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Blockchain Applications in Healthcare Finance: A Systematic Review
of Opportunities and Challenges for NHS General Ledgers in United
Kingdom
Emmanuel Achori and Timothy Olaniyi
Finance Department, NHS Kent and Medway Integrated Care Board, Hull, East of Yorkshire, United
Kingdom
DOI: https://doi.org/10.47772/IJRISS.2025.910000181
Received: 28 September 2025; Accepted: 04 October 2025; Published: 07 November 2025
ABSTRACT
This systematic review explores the potential applications of blockchain technology within the financial
operations of the UK's National Health Service (NHS), specifically focusing on its impact on general ledgers.
The NHS, a complex and vast healthcare system, faces significant financial management challenges, including
data fragmentation, inefficiencies in transaction processing, and issues with transparency and auditability.
Blockchain, with its inherent characteristics of decentralization, immutability, and cryptographic security, offers
a promising paradigm for addressing these issues.
This paper systematically reviews the opportunities that blockchain presents for enhancing financial
transparency, streamlining payment processes, improving data integrity, and reducing administrative overhead
in NHS general ledgers. Concurrently, it critically examines the significant challenges to its adoption, including
regulatory hurdles, interoperability concerns, scalability limitations, and the substantial investment required for
implementation and training. By synthesizing current literature and identifying key themes, this review aims to
provide a comprehensive understanding for policymakers, financial managers, and technology innovators within
the NHS regarding the strategic implications of integrating blockchain into healthcare finance.
Keywords: Blockchain, Healthcare Finance, NHS, General Ledgers, Distributed Ledger Technology, Financial
Transparency, Opportunities, Challenges, Systematic Review.
INTRODUCTION
The National Health Service (NHS) in the United Kingdom is one of the largest and most complex healthcare
systems globally, characterized by its universal access and significant financial scale. Managing its vast financial
operations, which involve numerous trusts, suppliers, and diverse payment streams, presents considerable
challenges. These challenges include maintaining accurate and transparent general ledgers, ensuring efficient
and secure transaction processing, and mitigating fraud and errors across a highly distributed network (National
Audit Office, 2024). The traditional centralized financial systems often struggle with data silos, reconciliation
issues, and a lack of real-time visibility, leading to inefficiencies and increased administrative costs (Healthcare
Financial Management Association, n.d.).
In parallel, blockchain technology, a form of Distributed Ledger Technology (DLT), has emerged as a
transformative innovation with the potential to revolutionize various sectors, including finance, supply chain,
and healthcare. Its core principles are decentralization, immutability, transparency, and cryptographic security
and these offer a compelling solution to many of the systemic issues plaguing conventional financial
infrastructures (SFMagazine, 2024). While much of the discourse around blockchain in healthcare has focused
on patient data management and supply chain logistics, its applications in healthcare finance, particularly within
the context of large public systems like the NHS, remain an area ripe for systematic investigation.
This academic journal article aims to provide a systematic review of the opportunities and challenges associated
with integrating blockchain technology into the NHS's general ledger systems. By examining existing literature,
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case studies, and expert opinions, this review seeks to: (1) delineate the fundamental financial challenges faced
by the NHS; (2) explore how blockchain's unique attributes can address these challenges; (3) identify the
potential benefits, such as enhanced transparency, improved efficiency, and reduced costs; and (4) critically
assess the significant barriers to adoption, including technological, regulatory, and organisational hurdles. The
ultimate goal is to offer a balanced perspective on the feasibility and strategic implications of blockchain for
NHS healthcare finance, informing future research and policy development.
Background on Blockchain Technology
Blockchain technology, often referred to as Distributed Ledger Technology (DLT), is a decentralized,
distributed, and immutable ledger that records transactions across a network of computers. Unlike traditional
centralized databases, where a single entity controls the data, blockchain operates on a peer-to-peer network
where all participants maintain a copy of the ledger. This distributed nature enhances transparency and resilience,
as there is no single point of failure or control (Turing, n.d.)
The fundamental components of blockchain technology include:
1. Blocks: Transactions are grouped into blocks, which are then cryptographically linked together in a
chronological chain. Each block contains a cryptographic hash of the previous block, a timestamp, and
transaction data (One NHS Finance, n.d.).
2. Decentralization: There is no central authority governing the network. Instead, consensus mechanisms
(e.g., Proof of Work, Proof of Stake) are used to validate transactions and add new blocks to the chain,
ensuring agreement among participants (ScienceDirect, 2023).
3. Immutability: Once a transaction is recorded on the blockchain and a block is added to the chain, it
cannot be altered or deleted. This creates a permanent and tamper-proof record, which is crucial for
auditability and trust (GeeksforGeeks, n.d.).
4. Cryptography: Advanced cryptographic techniques secure transactions and maintain the integrity of the
network. Each participant has a pair of cryptographic keys which refers to a public key for identification
and a private key for signing transactions ensuring authenticity and non-repudiation (Elangovan, 2022).
5. Smart Contracts: These are self-executing contracts with the terms of the agreement directly written
into code. Smart contracts automatically execute and enforce agreements when predefined conditions are
met, eliminating the need for intermediaries and reducing operational costs and delays (Investopedia,
2025).
While initially popularised by cryptocurrencies like Bitcoin, blockchain's potential extends far beyond digital
currency. Its application in various sectors, including supply chain management, intellectual property, and
identity management, demonstrates its versatility. In healthcare, blockchain has been explored for secure
electronic health records (EHR) management, drug traceability, and clinical trial data integrity (Blockchain in
Healthcare Today, n.d.). The unique characteristics of blockchain are its ability to create a shared, immutable,
and transparent record of transactions which make it particularly relevant for financial applications, where trust,
security, and efficiency are paramount.
NHS Financial Systems and General Ledger Challenges
The National Health Service (NHS) operates within a complex financial landscape, managing an annual budget
of over £180 billion (The King's Fund, n.d.). Its financial architecture is characterized by a decentralized
structure, with hundreds of individual trusts, clinical commissioning groups (CCGs), and other entities
responsible for their own budgets and financial reporting. This fragmentation, while allowing for local
autonomy, introduces significant challenges in financial management, particularly concerning general ledgers
(Healthcare Financial Management Association, n.d.).
Key challenges within the NHS financial systems and general ledgers include:
1. Data Fragmentation and Silos: Financial data is often stored in disparate systems across different NHS
organisations, leading to data silos. This makes it difficult to achieve a consolidated, real-time view of
financial performance across the entire service. Reconciliation between entities becomes a labour-
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intensive and error-prone process, hindering efficient financial oversight and strategic planning (One
NHS Finance, n.d.).
2. Inefficiencies in Transaction Processing: The sheer volume of transactions, from patient care costs to
supplier payments and inter-organisational transfers, often leads to slow and inefficient processing.
Manual interventions, paper-based processes, and legacy IT systems contribute to delays, increased
administrative costs, and a higher risk of errors (National Audit Office, 2024).
3. Lack of Transparency and Auditability: While the NHS is publicly funded, achieving comprehensive
financial transparency and robust audit trails across its vast network remains a challenge. The complexity
of inter-organisational transactions and the lack of a unified, immutable record can obscure the flow of
funds, making it difficult to track spending effectively and identify potential inefficiencies or
discrepancies (One NHS Finance, n.d.).
4. Fraud and Error Vulnerability: The fragmented nature of financial data and processes can create
vulnerabilities to fraud and errors. Detecting and preventing these issues is complicated by the lack of
real-time visibility and the difficulty in cross-referencing information across different systems (Reform,
2018).
5. Interoperability Issues: Integrating new technologies or standardizing financial reporting across diverse
existing systems is a major hurdle. The absence of common data standards and interoperable platforms
exacerbates the challenges of data exchange and consolidation (Gov.UK., n.d.).
6. Cost Pressures and Resource Constraints: The NHS continually faces immense cost pressures,
requiring optimal utilization of every pound. Inefficient financial processes divert valuable resources that
could otherwise be directed towards patient care. The administrative burden associated with managing
complex general ledgers adds to these pressures (Healthcare Financial Management Association, n.d.).
These challenges collectively impact the NHS's ability to achieve financial sustainability, make informed
strategic decisions, and ultimately deliver high-quality patient care efficiently. The need for innovative solutions
that can address these systemic issues is paramount, paving the way for technologies like blockchain to be
considered as potential enablers of change.
Opportunities for Blockchain in NHS General Ledgers
Blockchain technology offers a compelling suite of capabilities that can address many of the inherent challenges
within the NHS financial systems and general ledgers. Its core attributes which are decentralization,
immutability, transparency, and cryptographic security can be leveraged to introduce significant improvements
across various financial operations (AbdelSalam, 2023).
Key opportunities for blockchain in NHS general ledgers include:
1. Enhanced Financial Transparency and Auditability: A blockchain-based general ledger would
provide a single, shared, and immutable record of all financial transactions across participating NHS
entities. This distributed ledger would allow authorized stakeholders to view transactions in real-time,
significantly improving transparency and reducing the potential for discrepancies. The cryptographic
linking of blocks ensures that once a transaction is recorded, it cannot be altered, thereby creating an
unalterable audit trail that simplifies compliance and external audits (One NHS Finance, n.d.). This
enhanced transparency can foster greater public trust and accountability in how NHS funds are managed.
2. Streamlined Transaction Processing and Reconciliation: The current fragmented nature of NHS
financial systems often leads to delays and complexities in inter-organisational transactions and
reconciliation. Blockchain, particularly through the use of smart contracts, can automate and accelerate
these processes. Smart contracts can be programmed to execute payments automatically upon the
fulfillment of predefined conditions (e.g., delivery of services, approval of invoices), reducing manual
intervention, minimizing errors, and speeding up payment cycles between trusts, suppliers, and other
healthcare providers (Investopedia, 2025). This automation can drastically cut administrative overhead
and improve cash flow management.
3. Improved Data Integrity and Security: The immutable nature of blockchain ensures that financial data,
once recorded, cannot be tampered with. This significantly enhances data integrity, protecting against
fraud and unauthorized modifications. Cryptographic security measures safeguard sensitive financial
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information, making it more resilient to cyber threats compared to traditional centralized databases
(ITRansition, 2023). For the NHS, where data security is paramount, blockchain offers a robust
framework for protecting financial records.
4. Reduced Administrative Costs and Operational Efficiencies: By automating reconciliation,
streamlining payment processes, and providing a single source of truth for financial data, blockchain can
lead to substantial reductions in administrative costs. The elimination of intermediaries and manual
verification steps can free up financial staff to focus on more strategic tasks, thereby improving overall
operational efficiency within NHS finance departments (Healthcare Financial Management Association,
n.d.).
5. Facilitating Interoperability and Data Sharing: While challenges exist, blockchain can serve as a
foundational layer for improved interoperability. By establishing common protocols and standards for
recording financial transactions on a distributed ledger, it can bridge the gaps between disparate legacy
systems. This can enable more seamless and secure sharing of financial data across the NHS ecosystem,
fostering better collaboration and integrated financial planning (Gov.UK., n.d.).
6. Supply Chain Finance Optimization: Beyond general ledgers, blockchain can optimize financial flows
within the NHS supply chain. By tracking goods and services from procurement to payment on an
immutable ledger, it can ensure transparency, verify authenticity, and automate payments to suppliers,
potentially reducing costs associated with disputes, delays, and fraudulent activities (Hall & Partners,
n.d.).
These opportunities highlight blockchain's potential to transform NHS financial management from a fragmented,
labor-intensive process into a more transparent, efficient, and secure ecosystem. However, realizing these
benefits requires careful consideration of the associated challenges and a strategic approach to implementation.
Challenges and Barriers to Blockchain Adoption in NHS Finance
Despite the significant opportunities, the adoption of blockchain technology within the NHS financial landscape
is fraught with considerable challenges and barriers. These hurdles span technological, regulatory,
organisational, and economic dimensions, requiring careful consideration and strategic planning for successful
implementation (Balasubramanian, Shukla, Sethi, & Islam, 2021).
Key challenges include:
1. Regulatory and Governance Hurdles: The NHS operates under stringent regulatory frameworks,
including data protection laws (e.g., GDPR, Data Protection Act 2018) and financial regulations.
Integrating a decentralized technology like blockchain into such a highly regulated environment poses
complex legal and governance questions. Issues around data ownership, accountability for transactions,
and compliance with existing audit standards need to be meticulously addressed. The lack of clear
regulatory guidelines specifically for blockchain in public sector finance can deter adoption (BSI Group,
n.d.).
2. Interoperability with Legacy Systems: The NHS relies on a vast array of legacy IT systems that have
evolved over decades. Integrating a new, fundamentally different technology like blockchain with these
existing, often proprietary, systems presents a monumental technical challenge. Ensuring seamless data
exchange and compatibility without disrupting critical ongoing operations requires significant
investment in middleware, APIs, and careful system architecture design (Akter, 2024)
3. Scalability and Performance Concerns: Public blockchains, while highly secure, can face scalability
limitations, particularly in terms of transaction throughput and latency. For a system as large and
transaction-heavy as the NHS, a blockchain solution would need to handle an immense volume of
financial transactions in real-time. Private or consortium blockchains might offer better scalability, but
they introduce trade-offs in decentralization and transparency (Zhou, 2024). The performance
requirements for a national general ledger system are extremely high, and current blockchain
technologies may struggle to meet them without significant advancements.
4. Cost of Implementation and Maintenance: The initial investment required for developing, deploying,
and maintaining a blockchain-based financial system for the NHS would be substantial. This includes
costs for infrastructure, software development, cybersecurity measures, and ongoing operational support.
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Given the perpetual financial pressures on the NHS, securing adequate funding and demonstrating a clear
return on investment (ROI) for such a transformative project would be a significant barrier (Deloitte
Consulting LLP, n.d.).
5. Data Privacy and Confidentiality: While blockchain offers enhanced security, the immutable nature of
the ledger raises concerns about data privacy, especially for sensitive financial information. Although
transactions can be anonymized or encrypted, the permanent record could still pose risks if not managed
carefully. Designing a system that balances transparency with the need for confidentiality and compliance
with data protection regulations is crucial (Leeming, 2019).
6. Lack of Skilled Workforce and Training: The successful adoption of blockchain requires a workforce
with specialized skills in blockchain development, cryptography, and distributed systems. The NHS
currently faces challenges in recruiting and retaining IT professionals, and the niche expertise required
for blockchain would exacerbate this issue. Extensive training programs would be necessary to upskill
existing finance and IT staff, which represents another significant investment (University of Cambridge,
n.d.).
7. Resistance to Change and Organisational Inertia: Implementing a technology that fundamentally
alters financial processes often encounters resistance from stakeholders accustomed to traditional
methods. Organisational inertia, fear of job displacement, and a lack of understanding about blockchain's
benefits can hinder adoption. A robust change management strategy, coupled with clear communication
and stakeholder engagement, would be essential to overcome this barrier (Gökalp, Gökalp, Çoban, &
Eren, 2018).
8. Security Risks and Vulnerabilities: While blockchain is inherently secure, it is not entirely immune to
security risks. Smart contract vulnerabilities, potential 51% attacks (though less likely in a private
consortium blockchain), and key management issues could pose threats. Ensuring the highest level of
cybersecurity for a critical national infrastructure like the NHS financial system would require continuous
vigilance and investment (Mednexus, 2024).
Addressing these challenges requires a multi-faceted approach, involving technological innovation, policy
development, strategic investment, and comprehensive stakeholder engagement. Without a clear roadmap to
navigate these barriers, the transformative potential of blockchain in NHS finance may remain largely untapped.
Case Studies and Pilot Projects
While the theoretical potential of blockchain in healthcare finance, particularly for general ledgers, is widely
recognized, concrete, large-scale implementations within the NHS remain nascent. Most pilot projects and case
studies in healthcare blockchain have primarily focused on areas such as electronic health records (EHR)
management, supply chain traceability, and patient consent management (Yeung, 2021). However, insights from
these projects, alongside financial applications in other sectors, can inform the potential for NHS general ledgers.
Blockchain in Healthcare Data Management (Indirect Relevance)
Several initiatives have explored blockchain for secure and interoperable health data management. For instance,
projects like MedRec (DCI MIT., n.d.). and others have demonstrated how blockchain can create an immutable
audit trail for patient data access and sharing, enhancing security and patient control. While not directly financial,
the principles of secure, auditable, and decentralized record-keeping are directly transferable to financial ledgers.
The NHS has also shown interest in blockchain for data management, with discussions around using DLT to
give patients more control over their health records and improve data sharing across fragmented systems
(Reform, 2018). These pilots, though not financial, lay the groundwork for understanding the technical and
organisational challenges of deploying DLT within a large public health system.
Supply Chain and Pharmaceutical Traceability (Indirect Relevance)
Blockchain has seen more tangible applications in healthcare supply chains, aiming to improve transparency,
combat counterfeiting, and streamline logistics. Projects tracking pharmaceuticals from manufacturer to patient
demonstrate how an immutable ledger can verify product authenticity and ensure compliance (UCL Discovery,
n.d.). The financial implications here are significant, as improved supply chain efficiency can lead to cost
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savings, reduced waste, and more accurate financial reconciliation with suppliers. While not a general ledger
application, it highlights blockchain's ability to create a trusted record of transactions that underpins financial
flows.
Financial Applications in Other Sectors (Analogous Insights)
Outside of healthcare, blockchain has been piloted and implemented in various financial sectors to improve
general ledger functions, inter-bank settlements, and cross-border payments. For example, several financial
institutions have experimented with private blockchains to streamline reconciliation processes, reduce settlement
times, and enhance transparency between consortium members (Osmani, El-Haddadeh, Hindi, Janssen &
Weerakkody, 2021). These projects demonstrate the technical feasibility and potential financial benefits of using
DLT for ledger management, offering valuable lessons for the NHS regarding system design, governance
models, and the integration of smart contracts for automated financial operations.
NHS-Specific Explorations and Discussions
While a full-fledged blockchain-based general ledger system is yet to be implemented in the NHS, there have
been discussions and reports acknowledging its potential. The 'One NHS Finance' initiative and various reform
documents have highlighted DLT as a technology that could potentially replace existing services in NHS finance
entirely, offering real-time transaction verification and eliminating overheads (One NHS Finance, n.d.).
However, these remain largely conceptual or in early exploratory phases, underscoring the significant gap
between theoretical potential and practical, widespread adoption within the NHS's complex financial ecosystem.
The focus has often been on the broader benefits of DLT for data integrity and efficiency rather than specific
general ledger overhauls.
In summary, while direct case studies of blockchain transforming NHS general ledgers are scarce, the
experiences from related healthcare applications and financial sector implementations provide a roadmap. These
projects demonstrate the technical viability and potential benefits, but also highlight the considerable challenges
in translating these successes to the unique scale and regulatory environment of the NHS.
DISCUSSION AND FUTURE DIRECTIONS
The systematic review of blockchain applications in healthcare finance for NHS general ledgers reveals a
landscape of significant potential intertwined with substantial implementation challenges. The discussion here
synthesizes the findings, highlights key considerations, and outlines future directions for research and practical
application.
Synthesis of Opportunities and Challenges
Blockchain's core attributes are immutability, transparency, and decentralization which directly address critical
pain points in NHS financial management, such as data fragmentation, reconciliation inefficiencies, and
auditability concerns. The potential for real-time financial visibility, automated transaction processing via smart
contracts, and enhanced data security offers a compelling vision for a more efficient and trustworthy NHS
financial ecosystem. The ability to create a single, shared source of truth for financial transactions could
drastically reduce administrative overhead and free up resources for patient care (Healthcare Financial
Management Association, n.d.).
However, the path to realizing these benefits is not straightforward. The NHS's complex regulatory environment,
the formidable task of integrating with entrenched legacy systems, and concerns around scalability and data
privacy present formidable barriers. The lack of a skilled workforce and the significant upfront investment
required further complicate adoption. Moreover, the absence of widespread, direct case studies of blockchain
implementation in NHS general ledgers underscores the experimental nature of this application within the public
health sector (Yeung, 2021).
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Key Considerations for Blockchain Adoption in NHS
For the NHS to effectively leverage blockchain in its financial operations, several key considerations must be
addressed:
1. Pilot Programs and Phased Implementation: Given the scale and complexity of the NHS, a 'big bang'
approach to blockchain implementation is likely to fail. Instead, pilot programs focusing on specific,
well-defined financial processes (e.g., inter-trust billing, supplier payments for a particular category)
could provide valuable learning experiences and demonstrate ROI before broader rollout (Deloitte
Consulting LLP., n.d.).
2. Consortium Blockchain Model: A private or consortium blockchain, rather than a public one, would
likely be more suitable for the NHS. This model allows for controlled access, better scalability, and easier
compliance with data protection regulations, while still retaining the benefits of decentralization among
trusted NHS entities (BSI Group, n.d.).
3. Standardization and Interoperability: Developing common data standards and protocols for financial
transactions on the blockchain is crucial. This would facilitate interoperability between different NHS
organisations and ensure that the blockchain system can communicate effectively with existing legacy
systems, at least during a transitional phase (Akter, 2024).
4. Regulatory Clarity and Governance Frameworks: Policymakers and regulators need to develop clear
guidelines and legal frameworks for blockchain-based financial systems within the public sector. This
includes addressing issues of data ownership, liability, and dispute resolution in a decentralized
environment (barrier (Gökalp, Gökalp, Çoban, & Eren, 2018).
5. Workforce Development: Investment in training and upskilling the existing NHS finance and IT
workforce in blockchain technology is essential. This would build internal capacity and foster a culture
of innovation necessary for successful adoption (University of Cambridge., n.d.).
CONCLUSION
Blockchain technology presents a transformative, albeit complex, opportunity for revolutionizing financial
management within the UK National Health Service. This systematic review has highlighted that the inherent
characteristics of blockchain which are decentralization, immutability, transparency, and cryptographic security
offer potent solutions to long-standing challenges in NHS general ledgers, including data fragmentation,
inefficiencies in transaction processing, and issues of auditability and trust. The potential benefits, such as
enhanced financial transparency, streamlined reconciliation, improved data integrity, and reduced administrative
costs, are substantial and align with the NHS's ongoing efforts to optimize resource utilization and improve
accountability.
However, the journey towards blockchain adoption in NHS finance is not without significant hurdles. Regulatory
ambiguities, the formidable task of integrating with diverse legacy systems, concerns regarding scalability and
data privacy, and the substantial investment required for implementation and workforce development pose
considerable barriers. The current landscape shows limited direct large-scale implementations within NHS
general ledgers, with most existing case studies focusing on other healthcare applications or financial uses in
different sectors. These provide valuable analogous insights but underscore the need for tailored approaches
within the unique context of the NHS.
Moving forward, a strategic and phased approach is imperative. This includes initiating targeted pilot programs,
potentially leveraging consortium blockchain models for controlled environments, and prioritizing the
development of common data standards to foster interoperability. Crucially, clear regulatory frameworks and
significant investment in workforce training are essential to navigate the complex legal and technical landscape.
Future research should focus on rigorous economic impact assessments, advanced scalability solutions, privacy-
preserving designs, and longitudinal studies of pilot implementations to build a robust evidence base.
In conclusion, while blockchain technology holds immense promise for enhancing the efficiency, transparency,
and security of NHS financial operations, its successful integration into general ledgers will require a concerted
effort from policymakers, technology innovators, and financial stakeholders. By systematically addressing the
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identified challenges and strategically leveraging its opportunities, the NHS can potentially unlock a new era of
financial management, ultimately contributing to more sustainable and effective healthcare delivery.
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