Digital foundations: Why NHS transformation depends on interoperability

The digital integration challenge

While the Government’s announcement speaks about shifting care from hospital to community and embracing predictive and preventative medicine, we must first deal with the key problem: the NHS operates on many incompatible IT systems that cannot communicate with each other.

Despite some notable recent efforts, patient records are still trapped in digital silos; referrals still often rely on paper files and fax machines. While significant progress has been made in some areas, shared care records in regions like Greater Manchester and London have dramatically improved patient care by enabling clinicians to access comprehensive patient information across multiple providers, the success remains frustratingly inconsistent. It's still a structural impediment to every reform proposed.

How can you deliver integrated neighbourhood health services when a GP can't access a patient's hospital records? How do you implement outcome-based commissioning when data exists in incompatible formats across multiple systems?

Learning the lessons from the past

Achieving technology transformation in any large organisation is particularly difficult and the NHS is no exception to this. After the £12.7 billion National Programme for IT (NPfIT) problems in 2011, initially budgeted at £6.2 billion but ultimately costing taxpayers over £12 billion while delivering only £2.6 billion in actual benefits.

Progress continues, with 67% of NHS hospital trusts now able to access external patient data electronically, though opportunities remain for further improvement. These problems weren't due to a lack of funding or technical capability but rather stemmed from top-down approaches without something driving the bigger picture, and a natural resistance from healthcare professionals who found that the systems didn't meet their needs. While recent initiatives have shown promise, regional shared care records have delivered real benefits where implemented the patchwork approach perpetuates inequalities.

The latest NHS Single Patient Record consultation risks repeating these patterns unless fundamental governance issues are addressed, additionally Trusts procure systems independently, and while vendors resist true interoperability, citing technical reasons, and charge premium fees for integration. Voluntary compliance yields predictably poor results. Somehow the patient has been totally lost in all this, lost in a design sense and often in reality.

What real digital transformation requires

This is where the opportunity lies. The £10 billion technology investment, crucially ringfenced to prevent the budget raids that have undermined previous initiatives, represents a genuine chance for transformation. But success requires moving beyond the current pattern of promising proof-of-concepts that fail at the point of scaling. Interoperability in the NHS isn't about connecting systems, it's about people.

The investment could succeed, but only if there are fundamental changes to how the NHS approaches digital transformation.

Firstly, enforcement over encouragement could make interoperability standards legally mandatory for any system handling NHS data, including financial penalties for non-compliance and tie standards adherence to CQC registration and digital funding access.

So, we would suggest a Platform-First Architecture. Instead of trying to standardise everything, create national platforms for core functions of patient identity, appointments, referrals, and test results that all local systems must connect to via APIs, which makes enforcement chokepoints while preserving local flexibility.

Understanding vendor business models helps create mutually beneficial relationships. While some vendors have historically focused on proprietary systems, the market is evolving toward open standards and API-first architectures. The NHS's substantial procurement power, approximately £8 billion annually on medical equipment and consumables, can incentivize vendors to prioritize interoperability through clear requirements and long-term partnerships that reward compliance with national standards

We should therefore utilise the NHS's substantial annual procurement power strategically. The NHS collectively spends approximately £8 billion annually on medical equipment and consumables, with digital technology representing a significant portion. Despite this market power, trusts still purchase £3.4 billion worth of supplies outside centralised procurement. We should require demonstrable interoperability for any major contract and make vendors responsible for maintaining standards compliance, not Trusts.

Finally, a Regional Digital Authority could be established to give NHS regions real power and budgets for digital strategy, with authority to coordinate local implementations that have proven successful. Learn from the Greater Manchester and London examples, where shared care records have delivered tangible patient benefits and replicate these models systematically rather than hoping for organic adoption and give them the authority to block procurement that doesn't meet interoperability requirements, thereby balancing local needs with system-wide coherence.

Learning from international success

Other healthcare systems have tackled similar challenges with varying degrees of success. Denmark's national health IT infrastructure shows how regulatory mandates can drive interoperability. The country mandated that all healthcare providers use standardised messaging formats by law, with financial penalties for non-compliance, which enabled comprehensive patient data sharing across hospitals, GPs, and pharmacies within a decade. Estonia's digital health ecosystem goes further, with every citizen having a unified electronic health record accessible across all healthcare providers through a secure digital identity system.

Crucially, both countries achieved this through regulatory enforcement rather than voluntary adoption, proving that technical capability is not the limiting factor. The NHS faces greater complexity due to its size and existing fragmentation, but the fundamental challenge of forcing competing vendors to adopt common standards remains the same.

Other systems have shown it can be done, but only through sustained regulatory pressure backed by real consequences. Streeting repeatedly emphasises the need to address the "productivity crisis" in the NHS. Yet poorly integrated IT systems are productivity killers, forcing clinicians to log into multiple systems, re-enter data, and waste time searching for patient information across disconnected platforms. Without solving the underlying technology fragmentation, his productivity initiatives may face significant obstacles. You cannot optimise workflows when the digital infrastructure actively works against efficiency. 

The productivity problem

The real question isn't whether the NHS can be digitally transformed, the technology exists, FHIR for example, which has been called the most important new health interoperability standard for a generation. The challenge is whether the government can engender the wider will to enforce the difficult decisions required, which means confronting the reality that procurement law reforms and voluntary frameworks haven't solved the fundamental problem. There is little motivation for established vendors to adopt standards. It will mean telling vendors they cannot sell to the NHS without true interoperability, even when they cite challenging technical reasons for non-compliance. It means telling trusts that national standards constrain their IT autonomy. We have to get through these challenges together with compliance the central driving force.

Streeting's speech promises to end "Soviet-style statism" while maintaining central oversight. However, successful digital transformation may require more centralised control over technology standards rather than less. The market has struggled to deliver interoperability; only regulatory intervention can succeed.

Recent parliamentary scrutiny has highlighted the scale of systemic challenges facing the NHS. The Public Accounts Committee's analysis of DHSC's 2023-24 accounts revealed that the health system serves 1.7 million patients daily at a cost of £187.3 billion annually yet struggles with fundamental accountability and efficiency issues. The committee noted significant concerns about the lack of clear plans for achieving promised headcount reductions while maintaining service quality, a challenge that effective interoperability could help address through improved productivity and reduced administrative burden.

The stakes are higher than waiting times

Wes Streeting's vision for NHS transformation builds on substantial existing progress while addressing persistent challenges. The £10 billion digital investment, properly ringfenced and strategically deployed, represents a significant opportunity to accelerate the journey toward truly integrated digital health services. Success depends on combining continued investment with refined governance approaches that balance local innovation with system-wide coherence. By learning from both international examples and the NHS's own successful regional implementations, this transformation can deliver the responsive, efficient, and patient-centred health service that citizens deserve. The technical foundations exist; the opportunity now is to apply them systematically and sustainably across the entire system.

References

1. Dolfing, H. (2019). "Case Study 1: The £10 Billion IT Disaster at the NHS." Available at: https://www.henricodolfing.com/2019/01/case-study-10-billion-it-disaster.html
2. Takian, A., et al. (2017). "The UK's National Programme for IT: Why was it dismantled?" Health Policy and Technology, 6(2), 251-259.
3. House of Commons Committee of Public Accounts. (2024). "NHS Supply Chain and efficiencies in procurement." Available at: https://publications.parliament.uk/pa/cm5804/cmselect/cmpubacc/453/report.html
4. Digital Health. (2018). "Interoperability now the top priority for NHS IT Leaders." Available at: https://www.digitalhealth.net/2018/07/interoperability-now-the-top-priority-for-nhs-it-leaders/
5. Sheikh, A., et al. (2020). "Interoperability in NHS hospitals must be improved: the Care Quality Commission should be a key actor in this process." BMJ Health & Care Informatics, 27(1).
6. Protti, D. & Johansen, I. (2010). "Building National Healthcare Infrastructure: The Case of the Danish e-Health Portal." In Digital Healthcare: Empowering Europeans (pp. 297-314). Springer.
7. Estonia's e-Health Initiative. (2025). "Estonian e-Health Records: A Digital Transformation Success Story." Available at: https://e-estonia.com/solutions/e-health/e-health-records/
8. European Commission Digital Building Blocks. "Estonian Central Health Information System and Patient Portal." Available at: https://ec.europa.eu/digital-building-blocks/sites/pages/viewpage.action?pageId=533365863
9. Digital Health. (2025). "Most of public think that NHS single patient record already exists." Available at: https://www.digitalhealth.net/2025/05/most-of-public-think-that-nhs-single-patient-record-already-exists/
10. House of Commons Committee of Public Accounts. (2025). "DHSC Annual Report and Accounts 2023-24." HC 350. Available at: https://publications.parliament.uk/pa/cm5901/cmselect/cmpubacc/350/report.html