The COVID-19 pandemic transformed the way many people go about their day to day lives with digital technology becoming ubiquitous (While, 2023). Many services were switched to online, as evidenced by the seismic shift in finance, grocery and other retail shopping, with data being used to redesign banking and other services to increase convenience and allow selfservice. Similarly, digital health became the default approach, with information and healthcare provision being offered through digital means to minimise face-to-face contact. Many of these changes have now become standard practice, limiting access to many services, activities and resources for people who are able to use digital technology.
There is much talk about the greater use of technology improving the efficiency of the NHS and as a means of reducing healthcare costs, but the potential of digitally enabled care in the community is yet to be realised (Pritesh, 2024). Booking online appointments, renewal of prescriptions online and tele/virtual consultations are becoming the norm in many general practices. While this rush to implement digital health services will have winners, there will also be losers, many of whom will be the recipients of district nursing services (Age UK, 2023). The scale of the digital divide is graphically illustrated by the Good Things Foundation (2024) which provides a platform for the National Digital Inclusion Network and highlights the challenges that need to be overcome to change the current levels of digital exclusion.
The digital divide is not a new phenomenon with the Office for National Statistics (ONS) (2019) outlining the scale of the digital divide in the UK before the COVID-19 pandemic. The ONS emphasised that digital skills are as important as internet usage because without the necessary skills to confidently and safely navigate the digital world, users can be digitally excluded. While the scale of digital exclusion has declined over time, 10% of the adult population were described as non-internet users by 2018, with Lloyds Bank (2018) estimating that 8% of adults had zero basic digital skills and 12% had limited basic digital skills. The ONS (2018) noted that digital technology offered a range of benefits to people, including easier communication (with family, friends, services), access to information, saving time, cheaper retail as well as employment benefits for those of working age. While there have been fewer internet non-users over time, there were more women than men internet non-users with a persistent age gradient for both internet users and use of the internet ‘on the go’, with people aged over 75 years being non-internet users disproportionally and less likely to access the internet ‘on the go’. Similar trends were reported for people with one or more disabilities.
‘The use of online booking of appointments, renewal of prescriptions and tele/virtual consultations are becoming the norm in many general practices. While this rush to the realise a digital health service will have winners, there will also be losers, many of whom will be recipients of district nursing services.’
The House of Lords (2023) Communications and Digital Committee noted the mismatch between the then Conservative government's aspiration of global digital leadership and a sound strategy to tackle digital exclusion in the UK, especially in light of the unprecedented rate at which all public and other services were going online. The report asserted that 1.7 million households had no mobile or broadband internet in their homes, with as many as a million people having cut back or cancelled their internet packages due to the rising cost of living. An estimated 2.4 million people were unable to complete a single basic task to get online, such as opening an internet browser. Unsurprisingly, the report acknowledged that the causes of digital exclusion reflected longstanding social, economic and regional disparities, which are not easily solved. The report also noted that past initiatives had failed to make substantial progress, due in part to the requirements for digital inclusion being a moving target as technologies change and societal expectations evolve. Among this report's recommendations was the plea that all public-facing services should recognise the fact that making everything digital does not necessarily make the service better and not everyone wants to be online for long periods of time.
The House of Lords (2023) Communications and Digital Committee report was followed up by a House of Commons (2024) debate where the consequences of digital exclusion were acknowledged to result in sections of the population not being able to participate fully in UK society. Digital exclusion has three interrelated aspects, namely: lack of access (home or elsewhere), lack of ability (skills, confidence, digital knowledge, physical ability to get online) and lack of affordability (access to internet, internet enabled device) (Office of Communications (Ofcom), 2022). According to Ofcom's 2023 Technology Tracker, 7% of UK households did not have access to the internet at home. It is becoming apparent that even among internet users, there is a wide range of digital skills with over a quarter (27%) being ‘narrow users’ and only undertaking a few familiar tasks, with ‘narrow users’ more likely to be aged over 65 years (Ofcom, 2024). The Public Sector Bodies (websites and mobile applications) (No. 2) Accessibility Regulations 2018 (UK Government, 2918) requires public service websites and applications to make reasonable adjustments for the protected characteristic of disability and to meet the Web Content Accessibility Guidelines (WCAG) 2.1 AA (accessibility standard) (UK Government, 2023a), including publishing an accessibility statement with adherence being enforced by the Equality and Human Rights Commission (EHRC). The accessibility of private sector websites is overseen by the Department for Science, Innovation and Technology and action related to adherence remains ongoing. The latest UK Digital Strategy (UK Government, 2023b) lacked a specific digital inclusion strategy, which is still awaited, and there is increasing concern about the rural-urban digital divide adding to existing disadvantages (Vodaphone, 2023).
‘Smartphones assume a certain level of dexterity and familiarity with the online world, which many people over 80 years of age do not have and are unlikely to acquire. Additionally, people who have used their hands for heavy work may not have finger prints nor can they ‘swipe’ on a smartphone.’
A King's Fund (2023) project revealed the mixed experiences of people (n=11) in England and Scotland using digital technology within health and social care. While most reported positive experiences, others, including people with sophisticated digital skills, could not always make digitally enabled health services work for them. Where it worked, digitally enabled healthcare empowered and promoted a more active role in care, but the reverse was also true. When people experienced additional barriers and lack of choice, they felt unempowered and eschewed seeking support. The impact of digitally enabled health services may extend to carers with digital barriers being an unwelcome addition to their responsibilities.
Healthcare providers need to be constantly alert to the cost of the latest technology and everchanging digital skill requirements if they are to ensure equitable access to healthcare. Pritesh and Jabbal (2023) have highlighted how digital exclusion is complex, nuanced, dynamic and ever evolving, so assumptions about a demographic group should be avoided. At some point, anyone may be digitally excluded due to changes in their health or personal circumstances. Services should be mindful of assuming one size fits all; people's needs and preferences may change over time.
While it is understandable that the health policy needs to encourage the development of digitally enabled services, it also needs to emphasise that the development of digitally enabled services should not be to the exclusion of more traditional in-person services. Rather, digital and in-person services should be combined to meet the range of healthcare needs of the local populations. Digitally enabled services should be tested to meet the needs of people with limited digital capabilities, which makes nearly a quarter of the UK population (Lloyds Bank, 2019), if the benefits are to be accessible and usable as widely as possible.
To this end, the NHS England (2024) guidance states that the digital inclusion framework should be used: ‘to design and implement inclusive digital approaches and technologies, which are complementary to non-digital services and support’. The Lincolnshire Digital Health Toolkit shows promise in helping to identify those areas likely to have high levels of digital exclusion through existing data such as local levels of claiming Guaranteed Pension Credit, unemployment, low socioeconomic status, socioeconomic deprivation, poor academic qualifications, low physical activity and internet access (Mea et al, 2023). Identifying areas of likely digital exclusion will enable targeted interventions such as digital access kiosks in health centres.
McGrath (2024) has highlighted how inequality has been embedded alongside digital progress in the absence of structural change because of the reliance upon voluntary capacity and charitable donations, rather than a central government initiative. He has suggested that there are three quick fixes that the new government should undertake in their first year: revise the ONS definition of digital inclusion with a new, more holistic and up-to-date approach so that better data are collected; change the focus to outcomes and support regarding skills rather than tick boxes and fast delivery, and recognise the internet as an essential utility to protect consumers.
In the meantime I will continue to help people circumnavigate the new digital world for healthcare, local authority services and banking. Smartphones assume a certain level of dexterity and familiarity with the online world, which many people over 80 years of age do not have and are unlikely to acquire. Additionally, people who have used their hands for heavy work may not have fingerprints nor can they ‘swipe’ on a smartphone. I have to hope that those developing digitally enabled services consider the issues of accessibility and usability for the widest possible user population as an integral part of the design process.