Roz Davies on digital inequality in health and how the coronavirus emergency has pushed the issue to the top of the policy agenda; and created a rare moment for change.
As the novel coronavirus arrived in the UK, the health and care system moved fast to adopt some kinds of technology. Trusts implemented remote working solutions and virtual clinics, while primary care shifted to phone and video consultations.
As the NHS prepares for winter and the introduction of integrated care systems next year, the focus of politicians and policy makers has been on expanding these initiatives. To pick just one example, NHS England is creating a ‘talk before you walk’ model for emergency care that will require many patients to call NHS 111 before they go to A&E.
The potential problem is that a significant minority of people have not been able to access new, digital services and there is a danger their needs will be overlooked in this push to go ‘digital by default’. However, I am really hopeful that this will not happen.
People have seen that the impact of Covid-19 has been much harder on deprived areas than affluent ones. They understand that individual experience of this disease is very different, depending on many factors including pre-existing conditions and background, for example people from black, Asian and minority ethnic communities have been disproportionately affected.
They have also seen that people are digitally excluded from services, particularly education. They have been shocked that children cannot access online learning and support because they don’t have a laptop to use. So, I think things have changed, and that presents us with an opportunity.
The challenge is that this is not an easy problem to solve. Digital exclusion is a classic ‘wicked’ problem; one with interconnected causes that shift as you address them. But it is possible to identify three main causes; life context, digital access and skills, and system issues. Health inequalities is not a new issue.
Life context is income, housing, and having to deal with ‘things that matter to me’ like working multiple jobs or having to deal with domestic violence. It is the cause of digital exclusion that was laid bare to the public by Covid-19, but the NHS and social care understand it very well.
Digital access and skills is having the data and devices necessary to access digital services and the skills to use them. It would cost “peanuts” to address this in the context of the billions that the government spends on public services every year.
‘Prescribing’ data plans and devices might even save money in the long-term, by reducing the burden of ill-health on the NHS and the economy. However, it is the last factor, system issues, which includes staff attitudes and capabilities, that I want to emphasise, because it is often overlooked.
You cannot make progress on digital exclusion unless systems and the people working in them share perspectives with patients and carers. When we work with organisations, we look to design enhancements to tools and services so that they work for everybody.
Others might be less optimistic. We know that, at root, digital exclusion is about a lack of power, and that a lack of money is a major contributor to that. We know that tackling the roots of digital exclusion is a global issue, and not one that is top of many government’s policy agendas at the moment.
It’s also becoming clear that, as we head into the winter, more restrictions are already being imposed to tackle further waves of Covid-19, and that the impact will fall hardest on communities that have already been hard-hit.
Despite that, I think the public experience of the seven months of the pandemic, and the NHS’ response to it, mean that there is an opportunity to tackle digital exclusion in health. So, for everybody who wants to do that, here are my top five tips:
First, don’t start with the technology, start with a focus on people. Second, understand that people are not the problem, they are part of the solution. If they are not taking up some shiny new digital service, they will know better than anybody what the barriers are and how they can be addressed. They will have ideas and energy. And if you go ahead without them, you will not get anywhere.
Third, use co-design principles. You might think that the managing director of mHabitat is bound to say that, but by defining the problem and creating and iterating solutions together you are more likely to have success. Fourth, work with allies across the system and beyond. Find willing stakeholders, particularly in the integrated care systems and primary care, because they are really up for this.
And fifth, be aware that this is about genuine leadership and buy-in. You will have to invest resources in doing this: but it will improve the lives of our most excluded and vulnerable people and result in more effective and efficient services.
Roz Davies presented her views at a recent Highland Marketing advisory board meeting
Davies is managing director of mHabitat. The company is hosted by Leeds and York Partnership NHS Foundation Trust and supports people-centred digital innovation in health and social care.
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