As healthcare digitisation accelerated during the early phases of the pandemic, so too did the issue of digital exclusion. And, as a recent Digital Health roundtable with Virgin Media O2 Business discussed, it’s a complicated, deepening and multi-faceted problem with no one solution. Claire Read reports.

In the early phases of the pandemic, when the country was tightly locked down and virtual consultations had become a standard means of delivering care, staff at Oxford Health NHS Foundation Trust introduced a programme to reach the digitally excluded. Under the device loan scheme, patients who lacked technology or connectivity – and who therefore couldn’t access virtual consultations – were provided with a mobile with data. It appeared to be a simple and straightforward solution to the issue. It proved to be anything but.

“It became really complicated really, really quickly,” remembers Chris Walkling, the trust’s senior digital programme manager. The reason? Choices over precisely how to configure devices being provided to those with often complex problems and multiple vulnerabilities.

“Do we give you a device and say you can access wherever you want? That becomes quite problematic quite quickly because if, say, we’re working with somebody with a gambling addiction,” says Walkling.

“So then do we say: ‘Okay, we’re going to try and stop people from accessing all of these websites that we decide are harmful.’ I mean, that’s almost impossible to do.

“So do we then say, we’re actually going to lock this device down and only let you access the things that we want you to access? At which point that becomes very paternalistic.

“There are so many practical challenges on even the most simple thing, which is trying to give somebody connectivity.”

Walkling was speaking at a recent Digital Health roundtable. Run in association with Virgin Media O2 Business, it brought together a small panel to consider an issue that is increasingly high on agendas: digital exclusion.

Extended periods of lockdown served to dramatically accelerate the use of digital across all realms of life, with healthcare no exception. A report by the Centre for Economics and Business Research, commissioned by Virgin Media O2 Business, suggests that the NHS has made the equivalent of four years of digital progress since March 2020.

But that acceleration risks leaving some behind. Research estimates that 22% of people in the UK are without the digital skills needed for everyday life; 16% unable to use the internet or device without help; and seven percent almost completely offline. Even when someone is digitally literate, having a device and – particularly – access to adequate data can be a barrier to inclusion. That’s likely to become a bigger issue still as the cost of living crisis deepens.

As more healthcare moves online, the danger is that the excluded become more so. So just how should the NHS be approaching this issue?

The answer, our panel suggested, depends to some extent on precisely which excluded groups are being considered. Digital exclusion is often portrayed as an issue confined to older people or those at an economic disadvantage. But the discussion made clear it actually touches a far broader range of individuals, and in complex ways.

Emily Burch – associate director of physical health at Barnet, Enfield and Haringey Mental Health NHS Trust – suggested it was important “we look at cohorts of patients, at groups, as well as at individuals”.

“For example, there is a whole host of patients who are within our prison systems that automatically have no access to mobile phones, and a lot of them will have all sorts of different types of mental health and physical health issues,” she added.

There is also the challenge of those who actively choose to avoid digital engagement – not because of lack of skills or lack of access but because of lack of trust.

“I think it’s a rising issue,” said Louise Cave an advanced clinical practitioner at The Christie NHS Foundation Trust who is currently on secondment to NHS England.

“At the moment it’s a minority, but what if that minority starts to become the majority? We’ve then got a group that are excluded and quite possibly angry.”

As Burch put it: “We’ve got such a rich and diverse population that it’s quite challenging to think of who is going to be excluded and who isn’t”.

One panellist, however, was willing to make a brave estimate as to how many people were affected. Said Adrian Byrne: “In actual fact, probably more than 90% of the population are excluded from the health services at the moment in a digital way.”

Byrne, the chief information officer at University Hospital Southampton NHS Foundation Trust, clarified this wasn’t necessary because of lack of access to data and devices. Instead, it’s because their healthcare provider simply doesn’t offer a digital setup via which they can get the information they want and need.

Changing this would in part, Byrne suggested, involve suppliers to creating systems that meet the specific needs of the NHS and its patients. And getting the software right – making it tailored, easy to use, efficient – may in turn help another potentially digitally excluded group: clinicians themselves.

“Some of our clinicians seem terrified of interacting with patients digitally,” reported Mike Culshaw, chief technology officer at Pennine Care NHS Foundation Trust. “Unless I have clinicians that want to interact with people digitally, nothing will change.”

“A consultant physician once said to me: ‘The internet spoils the myth of medicine,’” revealed Clare Green, transformation director, South, Central and West Commissioning Support Unit (CSU). “When you have people that think like that, they will only change when they see their peers changing.”

Another issue is clinicians who ‘go rogue’. “We have a large number who do want to engage in digital, but on their own terms,” reported Simon Noel, chief nurse informatics officer at Oxford University Hospitals NHS Foundation Trust. “They won’t engage with the organisational systems, but they will engage with their own systems.”

It was another example of just how broad the issue of ‘digital exclusion’ can be, and that it is thus a problem with no one solution. It was therefore argued that addressing it will need to involve a range of partners. “It isn’t one organisation or one person’s task to fix this challenge,” stressed Martin McFadyen, head of public sector at Virgin Media O2 Business. “And nor is it one sector’s. This isn’t exclusively the domain of the NHS to fix.”

His colleague Mark Burton suggested it was incumbent on private sector companies to really understand what the problems are and to design solutions to help.

“A lot of organisations, including Virgin Media O2 Business, have people that have had boots on the ground in the clinical environment,” said Burton, the firm’s UK health sector lead. “So we do have some understanding [of that environment], but it’s really about us listening to your needs.”

Of course, there are sometimes practical challenges to building such relationships. During lockdown, staff at University Hospital Southampton NHS Foundation Trust decided to introduce a virtual handover of patients leaving the hospital to go to a care home. But practical problems cropped up.

“The nursing homes were having problems with using nhs.net accounts,” explained Sarah Bradburn, the trust’s chief nursing informatics officer. “Some private providers didn’t like them using the nhs.net account, they wanted them use their own accounts.”

It is the classic problem of overcoming the boundaries that sit between organisations. There was some optimism that the newly statutory integrated care systems (ICSs) might ease some of these issues, at least when considering digital exclusion of patients.

What also may have to happen, however, is acceptance that it will never be possible to ensure absolutely every person is digitally engaged. “I think digital exclusion is a big problem and I don’t know that we’re ever going to fix every part of it,” concluded lPamela Fearns, lead digital nurse implementer at The Christie NHS Foundation Trust.

“There will always be people who don’t want to be digital, who exclude themselves. I think if we could capture the majority, we’ll have done a good job.”

Panel:

  • Sarah Bradburn, chief nursing informatics officer, University Hospital Southampton NHS Foundation Trust
  • Emily Burch, associate director of physical health, Barnet, Enfield and Haringey Mental Health NHS Trust
  • Mark Burton, UK health sector lead, Virgin Media O2 Business
  • Adrian Byrne, chief information officer, University Hospital Southampton NHS Foundation Trust
  • Louise Cave, advanced clinical practitioner, The Christie NHS Foundation Trust (currently on secondment to NHS England)
  • Mike Culshaw, chief technology officer, Pennine Care NHS Foundation Trust
  • Pamela Fearns, lead digital nurse implementer, The Christie NHS Foundation Trust
  • Clare Green, transformation director, South, Central and West Commissioning Support Unit (CSU)
  • Jon Hoeskma, editor in chief, Digital Health (roundtable chair)
  • Martin McFadyen, head of public sector, Virgin Media O2 Business
  • Simon Noel, chief nurse informatics officer, Oxford University Hospitals NHS Foundation Trust
  • Chris Walkling, senior digital programme manager, Oxford Health NHS Foundation Trust