NHS England » The national context for digital primary care

The NHS relies heavily on data and digital services to serve patients and improve the health of the public. Making better use of data through innovative and joined-up digital services has been a key priority for a number of years.The NHS Long Term Plan made a commitment that every patient should have access to digital-first primary care by 2023/24.

In 2018, the Government reiterated its commitment to advancing the use of technology and set priorities for action in the NHS in a policy paper, recently updated in 2022, in A plan for digital health and social care.

General practice has used electronic patient records for a long time and has led the way on patient-facing digital services. The patient record held by the GP practice is the primary record of care, or source record, and includes clinical information from service providers where the patient has received care .

Some of the change being promoted in the rest of the NHS will help bring other providers in line with primary care. The pace of planned change accelerated due to the COVID-19 pandemic with widespread digital technology introduced at a greater pace than originally planned.

Greater adoption of other digital services will have more significant implications for primary care, with both opportunities and implications for practices and primary care networks (PCNs) to consider. The changes proposed over coming years in the national digital technology plan address three main aims to:

improve patient care
support staff
transform local integrated care systems (ICS)

Improving care

A key aim of the planned developments in digital services is to improve patient care. This includes improving the safety, quality, and productivity of care, as well as the move towards more integrated care with more empowered patients.

Patient safety

Digital innovations are intended to play an important role in improving patient safety across the NHS. A national Digital Clinical Safety Strategy was launched for the NHS in September 2021. It aims to ensure the digital technologies used in health and care are safe, and that the NHS makes best use of technology to improve patient safety.

The national strategy comprises five principal areas:

collecting information about digital clinical safety to improve system-wide learning
expanding digital clinical safety training across the health and care workforce
creating a centralised source of digital clinical safety information
accelerating the adoption of digital technologies to record and track implanted medical devices
generating evidence for how digital technologies can be best applied to patient safety challenges

In hospitals and other NHS Trust settings, the adoption of electronic patient records, electronic prescribing, and improved linkages between different systems will be the main changes impacting safety in the early stages of the national strategy. For general practice, this will introduce new ways in which to link records and share information for patient care with other providers.

Learning from patient safety events

One practical way in which general practice contributes to safety improvement in the NHS is through reporting patient safety events. A new learning from patient safety events (LFPSE) service is due for national roll-out in 2023. A replacement for the National Reporting and Learning Service, this new service aims to make it easy not only to report events but to share learning from them, identify trends and access learning and advice from other teams and places. It will also make it easier for ICSs to agree priorities for changing care pathways to improve quality and safety.

It is expected that this updated service will enhance the benefits of reporting systems like Datix and the national Yellow Card Scheme.

Practices must register with the Medicines and Healthcare products Regulatory Agency (MHRA) Central Alerting System (CAS) for both email and mobile phone text alerts. CAS is a web-based national cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others.

Note: Locum GPs are not on the MHRA’s mailing list so it is good practice for host practices to share safety alerts with any locums they may be employing at the time.

The Care Quality Commission (CQC) provides guidance on the systems practices should have in place to respond to these alerts.

Standards, assurance, and cyber security

Interoperability

The NHS is working to develop standards and interoperability in digital services to deliver joined up, person-centred care. These will underpin data sharing so that the right information is available at the right time for those who need it. It will support ICSs by enabling information to flow between health and social care systems, improving health outcomes for individuals and populations. This is a Government priority for all statutory services, laid out in the document Data saves lives.

Updates on the work of the Standards and Interoperability team are available by clicking this link. There is another article in this series covering interoperability in more detail.

Information governance

A new national information governance portal provides all NHS organisations with approved guidance on a wide range of information governance issues. This gives staff assurance that they are following national guidance wherever possible, and that standards are applied consistently across all NHS organisations.

There is also another article in this series on information governance and data protection.

Cyber security

The NHS is working to strengthen the resilience of health and care digital systems to cyber-attack, protecting individuals and technological advances in care. There is another article in this series covering cyber security in primary care in some detail.

Suppliers and/or providers of digital services may themselves also be subject to cyber security breaches, e.g. Onedavanced.

Quality, productivity, and sustainability

A great deal of digital innovation in the NHS is focused on improving clinical quality and appropriateness, the productivity of services or the environmental impact of healthcare.

Patient pathways

In emergency care, nationally supported programmes are seeking to connect patients more directly with the most appropriate service, reduce delays and information handover errors, and provide better information for local service planning. Some initiatives are already in place such as:

enabling patients calling 111 to be directly booked into GP appointments where appropriate or into the
community pharmacist consultation service (CPCS) – referrals can be made by general practice

NHS providers and ICSs are using digital solutions to improve patient pathways for elective care. These aim to reduce waiting times, improve patient wellbeing, and reduce duplication of work for staff. Examples of projects include the use of home-based pre-surgical support to help improve preparation for surgery and patient outcomes, support for early discharge, home rehabilitation, and more personalised follow-up care.

Many digitally enabled pathway innovations seek to improve care along the whole patient journey, including at the interface between primary, secondary and community care teams. Case studies and advice for 8 clinical areas have been collected into ‘digital playbooks‘. These can inform ICSs seeking to increase clinical appropriateness and effectiveness, reduce waiting times and improve patient experience. The collection of playbooks is growing as new nationally approved innovations are developed.

Case Study | Teledermatology

38 GP practices in East Suffolk used a new teledermatology pathway for patients with concerning skin lesions. Software linked with the clinical system captured high quality photographs from the patient or in the practice and transmitted them to the dermatologist for review within two working days. Inclusion of patient demographics and medical history was handled automatically by the software, reducing time for the referring clinician. Use of hospital appointments was reduced by 47% and 12% of patients were fast-tracked to the suspected cancer pathway.

Patients and GPs were able to track referrals in real-time using a secure app.

Remote care

Providers across the NHS are embracing digital solutions which enable patients to be cared for at home, and to play a bigger role in their own care. These offer benefits in terms of reducing the burden of travel for patients and carers, reducing the carbon footprint of the NHS, empowering patients, and enhancing the management of long-term conditions.

Online consultations and video consultations have been used by more innovative practices and some other providers for several years, but their use increased significantly during the COVID-19 pandemic. The most immediate benefit was the reduction in infection risk. More recent research has shown that the information captured through the online consultation submissions from patients enables a more consistent and standardised approach to information gathering, navigation and triage for practices. NHS England has a dedicated area on the FutureNHS collaboration platform (log-in needed) with helpful resources to support the implementation and usage of online consultations.

There has also been a growth in the use of remote monitoring to support virtual ward services, allowing patients to receive step-up or step-down care in their own home. For those not under secondary care on virtual wards, patient monitoring of vital signs such as blood pressure, peak flow, or weight can also enable patients to play a larger role in managing their long-term conditions, with results being transmitted to the practice electronically for clinician review. There is a particular focus on supporting more people to monitor and manage their blood pressure at home, including support for the provision of monitors.

Patients who have electronic access to their full medical record have been found to have improved satisfaction, take more responsibility for their health and make more appropriate use of healthcare services. The GP contract has afforded patients the ability to view selected aspects of their GP record since 2019. This functionality is available in GP clinical systems but is not yet widely provided by electronic records systems used in other parts of the NHS. Since November 2022 NHS England has been working with practices to extend the ability to view one’s own GP record to include the full-text details for all new entries.

Social care is also the focus of considerable technology development. Here, many providers are yet to benefit from tools common to the NHS such as fast internet connections and electronic records. It is estimated that at least 1.7 million people in England are already using assistive technologies such as personal alarm systems and medication reminder apps and sensor technologies which monitor movement and identify falls at home.

The desire for more integrated working is also accelerating the development and use of digital records in social care, and the white paper People at the Heart of Care includes a number of commitments to support this.

In terms of digital services, the Health and Social Care Network (HSCN) was designed to provide a reliable, efficient and flexible way for health and care organisations to access and exchange electronic information. Social care providers can also use the Personal Demographics Service – FHIR API to check NHS numbers and patient demographics.

Smoothing the flow of information

At present, the use of multiple software systems and standards in health and care creates challenges for using and sharing data. It is common for numerous, different, clinical systems to be used within the same NHS Trust.

Significant progress has been made in digitising paper and work flow from pathology labs, communicating test results and hospital discharge or assessment notes, to practices using GP Connect and the Message Exchange for Social Care and Health (MESH).

NHS England is working with pathology services to develop standards for the consistent recording and sharing of pathology data. This will make it easier for pathology ordering, processing, and reporting to be done reliably and efficiently, as well as smoothing the process of inserting results into patient records.

Standards will include the use of a national standardised list of pathology test request and result names, using SNOMED CT (a set of standardised units of measure for test results) and an interoperable set of electronic messaging specifications.

National information governance guidance on sharing data between NHS providers as well as NHS providers and the voluntary sector is available from the national Information Governance portal:

the Information Governance Framework for Integrated Health and Care: Part 1 – Shared Care Records has been developed to provide a structured approach to ensure shared care records meet their legal obligations
guidance on sharing information about health and care users with the voluntary sector

Supporting staff

The second major aim of NHS technology development is to support staff, by making it easier to perform their duties and improving their experience as employees. When introducing new digital systems for existing staff or when inducting new staff, training services are available to support the safe, effective use and optimisation of clinical systems.

When local or national systems are deployed, implementation staff should have accreditation (Association of Project Management Group – APMG – or equivalent level industry standard) in undertaking benefits realisation, stakeholder engagement and business change support.

Nurses working in primary care are nationally supported by the National Digital Primary Care Nurse Lead. The National Chief Nursing Information Officer for England (CNIO) has an active NHS Futures platform which includes the dedicated areas for Primary Care nurses (log-in required).

Opportunities also exist for nurses involved in primary care to join networks including the national and local Shared Decision Making Council, leading on the digital agenda from the point of care for nurses.

Education and training articles in these Guidelines are listed in below.

Automation

The General Practice Forward View published in 2016 noted the potential for the automation of some work to improve efficiency and release time for general practice. Since then, interest has grown in the automation of mundane tasks and the use of artificial intelligence to support decision-making. Further developments are increasingly helping to automate complex workflows.

Robotic process automation (RPA) is a type of software increasingly used by NHS and local government teams to automate highly repetitive and simple tasks. An RPA bot is an app that can interact with other software to undertake tasks that would normally be performed by a human user, such as copy-and-paste, naming and moving files, and extracting standardised information from documents.

Although simple, these tasks can take up a lot of staff time and can be prone to error. It is estimated that the NHS could free up staff time worth up to £12.5 billion a year, almost 10 per cent of its annual running cost, by investing in a far-reaching programme of automation.

Unlike in some industries where there are fears that automation will lead to job losses, in health and social care it will complement human skills and talents by reducing the burden of repetitive administrative tasks by freeing up staff to spend more time on direct clinical care with patients.

Use of RPA in the NHS is currently at an early stage but there is a lot of work underway to develop new solutions. NHS England is supporting work in two national centres of excellence focused on automating administrative processes in HR, workforce, finance, IT, and procurement.

In general practice, early experience with automation of certain processes points to potential benefits for both patients and practices. Commentators also note the importance of careful implementation to ensure the use of technology does not weaken personal relationships or the power of human decision-making in care.

Research indicates that approximately 44% of all administrative and clerical tasks in general practice can be either mostly or completely automated. Looking across different staff in the practice, no role can be replaced by automation, but significant time could be released for every role. The areas with the greatest potential benefit were found to be letter writing, referrals administration, some phone calls and communication among staff, report preparation, auditing of records, and some aspects of handling test results.

A national community for RPA is available on the FutureNHS collaboration platform (log-in needed) giving information and opportunities to connect with others involved in developing and deploying RPA.

Decision support and artificial intelligence

The NHS is supporting the development and implementation of artificial intelligence (AI) in health and care. The ability to analyse large amounts of complex information in a relevant way holds the potential to make a significant impact on care. The NHS is working to develop the technology, harness the benefits and support the safe and ethical use of AI.

The Artificial intelligence article in this series provides more information and links to helpful resources about how AI might support high quality health and care.

Workforce management

The NHS recognises the considerable pressures on primary care and is accelerating work to provide a better employee experience for staff. These projects are intended to reduce daily stresses or disruptions.

Care Identity management

Care identity management (CIM) allows NHS and healthcare staff to register for a ‘care identity’. This is a digital identity that is then linked to the health and care organisations they work for. Current innovation is focussed on reducing the amount of time staff spend logging in to different services on a computer. It is intended that all NHS-employed staff should have access to single sign-on for the majority of the services they use regularly. In one Trust alone, this could save 130 hours of staff time each day.

Another programme of work is developing ‘digital passports’ for NHS-employed staff. This single proof of identity would make it much simpler for staff to work in more than one organisation, to move jobs and to take on roles that are shared across organisations. This work was accelerated to support the response to the COVID-19 pandemic.

Electronic staff records and e-rostering

The use of electronic staff records, and associated services, has been growing slowly in recent years, and the NHS nationally is working to accelerate this. Having an electronic staff record reduces the administrative burden of processes for payroll, workforce management and planning.

For staff it provides easier access to key information and documents.

Increasingly, employers are also adding functions for e-rostering and e-job planning. These create simple processes for requesting and tracking leave, matching available staff to overtime shifts, and promoting a consistent approach to continuing professional development.

Funding and guidance are increasingly being made available to support the use of these systems, and interest is growing in using them in primary care networks (PCNs) and general practices. For PCNs this can be particularly helpful with managing more complex rotas, for example:

where a shared service is served by staff from different practices (such as an urgent care service)
where staff work across multiple different sites (such as social prescribing link workers or physiotherapists)

For practices, electronic staff records can make it easier to track the completion of mandatory training by individual staff, for example to demonstrate compliance with CQC regulations.

Transforming systems through data

The data created by everyday health and care activity is a vital resource to inform planning and research. The GP appointments data dashboard provides information about activity and usage of GP appointments at practice level and can be useful to inform practices about their own activity and the impact of seasonal pressures for management purposes.

NHS England is committed to extending the usefulness and impact of data, to enable better decisions about services and innovations to be made, faster.

Data about patient care and the activity of providers can help to:

monitor and improve public health
identify the need for new or different services in specific areas or for specific groups of the population
assess the benefits and risks of new ways of working

Nationally the NHS has committed to making data more accurate, comprehensive, accessible and comparable. The approach of the new NHS is to ‘digitise, connect, and transform’ services.

Data for planning and research

General practice data has been used to inform research and planning for many years. The NHS intends to update the arrangements and technology for extracting and using GP data, and is consulting on plans to introduce General practice data for planning and research (GPDPR). This is part of wider work to improve datasets and reduce the manual burden of data extraction and processing.

Reducing inequalities

Another major use for population-level data aggregated from general practice systems is to reduce inequalities. The increased use of integrated local systems and incentives for PCNs to use population health management (PHM) has increased the focus both on the issue of health inequality and the potential for data to target solutions appropriately.

There is another article in this series on population health management.

A national equality, diversity, and health inequalities hub has been established. This provides comprehensive information about the commitment to reducing inequalities, including advice on the use of health and care data by local systems and healthcare providers. It also outlines the legal duties and requirements that NHS providers should meet.

There is another article in this series on Health equalities and digital inclusion.

Other helpful resources

NHS England Securing Excellence in Primary Care (GP) Digital Services: The Primary Care (GP) Digital Services Operating Model 2019-21
The Health Foundation, Switched on: how do we get the best out of automation and AI in health care?
NHS England, Understanding artificial intelligence (AI)
NHS England, Digital primary care maturity assessment

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