Compare and contrast these two nations. We have the UK, a land where one in five NHS Trusts is paper-based. This means records are kept on paper, and must be physically transported between hospitals, sometimes by taxi. Records are occasionally lost.
When computers are used, the performance can be appalling. A medic in Kettering hospital says it takes her 10 minutes to log into the hospital system. “Sometimes I just give up and go to another computer,” she reveals. Overall, only 1 in 10 trusts is completely digitised.
How about the police? Northamptonshire Police posts speeding tickets to drivers and demands an ink signature posted back. Do it online? No chance. The police confirm it is possible to send documents by post or fax. Yes, fax. A primitive network of printers popular in the 1980s.
Now swivel the globe to Estonia. This tech unicorn factory is regarded as a paradise for digital living. The entire government runs on a slick online interface. A single ID code offers citizens access to almost all its public services. The login is identical for all. Vote online. Get a prescription. Pay tax. Form a company. All with a single personal number and PIN.
Most incredibly of all, the entire Estonian system is run for around €100 million a year, according to 2020 figures from the State Audit Office.
So why is the UK so far behind Estonia?
A big reason is the single identifier. At birth, Estonians are assigned an ID number for life. The national IT system is built around it. Brits have no such number, but instead use a multiplicity of identifiers: passport number, NHS number, National Insurance number, Unique Tax Reference, driving licence and so on. It’s chaos.
“We’re not joined up,” observes Deryck Mitchelson, who was chief information officer of NHS National Services Scotland from 2018 until January. “Even in the same service, things differ. In Scotland, we’ve got the CHI – the Community Health Index number – which is the same as but separate from the NHS in England and Wales.” There are three distinct NHS numbering systems: one for England, Wales and the Isle of Man; one for Scotland; and one for Northern Ireland. He has studied the impact this fragmentation has on government IT. “There are just too many identifiers,” he says. “Data is siloed in local systems. In Scotland, each health trust manages its own records. None of them passes on information, which is why you see big delays. There’s no one source of truth.”
During the pandemic, Mitchelson needed to create an integration layer to share patient information across the Scottish and English NHS systems to monitor patients. “People ask what sits between the NHS systems and connects them. The answer, really, is nothing.” It’s a disaster. The NHS app failed to show double vaccinations if one was in another nation of the UK, meaning some Brits couldn’t prove their status when abroad.
Even the current ID processes are poor, being based on names and date of birth. Mitchelson says he went for a blood test and the nurse forgot to ask his middle name, preventing the system from recognising him. The sample was thrown away as it could not be logged. “I deliberately tried to disrupt the system,” he says. As a small gesture, he would refuse to print documents, demanding a digital version. “Unless people take a stand, it isn’t going to change.”
Now back to Estonia. The entire nation runs on X-Road, a national data-sharing platform that stores all data on the cloud on compatible systems. The department of education maintains school records and the department of health logs medical data, but all state systems are interoperable. There is a once-only policy, so information is never input twice. Data can flow from one service to another with no information loss. No application is more than 13 years old. Anything older is rebuilt. This means, for example, that ambulance drivers can view patient information on an e-ambulance app. Doctors and paramedics can see blood type, allergies, treatments or pregnancy at a glance.
The X-Road backbone allows apps and services to be built at speed. Almost 100% of the work is undertaken by private contractors, usually smaller agencies rather than the big-name consultancies used in the UK.
The Estonian approach is so outstanding that Finland and Iceland are now using the X-Road model. Mexico is a recent adopter. Even Japan has signed a digital cooperation agreement with Estonia for mutual assistance and learning.
Could the UK follow? The structure is there. The UK is a member of the Digital Nations group, a collection of nine nations that includes New Zealand, Denmark, Israel and Estonia, with a common goal of modernising IT. But there’s no obvious sign that the UK desires to learn.
Sion Smith is CTO of OSO, a tech consultancy which works on software design for the likes of NHS Wales and the Department for Work and Pensions, says there is no overall direction, and no plan in place to emulate Estonia. “I’ve never heard Estonia mentioned. Never.” Instead, he says, the mindset in the UK is “reactive”, focused on fixing immediate problems as they occur. “I don’t blame civil servants. They lack experience. They lack understanding,” he says. Even lone politicians are hard to point the finger at. “It’s the system. Politicians don’t stay around long enough. There’s a four-year lag between what gets approved and what gets done. By that time the politician has moved on.” The result is archaic, dysfunctional systems. “We talk about tech debt when code is not optimal or usable. The NHS is tech debt on steroids,” he says.
Could the UK take baby steps and adopt a single ID code, like Estonia? Political objections of Orwellian surveillance are a major obstacle. Estonia evades this debate by giving citizens the right to see who views their data. An ID code can thus increase transparency.
“If it’s done properly, a single ID gives you much tighter security and controls,” says Mitchelson, who is now chief information security officer of cyber firm Check Point. “If there is a fraud, you can immediately switch off access to other services. It gives more visibility and allows the consumer to manage their data.”
So, a model exists for the UK to learn from. It’s cheap to run. Secure. Proven. And Estonians are enthusiastic about sharing their knowledge.
As Estonia rises in prominence, thanks to a soaring GDP per capita and a reputation as e-Estonia – the land of code – its example will prove ever harder to ignore.