Category: Health and Healthcare

Digital Inclusion and NHS Digital Healthcare: An Overview of Key Issues

01/10/2022 

Background

This research brief provides an overview of some key issues regarding the relationship between digital healthcare and digital inclusion. As with other public sectors, the National Health Service (NHS) is increasingly utilising technological and digital tools in service delivery. Yet, the successfulness of reforming the NHS through digital means depends largely on a sufficient digital health literacy in the UK population, and research has indicated the risk of the digital divide being widened due to the implementation of technologies in healthcare delivery. 

After offering a brief description of the state of digital health care within the NHS, this overview discusses the impact of the pandemic upon digital health, the rural-urban digital divide, and patient engagement. Towards the end, we provide policy recommendations in light of current research.

The State of Digital Healthcare in the NHS

Digital technologies have been used to shape public service delivery across the United Kingdom, in order to make them more citizen-engaged and participatory. Public departments have turned towards analytics, mobile, social, and cloud platforms in order to make service delivery more efficient and to connect more directly with citizens. The National Health Service is no exception, and several policy initiatives have been launched to ensure a successful digitalisation of the healthcare sector: Personalised health and care 2020 (2014), Information and technology for better care (2015), NHS Digital Academy (2017), and The NHS Genomic Medicine Service. The NHS is now prioritising the shift towards what is commonly referred to as eHealth.

Although eHealth is an evolving term, it typically refers to the following four services (Deloitte, 2015, pp. 3-4). 1) Digital Health Systems - the largest sector within UK digital health systems - which includes electronic health records and e-prescription services. 2) Telecare, which involves using communication and information technologies to deliver care at distance, as well as offering ways of supporting self-management and individualised feedback (McLean et al., 2013). 3) mHealth, which is related to telecare, but designates the specific usage of mobile technology to achieve improved health, enhance communication between carers and patients, monitor health conditions in real-time, and reduce isolation (Deloitte, 2012). 4) Data analytics, which can be used for predictive purposes, such that electronic patient records are analysed in order to “generate risk scores to highlight those that are likely to be re-admitted in the near future” (Imison et al., 2016, p. 11).

Digital Health and the Pandemic

According to a European Parliament brief, the COVID-19 pandemic accelerated the rise and implementation of digital health (Negreiro, 2021). The study highlights how the pandemic has boosted innovation in digital health in several distinct ways. First,  teleconsultations experienced a sharp uptick during the pandemic, partly due to governmental recommendations to stay at home. For example, the demand for Top Doctors UK, which provides medical e-consultations, multiplied by 30 (Negreiro, 2021, p. 3). Moreover, AccuRx, providing a similar service, conducted over one million video consultations during the beginning of the pandemic, and was utilised by 6700 medical practices.

Telemedicine became likewise a normal medium for healthcare delivery, which allowed healthcare to diagnose patients remotely, but also to collect new data from patients in order to improve service delivery. Indeed, about “84% of patients using virtual care in March 2020 were doing so for the first time” (Negreiro, 2021). In a UK context, by April “almost half of appointments in general practice took place remotely” (Morris, 2020). Many patients with pre-existing conditions turned to online consultations in an effort to avoid exposure to COVID-19. The expectation is that telemedicine will secure a permanent place in healthcare post-pandemic (Ahmed, Sanghvi, and Yeo, 2020). This rise in usage of telemedicine can partly be explained by the recommendation by NHS England that “Face to face appointments should only take place when absolutely necessary”.

While Big Data and Artificial Intelligence were already being utilised before the arrival of the pandemic, they have become more important over the last two years and are now utilised for resource management, data analytics to support scientific research, the personalisation of medicine, as well as diagnosing illness and recommending treatments (Freger, Crump, and Scott, 2021). A data-driven approach is strongly reflected in a recent NHS policy paper, “Data saves lives: reshaping health and social care with data”, which states that “data was at the forefront of this country’s fight against coronavirus” (Department of Health and Social Care, 2022).

Although the pandemic has highlighted the importance of digital tools in delivering healthcare, it remains the case that many people are unable to access eHealth due to a lack of basic digital skills, and that the implementation of such technologies within the NHS may in fact be “widening health inequalities” (Hutchings, Edwards, and Scobie, 2021, p. 45). This concern is echoed in a British Medical Journal editorial, which urges policy makers to “address access issues for the digitally excluded and any potential liabilities arising from the shift to virtual consultations…” (Feger, Crum, and Scott, 2021). Indeed, senior health officials have warned that the NHS has not found the right balance after the pandemic and that virtual GP consultations may be considered a form of digital exclusion (Pinkstone, 2022). In addition to the problem of user-related digital exclusion, research further indicates the need to mitigate an e-skills gaps among health professionals themselves (Negreiro, 2021, p. 8). This has also been raised in the NHS’s digital inclusion guide for health and social care, which notes that  some healthcare professionals do not have the knowledge, or perhaps the confidence, to employ digital tools (NHS Digital, 2019, p. 30).

Health Equality and the Rural-Urban Digital Divide

Research demonstrates significant health variation depending on residential context. Some studies have demonstrated poorer health outcomes in the North and West, compared to the South and East (Hacking, Muller, and Buchan, 2011). This trend has seemingly continued in England (Allan, Williamson, and Kulu, 2017), and various reasons have been proposed to explain this phenomenon, ranging from spatial variation to contextual factors (Maas et al., 2009). However, it should be noted that current research gives mixed messages regarding the connection between spatial location and health outcomes. On the one hand, some research indicates that rural citizens overall enjoy better health, which may be due to the availability of green spaces (Maas et al., 2006), lower crime (Higgins, Robb, and Britton, 2010), and lower pollution levels (Ruckerl et al., 2011). On the other hand, the “rural idyll” may be exaggerated as those in rural areas experience specific health disadvantages. For example, rural healthcare providers have suffered due to the centralisation of the NHS. It has been noted (Local Government Association, 2019, p. 24) that longer distances in rural communities to GP surgeries, hospitals, and dentists, mean that those residents more frequently experience health inequalities. Longer distances to sources of healthcare means that there is a decreasing rate of service, leading to negative health outcomes. These problems were exacerbated by the COVID-19 pandemic (Palmer and Rolewicz, 2020). Generally speaking, healthcare teams in rural areas are smaller compared to urban counterparts, “with the trend in workforce numbers failing to keep up with the national picture” (Palmer and Rolewicz, 2020, p. 12).

Some have expressed the hope that the application of digital health may aid in overcoming these spatial issues. Telehealth, for example, allows smaller rural hospitals to provide healthcare services locally with lower costs, which can allow rural citizens to access speciality care without having to travel long distances. However, the rural-urban digital divide poses a significant challenge to a successful implementation of digital technologies. According to a Good Things Foundation study (2013),  9.5 million UK adults lack sufficient basic digital skills, and 5.9 million of this group has never been online or engaged in online activities. In a research report regarding digitality in North West England, data shows that 28% lack digital skills, and that people aged 65 above, as well as those on lower incomes, “are more likely to experience digital poverty” (Walker, 2022, p. 3). Rural communities exhibit the highest rate of internet non-users, with 80% of rural households having standard broadband availability (compared to 98% of urban households), and 21% having superfast broadband availability (compared to 86% of urban households). Moreover, rural internet users are “5 times more likely than urban internet users to think that their connection is ‘too slow’” (Farrington et al., 2015, p. 33). Here we can see that insufficient connectivity and a lack of digital skills drive digital poverty, thus impacting negatively on the ability of rural citizens to reap the benefits of digital healthcare solutions.

Patient Engagement and User-friendly Digital Health Tools

Some research indicates that eHealth may facilitate a more interactive relationship between health professionals and patients (Hutchings and Sherlaw-Johnson, 2022). In a systematic review by Barello et al. (2016), eHealth was considered a useful care-management tool by a majority of patients. Indeed, it was considered especially useful by people with chronic conditions, “because they have to daily confront with self-management of the pathological illness condition” (2016, p. 4). Granström et al. (2020) elaborates on the empowering potential of digital technologies, suggesting that patient-centred care can enable patients to feel an ownership of their condition through accessing healthcare information, including test results, medical records, and agreed outcome-measures. A more flexible communication between professionals and patients, enabled by digital technologies, can lead to a relationship of “collaboration on more equal terms” (Granström et al., 2020, p. 12).

In addition to the lack of basic digital skills, accessibility has been identified as a significant barrier to greater patient engagement through digital health solutions, meaning that services fail in meeting specific user needs (Healthwatch, 2021).

Policy Recommendations

1) We need to proactively boost digital health literacy in the general population in order to secure a UK wide benefit of a digitised NHS. Significant steps have been taken in this direction, including the NHS Digital funded Widening Digital Participation based at the Good Things Foundation. This three-year programme trained over 200,000 people to use digital health resources (Tinder Foundation, 2016), after which 59% of learners gained confidence in using digital health tools and 65% felt more informed about their health. This programme concluded in March 2020, the month when the United Kingdom entered its first lockdown. More programmes and initiatives like this will be needed so as to boost digital health skills in the population.

2) In addition to enhancing digital health literacy among the general public, research also points towards the need of upskilling the healthcare workforce, as “not all health and care staff have the skills and knowledge to recommend digital health services…to patients” (NHS Digital, 2019, p. 11). We welcome a recent Digital Readiness Education Programme, which seeks to create an “uplift of digital skills and awareness across the health and social care workforce” (NHS Health Education England).

3) It is crucial to design user-friendly healthcare applications to improve accessibility. In order to design effective health technologies, patients’ needs, abilities, and intentions ought to be the “main source for design ideas and implementation” (Triberti and Brivio, 2020, p. 167). This needs to, furthermore, refrain from designing healthcare applications based on prototypical representations, and instead opt for a deeper understanding of users’ social and cultural context.

References 

Ahmed, S, Sangvhi, K. and Yeo, D. (2020). Telemedicine takes centre stage during COVID-19 pandemic. BMJ Innovations. Online First. http://dx.doi.org/10.1136/bmjinnov-2020-000440.

Allan, R., Williamson, P. and Kulu, H. (2017). Unravelling urban–rural health disparities in England. Population, Space and Place, 23(8): e0273.

Barello, S. and Graffigna, G. (2015). Patient engagement in healthcare: pathways for effective medical decision making. Neurophysiological Trends, 17(April): 53-65.

Deloitte. (2015). Digital Health in the UK: An industry study for the Officer of Life Science. [Online]. Available at: https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/digital-health-in-the-uk.html.

Department of Health and Social Care. (2022). Data saves lives: reshaping health and social care with data. Available at: https://www.gov.uk/government/publications/data-saves-lives-reshaping-health-and-social-care-with-data/data-saves-lives-reshaping-health-and-social-care-with-data.

Negreiro, M. (2021). The rise of digital health technologies during the pandemic. European Parliamentary Research Service. Available at: https://www.europarl.europa.eu/RegData/etudes/BRIE/2021/690548/EPRS_BRI(2021)690548_EN.pdf.

Farrington, J., Philip, L., Cottrill, C., Abbott, P., Blank, G. and Dutton, W. (2015). Two-Speed Britain: Rural and Urban Internet. Available at: https://aura.abdn.ac.uk/bitstream/handle/2164/5263/Two_speed_Britain_report_web.pdf;jsessionid=F693B40461CD60A23442FFF4F1127B3B?sequence=2.

Feger, H., Crump, B. and Scott, P. (2021). UK learning about digital health and COVID-19. BMJ Health and Care Informatics, 28:e100376. http://dx.doi.org/10.1136/bmjhci-2021-100376.

Granström, E., Wannheden, C., Brommels, M., Hvitfeldt, H., and Nyström, M.E. (2020). Digital tools as promoters for person-centred care practices in chronic care? Healthcare professionals’ experiences from rheumatology care. BMC Health Services Research, 20(1108): 1-15. https://doi.org/10.1186/s12913-020-05945-5.

Hacking, JM., Muller, S. and Buchan, IE. (2011). Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study. British Medical Journal, 342:d508. https://doi.org/10.1136/bmj.d508.

Healthwatch. (2021). Locked out: Digitally excluded people’s experiences of remote GP appointments. Available at: https://www.healthwatch.co.uk/report/2021-06-16/locked-out-digitally-excluded-peoples-experiences-remote-gp-appointments.

Higgins, N., Robb, P. and Britton, A. (2010). Geographic Patterns of Crime. In Home office (2010) Crime in England and Wales 2009/1: Findings from the British Crime Survey and Police Recorded Crime, pp. 165-194. London: Home office.

Hutchings, R., Edwards, N. and Scobie, S. (2021). Fit for the future: What can the NHS learn about digital health care from other European countries? [Online]. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/research/fit-for-the-future-what-can-the-nhs-learn-about-digital-health-care-from-other-european-countries.

Hutchings, R. and Sherlaw-Johnson, C. (2022). Supporting patient engagement with digital health care innovations: Lessons from the Care City test bed. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/research/supporting-patient-engagement-with-digital-health-care-innovations-lessons-from-the-care-city-test-bed.

Imison, C., Castle-Clarke, S., Watson, R. and Edwards, N. (2016). Delivering the benefits of digital health care. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/research/delivering-the-benefits-of-digital-health-care.

Local Government Association. (2017). Health and wellbeing in rural areas. Available at: https://www.local.gov.uk/publications/health-and-wellbeing-rural-areas.

Maas, J., Verheij, R., de Vries, S., Spreeuwenberg, D., Schellevis, P. and Groenewegen, G. (2009). Morbidity is related to a green living environment. Journal of Epidemiology and Community Health, 63(12): 967-973. http://dx.doi.org/10.1136/jech.2008.079038.

McLean, S., Sheik, A., Cresswell, K., Nurmatov, U., Mukherjee, M., Hemmi, A., and Pagliari, C. (2013). The impact of telehealthcare on the quality and safety of care: a systematic overview. PLoS One, 19(8): e71238. https://doi.org/10.1371/journal.pone.0071238.

NHS Digital. (2019). Digital inclusion guide for health and social care. Available at: https://digital.nhs.uk/about-nhs-digital/our-work/digital-inclusion.

NHS Health Education England. The Digital Readiness Education Programme. Available at: https://www.hee.nhs.uk/our-work/digital-readiness.

Morris, J. (2020). The remote care revolution in the NHS: understanding impacts and attitudes. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/resource/the-remote-care-revolution-in-the-nhs-understanding-impacts-and-attitudes.

Palmer, W. and Rolewicz, R. (2020). Rural, remote and at risk: Why rural health services face a steep climb to recovery from Covid-19. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/research/rural-remote-and-at-risk.

Pinkstone, J. (2022). Virtual GP appointments are a form of 'digital exclusion', NHS chiefs admits. The Telegraph. Available at: https://www.telegraph.co.uk/news/2022/06/13/virtual-gp-appointments-form-digital-exclusion-nhs-chiefs-admits/.

Rückerl, R., Schneider, A. and Breitner, S. (2011). Health effects of particulate air pollution. A review of epidemiological evidence. Inhalation Toxicology, 23(10): 555-592. https://doi.org/10.3109/08958378.2011.593587.

Tinder Foundation. (2013). Doing Digital Inclusion: Rural Handbook. Available at: https://www.goodthingsfoundation.org/insights/doing-digital-inclusion-rural-handbook/.

Tinder Foundation. (2016). Health and Digital Health: Reducing Inequalities, Improving Society. [Online]. Available at: https://www.goodthingsfoundation.org/insights/widening-digital-participation/.

Triberti, S. and Brivio, E. (2020). User-Centred Design Approaches and Methods for P5 eHealth. In Pravettoni, G. and Triberti, S. (Eds.). P5 eHealth: An Agenda for the Health Technologies of the Future. Switzerland: Springer Open, pp. 155-171. Available at: https://link.springer.com/book/10.1007/978-3-030-27994-3.

Walker, T. (2022). Tackling digital poverty in rural communities: national policy briefing. Work Foundation. Available at: https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/lums/work-foundation/NationalPolicyBrief.pdf.