One of the areas that the NHS response to COVID-19 has progressed at pace is our adoption of digital platforms to communicate with our patients. GPs and hospital consultants are seeing and assessing patients via video consultation at a scale never previously seen. The national roll-out of NHS 111 will necessitate virtually all attendances to emergency departments to be via a telephone or digital triage process.
Good practice when we are changing how a service is delivered is to consider the quality impact on service users—specifically we are required to consider any impacts that may adversely affect any patient group.
Davies (2020), writing on behalf of the NHS Confederation, shares the ‘NHS Reset’ campaign plans in light of the pace of change towards digitalisation, focusing on the inclusion agenda at this time of rapid change. Davies reports that, although there is a section in the emerging NHSX tech plan vision on digital inclusion, that it does not appear to be strong on the national agenda.
These concerns were also reflected in the Topol review (2019). This identified that an individual's engagement with digital technology plays a key role in determining outcomes such as uptake in the health service. Furthermore, the review highlighted that, although technological innovation in health can help to redress health inequalities, it could conversely have the potential to exacerbate them unless consideration is given as to how they affect equality and equity, including the risk that vulnerable groups might be excluded or exploited.
Drawing on experience, Davies (2020) offers three areas to consider for NHS leaders when considering designing digital enhancements:
- Co-design and integrate digital inclusion into digital activities from the beginning. People who are digitally excluded are not the problem, they are the solution. Co-design needs to start where people are by exploring life-context factors, digital capability and system factors
- Digital inclusion is a complex partnership issue to be solved together. At its best, inclusive digital transformation strategies mobilise informal community action, semi-formal voluntary sector activity and more formal public sector services
- It will not happen without targeted resources and leadership buy-in, but it could be developed at a low cost if it is co-designed in from the beginning of every digitally enabled activity.
National Voices et al (2020) published The Doctor Will Zoom You Now, a rapid, qualitative research study that aimed to understand the patient experience of remote and virtual consultations. It recognised that there are some significant opportunities in the use of technology and remote consultations. They found that, for many people, remote consultations can offer a convenient option for speaking to their health professional. Patients valued rapid access to clinicians, and they value not having to travel and take time out of their day to attend appointments.
However, the research showed that there is no one-size-fits-all solution, and that the key to a successful shift to remote consultations will be understanding which approach is the right one based on individual need and circumstance. A blended offer, including text, phone, video, email and in-person was concluded to provide the best solution.
The National Voices et al report set out seven key areas for consideration:
- Boundaries: respecting people's time and where appointments fit in with their lives
- Quality personal communication
- Preparation and information: providing guidance and setting expectations
- Choice of phone, video or text/email and in-person, to meet the needs of people: what is right for the person and what is right for the situation
- Test, learn and improve: designing the remote experience with patients and carers
- Being inclusive: meeting the needs of people for whom remote access is not possible or appropriate
- Opportunities: such as interaction with patient notes, recording of appointments, education and training, and the use of existing patient groups to provide local support networks to increase confidence and access.
From the reviews and work to-date on increasing our ability to be digital by default going forwards, it is clear that there is more work to do, and that a significant proportion of the population is digitally excluded because they do not have access to the internet and/or have low levels of digital literacy. It is also clear that there are people who are less likely to be able to access online services for a number of reasons—older people, people with disabilities, specific communities, and those on low incomes.
It is essential, when we are designing and implementing more digital interfaces with our patients, that the risk of ongoing or increasing health inequalities are considered and mitigated and that the co-designing of these interactions is firmly adopted.