A seamless, smarter and sustainable NHS

Dr Arvind Madan 
GP Partner, Hurley Group

Imagine a world where healthcare is not rationed by our capacity to deliver it. One where any patient query can be addressed, day or night, with such adeptness that our barriers to entry can be removed or at least lowered. Many would argue that at least a third of NHS interactions today, whether in general practice, outpatients or urgent care, were of limited value or wholly avoidable. So perhaps unlimited healthcare, in some form, is not so unimaginable if we used existing resources more wisely.

If we do it right, the NHS of 2035 will be a profoundly transformed service, built upon empowered patients, AI-enabled delivery and sustainable funding that drives a return for UK Plc. It will be designed to seamlessly integrate services across primary, community and secondary care, ensuring the right care, first time, every time. This vision outlines the key pillars underpinning a vision for the NHS in 2035.

Enhancing triage and patient flow: intelligent navigation as the default

An NHS littered with low-value interactions costs our citizens millions of avoidable journeys and billions of NHS pounds. Continuing to let patients simply guess what service they need without sufficient guidance or steer is both unsafe and unsustainable in a tight financial climate.

The single most impactful and easily implemented change we can make to patient flow is to institute a system-wide triage-led model of ‘care traffic control.’ Integrated triage systems that guide patients to the right care between connected, seamless interfaces between primary, urgent and specialist care is overdue. This will short-circuit unnecessary touchpoints in the patient journey, underpinned by advanced AI-supported triage platforms. These systems will:

• Guide patients seamlessly between self-care, primary care, diagnostics, specialist care and A&E, using channel shift between online, phone and in-person interactions, as needed.
• Use natural language processing, biometric data capture, and the patient history to auto-route cases with increasing accuracy. 
  Detect and escalate red-flag symptoms, including those submitted via online interactions, wearables and home devices during out-of-hours periods. 
• Directly connect patients with self-booking options as appropriate, reducing administrative bottlenecks and service workload.
• Create fluidity of case transfer with channel shift across settings and clinician types, based on each patient’s ability to engage, and their clinical need. Moving data around the system, not just people. 

Beyond navigation within the primary care team, AI navigation should be extended into secondary care teams so that appropriate cases can be routed straight to diagnostics or specialist care without delay, such as breast clinics. The wiring of AI navigation tools locally should support horizontal and vertical signposting through digital integration. Additionally, richer data collection drives AI enhancements to the triage process and promotes a higher remote case closure yield by clinicians, thereby driving up their productivity. The principle should be to take a comprehensive history once and use it to get the right service first time. As triage systems mature, they will become more nuanced, for example detecting which patients would benefit from continuity with a particular clinician, rather than simply offering the first available appointment. 

Currently only around 10 per cent of patient demand is coming in using online consultations. Yet we know that the more we can drive inbound demand online, the greater our opportunities to route that demand correctly and close each case with the lowest effort. Therefore, we should double down on supporting practices to adopt a total triage model of phone calls and online consults. Eventually this could include data capture from automated phone systems, which will further drive work to the right place.

Practices have historically constrained online access through capping numbers and switching off their online consultation platforms during core hours. Their contracts are top sliced to pay for access to out-of-hours services, so they understandably choose not to absorb this additional demand. Yet up to 40 per cent of patients attending A&E could have been dealt with through self-management or in primary care. While steps to cover elements of demand during core hours are being addressed in the new contract, there is a strong case for GPs being resourced to keep their online access available 24/7 to repatriate primary care suitable A&E attendances back to primary care. This will require online platforms to be able to detect serious symptoms out of hours and escalate these cases to urgent care as appropriate.

By 2035, we should target over 80 per cent of patient demand entering the NHS digitally, either through the NHS App or semi-automated phone systems, creating rich datasets that feed real-time service planning. Data from these platforms will not only power AI improvements but also drive increased rates of remote case closure, thereby freeing up clinical capacity for the minority unable to transact online. This would be a step on the road to unrationed healthcare.

Empowering patients to self-manage long-term conditions

The NHS of the future will embrace its role in enabling patient autonomy. With over 40 per cent of adults in England living with at least one long-term condition (LTC), we need to activate the digitally literate population to self-manage a greater proportion of their needs. Remote patient monitoring (RPM), through symptom and biometric tracking apps, can support this self-management and early intervention. This could be complemented with data from wearables and devices, with all this data feeding into a monitoring dashboard shared between primary and secondary care teams.

Proactive management of these LTC cohorts of patients could be delivered within the emerging service configurations, such as place or neighbourhood. These capabilities could form part of each practice’s online consultation platform, so hub-based multidisciplinary teams are managing both inbound requests for episodic issues and supporting patients proactively with their chronic conditions. From a service configuration perspective, we could combine hubs with virtual ward teams to provide 24/7 step-up and step-down wrap around care. 

Ideally, LTC RPM should be incorporated into the NHS App. From the patient’s perspective, their personalised version of the NHS App should not just allow them to send an online consultation request but also share the care of their LTC with their clinical teams using the clinician-facing dashboard. Supporting patients to self-manage while giving them the confidence of knowing their clinical team is tracking their status represents a step-change in the NHS offer to the patients. 

Through these capabilities, patients will transition from passive recipients of episodic care to active partners in the management of their health. Earlier intervention will also enhance patient empowerment, improve health outcomes, reduce A&E attendances, avoid unnecessary hospital admissions and reduce avoidable activity for the NHS.

Instead of today, where we pay for the consequences of poorly managed LTCs in more expensive hospital settings, we will offer patients the ability to have their condition continually monitored by their own clinicians, in a way that makes it easy for the clinicians to do so.

Increasing workforce productivity through technology and automation

By 2035, NHS clinicians will be supported by an AI-enabled digital co-worker. The system will no longer depend solely on increasing headcount to meet growing demand. Instead, investment in automation and intelligent tools will revolutionise primary and secondary care productivity.

Benefits of automation in general practice include all administrative tasks, such as repeat prescriptions, document coding, referral generation and results management - activities that collectively cost practices thousands of hours a year. The centre should invest in the widespread adoption of approved models using intelligent robotic process automation.

AI-driven clinical support tools using large language models will assist with case summarisation, triage and clinical decision support using the electronic health record (EHR) and national guidance. It will also generate responses to patient queries for clinicians to validate and send back. Ambient voice technology to generate medical notes and send patients a note of the consultation and self-help resources will be the norm. Some practices are already trialling AI-created avatars of their clinicians in multilingual videos encouraging patients to take up preventative services, such as immunisations.

One could argue that, as businesses, practices should be investing in many of these tools which exist now for themselves, and some are starting. However, the pace of adoption is slow, and the cost of primary care inefficiency is borne manyfold over by the wider system, so a centrally supported scale up is necessary.

Financial alignment and incentives for sustainability

GPs know how much they are funded to run their practices but have very limited understanding of what their practice costs their health system in investigations, prescriptions, referrals, A&E attendances and admissions. Commissioners have historically failed to share, incentivise or resource GPs to reduce their avoidable costs to secondary care. Clearly this broad concept needs a revised payment mechanism to gradually accelerate the left shift in resources to develop a richer range of services in the community over time, but differential investment into primary care is required to underpin the system change.

A key enabler of a future NHS is a redesigned funding model. By 2035, financial incentives must be closely aligned with system-wide outcomes. A new gain-sharing model will be necessary to incentivise primary care providers to continually expand their services from resources they release from avoidable secondary care activity.

In addition, to ensure equitable access to healthcare we should reintroduce the Deprivation Allowance (or similar equity-based model) to support practices in high-need areas. They suffer the challenges of looking after more deprived populations, struggling to hit targets, and having fewer clinicians per capita. This is asking highly mobile GPs to do a harder job with more challenged communities for less remuneration. Gaps are beginning to show.

Advancing population health management and data utilisation

The NHS of 2035 will be a data-first system, built on a foundation of advanced population health management. Predictive analytics will guide resource allocation, service design and preventative outreach programmes. 

Harnessing data-driven insights can improve resource allocation and enhance health outcomes. Community-based disease management initiatives should be expanded to integrate specialist input alongside primary care teams, reducing reliance on hospitals. 

Too many patients are denied preventative care as, due to the volume of work, their diagnosis is often not coded, so they are not included on the disease register and never receive treatment. Using AI, we can now find these codes buried in the unstructured information in the primary care EHR, identify these patients and increase the uptake of preventative management. We should drive up prevalence detection as delays cause patient harm and ultimately cost the NHS more.

The system is fearful of data-sharing and working with the academia and life sciences sectors on research. Data-sharing projects, underpinned by trusted governance frameworks, should be promoted to build public trust and clinician confidence, acting as exemplars to encourage greater cooperation across the system.

Moreover, predictive analytics for resource planning should be implemented, allowing for better anticipation of healthcare demands and preventing system bottlenecks. These strategies ensure a more efficient, data-driven approach to healthcare planning and delivery.

Primary care infrastructure fit for the future

Half of all GP practice premises are unfit for purpose. Long-term NHS transformation requires investment in modern community facilities and upgrading primary care premises.

Adopting innovative funding models such as inflation-linked leases used in Ireland’s HSE system, with integrated care boards as leaseholders, to attract private sector investment and doing away with the archaic bottleneck of District Valuer assessments could unlock our ability to fund significant numbers of state-of-the-art primary care/out-of-hospital facilities.

By co-locating health and wellness services, integrating primary care services, diagnostics, mental health services, and social care under one roof – supporting prevention, early intervention and team-based care, these premises will become the heart of the neighbourhood ecosystem. They will be the community assets through which we bring to life the health benefits of horizontal and vertical integration for a population and economic benefits for the NHS.

Conclusion

By 2035, the NHS should no longer be defined by queues, delays and inefficiencies. Instead, it will be defined by agility, intelligence and personalised care. By implementing these concrete, focused actions we can create a more efficient, patient-centred NHS without exceeding existing budgetary constraints. This transformation requires vision, investment and bold leadership. But the prize is worth it: a healthcare system that is accessible, equitable and sustainable – for patients and staff alike.