Broadening the access to digital care
Dr Leah Jones
Healthcare insurers and providers now need to consider some important issues as part of the digital healthcare revolution if we are to keep up the momentum. Dr Leah Jones, head of behavioural insights at Bupa, analyses where we are at.
Before Covid-19, the preventative use of fitness and well-being apps was increasing; however, telemedicine had been slow to take off because face-to-face care remained the preferred option.
In January to February 2020, 96% of households in Great Britain had internet access, up from 93% in 2019 and 57% in 2006 when comparable records began.1
Fast forward to when the pandemic struck and overnight patients and healthcare providers were forced to switch their interactions online. Many countries adopted digital-first strategies, remote monitoring and telehealth platforms to enable healthcare provision without the risk of transmitting Covid-19.
In the UK, primary care embraced telehealth at scale and deployed a new digital-first pathway as a route to managing streaming of care to the appropriate place.
Our own Digital GP service saw a 50% increase from just over 8,000 to just under 12,500 appointments a month between February and March 2020.
Internet use became almost necessary for survival rather than a luxury; however, during the pandemic years there were still an estimated 2.6m people who were offline.2
A May 2021 report by McKinsey and Company3 found that 88% of people said that they had used telehealth services at some point since the pandemic began. And furthermore, 83% of clinicians surveyed in 2021 offered virtual services, compared with only 13% in 2019.
With telemedicine the default option, things looked promising for the long-awaited digital healthcare revolution.
In April 2020, use of telehealth was 78 times higher than in February 2020. But that spike in uptake has now stalled at 38 times higher than pre-Covid-19 levels. And while more physicians could offer care via telehealth, they still continue to recommend in-person care when possible again in 2021.3
With 90% of the population in an Ofcom survey having a smartphone,4 we could be forgiven for thinking that people would be keen to continue to use telehealth, as it offers a quick and convenient way to access healthcare. However, there are some hurdles that we need to overcome to ensure greater uptake of digital healthcare:
Data security and privacy
Our health data contains our most private information, so it is understandable that patients would be concerned about its safety and use.
Concerns about the privacy and security of electronic health information usually fall into two categories:5
- Inappropriate releases of information from individual organisations; for example, if an authorised user intentionally or unintentionally shares the information in breach of the organisation’s rules – for example, a data leak – or when outsiders hack into an organisation’s computer system to steal data and hold it ransom with the threat of releasing it.
- The systemic flow of information throughout healthcare and related industries and the use of this information in a way that may be against the interest of the patient or perceived as invading the patient’s privacy – for example, sharing information which the patient may be embarrassed about.
Even before the introduction of electronic medical records, the healthcare sector took significant steps to protect patients’ health information and maintain its confidentiality.
These same principles – deciding who can access the health information and whose needs for access are legitimate and put policies in place to ensure this – still apply with digital health information.
There are numerous mechanisms that can be used to protect electronic health information. These include both technical measures to improve network and computer security and the kinds of organisational measures mentioned above to make sure that only those who need to can access patients’ information.
Preference for face-to-face care
Analysis of GP practice data carried out by The Health Foundation found that 10% of patient care requests made to GP practices between March and September 2021 indicate a preference for a face-to-face consultation.6
At population level, this still represents a significant number of people who we need to ensure can access healthcare in a way that meets their needs.
A survey by Healthwatch Wandsworth7 found that views and experiences of using digital and phone appointments were mixed, even among different sections of the community.
Although some people praised and preferred phone appointments, particularly for routine checks, others fed back negative experiences including long waiting times to speak to a healthcare professional, rushed calls and feeling that they did not provide the same level of care as face-to-face appointments.
It seems that confidence using technology may be a factor in this. A study of colorectal cancer patients found that those with experiences of using video calling in daily life seem to choose videos over face-to-face consultations more often.
Patients who were hesitant in choosing a video consultation spoke of feeling insecure about using new technology.
However, 38% of patients in the face-to-face group were willing to try a video consultation in the future, but said they first wanted to get familiar with using video calling in daily life before using it for health purposes.8
The key to successful remote consultations is understanding which approach is the right one based on individual patient’s needs and circumstance.9
Healthwatch Wandsworth has put together a list of tips to help patients and healthcare professionals get the most out of the virtual health and care experience entitled The Doctor Will Zoom You Now.
Lack of digital literacy
There are many definitions of digital literacy, but, put simply, it means having the information technology skills needed to search, sort, evaluate and use online information.
Covid-19 highlighted the importance of digital literacy and widening access to online information by helping people to gain the skills they need to navigate and judge whether what they read is true or false.
According to the National Literacy Trust, in the UK 7.1m adults read and write at or below the level of a nine-year-old, and 43% of adults do not understand written health information.
With healthcare services, information and advice increasingly dependent on the internet, navigating digital information adds yet another layer of difficulty for those struggling with literacy who may also lack technological skills.
Health Education England’s National NHS Knowledge and Library Services team is working with the Chartered Institute of Library and Information Professionals to improve health and digital literacy at local level.
Its initiative is aimed at empowering patients, their families and carers by giving them the tools they need to maximise the health information and digital resources available to them.
Fragmentation of provider systems
People want services that are designed around them. At Bupa, we are trying to create a single front door for customers behind which we integrate a range of provider systems.
This requires providers and payers to work together.
Financial factors
According to the UK Consumer Digital Index 2021,2 26% of people who had not used the internet in the previous three months said it was because it was ‘too expensive’.
This is backed up by a review by Ofcom4 which found that 11% of fixed broadband households with the lowest incomes (up to £10,399) and the same proportion of those receiving means-tested benefits experienced an affordability issue with this service, which meant they had to modify or cancel their contract.
Furthermore, the UK Consumer Digital Index 20212 found that more than a third of UK benefit claimants have very low digital engagement.
The digital engagement score looks at people’s online spending, their interaction with digital services and products, and their use of digital devices and fintech services that use technology to provide automated banking and other financial services.
The average benefit claimant scored zero across many measures – however, 14% of their spend is online, some of it on mobile phones. They tend not to use email or online banking.
Benefit claimants are also more likely to have less digital engagement compared to the rest of the population and there is a greater digital disparity within this group.
Given the inability to leave home during the spring 2020 lockdown, the UK Consumer Digital Index 20212 found that millions of people across the UK struggled to engage with the online services required to access support.
Encouragingly, however, digital engagement has also increased for this population across the board since 2020.
Groups at risk of digital exclusion
When thinking about digital healthcare services, we need to be mindful that certain segments of the population are more likely to be offline than others.
These are:
Older adults: The ability of new telehealth initiatives to reach older people is uncertain, as many do not have smartphones or computers and some have poor or no connectivity due to their location.10
The older a person is, the more likely they are to be digitally excluded, according to the UK Consumer Digital Index 2021.2
This is exacerbated in those who live alone, have a limiting or impacting condition such as hearing or dexterity and are financially vulnerable.
Older people are also less likely to own a PC, laptop, tablet or smartphone, and less time spent online tends to correlate with lower confidence and comfort accessing digital services.
Disabled people: Having a condition that limits or impairs the use of communications services – such as hearing, eyesight, mobility, dexterity, breathing, mental abilities, social behaviour or mental health – is also likely to be a barrier to using digital services.11
Households including someone with a limiting or impacting condition were also more likely than average to experience affordability issues with their broadband service (8%) and to say they had cancelled the service (2%) according to the Ofcom report.11
Minority ethnic groups: The technology required to implement telehealth consultations may be problematic for some patients from racial/ethnic minorities because of the cost of equipment, limited understanding of the use of equipment and limited digital literacy.12
The financial barrier is demonstrated by the unemployment and income data. From January to March 2022, the UK unemployment rate was 3.1% for people from a white ethnic background compared to more than double that (7.1%) for people from minority ethnic backgrounds.13
Coupled with the fact that black households (54%) were most likely out of all ethnic groups to have a weekly income of less than £600,14 it is no surprise that one hurdle to accessing digital healthcare is an inability to afford internet connections and the devices required to access telehealth.
This is further exacerbated by the added complication of language proficiency and cultural considerations.
Conclusions
1. Covid-19 has shown us that digital healthcare is a good way to interact with patients, particularly when we adopt a hybrid of digital and face-to-face consultations.
2. Use of Bupa’s Digital GP has continued to climb steadily as the UK returns to normal life again, from almost 12,500 in March 2020 to almost 49,000 in July 2022.
3. While digital healthcare is not clinically appropriate for all circumstances, it is particularly suited to things such as follow-up appointments and the treatment of some ongoing chronic conditions where a physical assessment isn’t necessary.
4. However, in adopting a digital approach, we need to create a way forward that is accessible to all and takes account of patient needs and preferences.
5. We need to bear in mind the challenges faced by groups who tend to be digitally excluded and develop services that help them overcome the barriers to access – for example, by offering options in multiple languages and alternative formats.
References