The fortnightly newsletter that unpacks system leaders’ priorities for digital technology and the impact they are having on delivering health services. Contact Ben Heather in confidence here.

On 28 March, patient app suppliers met with NHS England digital officials to discuss the NHS app.

One supplier told HSJ the meeting was tense and they were left “worried and confused”. Another called it “hostile” and “a box-ticking exercise”. NHS England interim chief digital officer Tara Donnelly told HSJ the event was a success with suppliers welcoming a new “way in” into the NHS market.

Whichever version you credit, NHS policy has shifted decisively towards centralising digital patient services, starting with primary care, under one app.

A universal NHS digital offer that stitches together disparate services into a single icon on a patient’s phone has intrinsic appeal. But as the NHS app expands this year, it will have to win over suppliers that see it as a commercial threat, stretched GPs, and patients with little patience for empty digital offerings.

Before the NHS app

The NHS app is not the first attempt to get GPs and patients to move their interactions online.

In 2014, NHS England set up the “GP Online Services” programme to give patient’s electronic access to their GP records, repeat prescriptions, and appointment booking. Instead of a single NHS app, these online services were to be provided by incumbent GP IT suppliers (Emis, TPP, etc) and a mix of smaller companies. GPs have also been contractually required to “offer and promote” online services to patients since 2015.

However, these past efforts have had mixed success. About one in four patients in England are registered for online GP services, collectively booking about a million appointments electronically a month. But three in four are not.

Jeremy’s expanding app

Jeremy Hunt announced the NHS app at the Health and Care Innovation Expo in September 2017. Without the app bit, it was almost identical to Mr Hunt’s announcement the year before regarding the NHS.uk website (access to patient health records, electronic booking, repeat prescriptions, connect to NHS 111 digital triage, data sharing preferences). Some digital health officials still dub it “Jeremy’s app”.

After a few pilots with different suppliers in late 2017, NHS Digital announced in July last year it had signed a £6.3m contract with software company Kainos to build a single national app.

The role of the app had now expanded beyond Mr Hunt’s original conception and will likely expand further. The NHS long-term plan says the app will become the NHS digital “front door” for patients, connecting with local and national services, supporting self-care and “integrating into patient pathways”. NHS Digital is testing how the app might connect with video and other digital GP consultation services (not very well thus far) and there are plans to expand to hospital outpatient bookings.

But first, NHS England needs to convince health app suppliers, clinicians, and patients the NHS app is worth their time.

App vs app

With suppliers, there are signs of trouble. Several that have spoken to HSJ see the app as a bid for their market share (actual or potential) from the same central NHS bodies (NHS England and NHS Digital) that control said market. Comments from NHS England that all GPs will be required to use the NHS app and that this may “challenge” some existing suppliers commercially will not have helped.

NHS England’s rejoinder is that the NHS app will not compete with existing products but provide a new (better) way-in to the NHS market for digital innovators. In this version, the app acts more as a platform, providing a few national services (booking, record access, etc) but connecting to other third-party software for everything else. Thus far none of these third-party apps can connect to the NHS app.

If software suppliers opt-out of connecting to the NHS app (or simply can’t), this will undermine its value to patients and clinicians as the single digital front door, starting with GPs.

An empty app

Nearly all GPs can already provide online services, but most patients do not use them. This is partly because GPs have not promoted the service. It can also be difficult to register for these services or, once registered, the GP practice may not have made any appointments available for booking electronically.

The NHS app will need to do better to get GPs onboard. All GPs will be technically connected to the app by July, but it does not follow that they will make it useful to patients. A common complaint in patient feedback from the NHS app pilot late last year was a dearth of GP appointments available to book online. A requirement in the 2019-20 GP contract to make a quarter of all appointments available online will create some pressure but, despite NHS England’s assertion, there is no requirement for any GP to use the NHS app. Ms Donnelly told HSJ GPs were “very keen” to connect with the app despite no financial carrot or stick compelling them to do so.

If not enough health app suppliers or GPs buy-in to the NHS app, patients will get a shoddier product. NHS England data shows that, in seven months to the end of March, 7,350 people had registered to use the NHS app. During that time, most of these people had not used two of the app’s core national services: ordering a prescription or booking a GP appointment (a third of appointments booked were also cancelled). The most popular service among patients was viewing their GP record and looking up symptoms. These are important steps but a long way from a universal digital front door to the NHS. NHS England is planning more publicity around the NHS app this summer when all GPs are connected.

Cometh the hour, cometh the app

Despite these risks, there is a clear market for what the NHS app is selling. Overall, most people that have used the NHS app like it, according to NHS England’s pilot evaluation. Figures show that, for every patient that has registered with the NHS app, two more are waiting for their GP to connect. The recent proliferation of patient app companies in the NHS, and the alarm caused by a new government-backed contender, also suggests confidence in a growing market to be fought over.

But for the NHS app to succeed as a single front door into this market, it will need stronger buy-in from both software suppliers and GPs. Only then will the majority of patients download the NHS app and use it.