Welfare more than offset the deaths from warfare in England. The biggest improvements in life expectancy happened during the decades of WWI and WWII because of the government’s increase in welfare (Preston 1972). And in 1948, the UK created the National Health Service.

Open

Preston, 1972

Country’s healthcare system in a nutshell

In the United Kingdom, the National Health Service (NHS) provides publicly funded universal healthcare coverage (Our World in Data, n.p.), along with publicly funded care providers. Every individual is required to register with a primary care general practitioner (GP). GP appointments are free of charge, and access to secondary care typically requires a GP referral.

Healthcare is devolved to each of the four nations of the United Kingdom, with NHS England serving the largest population of 58 million people. England separated government-owned providers from government-funded payers, while Scotland (5.5 million), Wales (3 million), and Northern Ireland (2 million) did not.

Despite the dominance of the public system, private healthcare options, as well as various alternative and complementary treatments, are available to those who can afford them. (European Observatory on Health Systems and Policies, 2022)

Public vs private

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Source: The World Bank.
The pink column refers to the public expenditure as a % of the country’s total healthcare expenditure. The blue dot is the country’s expenditure on health per capita, expressed in international dollars at purchasing power parity.

The national portal

History

NHS England’s NHS App’s 2019 launch was a significant milestone in the modernisation of the National Health Service. Developed collaboratively by NHSX, NHS Digital and NHS England, the project got support from Health Ministers Jeremy Hunt and Matt Hancock, who both saw the app as a force driving technological advancement within the NHS.

Launch

Eight fundamental patient care challenges in 2017 drove the Secretary of State’s investment in the NHS App, from symptom checking and triage to facilitating end-of-life care choices. Additionally, the app aimed to facilitate administrative tasks such as booking GP appointments, ordering repeat prescriptions, and managing data sharing and organ donation preferences.

The pilot phase began in October 2018, in regions including Liverpool, Staffordshire, Redditch, Bromsgrove, and others. During this phase, the app provided essential functions such as symptom checking, appointment booking, prescription orders, and access to patient records.

From 2019, it was planned that the app would support GP video consultations and integrate with wearable devices like the Apple Watch and Fitbit. These have not yet developed and are in future roadmaps. So is future integration with the NHS e-Referral Service, allowing patients to book hospital or clinic appointments.

By January 2019, the app was available for download, though each GP practice needed to release data and appointment slots. This functionality was enabled through direct contracts between NHS England, GP providers and GP software companies, so shaping the app’s delivery focus (Bostock, 2019).

The NHS login provided a robust identity verification system. Patients could do this remotely without taking up clinical time or waiting.

Expansion

The app should not have additional features but instead serve as a platform for others to innovate on top of. NHSX CEO stated this in 2019 (Duffy, 2020). NHSX was established as the central IT department for the NHS.

In 2020, Patients Know Best (PKB) became the first Personal Health Record (PHR) to integrate with the NHS App. It included PKB’s full health and care records and functionality.

COVID-19 Pass

Starting on 17 May 2021, the NHS App began displaying COVID-19 vaccination records, initially to support international travel. Over the following months, this feature evolved into the “NHS COVID Pass”. Lockdowns significantly increased the use and adoption of the NHS App.

Open

Monthly new NHS App downloads and registrations. Kc et al. (2023) 'Uptake and adoption of the NHS App in England', British Journal of General Practice, 73(737), pp. e932–e940.

PEPs vs PHRs

In 2022, NHS England introduced the term Patient Engagement Platform (PEP). As NHS England’s starting focus was administrative, the first PEP procurements focused on hospital appointment management features. Next were letter display and questionnaire completion features.

NHS England is expanding focus to clinical usage, releasing clinical data to deliver clinical transformation. This functionality relies on PHRs.

Features

England is the only country identified in this research that has successfully created a marketplace for healthcare innovation through the NHS App.

NHS England achieved this by integrating private companies’ features into its public platform. This has created a competitive environment where private developers are incentivized to create high-quality, innovative solutions that meet the needs of NHS patients (Al-Ubaydli, 2024).

The NHS App has therefore three sets of functionality:

1. National functionality, paid for and built through central government funding. This was the starting point of the NHS App in 2019.

2. GP-commissioned functionality determined extra features each patient sees, i.e. functionality their GP surgery had chosen for all the patients in that surgery. This was the initial marketplace of electronic consultation systems and personal health records.

3. Secondary care-commissioned PEP features. Each patient sees additional functionality that their hospital has bought for the patients treated at that hospital. This use interface organised around appointments, starting with administration features and expanding to clinical features.

This page shows all the organisations, their corresponding product and their functionality which have integrated with the NHS App: https://digital.nhs.uk/services/nhs-app/how-to-integrate-with-the-nhs-app/nhs-app-integrated-partners-and-services

Core national functionality

The core national functionality allows patients to interact with their GP’s electronic health record system, including the ability to:

• Order repeat prescriptions.

• Nominate a pharmacy for prescription collection.

• Book and manage appointments.

• View their GP health record, including information such as allergies and medications.

• Book and manage COVID-19 vaccinations.

• Access their NHS COVID Pass.

• Register their organ donation decision.

• Choose how the NHS uses their GP data.

• View their NHS number

Screenshots of core NHS App functionality

Open The homepage include shortcuts to some of the most used areas of the NHS App. For example, patients can request repeat prescriptions and use 111 online.	Open Other shortcuts on the homepage include viewing their GP health record, view and manage prescriptions, view upcoming and past appointments. Patients can also see their messages and switch profle, to see the NHS App account of a relative or a person they care for.	Open The ‘Services’ page includes requesting repeat prescriptions, contacting their GP about a health problem, contacting their GP survgery for a docuent or update, and checking for available GP appointiments.	Open Other services include using 111 online, finding NHS services near them, and booking, canceling or changing a covid-19 vaccine appointment.
Open Lastly, services include browsing trusted NHS health and medicines information, as well as finding covid-19 guidance. Some of these services depend on the GP surgery, so not all patients will see all of these options.	Open When using the 111 online service, patients are asked to agree to give certain information with the online service.	Open Patients can then check whether their details are correct.	Open Patients can then read more information on the functioning of the service and click start.
Open The App presents then a list of symptoms the patients must check. If any of these symptoms is present, the patient should call 999.	Open After checking the list of symptoms, the patient can select they have none of those.	Open The patient will be then asked whether they are home or not. At this stage, the patient can use 111 online.	Open To request a prescription, patients can click ‘request repeat prescription’ on the home page. The patient will be able to see and change their nominated pharmacy.
Open The patient will then see their medicines and select those needed.	Open Once the patient confirms, they can see wat they can do next, and check the request status.	Open The request status page shows whether a medicine has been approved or whether it is waiting for approval.	Open To view referrals and hospital appointments, patients can select ‘upcoming and past appointments’ in the App homepage, and then 'hospital referrals and appointments'. Patients can book and manage the selected referrals.
Open From the homepage, a patient can navigate to the ‘Switch profiles’ section.	Open The patient will then see - upon receiving access from their GP - the linked profile.	Open The next page shows which services the patient can use on behalf of the linked person.	Open While the patient is using the profile of the linked person, they can always use the yellow button on top of the page to go back to their original profile.

The NHS App increasingly integrates informational resources, allowing patients to:

• Use NHS 111 online to answer questions and get instant advice or medical help nearby.

• Search trusted NHS information and advice on hundreds of conditions and treatments.

• Find NHS services near them.

Appointment booking

Suppliers include: DrDoctor, Netcall, Patients Know Best, Zesty

Screenshots of Zesty inside the NHS app

Open Patients will receive NHS App push notifications.	Open NHS App home page.	Open Patients can click on ‘Appointments’ on the menu at the bottom of the page. From the NHS App Appointments page, they can select ‘GP surgery appointments’ and ‘Referrals, hospital and other appointments’.	Open Once patients select ‘Referrals, hospital and other appointments', they can see a list of referrals they need to action and their upcoming appointments. If patients want to view more details about an appointment or manage it, they can click on ‘View or manage this appointment'.
Open The patients are then informed this service is offered by Zesty.	Open Patients can see their booked appointments and whether there’s any action needed.	Open Patients can ask to cancel appointments through the App.	Open Cancelled appointments present a ‘Cancelled’ label.
Open Patients can also ask for appointments to be rescheduled.	Open When asking to reschedule an appointment, the patients are presented with a page describing how the feature works, and are warned once the appointment is rescheduled, they can no longer attend at the old scheduled time.	Open Patients will read the full warning and then click on ‘Start’.	Open If there are no other appointments slots available, patients will be shown the above sceen.
Open Patients can receive and access hospital letters, such as appointment letters, post clinic and discharge summaries.	Open Patients can receive push messaging within the NHS App from multiple organisations.	Open Patients can receive and access pre-appointment, pre-assessment or waiting list validation questionnaires.

Electronic consultations

Suppliers include: eConsult, accuRx, TPP (Airmid), engage health (mostly in primary care)

These apps allow patient-initiated triage, i.e the patient answer the software’s questions so the software assesses and recommends the urgency for clinicians.

Screenshots of eConsult inside the NHS app

Open Services	Open eConsult	Open Child proxy	Open Privacy policy
Open Condition list	Open Safety netting	Open Describe symptoms	Open How can we help
Open Have you tried anything for this	Open Clinical question	Open Clinical question	Open Clinical question
Open Clinical question	Open Urgent symptom divert	Open Clinical question	Open Clinical question
Open Clinical question	Open Clinical question	Open Clinical question	Open Contact preferences
Open Confirmation

Personal health records

Patients Know Best (PKB) integrated with the NHS app in 2020. PKB gives the NHS App user full PKB functionality, beyond the GP-only the standard NHS App functionality.

Screenshots of Patients Know Best within the NHS app

Open . To view Messages, patients can click on  'View your messages' from the homepage or 'Messages' in the navigation menu.	Open They can then click on 'Your hospital and specialist doctors'.	Open Patients are informed this service is provided by Patients Know Best'. They can click 'Continue'.	Open The Events & messages page displays letters and documents from integration engines and hybrid mail solutions. Includes free-text secure messages, with the option to attach photographs and videos.
Open To see the Library, patients can click on ‘Your heath' in the main NHS App navigation menu, then click on ‘Your health choices’ and 'View links from your health team’.	Open Patients are informed this service is provided by Patients Know Best'. They can click 'Continue'.	Open The Library contains links to external websites and documents from verified resources.
Open Patients can click on 'Upcoming & past appointments' from the NHS homepage or from the 'Your health' page. They can then click on Click on 'Hospital referrals and appointments' in the submenu, and on on 'Additional appointment information'.	Open Patients can see a list of their appointments and can click on 'View or manage this appointment' for any of them.	Open If the appointment is from PKB, patients will be directed to PKB. They can click 'Continue'.	Open The Appointments includes data from EHRs, such as time, date, location (and virtual consultation links). Patients can add other appointments they are aware of. Some organisations offer appointment messaging: this allows patients to send secure messages to reschedule or cancel their appointment. If the organisation that added the appointment offers this service, patients will see buttons to reschedule or cancel the appointment.
Open To view their medications, patients can click on 'View and manage prescriptions' on the NHS App homepage or from the 'Your health' menu.	Open Patients can then click on ‘Hospital & other medicines’.	Open Patients are informed this service is provided by Patients Know Best'. They can click 'Continue'.	Open Patients will land on the PKB Medicines page. Data can be entered by the patient, including over-the-counter substances, and can come from EHRs.
Open To view either Symptoms, Measurements, or the Journal, patients can click on 'Your health' in the main NHS App navigation menu.	Open They can then click on ‘Your health choices’.	Open They can then click on ‘Track your symptoms' and 'Track your health’.	Open Patients can choose whether to see their Symptoms, Measurements, or the Journal.
Open On the Symptoms page, patients can add symptoms, including their severity.	Open On the Measurements page patients can manually enter of measurements. PKB also collects data automatically from OMRON, vital signs monitoring solutions, and other devices.	Open On the Journal page, patients can document what happened to them (thoughts and feelings) or questions to remember for their next appointment.
Open To view the Care plans, patients can click on 'Your health' from the main NHS App navigation menu.	Open Patients can then click on ‘Care plans’.	Open Patients are informed this service is provided by Patients Know Best'. They can click 'Continue'.	Open Care Plans can be co-edited and co-created by patients, professionals and carers. They can include videos and interactive content, with patients contributing in their own words. They can displays symptoms, test results, and measurements. They can feature action plans that shares verified professional guidance.
Open To see imaging and test results, patients can click on 'Your health' in the main NHS App navigation menu.	Open They can then click on 'Test results and imaging'.	Open Then click on ‘Hospital-ordered Test results’.	Open They can then choose whether to see tests or imaging results.
Open Test results have both charted and tabular displays which include reference ranges and change from previous results.	Open On the Imaging page, patients can view reports and associated images, including X-rays, MRI scans, and CT scans.	Open If patients click on ''Your health' in the main NHS App navigation menu, then on 'Your health choices' and 'Share records with your health team', they land on the Sharing page, where they can choose who can access their record and invite additional professionals to do so.

Challenges and areas for improvement

The main area for improvement is that the NHS App shows the features to patients based on NHS organisation, not by patient. So either all the patients in a hospital can use a particular functionality or none.

Additionally, organisations must choose one supplier for each feature. For example, when it comes to appointment management, a hospital can only work with one appointment booking supplier for all appointments.

Statistics

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NHS App page views per month, from January 2023 to July 2024. No data is available for the empty months (PKB interviews, 2024).

April 2024

Based on PKB interviews:

• One in six users logs into the NHS App each month.

• A repeat prescription is processed every second, saving saves GPs an average of three minutes per interaction.

• 85% of GP records are accessible to patients. The remaining 15% are in breach of contractual obligations.

• In April 2023, 6 million patients accessed their GP records within a month. By April 2024, this number had increased to 17 million.

• The NHS 111 service via the app is nine times cheaper and four times faster than traditional phone calls.

December 2022

Older statistics showed cumulative sign-ups of over 30 million (Department of Health and Social Care et al., 2022). Over the year:

• 7 million new users registered.

• The app facilitated 1.7 million GP appointments and processed more than 22 million repeat prescriptions.

• GP records were viewed over 65 million times throughout the year.

• More than 21 million repeat prescriptions were ordered via the app, a significant increase from 9 million in 2021.

• Approximately 128,000 individuals registered their organ donation decision through the app.

• New features allowed users to receive GP notifications and manage hospital appointments, used over 800,000 times.

• Within four weeks of enabling the COVID-19 vaccine appointment feature, over 28,000 bookings were made through the app, representing 9% of all vaccine appointments.

Bibliography

• Al-Ubaydli, M., 2024. What makes the NHS app successful? Digital Health. Available at: What makes the NHS App successful? (accessed: 25 July 2024).

• Barclay, S., Lord Markham, C., Department of Health and Social Care, NHS Digital, NHS England, 2022. NHS App hits over 30 million sign-ups. Available at: NHS App hits over 30 million sign-ups (accessed: 12 October 2023).

• Department of Health and Social Care, NHS England, NHS Digital, The Rt Hon Steve Barclay MP, Lord Markham CBE. (31 December 2022). NHS App hits over 30 million sign-ups. Available at:NHS App hits over 30 million sign-ups (accessed 12 October 2023).

• Duffy, D., 2020. Matthew Gould outlines the digital mission of NHSX. Hospital Times. Available at: Matthew Gould outlines the digital mission of NHSX - Hospital Times (accessed: 25 July 2024).

• European Observatory on Health Systems and Policies, 2022. United Kingdom: health system summary 2022. Available at: United Kingdom: health system summary | European Observatory on Health Systems and Policies (accessed: 12 October 2023).

• Kc, S., Tewolde, S., Laverty, A. A., Costelloe, C., Papoutsi, C., Reidy, C., Gudgin, B., Shenton, C., Majeed, A., Powell, J. & Greaves, F., 2023. Uptake and adoption of the NHS App in England: an observational study. The British Journal of General Practice: The Journal of the Royal College of General Practitioners, 73(737), pp. e932–e940. Available at: Uptake and adoption of the NHS App in England: an observational study (accessed 3 November 2024).

• NHS app goes live with full rollout to GP practices promised by July. GP Online. Available at: NHS app goes live with full rollout to all GP practices promised by July (accessed: 25 July 2024).

• NHS, 2023. About the NHS App. Available at: About the NHS App (accessed: 12 October 2023).

• NHS Digital, 2024. NHS Digital Transformation: The Road Ahead (video). Available at: eConsult is now available within the NHS App | Submit an eConsultation using the NHS App | subtitles (accessed: 25 July 2024).

• NHS Digital, 2024. The Future of NHS Technology (video). Available at: Using the NHS APP (accessed: 25 July 2024).

• Preston, S., Keyfitz, N. and Schoen, R., 1972. Causes of death: life tables for national populations. New York: Seminar Press.

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