I remember looking at the plans and seeing two things simultaneously.
The first was what everyone else in the room was seeing. A healthcare infrastructure of extraordinary ambition — medical cities designed to deliver world-class treatment to people who had never had reliable access to it. Thousands of beds. Thousands of doctors and nurses. Outreach programmes reaching into rural communities. Digital health initiatives connecting patients to specialists across vast distances. A tiered system designed so that nobody would be turned away regardless of what they could pay.
It was, by any measure, a remarkable thing to be part of.
The second thing I saw was everything else.
Not because I was looking for it. But because thirty years of working across public sector programmes — education, justice, social services, community infrastructure — had given me a particular kind of peripheral vision. When you’ve spent long enough watching what happens to people when systems fail them, you develop a sensitivity to what those same people might do if the conditions were right. What becomes possible when capability, location, and intent converge in the same place.
And what I could see, looking at those plans, was that the conditions were extraordinary.
What the plans actually contained
The medical cities were designed around a core set of capabilities. Healthcare delivery at the centre — but surrounding it, and essential to it, a ring of complementary functions. Education and training facilities. Manufacturing capability. Research and development infrastructure. Commercial and administrative zones. Community services.
All of it in one place. All of it connected. All of it built around the premise that healthcare doesn’t happen in isolation from the rest of life.
That premise was right. But it didn’t go far enough.
The education and training infrastructure wasn’t just a pipeline for nurses and doctors. It was a learning capability that could be extended to agricultural practice, to business skills, to the kind of foundational education that gives people the tools to improve their own circumstances. The manufacturing capability wasn’t just a supply chain for medical equipment. It was a platform for local production, for small business development, for the kind of economic activity that generates employment and keeps value inside a community. The research and development function wasn’t just a support system for clinical innovation. It was a mechanism for understanding hyper-local need.
And the physical presence itself — the fact of a medical city in a specific location, with infrastructure, with footfall, with the trust of a community that had watched it being built — that was perhaps the most undervalued asset of all.
The pattern was familiar from UK programmes. A community hub that started as a health centre and became the anchor for everything else a neighbourhood needed. A digital infrastructure built for one purpose that became the foundation for ten things nobody had planned.
The scale was not.
The conversation that didn’t happen
I raised it. Not formally — there was no formal process for raising it, which was itself part of the problem. But in the conversations that happen around the edges of large programmes.
The response was not hostile. It was something more difficult to work with than hostility.
It was a kind of polite incomprehension. We’re building healthcare infrastructure. That’s what the programme is. That’s what the investment is for. The suggestion that the same infrastructure could deliver wider outcomes wasn’t rejected after consideration. It simply didn’t connect. It was answering a question nobody had asked.
And that was the end of it. Not a decision. Not a refusal. A non-conversation. The kind that leaves no record and costs nothing visible and forecloses an enormous amount of possibility without anyone being aware that a decision has been made.
What it taught me
The wider potential wasn’t hidden. It was visible to anyone who looked at the plans with a different question in mind. It didn’t require additional investment to identify, just a different question asked earlier, by someone whose job it was to ask it.
But nobody had that job. The brief defined the boundary. The boundary defined the conversation. And the conversation found exactly what it was designed to find.
The programme built what it was designed to build. People are being served who weren’t before. That matters enormously.
The missing piece is a conversation that could have happened when the plans were being drawn — the one about what else this could be for.
That conversation didn’t happen because nothing in the programme was designed to make it happen.
That’s the problem I’m writing about.
*This is the third entry in the Predictive Purpose journal — a book being built in public. If you’re reading this for the first time, start at the beginning. Subscribe at neilcatton.substack.com.
Neil Catton is the author of The Next Evolution, The Cognitive Crucible and The Shadow System - available on Amazon, and writes at the intersection of technology, ethics, and human purpose.