It sounds obvious in theory. Who better to run a healthcare business than the people doing the actual healthcare? But the reality, at least on both sides of the Atlantic, is that medicine has quietly drifted away from doctor ownership, and most of us barely noticed it happening. Partly because we were too busy. And partly because, as a profession, we’ve never been particularly comfortable talking about money.

That discomfort is costing us more than we realise.

In the US, the numbers tell the story plainly. Back in the 1990s, somewhere between 60 and 75% of physicians were self-employed. Today, that figure has collapsed to around 30 to 40%, with hospital systems, private equity firms, and insurers absorbing what used to be independent practices. When private equity really leaned in around 2017, particularly in dermatology, anaesthesiology, and emergency medicine, the model became familiar: acquire the practice, pay the founding doctors a lump sum, lock them into a three to five-year contract, then shift the metrics toward productivity and profit. The doctors who stayed on became employees. Younger ones joining never had the option of ownership at all.

The UK got there differently, but ended up in a similar place. GPs technically operate as independent contractors to the NHS, but the funding model, contract constraints, and bureaucratic weight mean that clinical autonomy has become something of a polite fiction. Hospital consultants have even less say. You’re operating within a system largely designed without you, and often despite you. In 2026, there seems to be a new shift towards reducing the amount of doctors and even replacing them with Advanced Clinical Practioners, even more of an example where doctors have less say.

When doctors aren’t owners, the KPIs of the business stop reflecting the actual goals of medicine. This is why I am very bullish on this series generally, most healthcare decisions boil back to being business decisions. Patient outcomes become secondary to throughput. Prevention gets deprioritised because it doesn’t generate activity. Nobody sat down and decided this was the goal. It’s just what happens when the people closest to the patient have no stake in how the organisation performs. If you want to understand why the profession’s values, continuity of care, patient-centred decisions, clinical integrity, keep getting eroded, follow the ownership structure. The values of any institution tend to reflect the values of the people running it. Fewer doctors at the ownership table means fewer doctors shaping what the institution actually optimises for. Or one could argue is the instiution even optimising for what doctors would want to be optimising for? Is it about High Quality Care or High Output Care?

This is why the cultural allergy to money talk in medicine is such a problem. I strongly believe the advice most UK doctors get about ‘Don’t worry about the money until you’re a consultant’ is terrible advice. It gets dressed up as professionalism, as though being above financial considerations is somehow noble. But it isn’t noble. It’s naive. And it’s left the profession increasingly unable to protect itself. When pay disputes come up, when contract negotiations happen, when health systems restructure, doctors who have no ownership stake, no equity, no financial literacy built into how they think about their careers, find themselves with very little leverage. You can’t advocate effectively for the profession from a purely employed position when the people across the table have spent years thinking about nothing but the economics.

The counterargument to all of this is real though. Running a practice is hard. The admin, the compliance, the HR, not knowing how much you’ll make. It’s a full-time job layered on top of an already full-time job. The NHS absorbs a lot of that friction, and not everyone wants to be an entrepreneur. Fair enough I totally get it.

But we’ve overcorrected. We’ve let “this is complicated” become “don’t bother.” The more doctors are told that ownership is too hard, too risky, too much, the more ground we lose. And we’ve been losing ground on it for decades. As much as everyone can’t and shouldn’t be an entrepreneur, we shouldn’t be discouraging the ones that do because they can fly the flag for the values of the profession. In the same way not everyone can be a surgeon, but those who do should be championed

My view is that ownership should be something the profession actively pushes toward. Not every doctor needs to run a practice, but more of us should be thinking about it, trained for it, and encouraged toward it, because the doctors who do own have an outsized voice on behalf of everyone who doesn’t. They’re in the rooms where decisions get made. They sit on boards, shape contracts, and push back on the metrics that everyone else just has to live with. This is the same in other sectors; the people who own the businesses on the high street have a strong hold on outcomes for the local community because they have financial power.

Ownership doesn’t only exist in the entrepreneurial capacity it also exists as intrapreneurs. Doctors should be actively encouraging each other to take on board roles within the hospital or local department. You will find in the majority of hospitals, there is no doctor on the board, even as a Non-Exec Director.

Medicine has always prided itself on its values. But values don’t sustain themselves. They need to be defended by people with the power to defend them. Right now, we’re handing that power away and calling it simplicity.

Articles

https://www.ucl.ac.uk/news/2024/sep/20-fall-gp-surgeries-while-patient-lists-grow

Have you ever noticed that doctors and surgeons have a fundamentally different relationship with money?

Not in terms of how much they earn. I mean, in how they think about what they’re selling.

A doctor, broadly speaking, sells time. The whole structure of medical work is built around it. Your Clinics are scheduled in ten-minute slots, On calls are measured in hours, Job plans for consultants are carved up into programmed activities, which are essentially time blocks dressed up in NHS language. When a doctor asks for more pay, the argument almost always comes back to the same place: I am working X hours and I should be paid Y per hour. It’s a reasonable argument. But it’s also a losing one.

Now think about a surgeon. Or a dentist.

A surgeon isn’t pricing their time. Nobody sits across from a patient and says “the cholecystectomy took 47 minutes so here’s what I’m charging.” The procedure has a value. That value reflects years of training, the judgment calls made before anyone opens anything, the risk managed in the room, and the outcome delivered on the other side. You’re not paying for 47 minutes. You’re paying for the fact that it went well. So in essence you are selling the outcome of the surgery.

Dentistry is even more instructive, especially in the UK, where you can see both models running side by side. NHS dentistry is clunky and underfunded, but private dentistry has fully embraced procedure-based pricing. Nobody apologises for charging £800 for an implant. The procedure has a price. That price reflects skill and expertise and outcome, and the conversation about whether it’s fair happens in a completely different register to the one medics are having.

And here’s what I’ve noticed anecdotally, so please take this as observation rather than gospel. There seems to be a different cultural reception to money talk across these groups. Surgeons and dentists seem more comfortable having commercial conversations. When i’m reaching out to either tthey are more receptive to discussing money generally. More open to giving you advice that pertains to how to build a career and also how to build wealth. Medics on the other hand are still largely fighting for incremental pay rises and comparing themselves to other employed professionals. Teachers. Lawyers. Civil servants.

That comparison is the trap.

When you benchmark yourself against other people who sell time, the argument becomes about relative hourly rates. And that is an exhausting argument to win because it never ends. Someone will always find a reason why your hour shouldn’t be worth more than someone else’s. But when you price an outcome, the conversation shifts. The question is no longer what is an hour of you worth. It’s what is this result worth, and what does it cost if you get it wrong.

I think some of this is structural. The NHS trains doctors to think in time units because that is how the system is designed. Job plans, clinic slots, rotas. It’s all time. So it makes sense that the culture follows the structure.

But I also think some of it is something older and harder to name. Medicine has always carried this idea that being too focused on money is somehow in tension with caring about patients. That the truly dedicated doctor is above commercial thinking. Surgery doesn’t carry that same weight, maybe because procedural work feels more like a craft, and we’ve always been comfortable pricing craft.

Whatever the reason, the practical effect is this: if you’re always selling time, you will always struggle to justify why your time should cost more. Because someone will always find a cheaper hour. But if you’re selling judgment, expertise, and outcome, the case makes itself. The knowledge that goes into a diagnosis. The pattern recognition built over fifteen years. The decision made at 2am that saved someone from a week of unnecessary treatment. None of that fits neatly into a time slot. And yet that’s exactly how we’re pricing it.

I don’t have a clean answer for what this means. But I think it matters for how the profession talks about its own value. And it definitely matters for what the business of healthcare looks like as AI, physician associates, and new care models start to do more of the time-based work that doctors currently own.

If we don’t change how we frame what we’re worth, someone else will frame it for us.

And they won’t be generous about it.

It’s fairly normal to hear that someone collapsed and died in Zimbabwe in their 40s, whereas in the UK if this happened this would be something that is completely unheard of.

The current state of affairs in Zimbabwe means that good healthcare is inaccessible for the majority of the population. Most people are a big distance away from a facility that can help them!

If we want to improve care in Zim, there are many ideas that all could work, such as having more doctors/nurses, building more clinics, improving public health, community initiatives, etc. However, I think all of these ideas boil down to one core idea.

If you want to improve healthcare in Zimbabwe there needs to be money in the system before people become ill

This allows for the ‘business’ of the health facility to remain open and operational. It allows for services to expand, staff to be paid, and it allows for the stock and drugs to be ready for the time you become unwell. This is a challenge that most healthcare systems around the world face, for example, in the UK, with the rising cost of care, one of the biggest challenges is where the government can get even more money to provide free healthcare to the public. This is being done via measures such as increasing taxes.

However Zimbabwe is a cash-based economy, and a lot of people are in informal employment. For the government to successfully collect enough tax revenue to fund healthcare will be a massive challenge. To some, it may seem as if there are more important challenges to solve first, such as employment or infrastructure, etc.

Some of the ways you can fund the system before people get ill

1. Insurance - Having a health insurance that actually does cover people, whether its at an individual clinic or at a nationwide service. This allows us to know that people are paying into a system before they get unwell, so that the day they are unwell the ‘lifeline’ of the healthcare business has allowed it to be open. Given a cash-based economy and the employment situation, this will need an element of creativity for it to work successfully. I’m thinking off the top of my head here but imagine a partnership with Net-One and Econet so that every time people top up a dollar on their phone (credit), a percentage of that goes towards the cost of care. This allows people to still have a service, but without thinking of it too much!

2. Diaspora remittance - Unfortunately, the by-product of life in Zimbabwe meant that loads of people left looking for better jobs. Those in the UK, Canada, and Australia send a lot of money back home each year. Building an app that can compete with a World Remit or Remitly under the premise of instead of the app taking a fee for its operations, the fee we take to fund healthcare in Zimbabwe. This is a method that people can send money back to Zim and also know that their loved ones can receive healthcare as a result.

I have a video where I explore how we can improve these things in Zimbabwe and i would love for you to let me know your thoughts.

As always, these are just ideas, I believe that the people who are on the ground living with this reality every day probably have better solutions than my self.

Until Next Time Friends…

There is this specific type of patience that you develop as a Black Man. The patience that is walking into a barber shop on a Saturday Afternoon and seeing six people ahead of you in the queue. You sit down because you know at the end of it the trim is going to be worth it.

Nobody tells you how long it’s going to take and by the time its almost your turn, the barber decides that he needs to pick up his daughter from after school club!

You wait the experience out because you’re not just getting a haircut you are getting seen!

I write this as I am sitting in the barbershop. I booked an appointment for 10:45 however it is now 12:12 and i’m still waiting! It got me thinking, this is very similar to how the NHS works…

The average experience for a patient is
You ring at 8am, The line drops.
You ring again. Engaged.
You try the online system. It tells you there are no appointments.
You call back at 8:04. You get through. You’re number eleven in the queue.
You wait. You explain your symptoms to a receptionist who isn’t a doctor.
You get a callback slot.
The doctor calls twenty minutes late because their clinic was running over, but they call. And in that ten-minute conversation, something shifts.

You’re not just getting a random conversation but something that has been causing you pain and discomfort is now finally being addressed.

The waiting, the frustration and the relief are all real feelings that you experience thru all of this. By the time you hang up, the 8am chaos and stress has already started to fade. Similar to by the time I leave the barbershop with a sharp lineup sharp, this two hour wait will be something of the past.

There’s a concept in behavioural economics called the peak-end rule the idea that we don’t judge an experience by its average, but by how it felt at its most intense moment and how it ended. The rest is largely noise.

A painful procedure followed by genuine warmth from a doctor is remembered more kindly than a painless one that ended with indifference. A long wait followed by a barber who actually listens to what you want who doesn’t just nod and do whatever is remembered as a good experience regardless of how long it took (This is how my new barber makes me feel).

The barbershop has always known this, even without the academic language. The craft at the end earns the patience at the beginning. The conversation during earns the loyalty that keeps you coming back.

The NHS knows it too, even if it has stopped acting like it does. When the relationship is right when the GP has seen you three times, knows your mum has hypertension, remembers you came in anxious last winter the system feels bearable. Not because the waiting times improved. Because the ending delivered.

What’s striking is that both institutions are built on a kind of unconditional loyalty that most businesses would kill for. People don’t just tolerate the inconvenience — they defend it. That’s my barber! That’s my GP/Hospital. The possessive is doing a lot of work in both sentences.

And both are under the same pressure right now. The barbershop faces the rise of mobile apps, walk-in chains, and the kind of frictionless convenience that younger generations are being trained to expect. The NHS faces the same, private GP apps that will see you in forty-five minutes, direct-to-consumer health brands promising care that fits around your life, not the other way around.

Some things aren’t broken. They’re just heavy.

The barbershop isn’t inefficient. It’s running a model of care that happens to also cut hair. The waiting is part of it the room fills up, people talk, the barber moves through each person with unhurried attention, and you watch enough of it to know that when it’s your turn, you’ll get the same.

The NHS, at its best, is the same kind of institution. Built not on convenience but on covenant. You show up and It will show up. Eventually.

The wahala is real. But so is what’s waiting on the other side of it.

That’s the business of care in full effect…

I filmed at a Private Hospital in Zimbabwe in a fairly affluent area. We toured their hospital, which had theatres, consultation rooms, and also a Centre for Regenerative Medicine.

My level of surprise comes from the fact that in the West, we are always sold an image of Africa which is negative, and to be honest, I’d bought it. I was expecting to see standards that were below anything I’d seen before however this clinic was largely superior to any NHS hospital I have ever been in my life.

There was an intentionality behind the entire clinic where they thought about what the patient would want, and they built everything around that. Everything from the food on the menu, an open garden, and knowing their patients by name. They even had a VIP section for their more affluent people or ministers who don’t want to be seen by the public.

The BIG disclaimer is that this was a private hospital that does cater to the upper 2% hence they can invest in their services, and not a lot of people in the country can access it.

My trip illustrated to me that there is so much opportunity to improve healthcare services in Zimbabwe because of the large gap that exists. This is a gap between the private and public sectors, a gap between the private sector and other private services globally. Those who can afford private healthcare in Zimbabwe are global ‘customers’, they expect a level of service they receive in London or Dubai to also exist in Harare. This poses its own set of challenges.

I’d love you to watch the episode and let me know your thoughts

Watch the Full Video Here:

Let me be honest before I made this video, I thought BUPA was just a slightly fancier version of the NHS. A place your employer pays into so you can skip the waiting list and get a nicer waiting room.

I was wrong.

BUPA is one of the most quietly sophisticated healthcare businesses on the planet. No shareholders. No stock price. And yet £16.9 billion in annual revenue spanning insurance, hospitals, dental clinics, aged care, and data. Lots of data.

Here’s what actually surprised me.

The structure is the strategy. BUPA operates as a provident association, meaning profits don’t go to shareholders, they go back into the business. On paper that sounds wholesome. In practice it gives them a structural advantage most healthcare companies can’t replicate. They can play a long game that listed companies simply can’t afford to play.

They’re not just selling insurance. They’re buying the whole chain. This is what vertical integration looks like in healthcare. BUPA doesn’t just pay your hospital bill, they increasingly own the hospital. And the clinic. And the data from both visits. That’s not a health company, that’s a platform.

But it’s not all clean. There are real tensions in the model, between their provident roots and their commercial ambitions, between the promise of private healthcare and the reality of what gets covered. I got into all of it.

The business of healthcare is rarely what it looks like on the surface. BUPA is a masterclass in that.

I broke the whole thing down, company structure, revenue streams, how they spend the money, and what founders can take from the model, in this week’s video.

👇 Watch it here: The £16.9B Company Most People Don’t Understand

https://youtu.be/RVvi_anKasw

If you’re building in healthcare, or just trying to understand how the money actually moves in this industry, this one’s worth your time.

Malone

Hey friends,

This week Microsoft launched their CoPilot Health system. This is a personal health AI tool which makes life easier for patients. They feel this is a step closer to “medical super intelligence”.

Why now?

Microsoft acquired a company called Nuance in 2021 and this was an early move into the health space. It didn’t make sense at the time however in hindsight they acquired a company that had penetration across 77% of US hospitals for $16Billion. They weren’t necessarily paying for the company but for the systems and connections on the back end.

Fast forward to today, they are launching Co-Pilot Health which is the front consumer end facing. People are already using general AI to search for their health queries so the companies are servicing a demand which is already there.

OpenAI, Microsoft, Amazon and AnthropIc can all acknowledge that if they are able to tap into the health space this is big business. The stickiness of a customer and trust one will build with the systems will be great if they can help consumers in their times of need.

I’m also very bullish on they’ve seen the “permissionless” era trend and they too believe they can have a slice of the piece. By permissionless I’m referring to how back in the day you’d have to go through Hollywood to be a movie star, now you can make your own YouTube channel. Or you’d need a record deal to make music, now you can blow from tiktok and soundcloud. I think healthcare will see a similar trend. Previously you needed a health institution to tell you about your health, soon we won’t and rely on your personal companion that knows you better than a single episode of care. Critics will be opposed to this future however when their is problems with workforce being unpaid and overworked, patients struggling to see a clinician, the solution that seems to solve people’s problems will win. This is already happening as Co-pilot receives 50million health enquiries a day…

If you want to hear more of my thoughts I share them in my most recent YouTube video. I’d love to hear your thoughts on this topic too!

Why Big Tech Is Obsessed With Healthcare (It's Not What You Think)

https://youtu.be/WRIFwh-YQiA

People are making healthcare decisions in the same way they choose everything else. Looking at reviews, word of mouth, branding, or simply just vibes. The same decision-making process to choose a coffee shop is being used to decide on picking their doctor, therapist, supplements, or sometimes people self-diagnosing themselves.

I think it started with the trust that was broken during COVID. This was trust with big institutions broadly, and healthcare unfortunately fell victim to this.

Guidelines changed weekly, one minute we were locked down and the next minute we weren’t. Amidst all this chaos, people ultimately had time and decided to take matters into their own hands. This was by doing their own research.

This behaviour did not stop once the pandemic ended. If you give people keys to have autonomy over their health, chances are they won’t give it up that easily. Healthcare-related searches on Google, TikTok, and Reddit are still on the rise and the wellness economy is exploding.

Healthcare has now become a consumer brand, and the people who win in this space are the ones who acknowledge this. They will be able to see that the psychology behind choosing a new coffee shop is going into healthcare decisions. Healthcare providers will be able to move forward with the times and help their patients.

This sounds like a great ideal, will it happen? I’m not sure traditional health systems will be able to keep up with demand. This is because the systems are so stretched and reacting to issues that come their way. This leaves a huge gap for others to enter the space. I believe OpenAI, Amazon and Anthropic are aware of this change, hence why there was a big push towards Health AI this year. They acknowledge that people are sitting up at 2 am and ultimately, the trust dynamics have changed. If they can be present for people in their darkest hour ultimately they gain the trust and respect.

This is a huge grey area in healthcare at the moment because it feels like navigating uncharted territory, and i know critics will say this is not safe. However, I think the trust dynamics and consumer expectations with healthcare have changed so patients will take matters into their own hands.

I have a longer video where i break this topic down even more here. I’d love to hear your thoughts

🔴Watch here: Why You Trust A Stranger on TikTok More Than Your Doctor

Welcome back to another edition of the Business of healthcare. We have 18 subscribers currently, if you are one of those people thank you so much for being part of this community.

This week I visited Neko Health, a company founded by Daniel Ek (Spotify Founder) and Hjalmar Nilsonne. When I started documenting my journey, this was one of the clinics I really wanted to get on the series. This was simply because I feel like they are really pushing the boundaries of what healthcare means. I caught up with the lead GP and learned a lot from the experience.

1. Subjective vs Objective: In medicine there are many metrics that are subjective such as how things sound, smell, and feel. There are many different ways to interpret these clinical markers. Neko has found a way to allow us to track this data and with repeated scans over the years you can have a longitudinal data set of your heart sounds so we can truly see if things have changed.

2. Prevention as a business model: Prevention is better than cure is something as old as time. People have known for decades that this is the way forewards yet it is rarely practiced. This is largely due to the business models in healthcare do not incentivise prevention. A large part of western health systems are reactive, we wait for things to happen and then react. People can make money when an intervention is done, however people are not paid for preventing a stroke?
   Neko is allowing consumers to pay directly to get insights about their health that will prevent them from going to hospital in the future. When you charge the consumer in this way, the service and the product has to be 10/10 to justify the spend. The experience has to be leagues about the traditional health experience so that by the time the consumer leaves, price is the last thing on their mind.

Where does the future of Neko lie?

I believe we are still in phase 1 of Neko and what they can truly do. Their moat will be around the data that they capture. Critics state that there is a lot of ‘worried well’ people who engage with this service, the reframe Dr. Sam uses in the episode i filmed with him is those who are engaged with their health. Everyone going through a scan is essentially building up a database of what ‘normal’ looks like. This data becomes extremely valuable when it is longitudinal. When we can see how a disease progressed over the years or how early warning signs of heart sounds changing before catching something else. This is where the beauty for Neko will lie.

I also believe in the not too distant future Neko will launch a companion platform. Imagine an LLM that is trained on your scans at a point in time but can integrate with your daily habits. This increases the value of that longitudinal data. Ultimately they are creating a ‘health system’ within the Neko universe that understands you so well.

They have recently raised $260m and i’m excited for where they will head. I believe that healthcare should be an experience. Healthcare should feel like a high end consumer/conceirge service. This is exactly what they are doing!

Until next time friends, x

Here is a 20min breakdown into the episode

Neko Health YT Video

Malone

PS: I’m trying a new content style where I “thought dump” and I hope this makes sense for you. I’d appreciate some feedback at the end!

I think this is a really naive statement to make and AI will do to medicine what Netflix did to blockbuster

Hear me out…

It’s very clear to see that the rise of AI is unprecedented. Developments that once took decades and now taking years. Teams are doing more with less and the world is changing right before us.

One of the biggest industries in most country’s is healthcare. It’s also fairly safe to say that there is so much room for improvement in healthcare and that’s exactly where AI comes in. To oppose doctors statements about “who’s going to do the human aspect” in the current model of healthcare doctors hardly spend more time with their computers than they do seeing patients.

Broadly speaking for every 1 hour a doctor spends with a patient they spend 2 doing clerical tasks https://time.com/6313270/doctors-overworked-patients-access/ or in this case or the average contact time is 4.9 minutes per patient https://pmc.ncbi.nlm.nih.gov/articles/PMC8198090/.

Let’s assume you’re looking after 20 patients, 1hr 38 minutes of your shift is direct patient time…

This is exactly where I see AI coming in and unfortunately I think a lot of healthcare will be slow to see this change coming. Some of it is denial, denial that something can do their job better. Some of it is an assumption that AI is not going to improve exponentially, it might not work today as I’m writing this but there is nothing to suggest it won’t be working by December 2025.

If we go to first principles, in an ideal health system you want your doctors to spend as much time as possible understanding and caring for their patients. You don’t want them sitting behind a desk summarising notes. AI will be tremendous at doing these repetitive tasks.

The flip side is that even if doctors and health systems dont embrace healthcare, patients definitely will. Back at first principles when you’re unwell you want help, we’ve seen with the rise of Dr. Google in previous years that people will take the help from the place that’s readily available. With new features such as AI summaries on Google, getting your health info, assisted by AI is becoming easier and easier. Now imagine if you can integrate a system with your data from your wearables such as an Apple Watch. Arguably your “AI doctor” will have so much data about you that it can personalised and help you as an individual!

I’m excited for AI in healthcare, I think it’ll increase efficiency and fundamentally provide a better experience overall for the patient. This comes at a cost though and potentially the cost can be the role of the doctor as we know it today changing…

I hope this made sense, I decided to just share my thoughts as they came rather than try to refine it. Do you prefer this raw approach or a more refined approach

In the early 2000s, Nike dropped the Total 90 football boots. They weren’t just boots, they were a cultural moment. Every young boy growing up wanted a pair! Nike sponsored tournaments, made TV ads that felt like mini-films, and built a product identity around precision, speed, and swagger. Everyone wanted them, even if they never played 90 minutes.

The Lesson:

Nike didn’t sell a product. They sold a feeling, the idea that wearing these boots made you part of an elite. The idea that wearing these boots would make you shoot like Wayne Rooney!

Three key moves:

1. Deep understanding of user dreams (not just needs).

2. A launch campaign that felt like a movement.

3. Distribution channels that made it easy to get in on the hype.

The Healthcare Application:

When the NHS rolls out new health services (like the COVID vaccine), it often focuses on logistics, not culture. Imagine if the NHS launched preventive health checks like Nike launched Total 90s:

• Taglines that tap into aspiration (“Stronger at 70 starts at 40”).

• Engaging campaigns with faces people actually relate to.

• Early access events in communities to build buzz.

Question:

If the NHS had a marketing department like Nike, which health campaign would you re-launch first?

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