Evaluating the national rollout of the NHS App in England using qualitative and quantitative methods.

Abstract

Background: In 2019, the NHS App was launched as a 'digital front door' to England's National Health Service, aiming to improve access to primary care, enhance patient experience, save time in general practitioner practices and promote self-care.

Aims and objectives: This project aimed to identify and understand the use and acceptability of the NHS App, to measure the extent to which it improved patient experience and influences health service access, and to understand patterns of early take-up and participation.

Methods: Qualitative work explored experiences and views on the acceptability of the app through 60 hours of observation in general practices, document analysis (approximately 100 documents), and 62 interviews and four focus groups with patients, carers, members of the public and staff across five general practices, as well as commissioners and policy-makers. Our theoretical approach used the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework. Quantitative work examined the impact of the NHS App on the usage of primary and secondary care, using routinely collected data. Firstly, using monthly NHS App user data at general practice level in England, descriptive statistics and time series analysis explored monthly NHS App use from January 2019 to May 2021. Secondly, data on the sociodemographic characteristics of the general practitioner-registered population and their healthcare needs at the general practitioner level were used as covariates to explore inequalities in app usage. Finally, NHS App usage data were also compared with measures of patient experience of care and care access extracted from the General Practitioner Patient Survey database.

Results: The qualitative analysis guided by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework illustrated the multiple layers of complexity when introducing a constantly shifting technology into a challenging environment such as English general practice, during and after a period of considerable societal turbulence caused by the COVID-19 pandemic. Quantitative work showed there was strong adoption of the NHS App even before the onset of the pandemic, although the introduction of the COVID-19 Pass feature was linked to a fourfold increase in downloads. Analyses by sociodemographic data found higher usage in less-deprived and less ethnically diverse practices, with a generally younger population. There were 25% lower registrations in the most deprived practices (p < 0.001), and 44% more registrations in the largest-sized practices (p < 0.001). Registration rates were 36% higher in practices, with the highest proportion of registered White patients (p < 0.001), 23% higher in practices with the largest proportion of 15- to 34-year-olds (p < 0.001) and 2% lower in practices with highest proportion of people with long-term care needs (p < 0.001). Analyses by patient subgroup and by patient experience of care showed mixed findings.

Limitations: There was no opportunity to evaluate the app or the app functionality in an experimental design. The technology itself, and the context, was changing during the study, which added challenges and complexity. The quantitative analyses used aggregated data rather than individual-level linked data.

Conclusions: The NHS App was introduced into a complex and changing landscape. It has achieved strong uptake, with the COVID-19 Pass feature increasing adoption substantially. Overall uptake and use have followed an inverse deprivation gradient, influenced in particular by age, ethnicity and healthcare needs. Different functions of the NHS App have been used to different extents, and with different patterns over time.

Future work: Further evaluation as the healthcare landscape and the functions of the NHS App evolve is warranted, including longitudinal studies using person-level data and further work on inequalities in access and use.

Study registration: This study is registered as ISRCTN72729780.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref.: NIHR128285) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 15. See the NIHR Funding and Awards website for further award information.