Digital healthcare is putting the most vulnerable at risk. Here’s how we can fix that

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From AI algorithms that pick up early cancers, to the ‘doctor-in-your-pocket’ smartphone video consultation, a string of next-generation healthcare technologies are being unveiled at a rapid rate.

For instance, as recently announced in England, users of the NHS app can now collect medications from a pharmacy without having to visit a healthcare centre, the usual paper slip given by doctors being replaced by an in-app barcode.

Such innovations have brought huge benefits to millions of patients. But the advantages of such digitisation are not distributed equally. According to a 2023 Ofcom report, one household in 13 has no access to the Internet and a similar proportion has no home computer. Yet even within connected households, the so-called ‘digital skills gap’ means many people could still struggle.


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Imagine this typical case. Dorothy and Bill are retired factory workers in their mid-70s. They have a home computer which plugs into the TV, a machine that can (just about) send emails to their daughter who lives abroad.

It’s clunky to use but they love to see news of the family coming through on the TV screen. But websites take a long time to load, so they don’t use the computer for much else. Bill has a smartphone and receives photos of the grandchildren on an instant messenger app, but he hasn’t worked out how to send any back.

Prompted by a text message from their GP surgery, the couple confirm that they have Internet access and supply their email address. A few weeks later, a message comes through inviting Bill for his annual health check and a shingles jab. But the subject line is unclear and the long message is impersonal and hard to follow.

As the couple have only ever received emails from their daughter before, they assume this message from their GP is junk mail and delete it. The result: Bill misses his check-up, runs out of blood pressure medication and remains vulnerable to shingles.

The digital skill gap

The problem is that entry-level home computing is designed mainly for basic gaming and simple email exchanges, not for interacting with data-hungry web platforms or sending high-resolution images of body parts. The same goes for a budget-level data bundle from a mobile phone provider.

To navigate the digital health space, people like Dorothy and Bill will need not only better technology but also the technical skills to operate it, such as being comfortable typing, using a mouse and interacting with dropdown menus.

Also key is ‘information literacy’ – that’s the ability to recognise when information is needed (e.g. an old address, or login code) and how to provide it. Then there’s health literacy – the ability to find, understand and use health information and online health services.

Typically, an individual is either digitally well-equipped, technically skilled, information-literate and health-literate – or simply isn’t. There’s little in-between. And, as a major University of Oxford analysis showed, the more markers of disadvantage a person has (low income, older age, preference for languages other than English, to list a few), the more difficult they’ll find accessing digital services. When several of these factors add up it’s even less likely that these disadvantaged patients would be able to connect via digital means with health services at all.

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Sadly, such inequalities are nothing new. In fact, it was 53 years ago that British doctor Julian Tudor Hart first proposed the ‘inverse care law’, a principle that argued people most in need of healthcare (the poor, the less well-educated, the older, the sicker) are least likely to receive it.

The ‘digital inverse care law’ has no simple solutions. Those lacking the necessary digital skills may be willing to attend the local library for computer training, but they should not be thought of as empty buckets which can be unproblematically ‘topped up’ with the complex set of skills on which they have missed out on.

What are the solutions?

What should NHS organisations be doing to ensure that everyone gets a fair deal in today’s digital world?

First, any digitally supported service should be designed or improved primarily for the patients who are likely to struggle to use it. A service that works for those who are unfamiliar with or unable to use computers and smartphones will almost certainly work for the rest of us. ‘Digital navigators’ – human staff who can help patients find their way about the service if needed – could be a great help here.

Second, healthcare providers need to go beyond the binary when assessing people’s digital connectivity and skills. Rather than asking patients whether they have an internet connection, we should ask them to describe what they are actually comfortable doing with technology, and then customise their health care package accordingly.

Third, remember that the most disadvantaged patients – those who may have complex health and social care needs – may be best served by an old-fashioned approach that does not require them to use technologies at all, especially when their needs are poorly met by such technologies. Such patients could have an electronic flag put on their record to remind busy staff to offer technology-free, or technology-light, options.

And finally, we should view digital exclusion first and foremost as a moral issue. As the founder of the NHS Nye Bevan said: “No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”

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