3. Key findings
3.1. Digital exclusion in health and social care
Digital exclusion is complex. Terms like 'the digital divide' are valuable for raising awareness and highlighting inequalities. However, the realities of digital exclusion are better understood as a spectrum - where digital access (devices, data connectivity), accessibility, skills, confidence, motivation and availability of support all combine to shape how and if people use the internet, and the balance of benefits and harms they get from the digital world.
Certain groups are more likely to be digitally excluded, including: older people (aged over 65), those who are financially more vulnerable, and those with a condition that limits their use of communication services. For more information see the Ofcom report Digital exclusion: A review of Ofcom’s research on digital exclusion among adults in the UK. While certain demographic factors are linked with digital exclusion on average, the issue is more complex. Personal, situational and environmental circumstances all impact how and when people use the internet and digital services.
There is a significant body of research on digital exclusion, and the link between digital exclusion and health inequalities. Key reports that informed the evidence review carried out at the outset of this research include:
In an increasingly digital society, the ability to use and benefit from online tools and services is becoming ever more important. Mainstreaming the use of digital channels, products and services in health and healthcare has accelerated since the start of the coronavirus (COVID-19) pandemic in 2020. This move towards digital services may impact on health inequalities for patients and service users, both in their ability to access services and the outcomes achieved.
COVID-19 has created a significant shift in our relationship with digital technology. The proportion of people online has continued to increase, and the range and types of services accessed have diversified, but this is not equally distributed. Some groups are using the internet less following the pandemic. For more information see the Ofcom report Digital exclusion: A review of Ofcom’s research on digital exclusion among adults in the UK.
There is growing awareness that digital inclusion, in terms of access, skills, motivation and confidence, impacts the broad range of factors that shape people’s chances of a healthy life and good health outcomes. For more information see the Good Thing’s Foundation report on Digital inclusion and online safety for adults in the UK: An evidence review. These broader factors, such as housing and education, are known as the social determinants of health. There is the risk that digital exclusion may restrict the potential for digital tools to benefit all groups and support better access to and experiences of health and care.
The Laura Wade-Gery review into data, digital and technology in the NHS also recognises this challenge and makes recommendations which situate digital inclusion within the wider context of health inequalities.
3.2. Accessing health and social care services online
More people have accessed online health services and digital tools as a result of the COVID-19 pandemic. Approximately 10 million more people in the UK used NHS sites or digital applications in 2021 compared with pre-pandemic in 2020, though this has since dropped again in 2022. Digital channels were key sources of information for people in finding out about the pandemic and managing the spread of the virus. For further information see Ofcom Online Nation reports for 2021 and 2022.
112,635,708 estimated visits were made to the NHS online service in March 2021 and 93,610,308 in March 2022 based on Adobe Analytics implemented on the NHS website [1]
37% of people in the UK use the internet to support their physical health, and 25% to support their mental health, as reported in the Lloyds Bank UK Consumer Digital Index
In 2021 almost half of people (49%) using digital apps or services reported that they helped them improve their health and wellbeing (including fitness), compared to 35% in 2020, as reported in the Lloyds Bank UK Consumer Digital Index
Our survey of the health and social care workforce confirms these trends. 70% of those surveyed, both practitioners and administrative staff, reported undertaking more work online with members of the public now than they did pre-pandemic. This increase was also reflected in the recently published research NHSX Adult Social Care Technology and Digital Skills Review.
A wide variety of digital tools and services were used by people to manage health and social care needs. Many people were using digital health tools or apps to help them improve their health and wellbeing, and this increased over the course of the COVID-19 pandemic. For more information see the Lloyds Bank UK Consumer Digital Index. Our survey found high levels of digital channel use amongst a nationally representative sample of the general public, with 4 in 5 people (79%) using some form of digital channel to meet a health and/or social care need.
Our survey of 1010 members of the public found that 61% had used the NHS website, 56% had used the NHS App and 42% had used a GP Practice App/website. Just over one-in-ten people (13%) had made use of a website to manage social care needs.
A wide array of online and offline services were used to meet health and social care needs. Digital channels which related to services provided by the NHS or by local social care services tended to be used on the recommendation or direction of the NHS or social care service. These included:
Remote consultations or meetings with members of the health and social care workforce to variously discuss, diagnose or treat medical conditions, or to discuss care plans. These included Zoom, Teams WhatsApp as well as more dedicated platforms such as Doctorlink or 8x8;
Patient access services to access medical records, connect with GPs, or manage healthcare (including the booking of appointments or repeat prescriptions). These included the NHS App, myGP and Patient Access. These channels were typically used because of past experience;
Using email or text messaging services to send photos or evidence to a member of the health and social care workforce;
Apps and wearable devices which helped people to manage ongoing health conditions such as diabetes or sleep issues as well as broader fitness levels; and
Completing care need and financial assessments, to progress care and support plans.
4 in 5 people (79%) had used a digital channel for managing a health or social care need over the past twelve months. These included:
Booking/ Reporting a COVID-19 test (PCR/ Lateral Flow)/ Booked a vaccination (66% performed this activity online, and 25% did it offline)
Booking an appointment with a GP, nurse or other healthcare practitioner (23% performed this activity online, and 44% did it offline)
Ordering a prescription (30% performed this activity online, and 28% did it offline)
Obtaining health advice for themselves/ someone else (25% performed this activity online, and 31% did it offline)
Booking a same-day appointment with a GP practice for an urgent issue (6% performed this activity online, and 27% did it offline)
Checking their health record or personal health information (25% performed this activity online, and 8% did it offline)
Managing/ monitoring health remotely (13% performed this activity online, and 11% did it offline)
Looking for information about care and support services or providers in the community (11% performed this activity online, and 5% did it offline)
Having a consultation with a care or support worker (4% performed this activity online, and 8% did it offline)
However, even amongst people who were more confident in their ability to access digital services there was a high level of variation in which services were accessed digitally, and which were accessed face-to-face or by telephone.
[1] Note that estimated visits is doubling the visits recorded to estimate the effect of the cookie banner, which has an opt in rate of 50% of sessions
3.3. Perceptions of digital channels for health and social care
The majority of both the health and social care workforce (90%), and members of the public (70%) believe that digital technology will play an important role in the delivery of health and social care in the future. Understanding people’s perceptions toward digital health and care services matters, particularly in the context of increasing motivation, because people’s behaviours usually reflect their attitudes and beliefs.
Members of the health and social care workforce felt digital channels offered the potential for efficiencies in timely and effective access and delivery of care.
72% of the workforce survey respondents agreed that digital technology allows the NHS to operate more cost efficiently
67% of the workforce survey respondents agreed that digital tools and services provide the opportunity for service users to get access to appropriate care
60% of the workforce survey respondents agreed that using digital tools and services to engage with service users will make them more efficient
This could include through the quality and timeliness of information gathered (e.g. through more effective triaging and pre-consultation information collation). Digital is also uniquely well placed to connect different parts of the health and social care system, helping ensure that different parts of 'the system' are sharing information on service users. This is particularly important for more vulnerable people who may have more contact points with public services.
Digital channels offer the potential to enable greater equality in access to services. For example by removing some of the practical barriers faced by certain groups that experience health inequalities, and through enabling more effective targeting of resource (both time and expertise) at groups most likely to require support. These same groups are those most impacted by digital exclusion.
While digital approaches offer some clear benefits, the health and social care workforce held concerns that they will be achieved consistently for everyone. This was reflected in a split in views toward the future use of digital in delivering services. 30% of the workforce surveyed would prefer to use digital for interacting with services users, 42% selected 'neither/nor' and 26% would not prefer to use digital to interact with service users. Similarly, while 49% of workforce survey respondents agreed that digital tools and services will lead to better quality of care for service users, 15% disagreed and 37% selected 'neither/nor'.
Digital was seen to be beneficial and preferred in certain circumstances, not as 'digital by default'. Factors influencing these views are discussed in the following section.
"Digital privileges the people who need the service the least, and shuts out those who need it the most." Clinical Psychologist
Members of the public acknowledged the potential for digital NHS services to save them time and make their life easier.
58% of the general public surveyed agreed that using services provided digitally by the NHS has the potential to save them time
55% of the general public surveyed agreed that using services provided digitally by the NHS has the potential to make their life easier
Both were valued, though more amongst those who were most confident and who made greater use of digital services already.
People were more mixed in their views toward the wider benefits around better quality of care and accessing the right support more quickly.
38% of the general public surveyed agreed that being able to access NHS services digitally will mean people get the right support more quickly
38% of the general public surveyed agreed that being able to access NHS services digitally will mean better quality of care for people 'like them'
Members of the public did, however, see digital as enabling a greater degree of connectedness between services in future. This could reduce the need for service users to repeat their circumstances to multiple professionals, a key frustration amongst those who use health and social care services on an ongoing basis. It may also enable services to deliver more holistic and preventative care, which would be of benefit to those impacted by health inequalities and digital exclusion.
While there are benefits of digital, a large proportion of people, regardless of digital confidence, either do not want to access health and care related services digitally (23%) or remain unsure (35%). Conversations with people highlight that comfort with the idea of using digital channels for health and social care services can differ depending on individual needs, attitudes and circumstances.
3.4. Factors influencing motivation and behaviour
To influence the use of digital channels to meet needs and/or deliver health and social care services, it is necessary to understand those factors influencing motivation. Motivation is about wanting to achieve something and is important in driving people’s behaviour toward meeting that goal. The COM-B model of behaviour change suggest it comprises 'reflective motivation' (the judgements people make and beliefs that people hold) and 'automatic motivation' (people’s desires, impulses and habits). For more information on COM-B see The behaviour change wheel: A new method for characterising and designing behaviour change interventions.
Based on interviews with members of the public and members of the health and social care workforce, four interrelated factors were identified which influence motivation to use digital channels:
Perceived effectiveness: how digital can deliver the expected service (and outcomes) quickly and efficiently.
Feeling understood: how digital can enable people to communicate their needs, to feel heard and understood by others.
Providing control: how digital can give people more control over the support they access (or deliver) through the NHS and social care system.
Confidence: beliefs in personal capabilities to access and use digital channels to meet health and social care needs (or to deliver health and social care services).
These factors are not unique to people experiencing digital exclusion. Everyone’s choices to use digital channels for health and social care may be influenced by their attitudes and feelings around these factors. However, those groups most likely to be digitally excluded (older people, unemployed people, people experiencing financial vulnerability, and disabled people and people with long term health conditions) may be disproportionately affected because of their wider needs, capabilities and circumstances.
1. Perceived effectiveness: Perceived effectiveness relates to the people’s beliefs about whether digital health and social care services are efficient and effective in meeting their needs. This includes expectations of a professional service (i.e. delivered by qualified practitioners) which helps to meet needs in a timely manner.
"[Good care is] when you get a good outcome to whatever has been the issue. So my mother had good care because when I rang 999 they came quickly and she was treated well." General Public
"Holistic, person-centred, accessible…in a way that is right for that patient…we need to be flexible." Occupational Therapist Manager
Where people held positive associations with information technology and online services more broadly, they were more likely to be positive toward digital health and social care services.
Where people had positive experiences of some digital health and social care services (e.g. management of online appointments), this helped motivate continued use of these specific services, and increased consideration of other services.
"This is now a great system for recording everything and everybody with permissions being able to access the information. Family members can feel like they are involved in their care because they can see exactly what goes on every day." Nursing Home Carer
However, people found inconsistency in experiences frustrating and tended to default back to those processes that had worked for them best in the past, without looking to re-engage with digital channels following a ‘failed’ experience. Examples included GP practice websites offering a more limited range of online services than those required, and in some cases less able to meet people’s needs (e.g. offering a more limited range of appointments than those available if calling by telephone).
There is a higher risk that people who are digitally excluded will have existing perceptions about the inadequacy of digital channels confirmed through poor experiences, reducing the likelihood they will try again in future.
"When you log in, it doesn't really work. Well, you know, you cannot see any appointments, and when you can you have to wait for them to confirm that the appointment [by phone]." General Public
"When it does go wrong, I feel like it's a personal attack on me and my intelligence, and it's [the computer is] personally ruining my day." Nursing Home Carer
The (actual or perceived) lack of consistency and adequacy of digital services can be anxiety provoking and undermine confidence that needs can be met through these channels. This is more common amongst those impacted by digital exclusion and presents a motivational barrier to using digital channels to meet health and social care needs.
The wider literature suggests positive judgements of effectiveness are more likely where people understand the information presented to them, what action to take, and whether a digital service provides clear benefits over past or current forms of care. For more information see The role of economic, educational and social resources in supporting the use of digital health technologies by people with T2D: a qualitative study. For those who are digitally excluded this might include greater convenience of access, timeliness of care or choice of support.
Perceptions of effectiveness also depend on people seeing services as relatable and relevant to them, their culture, values, circumstances, language and literacy levels. If people do not feel like the digital services are for people like them, they are less likely to be motivated to try them. For more information see Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review. Journal of Medical Internet Research.
For the health and social care workforce there were concerns around digital channels compromising care quality, with key questions around what good practice looks like in the delivery services and data security.
"There is so much out there, it is difficult to discern which apps or services have a clear evidence base behind them. If I am going to recommend someone to use one, I want to know that it’s been tried, tested and evaluated for impact. I want to know it’s been designed with members of the public and health professionals." General Practitioner
"How can you deliver care through a screen?" Social Worker
Interestingly, these same concerns around data security were much less prevalent among members of the public.
One-quarter of health and social care workforce surveyed (27%) had concerns about the accuracy and reliability of the healthcare information gained from digital tools and services
58% of the health and social care workforce surveyed felt providing health and social care services online will lead to some people having inadequate care
Just 19% of members of the public had concerns about data security that would impact their sharing of information, while this was a concern for 43% of the health and social care workforce surveyed
2. Feeling understood: Service users wanted to feel understood when communicating about health and social care issues. This related to feeling that someone is listening to and hearing them, and that they will be cared for, accounting for their individual needs. From a workforce perspective, a channel for clear communication was a prerequisite for delivering most health and social care services.
Good care was typically seen as being delivered through a trusting relationship built on interpersonal communications and a 'human touch'. This was felt to enable empathy and an understanding of individual situations, ensuring service users are heard, their needs listened to and understood.
"So you don't feel like you're in a factory in a conveyor belt. I think a human touch, the human factor is very relevant with everything." General Public
"For us, a nurse or a consultant to say ‘I hear you’, is such an important part of good care. You actually see the women’s shoulders drop and the emotions come out because someone is actually listening." Gynaecologist
Care delivered face-to-face was felt to provide reassurance, to facilitate trust and to enable members of the health and social care workforce to deliver the form of care/support required effectively. This reassurance was particularly important for issues where more emotional, diagnostic or therapeutic support was felt to be needed.
"I don’t think that the person [practitioner] cares any less, or does the job any less…but as the public we generally feel that we’ve been looked after better if somebody has kind of laid a hand on us or spoken to us face to face." Podiatrist
Other studies have shown that motivation to use a digital health service can increase where there are clearer opportunities for human interactions (both online and offline) and for peer-to-peer social connectedness. For more information see this systematic review: Factors affecting implementation of digital health interventions for people with psychosis or bipolar disorder, and their family and friends.
The fear with digital channels is that they will result in being processed as a 'faceless number' within a relatively rigid system, rather than being treated as a human being with individual needs and preferences. This is particularly the case for those who are digitally excluded because of the intersectionality of factors that can influence their motivation (or ability) to communicate online. For people who are more likely to be digitally excluded, face-to-face was also seen to reduce the risk of being persuaded to accept something different from what they wanted or felt was needed.
"If I’m sat in front of you and you are trying to get rid of me, I can sit tight. Once you say goodbye online you can’t touch a button and say something else, you are done and that is it." General Public
"Is healthcare about efficiency? Is caring about being efficient? Where is the warmth? Where is the humanity? I wouldn’t get that from health care being totally digitalised." General Public
Trust and reassurance can be facilitated by continuity of care. In offline services, there may be a sense of continuity as an individual sees the same GP or therapist, building up a relationship. There is an opportunity for digital channels to enable better data-connectedness, removing pressures on service users in having to repeatedly tell their story. This is particularly relevant in reducing the burden on more vulnerable service users and for those less confident accessing digital services.
"I have a complicated medical history and having to start again every time consultants have been switched, there's been an issue." General Public
From a workforce perspective, there was a corresponding concern that digital channels present a barrier to effective communications, and therefore care. Again this view was most prevalent amongst those health and social care staff with least experience using digital channels to deliver care.
"The screens almost form a barrier, almost like a table tennis net between you and the person." Social Worker
"If they don’t tell you things, you can’t spot things as easily [online] through their body language. Face-to-face is always the best scenario." Administrator NHS Children’s Specialist Services
There is an opportunity for digital channels to deliver against the needs of service users and those delivering a service by building elements of human connection into digital interactions. People will be more motivated to use digital where they know there is the option of engaging in a two-way conversation with a qualified member of staff if needed, and where digital is presented as one channel (among others) through which they can access support.
3. Control: Control relates to the extent to which people feel in control of the care they access (or deliver), and how digital channels support or undermine this. This can be influenced by the design of services, by the support and guidance provided to service users, and by the features offered by digital services.
Good care was described by the people involved in this research as person-centred ("the patient comes first"), designed to provide the user with a feeling of control and choice over how and when they are supported. People who are digitally excluded can benefit most from a service which is tailored to their needs, providing reassurances which influence their experience of a service and willingness to use it again in future.
People tended to have a preference for how they wanted to access health and social care support based on past experience, their understanding/beliefs about digital, and their presenting needs. Examples were provided of remote consultations being scheduled without any choice on the part of service users, or rationale (e.g. virtual assessments of fractures or falls in older patients). This lack of influence impacts feelings of control and satisfaction, particularly where someone may already lack agency or confidence that a digital service was most appropriate for them.
"If they're being forced to do it, or kind of heavily steered towards it, they're not going to engage with it particularly well. You need to offer choice, good quality care. Rather than one size fits all." Occupational Therapist
Those more likely to be impacted by digital exclusion may face other challenges, for example poorer health, lower levels of literacy or limited access to the internet. Many people who were less confident using the internet were also uncomfortable asking for support in improving their digital skills. Of those survey participants who lacked digital confidence in using the internet (N=112), over 2 in 5 people (41%) expressed discomfort in asking for support in improving their digital skills.
Care is needed in designing digital services with clear signposting to support or opportunities for interaction, to reduce the potential for people being unintentionally excluded from a service at a point of need.
"It is really frustrating when things don’t go according to plan for me. Once I talk to someone and they sort it for me, everything is ok." General Public
"The job of a receptionist is to deal with the worried anxious person who wants an appointment, and in the online setting that is the bit that is missing. That’s the bit we need to create. We need to create a sense of there being multiple channels, so that people can choose their own preference for how they can be communicated with." Expert stakeholder
"I’m concerned about excluding people. We can be easily blinded by the convenience, and this works really well for us because we don’t have to leave the office and we possibly put more patient appointments online and see more patients." Facilities Team Leader
4. Confidence: Confidence relates to people’s beliefs in their own capabilities to access and use digital channels to meet their health and social care needs. Higher levels of digital confidence were equated to lower levels of stress in accessing NHS services digitally, and greater levels of motivation to use digital channels to meet health and social care needs.
The majority of people were confident in their ability to access digital services, although this drops significantly for NHS health and social care services. Older people (aged 65+), disabled people and those with health conditions, and those in lower social grades [2] were significantly more likely to lack confidence in accessing digital health and social care services. These groups were also those most likely to be digitally excluded and most likely to experience health inequalities.
85% of the general public surveyed were confident in their ability to access digital services, dropping to 67% for NHS health and social care services
One quarter (25%) of those members of the public who lacked digital confidence (N=112) found the idea of accessing NHS services digitally to be stressful, and just 5% agreed that they would like to access health and social care services digitally
Lack of confidence was especially high in:
older people (34% lacked confidence compared with 11% of the general population)
those with existing illness or disability (19% lacked confidence compared with 8% of those without)
those in social grades D and E (43% lacked confidence compared with 13% in social grades A and B)
A lack of confidence was associated with:
a lack of familiarity with the range of NHS and social care services that can be accessed online;
a perceived lack of time to learn how to use digital services offered by the NHS and social care;
more negative views toward the value of digital services to save time or make life easier; and
concerns around data security.
"Everything is a fear button, you don’t want to click the wrong thing and make everything disappear and when you are dealing with patients - it’s all such sensitive data." Proactive Care Nurse
Confidence relates not just to people’s views toward their own technical abilities to use a digital platform, but also in their confidence to communicate their needs within this platform. People were concerned that they may say or do the wrong thing within a digital channel, and that this could lead to miscommunication, misunderstandings, and poorer outcomes than would be the case through a non-digital channel. In times of stress and/or urgency, this can lead to people defaulting to less risky channels which they are more familiar with and more confident in accessing.
"Those people need to speak up when they go for their appointments. If they speak up that then creates that communication which hopefully addresses the concerns they have. If they don’t speak up, no one will know what is happening." Hospital Operations and Training Manager
"It wasn't because I didn't trust the systems, but because I didn't trust myself." General Public
A common concern for both the health and social care workforce, and the general public, was that a 'digital by default' approach may leave the most vulnerable people behind: those who are less confident in accessing services digitally or in advocating for themselves. Providing reassurances that care will not be undermined or that users will get ‘lost’ in the system will be key in motivating the adoption of digital channels for health and social care.
"I’m concerned about excluding people. We can be easily blinded by the convenience, and this works really well for us because we don’t have to leave the office and we possibly put more patient appointments online and see more patients because we don’t have to get them into the building and need them to be on time." Facilities Team Leader
"There will be people who are scared to go online because they are scared about pressing the wrong button and that itself creates a level of anxiety." General Public
In this study, the vast majority of the health and social care workforce surveyed (92%) reported confidence in using digital technologies to deliver aspects of their work with service users. This dropped slightly to 82% when focused specifically on interacting with service users digitally (e.g. through a video consultation).
The qualitative research suggests that confidence is highest amongst those members of the health and social care workforce who were most familiar with the use of digital tools and services as part of their day-to-day role. Members of the health and social care workforce involved in the delivery of social care services, in particular carers working in care homes or community settings, were typically least confident. Confidence can be seen to come with greater familiarity and more regular use of digital channels for delivering care.
Both the Topol Review and the NHSX Adult Social Care Technology Digital Skill Review identify that confidence is the key barrier for the health and social care workforce. Key in motivating the workforce is their understanding and trust in the safety, effectiveness and efficiency of digital tools and services.
"I think I’m part of that generation now where it is a little bit scary. I’m not quite sure about it but once I use it, and I know what to do with it, I’m fine." Administrator NHS Children’s Specialist Services
[2] Social grades are a system of socio-economic classification used in the United Kingdom based on occupation, employment status, qualification, tenure and whether respondents work full time, part time or are not working. It results in six categories: A, B, C1, C2, D and E. Higher socio-economic grades (ABC1) are associated with more professional occupations and lower socio-economic grades (C2DE) are associated with more manual and unskilled occupations, or those unemployed.
