"Sure Start" for Teenagers in a Digital Age — An Exemplar Community Plan for Adolescent Health and Transition

At a glance

A new exemplar community plan for adolescent health, prepared for ICB and Community Trust planning teams, sets out how trusted people, accessible places and a connected digital layer can deliver a modern "Sure Start for Teenagers" — at the moment when national policy, funding and emerging local practice are converging behind exactly this model.

• Aligns with NHS England's 8 April 2026 transition guidance, the Youth Matters national youth strategy (£350m for up to 250 youth facilities; £70m for 50 Young Futures Hubs by 2029), the 10 Year Health Plan and Core20PLUS5 for children and young people
• Builds on emerging practice in East London (HealthSpot, Spotlight) and Bradford (school-based health hubs, Education Alliance for Life Chances)
• Positions the Digital Health Passport (DHP) as the young person–controlled digital bridge connecting care plans, self-management tools and local services across health, education and community settings
• Independently evaluated DHP outcomes: 96% user satisfaction, £8.21 ROI per £1 spent over three years, and statistically significant improvement in asthma symptom control
• Phase 1 standalone deployment can go live within weeks via G-Cloud, ahead of ICB single planning document submissions in mid-May 2026

📄 Download the full whitepaper (DOCX)

Author: Dr Greg Burch, Joint CEO & Clinical Director, Tiny Medical Apps. April 2026.

Important notice: This whitepaper has been written by Dr Greg Burch of Tiny Medical Apps Limited. It does not represent the views, policies or endorsement of any other organisation mentioned within the document, including those cited as exemplar projects or potential partners. Organisations are referenced for illustrative purposes only.

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Executive summary

Across England, a new approach to adolescent health is beginning to take shape — one that recognises young people are best supported not through fragmented services, but through connected, community-based models that meet them where they are.

National policy is now aligning behind this shift. NHS England's transition guidance, the government's Youth Matters strategy, and the 10 Year Health Plan all point toward a future where care is delivered through neighbourhood health models, supported by education, community organisations, and digital tools.

In practice, this is already happening:

• In East London, partnerships between youth services such as Spotlight and NHS providers have demonstrated how health support can be delivered effectively within youth settings — an approach often described as a modern "Sure Start for Teenagers."
• In Bradford, local partners including the Education Alliance for Life Chances are developing school-based health hubs, bringing health professionals directly into schools and tailoring support to the needs of each community.

These approaches share a common principle: young people are more likely to engage with care when it is accessible, trusted, and part of their everyday lives.

This whitepaper draws together these emerging place-based models into a simple, connected framework:

• People — trusted adults, health professionals, and peer support
• Places — youth clubs, community settings, and schools
• Digital — tools that enable continuity, self-management, and connection across services

While significant investment is now being directed into physical spaces — youth centres, schools, and community hubs — one critical element remains underdeveloped: how young people manage their health between interactions, and how care follows them across settings. Without a connected digital layer, there is a risk that this investment will recreate the same fragmentation in new settings.

The Digital Health Passport (DHP) is designed to support this layer. It does not replace existing NHS systems or services. Instead, it provides a young person–controlled digital bridge, connecting care plans, self-management tools, and local services across health, education, and community environments. By linking into NHS Login and aligning with national digital architecture, the DHP enables local innovation to scale.

"The Government is investing in services for young people and the NHS is developing tailored support for teenagers. There is an opportunity to address the communication gap between the NHS, council services with young people at the centre." — Dr Greg Burch, Joint CEO & Clinical Director, Tiny Medical Apps

Policy alignment

Three major national policy pillars have converged simultaneously, creating both the mandate and the funding landscape for this model.

NHS England transition guidance (8 April 2026)

The guidance sets out proposed actions for ICBs, providers and clinical teams to enable safe and effective transition for 0–25-year-olds. It explicitly requires ICBs to commission developmentally appropriate care, naming digital tools, community services, VCSE partners, social prescribing, neighbourhood multidisciplinary teams and education providers as essential commissioning partners. It references SEND, learning disability, looked-after children and care leavers — all priority cohorts for this model.

Sir James Mackey's planning framework (April 2026)

ICBs must provide a single planning document via regional teams by mid-May 2026, covering neighbourhood health models, proactive care, and the NHS App as digital front door. The adolescent transition section of these plans is precisely where this exemplar strategy is designed to be incorporated.

Youth Matters: Your National Youth Strategy (December 2025)

The government's ten-year cross-departmental plan commits £350 million for up to 250 new or refurbished youth facilities, £70 million for 50 Young Futures Hubs by March 2029, and £60 million for a Richer Young Lives Fund. Its two stated ambitions by 2035 are halving the participation gap in enriching activities between disadvantaged young people and their peers, and giving 500,000 more young people access to a trusted adult outside their home.

The 10 Year Health Plan and Core20PLUS5

The 10 Year Health Plan positions the NHS App as the digital front door to the NHS. Core20PLUS5 for children and young people identifies asthma, diabetes, epilepsy, oral health and mental health as clinical priority areas. The Sure Start for Teenagers model addresses all five through its integrated People, Places and Digital approach, with particular strength in reaching deprived and ethnically diverse communities as demonstrated by independent evaluation.

The problem this solves

There are 12 million people aged 10 to 25 in England — 18% of the population. This is one of the most formative phases of life, yet young people are too often let down by a healthcare system designed around children or adults, but rarely for those in between. The NHS England transition guidance acknowledges that unsupported transition leads to poorer health and social outcomes, reduced disease control, lower social participation and diminished educational achievement.

The following case studies illustrate the real-world problems this model is designed to solve.

Case study 1 — Marcus: the teenager at the youth club

Marcus is 15 and attends his local youth club three evenings a week for the boxing programme. He has been permanently excluded from school for repeated behavioural incidents. His youth workers recognise the pattern: difficulty regulating emotions, sensory overload, rigid thinking, and an inability to read social cues. Marcus is clearly neurodivergent, but he has never been assessed.

Without the model: Marcus falls through every gap. He is not in school, not under CAMHS, not on any pathway. His youth club is the only stable point of contact, but it has no connection to health services. He reaches 18 with no diagnosis, no support plan, and no route into adult services.

With the model: Marcus's youth workers are trained jointly with HealthSpot GPs in recognising neurodivergence and initiating appropriate referrals. The HealthSpot GP at the youth club conducts an initial holistic health assessment in a setting where Marcus feels safe, with his trusted youth worker present. A referral for neurodevelopmental assessment is initiated. The DHP holds Marcus's emerging care plan, accessible to his GP, the youth club, and any future education or employment provider he consents to share with. The boxing continues.

Case study 2 — Priya: the 14-year-old young carer

Priya is 14 and cares for her mother, who has multiple sclerosis. Alongside this, she manages her own health: moderate persistent asthma requiring regular review and medication. She is under 16, so she cannot use online triage systems independently. She cannot call during surgery hours because she is in school. Over six months, Priya's asthma control deteriorates and she attends A&E twice with exacerbations that could have been prevented.

With the model: Priya is seen at a local youth or school-based health hub, at a time that works for her — without age barriers or complex booking systems. A clinician reviews her asthma, updates her action plan, and records it on the DHP. Her care plan is now visible to her GP and school nurse. The DHP provides medication reminders and sends alerts on high-risk days for air quality or pollen. Through the DHP "My Area" function, Priya is connected to local young carers' support. Care becomes planned, visible, and continuous — rather than reactive.

Case study 3 — Jayden: the care plan that can't be seen

Jayden is 17, has epilepsy and anxiety, and is under two community providers. He also sees a school nurse, his GP, and a social prescriber. None of these professionals can see each other's care plans. His epilepsy rescue protocol, written by his community paediatrician, is not visible to CAMHS. His anxiety management plan is not visible to his GP. He is approaching his 18th birthday and will transfer to adult neurology and adult mental health — two further providers who will start from scratch.

With the model: Jayden's DHP holds his clinician-approved epilepsy rescue plan, his anxiety management plan, and his self-management goals in a single, young-person-controlled platform. Every consented care provider — across both community trusts, his GP, his school, and his future adult services — can view the plans Jayden chooses to share. The DHP does not replace any clinical record system; it holds the self-management layer that connects to everything else.

People — professionals, community and peers

The NHS England transition guidance is clear: staff across paediatric, adolescent and adult services must have the skills, competencies and knowledge to work with, engage and empower young people. Research cited in the guidance demonstrates that employing youth workers as the bridge between young people, their parents and multidisciplinary teams is effective. The Leeds Teaching Hospitals case study shows youth workers embedded in speciality services including oncology, diabetes, cystic fibrosis and rheumatology.

The Sure Start model extends this principle into community settings:

• GPs trained in adolescent health — delivering extended GP services in youth settings, with access to registered patient records where available within the borough
• Youth workers — the trusted adults who build relationships, support referrals, accompany young people to appointments, and provide continuity when clinical teams change at transition
• Peer supporters — young people with lived experience who support others navigating long-term conditions, mental health challenges, or the transition process
• School nurses and community practitioners — connected through shared care plans on the DHP, able to view and contribute to the young person's self-management record

Places — youth-friendly health hubs

The HealthSpot model

HealthSpot, developed in Tower Hamlets in partnership with Spotlight (Poplar HARCA's award-winning youth service), is one of the clearest examples of how youth settings can successfully deliver health support. The concept of a "Sure Start for Teenagers," originally articulated by Spotlight and now influencing national thinking on youth health provision, reflects a growing recognition that young people need accessible, community-based support that mirrors the early years model.

It offers GP appointments in a community youth setting, with youth worker support at every step of the referral and consultation process. HealthSpot is dedicated to supporting young people aged 11–19 (up to 25 where additional needs exist). The model has been replicated across East London — including in Hackney and Newham. In Hackney, the first-year pilot delivered over 800 appointments and received 256 referrals. The service reached highly vulnerable populations: 57% had a social care history, 29% had special educational needs, and 40% were eligible for free school meals. Satisfaction was outstanding, with 92% rating the service "Good" or "Excellent" and 95% stating they would return.

The HealthSpot model aligns directly with the Youth Matters commitment to build or refurbish up to 250 youth facilities and launch 50 Young Futures Hubs by 2029.

Youth clubs as health settings

Youth clubs are where young people already are. They are trusted, familiar, and free from the stigma and access barriers that prevent many young people from engaging with traditional health services. Each participating youth club or community space becomes a node in the neighbourhood health network, offering:

• Extended GP sessions at times that work for young people (evenings, weekends)
• Youth worker–supported health consultations and referral navigation
• Sexual health, mental health and wellbeing drop-in support
• DHP onboarding and digital self-management coaching
• Social prescribing and signposting to local services via the DHP "My Area" function

Schools as neighbourhood health hubs — the Bradford exemplar

While youth clubs provide a vital access point for many young people, schools remain the one setting that reaches almost every child, particularly in areas of deprivation. In Bradford, this principle is being put into practice through an emerging model of school-based health hubs, led by local partners including the Education Alliance for Life Chances.

Under the leadership of Kathryn Loftus, this approach recognises a simple but often overlooked truth: young people with long-term conditions or additional needs are far more likely to engage with support when it is brought to them in familiar, trusted environments rather than expecting them to navigate complex or out-of-reach health systems.

The Bradford model tailors provision at a postcode and catchment level, reflecting the specific needs of each school community. In practice, this means:

• Health professionals working directly within schools, alongside pastoral teams
• Targeted support for young people with long-term conditions, SEND, or unmet health needs
• Early identification and intervention based on local population need
• Integration with wider initiatives such as Living Well Schools and local public health priorities

In this context, the DHP acts as the connector — ensuring that care plans, self-management tools, and local services travel with the young person across settings: school, home, GP, and community services.

GP and community trust integration

The practical question every ICB planning team will ask is: how does this connect to what we already have? The answer: sequentially, starting simple and building outward.

The greenfield principle

The DHP is not a replacement for any NHS or social care clinical record system. It does not attempt to duplicate, compete with or override GP systems, community trust records, or acute EPRs. It occupies a greenfield: the patient-held self-management layer that no existing system adequately provides for young people.

This greenfield holds:

• Clinician-approved care and emergency plans
• Self-management goals, coaching and education
• Medication reminders and adherence support
• Health and wellbeing tracking (including validated patient-reported outcome measures)
• Environmental risk alerts (air quality, pollen, weather)
• Localised service information and signposting

Every element is focused on self-management and is controlled by the young person.

Sequential integration

Digital — the Digital Health Passport

Platform overview

The Digital Health Passport is a young person–controlled self-management platform designed to sit alongside — not replace — existing NHS clinical systems. It provides:

• Clinician-approved care plans and emergency protocols, viewable by consented professionals
• Medication reminders, adherence tracking, and coaching
• Health and wellbeing tracking using validated patient-reported outcome measures
• Environmental risk alerts (air quality, pollen, weather) linked to the young person's conditions
• "My Area" — localised service information and signposting, configurable by ICB and Local Authority
• A clinician portal for care plan creation, review, and population-level analytics
• A deployment dashboard providing real-time usage data for commissioning teams

NHS Login and the NHS App ecosystem

The DHP uses NHS Login as its authentication layer. This is a deliberate architectural choice with three important consequences:

1. Single identity across the NHS — the young person uses the same verified identity they will use for the NHS App, GP online services, and any future NHS digital service.
2. Alignment with the 10 Year Health Plan — the NHS App is positioned as the digital front door to the NHS. The DHP connects into this ecosystem through NHS Login.
3. Trusted two-way linkage to community providers — because the identity is NHS Login–verified, community providers (youth hubs, community trusts, Local Authority services, VCSE organisations) can trust that the young person is who they say they are, and the young person can trust that the provider accessing their care plan is legitimately consented.

Critically, whilst using the same NHS Login authentication as the NHS App, the DHP is fully customisable at a community level. ICBs and Local Authorities can configure local content, pathways, services and signposting through the CMS and "My Area" pages without any changes to national infrastructure. One lock and key, many rooms.

Standards and assurance

The DHP holds UKCA Class I marking (with EU MDR Class IIa upclassification in progress), is recommended by NICE, and carries the following certifications: ISO 13485 (Quality Management for Medical Devices), ISO/IEC 27001 (Information Security), Cyber Essentials Plus, DTAC (Digital Technology Assessment Criteria), and DCB0129/0160 (Clinical Safety). The platform is available on G-Cloud and can be commissioned without separate procurement.

Evidence of impact

The DHP has been independently evaluated by UCLPartners (Cheema & Burch, 2025). Key findings include:

• 96% user satisfaction
• £8.21 return on investment per £1 spent over three years, driven by avoided urgent and emergency care and improved productivity
• Statistically significant improvement in asthma symptom control (2.64-point improvement on the Asthma Control Test, exceeding the age-appropriate minimally important difference of 2 points for adolescents)
• Strong reach into deprived and ethnically diverse communities, with high representation from Core20PLUS5 populations
• High engagement and intent to continue use across the cohort

Commissioning and implementation

Commissioning route

The DHP is available on G-Cloud and can be commissioned per population footprint without a separate procurement exercise. Licensing is transparent, banded and scalable, supporting use by ICBs, Local Authorities, provider collaboratives and cross-system partnerships. HealthSpot commissioning follows existing extended GP access and youth service funding routes.

Phased rollout

Cost

DHP licensing is banded and capped by population footprint, ensuring predictable costs at scale with no capital investment required. HealthSpot delivery costs depend on local GP and youth service commissioning arrangements but are designed to operate within existing extended access and youth service funding envelopes. Joint training is available through G-Cloud Lot 3.

Conclusion and next steps

The evidence, the policy alignment, and the emerging practice across England all point in the same direction: young people need connected, community-based health support that meets them where they are, follows them across settings, and gives them control over their own care.

The Sure Start for Teenagers model brings together three elements that are too often developed in isolation: trusted people, accessible places, and a connected digital layer. Each is necessary; none is sufficient alone. A youth club without clinical input cannot address unmet health needs. A GP service without trusted relationships cannot engage the young people who need it most. And without a digital bridge, care plans remain siloed, transitions remain unsafe, and the investment in people and places risks recreating the same fragmentation in new settings.

The planning window is immediate. ICBs are preparing single planning documents for regional teams by mid-May 2026. The adolescent transition section of those plans is precisely where this model is designed to sit.

Next steps for commissioners

We invite ICB CYP leads, Directors of Public Health, Directors of Children's Services, and community trust leaders to take the following steps:

• Request a briefing. A 30-minute call with Dr Greg Burch to discuss how the model could be tailored to your ICB footprint, population needs, and existing partnerships. Contact hello@tinymedicalapps.com or 0207 859 4169.
• Include adolescent digital self-management in your planning submission. The DHP can be referenced as a commissioned or planned digital tool within the adolescent transition section of your ICB plan.
• Commission a scoping phase. A Phase 1 standalone deployment can be live within weeks via G-Cloud, with no integration dependencies.
• Identify local delivery partners. Consider which youth settings, schools, and community organisations in your footprint could host HealthSpot-style GP sessions or act as DHP onboarding sites.

A note on partnership

This document reflects emerging practice across multiple organisations working to improve outcomes for young people. TMA is working alongside expert partners including Spotlight and the HealthSpot programme, Bradford partners including the Education Alliance for Life Chances, and national charities such as YoungMinds. The organisations referenced are cited as exemplars of good practice; any formal collaboration or endorsement is subject to the agreement of the organisations concerned.

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📄 Download the full whitepaper (DOCX)

© Tiny Medical Apps Limited 2026. Author: Dr Greg Burch, Joint CEO & Clinical Director. Contact: hello@tinymedicalapps.com.