10 lessons from Estonia for NHS digitisation

Estonia proves that digital transformation is less about technology and more about trust, pragmatism and persistence, writes Tammy Lovell, editor at Digital Health

A few months ago I visited Estonia to see what the country could teach the NHS about digital health.

Estonia is often lauded as an example of digitisation having had a single patient record for every citizen in place since 2008. However, with a population roughly the size of Birmingham’s, it is often observed that a similar system may not directly transfer to the complex and fragmented NHS.

After all, isn’t it easier to take a population of 1.3 million on a journey with you than 69 million and a hugely disjointed NHS?

But Estonia has its own problems, such as limited resources of people and funding, meaning that it requires practical solutions which can scale.

The Estonian experts I meet are aware that we cannot simply transplant their health system to ours, but they see their agile country, where it’s easier to make things happen, as a fertile test ground for new ideas.

“There is no service in Estonia that can be simply lifted from Estonia and simply plugged into another country.

“We see that the important thing is to start from somewhere,” says Rannar Park, head of business engagement at the e-Estonia Briefing Centre.

Here are 10 lessons from Estonia:

1. Be radically transparent

“There’s a saying in Estonian that the trust is earned in spoonfuls and lost in buckets,” says Park.

“It’s hard, as a government, to win your citizens’ trust. And it’s even harder to keep it.”

He described Estonians as a discontented bunch who demand high standards and are no more trusting than the average UK citizen.

But digital health was not a ‘nice to have’ for the former Soviet state, but a necessity. They simply did not have enough medical workforce to serve the population without innovation.

Winning public trust required radical transparency from the government.

“We took the approach, that instead of just reaffirming to our citizens that everything is fine, you don’t have anything to worry about, we’re going to give you the harsh truth, and it has paid off.

“Over the last 20 years, we’ve earned our citizens’ trust, and we’ve managed to keep it,” said Park.

This includes transparency about who has accessed your data by allowing patients to see who has viewed their health record and why through the “data tracker” which leaves a trail each time a citizen’s record is viewed.

“It’s a tool for all the state institutions and our corporations to remember that there’s very few things that Estonian law takes as seriously as it does data protection,” he says.

When Estonia’s digital ID card was introduced, it was done with radical transparency.

“It’s about making sure that the citizens don’t feel like their rights are being infringed upon, that they understand what the services are that are being provided to them.

“If you don’t explain to the people why the system matters, why the card matters, why the identity matters, or how it guarantees a better way of life for you, well, of course, there’s going to be pushback,” Park adds.

2. It’s about the people, not the tech

The message I hear time and time again in Estonia is that transformation is about people.

“The technology is not the issue, and collaboration is the main thing,” says Mellis Lang, chief innovation officer at Helmes, the firm behind Estonia’s e-prescription service.

“You need the right people for the right problem.

“With small autonomous collaborative teams, understanding the business and the user – then you get the magic.”

He emphasises the importance of winning over clinicians and patients by “starting small” when implementing new technology.

“Doctors are unhappy. Patients are unhappy. So we need to collect the data. Let’s make it as easy as possible.

“And if you’re smart, then you bring the small wins to them,” he says.

Maksim Zukov, chief executive of software firm Kodality, adds: “As a patient, you don’t actually care about the tech. You just go to the pharmacy and get the medication dispensed.

“It doesn’t really bother you how these things work, but if it doesn’t work, then it’s a trust issue.”

3. Eat the elephant one bite at a time

Estonia introduced technology slowly starting with the digitisation of the tax service in 1999.

In the first year of digitisation only 1% of citizens used the online tax system, but by 2025 it had reached 99.96%.

“There are always going to be obstacles, there’s always going to be something that the people don’t like.

“It took us almost 15 years to reach more than 50% of our taxpayers doing their taxes digitally.

“It didn’t happen because it was easy. It happened because we kept badgering our citizens about how quick, how simple, and how understandable it is,” says Park.

4. Get the data architecture right

Estonia operates a “once-only” principle, which means that every single piece of data about the citizen can only exist once without duplication.

The systems are cross-country, cross-domain and cross-ministry, built on common baselines and infrastructure for health and other public services.

This has helped create a system where there is no single point of failure and no central access point to citizen’s data.

“If you look at the roadmap for digitalisation, we started with our legal framework to figure out how to best protect our citizens’ data.

“If we look at the more notable cyber incidents over the last 10-15 years, we’ve seen that these are incidents which have impacted one specific point of data, whether it’s been a passport photo, identity code, or personal code,” explains Park.

A hacker in the 2010s said in an interview that Estonian data is so annoyingly well separated that there’s no point in hacking into the system because you get very little for the money and time spent.

5. Make patient data accessible across the system

At the heart of Estonia’s approach is the principle that patient data should follow the patient.

“We’ve been building e-health for a long time and the idea is that information should always be available to any healthcare professional who has the right to access it, and to patients themselves.

“Since the mid-2000s we’ve made health data accessible to both providers and patients. This includes data from the private sector.

“You can’t provide complete care if you only see fragments of a patient’s history,” says Park.

In short, better data access underpins better care.

6. Use the data

Estonia has moved towards preventative and personalised health through the use of genomics, something which is also an ambition in the NHS 10 year health plan.

“We have a lot of data: decades of electronic health records, national registries, and even genomic samples.

“We need to use this data wisely to predict and prevent disease.

“For example, instead of inviting all women of a certain age for a screening programme, we can use genetic and health data to identify those at highest risk and target screening more effectively.

“That’s the move from population-level care to truly personalised care – predicting, preventing and tailoring treatments to the individual,” says Park.

7. Be pragmatic

Estonia started building its digital state in the 1990s out of necessity because it lacked the people to build a traditional government after gaining independence from the Soviet Union in 1991.

“We can’t afford our people to be paper pushers or bureaucrats because we simply lack the people.

“With a declining population, we need clever solutions to keep our state running.

“And for the last 30 years, making shortage an advantage has become somewhat of a mantra for us,” says Park.

“Our people, our populace, is expected to be critical in the best sense possible.

“We want you to criticise us and provide any kind of feedback, because that means you actually care.

“The worst thing for us is a quiet state. If our people get quiet, that means that they’ve lost interest,” he adds.

8. Knowledge is power

In Estonia, education is a core enabler of digital transformation, reflecting a long-term commitment to bringing citizens along on the journey.

“If we didn’t educate our leaders, if we didn’t educate our private and public sector and our representatives, none of this would be here.

“We see that the biggest obstacle for digitalisation is mindset.

“People are unwilling to change because they don’t understand the implications.

“So the Estonian approach for more than two decades has been one of transparency, honesty, and clarity,” says Park.

9. Be humble

There are few airs and graces in Estonia and there’s a sense that politicians are genuinely there to work for the people.

At an evening dinner we’re joined by Nele Labi, deputy secretary general for innovation at the Ministry of Social Affairs.

It would be an unlikely situation the UK, but in Estonia, it seems as if everyone knows each other and with a limited workforce everyone “wears two hats”.

Katrina Laks, co-founder of digital headache clinic Migrevention and board member of Health Founders Estonia, tells me: “Politicians are our neighbours. They’re civil servants who are there to serve us.”

In Estonia digitisation is not seen as a political football for electioneering and continuity is important.

“It [digitisation] has been a non-negotiable in every single government that we’ve had.

“We do digital well, and if we stop this train, it would have to force us to move backwards,” says Park.

10. Partner with the private sector

Around 96% of Estonia’s digital services have been built by the private sector.

“We know that we have to work with the private sector and the public sector hand in hand, because otherwise we would still be stuck in 2005 struggling to get people on board for our services.

“The collaboration between the private and the public sector has been there since 1991, and since our very first days of independence.

“The government has had to work with the private sector and they’ve formed a symbiotic relationship where one is in service to the other, and the other way around,” says Park.

Kertti Merimaa, vice president of Nortal Estonia, which built around 40% of Estonia’s digital infrastructure including its national patient records, says: “When we collaborate, it comes with a whole life cycle of the innovation starting out with a good idea, really consulting with the policy changes and only then moving towards digitisation.”

Estonia’s approach shows that digital transformation involves a sustained, system-wide effort built on trust, transparency and collaboration.

From starting small and proving value, to embedding data sharing across the system, progress has come through persistence rather than perfection.

Maybe something the NHS can learn from?