Closing the digital inequality gap
NHE’s Josh Mines investigates the state of digital NHS services and what can be done to increase participation of demographics with limited access and knowledge of modern technology.
Technology is transforming the way that services can be delivered to patients. For example, the digitisation of GP services offers a plethora of opportunities for appointment booking, patient records and repeat prescriptions to be more easily available online.
A long-term aim of this work is, quite clearly, related to efficiency. Digitalisation allows menial services to be delivered without the need, cost and time of manual administration. NHS England figures suggest that, in some cases, 6% of appointments could be dealt with by practice staff other than GPs, whilst another 4% of patients could avoid face-to-face contact if self-care service support was available. The organisation also found that reducing tele-phone calls, appointments and administration through the use of digital could deliver £29 per-patient cost savings.
In the constant struggle to streamline services and ease pressure on practices that are already struggling to cope with growing demand, these are invaluable and important savings that will benefit the health service hugely in the long term. But whilst NHS England quotes impressive figures that 66% of the adult population now own a smartphone, and 75% go online for information about their health, concern could be raised that certain demographics may be left behind as services increasingly move online.
The risk of exclusion
Adam Micklethwaite, director of business and innovation at the Good Things Foundation – a charity dedicated to tackling digital inequalities – explained the implicit risk that online services hold for people who are not as comfortable using modern technology like computers or smartphones.
“Digitalisation is clearly something that the NHS has to do, and an important part of the picture of making the NHS sustainable into the future,” he said. “But it carries the risk that a certain class of people are excluded.”
Back in 2015, a report into digital exclusion by doteveryone, carried out by Ipsos Mori, revealed that 12.6 million people did not hold what Micklethwaite calls the “five basic digital skills” required to fully benefit from technology: managing information, communicating, transacting, problem solving, and creating.
“There’s a very strong correlation between digital exclusion and social exclusion in all of its various forms,” he said. “If you don’t have those basic skills you are more likely to be elderly, more likely to earn a low income or be unemployed or disabled. If you are digitally excluded, then you are also more likely to have poor health and wellbeing outcomes.”
It’s exactly this exclusion that the Good Things Foundation works to avoid, explained Micklethwaite. “The more services the NHS makes digital by default, the more that population of people are going to find it difficult to access those services and that will exacerbate the inequalities that are there already, because they need those services there more than anybody else.”
Long-term benefits outweigh risks
Dave Taylor, a trustee at the Patients Association and a specialist in digital care, argued that while there are risks attached to digitisation, the long-term impact of sharing and accessing information digitally is something that will benefit the entire population in the long run.
“The underlying process of digitalisation is going to benefit everybody,” he said. “There is a proportion of the population who do not access the internet, and do not have the capacity to deal with the internet as it is currently presented, but I think that’s probably an issue that is going to get better over time.”
A research fellow at the Nuffield Trust, Sophie Castle-Clarke, elaborated on this point by saying that digital services did not have to provide a one-size-fits-all solution, but rather benefit those who can easily access them whilst freeing up time for GPs and primary care staff to spend on patients who required more personalised care.
“Digital services will never be right for everyone and particularly those with complex needs who stand to benefit from continuity and face-to-face care,” she explained. “The trick is being able to provide digital services to those who might really benefit, like patients with quite minor acute needs whose primary concern is quick access to a GP.”
Asked if the move towards more digital services will exclude certain members of the population, Taylor stated: “The premise is correct. As we put more services online, more people will not be able to access them. But the direction in which technology uses those services is going to become more and more accessible. It’s a two-pronged approach that’s needed: education and improving accessibility of services.”
However, according to Micklethwaite, digital inequality isn’t something that is going to go away by itself, and requires a hands-on approach: “If you just wait for it or assume the younger generation is going to help the older generation gain digital skills, or that demographic change is going to sort this issue out, we will still go through a considerable period of time where there will be a big digital divide, and that will mean more people miss out on digital benefits that allow them to lead happier, healthier lives.”
Widening Digital Participation
NHS England’s Widening Digital Participation programme was one scheme that aimed to give patients the tools to access the benefits of digital care. From July 2013 to April 2016, the programme aimed to teach more people how to access information about their health and how best to use the digi-tal services that the NHS provided.
It reached around 380,000 people, with 65% of participants saying they felt more informed about their health at the end of the initiative, whilst 59% said they felt more confident about using online tools to manage their health.
“It is literally about having that conversation and demonstrating the benefits of things, and showing how quickly you can order your prescription online or how easy it is to book an appointment,” explained Castle-Clarke. “A simple thing like that can mean that someone is more likely to do it in the future and feels confident to do it.”
She did, however, raise concern that with more routes available for patients to self-diagnose, there had to be efforts made to teach patients about their health, as well as simply the technology involved with accessing digital services.
“If you’re talking about someone looking at NHS Choices and understanding medical information, or Googling their condition to get some more information about it, then you need to have an understanding of the language that’s used, and you need to be able to interpret that information for yourself and understand it when you talk to your GP or another health professional,” said Castle-Clarke.
“Around 60% of England’s working age population finds reports made up of texts and numbers too confusing, and some people find NHS Choices overwhelming and difficult to use. It’s not just about ‘this is how you use a computer’ or ‘this is how you use an iPad or iPhone’, it’s also about ‘this is the kind of information’.”
Breaking the motivational barrier
But the solution to bridging the digital gap is further-reaching than education. The biggest enemy to participation has not been making older patients understand technology, but motivating them to realise the benefits of digital. An Ofcom survey last year discovered that one in 10 people had no intention of going online in the next year, with half of those people citing motivation as the reason for that.
“This motivational barrier is actually the biggest issue,” agreed Micklethwaite. “The support that we try and make happen through the Foundation is geared towards supporting and engaging people on their own terms, finding the personal hook about what could get them involved with digital and then working from there on a very person-centred basis. Sometimes it can take time to break through the motivational barrier and think: ‘I see digital could help me and lead to these improvements in my life’.”
Whilst it’s clear that a digital health service is an inevitable and sensible advance, it’s also important that these services are as accessible as they possibly can be to as many patients as possible. The importance of continued education about digital services cannot be understated, and should be carried forward to ensure the full benefits of a digital NHS are unlocked.
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