Over the past year, the NHS has been through an extraordinary period of challenge and change. At the forefront of this has been the incredible effort and commitment shown by those in the health service in dealing with the impact of COVID-19. Also significant is the way services have had to rapidly adapt to the new reality of delivering health care in a pandemic.

Some of the most notable developments have involved greater use of technology to reduce face-to-face contact and help manage demand. This includes increased use of established technologies and platforms: more phone and video consultations in primary and secondary care; wider use of devices and apps for remote working at home, including as part of virtual wards; increased use of the Electronic Prescribing Service; and wider use of the NHS website and NHS 111 online.

COVID-19 has also accelerated the uptake of newer technologies and platforms, such as the NHS app for appointment booking and patient record access; the rollout of video conferencing software to enable remote working and collaboration, including more professional-to-professional support for clinical decision-making; and the use of AI-driven image analysis to help diagnose and monitor the progression of COVID-19.

Though the NHS has previously attracted criticism for being slow to adopt and rollout new technologies, recent developments show it can do so at impressive pace and scale when conditions allow and staff are empowered to make change happen. Recent Health Foundation research on the service shifts accelerated by COVID-19 highlights some key factors that enabled these developments. A significant reduction in services released staff from other duties to concentrate on implementing and delivering change. A sudden, urgent common purpose simplified decision making and made it easier to collaborate and work across organisational boundaries. And important moves by national bodies supported change on the ground; for example, producing information governance guidance and procuring licenses to support the rollout of virtual consultations, publishing procurement frameworks, and purchasing equipment to support home monitoring.

Sustaining technology use beyond the pandemic

While COVID-19 has driven these recent technological steps forward, it is notable that several of them – such as greater use of video consultations or devices and apps for home monitoring – have nevertheless been longstanding NHS objectives whose uptake has been accelerated by the pandemic response.

Along with health systems around the world, there are ambitions for the NHS to make greater use of technology to improve quality and efficiency. And there are high hopes, including those voiced by Secretary of State Matt Hancock in summer 2020 and in the plans set out in the white paper in England in February 2021, that recent developments will help usher in an era of more technology-enabled health care beyond COVID-19 – a potentially positive legacy from a difficult time.

This long read aims to inform this agenda by investigating patient and staff experiences of the increased use of technology during the first phase of the pandemic (defined here as March to October 2020) and by exploring some of the challenges of implementing health care technologies in practice. Drawing on two YouGov surveys of UK adults and NHS staff conducted in October 2020, and on learning from the Health Foundation's programmes, we also ask what will be required to embed and sustain recent developments for the long term – offering lessons for providers and policymakers.

In our survey of UK adults (total sample size 4,326), conducted 26–28 October 2020, around two-fifths of respondents (39%) said that they had either ‘received NHS care for any health condition’ or that they (or their carer) had ‘communicated with the NHS about their health’ since the first lockdown began at the end of March 2020. And nearly all of this group (97%) said they had used technology in some way in doing so (defined broadly to include phone, video link, web, email, messaging, apps and medical devices).

Table 1 lists the technologies that respondents used. Phone consultations dominate, followed by some well-established uses of technology, such as booking appointments by phone or using the NHS website. But some emerging or less established uses of technology, including several explicitly promoted by national bodies, are also apparent. For example, accessing care records electronically, devices for home monitoring, video consultations, and the NHS app.

Table 1

While the speed at which technologies have been rolled out during the pandemic has been impressive, the context and pace of these changes also pose challenges.

First, it is likely that having to implement changes rapidly and under the constraints of a national health emergency means that some aspects of implementation will, understandably and necessarily, have been rushed or shortcut.

Implementing health care technology well can be a challenge at the best of times. Though people often focus on the technology in isolation, it is making it work in a real-world setting that enables the NHS and patients to derive the benefits. Doing this effectively depends on several factors, summarised in Figure 3. These include skills and knowledge; motivation and attitudes; user-centred design; ways of working; safety and equity; resources and infrastructure; and culture and leadership. It is not difficult to see how rolling out changes during a pandemic may have created challenges in each of these areas.

Figure 3

In our surveys, we asked those members of the public and NHS staff who had reported increased use of technology for health care during the COVID-19 pandemic some questions about their experiences.

1. Were patient and staff experiences of using technology positive or negative?

As shown in the table below, the vast majority of both public and NHS staff respondents reported positive experiences of the increased use of technology (and net positivity was even higher among NHS staff who had been personally involved in their organisation’s increased use of technology). This is an encouraging finding given the NHS has been under severe pressure during this period and it will be important to understand what went well and why to inform future technology deployment.

Age is sometimes cited as a factor affecting attitudes to technology and this was evident in our public survey, with a slightly larger proportion of younger people reporting positive experiences than the population as a whole and a slightly larger proportion of those age 55 and older reporting negative experiences. Furthermore, slightly larger proportions of people with a carer and unemployed people reported negative experiences (albeit within the context of large majorities of all these groups reporting positive experiences). It will be important to investigate the reasons for these differences, particularly from the standpoint of equity and digital inclusion, and how they can be addressed.

Figure 4

What is going to be required to learn from, build on and embed some of the positive technology-enabled developments we have seen during the COVID-19 pandemic? And how can the benefits be maximised?

In some quarters, the progress seen has led to talk of ‘locking in’ recent changes – based on the view that COVID-19 has sped up the rollout of some major innovations and with the job now done they can be preserved for the long term. The recent white paper in England, for example, sets out the aim to ‘make permanent the innovations that COVID-19 has accelerated’. But the issues highlighted here and in our survey suggest that the job is not yet fully done and further work is needed to evaluate and build on recent progress.

Priorities for NHS provider organisations

1. Revisit aspects of development and implementation

Front-line teams will need to revisit aspects of development and implementation that may have been shortcut during the COVID-19 pandemic.

This could include rapid steps to put in place more local evaluation, to ensure new approaches are safe and work for all groups of patients. Identifying issues around digital exclusion and putting in place mitigating actions or alternatives to ensure technologies are not creating or widening health inequalities will be particularly important.

It might also include more consultation and co-design with patients and staff to ensure new approaches are user-centred. Indeed, there may still be a need to develop and secure consensus about the future role of some technology-enabled approaches that were perhaps taken as a given during the pandemic.

Other implementation issues may need revisiting too, such as training needs or activities like customising technologies and optimising ways of working, which begin at implementation but subsequently become part of the iterative work of continuous improvement.

In short, though the speed at which technologies have been rolled out during the pandemic has rightly been praised, more work is going to be required to get the best out of them for the long term.

2. Think about longer term objectives

Technology-enabled approaches will need to be re-oriented towards serving longer term quality and productivity objectives beyond the pandemic.

For example, how can the recent deployment of devices for home monitoring develop from a useful way of monitoring health during a time of social distancing into a way of better supporting patients to manage their own health? How can the increased use of video consultations develop from a way of delivering health care at a time of reduced social contact into the vision for improving patient access, clinical productivity and use of the NHS estate outlined in the NHS long term plan? And how can we go beyond simply ensuring new technology-enabled approaches do not widen health inequalities towards the much more ambitious goal of harnessing the power of technology to ‘level up’ on health and make a particular difference for those who experience poorer outcomes? Changes such as these may require evolution of the interventions in question to focus on these longer term objectives.

3. Create the right environment for adopting and using technology

Leaders of organisations and systems providing NHS care have a crucial role to play in creating a conducive environment for adopting and sustaining innovation and technology. This includes engaging with their workforce to build a shared vision around technology-enabled care, and setting out how new uses of technology align with wider organisational strategy and values.

More specifically, organisational leaders will need to support their workforce in reorienting and embedding new technologies rolled out during the pandemic by empowering them to design and test changes and allowing them the time and space to do so. This will happen most effectively if there is a learning culture within the organisation or system with a commitment to continuous improvement. Our poll also highlights the need to ensure the right digital infrastructure and staffing are in place.

Priorities for policymakers and national leaders

1. Engage and consult the public and NHS staff  

NHS leaders in the four UK nations should support public engagement exercises and consultation on the future of technology in health care, ensuring representation from underserved groups and patients with complex needs.

There were many positive findings from our surveys, but it is also clear that not everyone had a good experience of using technology during this period. Research is needed to understand why a minority of the public and staff reported negative experiences and why some – particularly older people and those with a carer – rated technology-enabled approaches as ‘worse’ than traditional ways of delivering care, along with evidence-based actions to address problems and concerns.

It is also clear that the NHS has not yet ‘sealed the deal’ with the public as a whole on technology-enabled health care, with a significant minority appearing sceptical about its use beyond COVID-19. So there needs to be a meaningful conversation with the public and NHS staff to understand and address concerns, as well as to raise awareness and build confidence in these approaches. This will be particularly important for public-facing technologies, such as online appointment booking or mobile health apps, which potentially affect all users of the NHS.

2. Evaluate impacts before ‘locking in’ new approaches

Rather than rushing to lock in recent technological developments, policymakers should first ensure proper evaluation of their impact on the quality of care, including on health outcomes and patient and staff experience, and whether there have been any unintended consequences.

While the overwhelming majority of respondents to our poll found their experience of using technology during the first phase of COVID-19 positive, our poll also raised questions about the impact and quality of these approaches that requires further evaluation. In particular, there is a need to better understand what and who these technologies do and do not work for, rather than thinking of blanket, one-size-fits-all applications of technology. This means having a strong priority within NIHR programmes for such evaluations, including through approaches that can produce rapid results, such as the work currently underway by the BRACE and RSET teams to evaluate COVID-19 virtual ward models.

3. Help providers to focus on longer term objectives

Through a refresh of the NHS long term plan, and equivalent strategies in the devolved nations, policymakers should put in place a strategy of ‘reorientation’ – helping providers to develop and optimise the use of recent technological innovations to meet longer term quality and productivity goals.

This involves assessing which approaches are capable of serving longer term quality and productivity objectives – as has been happening through the Beneficial Changes Network in England, including work commissioned from the AHSNs and ARCs to evaluate and prioritise promising changes at a regional level – and then supporting providers to develop these approaches to achieve this. There is also growing awareness that critical to doing this will be understanding ‘what good looks like’ when it comes to technology-enabled health care.

At a national level, this work will benefit from greater alignment of thinking on technology and quality improvement, as well as ensuring that centrally-led programmes do more to bring technology and improvement communities together in practice.

4. Address the NHS’s workforce, skills and infrastructure needs in relation to technology

The forthcoming multi-year Spending Review and the next stage of national workforce strategies should explicitly address the workforce, skills and infrastructure needs of the NHS in order to exploit new and established technologies successfully over the long term.

Ensuring the NHS has adequate IT and equipment to make the most of new technologies was the top priority in our survey of NHS staff. Yet we know that capital spending in health care was significantly lower than the OECD average throughout the 2010s, resulting in a growing maintenance backlog. So recent increases in capital spending, only partly a consequence of COVID-19, will need to be maintained if the NHS is to keep pace with developments.

In addition, the staffing shortfall will need to be addressed if the NHS is to make the most of the opportunities technology presents.

Furthermore, while much support has been provided to more technologically advanced NHS providers in recent years, there is a need to focus on building the capability of less advanced providers as well. It is therefore important that funding recently committed in England and Wales, as well as future funding allocations, can be used to assist these organisations.

Looking ahead

Over the coming months, the Health Foundation will be playing its part in supporting this agenda. Our Q Exchange programme is funding 30 front-line teams to embed and sustain positive changes that have happened during the pandemic, including several projects focused on virtual care. Our Adopting Innovation programme will be supporting NHS providers and local health systems to create the conditions for more effective take-up of innovations and technologies. And we are supporting research projects to learn from the roll out of remote and asynchronous consultations before, during and after the pandemic, including studies led by the University of Oxford and Aberdeen University. Alongside this, the Improvement Analytics Unit, a partnership between the Health Foundation and NHS England and NHS Improvement, is evaluating COVID-19 oximetry (the use of small devices for measuring blood oxygen level) at home. And THIS Institute is undertaking a variety of projects to develop clarity on ‘what good looks like’ for remote care in areas such as antenatal services, mental health, heart failure and COPD.

As we emerge from the shadow of the pandemic, the NHS faces an important moment, where the choices made will determine not only the success or failure of recent technological steps forward, but also how fast and effectively the NHS will be able to grasp technological opportunities in future. Getting it right will mean seizing the moment to take stock and understand how these technology-enabled approaches can work to improve care for everyone, and then setting them on the right path to get there. Despite the challenges, with coordinated action at all levels of the health service, there is a real opportunity to build on recent progress during the pandemic and shape a positive technology legacy for the future.