If digital “by default” is the new normal for primary care, and the ambition for other parts of the health and care system, David Maguire, Senior Analyst at The King’s Fund explores how do we know that those with less ability to access care when it is provided digitally aren’t being left out?

Digital inequalities have been an increasing priority, not just as digital access to services has become more prevalent within the health and care system, but also as other public services move online. As the Good Things Foundation has highlighted, digital inequalities are becoming one of the social determinants of our health.

There’s a complex relationship between health outcomes and digital inequalities, with some groups who are already facing poor health outcomes also subject to digital exclusion. People living in rural areas have less access to, and slower, internet infrastructure, older people are less likely to own smartphones or connect to the internet, and people with lower incomes are less likely to have access to smartphones in their household and more likely to be on pay-as-you-go mobile phone contracts and data plans which can make it more expensive to access the internet.

Despite the increasing focus on digital exclusion, there are still some big gaps in our understanding. That is why The King’s Fund partnered with Public Health Wales to bring together the best research from around the developed world on how different health services have tried to address digital inequalities.

Preventing exclusion

There are some common themes in the studies we found, but there is no “silver bullet” when it comes to tackling digital inequalities. The NHS has been using a combination of approaches to enhance inclusion.

The successful projects we looked at all started by understanding the current context of their audience (“what makes people more or less likely to use digital tools?”) both through data they already had access to, as well as by involving users in development, listening to and understanding privacy and trust concerns as part of the design process, and working in collaboration with their audience. The projects we studied also enhanced the credibility of information by tailoring how it was presented to users, for example, by offering multiple languages or different digital avatars that better reflect the end users. Other projects we looked at had considered how digital services are accessed and, for example, provided online access points with support workers at common use areas like libraries. Another theme of the projects we studied was the need for realism.  Where the aim of a digital tool was to encourage healthy behaviour among users, the designers had to be realistic about what could be achieved with a digital product– sometimes public health interventions will be more effective when conducted face-to-face.

Unanswered questions

Despite reviewing the available evidence, we were left with some significant unanswered questions. For example, whilst there is evidence that designing digital tools with health inequalities in mind can enhance digital inclusion, there is little evidence that it ultimately improves the health outcomes of disadvantaged groups. We can see that there is a benefit to adapting apps and other information provision tools deployed in public health settings to account for digital inequalities, but it is not clear whether that benefit is worth the additional cost of development economically.

Most of the research we found came from international studies, particularly in the United States. There was a much smaller amount of detail on the nature of digital exclusion and how to address it here in the UK. Digital inequalities are not a static problem, rather the nature of digital inclusion will shift over time as technology and the way it affects our lives changes. To address inequalities in how care is provided digitally, we need to understand the specific challenges here in the UK. When recently speaking with primary care professionals about digital inclusion, I was taken aback by how many focused solely on older people, largely overlooking other factors that create barriers to accessing online services. To prevent inequalities worsening as services increasingly move online, we need to develop a sophisticated understanding of the issue, bringing in socio-economic factors and geographical issues that are also key to identifying populations likely to face digital exclusion.

Lessons to be learned

Having reviewed the research into health services’ efforts to reduce digital inequalities, it is clear there are several lessons to be learned.

Firstly, when setting out to use technology to improve health, there should be a clear logic model in mind. Often this starts with the process of finding out how to make information more “credible” to the user.

Secondly, we found that the evaluation of many digital inclusion projects was not sufficiently robust for others to draw clear conclusions. This is despite the nature of digital technology making it easier to gather evidence than with traditional face-to-face services. For best practice to spread across the country, we need to support each other with high quality evidence that answers some of those outstanding questions outlined above.

Thirdly, and importantly, none of the issues we found through this work should be taken as a reason to slow down or reduce efforts to improve access to care or information through digital technology. The evidence shows that the risks of digital exclusion can be mitigated against.

The trend towards digital access to care has been rapidly accelerated by the pandemic. This shift is long overdue, but the pace of change brings with it an increased risk that some people will be left behind. This is not an insurmountable challenge, and certainly not a reason to stymie digitalisation, but digital inequalities do warrant attention if everyone is to benefit from ‘digital by default’ services.