Discussion including overall findings, impact, implications and recommendations

Overall findings

Core lessons on the roll-out of the NHS App

In this section, we draw together the findings of our studies to bring together some interlinked reflections on the success of the roll-out of the NHS App – and also make a number of recommendations for policy, practice and future research.

The key messages which we have taken from this study are that:

1. Adoption of the NHS App has been high.
2. Adoption was, initially, driven by events around COVID – and in particular the introduction of the COVID Pass feature.
3. Different functions of the NHS App have been used to different extents, and with different patterns over time.
4. Roll-out has not been equal across different populations.
5. The app has done a good job on seeking to understand and build for patient needs. There is a need to focus more on understanding and meeting practitioner needs with further development of the NHS App.
6. There is an unresolved question about whether the NHS App represents ‘an app for the NHS’ or ‘the app for the NHS’.
7. NHS login – with a single account and linked data – present real opportunities for research and for tailoring patient offers, but as yet cannot be fully utilised.

We will explore each of these key messages in detail, and suggest specific policy, practice and research activities to be taken forward.

Adoption of the NHS App has been high

The first, and perhaps most important assessment, is that the adoption of the NHS App has been high. This can be observed in both the time frame that we studied in detail, and in the subsequent progress of the app roll-out. In December 2023, it was announced that it was being used by 75% of the UK adult population. This showed a steady if gentle increase from its figure of 68% in 2023. By the standards of most health systems around the world, this represents a substantial success. And given the scale of the NHS, marks it out as a unique national capability and resource to be built on. The UK parliamentary select committee on health and social care gave the NHS App a ‘good’ report on meetings its stated commitment on uptake – including using invited data from our study to make this assessment.

On a more reflective note, while the percentage of adults who have downloaded the app is a good top-level metric of adoption, it is simplistic compared to other measures of use and adoption. In particular, whether people download it once and then forget, or keep coming back to it, because they find it presents a significant and meaningful ongoing offer. In addition, our data in Chapter 3 suggested that there is a discrepancy between the numbers who download the app, and the numbers who are registered to use it with different levels of engagement.

The adoption and roll-out has been substantially influenced by external events

The second simple point to make about the adoption of the NHS App was not linear, but was driven by events in the wider world. In particular, the COVID pandemic drove the adoption of adoption, both in the initial lockdown phase, and then with the introduction of the COVID Pass on the app. An examination of the cumulative frequency charts of NHS App adoption show, in a simple observational analysis, that there are different rates of adoption on the app at different time points. These be broken down into:

1. pre COVID-19 – from launch of the app, to the start of the COVID pandemic, there was a gentle, if slow, growth in app adoption
2. initial COVID-19 response – app adoption started to increase rapidly in the period immediately after the lockdown
3. COVID-19 Pass functionality – after the introduction of the COVID Pass feature, adoption increased at its most rapid rate
4. post COVID-19 recovery and slow growth with addition of further features, a steady but shallow climb from its post COVID Pass plateau, to its current levels of 75%.

The nature of this adoption is by nature unlikely to be easily reproduced for other product launches, or launches of similar services in other health systems. In many ways, the COVID use cases presented a Trojan Horse to get the app used by and in the phones in the pockets of the majority of the population. However, while hard to recreate, this presents a genuine rare opportunity to make the most use of these events – and go with the grain of this almost enforced adoption.

In order to do this, the app needs to prove its worth as a regular and routine feature of health system access for a large part of the population. The health IT literature is well populated with examples of ‘one use and done’ apps which have high initial use and then tail off. The challenge for the NHS App is to retain its relevance, by providing the feature the patients really want, and that make NHS practitioners lives easier. If the app can be transformed into a platform that people want to come back to, again and again, it will enable it to become a mainstay of the NHS activity – and have the potential to become a genuine single ‘front door’ to many NHS services.

Different functions have been used to different extents

Beyond the nature of overall adoption patterns of the app, the real functionality of the app comes from how patients choose to make use of the different services it provides. One of the key findings of this report is that the app has several different functions – and they are used very differently, over time and by different groups of the population.

As discussed above – Single metrics of app adoption and usage do not tell the whole story. The functions provided by the app are broad, and have different use to different groups, reflecting on how useful they are to the public, but also how workable they are for the practices. Some have proved more popular than others and better meet the needs of the users. Some functions are clearly ‘hits’ – notably the use of prescriptions. In the language of digital development, this may represent the ‘killer app’ which drives regular use, particularly for certain key demographics, including those who are older and have long-term conditions – requiring them to frequently use repeat prescriptions.

Others are clearly popular, but usage is variable, and often dependent on whether the practices have the choice to make use of the feature – or the extent to which they have used it – for example, with appointment bookings (where the practice can choose not to use, or choose to use only for a limited number of appointments) and access to the care record – where access varies by practice – with some people seeing more than others.

Roll-out has not been equal across different populations

A further key finding is that roll-out has not been equal across different populations, leading to real risks of widening inequalities in health system access. Our data – which are limited and only at the ecological level – show clear variation in usage patterns by a number of characteristics.

Many of these gradients reflect well-established issues in healthcare provision well described by the inverse care law90 – with those in greatest need of services often least well served or least likely to access those services.

Here, we urge caution and further work to study these patterns of variation – what can be done to mitigate them, and when they cannot be easily mitigated, what can be done to make sure services can still be accessed by those with less access.

Less focused on practitioner needs

A more nuanced reflection from our findings is about who the app is designed and optimised for. It was clear from our work with the technical team building the product that an extensive amount of user testing with the public had been undertaken. However, while the roll-out has had a strong focus on user research and user needs for the public, it has not perhaps been as focused on user needs with practitioners, in particular GPs and practice staff who are required to promote/gatekeep the use of the app – often receptionists and practice managers.

Efforts primarily focused on development of the app and user-centred design mode. However, regarding the continued use and implementation at scale, unclear about whose remit it is, what does it mean to implement a complex technology that services different functions for different practices, focus is mainly on people and less on the NHS ecosystem.

We also noted that there was sometimes a lack of clarity regarding integrated care that is how primary and secondary care services communicate and how the different systems operate/whether it is accessible through the NHS App.

An app or the app?

The question of where the app fits in relation to the wider economy of digital offerings for primary care – including incumbents from private enterprise – remains unresolved. There remained a confusion regarding the purpose of the app, for whom it is intended and critically its position related to other competitors. While the app has proven successful, there is a persistent and continuing busy ecosystem of other digital services and apps that provide many of the features offered by the app.

The constantly changing features of the app pose further challenges, particularly for potential competitors, who may now be cautious of entering the market – if they can be replaced by the national offer at short notice.

Clear signalling to industry of their anticipated role – whether they can build into the app ecosystem, and what is due to be developed in the pipeline by the central NHS App team would all be important to allow industry to better collaborate.

National Health Service login

The backbone identity service that supports the NHS App, known as NHS login, provides the ability for the public to have a personal linked account with the NHS, and linked to their medical records and accompanying data. This is a potentially powerful tool for both linked services, personalised recommendations, and to provide powerful, personalised data for both service planning and research. At present, there is a technical ability to link data on app use with data on outcomes, diagnosis and service utilisation – however, it is not currently possible to link these data within existing consent approaches and information governance legislation. The app may represent a powerful tool for the future digitalisation of the NHS – but there needs to be an appropriate and trusted mechanism for data sharing and linkage.

Impact and learning

We believe the project has been impactful in that it has (1) provided information directly to the Health Select Committee in Parliament at their request on the effectiveness of digitisation in the NHS, (2) provided direct feedback to the policy and delivery team developing the app, to allow them to improve their product iteratively, and (3) contributed to a wider community of literature for academics and practitioners developing digital health interventions through contribution to the wider literature and discussion.

Providing information to Parliament

The programme team was approached by the Health and Social Care Select Committee of the Houses of Parliament, looking at digital transformation in the NHS in 2023. The inquiry explored the use of digital technology and examined how it needs to change to deliver an improvement in services and outcomes for patients. The inquiry approached our team and asked us to provide a submission. We created a bespoke evidence submission, responding to the specific questions they asked, with emerging findings from both the quantitative and qualitative aspects of the study91 and also included in Appendix 5 and Table 10.

Our findings were cited 14 times in the evaluation report of the select committee92 and used both as evidence of the success of the app in some respects around (1) high levels of uptake and use, (2) increasing a sense of control for patients managing their own health and (3) high levels of use of particular functions including the access to repeat prescriptions. However, our evidence was also used to highlight issues around (1) inequalities in access by demographics, (2) the lack of dedicated funding and support for GP practices to roll it out, (3) potential for increases in GP workload, (4) uneven availability of app functions across GP practices and (5) the need for a clear long-term strategy for the app. This led to the NHS App being rated overall as being ‘Good’ in terms of meeting the government’s commitment, but ‘Requires Improvement’ overall when also considering aspects of resourcing, impact and appropriateness.

The government response to this report noted the findings and highlighted a number of specific actions being taken to improve accessibility of the NHS App, including the use of proxy access, use of a patient and user panel to improve user understanding, and use of campaigns and wider media channels to reach wider groups.93

Direct feedback to the team

By working directly with the team (as described in Chapter 6), we were able to feedback findings each month to the NHS App delivery team. This allowed us to share findings, discuss interpretations, and suggest improvement to the programme delivery.

Many of our findings reflected their own experiences of running the programme, in particular the popularity of certain core functions including repeat prescription. However, we were able to provide novel analysis that they had not seen before, including the variation in access and the corresponding inequalities regionally and with populations with particular protected characteristics. This led to our work being presented to the NHS inequality board, and issues around inequalities being escalated within the thinking of the delivery team. While it is hard to demonstrate a direct causality, it is noticeable that specific delivery activity to reduce inequalities was initiated after the provision of our findings (which were also supported by their own user studies), including further user research on the needs of different ethnic groups, work to translate app content into different languages and work to increase engagement in digital channels target at diverse ethnic groups.

Wider academic and research dissemination

As well as informing the evaluation of this specific programme, the findings of this research should be generalisable to other similar developments and roll-outs of digital interventions. A full list of publications, conference presentations and public engagement events are included in Publications. In addition, we have prepared the following one-page summaries of simple messages on our findings from this project for three core groups: policy-makers and service commissioners, NHS teams working with the app, and patients.

Further funded project building on this work for Claire Reidy. Project title: A focused exploration of the experiences and perspectives of digital inclusion and exclusion for specific community groups accessing and using the NHS App. Lead: Claire Reid. Amount: £10,000. Funder: NIHR Applied Research Collaboration Oxford and Thames Valley.

Implications for policy-makers

Based on the overall findings regarding the roll-out of the NHS App, here are specific recommendations for policy and practice:

• Understanding usage patterns: while adoption of the NHS App has been high, it is essential to delve deeper into usage patterns beyond simple download statistics. Policy-makers should prioritise understanding how frequently users engage with the app and which features are most meeting the needs of their users. They should publicly report usage and adoption metrics by protected characteristics on a regular basis. This can inform ongoing development and improvements to ensure sustained usage.
• Addressing inequality in roll-out: take proactive measures to mitigate disparities in app adoption across different populations. Identify and address barriers to access, particularly for marginalised groups, to prevent widening health inequalities. Implement strategies to ensure equitable distribution and utilisation of digital healthcare resources – for example, through structured community outreach into groups with lower usage patterns.
• Engaging practitioners: place a stronger emphasis on understanding and meeting the needs of healthcare practitioners, such as GPs and practice staff, who play a crucial role in promoting and facilitating app usage. Involve practitioners in the development process and provide training and support to maximise their engagement with the app. The NHS App team should publicly report on the proportion of practices using various features – for example, appointment booking – on a regular basis to demonstrate primary care adoption.
• Support healthcare provider engagement: establish policies to support healthcare providers in engaging with and promoting the use of the NHS App among their patients. Provide incentives, training, and resources to encourage providers to integrate the app into their practice and actively promote its adoption.
• Clarifying purpose and positioning: provide clear communication regarding the purpose of the NHS App and its position within the broader landscape of digital healthcare services. Establish its unique value proposition compared to other competitors and articulate its role in improving healthcare delivery and patient outcomes.
• Foster collaboration and innovation: foster collaboration between government agencies, healthcare providers, technology companies, and other stakeholders to drive innovation and improvement in digital healthcare services. Encourage the development of interoperable systems and open standards to facilitate seamless integration and data exchange between different healthcare platforms.
• Evaluate impact and effectiveness: implement policies to monitor and evaluate the impact and effectiveness of digital healthcare initiatives like the NHS App. Collect and analyse data on adoption rates, usage patterns, and outcomes to assess whether these tools are achieving their intended goals and identify areas for improvement.
• Enhancing NHS login: recognise the potential of NHS login as a powerful tool for personalised healthcare services and data-driven insights. Address regulatory and governance challenges to enable secure data sharing and linkage, ensuring that user privacy and consent are prioritised.
• Capitalising on external events: acknowledge the role that external events, such as the COVID pandemic, played in driving adoption. Use this as an opportunity to solidify the app’s place as a regular and essential tool for accessing healthcare services. Continuously demonstrate its value beyond crisis situations to encourage continued usage.

Implications for practice

• Promote app adoption: actively promote the adoption of the NHS App among your patient population. Provide information and resources to educate patients about the benefits of using the app for tasks such as appointment booking, prescription management, and accessing medical records.
• Ensure equitable access: be mindful of potential disparities in app adoption across different patient demographics. Take proactive measures to ensure equitable access to the NHS App for all patients, including those from marginalised or underserved communities.
• Train staff: provide training and support to healthcare staff, including receptionists and practice managers, to effectively promote and support the use of the NHS App among patients. Ensure that staff are knowledgeable about the app’s features and can assist patients with any questions or issues they may encounter.
• Integrate the app into your workflow: integrate the NHS App seamlessly into your practice’s workflow to maximise its efficiency and effectiveness. Ensure that appointment bookings made through the app are seamlessly integrated into your scheduling system, and that prescriptions requested through the app are processed efficiently.
• Collect and act on feedback: regularly collect feedback from both patients and staff about their experiences with the NHS App. Use this feedback to identify areas for improvement and make necessary adjustments to enhance the app’s usability and functionality.
• Prioritise data security: prioritise the security and privacy of patient data when using the NHS App or any other digital healthcare tool. Ensure that appropriate safeguards are in place to protect patient information and comply with relevant data protection regulations.

Implications for patients

• Stay informed and engaged: keep yourself updated about digital healthcare offerings like the NHS App. Stay informed about the features it offers and how it can benefit you in accessing healthcare services more conveniently.
• Explore app features: take the time to explore the different functions of the NHS App to see which ones are most relevant to your healthcare needs. Whether it is managing prescriptions, booking appointments, or accessing your medical records, familiarise yourself with the features available to you.
• Provide feedback: if you encounter any issues or have suggestions for improvement while using the NHS App, do not hesitate to provide feedback. Your input can help shape future updates and enhancements to make the app more user-friendly and effective.
• Advocate for equitable access: be aware of potential disparities in app adoption across different populations and advocate for equitable access to digital healthcare resources. Encourage efforts to address barriers to access for marginalised groups to ensure that everyone can benefit from these technologies.
• Communicate with healthcare providers: keep your healthcare providers informed about your use of the NHS App and how it fits into your healthcare routine. Discuss any concerns or questions you may have about using digital healthcare tools to ensure that they align with your overall care plan.
• Protect your privacy: be mindful of your privacy and data security when using the NHS App or any other digital healthcare platform. Familiarise yourself with the app’s privacy policies and settings to understand how your personal information is being used and protected.

Recommendations for future research

Building on the findings of this project, we suggest some areas for potential future work – both looking at the NHS App in particular but also looking at other comparable lessons for digital health technologies and patient portals. Our recommendations focus on improving the evaluation process, enhancing data linkage capabilities, addressing inequalities in access, and supporting the integration of digital tools into healthcare delivery more effectively.

Enhancing data linkage for comprehensive evaluation

Given the challenges faced in linking data at both practice and individual levels, future research should focus on developing and testing new approaches for data linkage that are feasible within current governance and privacy constraints. Research could also examine alternative legal and consent frameworks that facilitate data linkage for research purposes while maintaining public trust.

Longitudinal studies on app usage and health outcomes

To better understand the long-term impact of the NHS App and similar digital tools on health outcomes and healthcare utilisation, longitudinal studies are recommended. These studies should aim to track individuals’ app usage patterns over time and correlate these with changes in health behaviours, access to care, service utilisation, and health outcomes. This would require overcoming current barriers to person-level data linkage but would provide invaluable insights into the effectiveness of digital health interventions.

Evaluating the impact of digital tools on healthcare inequalities

The findings suggest that the roll-out of the NHS App has not been equitable across all populations, potentially exacerbating existing health inequalities. Future research should focus on identifying the specific barriers to app adoption and use among marginalised and underserved communities. This includes qualitative research to understand the unique needs and preferences of these populations and developing targeted interventions to increase accessibility and usability of digital health tools.

Exploring the integration of digital health tools into clinical workflows

Research is needed to explore how digital tools like the NHS App can be better integrated into clinical workflows to support healthcare providers. This includes understanding the barriers and facilitators to the adoption of digital tools by healthcare professionals and investigating how these tools impact clinical practices, patient–provider interactions, and overall healthcare delivery efficiency.

Assessing the effectiveness of public engagement and consultation in digital health projects

Given the complexities around data sharing and linkage, as well as the potential for digital tools to impact public trust in the healthcare system, research into effective methods of public engagement and consultation is critical. This should include evaluating different strategies for involving the public in the development and implementation of digital health projects and assessing how these strategies impact public trust and acceptance.

Comparative studies on digital health platforms

Future research could benefit from comparative studies that evaluate the NHS App against other digital health platforms, both within the UK and internationally. Such studies could identify best practices, innovative features, and successful strategies for user engagement that could inform the ongoing development of the NHS App and other digital health initiatives.

Specific interventions to increase NHS App effectiveness and access:

In addition to the general research recommendations above related to digital health interventions and patient portals, there are specific recommendations for the NHS App that should be considered.

Design of the app

Further and ongoing user research should be undertaken to ensure that that the app is as usable and useful as possible – as part of the regular product development cycle for the app, and as new functions are added or improved.

Understand and optimisation of how the app is used in general practice

Building on our findings, further work should explore the mechanism by which the NHS App is used in general practice, how it alters workflows and displaces or reduces work, and how it can be optimised to safely improve efficiency and productivity within clinical pathways.

Evaluation of interventions to broaden access

The results have demonstrated inequalities in access to the NHS App. Specific interventions – including recommendations for support within general practices, and in wider civic society should be evaluated to see what benefit they achieve in widening access and reducing inequality – for example, NHS England’s new work to use libraries staff and volunteers to support access to the NHS App94 should be evaluated to see the impact it creates.