The NHS App was developed as a ‘digital front door’ to England’s NHS. This project aimed to identify and understand the use and acceptability of the NHS App, to measure the extent to which it improves patient experience and influences health service access, and to understand patterns of early take-up and participation.
The NHS App was rolled out in 2019 across the NHS in England at the direction of the Secretary of State for Health and Social Care. The app was launched with core features, including prescription ordering, access to test results and people’s own health records, general practitioner (GP) appointment booking, organ donation preference setting and display of the user’s NHS number and GP surgery details.1 It is also linked to a symptom checker and the NHS 111 service, and over time, it has integrated with further services, such as the COVID-19 vaccine pass, accessing vaccination and other health records, receiving messages regarding care, managing secondary care appointments, viewing hospital waiting times and receiving online consultations. Modifications within the app have been informed by user research.2,3 As of December 2023, there have been over 33 million downloads of the app,4 representing 75% of UK adults.
National Health Service England’s initial goals for the app were to improve access to primary care services, improve patient experience, save time in GP practices and promote self-care. There was no planned national evaluation of this app, which was introduced as a policy priority and constituted a novel complex intervention with potentially wide-ranging impacts on the use of healthcare services. This project is therefore important and timely as it provides the only national evaluation of a major component of the central plan to digitally transform the NHS.
The roll-out of the NHS App was in line with a general political discourse and drive towards harnessing digital tools for health care and was tied in with the roll-out of the NHS login. The NHS Long Term Plan5 set out the ambition for all patients in England to have the right to access digital consultations from their GP, while NHS England’s ‘digital first’ strategy, aimed to direct patients away from in-person engagements, through telephone, online or video consulting before face-to-face consultations.
The introduction of the NHS App also needs to be seen in the wider context of access to primary care services. Strategies to improve access to primary care services include several national initiatives, such as the Modern General Practice model in England, which focuses on ensuring equitable and easy access to care across multiple channels using optimised telephone systems, well-designed practice websites, as well as using digital tools such as the app. These approaches align with a global commitment to prioritise primary care access, as outlined in the WHO Declaration of Astana, which emphasises the significance of primary health care in achieving universal health coverage and supports the use of technologies to improve access to care and to involve individuals in their healthcare decisions.6 They also reflect on patient and public views regarding priorities for improving the NHS, with ease of access to GP appointments highlighted as one of the top two concerns.7
The delivery of the NHS App was led by NHS England and built by NHS Digital.8 Responsibility for the NHS App was taken on by NHSX, with NHS Digital remaining the main delivery partner. There was a rapid roll-out plan, with full national usability for all practices by July 2019 in England,1 and all patients with a long-term condition to have access to their care plan through the NHS App by 2020, through the Summary Care Record. However, by February 2020, a political shift from an app with ‘huge functionality’ to a ‘thin app’ as a platform for industry to integrate with (in the context of other apps from the digital health industry offering some similar features),9 and followed by the COVID-19 pandemic, which had some impact on this national roll-out. Over time, other competing apps (such as the NHS COVID-19 App) were at the forefront of NHSX’s delivery campaign. There was also an introduction of ‘total triage’ for patients in primary care in March 2020, where all care, wherever possible, was to be initially undertaken by remote means.10
Throughout roll-out, the app has been dubbed as serving to ‘ease pressures on GPs’, ‘provide more effective, personalised care’ and ‘freeing up valuable clinician time’.11 There have been ongoing developments of the NHS App, with additional features and integrations added throughout roll-out (including a vaccination certificate, linked profiles, GP messaging and authentication infrastructure), and it continues to be at the forefront of the digital health agenda in government policy. In the spring budget of March 2024, the Chancellor of the Exchequer announced £3.4B of funding for the NHS to invest in digital technology, including the specific aim to make the NHS App a single front door for patients. The future plans for the NHS App include greater use of messaging with healthcare providers, more preventative ‘keep me healthy’ content, and supporting integration with third-party apps and devices.
The NHS App is, in essence, a patient portal. Patient portals provide the potential for improved patient–provider communication via electronic messaging, direct appointment booking, prescription ordering, and provide users a platform to be more informed about their health.12 Research exploring patient access to electronic health records using patient portals underscores their potential to improve care co-ordination, enables self-management and supports empowerment by actively engaging patients in their healthcare decisions.7,12,13 While benefits of such technologies have been reported on several aspects of care, such as disease awareness, medication adherence and patient safety, issues around patient confidentiality, security and trust remain.13,14 There are also reports of unintended consequences of online access to health records with impacts on patient autonomy, documentation practices and increased workload, which affect patients and healthcare staff.15 Impacts on inequalities are also not well understood.16,17 Evidence suggests inequality patterns not only relate to patient portal adoption, which is generally lower in those who are elderly,18,19 ethnic minorities18,20 and from a lower socioeconomic status,19 but they are also reflected on sustained engagement trends and the use of different portal functionalities.20 Research highlights that users may show preferences for specific patient portal features, and their ability to engage with certain functions are influenced by factors such as age, digital literacy, health conditions and personal healthcare needs.21–23
To evaluate the app, this study had two workstreams. A qualitative approach used comparative case studies in five general practices to explore experiences and views on the acceptability of the NHS App through observations in general practices, document analysis, interviews and focus groups with patients, GPs, practice staff, commissioners and policy-makers. Our theoretical approach was based on the NASSS framework.24 Secondly, a quantitative element examined patterns of uptake and adoption of the app, and its various functions, and changes in use across different population groups. We also explored whether patients’ experience of access to their general practices and their overall practice experience influences engagement with the NHS App. Alongside analysis of aggregated NHS App usage, we had originally aimed to use bespoke data linkage of individual patient data, but this was not possible as discussed later in the monograph and this change was agreed with NIHR.
In this monograph, we first (see Chapter 2) describe the qualitative study (see Methods and Results), then in Chapters 3–5, we will describe the three quantitative studies (see Methods and Results). These empirical chapters reproduce work which has been published in, or is currently under review, with academic journals (with appropriate attribution and copyright permission). We discuss all the findings in the subsequent chapters, and also provide details of how we involved patients and the public in this work. We conclude with sections on the impact of the work, implications for policy-makers, and our recommendations for future research.