Low-code and no-code platforms have made app development dramatically more accessible. But building something like the NHS App is less about front-end design and more about navigating one of the most sensitive, fragmented, and highly regulated data environments in the UK.
At a glance, the NHS App looks like any other app on our phones – a convenient interface to access services like test results or prescriptions. But under the hood, it relies on deeply complex, often outdated infrastructure. The technology that enables these patient-facing features must operate across hundreds of hospitals, each with bespoke, often decades-old systems.
This isn’t unique to healthcare. Engineers in aerospace, nuclear, and defense face similar integration challenges: mission-critical systems built in the 1970s are still live today, propped up by domain experts who have spent decades maintaining them. You can’t simply switch these systems off. Instead, transformation must work around them – modernizing from within, while preserving service continuity.
The backend challenge
Digital transformation in healthcare is notoriously fragmented. While most CTOs can relate to the frustrations of siloed systems, healthcare takes it to another level. The latest generation, and leading Electronic Health Record in the UK by market size (25%) was optimistically named for the then upcoming Y2K.
Other systems are even older and, in some cases, the only people who understand how they work have delayed retirement simply to keep things running. These highly complex systems are the backbone to hospitals and are mission critical.
This creates significant challenges for integration. There are no clean REST APIs, no plug-and-play data gateways. Interfacing with these systems means navigating non-standard specs – or worse, undocumented ones – requiring deep insider knowledge. Where standards do exist (HL7, FHIR) these are implemented differently by different vendors, and even with a single vendor they can be used differently in practice within the same hospital.
Often, the first step in any digital upgrade is untangling the gap between what a system technically holds and what’s happening on the ground. Data must be restructured, manipulated, and reconciled to reflect real-world operations.
Even once technical integration is achieved, operational change can lag behind. True transformation requires hospitals to rethink ways of working – not just adopt new tools. The real value lies in modernizing these practices: digitizing clinic-by-clinic workflows, automating manual processes, and aligning backend data structures with real-life patient journeys.
This backend burden is a familiar challenge across industries. In sectors from banking to logistics, transformation depends on stitching together legacy platforms with modern APIs, standardizing data, and building for edge cases. But healthcare adds further complexity: regulatory scrutiny, cash-strapped buyers, disconnected procurement processes, and risk-averse culture all slow innovation.
Even promising national tools like the NHS’s Federated Data Platform (FDP) have struggled to gain traction – not because the technology isn’t sound, but because it’s often a “solution in search of a problem,” lacking alignment with day-to-day clinical needs.
Trust and adoption
Front-end platforms like the NHS App can support behavioral change – but only when the experience is consistent, intuitive, and clearly beneficial. Users don’t trust apps because they exist. They trust apps because they deliver.
In many sectors, this is well understood. Healthcare could learn from Amazon’s model of standardized checkout, delivery and returns. We need to move from a patchwork of inconsistent user experiences to a standardized, streamlined journey that just works, regardless of provider.
The NHS App is, rightly, pushing hard for a common user experience. It looks like a single app but is actually powered by numerous 3rd party platforms that do the last mile integration to the myriads of hospital systems. The NHS App has a well-defined design system, and every platform it integrates with undergoes user journey testing for each new feature added to the app.
Even with this approach, there is a limit to how consistent it can feel for a patient. Getting full coverage of all appointments in the country will eventually require integrating with all the old legacy systems and not all of those support modern workflows.
Right now, patient experience with the NHS App varies widely. Some trusts enable rich appointment functionality. Others don’t. Some integrate with backend systems; others rely on manual workarounds. This inconsistency creates friction – and undermines adoption.
System-wide integration
The NHS App is a valuable interface – but it currently only accounts for 16% of patient interactions. The real work lies behind the scenes: integrating ancient systems, transforming operational practices, and ensuring that clinical and admin teams can trust and use the data in front of them.
Time will tell if the government’s plans to ramp up the app’s functionality as part of its 10 Year Plan will be successful.
This isn’t a healthcare-specific lesson. For developers building systems in any regulated, data-sensitive industry, the message is the same: front-end transformation is only possible when backend systems are integrated, legacy infrastructure is respected (but modernized), and user trust is earned through consistency.
Ultimately, scaling change isn’t about the app. It’s about what happens before the user ever opens it.
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