Tackling the digital divide

A recent report by Public Policy Projects has said that ICSs need to use digital innovation in order to reduce health inequalities. HB picks out some key points from the report

Public Policy Projects is a global policy institute that provides practical analysis and development across different sectors, including health, social care, life sciences, net-zero and climate change.
The report, The Digital Divide: reducing inequalities for better health, investigates the digital divide and sets out a number of steps to be taken to make sure that the introduction of digital is done in a way that benefits all communities.
In the foreword to the report, Richard Stubbs, chief executive officer of Yorkshire and Humber Academic Health Science Network and chair of the report said: “Digital technology undoubtedly presents a significant opportunity to positively transform the delivery of health and care services in England and Wales. However, accelerating the transformation of health care through digital simultaneously carries the potential risk of widening the health inequality gaps that exist within our communities.”
Stubbs said: “Through the process of crafting this report, it has been a privilege to have heard many examples throughout the country where co-produced, thoughtful, and focused interventions are tackling this potential divide head on, with real impact as a result. They are trailblazers for the rest of us to follow, and many of the case studies that we heard are featured in this report. Thank you to all who gave their time to engage in our roundtables.
“There is no doubt that digital is here to stay; the pandemic has demonstrated how rapidly the health service can move to digital channels to ensure the continuation of care delivery. But if we are to truly unlock the power of digital for all our communities, then we must always be watchful of the potential risk that the digital divide brings. And though technology will obviously be part of the change to come, much of what will truly make the difference will come from the way that we engage with our patients and citizens; building trust with communities is essential to the equation, as well as co-production and empowerment that creates good user experience of the new models of digital healthcare delivery.”

Health implications
The report highlights that the digital divide has a direct negative impact on health inequalities in England and Wales. In this case, “digital divide” refers to the gap between those who are digitally enabled and those who are not. Digital enablement is when people have the devices, connectivity, access, capability, motivation, support and participation to navigate online, and to use digital services. In NHS terms, digital transformation means that health services and information are available and accessible online.
Digital enablement and digital engagement are known to have an impact on health. They are also known to have an impact on social determinants of health, including education, employment, housing and finances. Following on from this, some groups of people are more likely to be digitally excluded and there is an overlap between people who are digitally excluded and those who are at highest risk of health inequalities. People over 70, people with disabilities or long-term health conditions, and people with a lower literacy rate or educational attainment are more likely to be digitally included. On the other hand, research from The Nuffield Trust found that groups of patients likely to be in relatively good health (including younger, white, highly educated, living in more affluent areas) are more likely than other patients to successfully navigate online access to care. The report notes that while several factors contribute to the link between digital exclusion and health inequalities, “the digital divide can be seen to contribute significantly to existing health inequalities”.

Digital services
The report acknowledges that many public services are increasingly available online, as a result of acceleration during the pandemic, and this includes health services. The pandemic has highlighted the benefits of digital healthcare – the report points out the use of digital and data keep more comprehensive records for patients, better monitor population health, and roll out innovative digital health treatments. During the pandemic, with the need to reduce face-to-face interaction, virtual consultations became normal.
However, the report also points out that the pandemic has also revealed inequalities in digital access and health. The report states: “If these inequalities in connectivity and access are not addressed, health inequalities will persist and are likely to be exacerbated.” The report highlights that some sections of society were more severely impacted by Covid than others. Statistics from the Office of National Statistics reveal that those living in the most deprived areas of England and Wales are approximately twice as likely to die after contracting the virus as people living elsewhere, and mortality rates for the virus were highest among males of Black ethnic backgrounds.
The introduction of the report states: “Maximizing this opportunity will require digital connectivity to become an area of priority for all stakeholders. Digital innovations and data must also specifically target the reduction of health inequalities. This report makes a series of recommendations which, if implemented, will reduce the health inequalities exacerbated by the digital divide, and make more appropriate use of digital and data to target the health of those in underserved communities, and to identify the areas of greatest need in a population. It is acknowledged that these issues are prevalent across the devolved administrations.”
In preparation for the report, which focuses on the health systems operating in England and Wales, roundtables were held with NHS stakeholders, public health experts, integrated care system (ICS) representatives, local authorities, charities, academia, and medical technology providers.

The report sets out eight recommendations, the first of which is: “The Department for Levelling Up, Housing and Communities should change the English indices of deprivation to encompass digital access and skills”. This recommendation is intended to improve the measurement and documentation of people who are not digitally engaged.
The second recommendation is: “Integrated Care Boards should be responsible for convening and supporting trusted staff in all public services, including health and care, to assess and support those who want to get online”. This means that support programmes should be context specific, as well as tailored to the specific needs of a community. There should also be walk-in centres that provide access, connection and devices, as well as support on digital skills, confidence and safety.
The third recommendation: “Digital-by-default must operate in the context of the digital divide” means that all government services including healthcare must be accessible equally by digital and non-digital pathways, as a digital-by-default approach may lead to those who are not digitally engaged being at a disadvantage and widen existing health inequalities.
Fourth comes: “NHS England should make Digital training mandatory for all health and care staff”. This is because health and care staff need to be confident and comfortable to access online systems in order to provide the best care, as digital channels become more prominent. This should also include training on the digital divide and its impact on health outcomes, as well as how to support patients to become digitally engaged.
The fifth recommendation is “NHS England should update their Digital Technology Assessment Criteria (DTAC) to ensure that products and interventions are designed specifically tailored to the needs of those with additional accessibility requirements (particularly those with few digital skills, people with disabilities or long-term health conditions, people over 70 years old, and people with English as a second language).” This means putting a focus on good user experience. It is noted that if a service is not accessible to those who need it the most, this will worsen existing health inequalities.
“Integrated care systems should instil a culture of real-world evaluation for health interventions” is the sixth recommendation. This means that data on health and social determinants of health should be collected before and after interventions in order to build up a base of evidence that can be used to inform.
The penultimate recommendation is that “All should be given access to all their health and care data with summary analytics, and the information should be easily accessible within the NHS app.” This is intended to create trust in the system.
Finally, “New digital care pathways and other support services must be co-produced with the communities they serve”. This means that in order to ensure that services are useable and appropriate for those using them, end users should be involved at every stage of the design and implementation process.

Digital skills
The report concludes: “To reduce the health inequalities brought to our attention during the Covid-19 pandemic, concerted effort must be made to reduce the digital divide and its impacts on health. As healthcare services and tools become increasingly reliant on digital channels, digital skills have become central to the management of health. Simultaneously, digital access and skills impact upon all the SDOH, and therefore digital competence confers benefit to individuals across a broad range of non-medical factors which influence health outcomes (including housing, employment, education, and financial factors). The digital enablement of the population, where appropriate, must be a priority to ensure that no one is left behind and health inequalities are reduced.
“In order to achieve improved digital access for better health, digital access must first be recognised as a significant determinant of deprivation and health. To address this gap, measurement and documentation of those who are not digitally engaged must be improved. ICSs should convene and support staff in health, care, and other public services to provide digital support to communities, tailored specifically to the needs of the individuals in an area. It must be recognised that while digital access and skills can improve health status it may not be appropriate or safe for everyone to be online, and therefore all government services, healthcare included, must be provided at a high level via offline channels.”

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