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If you’re leading a post-seed health tech scale-up, there’s a familiar pull to keep going exactly as you are.
The product has traction. The team is growing. There’s real energy and enthusiasm in the business, and a strong temptation to keep building at the same pace that got you this far.
That momentum matters. But this is also the stage where a quieter risk starts to build. We see it time and again in health tech companies moving from startup to scale-up. It’s called governance debt, and it plays a bigger role in growth than most teams expect.
When the ways of working that got you here stop helping.
In the early days, speed matters. Decisions are quick, roles overlap, and people step in wherever they are needed. That flexibility is often what keeps a startup alive.
The problem is what happens when the company starts to scale.
At that point, those same ways of working can begin to creak. Governance debt does not usually show up as one big failure. It shows up as patterns. Constant firefighting. Being caught out by regulatory requirements late in the process. Deals are slowing or stalling because something was not anticipated. People are leaving because chaos starts to feel normal. Leaders are spending more time reacting than planning.
Sometimes the signs are more subtle. Sometimes they are hiding in plain sight.
A raft of policies and procedures has appeared, some pulled together quickly (maybe with the help of an LLM), to get a supplier questionnaire over the line. The business is somewhere between version 3.5 and 4 of its privacy policy. The website still references the founder’s home address.
None of this feels catastrophic. But it is often the moment you can tell governance debt exists, whether you have named it yet or not.
So what do we actually mean by Governance Debt?
Governance debt is what builds up when organisations continue to grow on foundations that were never designed to carry the weight they’re now placing on them.
In simple terms, it’s building on sand.
Informal decisions, unwritten assumptions and short-term fixes can hold a startup together. But as pressure increases — from regulation, clinical risk, data protection or investor scrutiny — those foundations start to shift.
Like technical debt, governance debt often stays hidden. Scale is what exposes it.
In health tech, that pressure might come from clinical risk, patient safety, data protection, regulatory scrutiny, or investor due diligence. When it arrives late, the consequences tend to be expensive and disruptive.
When governance catches up with you.
Health tech doesn’t lack examples of what happens when governance fails to keep pace with growth.
Babylon Health is often cited as a worst-case scenario. Whatever mix of factors contributed, the lesson is a familiar one to anyone working in this space: when governance, clinical assurance and operational discipline fall behind, trust erodes quickly. And once trust goes, growth rarely recovers.
Not every company faces that level of fallout. But the underlying point matters.
In health tech, governance problems don’t stay theoretical. They affect patients, staff, partners and your licence to operate.
“Slow is smooth. Smooth is fast.”
There’s a phrase I always come back to in our work. It comes from the Navy SEALs:
Slow is smooth. Smooth is fast.
It sounds counterintuitive in a venture-backed environment. But it captures something we see again and again.
When teams move too fast without structure, things fall over.
When decisions are anticipated, aligned and understood, progress accelerates.
Good governance doesn’t slow you down. It helps you see what’s coming, rather than being run over by it.
I’ve worked with many different health tech organisations that are looking to scale, and the contrast between them can be striking.
The companies that scale well aren’t perfect. But they are intentional. They tend to put a few things in place early.
Leadership that sets the tone
Not just growth targets, but a clear commitment to quality, safety and long-term outcomes. In health tech, this often includes senior clinical voices who can ground decisions in real-world impact.
Clear, connected ways of working
Work is treated as a set of related processes, not heroic individual effort. That makes it easier to improve things without everything grinding to a halt.
People who understand why their work matters
Teams know how their work affects others, including patients. That clarity protects culture as the organisation grows.
Decisions backed by evidence
Founder intuition gets companies started. Data, learning loops and evidence are what help them scale safely.
Read like this, it all sounds sensible. And you might be thinking::
That’s great, but where do you actually start?
The framework is already there.
A useful way to think about governance is through a performance lens.
Any good coach will tell you that performance is not just about what happens on race day. It is built on fundamentals: strength, conditioning, recovery, and technique. You do not work on everything at once, but you do pay attention early, because those foundations are what allow you to perform when it matters.
Governance works in much the same way. When the fundamentals are in place, organisations can move faster, adapt more easily, and respond under pressure without things falling apart.
What often surprises people is that this way of working is not new.
The principles behind good governance are already built into established quality management frameworks like ISO 9001. The problem is perception. ISO is often seen as heavy, bureaucratic, or something to deal with later.
That is not how we see it used well.
The health tech teams we work with do not always need to adopt ISO wholesale. We use it as scaffolding, stripping it back to what is proportionate, practical, and useful for the stage they are at. I have just been involved in exactly this kind of work with a client, and it is genuinely exciting to see them take the framework and start running with it as they grow.
It is not bureaucracy. It’s a pragmatic structure that supports growth. More often than not, organisations aren’t starting from scratch. They just need the right perspective to see what is already there, and how to bring it together in a way that fits their size, risk, and ambitions.
That is where right-sized governance makes the difference
Governance as a growth decision.
Here’s the reframe we keep coming back to:
Good governance isn’t the opposite of growth.
It’s how growth holds.
That’s because:
- It protects investment.
- It improves decision-making.
- It helps teams stay aligned as they grow.
- It builds trust with regulators, partners and patients.
And it’s far easier to put in place early, before you’re trying to untangle problems later.
The real question
If you’re scaling a health tech company, the real question isn’t:
How long can we put governance off?
It’s:
What kind of growth are we building towards?
Fragile growth relies on heroics.
Sustainable growth is built on foresight, clarity and trust.
That’s the flag we fly at 8fold. And it’s the choice facing every health tech company as it moves from proving something works to making it last.
This is the part that often gets missed.
Putting good governance in place now can feel costly, in terms of money, but also in precious time and hard-earned momentum. It can feel like slowing down at exactly the moment you want to speed up. But in our experience, leaving it too late almost always costs far more in all ways: time, money, and momentum.
Most scale-ups don’t need a full-time governance hire at this stage. What they need is the right expertise, at the right moment, and in proportion to the risks they’re actually carrying.
That’s where working with an external team like 8fold can make sense. It gives access to experience and perspective without the overhead, and helps put foundations in place that support growth, rather than constrain it.
The question isn’t whether governance matters; it’s whether the way you’re working today is setting you up for the kind of growth you want tomorrow.
If you’re at this stage and want to talk it through, we’re always happy to have a conversation. Sometimes a single discussion is enough to help you see what’s already working, and what might need attention next.
We’re the experts that have your back.
Speak to a member of our team about how we can help you adopt “Good Governance” to accelerate your growth and stabilise your foundations.
