The Great Health and Social Care Reset for the Big Data Economy Part 1.2: A Timeline of NHS Capture 2014-2019

The Five Year Forward View released in 2014

In 2014 Simon Stevens left his position as head of the global division of American health insurance giant UnitedHealth for the appointment of Chief Executive of NHS England, a role he continued to hold until he was succeeded by Amanda Pritchard in August 2021.

His Five Year Forward View, ^[1] released in October 2014, faithfully adheres to both the diagnosis of the healthcare crisis and the proscribed solutions laid out by the WEF Sustainable Health Systems project in which Stevens was heavily involved (see Part 1.1).

As part of the ‘new models of care’, Stevens oversaw the embedding of UnitedHealth’s UK subsidiary Optum into the NHS in 2015 by introducing Optum software, algorithms, personnel and business practices, and training of local council leaders. ^[2] He also brought in health insurance company Centene, ^[3] owner of Operose Health (until 2023), which is the largest GP surgery operator in the NHS, and orchestrated Virginia Mason Hospital’s partnership with five Foundation Trusts. ^[4]

Simultaneously, ‘vanguards’ in 50 areas were given the task of developing and testing these new care models. ^[5] The following year the NHS and local councils formed Sustainability and Transformation Partnerships (STPs), originally called Sustainability and Transformation Plans, covering all of England, for the delivery of the NHS Five Year Forward View ^[6] (5YFV). The STPs were rolled out to enable the wide-scale introduction of Accountable Care Organisations (ACOs) and Accountable Care Systems (ACSs) from 2018. ^[7] These were first trialled in the NHS at three beacon sites from 2003, as mentioned in Part 1.1.

Michael MacDonnell, another participant in both the WEF and Imperial College’s Institute for Global Health Innovation initiatives (as Senior Fellow at the Centre for Institute of Global Health Innovation), acted as head of policy for the Sustainability and Transformation Plans framework as a whole. Ron Webster and Amanda Doyle, who were also WEF workshop participants, were tasked with leading individual STPs in West Yorkshire and in Lancashire and South Cumbria, respectively. ^[8]

The initial introduction of ACOs, that were characterised by Keep Our NHS Public as ‘autonomous business units’ unaccountable tolocal populations or Parliament, and ‘motivated by accountancy, and managed by financiers’, ^[9] proved highly controversial. Two separate legal actions were launched to challenge them in 2017. ^[10]

One of the groups that lodged a judicial review, ‘999 Call for the NHS’,argued that the ACO contracts’ shift to a single, annual budget for a population, rather than a payment by services used model, breached sections 115 and 116 of the Health and Social Care Act 2012. ^[11]

Although both challenges were ultimately unsuccessful, as a consequence the government was forced to delay ACO implementation until a public consultation had been carried out. In addition, following the bad publicity around ACOs, a name change to Integrated Care Boards or Systems was instituted. This paralleled a similar scenario in the U.S. ACOs were called Health Maintenance Organisations (HMOs) until 2013 when Kaiser changed the name in response to HMOs falling into disrepute, due to lawsuits which alleged that they were denying patients care and not enrolling expensive patients. ^[12]

The contention over the legality of erasing the NHS founding principle of ‘equal care for equal need’, through allowing ACOs or Integrated Care Systems’ full control over budget spending was rendered moot through changes introduced in the 2022 Health and Care Act, (covered in Part 1.3).

Returning to key features of the ‘new models of care’, one of these was the introduction of multi-speciality community providers, i.e., primary care super-hubs which would aim to ‘shift the majority of outpatient consultations and ambulatory care out of hospital settings’, ^[13] and reduce specialist care facilities. ^[14]  Further cost savings were sought through expanding the roles of less qualified staff to facilitate a cheaper workforce. ^[15]

As a result of new funding models introduced in the 5YFV, including the phase out of the Minimum Practice Income Guarantee from 2014, which made smaller practices financially unviable in many cases, a large-scale progressive closure of GP practices occurred. ^[16] A rare event pre-2013, the rate of GP surgery closures has since risen to between 2-8 a week, with a resulting 1398 practices in England alone lost by May 2023. ^[17]

Unsurprisingly, the transformation of digital care was another important focus. This was to be achieved through introducing interoperable electronic health records, expanding the set of NHS accredited health apps to help patients manage their own health and care, and making online GP appointments and repeat prescription requests routinely available. ^[18]

The 5FYV also set out the intention for the NHS to become one of the best places in the world to ‘test innovations that require staff, technology and funding all to align in a health system, with universal coverage serving a large and diverse population.’ ^[19]

Amongst the ‘mechanisms’ used to achieve such a vision were plans for ‘health and care new towns’, which would integrate, ‘not only health and social care, but also other public services such as welfare, education and affordable housing’. ^[20] The NHS Test Bed and Trials programme is also mentioned and described as, ‘real world sites for “combinatorial” innovations that integrate new technologies, bioinformatics, new staffing models and payment-for-outcomes’. ^[21]

The NHS Healthy New Towns project begins in 2015

The NHS has been involved in the roll out of Internet of Things (IoT) connected homes since 2015 through their Healthy New Towns project; followed by the test beds and trials programmes in 2016 and 2018, ^[22] as well as more recent initiatives that will be covered in Part 2.1 of this series.

Ten sites for Healthy New Towns were selected from across England and Scotland to showcase ‘new models of technology-enabled primary care’, ^[23] and ‘digitally enabled local health services that share physical infrastructure and staff with schools and community groups.’ Construction of the exemplar healthy communities began in 2015-2016 and is ongoing.   

The ‘key lessons’ from the Healthy New Towns programme were distilled into four publications overseen by a team drawn from the NHS, Public Health England, the Town and Country Planning Association, The King’s Fund, The Young Foundation and PA Consulting. ^[24]

Putting health into place: principles 9-10 states

To support the growth of the new and integrated approaches to health and wellbeing described in Principle 9, new developments need buildings that help to break down the traditional boundaries between different services. One of the important ways this can be done is through co-locating key services into health and wellbeing centres or community hubs, bringing together GP practices, other health care services, and a range of leisure, education, wellbeing and community activities in one place (see Principle 7). ^[25]

The blurring of spatial boundaries between healthcare and other public facilities in the built environment, and of caregiver boundaries between professional medical staff, VCSE service deliverers and ‘peer supporter/signposters’ ^[26] are stated goals of an ‘assets based’ approach, ^[27] explored in more detail in The Wigan Deal section below.

This approach has been carried over into the practice of boundaryless pooling of resident data. In the Darlington project, NHS England boasts of establishing effective data sharing between available health, social care, local authority and voluntary organisation sources, alongside building smart houses in neighbourhoods with ‘built in monitoring and information access.’ ^[28]

Similarly, Whyndyke Garden Village has developed a digital masterplan with a ‘platform for affordable smart homes and digital community infrastructure.’ ^[29] A ‘smart home’ is explicitly highlighted in the report Putting health into place principles 4-8. Design, deliver and manage as one of the four criteria can be used to create housing that ‘supports health and wellbeing’. ^[30]

Behavioural nudge strategies (as mentioned on p. 35 of the Five year forward view) to encourage the adoption of ‘healthier behaviours’ by residents are also central to the Healthy New Towns mission. New arrivals to Northstowe receive an information pack with financial incentives to encourage ‘active and sustainable travel choices’, including subsidised bus tickets and money-off vouchers for cycle-training ‘taster’ sessions and kit, as well as face-to-face advice from the ‘travel plan co-ordinator’. ^[31] Citiesmode was selected as ‘competition winner’ by NHS England and the local clinical commissioning group, to design the ‘Halton Connected’ programme, which includes the offer of an app for local residents that rewards walking with discounts at local shops. ^[32]

The creator of Ebbsfleet Garden City, Ebbsfleet Development Corporation, funded a local version of the BetterPoints scheme until at least 2022-23. This smartphone app encouraged local residents to record their walking, wheeling, running and cycling activities in exchange for points, which were redeemable as vouchers at selected outlets, charity donations, or entries in prize draws. ^[33]

BetterPoints has been delivering incentivised smart phone app-based behaviour change programmes since 2010, primarily in collaboration with local councils. ^[34]

These programmes combine active travel goals with public health objectives such as reduction of smoking or obesity in the target population.

‘Public Health Principal’ at Buckinghamshire Council, Sally Hone, is quoted in a BetterPoints return on investment case study endorsing the scheme: ‘The app being led by behaviour change and the COM-B model means it complements the wider work being done in Public Health.’ ^[35]

The app incorporates gamification and geofencing features that enables clients to set specific zones for activities and rewards for the users of their tailored app.

BetterPoints’ conscious positioning as players in the emerging impact economy is evidenced by their having sought and achieved the B-corp certification ^[36] for ‘positive social impact’. Additionally, they state on their website that BetterPoints programmes are, ‘designed to align with UN Sustainable Development Goals and to help achieve them.’ To do so, clients are provided a dashboard that allows them to ‘track and measure their impact’ on key indicators including ‘carbon and nitrogen savings’, achieved by altering the travel or other behaviours of the target cohort of app users. These dashboards, they explain, enable clients to ‘configure graphs, charts and heatmaps, for example for ESG reporting, strategy analysis, infrastructure planning, and healthcare monitoring.’ [My emphasis.] ^[37]

The Wigan Deal: from 2014

Wigan, as the third worst hit area for government austerity funding policies since 2010, ^[38]  has been widely recognised as a pioneering council for its work ‘trialling radical new ways to deliver public services’ ^[39] which secured it a place as one of Nesta and the Local Government Association’s six ‘creative councils’. ^[40] It has also been lauded by the NHS privatisation lobbying think tank King’s Fund as an ‘NHS role model’, ^[41] since they suggest that the NHS, in place of the council, could lead a similar ‘placed-based’ cross-agency endeavour elsewhere. ^[42]

On a side note, Nesta states on their website that they, ‘shared the learning from the Creative Councils programme with our partners at Bloomberg Philanthropies, who applied it to the ‘Mayors Challenge’ in the United States and then across Europe’, with a ‘Mayors Grand Prize for Innovation’ awarding cash sums for winning initiatives. [40]

The Wigan Deal was implemented in 2014 under the leadership of then Chief Executive of Wigan Council Donna Hall, now Chair of the ‘innovative national think-tank’ — the New Local Government Network, and executive coach to local government and combined authority leaders. ^[43] Hall has held several senior level NHS positions including Chair of Bolton NHS Foundation Trust ^[44] and Integrated Care System Adviser to NHS England. ^[45] She was awarded a CBE in 2009 for innovation in public service. ^[46]

The deal centres on an ‘assets based approach’, entailing a ‘new social relationship’ [^38] between citizens and government. In a nutshell, what this amounts to is taxpayers taking on (pared down) unpaid provision of social services including social care for adults and disabled people, sporting and library facilities, and community centres. In addition, Wigan residents are required to submit to the wide-scale digitisation of communication and many services (e.g. The MyAccount website to enable residents to access information and services and the ‘Report It app’ for reporting local issues such as litter and pollution), enabling collection and sharing of data about service users. In ‘return’, the council pledged to freeze council tax. [^38]

Despite their rhetoric around the ‘relational’ and ‘co-creative’ aspects of The Deal, the council admit stakeholders such as council staff and the public were not involved in its design or planning. [^38] A number of residents and market traders accused the council of ignoring their concerns and campaigning efforts to prevent the demolition of Wigan town centre and outdoor market ^[47] to make space for a new development. The council’s development plan entailed building a hotel and residential housing, and replacing retail space with ‘co-working hubs’ for digital and technology start-up businesses. The council was also reproached by the MP for Leigh for ‘acting like communist China’, after it removed a librarian from their workplace mid-shift for a social media comment objecting to the involvement of Chinese firm ‘Beijing Construction Engineering Group International’ in the redevelopment. ^[48]

Hall herself previously attracted controversy for allegedly using the police force as her ‘private enforcement agency’ to intimidate and silence four other councillors who had successfully objected to her unlawful staging of a by-election, to replace a councillor who had not actually resigned. ^[49]

Hall attributes part-inspiration for this model to Hilary Cottam, the founder of social enterprise ‘Participle’, and her concept of ‘relational welfare’. The council participated in Participle’s ‘LIFE’ programme (building new Lives for Individuals and Families to Enjoy) from 2011, ^[50] which targeted families in chronic crisis, to reduce their dependency on services and collect and monitor their data on online ‘lifeboards’. ^[51] Cottam, who received an OBE in 2019 for her ‘services to the welfare state’, also boasts on her illustrious CV a period of employment at the World Bank, and recognition by the World Economic Forum as a Young Global Leader for her work in the field of social change.

Wigan Council has transferred ownership of certain former council-owned buildings to community organisations ^[52] to run under the community asset scheme, [³⁸] as part of its move from ‘building-based services to flexible provision accessed within community settings.’

Smaller ‘seed funding’ council grants have been offered to local community groups. However, the lack of availability of larger pots of grant funding from either Wigan Council or other national bodies [53] opened the door to financing by Nesta’s ‘Arts Impact Fund’ for the renovation and expansion of The Old Courts, operated by ‘Arts at The Mill’. ^[54]

As part of Nesta’s involvement in the project, which included the provision of a more than half a million pound loan, ‘tracking social impact metrics’ were embedded into the Centre’s running operations. [55]

Managing Director of the centre David Jenkins on the ‘Good Finance’ podcast, ‘The Old Courts – using investment to create a sustainable arts centre’, regrets that the majority people in the sector he had spoken to viewed social finance as a ‘last resort’, ‘once all grant seeking routes have been exhausted.’ [56] However, he admits that for the purchase of the Old Court theatre (part of the centre’s expansion), he had sought to blend social finance with grants, ‘as opposed to going solely for social investment’, to keep overheads low enough that local groups had consistent access to the space instead of having to prioritise commercial hire: ‘We want to have a turnkey approach to enable community groups to be able to use the space, which, the less revenue we have to pay back on a monthly basis makes that easier.’ [56]

It was reported in October last year that Arts at The Mill had gone into temporary administration to safeguard creditors interests, after huge costs were incurred from routine construction work causing structural damage to the Old Courts venue. [57] The amount owing to Nesta by 2025 was £678,000, which appears to represent a significant Return on Investment for Nesta over the original £590,00 loan they provided in 2017. [57]

Wigan Council has more recently updated the deal with its The Deal 2030 plan. ^[58] The accompanying 2019-2025 Digital Strategy sets out

During the 10 years of our Deal 2030 Strategy the world and our communities will be transformed again through the digital developments that will enhance (and potentially cause harm) to the lives of our residents. 5G, full dark fibre, Artificial Intelligence, Augmented Reality, Smart Cities and ubiquitous internet of things devices will all impact on all aspects of our lives from education, health, employment opportunities and our physical infrastructure and what we do and how we do it as public services. ^[59]

They express intent to ‘leverage new emerging “SMART” technologies as they enter the digital market. . .to improve our delivery going forwards across all our services’, as well as to improve health and wellbeing as illustrated below:

Nesta’s People Powered Results and The NHS in 2030 report: 2013-2015

Geoff Mulgan, Nesta chief executive until 2019, claims credit for developing ‘the set of ideas under the label of “the relational state’’’ in the late 2000s’, [60] which went on to inform the Wigan Deal. Mulgan characterises the relational state as, ‘intelligence shared between state and citizen. . .which implies changes to roles, metrics and accountabilities, and often bigger roles for personal coaches, mentors and guides.’ ^[61]

In 2013, Nesta’s ‘People Powered Results’ programme succeeded Nesta’s ‘People Powered Health’ initiative (see article 1.1), informed by the latter’s foundations. ^[62] People Powered Results, which ran until 2023, developed ‘the approach for national and regional programmes’, including NHS England’s personalisation agenda and elective care transformation strategy which were taken up by The NHS Long Term Plan. ⁵⁸

Central to the personalisation agenda was the initiation of integrated personal commissioning (IPC): ‘a new voluntary approach to blending health and social care funding for individuals with complex needs.’ ^[63] In addition to ‘care plans and voluntary sector advocacy and support’, IPC introduced ‘an integrated, “year of care” budget’ to be managed either by patients, councils, the NHS, or a voluntary organisation on the patient’s behalf.

In a report by SharedLivesPlus, an organisation promoted in Nesta’s People Powered Results write-up, ‘networked models of care’, facilitated by personal health budgets and involving key roles for family and community members, are lauded as a ‘cost-effective intervention.’ ^[64]

As part of People Powered Results, Nesta partnered with Re!Institute in Essex to adapt their ‘100 day challenge’ method to the UK’s health and care system, and scaled this across the health system. One such challenge took place in Essex in 2019, with the stated goal of ‘increas[ing] opportunities for people with a learning disability and/or autism to live meaningful lives.’ It resulted in the transformation of the Council’s largest day centre provider to an ‘innovative and inclusive employment and community inclusion service’, which saved the council an estimated £15m in lifetime costs for the 129 service users who were transferred into paid employment through it. ^[65]

As explained by SharedLivesPlus, harnessing ‘community development and building social capital’ to actualise ‘collaborative healthcare’, means not just ‘finding ways for people to help services or vulnerable people’ but also seeking contributions to the community from people with support needs, which they claim helps such individuals to ‘achieve better health and wellbeing’. ^[66]

Another of the 100 day challenges was the reduction of Accident and Emergency admission rates through schemes such as ‘zero day admissions’. ^[67]

In July 2015 Nesta released the report The NHS in 2030: a vision of a people-powered, knowledge-powered health system.

The document focuses on two thus far ‘underexploited’ assets to leverage transformation: digital innovation and social innovation. The latter was also a target of People Powered Results, and according to Nesta, ‘key to a revolution in how people are involved in their own care and that of others.’ ^[68] It presents many themes by now familiar to the reader in envisaging:

• Self-management and peer support/digital health communities ^[69] to realise the ‘financial benefits’ of reducing demand for primary and acute care services; ^[70]
• Reduction in the need for expensive buildings or services. (‘Big hospitals can reduce in size, and district hospitals have closed altogether, or been reconfigured as community health resources where a range of clinical and non-clinical groups support communities to live healthier lives.’); ^[71]
• New specialist centres utilising a ‘factory-line model of production’ standardised processes/procedures, and employing fewer people than current equivalent services; ^[72]
• Lowered prices and reduced time-to-market for drug and treatment development, achieved by changing regulations and executing multiple steps in parallel; ^[73]
• The whole of the NHS as a ‘natural laboratory’ with a new institute to ‘support and evaluate People Powered Health research.’ ^[74] They state, ‘Frontline centres are also research facilities, connected to a network of regional research hubs. Together they continue to try to understand the complex interactions between biological, behavioural and environmental factors in an individual.’ ^[75] (It is admitted that obtaining consent from all patients being experimented on, ‘particularly when those experiments are built on behavioural insights’, ^[76] i.e., behavioural manipulation, is problematic, however this is not seen as an obstacle to implementation);
• A ‘precision medicine’ paradigm entailing the increasing replacement of pharmaceutical treatments with ‘more devices and behavioural change’ interventions; from-birth genome-sequencing; ^[77] use of phenomic data; [78] ubiquitous ‘sensor technology’ for biological and behavioural monitoring including molecular diagnostics/ testing kits, portable EEG monitors, ^[79] wearables and ingestible sensors; ^[80]
• Healthcare data no longer comprising specific ‘parcels’ but the aforementioned continuous monitoring. ^[81] Doctors similarly are expected to be under like surveillance to monitor their performance; ^[82]
• Coordination with food retailers, architects and town planners to prompt healthier choices, and actions taken to reduce consumption of ‘vice goods’. ^[83]

The report also endorses social impact bond (SIB) centred funding models, stating, ‘Key to scaling these practices will be financial models that enable upfront investment to fund preventative work,’ and mentions the Ways to Wellness, Newcastle based ‘social prescribing’ SIB, (see also The NHS Long Term Plan section), as an example of one of the ‘handful of SIBs in this field already’; Ways to Wellness was part of Nesta’s People–Powered Health/Results programme. ^[84]

Nesta, which boasted the accolade of being ‘the most active impact investor in the UK’ by 2022, ^[85] began providing seed funding for other impact investing foundations in addition to making direct investments itself through Nesta Impact Investments from 2012, as part of its stated objective of driving innovation in investing. ^[86] Its portfolio of 40 includes investments in edtech, food tech, climate tech and the future of work and productivity, as well as health tech investments, which ^[87] align with its three key missions of giving every child a ‘fair start’, halving obesity by 2030, and creating a ‘sustainable’ future.

A more recent article on Nesta’s website endorses Alex Pentland’s ‘living lab’ concept (see article 1.1) as key to preventative health enthusing, ‘With smart regulation, the UK could become the centre of this global effort — a living lab — anchored in the unmatched data opportunities offered by the NHS as the world’s largest healthcare system’.

It introduces the idea of the “exposome”, i.e., ‘the system of all external factors that influence our health and wellbeing trajectory’, and argues for the necessity of ‘connecting genetics, biological, behavioural, environmental and financial data’ [my emphasis] to realise this ‘holy grail of health akin to the genome’. ^[88]

Social impact bonds and impact investing: a brief critical explainer

The UK government has been financing the ‘impact’ market infrastructure since 2011 through the Department of Work and Pensions (DWP) innovation Fund, Big Society Capital, the Life Chances Fund, Commissioning Better Outcomes, and most recently the Institute for Impact Investing’s funding of social impact bonds. ^[89]

Social impact bonds surfaced as a proposed sustainable financing instrument for healthcare globally in the Institute of Global Health Innovation’s report Creating Sustainable Health and Care Systems in Ageing Societies. ^[90] They began to be implemented in the UK’s healthcare sector from 2014, as explained below.

The Cabinet Office’s ‘Centre for Social Impact Bonds’ provides the following definition of SIBs, also known in the UK as Social Outcomes Partnerships: ^[91]

To qualify as a SIB… there must be:

• A separate contract between a commissioner and a delivery agency (sometimes called a Special Purpose Vehicle (SPV));
• Payment from the commissioner for the achievement of one or more outcomes by the delivery agency;
• At least one investor legally separate from both the commissioner and the delivery agency; [and] 
• Some or all of the financial risk of non-delivery of outcomes sitting with the investor. ^[92]

The 2014 ‘Commissioning Better Outcomes’ evaluation for the Big Lottery Fund: Social Impact Bonds: The State of Play, touches on potential problematic aspects of SIBs. Commissioners who were surveyed in the research that the report authors’ conducted identified the potential for metrics being set that create ‘perverse incentives’. [93] The report gives a theoretical example of such as payments for reducing the number of children in care, which incentivises the removal of children from care who, presumably for reasons of safety and well-being, should remain in the care system. ^[94] (See also reporting on the 2015 Goldman Sachs funded SIB in Utah that denied special education to over 99% of the students that were in the early childhood Pay for Success program. ^[95])

An academic scoping review of SIBs for non-communicable diseases found, ‘Conflict of interest and lack of public disclosure were common issues in both the published and grey literature on SIBs.’ ^[96]

The Government Outcomes Lab concedes there has indeed been ‘evidence of gaming in SOPs, particularly in earlier contracts’, with providers engaging in ‘various forms of gaming’, including ‘creaming/cherry-picking’ — such as selecting beneficiaries that are more likely to achieve the expected outcomes and leaving outside the cohort the most challenging cases, or ‘parking’ — neglecting beneficiaries that are less likely to achieve the expected outcomes and leaving them outside the cohort. ^[97]

In the same way that Private Finance Initiative’s cost the taxpayer more long-term, (see Part 1.1) SIBs are ultimately a more costly way to finance the scaling up of preventive programs than governments simply paying service providers to expand an intervention to more beneficiaries.

Some critics, with whom it is no doubt clear I agree, have gone further in their denunciations of social impact investing by arguing that it entrenches societal-wide perverse incentives for conditions of inequality and scarcity. ^[98]

Austerity is necessary both for the finance model (i.e. private investors’ involvement in ‘pay for success’ contracts for the public services the government can ‘no longer afford’) and for growing the capitalisable markets in poverty related social problems: homelessness, unemployment, poor mental and physical health, educational underachievement etc.

Research and Innovation’s report The Future of Impact Investment in Healthy Ageing is explicit about the opportunities arising for ‘market players’ from the ‘vulnerabilities linked to the expected economic fall-out’ of lockdowns in the UK. ^[99]

The most lucrative profit opportunities from setting up these markets exist at the level of financialisaton by hedge funds in betting for and against outcome achievements, and trading on people as securitised debt products. ^[100]

Within an impact economy, if successfully scaled, ordinary people will be expected to perform ‘self-improvement behaviours’, to reduce their ‘debt burden’ to society, with compliance incentivised through both carrot and stick behaviourist reinforcements, but primarily tied to the coercive lever of material dependency on this system for meeting their basic survival needs. This lever is likely to become ever more critical in the wake of the anticipated mass dispossession of workers, as a result of their human labour being displaced by fourth industrial revolution technologies, principally AI and robotics. ^[101]

Another key reason for the push to implement social impact investing is the rationale it provides for embedding smart surveillance and real-time data gathering into service operations to track service users; essential infrastructure for an economy run on big data. This data can then also be used to train AI and robotics: the technologies earmarked to administrate the system.

Such changes are necessitated by the replacement of ‘contract frameworks, designed around activities and inputs’ ^[102] by an outcomes measurement centred return-on-investment model. As Social Finance’s report on their Care and Wellbeing Impact Investment Fund (discussed in the following section) enthuses, amongst the ongoing positive impacts of its 14 ‘proof-of-concept’ health and care sector SIB’s, ‘specific tools such as the dashboards are being adopted widely across the H&SC system’, and are being ‘extended to include additional data to look at things such as health inequities.’ ^[103]

A fuller exploration of why the ruling class are attempting to orchestrate the transition to an impact-led economy, and how they have conspired to achieve this is covered here, in Part 2 of this series, and in great breadth and depth on the blog on youtube channel [104] of Alison McDowell. 

The development of healthcare social impact bonds (SIBs) in the UK from 2014

Useful information on the history of the development of SIBs in the UK is provided in the aforementioned report Social Impact Bonds: The State of Play:

Social Finance was launched in April 2008 to accelerate “the creation of a social investment market in the UK” (Social Finance, 2008). In August 2009 they published a paper (Social Finance 2009) arguing the case for Social Impact Bonds in a number of areas including reducing reoffending rates of short sentence offenders; reducing the number of young people entering Pupil Referral Units; reducing the need for residential placements for children in care; andreducing acute hospital spend through the increased provision of community-based care.  ^[105]

Social Finance, co-founded by Sir Ronald Cohen (who is also co-director of the Global Impact Investing Network created in 2015 in collaboration with the Rockefeller Foundation, ^[106] and its predecessor the 2013 Social Impact Investing Taskforce ^[107]) set up the first ever social impact bond in 2010. This aimed to reduce short sentence re-offending rates of prisoners at Peterborough Prison.

16 SIBs in the areas of unemployment, homelessness and children’s social care and adoption were active in the UK by 2014, with multiple health and social care bonds under development. ^[108]

The Government Outcomes Lab (GOL) was set up by the UK government in partnership with the University of Oxford to investigate evidence around the use of social impact bonds. It shows that of the 55 pre-active (but contracted), active, or completed health-related SIBs by 2025, 15 are in the UK, more than any other country. ^[109] The GOL Indigo dataset appears to be an incomplete listing however, as several more projects are mentioned in a 2021 BMJ scoping review. ^[110]

Social Finance has played a pivotal role in promoting SIBs in health and social care through its ‘proof-of-concept’ 2015 Care and Wellbeing Fund, designed to ‘stimulate the development and scaling of innovative community based models to manage long term conditions and care for older people’, and ‘to test different financing mechanisms such as social impact bonds (SIBs) and other forms of repayable finance/grants to fund activity and services in H&SC’. ^[111] Half the fund endowment was provided by Macmillan Cancer Support and the other half by Big Society Capital. ^[112]

The Fund devoted 50% of its assets to End of Life care outcome-based contracts (EoLC) for ‘innovative models that target preventative and community based care’, because they found this health and social care sector offered better financial returns. ^[113]

In 2019, Macmillan launched the ‘End of Life Care Fund’ as sole investor to continue work in End of Life (EOL) projects. ^[114] One of these was The Rapid Intervention for Palliative and End-of-Life Care (RIPEL) project, which reduced the number of days service users spent in hospital in the last year of life by 11 (on average), through launching home-hospice centred services. ^[115] It has been the biggest social outcomes contract in the NHS so far and the first one directly contracting with the service provider, Oxford University Hospitals. ^[116]

The fact that social impact investing was endorsed in NHSE’s Commissioning Guidance 2022 ^[117] and that the NHS Confederation’s chief executive Mathew Taylor called for every ICS to have ‘a portfolio of social investments’ ¹⁰⁷ the following year, have been held up by the Fund as evidence of its success in mainstreaming social Investment in the NHS.

The specific objectives sought in the EOL SIBs all revolved around reductions in ‘unplanned hospital activity’, or emergency admissions for those in care homes or identified as being ‘in their last year of life’. ^[118] Several projects, including Somerset’s ‘The Talk About Project’ [113] and Haringey’s ‘Advance Care Plan Facilitator in Care Homes’ [113] sought to achieve this through developing advance care plans with patients that, presumably, agreed to the withdrawal of life saving or life prolonging care, as Haringey saw a 14% reduction in emergency admissions following Advanced Care Plan implementation. [113]

The Highland Hospice EOL SIB feature in their ‘stories’ one ‘fiercely independent’ cancer patient who ‘refused to be a burden to anyone’, ^[119] and another, a woman in her mid-60s, who decided to stop chemotherapy treatment for lung cancer. ^[120]

The introduction of SIB structures into the NHS that directly financially incentivise the withdrawal of medical care from patients considered to be ‘end-of-life’ adds a concerning backdrop to the controversial Assisted Dying Bill, which could enable such cost savings through early physician-assisted-suicide. 80 safeguarding amendments from critical MPs have been rejected in the House of Commons ^[121] (the Bill is now being debated in the House of Lords).

NHS Test Beds and Trials launched in 2016 and 2018

In January 2016 the first wave of NHS test beds, seven separate trials involving an initial cohort of 4000 patients, was announced at the World Economic Forum Davos meeting: ‘Mastering the Fourth Industrial Revolution’. ^[122]

The ‘Test Beds at a glance’ infographics in the Test Beds: the story so far NHS England report provide a useful overview of these seven test beds which the report states were designed to tackle clinical challenges ‘such as dementia, diabetes and mental health through technology including algorithms, sensors and the Internet of Things’. 

The programme aimed to generate evidence to ‘drive the uptake of digital innovations at scale and pace across the health and care system’, and to harness the potential of digital technologies to support self-management, early diagnosis, prevent unnecessary hospital admissions and bring care closer to home.’ ^[123]

We also learn from the report that the programme is unprecedented in scale involving ‘40 innovators, 51 digital products, eight evaluation teams and five voluntary sector organisations’, [124] as well as partnerships with a list of businesses, charities, and universities.

It was funded by NHS England, the Department of Health and the Office for Life Sciences. [123] The two first wave healthcare related ‘Internet of Things Test Beds’: Technology Integrated Health Management and Diabetes Digital Coach, were part of the UK government funded IoT programme ‘to support the Internet of Things industry and boost economic growth’, and were managed by Innovate UK. ^[125]

One of these, the ‘Care City’ trial, connected surveillance technologies such as ‘GPS trackers, door and electricity monitors, motion sensors, vital sign readers and an avatar’ for 24/7 monitoring of dementia patients. If the data identified a significant deviation from baselines, a healthcare professional would receive an alert and decide what type of support to enlist such as, ‘a call to their carer; a GP appointment; a home visit from the Alzheimer’s Society Dementia Navigator or, if necessary, contacting the emergency services.’ ^[126] One of the stated objectives of the trial was to reduce A&E admissions in the cohort.

In Nuffield Trust’s evaluation of the Care City trial, they state that because the trial was classified as a ‘service evaluation’ rather than research, it was not subject to need for approval from the Health Research Authority (HRA), (which would also have required approval from the HRA’s research ethics committee). ^[127]

Another trial, ‘RAIDPlus’, led by Birmingham and Solihull Mental Health Foundation Trust, (with West Midlands police listed as one of the partners) explored a ‘predictive algorithm, using different data sources, to identify patients who are at greatest risk of experiencing a mental health crisis’, ^[128] which they term a ‘risk stratification’ approach, ^[129] in addition to a ‘demand and capacity dashboard to capture real-time data on patient flow and optimise bed and staff availability.’ ^[130] A RAIDplus mobile app was developed with commercial partner Telefonica. ^[131]

The Test beds programme: Information Governance: learning from wave 1 report states that the current legal basis for the use of identifiable information for population segmentation and risk stratification is Section 251 of the NHS Act 2006. ^[132] However, there was evidently internal doubt over its legality, as the report discloses that the RAIDPlus Test Bed ‘sought legal opinion regarding the proposed flow of pseudonymised patient data from an NHS Trust to a commercial technology partner.’ ^[133] It is also admitted that ‘. . .partners within Test Bed sites typically overlooked the increased importance of accessibility and transparency around data processing activity under the General Data Protection Regulation.’ ^[134]

The report also references the test beds’ compliance with the 2018 EU General Data Protection Regulations. However, the health-related exemptions (h) to Article 9 which concern the processing of personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, trade union membership, sexuality, genetic, biometric or health data, are worryingly broad. They include data ‘for purposes of management of health and care systems and services’, thanks to amendments successfully lobbied for by the NHS Confederation and the Wellcome Trust. ^[135]

In October 2018 the Department of Health and Social Care, in partnership with Innovate UK and UK Research and Innovation, announced £7 million funding for a further seven test beds. ^[136]

The second wave of NHS test beds occurred in tandem with the launch of the government’s 5G testbed and trial programme, set up to forward the development of 5G services and applications in the UK across multiple sectors. ^[137]

Liverpool 5G Create: 2018

One of these trials was the Liverpool Health and Social Care trial ‘5G Create’ which from April 2018 established a private 5G mmWave network to support telehealth services for 179 people in the underprivileged community of Kensington, Liverpool. ^[138]

 

The project was delivered by Liverpool Consortium — a public, private and third sector partnership encompassing the City Council, Liverpool Universities and NHS Trusts, as well as wireless companies — and claimed to be the first 5G supported health trial of its kind in Europe. The consortium was given £4.9 million government funding to test whether 5G technology ‘provides measurable health and social care benefits in a digitally deprived neighbourhood.’ It claimed projected savings to health and social care services of ‘over £200k per 100 users per year (dependent on the technologies used).’ [132]

 

The report asks and answers the question, ‘Why are we doing this?’ by explaining how the analogue switch off in 2025 will render ‘existing telecare solutions’ obsolete and claims that poor access to affordable and reliable [internet] connectivity by Liverpool residents had had isolating impacts. 

One trialled case that was mentioned in a government ‘early impact evaluation’ was a ‘loneliness app’ developed by games developer and virtual simulation experts CGA Simulation, ^[139] which‘brings people together to take part in online quizzing, games, and chat, to combat loneliness.’

Also trialled was the ‘Haptic Hug vest’, a wearable vest that gives ‘virtual hugs’ by physically reproducing the pressure felt on the chest and back and aims to ‘help connect isolated older people with family and friends who may live some distance away.’ ^[140]

Some Liverpool residents objected to the technologies being tested, as the government report mentions ‘large-scale anti-5G protests, which absorbed management resources and capacity’, in addition to stolen equipment; the latter creating delays whilst replacements were obtained. ^[141]

Pandemic Preparedness Exercises: 2015-2018

Whilst the Johns Hopkins University hosted Event 201 has been the subject of significant scrutiny in the wake of the COVID-19 pandemic, less attention has been paid to the eleven secret pandemic modelling exercises Public Health England (now subsumed into the UK Security Agency ^[142]) conducted in collaboration with government departments between 2015 and 2019. ^[143]

These included the Ebola Preparedness Surge Capacity Exercise in March 2015; Exercise Alice to test response to Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) in February 2016; Exercise Cygnus to test impact of a hypothetical flu pandemic in October 2016; Exercise Cerberus to assess preparedness and response to public health emergencies in February 2018; and Exercise Pica to test NHS primary care preparedness and response to pandemic influenza in Sept 2018. [144]

Public Health England only released details of the exercises, which were previously deemed secret on the grounds of national security, when forced to respond to a hospital consultant’s freedom of information request ^[145] after much hedging, in May 2021.  The UK COVID-19 Inquiry report, released in 2024, discloses that the Local Government Association itself

. . .only obtained disclosure of the [Exercise Cygnus] report as a result of legal proceedings brought by another body in 2020. It was not aware of Exercise Alice until the autumn of 2022, when its existence became known through the work of this Inquiry. There was no local government involvement in Exercise Alice, nor were its report or recommendations shared. [146]

Counter to dominant COVID-19 narratives which bemoaned pandemic ‘unpreparedness’ and the lives lost due to poor adherence to contingency plans (evident in the spin attached to some of the mainstream media coverage ^[147] of the declassified documents), many of the ostensibly novel and unprecedented methods that were implemented to (purportedly) suppress COVID-19 infection by the health and social care services were planned and deliberated during these exercises.

Exercise Alice recommended, ‘. . .options to restrict the movement of symptomatic, exposed and asymptomatic patients – whether voluntary or ‘through the imposition of restriction’; ^[148] temperature screening of returning travellers; ^[149] a ‘web-based’ ‘live tool or system to collect data from MERS-CoV contacts’; ^[150] and ‘community sampling’; ^[151] all of which were operationalised (see article 1.3 for more info on the latter) during the COVID-19 event. 

Guidance from the Pandemic influenza briefing paper: NHS surge and triage was also enacted, which gave detailed instructions on how to carry out ‘population based triage’ i.e. denial of care to patients categorised as either less likely to survive, or whose lives were deemed less valuable to save in the event of surge demand. The document, which gives away that it was never intended for public consumption where it states, ‘The majority of the detail in this paper will not be replicated in any publicly available documentation’, explicitly calculates the number of deaths in the thousands that could be expected should it become necessary to ‘suspend critical care to support the wards’, ^[152] and advises to ‘cease ventilation’ and ‘withdraw ventilation’ in the event of a ‘severe pandemic’. ^[153]

Similarly, Exercise Cygnus proposed, ‘Reverse-triage plans, under which patients from hospitals would be moved into social care facilities’, [154] in addition to population triage, i.e. ‘The emptying of all intensive care beds in the country in order. . .to save more lives.’ [155] Then Secretary of State for Health and Social Care, Jeremy Hunt, testified at the inquiry to expressing an unwillingness to authorise such measures during Exercise Cygnus. As a result, ‘entirely new protocols’ were developed to allow such (non) authorisation to be circumvented. 

The Parliamentary and Health Service Ombudsman’s 2024 released report, End-of-life care: improving “do not attempt CPR” conversations for everyone found the misuse of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) notices during the pandemic raised serious questions about ‘whether a human rights-led approach is being taken to patients’ care’: [156]

On 20 March 2020, the National Institute for Health and Care Excellence (NICE) released guidance stating: “all adults on admission to hospital, irrespective of COVID-19 status, should be assessed for frailty using the Clinical Frailty Scale (CFS) and that comorbidities and underlying health conditions should be considered.” Different interpretations of this guidance led to allegations of blanket DNACPR decisions in hospital and residential care settings, especially for disabled people and older people. ^[157]

The Coronavirus Act, decried by Big Brother Watch as ‘the most draconian powers ever proposed in peace-time Britain’, ^[158] was also premeditated, at least in outline, years ahead. The 2017 Pandemic Influenza Briefing paper states

The concept of a pandemic influenza bill has been discussed within health[sic] and across government. A number of aspects of legislation and regulations are being considered that could be amended during pandemic… [which] include things around teacher/ carer to child rations, death certification, and regulations around clinicians returning to the NHS after leaving the service for retirement or other reasons. ^[159]

The latter two specific concerns were legislated for in the Coronavirus Act (Schedule 2, Section 18, and Schedule 13). ^[160]

In Exercise Pica’s report the emergency response to the hypothetical pandemic, including withdrawal of all but ‘essential skeleton services’ and drastically reduced public transport provision, was envisaged as ongoing over a period of four months with a potential further winter wave. ^[161] If this was the timeframe for a lockdown scenario predetermined by NHS leadership, the ‘three weeks lockdown to flatten the curve’ messaging, ^[162] broadcast as official public health strategy to secure initial compliance, appears to have been deceptive. Second and third waves of infection were also anticipated in the report, along with potential vaccine refusal from a segment of the public which would necessitate adapting messaging accordingly: ‘There needs to be focus on an anticipated second wave vaccination programme, with members of the public potentially showing lethargy or non-compliance during the second wave which could reduce uptake.’ ^[163]

The Connected Health Cities project: 2016-2020

The inspiration for Connected Health Cities has been attributed to Professor Iain Buchan, ^[164] Associate Pro Vice Chancellor for Innovation at the University of Liverpool, who went on to lead the Liverpool Combined Intelligence for Population Health Action (CIPHA) project from 2020 (see Part 1.3).

The Department of Health funded £20 million pilot was delivered by the Northern Health Science Alliance: a partnership of over 20 organisations ^[165] established by Universities and NHS Trusts in the North, and the Northern Academic Health Science Network. It worked to actualise a vision of health data as a ‘currency for inclusive economic growth’ ^[166] through a number of initiatives.

These included the Great North Care record ^[167] — one shared care record for the 3.6 million patients across the North East and Cumbria available to all NHS personnel and services; the Newcastle University led SILVER (Smart Interventions for Local Vulnerable Residents) project that linked datasets across healthcare, social care, criminal justice, housing and education to help agencies develop ‘sustainable interventions’ for vulnerable families; ^[168] and Born in Bradford, a large-scale birth cohort research study tracking the lives of 30,000 Bradfordians ^[169] through linked datasets across primary care, hospital, community, laboratory, radiology and education records to ‘test how data linkage can support tailored and effective interventions in early childhood.’ ^[170] This data collection included joining Born in Bradford participants’ health records with personal data including genomics, metabolomics (i.e. the systematic study of the unique chemical fingerprints that specific cellular processes leave behind, tied to precision medicine development) and biobank samples.

It is worth highlighting that in the same time frame that the CHC’s ‘Connected Bradford’ project was opening up access to linked datasets of 700,000 residents, the first social impact bond in the city aimed at reducing rates of full-time residential care entry for children with learning disabilities and challenging behaviour, ‘Bradford Positive and Included’, ^[171] was launched (April 2017).

Social Finance engaged with Bradford District Council, NHS Airedale and Wharfedale Craven Clinical Commissioning Groups and the Schools Forum to secure financial support from Care, Health and Education budget holders to co-commission the SIB. A ‘Schools Forum’ document mentions that the proposed new service aligns with the focus of the National Transforming Care Plan led by NHS England, ‘to provide more care in the community, with personalised support delivered by multi-disciplinary health and care teams.’[172]

One of the Connected Health Cities stated three principal objective was to ‘develop a social license for the use of data driven transformation.’ ^[173]

The report states, ‘Citizen involvement and civic pride are key to harnessing whole system data and analytics without controversy. . .media coverage of Connected Health Cities has been overwhelmingly positive with the #DataSavesLives movement spreading as far afield as Australia.’ ^[174]

Their approach to gaining public trust in the use of sharing health data for ‘research purposes’ ^[175] included citizens’ juries; focus groups and public debates; and musical performances and immersive games. ^[176] An immersive ‘Earworm Game’ was deployed at the 2018 Bluedot festival and other subsequent festivals which involved ‘[P]layers working together to uncover the best treatment for a virus that attacks the brain over five minutes. The better they are at accessing patient data, putting data security in place and gaining public trust, the more likely they are to win.’ ^[177]

‘The Digital Think Tank’ led by the University of Cumbria was also employed, seemingly, to disabuse healthcare professionals of their ‘reluctance to share data for clinical purposes (due to data confidentiality and security concerns)’. ^[178] ‘Active liaison and engagement activities’ carried out with clinicians and GPs resulted in 100% of the 86 GP practices selected for the Born in Bradford study agreeing to sign new data sharing agreements. ^[179] These agreements included access to historical datasets up to 30 years backdated, for ‘research, improvement and innovation projects.’ ^[180] There is no information provided about whether individual patients at these practices were notified or given an opt out option for their pseudonymised data being used thusly.

Connected Health Cities developed a pipeline of international collaborations by health system leaders for ‘scale-up, sustainability and knowledge transfer’, which included the Institute for Global Health Policy Research, and the ‘WEF Centre for the Fourth Industrial Revolution’, Japan. ^[181]

The NHS Long Term Plan released in 2019

The NHS Long Term plan (LTP) was launched in January 2019. The key takeaways are summarised below.

It details a patient’s experience of ‘markedly different’ planned models of care by 2029, ^[182] centred on use of the NHS smartphone app, (or browser equivalent), as a ‘digital front door’ ^[183] to an online triagewith ‘tiered escalation depending on need’, which will ‘help them manage their own health needs or direct them to the appropriate service.’ Increasingly, AI run automated smart systems will manage the triage. ^[184]

To enable the self-management of conditions, the plan commits to working ‘with the wider NHS, the voluntary sector, developers, and individuals in creating a range of apps to support particular conditions.’ ^[185]

‘Preventive and anticipatory care models’ ^[186] are a major focus of the plan, with the ‘connecting of home-based and wearable monitoring equipment’ (examples given include digital scales to monitor the weight of someone post-surgery; a location tracker for someone with dementia; and home testing equipment for someone taking blood thinning drugs) envisaged to ‘predict and prevent events that would otherwise have led to a hospital admission.’ ^[187] The plan states that even when ill, people will be ‘increasingly cared for in their own home’, with an ‘option’ of physiological monitoring with ‘wearable devices’. ^[188]

The 2019 government commissioned The Topol Review: Preparing the healthcare workforce to deliver the digital future. An independent report on behalf of the Secretary of State for Health and Social Care (examined below), reveals more about the NHS app’s planned functionality: ‘By 2021, [the NHS App] will allow people to upload data from their wearables and lifestyle apps. . .and consent for those data to be linked with their health records.’ ^[189]

The intent to merge multiple digital surveillance data streams with each patient’s single electronic healthcare record is confirmed in the LTP where it states

We will make frictionless APIs [application programming interfaces – key to achieving data interoperability]  available to industry and the developer community to stimulate innovation and support integration with other products. . .The initial API and workflow integration initiatives will develop towards full integration with smart home and wearable devices [my emphasis]. ^[190]

Of key import is the clear coordination with the burgeoning UK health and social care impact investing market, evident in both the plans’ prioritised objectives and its stated vision of ‘putting the NHS back onto a sustainable financial path’. ^[191]This will be enabled through ‘longitudinal health and care records linking NHS and local authority organisations’, like those in the Connected Health Cities project. ^[192]

The NHS Long Term Plan Implementation Framework further confirms this in its summary of the LTP:

The Long Term Plan set out how the NHS is supporting wider social impact across England including support focused on health and the justice system, veterans and the armed forces, health and the environment, health and employment, and anchor institutions. ^[193]

Specific objectives of the LTP noticeably correspond to outcomes from active or completed social impact bonds by 2025 in the UK healthcare policy sector. This includes

• The withdrawal of A&E care, specifically for heavy user groups including those with substance abuse issues ^[194] (e.g.: Cornwall Frequent attenders Project/Addaction) ^[195] and the elderly (e.g.: End of Life Care integrators Bradford, ^[196] Somerset, ^[197]  Sutton, ^[198] Hillingdon, ^[199] and North West London ^[200] and Enhanced Dementia Care service, Hounslow); ^[201]
• Social prescribing to help patients manage their long-term health conditions in lieu of use of primary and secondary care services ^[202] (e.g.: provision of a social prescribing framework and offer at scale across Northamptonshire, ^[203] Ways to Wellness, ^[204] and Community Owned Prevention/Thrive);^[205]
• Preventative lifestyle interventions of weight loss, improved nutrition and improved mental wellbeing for adults at risk of developing Type 2 diabetes ^[206] (e.g.: Healthier Devon ^[207]);
• Cross-sectoral targeted interventions comprising ‘alternative life pathways’ (educational achievements, ‘health literacy’ etc) for vulnerable/at risk children ^[208] (Chances Programme – being delivered by 15 different councils). ^[209]

The LTP also commits to ‘supporting people with severe mental illnesses to seek and retain employment’, ^[210] and boasts of having already launched ‘the world’s largest trial of IPS (Individual Placement and Support) services’ in collaboration with national and local government in 2018. ^[211]

The question of why the UK’s national health provider is assuming a malevolent Department of Work and Pensions function of coercing the severely unwell ‘back to work’, whether paid or unpaid, is illuminated by understanding the NHS’s emerging role, including more recently as commissioner, in the nascent social impact ecosystem. Thanks to the work of the Department of Work and Pensions Innovation Fund, since 2015 ‘employment and training’ is the most developed social impact sector in the UK to date, and the very unwell are an important pool of exploitable human capital for this.

The Topol Review released in 2019

The NHS Long Term Plan references Professor Eric Topol’s report (The Topol Review: Preparing the healthcare workforce to deliver the digital future ^[212]) into workforce changes needed to ‘maximise the opportunities of technology, artificial intelligence and genomics in the NHS,’ ^[213] as the guidance used for the NHS Workforce Implementation Plan.

Similarly to the research interests of Sandy Pentland explored in the previous article, Eric Topol’s biomedical research company Scripps Research is credited by the World Economic Forum as a pioneer in exploring how wearable devices like activity trackers and smartwatches can provide valuable health insights, ‘including a more precise identification of viral infections’. ^[214] And like the MIT media lab, Scripps Research pivoted to COVID-19 detection through wearables research projects during the COVID-19 event.

The February 2019 published review was supplemented by a report by Dr Tom Foley and Dr James Woollard: The digital future of mental healthcare and its workforce: a report on a mental health stakeholder engagement to inform the Topol Review. ^[215]

Both reports anticipate a sea change in professional roles, entailing the replacement of trained professionals with virtual therapists; ^[216] speech recognition and natural language processing triage bots; ^[217] and rehabilitative, wearable, companion robots. ^[218] Staff will train to use robotics and other transformative technologies at simulation centres ^[219] and through ‘digital education platforms such as Massive Open Online Courses (MOOCs)’ ^[220] in place of teaching professionals since, ‘The traditional model of learning clinical skills from senior colleagues will not apply. In many cases, more junior staff will be early adopters and champions.’ ^[221]

A prominent focus on genomics is expected to yield the benefits of routine polygenic risk scoring through low cost ‘genotyping arrays that allow stratification of individual levels of genetic risk for a host of common diseases’, ^[222] to be used in conjunction with demographic and lifestyle scoring, ^[223] and further into the future, the re-writing of the genome and CRISPR gene editing. ^[224]

The Topol Review states, ‘The convergence and complementarity of the three major technologies – genomics, sensors and AI – will enable the development of virtual medical coaches.’ ^[225]

A quote featured in the report from Topol himself explains

[U]ntil now the digital revolution has barely intersected the medical world. But the emergence of powerful tools to digitise human beings with full support of such infrastructure creates an unparalleled opportunity to inevitably and forever change the face of how healthcare is delivered. ^[226] [My emphasis.]

As with Nesta’s future healthcare vision discussed above, the intersection of the digital revolution with medicine imagined in these two reports necessitates a dystopian level of surveillance, which would preclude any vestige of a private life for patients/citizens.

Foley and Wollard admit ‘profound implications in terms of the level of surveillance that. . .[some of these technologies] place on the patient’ ^[227] but envisage, ‘changing public attitudes to data sharing’ and ‘a new values-based approach’ replacing ‘current medical ethical frameworks’ as potential enablers. ^[228]

They state that

Data from smartphones, sensors, social media, neuroimaging and genomics will be linked with data from EHRs, as well as from health and care data sets. . . ^[229] in the next five years it will become increasingly common to link NHS data sets with others from outside of healthcare. ^[230]

Additionally, ‘An increasing range of sensors in the home and on the person will give remote clinicians access to data that would currently not even be available on an inpatient ward.’ ^[231]

Intra-body surveillance through ingestible and nanotech sensors form part of this expected network. ^[232] Developing the evidence base for digital biomarkers and their correlation to mental states including the physiological, e.g., heart rate; cognitive, e.g. screen use; behavioural, e.g. global positioning system data; and social, e.g., call frequency; is a stated priority for the next ten years. This, in order to facilitate, ‘opportunity to rapidly feed back and adapt the non-healthcare (digital and real world) environment to promote better mental health’, with the involvement of ‘employers and government organisations’. ^[233]

Foley et al. elucidate: ‘Effectively, the workforce may become a sensor network, initially recording text, then voice, and eventually, even the staff’s physiological indicators could drive predictive algorithms to identify potential high-risk or high-cost events in inpatient or community settings.’ ^[234]

Moreover, mentions of applications for ‘phenotypic information’ ‘extracted from social media to aid the prediction and monitoring of mental health disorders’; ^[235] the ‘ubiquitous use’ of the ‘predictive analytics’ embedded in electronic patient records; ^[236] the potential of these technologies to ‘challenge longstanding diagnostic classifications’ and provide opportunities for ‘preventative and early intervention strategies’ ^[237] (under the label of ‘precision psychiatry’) ^[238] are strongly suggestive of a potential pathologisation of dissent (the precedent for which exists in historical totalitarian societies ^[239]).  ‘Good mental health’ appears to be being equated to successful adaption to dehumanising and repressive systems of surveillance-based control. What’s more, the emphasis on predictive analytics in the guise of preventative health illuminates a drive towards the predictive profiling of digital citizens as potential debt burdens to society, to align with global finance driven impact markets. ^[240]

Part 1.3 of the series explores the evidence for COVID-19 as a ‘reset’ and fast-forward for the pre-planned and already partially implemented internal reorganisation of health and social care to a digital first, and increasingly digital only, care model, which embeds intrusive surveillance and data harvesting.

---

[1] NHS England. Five Year Forward View. October 2014. [Online]: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

[2] Cave, T. ‘Why are GPs being Told to Hand Billions-Worth of NHS Decisions to Private Health Firms and Their Lobbyists?’ OpenDemocracy. 3 May 2015. [Online]: https://www.opendemocracy.net/en/ournhs/why-are-gps-being-told-to-hand-decisions-to-private-health-firms-and-their-lobbyists/ (https://archive.is/k33Tg).

[3] Public Matters. Health and Care Bill 2021: the NHS, the law, and democracy. YouTube; 26 July 2021. [Online video]: https://www.youtube.com/watch?v=7vjoR7LnDqU (Timestamp, from 05:50.)

[4] Burgess, N., Currie, G., Crump, B., Dawson, A., (2022) Leading change across a healthcare system: How to build improvement capability and foster a culture of continuous improvement. Report of the evaluation of the NHS-VMI partnership. Warwick Business School; Spring 2022. [Online]: https://warwick.ac.uk/fac/soc/wbs/research/vmi-nhs/reports/report_-_leading_change_across_a_healthcare_system_22.09.2022.pdf

[5] NHS England. New Care Models: Vanguards – developing a blueprint for the future of NHS and care services. September 2016 [Online]: https://www.england.nhs.uk/wp-content/uploads/2015/11/new_care_models.pdf

[6] Pickett, L. Sustainability and transformation plans and partnerships: Briefing paper CBP-8093. House of Commons Library; 29 September 2017. [Online]: https://researchbriefings.files.parliament.uk/documents/CBP-8093/CBP-8093.pdf p. 3

[7] NHS Providers. STPs And Accountable Care, background briefing. 15 January 2018. [Online]: https://nhs-providers.uksouth01.umbraco.io/media/zq4fxsrv/stps-and-accountable-care-background-briefing-january-2018.pdf p. 7

[8] Player, S. ‘The Truth about Sustainability and Transformation Plans: How Simon Stevens Imposed a Reorganisation Designed for Transnational Capitalism on England’s NHS.’ Socialist Health Association; 31 October 2021. [Online]: https://sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/ (https://archive.is/Btfg3)

[9] O’Sullivan, T. ‘Judicial Review 23/24 May Challenging Legality of Introduction of ACOs.’ Keep Our NHS Public. 21 May 2018. [Online]: https://keepournhspublic.com/judicial-review-23-24-may-challenging-legality-of-introduction-of-acos/

[10] Bate, A. Accountable Care Organisations. Briefing paper CBP-8190; House of Commons Library. 6 July 2018. [Online]: https://commonslibrary.parliament.uk/research-briefings/cbp-8190/ p. 15

[11] Ibid.

[12] Harrington, H., Ormerod, J. ‘Accountable Care Organisations: Their potential impact on delivery of health & social care to patients in England’s NHS.’ Public Matters. January 2018. [Online]: https://publicmatters.org.uk/wp-content/uploads/2018/01/Accountable-Care-Organisations-briefing-final.pdf p. 10  

[13] NHS. Five Year Forward View. NHS England. October 2014. [Online]: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf p. 19

[14] Ibid., p. 23

[15] Ibid., p. 19

[16] Carter, R., Kaffash, J. ‘Why GP practices close for good.’ Pulse Today. 5 September 2022. [Online]: https://www.pulsetoday.co.uk/analysis/lost-practices/why-gp-practices-close-for-good/ (https://archive.is/awykS)

[17] Checkland, K., Gibson, J., Hutchinson, J., Kontopantelis, E., Sutton, M. ‘Consequences of the Closure of General Practices: a Retrospective Cross-Sectional Study.’ British Journal of General Practice. 16 May 2023. [Online]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10227999/  (https://archive.is/4QgWk)

[18] NHS. Five Year Forward View. NHS England. October 2014. [Online]: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf  p. 32

[19] Ibid., p. 34

[20] Ibid., p. 35

[21] Ibid., p. 34

[22] Galea, A., Hough, E., Khan, I. Test Beds the story so far. NHS England: London; 2017. [Online]: https://www.england.nhs.uk/wp-content/uploads/2017/09/test-beds-the-story-so-far.pdf   

[23] NHS England. ‘NHS Chief announces plan to support ten healthy new towns.’ 1 March 2016. [Online]: https://www.england.nhs.uk/2016/03/hlthy-new-towns/ (https://archive.is/TOtj5)

[24] NHS England. ‘Healthy New Towns.’ [Online]: https://www.england.nhs.uk/ourwork/innovation/healthy-new-towns/ (https://archive.is/8zCdF)

[25] NHS England. Putting health into place principles 9-10: develop and provide healthcare services. London; September 2019. [Online]: https://www.england.nhs.uk/wp-content/uploads/2019/09/phip-3-develop-provide-healthcare.pdf p. 22

[26] Ibid., p. 14

[27] Ibid., p. 14

[28] NHS England. ‘Healthy New Towns: Demonstrator Sites: Darlington.’[Online]: https://www.england.nhs.uk/ourwork/innovation/healthy-new-towns/demonstrator-sites/darlington/ (https://archive.is/6sxIb)  

[29] NHS England. ‘Healthy New Towns: Demonstrator Sites: Whyndyke.’[Online]: https://www.england.nhs.uk/ourwork/innovation/healthy-new-towns/demonstrator-sites/whyndyke/ (https://archive.is/hkIeX)

[30] NHS England. Putting health into place principles 4-8: design, deliver and manage. London; September 2019. [Online]:  https://www.england.nhs.uk/wp-content/uploads/2019/09/phip-2-design-deliver-manage.pdf p. 38

[31] Ibid., p. 22

[32] Hefma (Health estates and facilities management association). ‘NHS competition challenges ideas to design for life.’ [Online]: https://www.hefma.co.uk/news/nhs-competition-challenges-ideas-to-design-for-life (https://archive.is/k0fWH)

[33] BetterPoints. Motivating healthy activity in Ebbsfleet Garden City. 31 October 2023. [Online]: https://www.betterpoints.ltd/download/motivating-healthy-activity-in-ebbsfleet-garden-city/ (https://archive.is/UJHVx)

[34] BetterPoints.‘Active Travel in Wales – Engagement and Communication is Crucial, Webinar Attendees Told.’ 29 July 2021. [Online]: https://www.betterpoints.ltd/blog/active-travel-in-wales-engagement-and-communication-is-crucial-webinar-attendees-told/ (https://archive.is/7Nzgn)

[35] BetterPoints. Buckinghamshire behaviour change programme paid for itself four times over. 29 May 2024. [Online]; available to download at: https://www.betterpoints.ltd/download/buckinghamshire-behaviour-change-programme-paid-for-itself-four-times-over/ p. 2 of report

[36] B Corporation UK. ‘B Corp Certification.’ [Online]: https://bcorporation.uk/b-corp-certification/ (https://archive.is/GQgHd)

[37] BetterPoints. ‘About us.’ [Online]: https://www.betterpoints.ltd/about-us/ (https://archive.is/ARgej)

[38] Centre for Public Impact. ‘The Wigan Deal.’ 22 May 2024. [Online]: https://www.centreforpublicimpact.org/case-study/the-wigan-deal (https://archive.is/myMCB)

[39] Ibid.

[40] Nesta. ‘Creative Councils.’ [Online]: https://www.nesta.org.uk/project/creative-councils/ (https://archive.is/QMctC)

[41] The Newsroom, Wigan Today. ‘Health expert says Wigan Deal is an NHS role model.’ London: National World Publishing; 10 July 2018. [Online]: https://www.wigantoday.net/health/health-expert-says-wigan-deal-is-an-nhs-role-model-1015103 (https://archive.is/xWpM5)

[42] Naylor, C., Wellings, D. A citizen-led approach to health and care: Lessons from the Wigan Deal. London: King’s Fund; 2019 [Online]: https://www.kingsfund.org.uk/insight-and-analysis/reports/wigan-deal p. 3

[43] LinkedIn. ‘Donna Hall.’ Accessed September 2025. [Online]: https://uk.linkedin.com/in/prof-donna-hall-cbe-11555a322

[44] Bolton NHS Foundation Trust. ‘Professor Donna Hall CBE to step down as Chair of Bolton NHS Foundation Trust.’ 11 October 2022.  [Online]: https://www.boltonft.nhs.uk/news/2022/10/donna-hall-to-step-down-as-chair-of-bolton-nhs-foundation-trust/ (https://archive.is/j6vuX)

[45] Hall, D., Pearson, D. ‘Stop Debating whether ICSs are the Answer – Get on and Make them Work.’ Health Service Journal. 29 June 2023. [Online]: https://www.hsj.co.uk/integrated-care/stop-debating-whether-icss-are-the-answer-get-on-and-make-them-work/7035080.article (https://archive.is/EGznp)

[46] PossAbilities. ‘Professor Donna Hall CBE -Chair.’ [Online]: https://www.possabilities.org.uk/lone/?post=113 (https://web.archive.org/web/20220524234932/https://www.possabilities.org.uk/lone/?post=113)

[47] Timan, J. ‘Wigan Market Traders Fear for their Futures.’ Wigan Today. London: National World Publishing; 18 May 2021. [Online]: https://www.wigantoday.net/news/people/wigan-market-traders-fear-for-their-futures-3241487

[48] Vincent, M. ‘Council is Accused of Acting like “Communist China” after Librarian of 30 Years is Suspended for Criticising a Beijing Firm’s Investment in the City.’ Daily Mail. London: Associated Newspapers Limited; 6 June 2021. [Online]: https://www.dailymail.co.uk/news/article-9657335/Wigan-Council-accused-acting-like-communist-China-librarian-30-years-suspended.html (https://archive.is/CGCFD)

[49] Johnston, N. ‘Greater Manchester Police Accused of Conspiring to Silence Council Chief’s Critics.’ The Times. London: Times Media Limited; 17 October 2019. [Online]: https://www.thetimes.com/uk/crime/article/greater-manchester-police-accused-of-conspiring-to-silence-council-chiefs-critics-t7xjx6ls0  (https://archive.is/THmHT#selection-1401.0-1401.82)

[50] Naylor, C., Wellings, D. A citizen-led approach to health and care: Lessons from the Wigan Deal. King’s Fund; London; 2019. [Online]: https://www.kingsfund.org.uk/insight-and-analysis/reports/wigan-deal p. 16

[51] Nesta. ‘LIFE: from Participle and Swindon Borough Council.’ [Online]: https://www.nesta.org.uk/project/reboot-britain/life-from-participle-and-swindon-borough-council/ (https://archive.is/ZJjZy)

[52] Mutch, J. ‘The Beehive Centre “Thriving” Two Years After Volunteers Given Control of Facility.’ Leigh Journal. London: Newsquest Media Group; 14 April 2018. [Online]: https://www.leighjournal.co.uk/news/16159987.beehive-centre-thriving-two-years-volunteers-given-control-facility/

[53] Good Finance. The Old Courts – using investment to create a sustainable arts centre. [Online]:  https://old.goodfinance.org.uk/latest/post/old-courts-using-investment-create-sustainable-arts-centre (Timestamp, from 02:52.)

[54] Nesta. ‘The Old Courts.’[Online]: https://www.nesta.org.uk/feature/arts-impact-fund-portfolio/old-courts/ (https://archive.is/oeGYV)

[55] Figurative. ‘Case study: The Old Courts.’ [Online]: https://figurative.org.uk/case-study/the-old-courts/  (https://archive.is/1RXUX)      

[56] Good Finance. The Old Courts – using investment to create a sustainable arts centre. [Online]:  https://old.goodfinance.org.uk/latest/post/old-courts-using-investment-create-sustainable-arts-centre (Timestamp, from 14:35.)

[57] Stone, M. ‘NPO Owing Over £1.6m Enters Temporary Administration to Safeguard Creditors’ Interests: Arts at the Mill has gone into administration more than two years after its Old Courts venue was forced suddenly to shut its doors due to structural damage caused by contractors, resulting in income loss of around £4m.’ Arts Professional. 28 October 2025. [Online]: https://www.artsprofessional.co.uk/news/npo-owing-over-1-6m-enters-temporary-administration-to-safeguard-creditors-interests (https://archive.is/U2zmY)

[58] Wigan Council. The Deal 2030: our people, our place, our future. [Online]: https://www.wigan.gov.uk/Docs/PDF/Council/The-Deal/Deal-2030.pdf

[59] Wigan Council. Digital strategy 2021-2025. [Online]: https://www.wigan.gov.uk/Docs/PDF/Council/Strategies-Plans-and-Policies/Digital/Digital-strategy.pdf p. 3

[60] Mulgan, G. ‘Ideas: Governments: The Relational State.’ [Online]: https://www.geoffmulgan.com/faqs-2 (https://archive.is/XjF27)

[61] Henggeler, A., Marsh, O., Mulgan, G. ‘Navigating the Crisis. How Governments used Intelligence for Decision-Making During the Covid-19 Pandemic.’ International Public Policy Observatory; December 2022. [Online]:https://theippo.co.uk/wp-content/uploads/2022/12/Navigating-the-crisis-Intelligence-Report-12.12.pdf p. 11

[62] Nesta. People powered results: reflections on 10 years of people power in action. London; 2023. [Online]:  https://media.nesta.org.uk/documents/People_Powered_Results_Reflections_on_10_years_of_People_Power_in_Action_dD6ppAv.pdf p. 9

[63] NHS England. Five year forward view. October 2014. [Online]: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf p. 13

[64] Inclusive Change Partnership (Shared Lives Plus, Community Catalysts, In Control, Inclusion North and Inclusive Neighbourhoods). Collaborative healthcare: supporting CCGs and HWBs to support integrated personal commissioning and collaborative care. October 2017. [Online]: https://inclusiveneighbourhoods.co.uk/wp-content/uploads/2017/10/collaborative-healthcare-guide.pdf p. 15

[65] Nesta. People powered results: reflections on 10 years of people power in action. London; 2023. [Online]: https://media.nesta.org.uk/documents/People_Powered_Results_Reflections_on_10_years_of_People_Power_in_Action_dD6ppAv.pdf p. 23

[66] Inclusive Change Partnership (Shared Lives Plus, Community Catalysts, In Control, Inclusion North and Inclusive Neighbourhoods). Collaborative healthcare: supporting CCGs and HWBs to support integrated personal commissioning and collaborative care. October 2017. [Online]: https://inclusiveneighbourhoods.co.uk/wp-content/uploads/2017/10/collaborative-healthcare-guide.pdf p. 13

[67] Nesta. People powered results: reflections on 10 years of people power in action. London; 2023. [Online]:  https://media.nesta.org.uk/documents/People_Powered_Results_Reflections_on_10_years_of_People_Power_in_Action_dD6ppAv.pdf  p. 16

[68] Bland, J., Khan, H., Loder, J., Symons, T., Westlake, S. The NHS in 2030: a vision of a people-powered, knowledge-powered health system. London: Nesta; July 2015. [Online]: https://media.nesta.org.uk/documents/the-nhs-in-2030.pdf p. 4

[69] Ibid., p. 14

[70] Ibid., p. 8

[71] Ibid., p. 8

[72] Ibid., p. 31

[73] Ibid., p. 8

[74] Ibid., p. 9

[75] Ibid., p. 12

[76] Ibid., p. 34

[77] Ibid., p. 9

[78] Ibid., p. 11

[79] Ibid., p. 17

[80] Ibid., p. 12

[81] Ibid., p. 34

[82] Ibid., p. 27

[83] Ibid., p. 28

[84] Ibid., p. 25

[85] Pratty, F. ‘Nesta has a Fresh £50m to Back UK Impact Startups with Patient Capital.’ Sifted. 30 November 2022. [Online]:   https://sifted.eu/articles/nesta-uk-impact-investment-50m (https://archive.is/1TlBP)

[86] Nesta. ‘Impact investment.’ [Online]: https://www.nesta.org.uk/feature/innovation-methods/impact-investment/ (https://archive.is/TfK4E)

[87] Nesta. ‘Nesta impact investments.’ [Online]: https://www.nesta.org.uk/project/impact-investments/ (https://web.archive.org/web/20251206214900/https://www.nesta.org.uk/project/impact-investments/)

[88] Nesta. ‘Make the UK a Living Lab for Mapping the Exposome.’ [Online]: https://www.nesta.org.uk/feature/minister-for-the-future/better-than-well/make-the-uk-a-living-lab-for-mapping-the-exposome/ (https://web.archive.org/web/20250126105627/https://www.nesta.org.uk/feature/minister-for-the-future/better-than-well/make-the-uk-a-living-lab-for-mapping-the-exposome/)  

[89] Department for Culture, Media and Sport. Social Impact Bonds: An overview. 2017. [Online video]: https://www.youtube.com/watch?v=DlXdCV9KyuE

[90] Hope, P., Bamford SM., Beales, S., Brett, K., Kneale, D. et al. Creating sustainable health and care systems in ageing societies: report of the ageing societies working group. London: Imperial College; 2012 [Online]: https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/public/Ageing.pdf

[91] Cabinet Office, Department for Culture, Media and Sport and Department for Digital, Culture, Media & Sport. Social outcomes partnerships and the Life Chances Fund. 16 November 2012. [Online]: https://www.gov.uk/guidance/social-outcomes-partnerships (https://archive.is/ouJte)

[92] Fox, T., Hickman, E., Ronicle, J., Stanworth, N. Social impact bonds: the state of play. November 2014. [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/resource-library/social-impact-bonds-state-play/ p. 1

[93] Fox, T., Hickman, E., Ronicle, J., Stanworth, N. Social impact bonds: the state of play. November 2014. [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/resource-library/social-impact-bonds-state-play/  p. vi

[94] Ibid., p. 27

[95] Ravitch, D. ‘Warning! ESSA Threatens Special Education.’ 2 December 2015. [Online]: https://dianeravitch.net/2015/12/02/warning-essa-threatens-special-education/ (https://archive.is/5kNpf)

[96] Hulse ESG., Atun, R., McPake, B., Lee JT. ‘Use of social impact bonds in financing health systems responses to non-communicable diseases: scoping review.’ BMJ Global Health; March 2021 [Online]: https://pmc.ncbi.nlm.nih.gov/articles/PMC7938989/ (https://archive.is/qrVJm)

[97] Ibid., p. 96

[98] Cudenec, P. ‘Wising Up to the Impact Scam.’ Winter Oak Publishing; May 2023. [Online]: https://winteroak.org.uk/wp-content/uploads/2023/05/impact.pdf (https://archive.is/WrAZy)

[99] Crampin, H., Woods, T. The future of impact investment in healthy ageing: Report of key findings and recommendations

from a study commissioned by UKRI. UKRI and Collider Health; November 2020. [Online]: https://www.ukri.org/wp-content/uploads/2020/11/UKRI-131120-SocialInvestmentReport-V2.pdf p. 8  

[100] Real Talk With ZSJ. Episode 10: What’s the connection between hedge funds & educational and social justice causes? Youtube;28 January 2021. [Online video]: https://www.youtube.com/watch?v=2cdjwOCBrTE

[101] Monaghan, C., Joury, S., Laláková, E., Woerdeman, S. Fertile Ground: A mapping and analysis of the vibrant ecosystem of organisations across Europe working to transform our economic system. Commissioned by Partners for a New Economy. October 2025. [Online]: https://www.metabolic.nl/publications/fertile-ground/ p. 19.

[102] Kawa, L. The care and wellbeing fund: a retrospective. Social Finance. September 2022. [Online]:  https://www.socialfinance.org.uk/assets/documents/care_and_wellbeing_fund.pdf p. 33

[103] Ibid., p. 34

[104] Alison McDowell. On Impact Investing, Digital Identity and the United Nation’s Sustainable Development Goals. Youtube; 11 March 2020. https://www.youtube.com/watch?v=QqFTyYhfNQs&t=8s

[105] Fox, T., Hickman, E., Ronicle, J., Stanworth, N. Social impact bonds: the state of play. November 2014. [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/resource-library/social-impact-bonds-state-play/ p. 11

[106] The Rockefeller Foundation. ‘Global Impact Investing Network (GIIN).’ [Online]: https://www.rockefellerfoundation.org/bellagio-bulletin/from-the-archives/global-impact-investing-network-giin/ (https://archive.is/DshRP)

[107] Gov.uk. ‘Social Impact Investment Taskforce.’ [Online]: https://www.gov.uk/government/groups/social-impact-investment-taskforce (https://archive.is/lgkF5)

[108] Fox, T., Hickman, E., Ronicle, J., Stanworth, N. Social impact bonds: the state of play. November 2014. [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/resource-library/social-impact-bonds-state-play/ p. 14

[109] Government Outcomes Lab. ‘Impact Bond Dataset: Policy Sector: Health.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/?query=&policy_sector=Health (https://archive.is/BS7zR)

[110] Hulse, ESG., Atun, R., McPake, B., Lee, JT. ‘Use of Social Impact Bonds in Financing Health Systems Responses to Non-Communicable Diseases: Scoping Review.’ BMJ Global Health. March 2021. [Online]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938989/

[111] Social Finance. The care and wellbeing fund: a retrospective. London: Social Finance. September 2022. [Online]:  https://www.socialfinance.org.uk/assets/documents/care_and_wellbeing_fund.pdf p. 7

[112] Ibid., p. 3

[113] Ibid., p. 10

[114] Saunders, K. ‘Team Work Refines Social Finance Model.’ Healthcare Financial Management Association. 25 April 2025. [Online]: https://www.hfma.org.uk/articles/team-work-refines-social-finance-model (https://archive.is/Wlsg0)

[115] Social Finance. ‘Pioneering Social Investment: the Macmillan End-of-Life Care Fund.’ 30 June 2025. [Online]: https://www.socialfinance.org.uk/insights/helping-people-to-live-and-die-well-the-team-behind-ripel-an-innovative-palliative-and-end-of-life-care-service-in-oxford (https://archive.is/N6SvZ)

[116] Social Finance. ‘Improving End of Life Care Through Co-Designing and Scaling New Approaches.’ [Online]: https://www.socialfinance.org.uk/work/improving-end-of-life-care-through-innovative-finance (https://archive.is/ccgej)

[117] Social Finance. The Macmillan end of life care fund. September 2023. [Online]: https://www.socialfinance.org.uk/assets/documents/Macmillan-EOLC-Fund-Overview-Sept-23.pdf p.2 (https://archive.is/Eu9cP)

[118] Social Finance. ‘End-of-Life Care Projects Enabled Through the Care and Wellbeing Fund and the Macmillan End-of-Life Care Fund.’ [Online]: https://www.socialfinance.org.uk/our-end-of-life-care-projects (https://archive.is/FlNtH)

[119] Highland Hospice. Case Studies: Liz’s story. [Online]: https://highlandhospice.org/uploads/library/EOLCT-Case-Study-Lizs-story-June-2024.pdf (https://archive.is/R0dpE)

[120] Highland Hospice. Case Studies: Shirley Ann’s story. [Online]: https://highlandhospice.org/uploads/assets/EOLCT-Case-Study-Shirley-Anns-Story.pdf (https://archive.is/blOhK)

[121] Right to Life News. ‘Week Three Wrap-Up: Over 80 Amendments to Better Protect the Vulnerable from Assisted Suicide Rejected.’ 3 March 2025. [Online]: https://righttolife.org.uk/news/week-three-wrap-up-over-80-amendments-to-better-protect-the-vulnerable-from-assisted-suicide-rejected (https://archive.is/jL2iu)

[122] World Economic Forum. ‘What is the Theme of Davos 2016?’ 16 November 2016. [Online]: https://www.weforum.org/agenda/2015/11/what-is-the-theme-of-davos-2016/ (https://archive.is/Jq7TJ)

[123] NHS England. Test beds programme: information governance – learning from Wave 1. September 2018. [Online]: https://www.england.nhs.uk/wp-content/uploads/2018/09/test-beds-programme-information-governance-learning-from-wave-1.pdf p. 1

[124] Galea, A., Hough, E. and Khan, I. Test beds the story so far. London: NHS England; September 2017. [Online]: https://www.england.nhs.uk/wp-content/uploads/2017/09/test-beds-the-story-so-far.pdf p. 8

[125] Innovate UK. ‘Internet of Things: £1 Million to Support New Hardware.’ Gov.uk; 1 September 2016. [Online]: https://www.gov.uk/government/news/internet-of-things-1-million-to-support-new-hardware (https://archive.is/81oDO)

[126] Galea, A., Hough, E. and Khan, I. Test beds the story so far. London: NHS England; September 2017. [Online]: https://www.england.nhs.uk/wp-content/uploads/2017/09/test-beds-the-story-so-far.pdf p. 24

[127] Sherlaw-Johnson, C. Evaluation of the Care City NHS England Test Bed: Wave 2. London: Nuffield Trust; 14 June 2019. [Online]: https://www.nuffieldtrust.org.uk/sites/default/files/2019-10/evaluation-protocol-v13-final.pdf p. 29

[128] NHS England. Test beds programme: information governance – learning from Wave 1. London: NHS England; September 2018. [Online]: https://www.england.nhs.uk/wp-content/uploads/2018/09/test-beds-programme-information-governance-learning-from-wave-1.pdf p. 2

[129] Ibid., p. 7

[130] Galea, A., Hough, E. and Khan, I. Test beds the story so far. London: NHS England; September 2017. [Online]: https://www.england.nhs.uk/wp-content/uploads/2017/09/test-beds-the-story-so-far.pdf p. 22

[131] The King’s Fund. George Tadros: The RAIDPlus Test Bed Vision. 2017. [Online Video]:  https://www.youtube.com/watch?v=PI8TVWsmVxU (Timestamps, 03.15 and 04.36.)

[132] NHS England. Test beds programme: information governance – learning from Wave 1. London: NHS England; September 2018. [Online]: https://www.england.nhs.uk/wp-content/uploads/2018/09/test-beds-programme-information-governance-learning-from-wave-1.pdf  p. 7

[133] Ibid., p. 49

[134] Ibid., p. 36

[135] Anderson, R. Online patient records – safety and privacy. 24 April 2013. [Online]:  https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fmedconfidential.org%2Fwp-content%2Fuploads%2F2013%2F04%2FmC_launch_Ross_Anderson_24APR13.pptx&wdOrigin=BROWSELINK Slide 19 

[136] Department of Health and Social Care, Innovate UK and UK Research and Innovation. ‘Faster Access to Treatment and New Technology for 500,000 Patients: The Secretary of State for Health and Social Care has announced £7 million in funding for 2 new programmes.’ 23 October 2018. [Online]: https://www.gov.uk/government/news/faster-access-to-treatment-and-new-technology-for-500000-patients (https://archive.is/65hlk)

[137] Department for Digital, Culture, Media and Sport. UK 5G testbeds and trials. London: The Stationary Office; 2017. [Online]:   https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/652263/DCMS_5G_Prospectus.pdf p. 16

[138] Liverpool 5G Ltd. ‘Health and Social Care Testbed.’ 2020. [Online]: https://liverpool5g.org.uk/health-social-care-testbed/ (https://archive.is/ZiEVU)

[139] Department for Digital, Culture, Media & Sport. Process and early impact evaluation of the 5G Testbeds and Trials Programme

Case Study Annex. London: The Stationery Office; 22 June 2020. [Online]: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/941811/2020-09-30_-_Programme_Initial_Evaluation_-_Case_Study_Annex_-_Final__1___2___1___1_.pdf p. 85

[140] Beech, L., Porteus, J. The TAPPI inquiry report. Technology for our ageing population: Panel for innovation – phase one. The Dunhill Medical Trust and Housing LIN. October 2021. [Online]: https://thinkhouse.org.uk/site/assets/files/2508/lin1021.pdf p. 50

[141] Department for Digital, Culture, Media & Sport. Process and early impact evaluation of the 5G Testbeds and Trials Programme: Case Study Annex. London: The Stationery Office; 22 June 2020. [Online]: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/941811/2020-09-30_-_Programme_Initial_Evaluation_-_Case_Study_Annex_-_Final__1___2___1___1_.pdf p. 83

[142] Digicomply. ‘Public Health England (PHE) – Transitioning to UK Health Security Agency (UKHSA).’ 29 October 2023. [Online]: https://www.digicomply.com/food-regulatory-bodies-standards-and-authorities/public-health-england-phe-transitioning-to-uk-health-security-agency-ukhsa (https://archive.is/Eb4AC)

[143] Dalton, J. ‘Eleven Pandemic Exercises were Carried out Before Covid, Government Admits.’The Independent. 11 June 2021. [Online]: https://www.independent.co.uk/news/uk/home-news/pandemic-exercise-covid-coronavirus-phe-nhs-b1863753.html (https://archive.is/CZajc)

[144] Baroness Hallett. UK Covid-19 Inquiry module 1: The resilience and preparedness of the United Kingdom. A report by The Rt Hon the Baroness Hallett DBE Chair of the UK Covid-19 Inquiry. London: HH Associates Ltd, 18 July 2024. [Online]: https://covid19.public-inquiry.uk/wp-content/uploads/2024/07/18095012/UK-Covid-19-Inquiry-Module-1-Full-Report.pdf p. 198

[145] CyngusReports. ‘Timeline.’ [Online]: https://cygnusreports.org/timeline/ (https://cygnusreports.org/timeline/)

[146] Baroness Hallett. UK Covid-19 Inquiry module 1: The resilience and preparedness of the United Kingdom. A report by The Rt Hon the Baroness Hallett DBE Chair of the UK Covid-19 Inquiry. London: HH Associates Ltd; 18 July 2024. [Online]: https://covid19.public-inquiry.uk/wp-content/uploads/2024/07/18095012/UK-Covid-19-Inquiry-Module-1-Full-Report.pdf p. 116   

[147] Booth, R. ‘Coronavirus Report Warned of Impact on UK Four Years Before Pandemic.’ The Guardian. 7 October 2021. [Online]: https://www.theguardian.com/politics/2021/oct/07/coronavirus-report-warned-of-impact-on-uk-four-years-before-pandemic (https://archive.is/9P0zE)

[148] Public Health England. Report: Exercise Alice: Middle East Respiratory Syndrome coronavirus (MERS Cov-2). 15 February 2016. [Online]: https://s3.documentcloud.org/documents/21080373/report-exercise-alice-middle-east-respiratory-syndrome-15-feb-2016.pdf p. 12

[149] Ibid., p. 11

[150] Ibid., pp. 13, 16.

[151] Ibid., p. 4

[152] NHS England. Pandemic influenza briefing paper: NHS surge and triage. 8 September 2017. [Online]:  https://cygnusreports.org/wp-content/uploads/2021/07/Pandemic-Influenza-Briefing-Paper-NHS-Surge-and-Triage.pdf p. 4

[153] Ibid., p. 12

[154] Baroness Hallett. UK Covid-19 Inquiry module 1: The resilience and preparedness of the United Kingdom. A report by The Rt Hon the Baroness Hallett DBE Chair of the UK Covid-19 Inquiry. London: HH Associates Ltd; 18 July 2024. [Online]: https://covid19.public-inquiry.uk/wp-content/uploads/2024/07/18095012/UK-Covid-19-Inquiry-Module-1-Full-Report.pdf  p. 113

[155] Ibid., p. 148

[156] Parliamentary and Health service Ombudsman. End-of-life care: improving ‘do not attempt CPR’ conversations for everyone. 2024. [Online]: https://www.ombudsman.org.uk/sites/default/files/End_of_life_care_improving_do_not_attempt_CPR_conversations_for_everyone.pdf p. 7

[157] Parliamentary and Health service Ombudsman. End-of-life care: improving ‘do not attempt CPR’ conversations for everyone. 2024. [Online]: https://www.ombudsman.org.uk/sites/default/files/End_of_life_care_improving_do_not_attempt_CPR_conversations_for_everyone.pdf p. 15

[158] Big Brother Watch. ‘”Two Years is too Long” for “Draconian” Coronavirus Bill Warn MPs and Rights Groups.’ 23 March 2020. [Online]: https://bigbrotherwatch.org.uk/press-releases/two-years-is-too-long-for-draconian-coronavirus-bill-warn-mps-rights-groups/ (https://archive.is/lRKxN)

[159] NHS England. Pandemic influenza briefing paper: NHS surge and triage. 8 September 2017. [Online]: https://cygnusreports.org/wp-content/uploads/2021/07/Pandemic-Influenza-Briefing-Paper-NHS-Surge-and-Triage.pdf p. 8

[160] Great Britain. Coronavirus Act 2020. London: The Stationery Office. 25 March 2020. [Online]: https://www.legislation.gov.uk/ukpga/2020/7/notes/division/39/index.htm (https://archive.is/yuo0E)

[161] Public Health England. Report on Exercise Pica: NHS primary care preparedness and response to pandemic influenza. 5 September 2018. [Online]: https://cygnusreports.org/wp-content/uploads/2021/10/Exercise-Pica-full-report.pdf p. 19

[162] Lilico, A. ‘Three Questions the Covid Inquiry Must Answer.’ The Telegraph. 14 June 2023. [Online]: https://shorturl.at/2YoeX

[163] Public Health England. Report on Exercise Pica: NHS primary care preparedness and response to pandemic influenza. 5 September 2018. [Online]: https://cygnusreports.org/wp-content/uploads/2021/10/Exercise-Pica-full-report.pdf p. 15

[164] Northern Health Science Alliance. Connected Health Cities impact report 2016-2020. Newcastle: The Northern Health Science Alliance; May 2020. [Online]: https://86a0896d-fe0e-4794-831e-b6daadd07e7c.usrfiles.com/ugd/86a089_bb3031f66a974501a2f4437bc3c3c631.pdf p. 4

[165] Ibid., p. 7

[166] Ibid., p. 11

[167] Ibid., p. 124

[168] Ibid., p. 129

[169] Ibid., p. 46

[170] Ibid., p. 113

[171] Government Outcomes Lab. ‘Bradford positive and included.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0112/  (https://archive.is/le0gz)

[172] Bradford Council. Matters arising 20 July 2016: social impact bond (update). [Online]:  https://bradford.moderngov.co.uk/documents/s13012/MATTERS%20ARISING%20-%20SIB.pdf (https://archive.is/5GPNk)

[173] Northern Health Science Alliance. Connected Health Cities impact report 2016-2020. Newcastle: Northern Health Science Alliance; May 2020. [Online]: https://86a0896d-fe0e-4794-831e-b6daadd07e7c.usrfiles.com/ugd/86a089_bb3031f66a974501a2f4437bc3c3c631.pdf p. 17

[174] Ibid., p. 10

[175] Ibid., p. 94

[176] Ibid., p. 30

[177] Ibid., p. 36

[178] Ibid., p. 71

[179] Ibid., p. 113

[180] Ibid., p. 114

[181] Ibid., p. 23

[182] The NHS. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ p. 92 of plan

[183] Ibid., p. 25

[184] Ibid., p. 95

[185] Ibid., p. 93

[186] Ibid., p. 101

[187] Ibid., p. 17

[188] Ibid., p. 92

[189] Ibid., p. 46

[190] Ibid., p. 97

[191] Ibid., p. 100

[192] Ibid., p. 99

[193] NHS England. NHS long term plan implementation framework. June 2019. [Online]: https://webarchive.nationalarchives.gov.uk/ukgwa/20250506070725/https://www.england.nhs.uk/wp-content/uploads/2022/07/long-term-plan-implementation-framework-v1.pdf p. 22

[194] The NHS. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ p. 7 of plan

[195] Government Outcomes Lab (GOL). ‘Cornwall Frequent Attenders Project.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0167/ (https://archive.is/Iq6VC)

[196] GOL. ‘End of Life Care Integrator – Bradford.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0300/ (https://archive.is/ixicV)

[197] GOL. ‘End of Life Care Integrator – Somerset.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0299/ (https://archive.is/N558Z)

[198] GOL. ‘End of Life Care Integrator – Sutton.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0308/ https://archive.is/a0SU9

[199] GOL. ‘End of Life Care Integrator (Hillingdon).’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0129/ https://archive.is/a7BfG

[200] GOL. ‘North West London End of Life Care Integrator.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0114/ https://archive.is/bZTfA

[201] GOL. ‘Enhanced Dementia Care Service.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0170/ https://archive.is/edOOF

[202] The NHS. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ pp. 5,25,43 of plan

[203] GOL. ‘Provision of a Social Prescribing Framework and Offer at Scale across Northamptonshire.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0228/ (https://archive.is/MmWCy)

[204] GOL. ‘Ways to Wellness.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/case-studies/ways-wellness/ (https://archive.is/XvJcJ)

[205] GOL. ‘Community Owned Prevention.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0126/ (https://archive.is/GQyWS)

[206] NHS England. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ p. 7 of plan.

[207] GOL. ‘Healthier Devon.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0116/ (https://archive.is/WW6Uv)

[208] NHS England. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ pp. 55, 69, 72, 93, 97, 118 of plan.

[209] GOL. ‘Chances.’ [Online]: https://golab.bsg.ox.ac.uk/knowledge-bank/indigo/impact-bond-dataset-v2/INDIGO-POJ-0198/

[210] NHS England. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]; Available to download at: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ p. 43 of plan

[211] Ibid., p. 117

[212] Topol, E. The Topol Review: Preparing the healthcare workforce to deliver the digital future. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-2019.pdf

[213] NHS England. The NHS long term plan: Version 1.2. London: NHS England; January 2019. [Online]: https://webarchive.nationalarchives.gov.uk/ukgwa/20230418155402/https:/www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ p. 87

[214] World Economic Forum. ‘Pivoting Health Research to take on COVID-19: Detect Lessons.’ March 2020. [Online]:  https://www.weforum.org/stories/2020/03/pivoting-health-research-to-take-on-covid-19-detect-lessons/

[215] Foley, T., Wollard, J. The digital future of mental healthcare and its workforce: a report on a mental health stakeholder engagement to inform the Topol Review. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-Mental-health-paper.pdf

[216] Ibid., p. 21

[217] Topol, E. The Topol Review: Preparing the healthcare workforce to deliver the digital future. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-2019.pdf p. 33

[218] Ibid., p. 30

[219] Foley, T., Wollard, J. The digital future of mental healthcare and its workforce: a report on a mental health stakeholder engagement to inform the Topol Review. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-Mental-health-paper.pdf p. 29

[220] Ibid.

[221] Ibid.

[222] Topol, E. The Topol Review: Preparing the healthcare workforce to deliver the digital future. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-2019.pdf p. 29

[223] Ibid., p. 34

[224] Ibid., p. 31

[225] Ibid., p. 36

[226] Ibid., p. 18

[227] Foley, T., Wollard, J. The digital future of mental healthcare and its workforce: a report on a mental health stakeholder engagement to inform the Topol Review. London: Health Education England; February 2019. [Online]: https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-Mental-health-paper.pdf p. 31

[228] Ibid., p. 31

[229] Ibid., p. 19

[230] Ibid., p. 17

[231] Ibid., p. 23

[232] Ibid., p. 14

[233] Ibid., p. 21

[234] Ibid., p. 25

[235] Ibid., p. 5

[236] Ibid., p. 35

[237] Ibid., p. 8

[238] Ibid., p. 29

[239] Cohen, BMZ. ‘Resistance: Pathologising Dissent’. Psychiatric hegemony. London: Palgrave Macmillan; 2016 [Online]: https://link.springer.com/chapter/10.1057/978-1-137-46051-6_7

[240] Argusfest. SMART contracts for enforced behaviour. 2022. [Online Video]: https://www.youtube.com/watch?v=iX5KyHQPl24