Digital technology in healthcare was vital during the COVID-19 pandemic to make sure that people maintained access to health services when they were not available in-person. However, the move to digital healthcare disadvantaged some patients and placed them at risk of greater inequality and vulnerability. Here, Dr Omer Ali, Dr Elizabeth Dalgarno, Dr Claudia Pagliari and Professor Arpana Verma explore who might be left behind in the move to digital healthcare and what policymakers can do to mitigate against emergent inequalities.

• The digital divide and health inequalities often intersect, with groups most likely to need healthcare being the ones least likely to have strong digital skills.
• Many people will need to be taught how to use digital technology, as well as improving other literacy skills if they are to be included in the future of digital healthcare.
• Access to technological devices and ongoing support will be crucial for disadvantaged communities.

The COVID-19 pandemic has driven many of our activities online – including healthcare. While the digital revolution in the NHS has brought many benefits, further shifts such as remote consultations and monitoring during the pandemic, have the potential to leave people behind. Now, more than ever, digital skills are needed to navigate the world, especially while social distancing and restrictions mean that we spend more of our time online, but for many people this is not possible. The UK government aims to transform patient outcomes through technology, but does this benefit everyone equally? And who is left behind?

Digital access is not enough

Ensuring the whole population has access to the internet is vital in the technological age, yet access to digital services in the UK is deeply uneven. Currently, 4% of UK households do not have internet access, 3.8 million people (7% of the population) have never used the internet and 9 million cannot use the internet unassisted. The older and more deprived you are, the less likely you are to be digitally engaged, with lower socioeconomic groups more likely to face barriers to getting online and less likely to have the skills to use digital devices. People with disabilities are also less likely to be online. We know that these groups are disproportionately affected by ill health and are at more risk of complications related to COVID-19 and to suffer from social isolation – these differences have only been highlighted further by the pandemic. In light of this, the NHS should measure the use of digital health services by these groups and how this impacts on access to healthcare; after all, they are the biggest users of healthcare services. Digitisation of patient-facing services in the NHS needs to explicitly include strategies to engage these groups and ensure health inequalities are not widened even further.

The importance of access to the internet is reflected globally in the United Nations (UN) Sustainable Development Goals (SDG 17.8). However, access is of no use if people don’t have the skills to make best use of the internet.

Improving digital skills in the clinically vulnerable

Digital literacy can be enhanced by targeting the most vulnerable with mass digital literacy programmes. This could be done through expanding projects such as the NHS Widening Digital Participation Programme which delivered digital skills training through local hubs working together with councils, libraries, community groups and volunteers thanks to a collaboration between the NHS and the Good Things Foundation. Scaling up this network further could help reach the estimated 23.5 million who have low to very low digital engagement according to the Consumer Digital Index.

Targeted skills training could begin by identifying clinically extremely vulnerable and shielding groups. They are at high risk of complications related to COVID-19 and isolation related to social and digital exclusion. This could also be led on a locality level such as the Greater Manchester Digital Inclusion Taskforce. This will allow for targeted skills training for those most in need. We should bear in mind that many older adults do use the internet successfully and as many as 26% of those aged 70-79 consider themselves digitally skilled.

Ethical questions in digital healthcare

As we increasingly move more of our health services online, we should also consider the ethical implications: could we be widening health inequalities by moving more of our health service online? Is the increasing trend towards remote monitoring necessary? Who owns the data that is collected and how is privacy safeguarded? Will it result in a better experience of care and better treatment or will it compromise patient safety?

We must recognise the privacy concerns of patients. According to the Information Commissioner’s Office, healthcare accounts for the most personal data breaches, making up 19.7% of the total. Concerns around privacy became particularly prominent in the wake of the failed Care.data launch in 2013, along with more recent concerns surrounding the Test and Trace app. There is a growing concern around whether digital interventions can maintain the same level of ethical principles afforded to patients prior to these digital innovations. Respecting autonomy or ‘self-rules’ may not be achievable if individuals are implicitly coerced into accepting these changes against their will. Healthcare should be justly available to all and ensure access to care with digitisation is equal. Furthermore, it is those with the least digital literacy that we often exchange the most information about, such as those on the shielding list or in social care. This raises questions of power and control and whether digitisation and data sharing always really empowers the individual.

Digital literacy should not be viewed on its own – it intersects with many other aspects of health, and health literacy often overlaps with digital literacy. People with low literacy are more likely to experience increased hospitalisation or death and less likely to engage with preventative health, which is why health literacy campaigns need to run alongside digital literacy campaigns. Additionally, often the facilities available to people locally dictate what support and services they can access; ensuring there are facilities with free digital devices and support on how to use them, should be prioritised so that nobody misses out, including during lockdowns.

Digital, health and financial literacy

The pandemic has highlighted the gap in achieving equal access to education for children who do not have digital devices and we know that education and health are intrinsically linked. We also know that globally there is a gender digital divide, with girls and women having less access to technology and the internet. Without a combination of digital, health and financial literacy it will be very difficult to break out of a cycle of poverty and ill health. To study the best ways to tackle this and co-produce a solution with local communities, we are working with communities in Doncaster, West Cheshire and Manchester alongside academics from across the country to identify research questions that matter most to them and co-produce solutions to the above. We hope that by taking a collaborative approach we will be able to achieve lasting solutions that work for the most deprived communities in our towns and cities.

Digitising health services should be more than just putting services online. Many communities will require access to free-to-use digital devices, the internet, and active support, and it is likely that a large campaign will be needed to improve digital literacy for all. Particular attention should be paid to ensuring that an ethical approach is taken and patients and the public are involved in leading the design of digital health projects, to ensure their specific needs are met.

This article was originally published in On Digital Inequalities, a collection of thought leadership pieces on how to address the inequalities we are seeing in the digital space, published by Policy@Manchester.

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