Four fifths of NHS trusts still using pen and paper for record keeping

A paper-free NHS remains a distant reality, suggests BMJ analysis

Twenty-five years after the government’s first push to digitise the NHS, an investigation by The BMJ reveals that only about a fifth of hospital trusts in England are using fully electronic systems for clinical record-keeping.

Responses to freedom of information (FOI) requests show that just 39 out of 184 trusts (21%) reported using paperless systems to document clinical notes, while 79% (145) said they still rely on pen and paper to some extent. Just a quarter (45) reported using fully electronic systems for prescribing medications.

The figures have not shifted much since a similar BMJ audit of trusts in 2023, suggesting the drive to digitisation in the NHS continues to stagnate.

Most trusts that reported using a hybrid system of electronic and paper patient notes cited ongoing or future plans to transition to a fully electronic system.

Although shifting from paper to digital systems promises benefits such as easier information sharing, enhanced data security, and joined-up care, progress remains slow, with some trusts now nearing their third decade of ‘digital transition’.

For example, patient notes at Salford Royal started going digital in 2000, Leeds in 2003, and James Paget and Airedale trusts in 2012, all of which are still ongoing. Even some “fully electronic” trusts say they still use paper to record patient notes in specific departments.

Of 156 trusts that specified the electronic system they used, nearly a third (49) were using two or more programmes, with one trust using six. Doctors say navigating multiple systems is a clinical and administrative burden, especially for trainees who rotate every four to six months.

Pritesh Mistry, fellow in digital technologies at public health thinktank The King’s Fund, notes that funding constraints, complex implementation timelines, insufficient hardware, and clunky user interfaces continue to impede progress and force a reliance on paper systems.

However, those working with paper systems don’t necessarily have it any easier. Izzie Jordan-Evans, a Foundation Year 1 doctor at University Hospitals Sussex NHS Foundation Trust, says working in this way “feels increasingly archaic” and “can lead to clinical errors.”

While past strategies focused on becoming paper-free, the government’s new 10 Year Plan for the NHS shifts focus towards AI-powered ambient voice technology (AVT) to automate clinical note-taking by 2035.

A 2025 trial of AVT at Oxford University Hospitals reported reduced documentation time for nearly 87% of users, with over half saving at least 30 minutes per day.

Oxford’s director of innovation, Megan Morys-Carter, emphasises the need to keep a ‘human in the loop,’ but some experts question this approach as a robust safety mechanism, saying it may shift accountability away from makers of AI tools, and towards the clinicians who use them.

“The ever-present risks of technology failure or cyber-attacks means paper is likely to remain an essential failsafe option to maintain services even after 2035,” adds Mistry.

Spokespeople for both NHS England and the Department for Health and Social Care acknowledged that trusts move at different speeds but reaffirmed their commitment to digital transformation to deliver safer, more joined-up care.

05/08/2026

Notes for editors
News: Exclusive: Four fifths of NHS trusts are still using pen and paper for record keeping, 25 years after first digitisation push doi: 10.1136/bmj-2026-100436

Link to Academy of Medical Sciences press release labelling system: http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? No
Evidence type: Data analysis
Subject: NHS digitisation