Derrick Khor shared a healthcare innovation ecosystem map on LinkedIn recently. It is a good one, and maps like it do the rounds every few months. Regulators, accelerators, grant bodies, trade associations, investors, the academic centres. All of it useful. All of it supply side. Every organisation on the map exists to help a founder build a product that is good, safe and funded. Not one of them tells the founder who actually pays for it.
That is the harder map, and almost nobody draws it. In health the buyer is rarely the patient. And it is almost never just the NHS, though that is where most founders point first and where most pilots quietly stall. The demand side has as many categories as the support side, and until a founder can see them, "go to market" means "chase the NHS and hope".
The two questions
Every health buyer is defined by two things. Whose budget, and whose patient.
When the same organisation holds the money and the patient relationship, you have a direct sale. A trust, a private hospital, a consumer paying for themselves. When budget and patient sit apart, you have a channel, and the party in the middle, the one that holds the relationship and routes the money, is where the power sits. An EAP does not own the patient for long and does not hold a clinical budget, but it sits between the employer’s money and the employee, and that position is worth more than either end. Map the buyers this way and the whole demand side falls into shape.
The categories
Ten, give or take, and the NHS alone is four of them.
1. Statutory NHS (mostly direct). Whose budget: public. Whose patient: the NHS.
Not one buyer but four, with different budgets, cycles and decision-makers. NHS England and national programmes buy through frameworks. Integrated Care Boards commission for a population. Trusts, split across acute, mental health and community, buy operational and clinical tools. Primary care, PCNs and GP federations are the fourth. All slow, all evidence-heavy, DTAC and DCB and DSPT before anyone signs, and all capable of funding a pilot they never scale.
2. Private medical insurers (direct). Whose budget: claims. Whose patient: the member.
Bupa, AXA, Aviva, Vitality, WPA. They pay to take cost out of claims and to hold a proposition edge in a market where every mental health page reads the same. Medium cycle, clinical governance sign-off, and they will not route members into anything they cannot stand behind.
3. Group risk and protection insurers (direct). Whose budget: workplace protection. Whose patient: the insured employee.
Income protection, critical illness, life. A separate budget from private medical insurance, and an underused one. They buy early intervention and return to work, because a person back at their desk is a claim that closes. Rarely targeted by digital health founders, which is exactly why it is worth targeting.
4. Employers, direct (direct). Whose budget: HR, benefits, wellbeing. Whose patient: the employee.
They buy engagement, productivity and retention. The budget is real but the sales motion is one company at a time, which is slow and expensive unless you are large enough to run an enterprise team. Most founders reach this money better through the layer above them.
5. Workplace intermediaries (channel). Whose budget: the employer’s, routed. Whose patient: held on the employer’s behalf.
EAP providers, occupational health, and the benefits consultants, Aon, Mercer, Willis Towers Watson. These do not pay you directly and they are not the end user, but they hold the employer relationship and they decide what reaches the workforce. Lock one of these and you reach hundreds of employers without selling to any of them. This is the category with the most reach on the map for most workplace-health products.
6. Private providers (direct). Whose budget: operational and clinical. Whose patient: theirs.
Hospital groups, HCA, Spire, Nuffield, Circle. Clinic chains and group practices. Individual practitioners. Pharmacy. They buy throughput, retention and a way to stand out. Faster to a decision than the NHS, and in a group practice one clinical director decides for fifty clinicians.
7. Pharma and life sciences (direct). Whose budget: patient support, evidence, partnerships. Whose patient: shared with the prescriber.
Companion tools, patient-support programmes, real-world evidence, digital-therapeutic partnerships. Big cheques and long cycles. They buy adherence and data. Underrated by founders who think of pharma as a competitor rather than a customer.
8. Consumers (direct). Whose budget: their own. Whose patient: themselves.
Fast to reach in theory. In practice, expensive to acquire and low willingness to pay for health specifically, which is why so many consumer health apps are really funnels for something else. A cash line and a proof point, seldom the growth engine on its own.
9. Public sector beyond the NHS (direct). Whose budget: public, non-NHS. Whose patient: a defined population.
Local authority public health, DWP and return to work, defence and justice health, social care. Population budgets, heavy procurement, and a mission fit that can open doors the NHS keeps shut.
10. International health systems (export). Whose budget: another country’s. Whose patient: theirs, under other rules.
A different rulebook per market, reached through Healthcare UK and trade routes. US payers and employers, the Gulf, and others. A whole second demand map, and the reason regulatory choices made at home either open the door or bolt it.
How to break it down
The list is not the useful part. The scoring lens is. Lay six axes over any buyer and the priority order stops being a matter of taste.
Budget owner: who actually holds the money. No budget, no sale, however keen the champion.
Patient owner: who holds the relationship and the distribution. Decides whether you sell direct or through a channel.
Sales cycle: weeks, months or quarters. A pre-revenue company cannot survive a buyer whose cycle is longer than its runway.
Evidence bar: what they demand before signing. DTAC, a device class, ISO 27001, published outcomes. The bar sets the cost of entry.
Pricing model: per life, per seat, per outcome, per licence, subscription. Determines whether volume or value carries the revenue.
Scale past pilot: the one everyone forgets. Some buyers fund pilots as a habit and scale almost none. That is where products go to die.
Score a buyer on those six and its place in the queue is obvious. Short cycle, low evidence bar, clear budget owner and a real path past the pilot go first. Biggest budget with the longest cycle and the highest bar goes last, whatever its size on a market-sizing slide.
The NHS is the biggest budget and the worst score on cycle, evidence and scale past pilot. That is the whole trap in one line.
The point
Pick your buyers on purpose. The companies that scale are not the ones with the best product on the support-side map. They are the ones that found a buyer who pays now, with a cycle they could survive and a route past the pilot, and built the NHS relationship in parallel rather than betting the company on it. That commercial route to market is the category the ecosystem maps leave out, and it is the one that decides who makes it.
With thanks to Derrick Khor, whose ecosystem map prompted this.