> I have no doubt that it's an extremely complicated mixture of 100s of systems, but anyone who has lived here knows how terrible it is.

Yep, as someone who's worked at a couple of small startups trying to sell into the NHS, it's terrible. A big part of the problem seems to be that there's no centralised procurement: each trust (of which there are ~200) does their own precurement. And a lot of the companies (the big established players are the worst) at most pay lip service interoperability. So you end with a big mess of system that don't talk to each other.

And they're not setup to pay "market rates" that are competitive with private employers to their in-house developers. So it's hard for them to attract and retain good in-house developers where they have them (although there are still some great people working there).