If we want to maximise the potential of digital health technologies to benefit patients we need to do more to engage with those who are digitally excluded.
Despite the NHS Long Term Plan stating that ‘while we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do’, former Health Secretary Thérèse Coffey decided to not publish the government’s long-promised Health Disparities White Paper setting out plans to tackle inequalities exposed by the Covid-19 pandemic.
The past three years have certainly shone a light on the preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies – with digital health and care lauded as a way to address these challenges by improving efficiency, widening access to services and increasing the ability of healthcare professionals to provide early intervention and high-quality care.
Indeed, the Government’s digital transformation strategy, as well as recent Levelling Up the United Kingdom and Integration White Papers are championing a digital revolution within the NHS, but this also means patients who are unable to access or use digital technology will suffer unequal access to health services, putting their health and wellbeing at risk.
Who experiences digital health inequality?
A recent report – Putting patients first: championing good practice in combatting digital health inequalities – by the Patient Coalition for AI, Data and Digital Tech in Health shows 10% of the adult UK population do not use the internet, with over half of adult internet non-users being over the age of 75.
ONS data shows that only 51% of households earning between £6,000-10,000 had home internet access compared with 99% of households with an income of over £40,001, with other barriers to access including slow broadband speeds in rural areas, the fact that up to 42% of adults in the UK struggle to understand and use medical information, and that the NHS website does not offer information to be translated into other languages.
The worrying result is that patients unable to read or understand online information may not recognise their symptoms, understand their condition, access help or manage their medication and treatment.
Trust issues
If the digital transformation of the NHS is to work, the first step is to tackle digital inequalities for patients, which means understanding their needs, and barriers at the point when these processes are being developed.
‘We had some interesting learnings from the Covid vaccination program about how best to reach patients,’ admits one PCN lead from the Midlands (who has chosen to stay anonymous). ‘As well as sending letters we used digital platforms to get greater reach. However, our analysis showed this digital engagement was still missing out on certain populations and areas of deprivation in our PCN, creating an inadvertent inequality in that way.’
The solution, he says, was to ‘bin the digital idea’ and go out into these communities in person. ‘We spoke to these communities via their shops, places of worship and community areas, and set up remote clinics,’ he says, ‘and while this did increase uptake somewhat we still didn’t get everyone we wanted to target.’
The reason, believes our anonymous PCN lead, is that ‘digital inequalities are not always necessarily about not being able to afford a smart phone. It’s to do with trust – in the security, the data and the process. For that to change the political golden thread around digital engagement needs to happen. The local leaders within that demographic need to talk to people, and if they need education, reassurance and support then that’s what we need to do.’
Mahesh Shah is the founder/director of the Mall Pharmacy in Luton, and a Primary Medical Services Partners Member of the Bedfordshire, Luton and Milton Keynes Integrated Care Board. He believes there is another side to digital health inequality that is being overlooked – which is digital health inequalities between healthcare professions.
‘From my perspective as a pharmacist it feels like in discussions of ‘primary care’ there is scant mention of pharmacy,’ he says. ‘When people talk about primary care it’s GPs that are front and centre in their minds, and pharmacy as an integral part of the primary care team seems to have been forgotten despite the evidence of what we did in the covid lockdowns as the only HCPs available to see people in person.’
Interoperability issues
This inequality of status is also reflected in the inequality of access to patient records, says Shah: ‘We need to be connected and interoperability is an important issue but, for example, pharmacists are granted read-only rather than read-write access.’
Another pressing digital inequality issue for HCPs is a lack of interoperability between technology systems.
‘In primary care there is a multitude of clinical systems and they don’t ‘talk’ to one another’, says our PCN lead. ‘As a consequence we have identified the inability of one system to talk to another is creating another kind of digital health inequality as it stops patients getting the right care at right time and right place. If there was going to be a game changer it’s enabling these systems to talk to each other and be interoperable.’
In its latest report – Interoperability is more than technology: The role of culture and leadership in joined-up care – The King’s Fund acknowledges that using digital health technologies to overcome silos has been ‘a longstanding challenge’.
The report says that while digital health interoperability has ‘traditionally been considered a technology problem’, good technology is not enough for interoperability to succeed, and it is relationships between staff and organisations that are vital for success. ‘Staff who do not work well together tend to control digital technologies and medical information in a way that hinders sharing and collaborating’, says the report, but ‘leaders who prioritise building relationships across organisations view digital tools as an extension of these relationships which in turn helps interoperability.’
Work in progress
Despite more work still to be done, there are examples of solutions to digital inequalities being put into practice across the country.
- Surrey: Yousaf Ahmad is ICS Chief Pharmacist and Director of Medicines Optimisation NHS Frimley, and says Frimley Health and Care Integrated Care System has implemented a number of strategies: ‘With patients/residents, across our system we have some of the most diverse populations with varying degrees of deprivation and social economic differences, so as a system we are working with multi-agency partners to investigate further how we can support this inequality’, he says, ‘and on the workforce side we are creating a single platform of medical records that allows us to uniformly share information about our patients/residents across health and social care but also have a single record of all care being provided.’
- Leeds: The 100% Digital Leeds program supports hyper local digital health hubs and is led by the digital inclusion team in the Integrated Digital Service (IDS) at Leeds City Council and Leeds Health and Care Partnership NHS West Yorkshire Integrated Care Board. The model uses the existing LCP place-based cross-sector network to identify trusted community partners in the area and bring them together to develop their digital inclusion offer as a network of Digital Health Hubs where people can get support in the community to make the most of the internet to improve their health and wellbeing.
- Devon: In the winter of 2020/21 Devon Communities Together – the Rural Community Council for Devon – conducted a survey on how digital exclusion affects the lives of socially isolated people in later life living in rural communities in Devon, with 80% of people aged 65+ indicating they are not comfortable/confident online, and respondents saying they were wary of the need to access healthcare digitally and nervous this would be imposed on them. This resulted in the key learning that reducing digital health inequalities requires taking the time to understand someone’s digital capability and avoiding generalising.
Co-designing solutions
Tim Brazier is the managing director of Thrive By Design, a multi-disciplinary team hosted by the NHS that works on co-designing digital innovation and improvement, and inclusive digital transformation. He says: ‘When we launched in 2014 our original focus was around digital innovation to help co-design and co-production within the health and care sector, but the pandemic gave us a period of reflection. We realised that if we don’t make sure that technology tackles health inequalities we will end up with a two-tier health system for those who can access and use tech, versus a different experience for those who can’t and won’t.’
Brazier says another consideration is that ‘a lot of health inequalities in communities don’t present themselves to the NHS so we can’t pretend we know about and tackle them all from the comfort of the environment we work in. Instead, we have to look at where people go to as their trusted places and spend some time there to see, feel and hear what’s going on. Do this and you will soon find out there is so much more to inequality than you thought, and to tackle it effectively you need to build partnerships where people already have trusted relationships. If you think you can do it on your own you will fall very short.’
