In December, Martha Lane Fox set out four key recommendations to the National Information Board, including: 

An ambitious target that at least 10% of registered patients in each GP practice should be using a digital service such as online appointment booking, repeat prescriptions and access to records by 2017.

My assumptions

When I first read the recommendations I thought how ambitious can a target of 10% be? I use digital services whenever I can, I prefer them and would rather go online than pick up the phone or go somewhere in person. I know not everyone has the same view as me, but surely 10% do?

However, some appropriately timed pop-up research at a GP practice reminded me that I shouldn’t be making assumptions or guesses – I should be using data and evidence from real users.

What we learnt

There is an appetite for digital. Not just from the 18 users we spoke to at the practice on that day, but from nearly every user we have spoken to over the course of the Alpha project.

But that appetite has not always transferred directly into the use of existing digital services:

“At my GP surgery I’ve seen a poster at my GP’s that you can talk to the GPs through this… but I haven’t got through the initial screen.”
(patient 88)


Easy to break, very hard to start. Anyone who’s signed up to a gym membership as a new year’s resolution can attest to this. None of the users we spoke to at the practice had booked their appointment online although many knew they could:

“I book things for leisure but I wouldn’t for clinical things.”
(patient 103)

Which just goes to show that turning on digital services and expecting users to flock to them is more hope than strategy.

Mental model

Users we spoke to often had views on how digital services might work or the benefits they might offer:

“I would call up because online they don’t always have same day appointments.”
(patient 94)

For this user, the chance of seeing no appointments when they log in is enough to put them off using the system. Even though it might offer exactly the same appointments as are available online.

“Sometimes I phone up and the lines are busy.”
Q: So would you go online?
“Nah. I’d just wait”
(patient 99)

This user is confident on the internet and uses it at home and work, but their view was that it was easier and better to call. We need to make services as easy to use online and better than the alternative if we want people to use them rather than just picking up the phone.

Digital isn’t automatically or necessarily better than the phone

Or, for many users, not even as good as. Some patients value the social interaction, while others believe the service they are seeking will happen more quickly if they call.

“If I log in, I might see no appointments, but if I ring, I might be able to arrange it.”
(patient 97)

“I wouldn’t book online, too much messing about.”
(patient 92)

Login difficulties

This learning struck me most. In a world where an Internet Address & Password Logbook is a 4.5 star rated product on Amazon, asking users to remember more passwords and login details for digital services they don’t use on a daily basis is never going to be popular. Users told us:

I haven’t got a username or password…
(patient 108)

I don’t know [my] ID…
(patient 105)

When the alternative is to phone up and use your name and date of birth, then what is the reward for remembering the login details?

What that means for future digital services

In short, digital services need to improve and we can start by building them based on user needs. Hinrich blogged recently about system needs.  Some of our services in the past have been meeting the needs of the system.

Take login credentials as an example. I’d be amazed if you could find me someone, anyone, who enjoys remembering usernames and passwords. I certainly don’t. I bet on the other hand you could find me plenty of people who want their information and data protected and held securely. And while these two things may seem incompatible, I don’t think they are.

How about services and security based on user needs? Take a service that requires a user to turn up in person, an appointment or collecting a prescription perhaps. Currently it’s very easy to do these services by calling on the phone – you’ll probably need to give your name and date of birth and then turn up in person at an agreed time. At the moment to do them digitally you’ll need a username and password and still turn up somewhere in person.

We need to look at how we deliver services as a whole, across all channels for the whole user journey. Just because something is available online doesn’t mean people will use it.

We want to make digital services that users prefer to picking up the phone. Digital services are not mandatory and we’re not turning off existing channels, so if we put friction into these services – like usernames and passwords when they are not needed – then why would anyone do it online?


  1. Whilst I understand all you are saying here about adoption and motivation, there is no stopping the global digital transformation that is underway. Access to ‘channel of choice’ has to be made available whatever the take up, it’s just the way it is. Perhaps some thought should be played out as to how to ‘incentivise’ use of digital channels; not an easy dilemma to solve given the emotional nature of many NHS interactions, but that should not stop investigations in the first place. There are many examples where people said digital channel access would not work back in the day; FS was once seen as the domain of f2f contact only.

    Just my opinion



    • Comment from Matt Stibbs

      As one of those people mentioned in this post who, despite generally preferring digital, still chooses to phone the GP for an appointment, I am not sure there could be a more appropriate incentive for using a digital service than “it’s better than not using it”.

      It could be argued that: a channel that doesn’t make things easier (and in fact provides a less good service) is not actually providing an alternative ‘choice’ – I can’t really ‘choose’ to book my GP appointment online if I want the same service that I get on the telephone.

      Day to day, I don’t get the impression that people think digital channel access won’t work in health – but understandably there are plenty who would argue that second-class digital channel access won’t.

  2. Comment from Andy Hadley

    Interesting, and not surprising. We, and especially the NHS centrally , have been very focussed on maximal rather than appropriate security. Booking an appointment – how many people phone and book for a mythical patient Ivor Cold, or as a prank for their friend ? Yes if you want to see the current record of Ivor Cold you need to be able to prove that you are them, and as a service, we don’t want empty slots. An easy validation is to get the user to enter a phone number, that we can text a reminder to. If that doesn’t match a pre-stored number, perhaps you ask something else. Keep it Simple :)


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