This project was fortunate to have both a PPIE coinvestigator and a committed group of PPIE participants who advised both the quantitative and qualitative aspects of the work. Dr Bernard Gudgin, a patient with much experience of PPIE, as well as expert knowledge as an IT specialist, was asked to join the team at the outset, while the original proposal and application were being developed. He was a Coinvestigator throughout the project, attending weekly project meetings and being involved in all discussions. In addition, we held six PPIE workshops at project initiation and set-up, through recruitment, and as data emerged. The workshops enabled a space for sharing, discussing and challenging insights gained, and considering and prioritising approaches and directions for continuing data collection. Further, through our weekly team meetings, the PPIE lead facilitated continued engagement throughout the study to ensure PPIE was involved in the process of data analysis and sense-making.
The following section describes our work from the perspective of our PPIE Coinvestigator and core team member, in addition to his fundamental input into our approaches and findings described elsewhere, alongside other PPIE activity, which is not reiterated here (e.g. as described in Chapter 2).
The NHS App: a PPIE perspective
There is confusion as to what the NHS App is. Searching on either Android or iOS for NHS App reveals scores of apps all branded with the NHS logo but many are commercial offerings and others are provided by specific parts of the NHS. In the first days of the app, there was a widely held view that its only role was to provide a COVID Pass. This was reinforced by the number of downloads of the app that occurred during the COVID-19 pandemic. However, the number of downloads does not automatically equate to usage. The COVID-19 Pass could have been used as a Trojan horse to establish the app as the ‘front door’ to a wide variety of NHS services – more widespread than the app itself. This was all very confusing for the public who often say their app does not provide a particular feature only to find that they are using an app, not the app. The NHS branding is widely recognised but is widely appropriated by many providers.
From the start the app was marketed as a gateway to all medical services, that would include features such as prescription renewals, GP appointments and many more. However, for these to work GP practices needed to implement the necessary backend to give the app access to their existing systems. This is no trivial task and with surgeries under much pressure, giving the administrative staff time to implement such access is inevitably a low priority. In particular, there is no financial incentive for GP practices to implement these links, particularly when many already have their own existing systems in place.
For any IT implementation to be successful often the most overlooked aspect is ‘wiifm’ – what is in it for me. In this case, what does it do for the patient; does it make it easier for them to make an appointment to see their GP, does it make it easier for them to order repeat medication, does it make it easier for them to make an appointment in secondary care? In many cases, the answer to these questions is often ‘doubtful’. The same question has to be asked (what does it do) for GPs, healthcare professionals and administrative staff.
We also noticed a marked difference between the use of the app between acute patients and those with a chronic condition. In the PPIE representatives’ experience, there are significant differences in usage between those with an acute condition and those with a chronic condition. The former normally want or need a quick intervention involving a GP or allied health professional (AHP), whereas those with chronic conditions are better at managing their conditions and are looking for support when something is not as it should be. Among regular users, many only use 1 or 2 functions and are often unaware of other offerings.
The app seems to have been developed on the principle of ‘Build a better mousetrap, and the world will beat a path to your door’. However, if the app is not marketed in a way that appeals to the end-user it will not take off. There is concern that the app has not been marketed in a way that will appeal to the end user both in terms of what it can do and what it will do. A particular area of concern is over the security of individuals’ data; there is no publicity of what steps are taken to protect an individual’s data.
It is the perception of the PPIE representatives that patients were not asked how they use the app or, more importantly, how they would like to use it. If there had been more consultation with patients, the take-up and eventual success of the app might have been higher. There are many examples of implementing major IT systems and the transferrable lessons that can be learnt. It appears to the patient public involvement representatives that such lessons have not been applied. For example, looking at any GP practice that has implemented the app, some functions are switched on whereas others are not. There does not appear to be any rationale for this, apart from ensuring receptionists maintain their role as gatekeepers.
But perhaps it is because implementing it requires a significant input of time and effort from practice staff. There is no provision for practices to be paid for the extra staff time needed and so the incentive to implement it are less than would otherwise be the case.
We have mentioned before the paucity of marketing of the app, and this is exaggerated by the question of whether there is one app or many and is the app designed as a self-contained app or is it intended to be a platform upon which others may develop further facilities? This is not clear to most patients, and there needs to be greater clarity around this.
In carrying out research, the question that needs to be asked is what do GPs, AHPs and patients need and what do they want. There appears to be little research in this area. It is also important to look at patient behaviour, how will they react and use different facilities? Perhaps the final question is: ‘Tell me what the App will do and ask what I want it to do’.