PUBLIC SERVICES

Preparing the
NHS for the A
Era: A Digital
Health Record
Every Citizen
PAPER 21ST AUGUST 2024

Our Future of Britain

initiative sets out a policy
agenda for governing in the
age of AI. This series
focuses on how to deliver
radical-yet-practical
solutions for this new era of
invention and innovation –
 concrete plans to reimagine
the state for the 21st
century, with technology as
the driving force.

CHAPTER
1

The UK has a new

government with a strong
mandate for reform of the
NHS. When Secretary of State
for Health & Social Care Wes
Streeting spoke at the Tony
Blair Institute’s Future of
Britain Conference shortly
after the election, he set out
his ambitions for that reform.
He described the “three big
shifts” required to put the
NHS back on track:

A shift from treatment to

 prevention.
A shift from hospitals to
primary and community
care.
A shift from analogue to
digital, with a focus on
innovation.

He also described his

ambition for the Department
of Health & Social Care to
become not just a
department of public service
but one of economic growth,
improving the health of
citizens so that they are better
able to live longer, healthier,
more productive lives. This
approach would also spur
collaboration between life
sciences and technology
companies to develop new
innovations in the UK.

Data underpin the

government’s ability to
achieve those three big shifts.
Earlier this year, TBI published
A New National Purpose:
Harnessing Data for Health; in
it we advocated for a National
Data Trust in the UK to
support R&D and drive
economic growth. Here we
propose a digital health
record (DHR) to drive
improvements to health and
care, and ensure that the NHS
is ready for the artificial-
intelligence era.

Each person’s DHR would be

the “single source of truth” for
their health and care data –
data that currently sit in silos
across hospitals, GP
practices, pharmacies and
phones. It would be the
fundamental building block of
all modern health systems
and open up a whole new
way of generating health and
delivering health care in the
future.

The DHR will have most

impact in primary care.
Inpatient hospital visits are
episodic, with clinical teams

able to access relevant

able to access relevant
personal health data through
the hospital record. It is out of
hospital where the impact of
an integrated, digital,
longitudinal health record will
be felt. The Fuller Stocktake
report[1] describes the three
core functions of primary care
– access, continuity and
prevention – all of which will
benefit from a DHR, especially
with the advent of AI.

Access: For patients with

an acute care need (such
as a fever, a cough or
pain), access to a DHR
would support services
such as 111 to make sure
they were seen by the
right person, at the right
time and in the right place
– and that their complete
medical record was on
hand when they were
seen.
Continuity: With a DHR,
patients with a long-term
condition could be
 empowered to take
greater control of their
health through apps and
digital therapeutics. It
would also facilitate care
closer to home, with all
members of a
neighbourhood team able
to work with up-to-date
information so that care
would be safer and more
effective.
Prevention: A DHR could
deliver precision public
health, offering tailored
advice, investigations and
early treatment based on
individual risk of ill health.

A DHR would also help the

NHS prepare for the AI era.
Health data are what AI is
trained and deployed on –
and, increasingly, data are
used to regulate AI. A DHR
would support the
development, adoption and
spread of AI technologies in
the NHS, supporting the drive
to increase productivity.
A DHR for every citizen would
also allow the UK to roll out
TBI’s proposed prevention
service, detailed in Moving
From Cure to Prevention
Could Save the NHS Billions: A
Plan to Protect Britain. Recent
macroeconomic analysis
commissioned by TBI on the
value of prevention described
how a 20 per cent reduction
in the incidence of six long-
term conditions could provide
a permanent uplift of 0.74 per
cent to the UK’s GDP within
five years (see Prosperity
Through Health: The
Macroeconomic Case for
Investing in Preventative
Health Care in the UK).

Investment in the country’s

digital and data infrastructure
may seem like a second-
order consideration at a time
when elective waiting lists
stand at more than 7 million[2]
and there are an estimated
250 people dying prematurely
 in A&E every week[3] – but
without it, long waits and care
failures will continue. There is
strong public support for a
DHR, with 89 per cent of
patients in favour of having
greater access to their
medical records, and 81 per
cent in favour of something
akin to a digital health
passport.

Professor the Lord Darzi is

undertaking a review of the
state of the NHS with a view
to reform, making it safer,
more effective and more
sustainable in the future.[4]
The digital infrastructure and
data underpinning the service
– including a DHR for every
citizen – must be part of that
reform.

CHAPTER
2
Professor the Lord Darzi’s
audit is expected to reveal an
NHS in urgent need of reform:
long waits and poor
outcomes, crumbling
infrastructure and outdated IT,
burnt-out and striking staff,
and record low rates of public
satisfaction.

The temptation is to ask for

more money, but the NHS has
never had more money and
staff than it does now (not
including the Covid years,
when extra funding and staff
were required for the vaccine
programme, PPE, and test
and trace).[5] Its budget for
the whole of the UK in 2022–

[6]
23 was £225 billion[6] and
spending on the NHS now
accounts for about 43 per
cent of day-to-day spending
in government departmental
budgets.[7] In fact, NHS spend
has outpaced GDP growth for
some time, crowding out
spending in other sectors and
steadily adding to national
debt.[8]

It is clear that this situation is

unsustainable and, upon
taking office, Secretary of
State for Health & Social Care
Wes Streeting was quick to
signal that he would put to an
end to the “begging-bowl
culture” of looking to
government for handouts
every winter. Productivity,
then, will be a key theme of
the proposed ten-year plan
for the NHS. A recent report
by the National Audit Office
revealed that the health
service now gets 45 per cent
more money than it did a
decade ago but is only doing
35 per cent more work.[9] A
failure to invest in capital
infrastructure – both physical
and digital – was cited as a
major causal factor.

The other priority must be

prevention. About 40 per cent
of the NHS budget is now
spent on the treatment of
preventable illnesses[10] and
by the end of this parliament,
sickness benefits are
expected to cost the taxpayer
an additional £64 billion a
year.[11] There is, however,
hope on both fronts.
Advances in biotech, pharma,
data, digital and artificial
intelligence could deliver the
gear change in both
productivity and prevention
that is needed. For example:

In pharma and biotech

the potential of GLP-1
agonist-type drugs is only
just being uncovered.
They appear to not only

suppress appetite but

suppress appetite but
also cravings;
independently of weight
loss, they also seem to
reduce the incidence of
heart attacks and strokes.
[12] AI is helping to design

novel antimicrobials,[13]
while new multi-cancer
early-detection blood
tests look set to transform
screening and early
diagnosis.[14]
Data and AI are being
trialled by the NHS in the
UK and in other countries
at every level of the health
system, to guide decision-
making and improve
operational efficiency. At a
national level, AI is being
tested to guide health
policy,[15] regionally to
coordinate care, in
hospitals to improve
operational efficiency, in
primary care to support
clinical decision-making
and in back-office
departments to deliver

administrative functions.
 administrative functions.
Digital technologies are
supporting patients and
staff, with digital
therapeutics empowering
patients to take greater
control of their own health
and remote monitoring
empowering clinicians to
care for patients in the
community.

In the AI era, it is simply not

enough for health systems to
amass as many AI
technologies as possible into
their current business models.
They need to appreciate just
how different the AI era will be
and how fundamentally
different they will need to look
to survive – and that includes
the NHS.

DHRs will be key to unlocking

the benefits of these new
technologies and establishing
new models of care. They are
fast becoming the
foundational building blocks
of modern health systems,
of modern health systems,
with countries across the
world investing in this critical
piece of digital and data
infrastructure. Estonia, for
example, earmarked 1 per
cent of its GDP to
fundamentally reform its
health-data infrastructure;
now 98 per cent of citizens
have a digital ID and everyone
has a DHR – and 20 per cent
have had their genome
mapped and linked to their
DHR.[16]

The structure and function of

DHRs vary but they tend to
have some key structures in
common:

FIGURE 1

The structure and

function of a digital
health record
1. Data core: Cloud
infrastructure that links
personal health data about
an individual from multiple
providers in one place.
2. Applications layer:
Interface between the data
core and the wider world,
where data are accessed
by users.
3. Patient portal: Secure
website or app through
which patients can view
their data, share them with
third parties and process
them using inbuilt
algorithms. Patients may
also be able to upload
content such as photos,
forms and wearables data.
4. Provider portal: Secure
website, app or provider-
management system
through which providers
can view the DHR, upload
content (such as diagnoses

and treatments) and

 process it using inbuilt
algorithms to support
clinical decision-making. It
can also be used to audit
provider quality and
performance against
benchmarks and
standards.
5. Insurer portal: Secure
portal through which
insurers can access
anonymised and
aggregated data about the
risk profile of the
population.

These features generate

some unique functions that
help prepare health systems
for the opportunities and
challenges that will be faced
in the AI era.

1. Data Core
The data core is the heart of a
DHR, essentially uniting

information about the citizen,

around the citizen.
around the citizen.

This will become increasingly

important in the AI era. AI is
already eroding the
asymmetry of information that
underpins the clinician-patient
relationship. In future, AI will
make medical advice more
widely, cheaply and quickly
available, making it far less
likely that any one provider
(even the NHS) will be able to
hold all relevant data about
one patient.

In reality this only exacerbates

an existing trend for people to
seek advice and treatment
outside the NHS. In 2023
nearly 45 per cent of young
people who saw a GP used a
private service[17] and more
patients than ever signed up
for private medical insurance.
[18] DHRs bring those records

together and include

information from: public and

private providers of care;

primary and secondary
primary and secondary
providers of care;
investigation and diagnostic
services; and wearable
monitoring devices.

Another key feature of the

data core is its capacity to
train clinical AI models. India’s
Apollo Hospitals group, for
example, has created its own
clinical intelligence engine
(CIE): a clinical decision-
support tool trained on
personal health data from its
millions of patients, the
insights of its many clinicians
and peer-reviewed journals.[19]
The CIE now has more than
1,300 conditions and 800
symptoms in its vocabulary,
and it is available to all 4,000
Apollo doctors through a
clinician portal and to all
customers through a
smartphone app.

The structure of the data core

determines the extent of its

functions. In a centralised
model, all data are stored
model, all data are stored
centrally in the cloud. Data are
uploaded, standardised,
labelled and stored in a
structured database, with
each citizen having their own
“bubble” of dedicated, linked
storage. In a federated model,
the data remain stored at
source but are called up as
and when required to support
decision-making. A hybrid
model can do both, storing a
core set of information
centrally but having links back
to local data-storage systems
to draw on as required.

There are two key benefits to

having at least some data
stored centrally. The first is
that it speeds up processing
times for the most common
analyses of the data in a DHR;
the second is that this kind of
centralised structure is
required for the training,
deployment and regulation of
AI models. This latter benefit

is important if the UK is to
consider developing some
sort of large language model
(LLM) to support clinical
decision-making for citizens
and clinical staff.

With hybrid DHRs there is also

a decision to make about the
amount and type of data that
are stored centrally, and what
can be called up as and when
required. In the US a state
body, the Office for the
National Coordinator of Health
Information Technology,
determines that core dataset,
which is called the United
States Core Data for
Interoperability (USCDI). This
dataset is flexible, changing
over time via a predictable,
transparent and collaborative
public process.[20] In the
future one could imagine
citizens having the option to
upload genomic data,
wearables data (such as heart
rate and respiratory rate),
microbiome data and real-

time environmental data

time environmental data
(such as ambient pollution
levels in their postcode).
Social determinants of health
such as housing quality and
employment status would
also be an option.

2.
Applications
Layer
The applications layer is the
interface between the DHR
and those requiring access to
the data within; application
programming interfaces
(APIs) are the gates through
which that information flows.
Each API has unique
specifications that define the
users that can access the
information, what information
that user is entitled to see and
whether the citizen has
consented to share the
information with that user.
APIs can also ingress
information into the DHR,
such as a new diagnosis from
the hospital.

Information about an
individual or a group of
individuals can be shared, and
those data may be personally
identifiable or they may be
anonymised. The three most
common users requesting
access to the information are
the patient, the provider (an
individual clinician or a wider
organisation) and the insurer,
although in some cases (with
patient consent) DHRs can
facilitate the sharing of
information with academic
bodies or commercial life-
sciences companies for the
purpose of research. Siemens
Healthineers is an example of
a company that provide this
DHR function, linking personal
health data for patients,
providers and insurers across
Europe and Latin America.

As with the data core, the

As with the data core, the

structure of the applications

layer determines its
functionality. Having open
APIs and complying with
internationally recognised
standards for data
interoperability – fast health-
care interoperability resources
(FHIR) standards, for example
– make DHRs optimally
interoperable, which is key if
they are to fulfil their potential.

Interoperability allows for

choice, and choice can help
with the capacity, innovation
and agility of health systems,
spurring entirely new models
of care.

First, capacity. An
interoperable DHR –
independent of a GP or local
hospital – immediately
expands capacity, allowing
citizens to consult a much
wider range of providers while
preserving both clinical safety
and continuity of care. A DHR
could expand primary-care
could expand primary-care
capacity in the UK, for
example, by facilitating wider
expansion of the Pharmacy
First scheme, drawing on the
skills and capacity in
community pharmacies to
deliver more screening,
vaccination, chronic-condition
management and acute care.
An interoperable DHR also
enables patients to navigate
entirely new digital pathways
of care.

Increased choice of provider

can also be a powerful driver
of innovation adoption in
primary care. This might be
technical innovation (such as
a new stethoscope that
detects heart failure) or care-
model innovation (such as
virtual wards or home-
treatment services). This is
important. The old model of
general practice (ten minutes
for one problem, by the time
you are already sick) still
prevails in most practices –
and hasn’t changed since the
inception of the NHS in 1948.
Harbr is an example of a
primary-care accelerator in
the UK doing great work to
scale innovation start-ups in
general practice, but an
element of competition and
contestability can help too.

Competition and
contestability are sometimes
said to be at odds with
integration, but global
evidence shows that
integrated care systems thrive
in a competitive market.
Montefiore, Kaiser
Permanente and Geisinger
are all highly innovative,
accountable care
organisations in the US,
providing integrated care for
whole populations of patients.
These organisations are in
competition with each other
for custom, which provides at
least some of the financial
incentive to innovate.
The same is true in Israel,
which has a publicly funded
health system. There, four
health-maintenance
organisations (HMOs)
compete to provide citizens
with a “basket of goods” set
by the Ministry of Health, to
which all citizens are entitled.
At least two of them, Clalit
and Maccabi, continuously
push boundaries in their
innovative approach to care
delivery; as such, it’s no
coincidence that health
outcomes in Israel far exceed
those in the UK.

Even in Spain, where health-

care provider Ribera Salud
runs an integrated health
system on behalf of the
government for Valencia’s
citizens, there is contestability:
if health outcomes and
performance objectives are
not met in the course of the
five-year contract, the
provider can be replaced.
In each of these examples,
the systems in question have
created an environment
where mobility of custom
propels innovation throughout
those systems. Providers are
encouraged to “pull”
innovation towards them,
rather than someone else
pushing it onto providers that
are sceptical of change and
resistant to externally
developed solutions.

The choice and mobility that

an interoperable DHR confers
will also be critical to the
agility of health systems in the
AI era, providing the flexibility
for them to evolve and adapt
as new treatments,
technologies and models of
care are developed. The
nature of AI as a general-
purpose technology,
pervasive across all sectors
and disciplines, will lead to an
acceleration in the pace of
innovation. Without choice

and movement, health

and movement, health
systems will become
fossilised in old models of
care.

Many private medical insurers

have started to recognise this
and prepare. AXA, for
instance, uses health-
technology platform
Healthanea to provide a DHR
functionality, mapping typical
care pathways and modelling
how they change in response
to new technologies and care
models. This means that AXA
can keep up, working with
innovative providers to make
new care pathways standard
practice. Healthanea is
piloting this technology in
Sweden, which is another
country with a national health
service, predominantly tax-
based financing and public
provision. Like the UK, it also
has a capitated health-
payment model.

In the US, this interoperability

has been mandated in law as

has been mandated in law as
a result of the 21st Century
Cures Act. Passed in 2018, it
compels the creators of all
electronic health records
(EHRs) to have open APIs,
making the data readily
available to all those with the
right to access it. This also
ensures that the data are
presented to users in an
agreed and standardised
format (so, for example, a
hypertension diagnosis in one
system is a hypertension
diagnosis in another). In
reality, this legislation can be
difficult to enforce and in the
UK, there are examples of
interoperability working
without legislation; Cheshire
and Merseyside integrated
care system (ICS) is one
example.

3. Patient
Portal
Patient portals are not
technically part of the DHR –
they are add-ons – but they
vastly improve functionality
and create a whole new use
case: self-care. The health-
care industry is decades
behind industries such as
retail and banking that made
this switch years ago, putting
control and responsibility into
the hands of consumers so
that they can make
autonomous decisions.

In the age of AI, this

autonomy becomes even
more powerful. Citizens are
about to be confronted with a
range of industry-grade,
consumer-facing apps that
could help them manage their
own heath. Patient portals
can act like a digital
marketplace for those apps,
with the option for citizens to
share their DHR to improve
the accuracy and
personalisation of the advice.
The NHS App is an example

of a patient portal that could

potentially do this. The AI-
enabled digital physiotherapy
app Flok Health, for example,
was recently approved by the
NHS for the self-management
of lower back pain, but
currently has to be accessed
outside the NHS App.

Patient portals don’t have to

be owned by or accessed
through “official” health
systems, however; in the US,
for example, the 21st Century
Cures Act enables people to
download their health records
from any provider and add
them to the Health Wallet app
on their smartphones. From
there they can download
third-party apps, share their
health data (with consent)
and get access to
personalised AI-powered
insights.

Through Apollo’s patient

portal (the Apollo ProHealth

app), patients can use the CIE

to support them in preventing
to support them in preventing
ill health, accessing timely
advice and treatment when
they do get ill and managing
longer-term conditions when
illness persists. The app gives
patients access to a chatbot-
based symptom-checker
(CSC), tailored advice on how
to manage chronic long-term
illnesses such as diabetes,
and a personalised health-risk
assessment and treatment
plan.[21] Each of these
functions uses a combination
of the patient’s own health
data and the analytics
capability of the CIE to give
bespoke advice.

Apollo’s AI cardiovascular-
disease tool uses recorded
medical data combined with
reported lifestyle factors and
wearables data to provide
each patient with a
personalised risk score and
prevention plan. This risk-
prediction algorithm is

constantly updated based on

the feedback it gets from
patients; the platform also
allows clinicians to track
progress and compliance
with the treatment plan, and
identify where intervention
may be required.[22]

Similarly, Greater Manchester

uses the GM Care Record
and patient portal My GM
Care to develop care plans
and share them between
health and social care.
Patients can also contribute
to those plans by adding
information such as blood
pressure, weight and mood.

4. Provider
Portal
Provider portals are an
interface through which
health-care providers (and, in
particular, clinical staff) are
able to view, edit and process

the DHR. Depending on the

tech stack, provider portals
tech stack, provider portals
can enable collaboration
between multidisciplinary
teams, new models of care
closer to home and the
performance management of
clinicians. In the AI era, they
also enable personalised
treatment for each patient,
based on individual
characteristics and risks of ill
health.

In Israel, HMO Clalit achieves

this using its Proactive-
Preventive Interventions
platform.[23] This clinical-
analytics platform analyses
each patient’s personal health
data and ranks their
management against gold-
standard guidelines – and
their outcomes against typical
benchmarks. It thereby
delivers real-time updates on
who is at risk and what to do
about it, allowing for tailored
advice and treatment options.
Meanwhile, Mayo Clinic uses
a common care record to
coordinate home-care
coordinate home-care
services for patients with
medical complexity. Multiple
community-care teams report
into a 24/7 command centre
with medical-speciality
oversight.[24]

A DHR with a shared provider

portal will be critical to
underpinning Dr Claire Fuller’s
vision for neighbourhood
teams (as set out in the Fuller
Stocktake report[25]), as well
as the shift towards
community-care models such
as virtual wards. The NHS’s
Shared Care Record
programme has delivered
provider portals for the
majority of ICSs, but more
transformation work would be
required to get them
embedded into GP workflows
and ICS care pathways.

5. Insurer
Portal
Portal
Insurer portals are not
technically part of a DHR,
though given it is often
insurers providing a DHR
function in other countries,
they commonly feature.
These portals allow insurers
to understand the risk of each
of their customers. This allows
them to set premiums and
copays, define the services
that each customer is eligible
for, balance their assets and
liabilities, and make sure they
at least break even (or, ideally,
make a profit).

The NHS often isn’t thought

of as an insurer, but it should
be; it’s the NHS’s insurer
function that allows UK
citizens to pay according to
their means, take according
to their need and receive their
services free at the point of
use. At present, however, the
NHS is unable to perform its
insurer function effectively. It
lacks the data to understand
the risk profile of its
population and it lacks the
mechanism to ensure that
risk profiles guide decisions
about entitlements and
allocation of spending –
namely, the services that all
UK citizens are entitled to and
therefore can expect the NHS
to deliver.

Ultimately, what the lack of

this mechanism leads to is
long waits across the system,
whether that’s waiting for a
GP appointment, waiting for
an ambulance, waiting for an
elective operation or waiting
to be seen in A&E. It also
leads to widespread
disappointment. Failing to
meet people’s expectations
of the health service,
especially when the tax
burden is so high, could lead
to people questioning exactly
what it is they are paying for
and whether it’s worth it –
and that attitude is insidious. It
undermines faith in the
principles of the NHS, just at a
 principles of the NHS, just at a
time when we need a
nationalised health insurance
system the most: the AI era.

With the advent of AI, the

world is entering an era
where, almost from the
moment someone is born, it
will be possible to determine
(with some degree of
accuracy) what they are going
to die of and when. In a
competitive health-insurance
market, that could make a lot
of people instantly
uninsurable. Only government,
with its unique capacity to
pool risk across the whole
population, can provide the
level of protection required,
protecting its citizens from
catastrophic health-care
costs.

CHAPTER
3
Before describing the
practical steps that the
government should take to
establish a DHR, it is worth
setting out a picture of the
landscape that currently
exists for integrated care
records in the UK, and some
of the issues that there have
been with progressing that
into a national record for every
citizen.

Current
Landscape
for Personal
for Personal
Health Data
in England
Endeavours to integrate
personal health data into a
DHR in the UK have been
fraught with difficulty; multiple
attempts have been
suspended or cancelled due
to concerns about
transparency, patient consent
and data security.

As a result, the UK has been

left with a mixture of
integrated health datasets:
some very narrow, nationally
integrated datasets such as
the Summary Care Record
(SCR), and many much
broader local ones. National
datasets tend to include the
kind of information required in
an emergency: basics such
as past medical history,
allergies and current
medications. Local datasets
are usually used to coordinate
are usually used to coordinate
care around complex patients
and have input from many
providers.

The SCR is an example of a

narrow, national database
with basic data. It draws on
the GP record and is most
commonly used in A&E, by
pharmacies and by other
authorised providers outside
of general practice. Private
providers are not able to
access it and it does not have
a direct link back to the GPs’
provider portal, nor into a
patient portal such as the
NHS App. Patients are unable
to view it and clinicians are
unable to make changes to it
– and it is updated only when
the GP record is updated.

Another example of a narrow

but nationally available

solution is the NHS App. At
present it can display basic
information from the GP
record and pathology results;
soon it will display information
from secondary providers too.
It is only available for patients
to view (they are unable to
share the data with third
parties) and at present there
is limited functionality in terms
of analytics: identifying when
patients are due a checkup or
screening.

One major problem that the

NHS App has is that only
about 80 per cent of patients
are able to view their GP
record through it.[26] The
reason for this is that many
GPs, as sole data controllers
of their patients’ health
information under GDPR
legislation, are understandably
reticent to share it for fear of
data breach and litigation.
This highlights another key
problem with data integration

in the UK: while open APIs

and interoperability standards
are almost universally
stipulated as part of NHS
supplier contracts, they are
rarely enforced because the
UK lacks the legislative
framework to compel vendors
to comply (and sometimes
because the NHS offers
inadequate terms in their
procurement contracts for
suppliers to comply).

An example of a
comprehensive, regional
offering in the UK is the
Combined Intelligence in
Population Health Action
(CIPHA) programme, which is
based on the Graphnet
record-sharing platform. This
programme combines
datasets across populations
of between 1 and 5 million,
drawing on data from mental-
health, primary-, secondary-
and community-care settings,
and includes local authority
social-care data and

additional datasets from the

likes of housing, 111 and 999
services.

Led by Frimley Health and

Led by Frimley Health and
Care ICS, and Cheshire and
Merseyside ICS, 11 ICSs
covering 17 million patients
operate the system and work
together. CIPHA uses the
data, analytics and associated
tools to provide insights for
service transformation in
areas such as the
management of patients with
long-term conditions (LTCs),
support for patients in care
homes, prevention
programmes (covering the
likes of strokes, fuel poverty
and diabetes) and the
management of waiting lists.
With its rich dataset, CIPHA is
able to provide those ICSs
with a comprehensive
understanding of the risk
profile of their populations,
which enables them to plan
services accordingly. CIPHA
includes patient access in

some ICSs, including the

ability to upload home-
monitored data such as blood
pressure and weight, as well
as ECGs. In some cases it
as ECGs. In some cases it
also feeds patient-level
insights back to clinicians in
primary care.

Patients Know Best (PKB) is

another example of a more
comprehensive and regional
solution.[27] Designed to unite
all data into a lifetime record
that is owned by the citizen,
PKB has about 18 million
registered patients to date. It
currently supports 19 ICSs in
collating, linking and
processing the mainly
primary- and secondary-care
records of local residents. The
records are hosted and
processed on the cloud and
communicated back to both
patients and GPs, with
actionable insights through
PKB’s patient portal and
clinician portal, as well as the

national NHS App. Patients

can authorise third parties to
access their record using
open APIs with FHIR[28] and
OAuth standards.[29]
OAuth standards.

There are also some

commercial, patient-facing
DHRs on the UK market; while
their use is fairly limited at
present, there is potential to
scale. An example is Apple,
which has agreements with
two NHS trusts (Milton
Keynes University Hospital
and Oxford University
Hospitals) to allow patients to
download and view their
hospital care records through
the Health app on their
smartphones, though this is a
viewing function only and
data cannot be exported or
processed.[30]

There are two other key

integrated health-data
solutions: secure data
environments (SDEs) and the
Federated Data Platform

(FDP).[31] SDEs are data

platforms used to provide
authorised researchers with
secure access to integrated
NHS data for R&D purposes.
They do not have a remit for
use as a DHR but have the
geographical footprint to act
as one.

The FDP is a group of 12

regional data platforms all
joined up to one national data
platform, designed to “bring
together operational data –
currently stored in separate
systems – to support staff to
access the information they
need in one safe and secure
environment”.[32] It draws on
secondary-care data and has
two target audiences: NHS
trusts and integrated care
boards (ICB)s. It helps trusts
with elective recovery and
supply-chain management; it
helps ICBs with population
health management (PHM)
such as planning services,
and care coordination such as
supporting hospital
discharges. There is also a
use case to ensure fair and
equal access to vaccination
and immunisation.

Use cases for the FDP are

strictly defined: they do not
include use of the platform as
a DHR and neither are there
any plans to develop its
analytics capacity to process
individual health data in this
way. There are no plans to
communicate actionable
insights back to the patient,
GP or relevant care team, nor
has it been designed as a tool
for monitoring primary-care
performance, driving payment
reforms or auditing patient
management against gold-
standard protocols.

The FDP is an NHS product,

so it is not designed to
ingress data from private-
sector providers or wearables,
nor interact with any personal
applications, and there are
also specific concerns about

the potential for the NHS to

be locked into a single vendor
for the analytics functions. In
addition, progress on the FDP
has been slow and there has
been a reticence within trusts
and ICSs to adopt it if they
have systems in place that
already function for them.

Practical
Steps the
Government
Should Take
to Establish a
Digital
Health
Record for
All Citizens
in the UK
Commit to a Digital

Health Record for

Every Citizen
Within One Term
The government should
commit to creating a DHR for
every citizen. This would
become the single source of
truth for every citizen’s
personal health data,
replacing the GP record as
the integrator of health
information. The DHR should
be able to ingress personal
health data from all NHS
providers of care (primary,
secondary and community),
as well as private- and third-
sector organisations, and
wearable devices. The DHR
should be hosted on cloud
infrastructure in a hybrid
model, with some data held
centrally and other
components federated.

Recommendation: The
government should commit
to creating a DHR for every
citizen within one term of

government.

Establish a Unit
Establish a Unit
Within DHSC to
Deliver the Digital
Health Record

The DHR should be a non-

proprietary resource
conferred on citizens by the
Department of Health &
Social Care (DHSC), rather
than a private entity or the
NHS. Its purpose should be to
safely collect and store the
personal health data of every
citizen, with citizens in turn
able to share that data with
chosen third parties if desired.
This investment should not
preclude IT budgets
elsewhere, which should be
ringfenced and protected.

We propose that the

government establish a
dedicated unit within the
DHSC to deliver this new
resource. This department
should report to the health
secretary and aim to have a
working minimum viable
working minimum viable
product for the DHR within
two years, and a
comprehensive record within
five years (one parliamentary
term). Governance of the
DHR’s design and build
should include representation
from clinicians (especially
GPs) and patients.

Recommendation: The
government should establish
a dedicated unit within the
DHSC to deliver a DHR,
reporting to the health
secretary.

Legislate for Joint

Data Controllership

The government should

legislate to make the health
secretary a joint data
controller with GPs. This will
be essential for the

functioning of the DHR, is

similar to the arrangement
agreed in Scotland and was
proposed in our recent paper,
proposed in our recent paper,
A New National Purpose:
Harnessing Data for Health.

Recommendation: The
government should legislate
to make the health secretary
a joint data controller with
GPs.

Legislate for
Interoperability

The government should

legislate to compel all vendors
of EHRs to comply with
internationally recognised
FHIR resources[33] – to
provide a framework for
exchanging electronic health
information consistently and
securely across different
health-care systems and
applications – and have open
APIs.

As previous attempts to
enforce interoperability
through contracts with
providers has failed,
providers has failed,
government should pass
legislation similar to the 21st
Century Cures Act[34] in the
US, compelling all EHRs to
have open APIs with health
information supplied in a
standardised, readable
format. This should apply to
both NHS and private
providers, as well as primary
and secondary care.
Mandated changes to
interoperability would need to
be adequately funded
however, as these changes
take considerable time, effort
and money.

This legislation should also

define the minimum dataset
required for ingression in this
format, similar to the USCDI,
and compliance should be
enforced retrospectively to
allow all existing data to be
ingressed to the new record.

Recommendation: The
government should legislate
to compel all vendors of EHRs
to compel all vendors of EHRs
to comply with internationally
recognised interoperability
standards, and have open
APIs.

Conduct a Public-
Engagement and
Deliberation
Exercise

The DHSC, with the NHS,

should embark on a public-
engagement and deliberation
programme before and during
the creation of the DHR, then
invest in adequate
communications when it is
implemented. This may
involve the public participating
in procurement decisions and
getting other opportunities to
provide input regarding the
process. Being able to
demonstrate that the DHR
has secure governance will

help to build and maintain

public trust.

Many of the ICSs with

Many of the ICSs with
advanced data stores already
have comprehensive
communication plans in
place, using adverts,
mailshots, social media, and
posters to communicate
changes. Some ICSs like One
London have done public
consultation sessions and
most Information Governance
boards include patient
representatives. There will be
plenty of learning here to
support the implementation
of a DHR more widely.

Recommendation: The
DHSC and NHS England
should conduct a public-
engagement and deliberation
exercise about the DHR and
then invest in adequate
communications when it is
implemented.

Commence a Rapid
Design-and-Build
Phase

The DHSC should commence

The DHSC should commence
a rapid design-and-build
phase, starting with a critical
evaluation of the options. How
that is achieved, however, is
open to debate. Below we
consider four options, each
with their own merits, though
they vary in likely cost, speed,
ease of implementation, ease
of use and propensity for
vendor lock-in.

Each will require testing,

piloting and graded rollout,
with both organisational
design and change
management in place to
support the new system and
ensure users are guided
through the transition
process.

The options considered are:

1. Build from scratch.

2. Build out from existing
secondary-care
infrastructure.
3. Build out from existing
 primary-care infrastructure.
4. Scale an existing digital
health record.

Here we summarise some of

the key pros and cons, before
going into more detail on
each approach.

1. Build From Scratch

Building a DHR from scratch

would require the national
procurement of both cloud
infrastructure (data core) and
software (applications layer),
followed by a process of
integration, ensuring
interoperability between
instances, with key providers
of information (such as GP
practices) and with users of
that information (such as
patients).

Interoperability is key between

any instances if a federated
platform model is selected
(so that DHRs in different
parts of the country can talk
parts of the country can talk
to each other), and also
between the data core and
applications layer (so that the
applications layer functions as
a true marketplace).

However, there are plenty of

examples of interoperability
not been achieved, even with
laws and contracts in place
mandating it. This can occur
when different suppliers are
procured to operate different
instances; interoperability
stalls because there is no
incentive for the instances to
cooperate. This has led some
health systems to procure
instances from one supplier
(despite effectively creating a
monopoly for them), which is
a consideration if the “build
from scratch” option is

selected.

Conversely, interoperability
between the data core and
the applications layer can be
lost when both are provided
by the same supplier. This is
because, when one supplier
holds the contract for both
data core and analytics layer,
there is an incentive to ensure
that the applications layer is
only really compatible with its
own third-party apps (or
third-party apps with which it
has an affiliation). As such, the
value of the applications layer
as a true marketplace is lost.

A potential solution to this

problem would be to procure
the data core and analytics
layer from separate suppliers,
then put strict terms and
conditions around whether
the supplier of the data core
could bid for application layer
contracts. DHSC could also
maintain strict control of the
APIs and distribution of API
keys, but to achieve this
control it would need a
governance board for the
DHR with independent
technical experts.
Building from scratch has one
key advantage: it means
being able to design a
bespoke solution. However, it
does not solve the problem of
the outdated tech stack that
exists in primary-care
practice-management
systems. This will have a huge
impact on how impactful a
DHR is in practice, as it is all
very well offering data but it is
the insights and actions that
follow that will impact care
and outcomes.

In addition to this, the initial

costs of development,
infrastructure and migration
are likely to be high for a
build-from-scratch option,
while large-scale IT projects
often face delays and
unforeseen challenges,
impacting costs and the
rollout schedule. Building from
scratch would likely require
external consultants with
relevant technical expertise to
oversee the design and build.
2. Build Out From Existing
Secondary-Care
Infrastructure

DHSC could also consider

using the existing FDP
infrastructure, though this
option would take some work.
It would require the
onboarding of primary-care
records, which has been
difficult historically because of
the challenge of getting buy-
in from GPs and the owners
of practice-management
systems. It would also add a
use case to the FDP for direct
patient care, which is a
controversial option.

Even then, however, the FDP

might not provide the
outcomes desired of a DHR.

The FDP is not a persistent

data store: it is a federated
model that draws on data as
and when required, which
puts a limit on the capacity of
government to develop AI
models trained on health data
as other countries have done.
A federated model can also
slow the processing time of
requests, and at present the
FDP contract makes it difficult
to separate out the provision
of a data core and the
applications layer.

The FDP has been slow to

make progress, in part due to
opposition from data-privacy
groups and in part due to
slow uptake from trusts and
ICBs. This may change given
the recent decision of NHS
England to mandate sign-up,
given that only around 50 per
cent of trusts have signed up
to the platform. Use of the
FDP infrastructure would also
mean the DHR was an NHS
asset, rather than a national
asset for citizens. That said,
the FDP may be a good
option as an insurer portal,
providing collated,
anonymised information for
the DHSC on the risk profile of
the population.
the population.

3. Build Out From Existing

Primary-Care
Infrastructure

An advantage of this option is

that most people in the UK
already have a primary-care
record; at the moment it is the
closest thing everyone has to
an integrated longitudinal
health record, and these
records sit with one of only
two major suppliers: EMIS and
TPP/SystmOne. This could
make it simpler and faster to
create one single, joined-up
national asset in the form of a
DHR.

In addition, primary-care
records are already

connected to a patient portal

(the NHS App) and a provider
portal (through the GP
practice-management
system) and one of the latter,
EMIS, is in 90 per cent of
pharmacies. Integration with
an existing provider portal
an existing provider portal
would be particularly useful
for multidisciplinary teams.
Neighbourhood teams will
need a common platform
with read/write access that
allows for coordinated
teamwork, even when
individual clinicians might be
working across different
geographies and on different
sites.

The difficulty with this option

is that procuring one (or even
two) of the suppliers to take
on a contract for a national
DHR creates a formalised
monopoly or duopoly, which
could lead to claims of anti-
competitiveness (with
potential for legal challenge)
and vendor lock-in (with
associated risks in terms of
price and dependency, and
the lack of a true marketplace
in the applications layer).

One potential solution is to

avoid the procurement route
altogether and pursue a
altogether and pursue a
public-private partnership. In
return for the national
contract, either one or both
systems would hand over the
UK licence for their products
to the DHSC – and with it the
data core, analytics layer,
clinician portal and right to
develop the tech stack to the
DHSC’s own spec.

Dealing with one or two

organisations would have the
advantage of tightening the
line of accountability for
rollout. And while there would
be vendor lock-in to these
systems initially, the structure
of the DHR could be
developed in such a way as to
ensure that the contract was

completely contestable within

five years.

This option would create a

single national asset that was
state owned and controlled
from the start. Full integration
with a provider portal could
with a provider portal could
also eliminate the need for
separate electronic-referral
pathways.

4. Scale an Existing Digital

Health Record

There are good reasons for

considering this option.
Several integrated-record
solutions already exist in the
UK – in fact it is estimated
that about 50 per cent of the
English population already
has a local solution with most
of the data required for a
DHR. The most advanced are
probably the Shared Care
Records in Manchester and
London.

The CIPHA programme,

based on Graphnet and
operating in 11 ICSs including
Manchester, covers 17 million
patients; One London,
operated by Oracle Cerner,
integrates primary- and
secondary-care records for 9
million people in the capital.
million people in the capital.
PKB is another solution
provider, with 18 million
patients on its books.

Building out the DHR from

existing Shared Care Records
in Manchester, London,
Frimley and elsewhere would
require a combination of the
following steps:

Adding functionality to the

existing solutions where
they exist, deploying a
standard API set to match
the agreed DHR
specifications.
Building new instances in
parts of the country
where none exist
currently.
Ensuring that each of the
instances are
interoperable with each
other.

Ultimately, the structure would

look like 15 to 20 instances
(data warehouses) across the
country, each covering a
country, each covering a
population of between 1 and 5
million. These instances
would ingress information
from a range of health-care
providers, then cleanse it, link
it and store it before offering it
to third-party applications
when required for viewing or
insight generation. Local
instances could then be
linked to one large national
platform that would be able to
connect data about individual
patients across the country,
making it a truly national
service.

National specification
standards for each instance
could ensure that each of the
instances performed the
functionality of a DHR, despite
being delivered by different
suppliers. For instance, a
common set of APIs would be
specified (the UK core
standard developed by NHS
England and owned by
HL7UK would be an obvious
place to start), meaning data
place to start), meaning data
could be held or organised
differently in each local data
store but still be served up
using a common format,
irrespective of the data store
in use. This would have to be
financed, of course.
Interoperability standards take
time, effort and money to
apply and have been
historically underfunded in
procurement contracts;
suppliers have even been put
out of business when these
stipulations have been
retrospectively applied. These
standards would also need to
be UK specific, as off-the-
shelf US interoperability
standards are not directly

applicable to UK systems.

The advantage of this solution

is that it builds on existing
infrastructure, with existing
information-governance
solutions, existing
relationships with clinicians
and system leaders, and
existing connections to
existing connections to
providers of care (such as
hospital EHRs).

That said, the coordinated

effort required to mobilise a
national project with multiple
suppliers, all integrating with
multiple providers, could
prove challenging to progress
at pace within one term of
government. Differing
approaches to data
architecture across regions
could also create
inconsistencies that make
national initiatives (such as
public health or Office for Life
Sciences strategy pieces)
much harder to deliver –

unless APIs are standardised.

It also means that data
control remains at a regional
level, potentially hindering
national initiatives.

Recommendation: The
DHSC should start a rapid
design-and-build phase of
the DHR based on an
 the DHR based on an
evaluation of the options
outlined above: build from
scratch; build out from
existing secondary-care
infrastructure; build out from
existing primary-care
infrastructure; or scale an
existing digital health record.

CHAPTER
4
TONY BLAIR
WHAT WHO
INSTITUTE
WE INSIGHTS WE
FOR GLOBAL
DO ARE
CHANGE

A DHR could transform the

way we generate health and
consume health care in the AI
consume health care in the AI
era, delivering all three of the
big shifts identified by the
health secretary in July 2024.
But while a DHR is necessary,
it is not sufficient. A proactive,
digital-first, tech-enabled and
community-based health
service will require parallel
efforts to support the
ambitions of the DHR and
help it achieve its potential.

Shift One: INFORMATION AND SE

From
Treatment to
Prevention
A DHR really could allow for a

pivot to a more proactive,

prevention-focused service.
This is because one of the
unique features of AI is its
ability to help with the
understanding of risk.
Understanding risk means
being able to predict events –
and predicting events means
and predicting events means
being able to prevent them.
When applied to the personal
health information in a DHR, AI
could generate a detailed and
personal understanding of
health risk for each citizen –
and even a mitigation plan.

For instance, AI in conjunction

with a DHR could identify
people at increased risk of
cancer and suggest earlier or
more frequent screening
programmes. It could detect
trends in blood tests that
suggest control of their long-
term condition is deteriorating
and prompt a change in
management. It could detect
risk factors for frailty that
prompt a review, avoiding a

fall and subsequent hospital

admission. It could also
identify people who are
eligible for new prevention
drugs and prompt a
consultation.

Identifying those at risk and

Identifying those at risk and
intervening early could be a
game-changer for patients
and the NHS – but as well as
analytics, primary care will
need more capacity and
funding. While a
comprehensive approach to
prevention is described in our
paper Fit for the Future: How a
Healthy Population Will Unlock
a Stronger Britain, here we
describe the policy
considerations that would
make a DHR successful in
supporting that mission.

Invest in an AI-
Powered Health-
Analytics Platform

The NHS should invest in the

development of a national AI-

powered health-analytics
platform to drive clinical
decision-making for patients
and clinicians in the UK. It
should be trained on the
anonymised contents of the
DHR, as well as peer-
reviewed journals and clinical
reviewed journals and clinical
insight from practitioners. It
should be a self-learning
system that regularly updates
its algorithms based on real-
world evidence and should
have strong governance with
representation from
government, academia, the
health profession and citizens
to protect against bias,
hallucinations, privacy and
cybersecurity issues.

Over time the platform would

become a personal digital
health assistant or “AI doctor”,
interacting with citizens
through an LLM. Citizens
could then consult this AI
doctor to help maintain their
health (through personalised
prevention plans and bespoke

health coaching), for advice

when they are unwell (through
personalised symptom
checks, self-care, triage and
navigation advice) and to help
them manage LTCs.
The AI doctor could also be
deployed to support
clinicians. It could be
incorporated in the triage and
navigation functions of 111, as
well as in GP management
systems. The latter would
drive clinical decision-making
and population health
management, and in the
future could support more
accurate and personalised
decision-making about
treatment.

The group responsible for

establishing this analytics
platform should be cross-
governmental and include
NHS England, the DHSC,
Genomics England and the
Royal College of General
Practitioners. Together with

industry experts, this group

could develop the platform
and then think about
exporting the tool for use by
health systems globally.

Recommendation: The
Recommendation: The
government should commit
to establishing a national AI-
powered health-analytics
platform.

Rapidly Expand
Capacity for
Prevention Activities
in Primary Care

Primary care will also need to

address its capacity issues if it
is to act on risk and deliver
targeted prevention. The
“8am rush” and weeks-long
delays for a GP appointment
are familiar to many, making it
difficult to add to the
responsibilities of general
practice. There are 4 million
people in the UK eligible for
treatment with a GLP-1

analogue for obesity, for

instance, but only 35,000
weight-management spaces.
[35] It is simply not feasible to

expect this drug to be rolled

out routinely for weight
management in general
management in general
practice.

In 2023, TBI proposed a new

prevention service in the
paper Moving From Cure to
Prevention Could Save the
NHS Billions: A Plan to Protect
Britain. Instead of relying on
existing general-practice
infrastructure, this service
would make greater use of
the skills and capacity that sit
in community pharmacy,
meeting people where they
are: online, at home and in the
high street.

A more detailed description of

the service is set out in The
Economic Case for Protect
Britain, a Preventative Health
Care Delivery Programme.
Crucially, this kind of service is

only possible with a DHR,

which would integrate
personal health information
across both services and
ensure a safe and
coordinated approach to
prevention.

Recommendation: Launch
Protect Britain, a preventative
vaccine and therapeutics
programme reporting into the
health secretary.

Prioritise
Prevention Spending

At our 2024 Future of Britain

Conference we presented
findings from our paper,
Prosperity Through Health:
The Macroeconomic Case for
Investing in Preventative
Health Care in the UK. This
research, conducted by
economist Andrew Scott from
the London Business School,
shows the direct link between
prevention and economic

growth, quantifies the size of

the impact and shows that it
is not necessary to wait a
generation to see the
benefits. It estimates that a 20
per cent reduction in the
incidence of six major LTCs
would increase GDP by 0.74
per cent within five years and
0.98 per cent within ten,
thanks to people living longer,
healthier and more productive
working lives.

There is a clear case,

benefiting both the economy
and public health, for
investing in prevention – but
prevention budgets are too
often cut. The public-health
spending grant, for example,
has been cut by 26 per cent
per person in real terms since
2015–16.[36] We propose a
new function carried out
jointly between the DHSC and
the Treasury, looking at the
impact of targeted prevention
spending on national income
before determining spending

budgets for the NHS.

Recommendation: The
DHSC should have access to
anonymised insights from the
DHR through an insurer portal,
DHR through an insurer portal,
to understand the risk profile
of the population. This will
help it to inform the allocation
of spending across
demographic groups and
time horizons.

Recommendation: The
government should establish
a national health accounting
mechanism between the
DHSC and the Treasury to
determine prevention
spending. Health should be
tracked as a national asset.

Shift 2: From
Hospital to
the
Community
A DHR will be critical to
delivering the shift away from
hospital-focused medicine to
community-based care. That
vision was set out in the Fuller
Stocktake report[37] and
makes the case for a more
tailored primary-care offer
depending on each person’s
risk and need. There are
different ways of segmenting
and stratifying populations,
but for illustrative purposes,
we can think of four broad
groups, listed below. A DHR
would help achieve a more
effective, convenient and
valuable model of care for
each.

Patients with
Complex Medical
and Social-Care
Needs

This group represents about 5

per cent of the population but
is thought to account for
about 50 per cent of NHS
expenditure.[38] A common
reason for the high
expenditure is that this group
relies on a wide range of
health and social-care
services – such as GPs,
secondary-care specialists,
secondary-care specialists,
social workers, mental-health
practitioners and district
nurses – to coordinate their
care. When this care fails it
leads to poorly managed
conditions and frequent
admissions to hospital (frailty
is a common example).

The value of a DHR in this

instance is twofold. First, it
provides a single version of
the truth for caregivers,
facilitating team-based care
even when team members
are not co-sited with each
other and delivering on the
vision of neighbourhood
teams, as set out in Fuller’s
vision. Second, analytics
applied to DHR data can track
risk over time, picking up on

early signs of deterioration so

that interventions are timely
and preventative.

Patients With Long-

Term Conditions
This group of patients may
have one or two LTCs that
they could take far greater
control of with the right
support, using digital
therapeutics, peer support
and regular remote advice
from specialists. One benefit
of a DHR for this group would
be the ability to navigate
entirely new digital pathways
of care online and to self-care
more effectively. In South
Korea, for example, Kakao
Healthcare has partnered with
Novo Nordisk to provide
diabetes care using a digital
diabetes-management
service,[39] and care pathways
are continuously updated in
line with best practice. In the
UK, Frimley Health and Care
ICS has used data to identify

and enrol more than 10,000

high-risk patients onto a
remote-monitoring
programme. Early-outcome
data has shown a 38.6 per
cent reduction in A&E
attendances, 53.7 per cent
attendances, 53.7 per cent
reduction in admissions and
26.7 per cent reduction in
outpatient appointments for
those on the programme.

The DHR could transform the

outpatient model. Rather than
patients attending in person,
continuous monitoring of
physiology (through the
integration of tools such as
blood-glucose monitors, as
well as self-reporting) could
enable GP teams and
specialists to access real-time
patient records, monitor risk
and only see patients when
clinically necessary.
Meanwhile, greater “patient
activation” (the ability to
better manage one’s own
care) could benefit the
system as well as patients:

those with the lowest level of

activation cost an average of
8 per cent to 21 per cent more
than those with the highest.
[40]
Patients Requiring
Temporal
Continuity

Even citizens who are

generally well go through
times when continuity is
preferable: pregnancy,
situations that require
palliative care or
investigations of unexplained
symptoms are examples. In
those circumstances, a DHR
would allow patients to
choose from a greater range
of services – even private-
sector services if they
preferred – while preserving a
digital continuity with their GP
and the NHS.

This could be important if, for

instance, a patient contracted
a private provider for palliative

care services but then

required urgent advice and
treatment from 111 or 999
overnight. Those NHS
professionals would have
access to a full, up-to-date
access to a full, up-to-date
record of that patient’s
condition and medications.
Use of private services in this
way could even be achieved
at no cost to the patient, if
those providers were
recognised by the NHS and a
tariff agreed. Combined with
nationally agreed and
transparent care pathways,
the DHR would allow patients
to propel themselves through
the referral, investigation and
consultation process without
constant back and forth with
their GP.

Patients Who Are

Generally Well but
Have an Acute
Same-Day Care
Need

A DHR coupled with AI would

mean patients could be more
effectively navigated to the
right service first time. This
would reduce the
inefficiencies inherent in
inefficiencies inherent in
patients attending a high-
resource setting
unnecessarily, or bouncing
between low-resource
settings that don’t meet their
needs. A DHR could also
transform the experience of
triage and navigation for
patients, facilitating a truly
omni-channel communication
that would see patients move
seamlessly between online,
in-person, text, email and
phone contact, all without
losing the thread of a
conversation or repeating
information. It can also
broaden the range of
providers that patients can
access when they are unwell,
as their medical history
comes with them.

It is clear from these four

examples that more tailored
primary-care services are
possible with a DHR, but more
tailored primary care also
requires diversity in the
primary-care offer – and this
requires scale. Below we
suggest measures that could
help achieve that diversity.

Commission
Primary Care at
Greater Scale

Primary care has been

moving steadily towards a
more diverse and tailored
offer for some time. The
traditional model of ten
minutes with a doctor to
discuss one problem by the
time you’re already sick
persists in some places, but
increasingly practices are
adopting a PHM approach.
This means applying
advanced analytics to locally
integrated datasets to risk
stratify and segment their

populations; it also means

they can design care around
cohorts of patients with
similar needs.

Commissioning primary care

Commissioning primary care
at greater scale would propel
this trend. Currently, primary-
care networks look after
populations of between
30,000 and 50,000, but some
federations look after far
greater numbers of patients
and can offer more tailored
services, with integrated
outpatient, diagnostic and
access hubs built in.

It is outside the scope of this

paper to advise on the
specifics of primary-care
delivery – the primary-care
organisations themselves are
in a far better position to
design what works for their
populations – but a value-
based contracting
mechanism could help. We
recommend that NHS
England considers a new

contracting mechanism for

primary care that is
outcomes-based,
commissions for scale
(populations of 250,000
patients) and has a gain-
patients) and has a gain-
share component. This would
see groups of practices
benefiting financially from
better outcomes and lower
rates of hospital admissions; it
would also facilitate the
movement of funds from
secondary to primary care
over time.

The new contract would not

be mandatory and could run
in parallel with the standard
General Medical Services
contract.[41] However,
practices could be
incentivised to take these
contracts if they offered other
benefits such as longer terms
(three years, for example),
lump-sum payments (for the
likes of digital and physical
infrastructure development)
or free services (such as

practice-management
software or other back-office
functions). These should be
offered on condition of
meeting outcomes-based
targets. In time the primary-
targets. In time the primary-
care landscape would change
to one with far fewer groups
of primary-care practices –
and meaningful choice for
patients over which group
they register with.

In developing this new

contract, however, we
recommend that NHS
England avoids
commissioning based on
geographical area, and
instead focuses on combined
list size. The reason for this is
that commissioning based on
geographical area precludes
patients from having
meaningful choice over their
primary-care supplier, and it
limits the ability of NHS
England to enforce
meaningful sanctions on

practices that don’t meet their

targets. NHS England could
even end up financially liable
for groups of practices that
go into deficit if there are no
alternative providers in the
locality.

Recommendation: NHS
England should consider
developing a new primary-
care contract for groups of
practices with a combined list
size of around 250,000.

Develop an Effective
Provider Portal in
Primary Care

The provider portal, through

which primary-care teams
can view and edit the DHR,
will be critical to delivering
primary care at scale. It can
also be used to apply a range
of analytics and algorithms in
order to conduct functions
such as the auditing of clinical
management against best

practice, the performance

management of clinicians
based on patient outcomes
and the execution of value-
based contracts.
At present the NHS has very
little control over the patient
portals used in primary care,
as each GP practice
commissions its own
practice-management
system independently. This
has created issues in the past
because the tech stack has
not been readily adapted by
the two dominant vendors in
the market: EMIS and
SystmOne. GPs lack the
contractual levers to demand
change, so added
functionality frequently relies
on workaround apps. This
means that user experience is
rarely prioritised and has led
to a proliferation of add-on
technologies, all with separate
interfaces that rarely integrate
with each other.

To gain greater control of the

provider portal, the DHSC
could consider two options in
building the DHR: procure an
entirely new practice-
management system for
general practice or work with
an existing one to build out
the tech stack.

Recommendation: To drive
the successful
implementation of the DHR in
primary care, NHS England
should either procure a new
practice-management
system for general practice,
acquire the UK licence for one
of the major practice-
management systems
already in existence or
support the rollout of existing
workaround solutions for a
functioning clinician portal.
NHS England could then work
with that practice-
management system to build
out the tech stack necessary
for modern general practice.

Publish Care
Pathways and
Broaden the Range
of First-Contact
Providers
In order to diversify the
primary-care offer for
patients, NHS England should
draft national pathways for
common conditions and
make these transparent to
patients through the NHS
App. This would allow a
patient, empowered by their
DHR, to progress along a care
pathway with a meaningful
choice of providers for
different steps on their
journey. For example, if a
patient needed a blood test
they could choose to have
that done in a pharmacy, at
hospital, at a GP surgery or at
home (with equipment
delivered through the post),
depending on waiting times,
preference and convenience;
the same would be true for
other primary-care services

such as imaging and LTC

management. Innovative ICSs
could even make local
adjustments to these care
pathways, to drive innovation
locally and online.
locally and online.

To progress along a care

pathway, moving seamlessly
between NHS and non-NHS
care providers, agreed
national tariff arrangements
would be required to ensure
that patients could rely on the
NHS to cover the cost.

Recommendation: Through
the NHS App, NHS England
should make transparent care
pathways for common
conditions.

Recommendation: NHS
England should agree national
tariff arrangements with non-
NHS providers of health and
care services, which patients
could access with their DHR.
For patients with longer-term

care needs, a DHR supports

the stratification and
segmentation of patients into
cohorts with similar needs.

Integrate the DHR

Integrate the DHR
and AI into the
Triage and
Navigation Process

Patients with an acute care

need that they are unable to
manage themselves may
need support in navigating
what is a confusing health-
care landscape. It may not be
immediately obvious to that
patient whether a GP,
pharmacy, urgent-care centre,
minor-injury unit, A&E
department, emergency
advice line or walk-in centre is
the right place to attend with
their problem.

It is easy to see why many

default to the highest
resource setting where the
barriers to entry are low (no
booking required) and all
potential diagnostics and
specialist advice are on site if
required. Existing triage and
navigation services in GP
reception and 111 do their
best, but without access to
best, but without access to
prior risk stratification and
clinical-decision support, the
impact is limited.

In other parts of the world,

CSC apps can offer
asynchronous advice,
sometimes over WhatsApp.
But if they reach the end of
their competence, or need a
human-in-the-loop to take
accountability for the advice,
the apps are able to facilitate
direct access to the most
appropriate doctor –
complete with a summary
and proposed care plan. Abi
Global Health provides just
such a service for patients
across the world, with health
insurers AXA, Zurich and
Allianz.[42]

Access to a citizen’s DHR, no

matter where they are or who
they are seeing, could vastly
improve the safety and
effectiveness of first-contact
care. In Estonia, the e-Health
record is a nationwide system
record is a nationwide system
that integrates data from the
country’s health-care
providers to create a common
record that patients can
access, functioning like the
proposed PHA. All patients
have this record and it
provides access to all
licensed medical practitioners
in Estonia.[43]

Recommendation: NHS
England should work to
integrate the DHR and the
national AI-powered health
platform into NHS 111 services.
This should then be used with
an LLM as a CSC, to power
triage and navigation within
the NHS 111 service.

Shift 3: From
Analogue to
Digital
A DHR will be critical to
helping patients navigate new
helping patients navigate new
digital pathways of care. This
will not just be through new
patient-facing apps but also
the ability to access a whole
world of online services: a
digital health service. At
present there is limited
regulation and understanding
of how to use these
applications and services, so
we suggest the following.

Build Out the NHS

App as a Patient
Portal

With 33.1 million logins in June

2024 and an active user base
of about 10 million, the NHS
App is well known and well
trusted. It already has good
functionality as a “digital front
door”, used most frequently

by users to view their health

records (20.5 million views in
June 2024), request repeat
prescriptions (3.3 million
requests in June 2024) and
book GP appointments,[44]
book GP appointments,[44]
with new functionality added
regularly. Patients are
increasingly able to track
secondary-care referrals, see
waiting times, check quality
ratings and book their first
appointment in secondary
care.

In terms of the data that

citizens can access and view,
most (85 per cent) have
access to their primary-care
data, while some have access
to screening, vaccination and
test results; soon they will be
able to upload wearables data
and access secondary-care
data. At present, however,
there are no plans to put the
information in longitudinal
form.

NHS England has great

ambitions for the app.

However, the budget for its
development is often
compromised due to
competing operational
competing operational
demands in the health
service.

Recommendation: NHS
England should increase and
ringfence spending on
development of the NHS App,
dedicating funds from the
productivity plan announced
in the Spring Budget to fund
it.

Create a Digital
Care Hub Within
the NHS App

The public already has access

to a limited number of NHS-
approved apps. However, the
desire of citizens to have
complete control over how
they view, share and process
personal health information
will become more urgent as

they gain access to high-

grade consumer-facing AI
through their smartphones.

The passing of interoperability

The passing of interoperability
legislation (as suggested
earlier in this paper) would
enable citizens to share data
contained in their DHR with
third-party apps to gain
personal actionable insights –
but not all apps accessed
through the App Store (or
equivalent) will be regulated.

Access to safe, regulated and

NHS-approved apps should
be provided in a Digital Care
Hub within the NHS App itself.
With consent from the
individual, these apps could
access relevant information
from the DHR (such as blood-
sugar readings) to help
support citizens in managing
their data. The apps would be
able to provide some clinical
advice but could also support
behavioural change, as well
as providing access to peer

support and specialist advice.

For this reason, the NHS App

must have the capacity for
must have the capacity for
patients to upload information
into the DHR themselves –
things like blood-pressure
readings, photographs and
voice recordings – and, if they
wish, download information to
use in another app. The third-
party app then needs the
ability to ingress data back
into the patient’s DHR.

Applications should be
procured centrally by NHS
England and made available
to citizens through the NHS
App; they could be branded
or white-labelled applications.
The information conveyed
back to the patient should be
their responsibility to act
upon, but should also be
ingressed into the DHR and
shared with their primary-care
provider.

Lessons should be learnt from

the NHS Apps Library, which
was discontinued after many
of the apps were found not to
meet appropriate levels of
meet appropriate levels of
clinical quality and data
privacy, and often exceeded
cost.[45] NHS England should
work with the Medicines and
Healthcare products
Regulatory Agency (MHRA)
and National Institute for
Health and Care Excellence
(NICE) to help curate this
range of apps, ensuring that
they are both safe and cost
effective. The regulation of
these apps should be
expedited, not just in terms of
safety and effectiveness but
also in terms of cybersecurity,
as this can delay their
implementation.

There should also be advance

agreement about which
organisation funds the apps:
NHS England or each local
ICS. Given its national role, we
suggest that NHS England is

best placed to fund them.

Recommendation: The NHS

App should develop a Digital
 Care Hub with the capacity to
draw on relevant personal
health data within the DHR
(where a citizen has explicitly
consented to the process).

Recommendation: NHS
England should work with
MHRA and NICE to curate a
range of safe, cost-effective
digital therapeutic apps for a
marketplace. NHS England
should procure these apps on
behalf of all citizens and install
them in the NHS App as
white-labelled applications.

CHAPTER
5

The UK faces a choice:

prepare the NHS for the AI era
or prepare to lose the NHS.

AI can help drive the step-

change in productivity that
the NHS needs, and help it
the NHS needs, and help it
pivot from a reactive sickness
service to a proactive health
service. But this is only
possible if the UK government
recognises the fundamentally
different era that the NHS
needs to survive in for the
next century – and if the NHS
continues to meet people’s
expectations when it matters
most.

A digital health record, put

into the hands of patients as
well as health professionals, is
the obvious solution. Other
countries are investing on
behalf of their citizens; the UK
should do the same. It will
require investment and must
be done in lockstep with
citizens to gain their trust,
preserving privacy, security
and patient choice at all
times. But it is eminently

achievable within one term of

government – and should be
considered an urgent priority.
CHAPTER
6

We would like to extend our

thanks to the experts who
offered their advice and
guidance in the development
of this report.

Mohammad Al-Ubaydli,
Patients Know Best
Rifat Atun, Harvard AI
Health Policy Lab
Patrik Bächtiger, Imperial
College London
Junaid Bajwa, Flagship
Pioneering (formerly at
Microsoft)
Raj Behal, One Medical
Adam Cohen, Johns

Hopkins University
Omar Daniel, Harbr
Penny Dash, NW London
ICS
Anna Dijkstra, IBM
Konrad Dobschuetz, NHS
Clinical Entrepreneur
Programme
Marc Donovan, Boots
Stephen Dorrell, Evergreen
Life
Lisa Drake, Redmoor
Heath
Nigel Edwards, NHS
Confederation
Murray Ellender, eConsult
Kim-Fredrik Schneider, Abi
Global Health
Dame Clare Gerada,
Hurley Group
Saira Ghafur, Institute of
Global Health Innovation,
Imperial College London
Declan Hadley, Cisco
John D Halamka, Mayo
Clinic Platform
Nick Harding, Operose
Health
Joe Harrison, NHS England
Jonty Heaversedge,

National Healthcare
Group, Singapore
Helen Holmes-Fogg,
Redmoor Heath
Vanessa Huang, BVCF
Management
Andrew Jones, Amazon
Indra Joshi, One
HealthTech
Mihir Kelshiker, National
Heart and Lung Institute,
Imperial College London
Stefan Kulik, Royal Mail
Melanie Leis, Institute of
Global Health Innovation
Meredith Leston, Alan
Turing Institute; University
of Oxford
Arvind Madan, eConsult
Meredith Makeham,
University of Sydney
Kenneth Mandl, Harvard
T.H. Chan School of Public
Health
Ben McAlister, Oracle
Gary McAllister, NHS
London; One London
Ursula Montgomery, Bayer
Tom Oakley, Feedback
Medical

Lord James
O'Shaughnessy, Health
Data Research UK
Niti Pall, Health 4 All
Advisory; AXA
Trishan Panch, Harvard
T.H. Chan School of Public
Health; Wellframe
Vish Ratnasuriya, Our
Health Partnership
Juliette Roche, Boots
Kristin-Anne Rutter,
Cambridge University
Health Partners
Samrend Saboor,
Siemens Healthineers
Vincent Sai, Modality
Marc Schmid, Redmoor
Health
Mark Sellman, Frimley
Health ICS; CIPHA
Neeraj Shah, Company
Chemists’ Association
Peter Skinner, NHS
England
Ian Smith, Surrey
Heartlands ICS
Harpreet Sood, Huma
David Stables, Endeavour
Health

Finn Stevenson, Flok

Health
Nick Thayer, Company
Chemists’ Association
 Katie Tryon, Vitality
Oonagh Turnbull, Tesco
Oliver Väärtnõu,
Cybernetica
Vishaal Virani, YouTube
Matthew Walker, National
Association of Primary
Care
Tom Whicher, DrDoctor

Footnote
s
1.
https://www.england.nhs.uk/publication/n
ext-steps-for-integrating-primary-care-
fuller-stocktake-report/

2.
https://www.england.nhs.uk/statistics/stati
stical-work-areas/rtt-waiting-times/

3. https://rcem.ac.uk/almost-300-
deaths-a-week-in-2023-associated-with-
long-ae-waits-despite-uec-recovery-
plan/

4.
https://www.gov.uk/government/news/ind
ependent-investigation-ordered-into-
state-of-nhs

5. https://ifs.org.uk/publications/past-
and-future-uk-health-spending

6. Ibid

7. Ibid

8. Ibid

9. https://www.nao.org.uk/wp-
content/uploads/2024/07/nhs-financial-
management-and-sustainability.pdf

10.
https://www.gov.uk/government/speeche
s/health-and-social-care-secretary-
speech-on-health-
reform#:~:text=Each%20year%2C%20the
%20burden%20of,go%20on%20treating
%20preventable%20conditions.

11. https://ifs.org.uk/news/42-million-
working-age-people-now-claiming-
health-related-benefits-could-rise-30-
end-decade

12.
https://www.ncbi.nlm.nih.gov/pmc/articles
/PMC10584355/#:~:text=GLP%2D1%20rec
eptor%20agonists%20appeared,14%25%
20when%20compared%20to%20placeb
o.

13. https://med.stanford.edu/news/all-
news/2024/03/ai-drug-
development.html#:~:text=Generative%20
AI%20develops%20potential%20new%2
0drugs%20for%20antibiotic%2Dresistant
%20bacteria,-
share&text=Stanford%20Medicine%20res
earchers%20devise%20a,the%20drugs%
20in%20the%20lab.
14. https://www.nhs-galleri.org/

15. https://healthpolicy-
watch.news/new-lab-aims-to-leverage-
digital-tools-for-health-policy-making/

16. https://e-estonia.com/story/

17. https://inews.co.uk/news/young-
people-turning-backs-nhs-private-gp-
2982185

18.
https://www.theguardian.com/society/202
4/apr/18/uk-private-health-insurance-
market-nhs-crisis-dental-cover

19.
https://www.prnewswire.com/in/news-
releases/apollo-hospitals-rolls-out-
clinical-intelligence-engine-cie-for-
doctors-across-india-301740454.html

20.
https://mmshub.cms.gov/sites/default/file
s/MMS-InfoSession-USCDI-Slides-
20231129.pdf

21.
https://www.apollohospitals.com/departm
ents/preventivehealth/prohealth-app/

22. https://apollo-aicvd-
v2.web.app/login

23. https://ictandhealth.com/news/i-
see-no-legitimate-rationale-for-delaying-
the-digital-transformation-in-healthcare/

24.
https://www.mayoclinic.org/departments-
centers/hospital-at-
home/sections/overview/ovc-20551797

25.
https://www.england.nhs.uk/publication/n
ext-steps-for-integrating-primary-care-
fuller-stocktake-report/

26.
https://www.england.nhs.uk/2023/12/millio
ns-more-people-given-access-to-their-
gp-records-online/

27. https://patientsknowbest.com/

28. https://digital.nhs.uk/services/fhir-
apis

29. https://oauth.net/2/

30.
https://transform.england.nhs.uk/key-
tools-and-info/data-saves-
lives/improving-individual-care-and-
patient-safety/patients-securely-
accessing-health-records-via-a-health-
app/#:~:text=In%20October%202020%2
C%20Milton%20Keynes,Health%20app%
20on%20their%20iPhone.

31.
https://www.england.nhs.uk/digitaltechnol
ogy/digitising-connecting-and-
transforming-health-and-
care/#:~:text=The%20NHS%20FDP%20is
%20a,instances%20of%20the%20NHS%
20FDP.

32.
https://www.england.nhs.uk/digitaltechnol
ogy/digitising-connecting-and-
transforming-health-and-
care/#:~:text=The%20NHS%20Federated
%20Data%20Platform%20%28FDP%29
%20is%20software%20that%20will,one%
20safe%20and%20secure%20environme
nt.

33.
https://kodjin.com/blog/understanding-
fhir-components-fhir-
resources/#:~:text=Resources%20are%20
the%20foundation%20of,represented%2
0in%20a%20standardized%20way.

34.
https://www.ncbi.nlm.nih.gov/pmc/articles
/PMC7762678/

35.
https://www.diabetes.org.uk/about-
us/news-and-views/wegovy-key-facts-
know-about-weight-loss-drug

36. https://www.health.org.uk/news-
and-comment/charts-and-
infographics/public-health-grant-what-it-
is-and-why-greater-investment-is-
needed

37.
https://www.england.nhs.uk/publication/n
ext-steps-for-integrating-primary-care-
fuller-stocktake-report/

38.
https://www.health.org.uk/publications/a-
descriptive-analysis-of-health-care-use-
by-high-cost-high-need-patients-in-
england

39. https://healthcare-
digital.com/digital-healthcare/kakao-
healthcare-novo-nordisks-digital-health-
partnership

40.
https://assets.kpmg.com/content/dam/kp
mg/pdf/2016/07/creating-new-value-
with-patients.pdf

41. https://www.england.nhs.uk/wp-
content/uploads/2020/12/20-21-GMS-
Contract-October-2020.pdf
 42.
https://www.abiglobalhealth.com/solution
s#services

43.
https://www.healtheuropa.com/estonian-
e-health-
system/89750/#:~:text=A%20patient%E2
%80%99s%20Electronic%20Health%20R
ecord%20is%20accessible%20to,data%2
0from%20another%20practice%20when
%20treating%20a%20patient%E2%80%
A6.

44.
https://www.digitalhealth.net/2024/03/mo
re-than-2-7m-people-use-nhs-app-
prescription-feature-in-first-2-months/

45.
https://www.pulsetoday.co.uk/news/techn
ology/mps-concerned-about-quality-
and-safety-of-health-apps-promoted-by-
nhs/

ARTICLE TAGS

ARTIFICIAL INTELLIGENCE DIGITAL TRANSFORMATION TECH

FUTURE OF BRITAIN - HEALTH HEALTH PUBLIC SERVICES

 NEWSLETTER

ical Ideas Pract

Radical Ideas
SIGN UP
Intelligence in your inbox. What Insig Who
Get the latest big ideas in strategy, policy and we do hts we
delivery in your inbox every month with our
newsletter. are
APPROACH INSIGHTS
ABOUT
SIGN ME UP PARTNERSHIPS US

FUTURE LEADERSHIP
OF
BRITAIN CAREERS

Tony Blair Institute, trading as Tony Blair Institute for COOKIES TERMS OF USE
Global Change, is a company limited by guarantee
registered in England and Wales (registered company
number: 10505963) whose registered office is One
Bartholomew Close, London, EC1A 7BL. PRIVACY POLICY ACCESSIBILITY

FINANCIAL STATEMENTS MEDIA CENTRE

CONTACT US