What does digital inclusion mean for the NHS? Understanding the role of technology in tackling health inequalities

Health inequalities are unfair and avoidable differences in health across the population that arise because of the conditions in which we are born, grow, live, work and age. Population groups suffering from health inequalities have been separated into four groups (often overlapping):

• People of lower socio-economic status.
• People living in areas of deprivation.
• People without a fixed address (e.g. traveller communities, homeless people or asylum seekers).
• Oppressed minority groups determined by protected characteristics (eg age, disability, ethnicity, religion).

There is evidence to suggest that these groups of people are most likely to encounter particular barriers to the use of digital technology such as poor digital literacy, accessibility issues (no income to buy devices/data, language barrier, disability) and fear or lack of motivation to engage with digital, which in turn leads to digital exclusion.

An estimated 11.7 million (22 per cent) people in the UK lack the basic skills needed to use the internet for everyday life and 4.7 million (7 per cent) people in the UK are still offline. The research shows that the factors affecting digital exclusion are often closely correlated with those likely to be impacted by health inequalities:

• 77 per cent of over 70s have very low digital engagement.
• People with a physical or mental impairment are 25 per cent less likely to have the skills to access devices and get online by themselves.
• People with an annual household income of £50,000 or more are 40 per cent more likely to have foundational digital skills than those earning less than £17,499.
• 4 in 10 people who claim benefits have very low digital engagement.

Digital exclusion in London

The groups in London are statistically most likely to be digitially excluded are older people, disabled people and people in social housing. This is further explained by the barriers to the use of digital technologies that these groups of people often face:

• Access: People in social housing suffering from poor socio-economic status are unlikely to be able to buy devices/data.
• Literacy: Most older or disabled people are known to struggle with digital literacy without additional training or support. People who have never used the internet before often say “they don’t even know where to start”.
• Trust/confidence: Online banking took approximately 10 years for people to trust this service and even now people, especially elderly people fear of online crime and lack trust in the digital systems, whether this be financial or health related.

Tackling digital exclusion and health inequalities

Over the past few years, and accelerated by the pandemic, multiple programmes and organisations across the country have been set up to improve digital access and address health inequalities. These include:

• The Widening Digital Participation programme, commissioned by NHS Digital and delivered by the Good Things Foundation. This programme aimed to ensure more people have the digital skills, motivation and means to access health information and services online. The results from the 2 phase programme with 220,000 participants in phase 1 (2013-16) and a further 166,162 in phase 2 (2017-20) can be found here and here, respectively.
• South West London Health and Care Partnership ICS are looking at health inequalities from a primary care perspective (part of the Transforming Primary Care programme) addressing digital access and health inequalities.
• Our Healthier South East London ICS recently held a digital inclusion collaboration workshop where they tested a number of project proposals. These included a pilot in Bexley of a scheme to improvement access and engagement with service users who have severe mental illness and/or learning disabilities, and a project in Lambeth to develop a Primary Care Network (PCN) digital inclusion toolkit.
• North East London (NEL) Tower Hamlets pathfinder assists people from ethnic minority backgrounds with the tools and information to access a GP or online services and to co-design ways to reduce exclusion. A report from the programme is available here.

All of these projects promote digital as a solution to address health inequalities. Through projects such as the mental health remote consultations evaluation undertaken by the Health Innovation Network, we are hearing that people want digital to be an enhancement of services, but not a replacement, and that choice and flexibility is essential. It is also vital that digital improvements to services do not come at the expense of further disadvantaging people who are digitally excluded.

In order to successfully develop initiatives that make a difference to communities, four key considerations should not be overlooked:

• Co-production of digital services with patients to ensure that all patient, service user and carer voices help to shape the work and ensure it delivers the maximum possible value to the community. Co-production should be considered at all stages of the project from inception to evaluation, and is best supported by a clearly defined involvement strategy.
• A form of Digital Equality Impact Assessment should be undertaken before progressing a project to ensure thought has been given to protected characteristic groups and to mitigate any potential increase of health inequalities.
• Parity of access to ensure patients using digital routes (eg an online access method for appointments) do not have an unfair advantage over patients using traditional access methods (eg a walk in enquiry or telephone call). Equity of access to care should ensure all patients are able to access effective, safe and timely care regardless of the method of care they choose to adopt.
• Robust and effective evaluation ensuring that services and pathways achieve their stated objectives. This is particularly relevant given that many services have had to adapt rapidly due to the Covid-19 pandemic, making normal measurement and evaluation more challenging in the short term.

Creating solutions that tackle both digital exclusion and health inequalities together will be crucial, and with the NHS moving towards a much more integrated and holistic commissioning model, there is hope that real progress will be made over the coming years in this area.