Why Addressing Digital Exclusion is Essential for Digital Health to Have Real Impact

With increasing discussion around digital services, big data, and AI in the NHS, an often-neglected question arises: Are the digitally excluded going to be left out of digital health?

As technology increasingly shapes the way we think about health services, a group is often missing from the hype—you could say invisible even.

That is the "Digitally Excluded". This risks exacerbating existing health inequalities in myriad ways.

Now that’s not to say all services can and should be delivered via digital channels. Nor will everyone want to use these digital channels. Yet the problem of digital inequality is that if we don't design digital programmes to address it, we implicitly decide for specific population groups that "they can't use these services".

This article is a short primer on digital exclusion in UK health, including who is excluded, why it matters, and what we can do about it.

What is 'digital exclusion'?

Whether you call it 'digital exclusion' or 'digital inequality,' it refers to some individuals' lack of access to the skills and capabilities needed to engage with devices or digital services that help individuals participate. When it comes to health, as more services and support move online, this exclusion or digital health inequality can impact patient health outcomes and experiences, too.

It's about more than lacking internet access.

Some people don't have access to the internet. Ofcom, the UK's telecoms regulator, estimates that about 6% of the UK population doesn't have internet or any device. In some areas of the UK, this figure goes up to 30-50% for those on benefits or over 65.

Digital inequality is about more than access to the Internet. It's about ease, comfort, and confidence in using the Internet to do various things.

Ofcom defines digital exclusion in 3 dimensions.

- Individuals who don't have access to the internet or a device.

- Individuals who can't afford/struggle to afford devices/data

- Individuals who feel they lack skills to navigate the internet safely, confidently and knowledgeably

But these are interconnected.

A Study by Lloyds Bank found that:

In England, 27 percent (14 million) of people have the lowest digital capability. This means they don't have regular access to a device or the skills and confidence to turn on a device, use an app, log in, and/or enter information on a digital device by themselves.

Who are the excluded?

People often fall into the trap of 'older people are not good with technology’ but it’s not a simple age issue.

Across the UK, 26% of those aged 70-79 say they feel confident using the internet. Yet, in some areas of the UK, over 50% of people over 65 don't have access to the internet.

Demographics and other factors play out differently across different parts of the UK and communities. It also highlights the underlying inequalities that exist already.

Demography, geography, language, and even past negative experiences on the internet can play a role.

For example, older people and those on low incomes are more likely to have challenges using the internet and digital tools. However, unstable connectivity can exacerbate these challenges if they live in rural areas.

Others may have issues due to language or accessibility challenges for health reasons. Beyond that, it could also be those who have had negative experiences, like victims of an internet scam.

Who is digitally excluded will depend on how these factors play out in a particular geography.

How do people experience Digital Exclusion?

In the real world, here's how people might experience digital exclusion.

"I can't afford a laptop or desktop to access the internet on a mobile. That makes it harder to do things like fill in some forms, compare items or find jobs or housing".

"I struggle to afford a data plan, so I have to limit or not use the internet".

'I can use the internet for basic things but don't feel confident using the internet for anything complicated like registering."

"I live in a rural/remote area where connectivity is pretty poor."

"My English is not good, so I don't feel confident navigating the internet, especially for my health."

"I have a limiting condition which makes the internet hard for me to use."

"I find NHS services difficult to access online; it is confusing."

What does all this have to do with people's health?

The answer lies in the inverse care law. Over 50 years ago GP Julian Tudor described how “perversely – people who most need health care are least likely to receive it.” Digital exclusion means we see this playing out in digital health services too. Which is not what the promise of digital was. The goal of digital tools in part was to improve appropriate access. Surely, that should include those who might benefit from the tools and technologies but don’t have the devices, data, skills or confidence yet.

This digital inequality can have an impact on health through a number of ways.

1) Via limited / lack of access to services.

Some specialist services may only have online options due to staff shortages, or the company supplying them is in digital health.The focus on digital might also mean that some in-person services are harder to get.

Some services may be faster or easier digitally, e.g., repeat prescriptions, screening/appointment bookings, etc. Without digital option they could end up being cumbersome for certain groups.

2) Via lack of access to good/quality health information.

Credible online information (either from the patient's own clinician or other evidence-based content) can be a determinant of good health. Access to quality health information is increasingly important in a world of chronic, lifestyle illness.

Alongside access to meaningful health information online, a lack of digital skills and the ability to distinguish what is good quality health information, health scams can be harmful.

This extends beyond not having access at all. For example, use can be limited, where individuals can only access the internet by phone, making it harder to access certain forms or websites. King's Fund found that NHS websites/services were notorious for complicated user experiences.

3) Via limited / lack of access to jobs, housing, and benefits systems.

Most job applications, housing applications, and Universal Credit are primarily online. Without internet access, it can be hard to engage in these processes. People are unable to access information, forms, applications, and guidance, which can hold them back from good employment and even housing. We know that good quality employment and housing are strongly associated with health.

4) Via lack of digital footprint, meaning 'invisibility' in datasets.

Digitally excluded groups often overlap with people who are less likely to engage with the health system anyway. They can become invisible in datasets available to clinicians and decision-makers, and digital exclusion can further exacerbate this.

Whether an NHS organisation is trying to understand what key issues in the area are, a team redesigning a service to make it better for patients, or an AI algorithm using available training data to create a clinical decision-support tool, digitally excluded individuals may not show up, which can mean services are not tailored to them. At the extreme, this can have serious consequences for their health.

What's crucial is that many of the characteristics of the people likely to be digitally excluded also overlap with those likely to need the most health support and can even benefit from remote health support.

So, digital health inequality can deepen differences in health outcomes between people.

Conversely, finding ways to bring the digitally excluded into the digital fold presents chances to do better.

On one research project, I remember interviewing a clinician who said they had to think hard about asking low income patients to come into the clinic for routine health monitoring. These patients really couldn't afford to keep paying travel costs to get to the doctor unless they physically had to be there. Providing meaningful ways for these patient to communicate with their doctor digitally could help. This is only possible with the proper support.

So, what can we do?

It's vital that NHS and mainly digital health companies take digital exclusion seriously. There are growing initiatives in the NHS, but all those developing digital health must take meaningful steps to ensure patients are included.

Tackling digital exclusion is complex, and solutions will depend on local areas and the needs of people in those areas. It's not a case of making everyone go online.

Some people also don't want to use technology to access and receive health services. For many cases or health services, providing digital services is not appropriate or realistic either. We are also figuring out which services are effective online and which aren't.

How can health systems ensure adequate support is available?

In a future article, I'll focus on practical ways organisations are approaching digital health inequality. This includes looking at devices and data support, UI/UX, community services, and data usage.

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