Week 7 of 10
The digital neighbourhood
Digital is the shift with the best record of delivery and the worst record of inclusion, and a neighbourhood service inherits both.
A promise with dates on it, and a record of slippage
Equity and excellence, the health white paper of 2010, promised "an information revolution" and made shared decision making the norm in the phrase "no decision about me without me" (Equity and excellence, 2010). The information revolution was "also about new ways of delivering care" and about "enabling patients to communicate with their clinicians about their health status on-line", and its stated purpose was "to correct the imbalance in who knows what".
Four years later Personalised health and care 2020 turned the ambition into deadlines. It foresaw "an end to paper records in all NHS-funded care contexts within six years", and then set the commitment out as a numbered proposal: "All patient and care records will be digital, real-time and interoperable by 2020. By 2018 clinicians in primary, urgent and emergency care and other key transitions of care contexts will be operating without needing to use paper records" (Personalised health and care 2020, 2014).
The same document recorded its own starting point. In 2014, 59 per cent of citizens in the UK had a smartphone and 84 per cent of adults used the internet, yet "only 2% of the population report any digitally enabled transaction with the NHS". For clinicians, it said, "the arrival of the digital age has often been experienced not as a force for good but rather as an intrusive additional burden" (Personalised health and care 2020, 2014).
The NHS Long Term Plan restated the destination in 2019: "Digitally-enabled primary and outpatient care will go mainstream across the NHS", and within five years "every patient in England will have a new right to choose" a digital-first consultation, across roughly 307 million GP consultations a year (The NHS Long Term Plan, 2019). The 10 Year Health Plan of 2025 names the sharpest date yet. By 2028 the NHS App is to be "a full front door to the entire NHS", and the new single patient record is to be viewable by patients on the app from 2028, subject to legislation (10 Year Health Plan, 2025).
What has arrived is real: general practice could not now run on paper. What has not arrived is the inclusion, and the tell is that the same commitment has had to be made three times in fifteen years. A neighbourhood service inherits both halves.
What a neighbourhood team needs, and what the trials show
Strip away the platform language and a team needs four digital components: a shared care record that the whole team can read and write to, remote monitoring for people with long-term conditions, an online route into the practice that does not remove the other routes, and digital referral between the team and the hospital. The framework supplies the first by instruction. ICBs and providers are to "standardise the expectations of data sharing between neighbourhood health services and hospitals", including social care, so that neighbourhoods can put in place more effective proactive care (Neighbourhood Health Framework, 2026). The community nursing record is the test case: written in a patient's home, often by a lone clinician, and the part of the record most likely to be incomplete when the next service opens the file.
The evidence for remote monitoring is the strongest in this week and the most conditional. The Whole Systems Demonstrator trial randomised 179 general practices and recruited 3,230 people with diabetes, chronic obstructive pulmonary disease or heart failure. Telehealth was associated with a lower admission proportion (odds ratio 0.82, 95 per cent confidence interval 0.70 to 0.97) and lower mortality at 12 months, 4.6 per cent against 8.3 per cent (Steventon et al., 2012, BMJ). The authors' own reading is more careful than the headline: differences in emergency admissions "were greatest at the beginning of the trial", when the control group showed "a particularly large increase", and they could not explain it.
The heart failure trials that followed did not reproduce the effect. BEAT-HF randomised 1,437 people discharged after a heart failure admission to telemonitoring plus nurse coaching or to usual care, and readmission at 180 days was 50.8 per cent in the intervention group against 49.2 per cent in usual care, an adjusted hazard ratio of 1.03 (Ong et al., 2016, JAMA Internal Medicine). The one significant difference was in quality of life. In chronic obstructive pulmonary disease, the Cochrane review of 29 studies found that COPD-related hospital readmissions "are probably reduced" at 26 weeks by remote monitoring plus usual care (hazard ratio 0.42, 95 per cent confidence interval 0.19 to 0.93), while showing little to no difference in exacerbations, quality of life, all-cause hospitalisation or death (Janjua et al., 2021, Cochrane Database of Systematic Reviews).
Read together, the trials tell a team what it is buying. Remote monitoring changes the management of a defined risk, in a patient who has already been in hospital and whose condition is known. It does not change the trajectory of a long-term condition, and the trials that improved experience rarely moved admission. A team that buys it to take pressure off the hospital rather than to manage a named cohort will record it as a failure.
The exclusion risk, quantified
Inclusion is where the delivery record breaks. The GP Patient Survey, which collects feedback from more than 700,000 people a year, shows that 41 per cent of respondents had booked a GP appointment online in the previous 12 months, but only 29 per cent of those aged 75 to 84 had done so. Among patients in the most deprived fifth of the population, 44 per cent said it was easy to contact their practice through its website, against 50 per cent in the least deprived fifth. The same analysis reports that 8.5 million adults lack the most basic digital skills and that 2.4 million households struggle to afford their mobile phone contract; 16 per cent of those who are offline find the internet too complicated and 13 per cent are concerned about data and privacy (The King's Fund, 2025).
Those numbers describe a gap. The qualitative evidence describes the mechanism. Greer and colleagues interviewed 20 mental health service users in south London who had been identified as digitally excluded, and found three things holding the exclusion in place: a perceived lack of knowledge, an inability to access the technology because of personal circumstances, and the barriers created by mental health difficulties themselves. Their conclusion is the one a service designer needs: overcoming exclusion "must address the multiple deprivations individuals may face in the offline world in addition to their individual mental health needs" (Greer et al., 2019, Journal of Medical Internet Research).
Ahmed and colleagues asked older adults of South Asian, Black African and Caribbean backgrounds about the digitalisation of primary care. Across 27 participants the pattern repeated: difficulty with online platforms largely because of language barriers and limited digital skills, reliance on younger family members or community organisations to get in, and a feeling that digital access had been "imposed without sufficient explanation or consent" (Ahmed et al., 2024, JMIR Formative Research).
Overlay the two literatures and the exclusion risk can be stated as a cohort. Take the groups a neighbourhood service is built around: people aged 75 and over, people in the most deprived fifth, people with severe mental illness, and people who do not speak English as a first language. On the survey evidence, each books, contacts and transacts online less than the population average. A service whose default channel is digital will reach that cohort last, at the point where the risk has already become an event.
The supported-digital model exists, and is not the default
The evidence on what does work is unusually clear. Poduval and colleagues studied a city-wide digital inclusion programme in the north of England that worked through voluntary sector community organisations, called Digital Health Hubs. From interviews with 30 service users and staff, the moderators of success were specific: community spaces, social activities, devices and Wi-Fi, and recipient-centred support built on community understanding, personalised regular help and trusting relationships. The outcomes users reported were improved social and emotional resilience and basic digital skills (Poduval et al., 2025, BMC Public Health).
The same literature shows that this support is not systematically provided by the health service. The Di-Facto study of digital facilitation in general practice, drawing on staff and patient surveys and ethnographic case studies in eight practices, found examples of facilitation but "often involved using passive or reactive modes of support", a "lack of clarity over where the responsibility for facilitation efforts lay", and a need for clear lines of responsibility, tools that work for patients and staff, and investment in staff time and training (Abel et al., 2024, Health and Social Care Delivery Research).
Kunonga and colleagues reviewed the reviews on digital technology and older people's access to care, and found seven eligible reviews covering 77 randomised trials and 50 observational studies, all built on low-quality primary studies. Their most useful finding for a team is an absence: no review examined technologies used for first contact access, such as online appointment booking, in older populations (Kunonga et al., 2021, Journal of Medical Internet Research). The service is being redesigned around a channel whose inclusive effect has not been measured.
Information governance across an organisational boundary
The framework does not ask teams to invent a legal basis. It asks them to confirm one. ICBs are asked to "confirm plans for having the appropriate data-sharing arrangements in place to do" the identification and evaluation of patients, and to standardise data sharing between neighbourhood services and hospitals, including social care (Neighbourhood Health Framework, 2026). The 10 Year Health Plan goes further and legislates: from 2028 patients should be able to view a single patient record on the NHS App, with a duty on providers to make the information they hold available to the patient (10 Year Health Plan, 2025).
Four things are required of a cross-organisation team, and each is a document rather than a sentiment. A data-sharing agreement that names the lawful basis and the purposes for every party, not only the NHS ones. A common record and identifier set, which the Long Term Plan pointed to when it committed to expand the Community Dataset and integrate it with Local Health Care Records (The NHS Long Term Plan, 2019). A nominated person accountable for information governance across the partnership, because Di-Facto found that responsibility was seen as belonging to "others" (Abel et al., 2024). And a published position on the opt-out, since the plan is redesigning it and the fourth proposal in Personalised health and care 2020 was to "build and sustain public trust" (Personalised health and care 2020, 2014).
The limit of a consent-based model is arithmetic. A neighbourhood service identifies its cohort from linked data held in general practice, community nursing, social care and the hospital. If that is done only for the people who have consented, the cohort becomes the people who engage, which is precisely not the group the service exists to reach, and the evaluation inherits the same bias. Care for an individual can rest on the team's legal basis for direct care, but population identification and evaluation need an arrangement that covers everyone in the defined population, including people who never come online. That is why the framework speaks of data-sharing arrangements rather than consent, and why they are load-bearing rather than administrative.
The contested question: channel choice or infrastructure
The King's Fund's reading of public opinion is that people welcome digital access but want to choose how they use it, and that they saw digital access as "conditional on ensuring that patients have a choice" (The King's Fund, 2025). The plan takes a different line when it promises that services will happen "digitally by default" and "in a patient's home if possible" (Neighbourhood Health Framework, 2026). The gap between those two sentences is this week's contested question.
If digital is a channel choice, the non-digital route stays open at full capacity, the digital route is an addition, and not being online is a preference the person holds. If digital access is infrastructure, the service is responsible for the device, the connection, the skills and the support that make the route usable, and not being online is a cost the service carries.
The evidence points to the second reading, through the people the first reading fails. The groups least likely to book online are the groups the neighbourhood service is built around: 29 per cent of people aged 75 to 84 against 41 per cent overall, the most deprived fifth against the least deprived fifth, people with severe mental illness whose exclusion is compounded by material deprivation, and older adults who do not speak English as a first language (The King's Fund, 2025; Greer et al., 2019; Ahmed et al., 2024). A choice is real only when both routes are given the same capability and the same support, and the Di-Facto finding is that the support is not systematically there. Treating access as infrastructure means funding the digital health hub, the practice staff time and the shared record as part of the service, not as projects beside it.
The contested question
Whether digital access should be treated as a channel choice for the patient or as infrastructure the service must provide, including devices and support.
Working across professions
The channel and the excluded patient
Design the same appointment digitally for a patient of 82 with no smartphone and for a patient of 34 in work. The digital design is easy; the question is which profession notices the first patient is missing, and what the team does when nobody does. Ask each profession what their service would see.
For your profession
Written for the groups City St George's trains. Read your own first, then the two nearest to you: the disagreements between them are the working material.
General practice and primary care (including physician associates)
Advanced Clinical Practice MSc
What changes for you. General practice carries the digital front door. In this week's evidence 41 per cent of patients booked a GP appointment online, but only 29 per cent of those aged 75 to 84 did, and 44 per cent of patients in the most deprived fifth found the practice website easy to contact against 50 per cent in the least deprived. The framework makes the NHS App the default channel for practice messaging.
The decision on your desk. Whether to keep the online route open at full capacity for everyone while promoting it, or to triage it and risk turning a slow route into a closed one for the patients who already book least.
What goes wrong if this is done badly. The failure is a two-tier practice: patients who use the app get same day contact, and patients who cannot use it are triaged behind them, so the booking gap between the population and the 75 to 84 cohort widens rather than closes.
Community nursing and district nursing
Public Health and Specialist Community Nursing MSc/PGDip
What changes for you. District nursing writes the community record in a patient's home, often alone. The framework requires data sharing between neighbourhood services and hospitals, including social care, and the community nursing record is the part most often missing when the next service opens the file. Remote monitoring adds a stream of readings for long term conditions that has to land somewhere the district nurse can act on it.
The decision on your desk. Whether to accept a remote monitoring caseload without a named person reading the alerts in hours, or to refuse the monitoring until an escalation route exists that the district nurse can use on the day.
What goes wrong if this is done badly. Readings arrive into a record nobody else can see, alerts are not acted on, and the district nurse learns about a deterioration from the admission rather than from the data the service bought.
Adult social care
Partner profession: local authority adult social care
What changes for you. Adult social care is a partner profession here, not a City St George's programme. The framework's data sharing requirement names social care explicitly, and this week shows why: a cohort assembled from general practice, community nursing and hospital data is wrong if the local authority's records sit outside it. Social care staff also meet digital exclusion first, because the people they support are the least likely to be online.
The decision on your desk. Whether the local authority signs a data sharing agreement for the neighbourhood cohort, with its own lawful basis and purposes named, or stays outside and leaves social care need invisible in the identification.
What goes wrong if this is done badly. The cohort is identified without social care data, so people known to the council but not to the NHS are missed, and the shared record meant to join the service stops at the organisational boundary.
Mental health nursing and mental health practice
Mental Health Nursing BSc (Hons)
What changes for you. This week's exclusion evidence is mental health evidence. Greer and colleagues interviewed 20 mental health service users in south London who had been identified as digitally excluded, and found the causes were a perceived lack of knowledge, personal circumstances, and mental health difficulties themselves, compounded by material deprivation. A digital first route into the neighbourhood service therefore excludes the group with the worst physical health outcomes.
The decision on your desk. Whether the mental health practitioner records digital access need as a clinical fact on the shared care plan, so that the team must provide a non digital route, or leaves it as the patient's problem.
What goes wrong if this is done badly. People with severe mental illness fall off the digital route and reappear in crisis, and the admission is recorded as a mental health failure when the cause was the channel the service chose.
Speech and language therapy
Speech and Language Therapy BSc (Hons)
What changes for you. This week's sources do not name speech and language therapy once, and that silence is the finding. The digital components the week describes, online consultation, remote monitoring and the shared record, are built around spoken English and written text, which is what the Ahmed study found disadvantaged people who do not speak English as a first language. Swallowing and communication need are absent from every digital pathway the week discusses.
The decision on your desk. Whether to ask for a named place in the design of the neighbourhood digital record and consultation route, or to accept that communication and swallowing need will be added after the systems are procured.
What goes wrong if this is done badly. Video and online routes are procured without communication adjustments, swallowing risk is not represented in the shared record, and aspiration readmission follows a pathway built to prevent it.
Occupational therapy
Occupational Therapy BSc (Hons)
What changes for you. Occupational therapy is the second allied health profession in this panel and this week's sources are silent on it. The equipment, telecare and home adaptation work that occupational therapists authorise appears nowhere in the remote monitoring trials, the digital facilitation study or the framework's data sharing requirement. The week's exclusion evidence is about devices, connections and skills, which is equipment and daily function, the occupational therapy caseload.
The decision on your desk. Whether to claim part of the digital inclusion budget for the equipment and adaptation pathway, or to let devices and connectivity be treated as a cost the patient carries outside the neighbourhood service.
What goes wrong if this is done badly. Devices and connectivity are left to patients, so the people on the occupational therapy caseload who most need remote support are excluded, and the equipment pathway stalls between health and the council.
Pharmacy (pharmacists and pharmacy technicians)
Pharmacy MPharm (Hons) (awarded by Kingston University, delivered jointly with St George's, University of London)
What changes for you. The week's records material gives pharmacy no owner. The framework asks for structured medication information and direct prescribing to community pharmacies, the plan puts medicines management inside the NHS App, and remote monitoring for long term conditions generates readings that change medicines. The clinical pharmacist holds the whole medicines list, including care home residents with complex polypharmacy, so the shared record is only useful if pharmacy can write to it.
The decision on your desk. Whether the neighbourhood team gives the pharmacist write access to the shared record for structured medication reviews, or leaves pharmacy receiving prescriptions the team has already changed.
What goes wrong if this is done badly. Medication changes made on remote monitoring readings are invisible to the pharmacist, duplicate prescribing continues in care homes, and the avoidable admission is caused by the record rather than by the patient.
Public health and local government
Public Health MPH
What changes for you. Local government holds the deprivation and digital inclusion data this week turns on. The comparison between population fifths in the week's evidence is a survey measure, and the digital health hub model that works was a city wide programme delivered through voluntary sector organisations. Public health therefore holds the cohort definition and the best evidenced route to the excluded group, and neither sits inside the NHS record.
The decision on your desk. Whether the health and wellbeing board funds community digital support as part of the neighbourhood service, or leaves it to voluntary organisations already carrying the demand without resource.
What goes wrong if this is done badly. The inclusion work is delivered by unfunded community organisations, the hub closes when its grant ends, and the neighbourhood service records the cohort it could not reach as disengaged.
Critical commentary
Where this week is argued with
Full-text commentaries and critical analyses from peer-reviewed journals. The policy column tests the claim against what government actually commissioned. The practice column tests it against what staff can deliver. Read one from each before the contested question.
Policy-facing
Comment setting five challenges to England's digital-first public health policy and concluding that it has not reduced inequalities, because older minority ethnic adults face a triple disadvantage of low access, low literacy and financial hardship. It proposes digital alongside rather than digital first, and lands against the week's confidence that delivery and inclusion advance together. Article type: comment.
Viewpoint locating digital health inequity in political economy rather than individual capability, naming revenue-first corporate incentives, venture capital, unequal broadband access and uncertain reimbursement as structural barriers. It argues that training and clinical goodwill cannot fix what market design produces, and lands against the week's treatment of exclusion as a solvable delivery problem. Article type: viewpoint.
Perspective arguing that statutory accessibility protections for disabled people remain promises far from realised in digital health, and that accessibility should be enforced as a civil right through mandated universal design, disability data collection and funding incentives. It shares the week's inclusion aim but rejects relying on voluntary local commissioning to deliver it. Article type: perspective.
Practice-facing
Analysis from workshops with GP teachers arguing that digital consultation skills are not routinely taught, that remote consulting may increase rather than contain demand for urgent face-to-face care, and that clinicians need training in app appraisal, data sharing and digital exclusion. It lands against the week's assumption that digital delivery is already a settled success. Article type: analysis.
Commentary weighing pre-pandemic and COVID-era evidence on virtual consultations. It reports access gains for younger, employed and geographically distant patients, but warns that limited digital access, poor broadband and low technology literacy can widen disparities, and that the implementation evidence needed to make virtual care inclusive is thin. Article type: commentary.
Commentary from an international primary care panel arguing that remote consulting suits routine chronic disease work but is less safe for new diagnoses and complex care, and can add to clinician workload and stress when it dominates. It calls for skills, IT support and fair reimbursement, and lands against reading digital delivery as settled progress. Article type: commentary.
Key sources
The white paper that put the information revolution into English health policy, promising shared decision making as the norm in the phrase no decision about me without me, and describing the revolution as new ways of delivering care rather than transparency alone. It is the earliest of the three promises this week measures against delivery.
The document that converted the ambition into dated commitments, including digital, real time and interoperable records by 2020 and clinicians working without paper records by 2018. It also records its own baseline, that 59 per cent of citizens had a smartphone and 84 per cent of adults used the internet while only 2 per cent reported a digitally enabled NHS transaction, which is the gap this week argues has not closed.
The plan that made digitally enabled primary and outpatient care the mainstream, promised every patient a right to choose a digital first consultation within five years, and committed to connect home monitoring equipment to personal health records. It also promised to expand the Community Dataset and integrate it with Local Health Care Records, which is the interoperability commitment the neighbourhood record still rests on.
The plan whose third shift is analogue to digital, promising the NHS App as a full front door to the entire NHS by 2028 and a single patient record that patients can view on the app from the same year. It supplies both the sharpest date in the week and the plan's own framing that the service is behind the technological curve, which is the delivery record the week tests.
Department of Health and Social Care and NHS England (2026). Neighbourhood Health Framework. GOV.UK.
FULL TEXTThe framework that tells neighbourhood services what digital work is mandatory rather than optional. It requires standardised data sharing between neighbourhood health services and hospitals, including social care, and asks integrated care boards to confirm the data sharing arrangements needed to identify and evaluate patients reliably. It also sets the digitally by default expectation that this week's contested question turns on.
A synthesis of GP Patient Survey and deliberative evidence on the three shifts, including the finding that 41 per cent of respondents had booked a GP appointment online in the previous 12 months against 29 per cent of those aged 75 to 84, and that 44 per cent of the most deprived fifth found the practice website easy to contact against 50 per cent of the least deprived. It also carries the counts of 8.5 million adults without basic digital skills and 2.4 million households unable to afford a mobile contract.
The largest English trial of home telehealth, randomising 179 general practices and recruiting 3,230 people with diabetes, chronic obstructive pulmonary disease or heart failure. Admission proportion was lower in the intervention group and mortality at 12 months was 4.6 per cent against 8.3 per cent, but the authors report the admission difference was greatest at the start of the trial and cannot fully explain it. It is the strongest positive evidence in the week and the most contested.
A randomised trial of telemonitoring plus nurse coaching against usual care for 1,437 people discharged after a heart failure admission, followed for 180 days. Readmission was 50.8 per cent in the intervention group against 49.2 per cent, an adjusted hazard ratio of 1.03, with the only significant difference in quality of life. It is the null result that stops the Whole Systems Demonstrator finding being read as a settled effect.
A Cochrane review of 29 randomised studies and 5,654 participants covering remote monitoring with or without usual care and multi component telehealth. It found that remote monitoring plus usual care probably reduces COPD related readmission at 26 weeks, but showed little to no difference in exacerbations, quality of life, all cause hospitalisation or death, and most studies were at high risk of bias. It defines exactly what a commissioner can and cannot expect from remote monitoring.
An umbrella review of seven systematic reviews, themselves covering 77 randomised trials and 50 observational studies, on digital technology and older people's access to health and social care. Every included review rested on low quality primary studies, and no review examined first contact access such as online appointment booking. Its finding is an evidence gap at the exact point where the digital front door is being built.
Semistructured interviews with 20 mental health service users in south London who had been identified as digitally excluded. Three themes maintained the exclusion, a perceived lack of knowledge, an inability to access technology because of personal circumstances, and the barriers created by mental health difficulties, and the authors conclude that services must address the multiple deprivations people face offline as well as their mental health needs. It shows that exclusion is material as much as attitudinal.
Focus groups with 27 older adults from the three largest minoritised ethnic groups in England and Wales on digitalised primary care. Participants reported language barriers and limited digital skills, reliance on younger relatives or community organisations to get in, services felt to be built for English speakers, and digital access experienced as imposed without sufficient explanation or consent. It is the clearest statement of why the excluded group is also the group the service is built to reach.
Interviews with 30 service users and staff at Digital Health Hubs, a city wide programme that delivered digital support through voluntary sector community organisations. The moderators of success were community spaces, social activities, devices and Wi-Fi, and recipient centred support built on community understanding, regular personalised help and trusting relationships, with reported gains in resilience and basic digital skills. It is the supported digital model this week argues should be funded as infrastructure.
An observational mixed methods study of digital facilitation in general practice, combining staff and patient surveys with ethnographic case studies in eight practices. It found facilitation happening but often passively, no clarity over whose responsibility it was, and a need for clear lines of responsibility, usable tools and investment in staff time and training. It supplies the evidence that the support which makes digital access real is not systematically provided.