea is to scale in where we are for now because these are that impacts in terms of how big the markets we are in are certainly UK, France and Germany and feasibility that we are in there already and then really scaling things up is quite important.

11:28And when you went into those multiple geographies, we hear that scaling across Europe can be difficult because of different governance, different regulation, localization differences, supply. There's lots of different issues and challenges that can come with multiple geographies. what was your approach to dealing with that was that part of the the like was it partnerships was it acquisitions was it was it working and hiring local teams on the ground and growing those teams organically like how how did you approach that because again you did it very quickly and and i suppose to in order to go deep which is what you've done more recently that's going to require you know teams that really know that country rather than you know a company trying to impose itself it's it's going to feel much nicer of feeling like it's of the country if you know what i mean so yeah yeah what's your what's your approach been yes to that so like the the approach as i as i highlighted that was the reason where we said we need uh local expertise local gna companies people who are really glued into this live and breathe that market and that market is intuitive to them.

12:48And that's why the building blocks that I spoke about were put in place, wiring those companies. So we brought in the local expertise and then combined it with the power of platform on top. So we had in many ways, look, it was not as straightforward. These things are not easy to do. So anyone, any entrepreneurs listening, I don't want them to take away, oh, oh, damn, that's dead easy. And what a great way to build it. Look, I mean, I joke, and I'll come to the point. I joke that when you are growing businesses organically, you wish you could do acquisitions. And when you're doing acquisitions, you kind of missed the whole organic ways and how simple that was.

13:30So it's not as straightforward, but on a balance, it worked for us and in the way we approached it. So the beauty was that you have that local DNA and local plumbing, right? I mean, that was part of the value we paid, integrated with the social security system in France, you know, intuitively aware of how, you know, healthcare regulations, healthcare clinicians and all those things work together. And then we bring the other kind of force multipliers, if you will, of a scale and platform and technology and everything else. So that was the idea, and that's the approach we took. I don't think, again, I'm repeating myself, that I haven't seen any other approach working unless you give it 15, 20 years, perhaps.

14:26Now, look, at the face of it, yes, every market is different. Healthcare is regulated, reimbursed, consumed differently. But ultimately, what we do at an abstracted level is the same across the markets, which is we bring patients and practitioners together in the most efficient, convenient manner. Digital where it should be and human where it counts. That's our kind of model. And that is what we do in every market. Now, how we go to market and how we get paid in those markets depends on what the structure is. So in the UK, you know, in the nicest possible way, NHS and insurance are gatekeepers.

15:19You need to have a contract with them to get paid. OK, so that's what our business reflects. We have NHS business, we have insurance business and we have corporate business. Right. Because that's what the UK demands as a market. But what we do in the UK is exactly the same as we do in France, for example. But how we go to market in France, because it's different, because once you are blessed or authorized to be a healthcare provider and we got that certification, it's a challenging, tough process to go through. We got that. Then you're free to go to the entire country. You do not need any deals with individual bodies or institutions to access patients.

16:07It's like B2C, direct-to-consumer marketing. And it just happens to be paid by Social Security. Patients can come on your platform, consume healthcare, have the best consultation with the highest quality doctor. So our go-to market is different. So that's, you know, and what it means is that, yes, there are differences in terms of, you know, all the mechanics and the plumbing I spoke about. And, you know, you need to adhere to local regulations, how you hire clinicians and all of that. But it's 70-30 or two-thirds, one-third. Two-third of it is similar across the countries. And one-third of it is that which is nuanced and unlocal, right?

16:51So that's it in terms of, you know, what we've learned. And some of it was our hypothesis that we went in with. But a large part of that has, you know, held true. Now, layering on top and why this works across, because ultimately, the problems all these nations face are the same. Don't have enough clinicians and enough money to meet the rising demand. so what we do at an abstract level is similar the problems that we're solving are similar it's the mechanics underneath that differ and that's what our kind of secret sauce has been in terms of how we've been able to bring bring and match them as well together yeah i love that the um the secret sauce bit is interesting because what what you're not is private equity just buying businesses and potentially throwing them under the same logo but just leaving them how they were no there's a health hero way of doing things now you mentioned the platform you mentioned tech there are things that there is there's the health hero dna here that's also doing a lot of work to helping with this scale that is bringing down costs and working at efficiency it is delivering high quality it is in part putting digital where it should be and humans where it counts love that phrase by the way as someone in comms absolutely love that um and so i'm interested in in that now so i'm interested in what's what's special about the health hero way of doing things and so what makes the platform and the tech uniquely good and is there anything about particularly the the way that you do virtual primary care like is there anything is what's what's uniquely you about the way of doing that are there things that you care about specifically about the product there even clinically and going down into those weeds Is there anything special or specific about the way that you ask those things are done under the Health Hero brand?

19:06Great, great question. James, look, I've been thinking about it, right?

19:16Is what we do super special, very different? I mean, there are few things that we have in kind of tangible tools and stuff which are X factor and very hard to replicate. But that's not the reason how we've been able to scale and, you know, if I may say so, succeed. Well, there's only so much you can do differently, right, to a point. Exactly. I think it's far more intangible. It's been in our approach. I say it's because we are the grownups of the sector. We think about it in a grown up manner. So one of the things, and then you asked me about my background previously and how I was able to do these acquisitions and stuff.

20:03I missed that part. So after, you know, my entrepreneurial journey in, you know, retail and travel, I joined private equity, which is where basically the, you know, M &A and team making was, I was schooled in. So what I saw when I started in healthcare back in 2014 as a private equity investor was, you know, people were doing something quite flimsy almost, right? Just making two people talk on a video and claiming to disrupt healthcare or thinking that you're altering healthcare in some big way was not great, was not genuine, was not scalable, and those companies did not scale. That was one. So we really wanted to go deep and solve for the core issues.

20:57And I'll tell you how that has manifested. Right. Second. Also, I saw that, you know, digital entrepreneurs normally go overweight on patient experience that comes naturally to them. Right. That's what they've built previously in their previous lives or stuff. Now, that is necessary, but in health care, by no means sufficient. And in many cases, I saw that those companies were unable to get resonance with the, if I may again, gatekeepers of healthcare. Because like it or not, user is not the pair in Europe. So you've got to cater. There is a trifecta that you've got to cater for. Patients, practitioners, very important.

21:50They're a very important stakeholder and payers. So that's the trifecta in healthcare that you need to build for. And just solving for one is not going to do the work. So what we decided early on, that we're going to be a highly credible, high quality healthcare company, alongside being a digital and tech and now, you know, AI first, AI native, right? So that is where, you know, we built parts of my business. if you go in, they feel like NHS and they feel, you know, really healthcare and healthcare only. And the other part is as cutting edge and innovative as anyone, you know, in the startup ecosystem.

22:37And managing that yin and yang has been, you know, part by design, part by default, the culture we've created has been quite amazing. So those were the few things how we started doing it. And you spoke about something to report and announce. That is talking about healthcare quality. We got recently inspected for our NHS business in UK. And we got the third outstanding rating in a row by CQC. Wow. When we had two outstanding ratings in a row, I was never tired to say that we're the only company, not just digital, in healthcare to have two outstanding ratings in a row. And now we have three. So that's what tells you how seriously we take quality.

23:29Because one without the other is meaningless. us. Okay. And on that, we were the first and for a long time, the only company in Europe to have an ISO certification for telemedicine and so on and so forth, right? Our NPS scores, you know, go up to 93. I mean, we have different services and stuff, but, you know, from what I can say, nothing below 72, it varies between 72 and 93. Huge. Patient satisfaction scores are 96 % unheard of in healthcare. So all of that focus on quality and be very good at what you do day in and day out is really, really important. And then allow a great use of technology to do that.

24:19So that's what the cultural and DNA part of it, right? Now, zooming out, you said, what do we do as a business and how have we approached delivering health care? And this goes back to my first question that we're not just, you know, medical video call. Right. So we started with, let's say one thing we do extremely well is navigation. OK, I'll tell you what I mean by that. The biggest problem in healthcare is also the easiest to solve, right? That is a very inefficient triage today. Everyone who has even slight cold and flu or nothing at all ends up at a GP. And GPs have become kind of logistics sorting centers, right?

25:14Where you go to the GP and they'll tell you to get a blood test or do nothing or see a nurse or mental health therapist. or go to a specialist, right, is I don't think it should be that. I mean, it makes it a choke point, right, the primary care, and that's where all the headlines about waiting times and frustration and all of that emerges. We're turning it completely on its head so people don't end up, if you have a slight backache, you don't go to an orthopedic surgeon, right? I mean, you go through that initial triage, right, and that's what we're very good at, And this is where we have powerful tools, medical-grade tools that we use.

25:57We have a traversal engine, we say, which is a clinical brain. It has symptom assessment, health risk assessment, and all of that. It's been built over 25, 26 years, dozens of PhDs input into it, 65 million assessments. We use that as a base to do the navigation. So where we take the presenting condition, a technical word to say, what's wrong with you? We take that, match that with modality, another technical word. Modality is which mode would you communicate in? Do you need to go and see a doctor live or a video or phone call? Or could it be done through chat or some asynchronous means that you write, you know, fill in a form and you get your response, right?

26:43And that's very powerful. That's the second bit. And the third bit, what we do is connect to the right clinician type the first time, whether it should be a nurse or a mental health therapist, GP, cardiologist. And that we can do in milliseconds based on your input, that pathway. And that just completely reverses the whole thing, that you get the right care the first time around, great for patients, experience, and great for healthcare delivery and the system efficiency. So that whole navigation piece we do very well. And then there is what we call augmentation. Look, a lot of marketing words here, but bear with me.

27:33I mean, it helps encapsulate and communicates a point to us internally and also, you know, to our clients and patients. So augmentation is how do I give superpowers to my clinician? How do I augment their work, not replace their work? Digital where it should be, human where it comes, right? But augment their work. And this is by taking all the grudge work away, taking all the admin away. that's been our focus so far, right? When we started life, digital and technology was used to automate and digitize the paperwork and workflow. And now with AI, we can automate the work itself. And we'll come to that when we talk about AI.

28:16So we do a lot of augmentation of that. Take the admin away. We're now doing a lot of, of course, AI scribing and all of that. And we provide tremendous amount of decision support and so on, which makes our clinicians job not just faster, but better. It allows for better outcomes because they could be highlighted about certain conditions that might be rare and they might not have asked and so on. So that's the augmentation part. And final bit is orchestration, which we feel that, you know, healthcare has been largely, you know, hospital centric where, you know, you're broken and you go to the hospital, get fixed and come back.

29:03and now with chronic conditions and longevity and all of that, it's more out of hospital care, which is more important, which is where the cost burden is with chronic patients with their 80 % of the cost burden. And we think digital and out of hospital care are made for each other. Okay. And that orchestration, which includes, you know, can we do preventative, if we could prevent things from happening, right? Through the right protocols, nudges, and the personalized approach, right? When things do go wrong, then we can provide the care fast in the best possible manner rather than having to wait.

29:47And if you did need some secondary care, go to the hospital and stuff, we can do before and after more efficiently, that whole orchestration. So we do provide, we don't, you know, a lot of people think that Digital health is still, you know, doing a video call with your clinician. It's anything but. Think about what e-commerce was in late 1990s when, let's say, Amazon had just started. Okay? It was a shopping catalog with a shopping basket and a payment gateway. Right? So that's where digital health started in 2020. Right? A video call between two people. But e-commerce is anything but today. Yes, there is a catalog.

30:34Yes, there is a shopping basket and a payment gateway. But it has fundamentally re-architected how commerce is done. It's reset customer behavior, expectations, everything. Lightning fast logistics. I mean, it's not the same. And that's what digital health means and has the potential. And that's what we're doing. It's a new operating system for healthcare. rather than a video call right and that's what we're pioneering it's so interesting isn't it because um you know at the start when when you said ah basically you know we really all we do is bring clinicians to patients it's like no no no there's actually a lot of detail a lot of nuance a lot of dna that goes into this and the bit that i want to pull out here is your approach and your focus on staff actually um the augment part of what you said because i think i think you do perhaps even more for staff than than is immediately obvious because even when you talk about net promoter score mps that relies on the satisfaction of patients and the interaction is between one of your clinicians and the patient and so it still matters how you are treating the staff that will affect the net promoter score that's not a direct you know a staff just broadly happy with what's going on it's like no no no that they've got to be really happy with the interaction with that staff member as well and so your ability to recruit your ability to retain your you know how you treat them and part of that will be those things that you're augmenting for them the lack of note-taking but even even that element of getting triage right yep so that a pharmacist that has a list just sees drug problems and nothing rogue or weird gets through or repeat prescriptions or blah blah because also by the way that then comes off what the gp has to see so they're not seeing inappropriate stuff so actually part of their satisfaction in going to work is seeing the right patients for their skill set so they can practice at the top of their license and get satisfaction that way so i think it's it's really interesting to me i think the focus that you've got on all of those different things and it's no coincidence therefore that you get things like outstanding cqc when all of this ends up coming together because like we said how much can you really do differently it's like well okay maybe not in terms of like a percentage of the overall there's probably not but that final five percent probably has 500 things that you can that you can do and you've talked about you know 20 of them here and it is about getting those right and i just wonder i mean congrats on the cqc by the way that is a it's a great achievement my question there actually i don't know if you know the answer to this but what what makes outstanding compared to everything else what does everyone else fail on not fail like fail to get outstanding you know good or whatever like what what what do you think's made the difference there between good and outstanding that that what's everyone doing good and what are you doing outstanding that's the question of look there are five criteria that cqc rate on and I can't remember off the top of my head things like is the organization well-lit and where the patients stay and so on and so forth.

34:18There are five distinct areas in which you get rating and an overall, I think if you get three outstanding then you're overall outstanding as well. But the overarching thing that they're looking for is patient safety. Is this organization delivering the highest quality patient care. And that is broken down into, if I look at these five things and if they're good in that, then ultimately. But that is what CQC is focused on. And that varies from, did we take good care of patients? Did we give them the right prescription? Did we not over-prescribe or under-prescribe? And variety and variety of things.

35:04But it is patient safety. yeah well that's great because also then you're you know your triage components can be part of that as well i think one thing that people can people are concerned about with particularly any kind of ai triage system you know people get concerned about the overall safety what gets missed you know sensitivity and specificity does everything end up going to a and e does everything like these are the questions people have whereas you know knowing that that's gone through that and come out without standing as well is is well that must that must be of great comfort to you as CEO of the organization?

35:38Well, James, there are things. I got into this business after my other sectors that I've worked in because healthcare is the only, not the only, one of the key sectors where when you're successful as a business, you end up making a huge societal impact as well. So I have to choose between being a successful business person and doing good for society, right? So that's important. Now, let me tell you, You touched upon something very, very interesting there and which we pride ourselves. Now, the safest thing to do, the easiest and the safest is when anyone calls, you send them to A &E, right? You can't go wrong, okay?

36:21But the real skill comes in when you actually triage them properly and ask them not to. and still do it in a clinically safe manner. So let me tell you one service that we started and which has been a roaring success. With one of the regions that we work with, we started something called a care coordination service, okay? Which is where basically when the ambulance crew goes responding to 999 services, it was seen that 95 % of their cases ended up in A &E And that's where you see all these headlines about corridor care and ambulances lining up. Even before corridor care, this is in ambulance care, which, you know, they can't even get to the corridor, let alone hospital beds.