Can a private company drag the NHS toward prevention?

A night with Neko Health, and the case for taking consumer-pull seriously. For free subscribers, this is a preview of this fortnight’s Pigeon Insider (the paid upgrade).

Last edition, I wrote about the 40-year-old Inverse Prevention Law and why preventative health companies hit a structural ceiling. A fortnight later I hosted Hjalmar Nilsonne (CEO, Neko) and Nikita Kanani (Global Medical Director, Neko) at Hale House for a conversation about the future of prevention in the UK. Hjalmar presented a coherent counter-argument to last edition’s thesis and this edition is me thinking through whether it holds.

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What did Neko actually say?

Boil it down and Hjalmar was essentially proposing a theory of change. It was less a product pitch and more a claim about how healthcare systems shift and why, justifying the model Neko has chosen.

The theory has three moves.

First, the Spotify analogy. When was the last time you downloaded a song? Spotify didn’t kill free piracy (remember Napster?) by lobbying for stronger IP enforcement, it gave people something way better than the free option. The argument, by extension, is that preventive healthcare won’t be saved by policy or commissioning reform. It’ll be saved by someone building a product people actually want to use (buy). I know… “but healthcare should be free in the UK…” Park that for now. We’ll come back to it.

Second, the climate-tech parallel. Hjalmar spent a decade in renewable energy (before Daniel Ek DM’d him and altered his course) where carbon taxes and ETS schemes (where polluters pay for polluting) changed things far less than when decent electric cars turned up that people genuinely wanted to drive. He’s now applying the same theory to prevention, which is… don’t rely on policy, create something even more convenient/delightful that it changes behaviour entirely.

Third, the corollary. If consumer pull is what works, then vertical integration is what makes consumer pull possible. If you don’t speak tech, that means you can’t deliver a £299 scan profitably unless you control the hardware, the AI, the clinic, the operations and the experience. Bolt your prevention service onto someone else’s stack and the economics collapse.

All three claims are testable. Two have arguments either way. One of them is right in a way the UK healthtech industry hasn’t fully reckoned with. And, for me, the most interesting thing about the event was a GP who reframed the entire question, which I’ll come to.

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23 years of failing the same way

Let’s start with the strongest version of Hjalmar’s argument, because the UK evidence base is uncomfortably supportive. Also, was it Einstein that said the thing about doing the same thing over and over and expecting different results…?

In 2002, the Treasury commissioned Derek Wanless to model the long-term funding needs of the NHS. It’s fascinating if you haven’t read it. Wanless concluded that the NHS would only survive in something like its current form if the population became “fully engaged” with prevention. He gave two other scenarios, “solid progress” and “slow uptake.” You can probably see where this is going.

In 2007, Wanless returned to assess progress and guess what? The prevention warning had been blatantly ignored. In 2014 the Five Year Forward View called for “a radical upgrade in prevention” and quoted Wanless verbatim: that warning has not been heeded and the NHS is on the hook for the consequences.

In 2024, Lord Darzi’s review made the same diagnosis, again.

In July 2025, Wes Streeting published the 10 Year Health Plan, with “sickness to prevention” as one of three official shifts explicitly noting that the NHS prevention budget had been cut by 28% in real terms over the past decade. The NHS Confederation’s own analysis of whether this latest attempt will succeed is titled, with admirable honesty, “Is the left shift mission impossible?”

Twenty-three years, four governments and five major reviews gave the same diagnosis EVERY time. Prevention spending has gone down, not up.

Now, this is the empirical bedrock of Neko’s argument, and it’s genuinely strong. They don’t have to prove that consumer-pull is the right answer. They only have to prove that supply-side, policy-led prevention has failed for so long, and so consistently, that the burden of proof has shifted onto people defending the orthodoxy.

What’s odd is that the 28% real-terms cut to the prevention budget happened during the same period that successive governments published increasingly passionate prevention strategies. Coincidence? Nope. It’s a basic reality that prevention spending is the easiest line to cut when the acute system is in crisis, and the acute system has been in continuous crisis for fifteen years.

Every Health Secretary has had to choose between A&E today and prevention in a decade. We run 5 year political cycles so of course every Health Secretary has chosen A&E. You wouldn’t want the next government benefiting from your tough decisions…

Against that backdrop, the consumer-pull thesis has earned a hearing. And Neko has earned the right to make it more than most, because they’ve been unusually transparent about their actual data:

• Year One report (2023, Stockholm): of 2,707 scans, 1% identified life-threatening conditions the patient was unaware of, 6.6% significant, 76% rebooked.

• Year Two report (2024, 4,362 scans): 6.4% important findings, 81.3% required no follow-up.

• The 2025 repeat-scan analysis showed measurable biomarker improvements between scan one and scan two for the 1,469 returning members, with the explicit caveat (their words, not mine) that this is “not a scientific study with a control group.”

They publish their false positives and they run their own follow-up clinics so the NHS doesn’t carry the burden of confirming what they’ve flagged. That’s important to bear in mind because a lot of us in the room had no idea this was the case. Where needed, Neko do follow up bloods, imaging etc. and package people, after all their investigations, back to the NHS, with a plan. The other important distinction is that this isn’t full body MRI, it’s diagnostics “for only what is actionable” with a focus on chronic disease. As someone put it, “this isn’t a load of un-evidenced tests and a ‘dump’ back on the GP.”

Objectively, from what I can tell, that’s a more defensible posture than the category average.

So, the picture so far… An undeniable 23-year failure of state-led prevention (is that too harsh?), a company that publishes more honestly than most of its peers, unit economics that don’t require a Babylon-style implosion (is that also too harsh?), and a theory of change that, viewed against the timeline, has earned a serious hearing.

That’s the foundation. The next bit is where the other arguments get scrutinised.

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Where the picture is bigger than either side

Strip the analogies back and Neko’s argument is this… High-quality operational and technological innovation, delivered at a price point that does actually widen access, creates a proof-of-concept that drags the public sector forward. The product becomes the argument. Build the thing that works, and the system has to engage with what you’ve built. Are they right? Well…