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Left Behind: How to Prevent Digital Exclusion from Isolating Our Most Vulnerable Patients

There can be little doubt that the Coronavirus pandemic that we are still living through forced major change on the NHS, and the way it interacts with patients. Remote appointment rates soared quicker than they ever would have done in normal times, and are still the subject of fierce debate.

The perfect blend of remote and face-to-face appointments has not yet been found.But in trying to protect the NHS—and those who use it—the use of technology and remote appointments has excluded some of the most vulnerable and marginalised people in our society. What lies behind this, and how can we begin to reverse it so that in today’s modern, ‘levelled-up’ Britain, nobody is left behind in the rush to embrace the digital agenda?

The NHS has long held ambitions to make itself a digital-first service. In its Long-Term Plan published in 2019, it stated its aim that every patient would have the right to this digital-first primary care. When Covid hit, this tech revolution gained a new and urgent pace. By April 2020, at the height of the Covid crisis, nearly 50% of appointments were carried out remotely. A year earlier, that figure had been just 10%. Guidance issued last year to GPs advised them to adopt a ‘total triage’ model so that all patients are screened remotely or by telephone before being given an appointment. 

But stories began to emerge of patients who suffered as a result of not being seen in person. Some never got that far, put off by tech they were not used to, languages they couldn’t converse adequately in, or by simple virtue of not being able to afford an internet connection or computer. Care was working, but it wasn’t working for everyone. Digital appointments quickly became a double-edged sword, removing obstacles for some and creating barriers for others.

Against this backdrop, Healthwatch launched a qualitative research project, with the aim of speaking to groups traditionally more likely to experience digital exclusion to understand why, and how this can impact their healthcare experience.

Who are the most excluded groups?

During their investigations, three groups of people emerged who were particularly susceptible to digital exclusion:

  • Non-native English speakers who struggle with the language and typically use an interpreter for their engagements with health and other services
  • Elderly people, especially those over 65 and those who lived alone
  • Disabled people especially those suffering from hearing or sight impairments, learning disabilities or mobility issues

Why are they excluded?

By talking to these people, and also interviewing healthcare professionals in primary care settings, they revealed the bleak reality of the digital exclusion which had become a reality for some. What was behind the reluctance to engage digitally? The following were amongst the most common reasons given:

  • a lack of interest in developing digital skills
  • unfamiliarity/fear of technology
  • language barriers, for example not being able to spell medication names when ordering a repeat prescription, and not being able to reply on body language or pointing
  • forgetfulness over how to use systems
  • fear of fraud, or of compromising security and privacy
  • economic circumstances—not being able to afford a computer or internet connection
  • the limitations of basic mobile phone contracts—not enough data to send images, or lack of reception, or calls are too expensive to wait on hold for prolonged periods
  • Blindness or deafness making tech use hard or impossible

Lack of adequate communication was cited by some interviewees; some reported they had not been told that their surgery was once again offering face-to-face appointments; another said they were unclear whether those unable to use online systems would be allocated an appointment automatically to have to wait for a call back. 

Practical things practices and PCNs can do

  • Be mindful when using ‘total triage’ that some patients can’t book appointments online or using digital tools. Let them know they can book in other ways too.
  • Use the tools available to support and improve the video appointment experience such as these guidelines on safe principles of online appointments, or this guide to remote intimate clinical examinations.
  • Try to partner with the voluntary and community sectors where possible to help people access the care they need.
  • Consider what the most appropriate type of appointment is for each patient – remote or in- person? Note down on their record if they will need support for future appointments e.g. translators.
  • Make sure the practice website clearly lists all the different ways you offer to book an appointment. Provide video guides in multiple languages if possible, to show how to use e-consult systems, for example.

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