Digital Government and NHS

The Problem

The NHS faces a structural mismatch. Acute hospital beds are chronically short. Around 13,000 of them are blocked every day by patients who are medically fit for discharge but have nowhere to go. Each blocked bed costs roughly 2,000 pounds per night, or 9.5 billion pounds a year if all 13,000 were freed. A&E waits stretch beyond 12 hours. GP appointments take 11 days on average. Meanwhile, multiple trials have shown that AI triage, virtual wards, and step-down care can resolve much of this. The technology exists. The evidence is strong. We have not deployed it at scale.

A. AI Smart Triage in Every GP Surgery

An NHS-funded AI triage trial in 2023 reduced average GP appointment waits from 11 days to 3. The system handles routine cases (repeat prescriptions, simple infections, minor injuries) while flagging anything clinically significant for immediate doctor attention. We deploy AI Smart Triage in every GP surgery within 2 years. Not optional. Not pilot-by-pilot. National rollout with central technical support, training, and implementation funding.

• AI triage handles the 40% of GP consultations that are routine and require no new clinical decision: medication reviews, test result discussions, minor ailment queries
• Freed GP time redirected to complex patients, preventive care, and mental health
• Patients with urgent symptoms triaged to same-day appointments, not told to call 111 or go to A&E
• The AI system is UK-built, NHS-owned, and runs on NHS infrastructure, not a US tech platform

B. AI Clinical Note-Taking

GPs currently spend 40% of their clinical time on documentation. AI transcription and summarisation tools reduce this to under 10%. Every GP gains back 2 to 3 hours of patient-facing time per day without working longer hours. The technology already works: Nuance DAX, Suki AI, and NHS-developed alternatives are in trial in British GP practices. We roll them out universally.

C. Self-Referral Through the NHS App

Up to 30% of GP appointments are for musculoskeletal conditions (back pain, bad shoulder, knee injury). A patient with a bad shoulder must currently see a GP, get a referral, and wait for a physiotherapy appointment. The GP step adds weeks, costs a slot, and adds no clinical value: the GP almost always refers straight on. A trial in Torbay saw self-referral cut waiting times from 10 weeks to under 3 days for 90% of patients. Health economist modelling shows self-referral saves £33 per patient. 200,000 people a month already self-refer for podiatry, audiology, and physiotherapy in England. Forge extends this substantially.

Conditions eligible for direct self-referral through the NHS App, without a GP appointment:

• Musculoskeletal: physiotherapy for back pain, shoulder, knee, hip, and repetitive strain injuries. Already working in parts of England. Made universal and mandatory.
• Mental health (major expansion): NHS Talking Therapies (CBT, counselling) accept self-referral directly through the NHS App with no GP gatekeeping. This service is substantially expanded and funded by removing mental health from the PIP disability benefit (see Section III) and redirecting the money to actual treatment. Self-referral, digital CBT available immediately for mild to moderate conditions, talking therapies within weeks not 18 months, and continuous clinical care for recovery. Mental health is treated as the health condition it is, by the NHS, rather than addressed with a cash benefit that treats nothing. Extended to ADHD assessment and eating disorder services where capacity allows.
• Audiology: hearing tests and hearing aid fitting. No GP needed. Already available in many areas. Made universal.
• Optometry and low vision: eye tests, urgent eye conditions (sudden vision change, floaters, red eye), and low vision assessment.
• Dermatology via photo: patients submit a photograph of a skin concern through the NHS App. A consultant dermatologist reviews it within 48 hours and advises: reassurance, GP prescription, urgent referral, or routine appointment. Already piloted at Oxford University Hospitals. Eliminates the GP-as-postbox step for most skin concerns.
• Podiatry: foot pain, nail problems, diabetic foot care. Already self-referral in many areas.
• Incontinence services and community nursing: extended by NHS England in 2024. Made universal.
• Sexual health clinics: already walk-in nationally. Maintained and expanded opening hours.
• Stop smoking and weight management services: direct referral without GP gatekeeping.

A clinical triage tool built into the NHS App asks 4 to 6 screening questions before completing the self-referral. Red flag symptoms (unexplained weight loss, neurological symptoms, blood in stool) route the patient directly to an urgent GP appointment instead. The app is not a bypass for safety-critical presentations. It is a bypass for the 30% of GP appointments that should never have been GP appointments in the first place.

D. Pharmacy First: Expanded From 7 to 30 Conditions

The NHS launched Pharmacy First in January 2024, enabling pharmacists to prescribe for 7 conditions (earache, sore throat, sinusitis, urinary tract infections, infected insect bites, impetigo, and shingles) without a GP appointment. In the first 11 months, over 1.2 million antimicrobial prescriptions were dispensed through this route. GP appointments freed. Patient waiting times reduced. No safety incidents attributable to the scheme.

This already works. The question is why it covers only 7 conditions. Forge expands Pharmacy First to 30 conditions, including:

• All current 7 conditions, made permanent and funded at full rate
• Hay fever and seasonal allergic rhinitis (prescription antihistamines and nasal steroids)
• Mild to moderate eczema flare-ups (topical steroids within an agreed management plan)
• Oral thrush and vaginal thrush (antifungals)
• Cold sores requiring antiviral treatment
• Head lice (prescription treatments)
• Mild skin infections not requiring systemic antibiotics
• Travel health vaccines and malaria prophylaxis (pharmacist prescribers already do this privately)
• Emergency contraception (already available, made fully funded)
• Routine blood pressure monitoring and hypertension medication titration within agreed protocols
• Inhaler technique review and step-up within agreed asthma management plans
• Uncomplicated type 2 diabetes monitoring and medication adjustment within agreed plans

Pharmacists in France prescribe for a broader range of conditions than this. Pharmacists in Scotland, Wales, and Northern Ireland already operate under a more expansive prescribing framework than England. The evidence base for trained pharmacist prescribing is strong and the safety record is good. The barrier is not clinical, it is regulatory inertia.

What is NOT included: complex or first-diagnosis conditions, anything requiring physical examination beyond what a pharmacist can safely conduct, anything requiring imaging or laboratory investigation before treatment, and anything where the risk of missed diagnosis outweighs the convenience of pharmacist prescribing. The 30-condition list is set by the National Institute for Health and Care Excellence with annual review. It is not open-ended.

Pharmacist prescriber training: independent prescribing qualification (Level 7) is funded for all community pharmacists who want it, through Health Education England. The qualification takes 26 weeks part-time. Approximately 15,000 additional pharmacist prescribers are targeted over the parliament.

E. Hard Targets, Hard Consequences

• GP appointment within 1 week for standard requests; 24 hours for urgent
• A&E 4-hour standard reinstated and enforced
• 18-week elective surgery target reinstated
• 4-week standard for consultant outpatient appointments
• Trusts missing targets repeatedly face management replacement and intervention, not bonuses and tolerance

F. Hospital at Home (Virtual Wards) Tripled

Virtual wards deliver hospital-level care in patients' homes. NHS England runs around 12,000 virtual ward beds today, roughly 20 per 100,000 population. The evidence base is now overwhelming:

• West Hertfordshire frailty virtual ward: 118 pounds per bed-day versus 569 for inpatient. Saving of 451 pounds per patient per day
• Liverpool heart failure virtual ward: 36% reduction in A&E attendance, lower mortality than inpatient comparison group
• East Kent pathway: one acute admission avoided for every 1.03 patients on the home pathway
• Multiple trials across England 2022-2025: consistent 30-40% cost reduction versus inpatient, maintained or improved outcomes

Forge triples virtual ward capacity in the first parliament: from 20 to 60 beds per 100,000 (36,000 nationally). The bigger prize is step-up prevention. Currently two-thirds of virtual ward use is step-down (early discharge from hospital). The bigger saving is preventing the admission in the first place: frailty teams in A&E and attached to ambulance services divert older patients with falls, infections, or chronic exacerbations directly to hospital-at-home. Target: 50% step-up by 2030.

G. 50 Public Step-Down Care Centres

50 publicly-run step-down care centres sited adjacent to major hospitals provide reablement and rehabilitation for medically-fit-for-discharge patients currently blocking acute beds. NHS-funded for the first 6 weeks matching the Care Act 2014 intermediate care entitlement. Co-located on hospital sites where surplus buildings exist, avoiding greenfield capital costs. Genuine rehabilitation: physiotherapy, occupational therapy, nursing review, social care assessment, community reintegration planning. Not a waiting room with a bed in it.

Freeing 13,000 blocked beds at 2,000 pounds per night generates up to 9.5 billion pounds annually in savings. Freeing one quarter (3,250 beds) saves 2.4 billion annually and funds the entire step-down programme with a surplus for further expansion.

H. Single Point of Assessment

An older patient with a fall is currently assessed by an ambulance crew, then A&E, then a community nurse, then a discharge team, then a social worker. Each assessment generates separate paperwork. Each handover loses information. The British Geriatrics Society identifies this fragmentation as the single biggest barrier to better frailty care. Forge consolidates:

• One phone number per Integrated Care Board for urgent community response, hospital-at-home, and frailty crisis services
• Multi-disciplinary triage team decides within hours: virtual ward, step-down centre, community response, or acute admission
• Frailty assessment teams in every A&E, led by consultant geriatrician, capable of diverting appropriate patients from acute admission within 4 hours
• One care record across health and social care, linked through UK X-Road (Section XVII). The hospital, GP, community nurse, social worker, and care home all see the same record in real time

I. Digital Government: UK X-Road

Estonia built X-Road: every government database connected through a single interoperability layer. Citizens interact with government once; data flows where needed. Result: 99% of public services online, 2% of GDP saved in admin costs, every Estonian saves 5 working days per year on bureaucracy. Forge builds UK X-Road connecting HMRC, DWP, NHS, DVLA, Land Registry, Companies House, local councils, and the courts. One application, one record, one update flows everywhere.

K. NHS Nursing Workforce: Ending the Agency Dependency

The NHS spent £3 billion on agency nursing staff in 2023/24. Recruitment agencies charged up to £2,000 for a single nursing shift. The Royal College of Nursing calculated that the same money could have paid the salaries of almost 31,000 permanent full-time nurses. The NHS is, in effect, training nurses, watching them leave for agency work paying significantly more, and then paying the agency premium to have them do the same job back again. This is not a mystery. It is the predictable result of NHS pay policy combined with flexible working preferences.

The problem is not agencies. It is vacancy rates.

There were 40,000 nursing vacancies in England in 2024. As long as those vacancies exist, trusts will fill them with agency staff because the alternative is leaving shifts uncovered. Capping agency spending without filling the underlying vacancies simply means unsafe staffing levels. Forge addresses the cause, not the symptom:

• NHS Nursing Compact: any nurse returning from agency work to a permanent NHS post receives a one-off transition payment equivalent to 3 months salary, a guaranteed flexible working arrangement negotiated at interview (not as an afterthought), and a protected continuing professional development entitlement of 5 days per year. These are the three most cited reasons nurses cite for preferring agency work: pay, flexibility, and professional development time. The Compact addresses all three.
• International nursing retention: overseas nurses who have worked in the NHS for 3 or more years receive a fast-tracked permanent residency pathway, ending the visa cliff-edge that pushes experienced nurses into agency work because their immigration status is tied to the employer rather than the profession.
• Nurse staffing ratios mandated in law: following the Australian model (implemented in Victoria 2000, New South Wales 2023), legally mandated minimum nurse-to-patient ratios. Victoria achieved a 14% reduction in adverse patient events and a 15% fall in nurse turnover within 3 years of implementation. Safe staffing levels reduce the burnout that drives nurses to leave the NHS entirely.
• Nursing degree apprenticeships at scale: funding for 10,000 additional nursing degree apprentices per year, allowing people to qualify as nurses while earning a salary, drawing from the workforce that already works in healthcare in non-registered roles. This is the fastest route to filling structural vacancies without relying on international recruitment.
• Agency cap tightened progressively: as the Compact reduces vacancies and nursing degree apprentices come through, the agency cap tightens from the current 155% to 130% by Year 3, and 115% by Year 5. By Year 5, the target is agency spend below £500m annually, down from £3bn. The saving (approximately £2.5bn) is reinvested in the Nursing Compact and apprenticeship programme.

L. Digital Imaging: No More Couriers, No More Lost X-Rays

An X-ray taken at an NHS hospital in London is currently stored on that hospital's Picture Archiving and Communication System (PACS). If the patient is referred to a specialist at a different trust, the images must be copied to a CD, the CD physically transported by courier, and the receiving clinician must load the CD into a machine that may or may not read it. In 2024. This is not an exaggeration: NHS couriers transport hundreds of thousands of imaging CDs per year. Some are lost. Some are unreadable. Some arrive after the consultation they were needed for.

The UK X-Road digital backbone (Section I above) resolves this permanently. But imaging specifically needs its own programme because PACS systems are not currently interoperable even within regions, let alone nationally:

• National Imaging Archive: a single cloud-based imaging repository, NHS-owned and UK-hosted, into which all trusts upload imaging in DICOM format. Any clinician with NHS login credentials and patient consent can access any image taken anywhere in England within seconds. The infrastructure exists: NHS England began procuring this in 2022 but implementation has been slow. Forge mandates completion by Month 18.
• No new imaging CD to be produced from Month 6. Hard deadline. Trusts must connect to the National Imaging Archive or the regional interim solution by Month 6. After that date, CD production stops. This forces the issue rather than waiting for voluntary adoption.
• AI-assisted radiology reporting: 40% of plain X-ray and CT reports can be validated by AI to the same clinical standard as a junior radiologist. NHS England already has AI radiology tools in use. Forge funds national rollout, reducing reporting backlogs and freeing consultant radiologists for complex cases requiring specialist interpretation.
• Pathology results through the NHS App: blood test results, biopsy results, and imaging reports accessible to the patient through the NHS App within 24 hours of being signed off. No more waiting for a GP appointment to be told your blood results are normal. The patient sees the result, the GP-written note explains what it means, and the GP appointment is freed for genuine clinical need.

J. NHS Procurement: Single National Purchasing

The NHS spends approximately £30 billion per year buying goods and services: drugs, devices, consumables, facilities management, food, linen, and IT. It does so through 200 separate trusts, each negotiating individually. The NHS Supply Chain exists but is used inconsistently. Documented price variation for identical items between trusts reaches 400% in some categories. A catheter that costs one trust £2.50 costs another £10.00 for the same product from the same manufacturer. This is not a small inefficiency. It is a structural failure that costs billions annually.

Single National Procurement Vehicle

• All NHS trusts required to use the National NHS Procurement Platform for all consumables, devices, and non-patented drugs within 3 years. Trusts retain clinical decision-making but not purchasing authority for standardisable products. The platform aggregates demand across the entire NHS, negotiating from a position of being the largest single buyer in Europe.
• Price transparency published quarterly. Every price paid for every category of NHS procurement published as open data. Suppliers who charge the NHS more than the lowest comparable European price face an automatic renegotiation trigger.
• Patented branded drugs excluded but generic drug procurement consolidated. The NHS already negotiates well on branded drugs through NICE. Generic drug price variation is where the waste sits.
• Medical devices standardisation. The NHS currently uses over 40 different makes of syringe driver, 30 different blood pressure monitors, and dozens of incompatible catheter systems. Standardisation to a national preferred list for each device category, with a transition period, reduces procurement costs and reduces clinical error from staff using unfamiliar equipment.
• Food and facilities management re-tendered nationally. Hospital food contracts, linen, cleaning, and estates management are currently contracted trust by trust. National re-tendering on 5-year rolling contracts reduces cost and improves quality standards consistency.

Estimated annual saving: £3 to 5 billion. This is not a cut to clinical services. It is the same goods and services at lower prices through the purchasing power that comes from acting as one organisation rather than 200.

K. Government Consultancy Cap and Civil Service Capability

The civil service spent approximately £4 billion on management consultants in 2023/24. McKinsey, KPMG, Deloitte, and PwC collectively received approximately £1.2 billion of that. The Government's own analysis suggests roughly 40% of this work could be done by permanent civil servants if the grade structure and pay ceiling did not make retaining specialist capability uneconomic.

Forge caps central government consultancy spend at £1 billion annually from Year 2, reducing to £500 million by Year 4. The saving of £1.5 to 2 billion annually is redirected to: 2,000 additional specialist civil service roles at market-competitive pay in areas currently outsourced (IT architecture, data science, project management, financial modelling), and a Civil Service Capability Fund that retains expertise rather than repeatedly buying it from the same four firms.

This is not anti-consultant. It is pro-capability. A government that cannot analyse its own data, model its own policies, or manage its own IT projects will always be dependent on external consultants regardless of the cap. The cap forces the investment in capability that the current model avoids.

L. Quango Review: 20% Reduction in Arm's-Length Body Spend

The UK has approximately 295 arm's-length bodies spending approximately £200 billion annually. Many do essential work that must be independent of government: the OBR, the BBC, the Environment Agency. Some duplicate each other in ways that have never been rationalised. Some have missions that have been superseded by other organisations or by technology.

A systematic Arm's-Length Body Review in Year 1, reporting within 12 months, targets a 20% reduction in the total number of bodies and a 15% reduction in administrative costs, while protecting the operational delivery function. Estimated saving: £3 to 4 billion annually in administrative costs, not front-line delivery. The review is conducted by the National Audit Office, not by management consultants.

J. Sovereign Data and the Palantir Question

The UK has committed approximately 900 million pounds to Palantir, including 330 million for the NHS Federated Data Platform and 240 million for the MoD without competitive tender. Switzerland walked away from Palantir on sovereignty grounds. Forge will too, carefully. Cancelling overnight would crash systems that NHS and government departments now depend on. The approach: maintain contracts until UK X-Road and replacement systems are demonstrably operational. Exit Palantir at break clauses (NHS FDP: 2027). Run parallel UK-built alternatives during transition. Procurement preference for British-led consortia. Sensitive data on UK-controlled infrastructure when alternatives are ready.