Date published: 28 September, 2023
Date last updated: 1 March, 2024
Digital

Inclusive digital healthcare: a framework for NHS action on digital inclusion

This document builds on previous NHS Digital guidance on digital inclusion for health and social care.

Use it to design and implement inclusive digital approaches and technologies, which are complementary to non-digital services and support.

Context

The adoption of digital technologies by both patients and staff has significantly increased over the last few years. Around 10 million more people in the UK used NHS websites or digital applications in 2021 compared with 2020, and NHS App registrations increased from 2 million people in 2021 to 30 million in 2023.

However, the benefits are not yet accessible for everyone.

Some particular groups face a higher risk of being digitally excluded; these groups also generally face a higher risk of health inequalities, including:

  • Older people, especially people over 75 years old
  • People in more socio-economically disadvantaged groups, such as people that have lower incomes or who are unemployed
  • Socially excluded groups, including people experiencing homelessness and people seeking asylum, people in contact with the justice system – also known as inclusion health groups
  • Disabled people and people with life-impacting conditions
  • People living in areas with inadequate broadband and mobile data coverage – more likely in rural and coastal areas
  • People less fluent in understanding the English language.

Digital exclusion can compound health inequalities by exacerbating challenges with access to healthcare, skills and capability to navigate and use services, and the general resources needed to lead a healthy life.

NHS England and integrated care boards have a statutory duty to consider how to reduce inequalities in access to and outcomes from health services. This duty on health inequalities is alongside public sector equality duty.  It means that the NHS must consider and take steps to address the barriers to digital health that some groups of people may face.

As the NHS continues with the recovery and improvement of its services, it is vital that the broadest population can enjoy the benefits of digital health and digital transformation delivery ambitions. Realising these benefits without further widening healthcare inequalities requires action on multiple fronts:

  • Designing user-centred and inclusive digital health approaches
  • Promoting widespread adoption of digital health approaches
  • Promoting digital inclusion – removing the barriers to digital approaches
  • Providing and maintaining non-digital healthcare support, alongside digital health approach.

The framework for NHS action on digital inclusion

This framework for action is designed to help NHS staff enable and encourage greater access to and improved experiences of healthcare, and increased adoption of digital approaches where that’s appropriate. It can be used when initiating, developing and updating services to help ensure that digital approaches and technologies are designed and implemented inclusively, and are complementary to non-digital support.

The framework builds on existing good practice and learning, including NHS Digital guidance on digital inclusion for health and social care, and responds to recommendations in the Wade-Gery Review.

As digital inclusion is a whole-of-society issue, this framework highlights the importance of collaboration at different levels and across sectors, particularly with local government, the voluntary sector, and grassroots community groups, but also with other players including business schools. Our collective challenge is how to ensure that ongoing digital transformation of the NHS is inclusive, effective and helps to reduce health inequalities.

The framework identifies five domains where action is needed:

  • Access to devices and data so that everyone can access digital healthcare if they choose to and experience the benefits
  • Accessibility and ease of using technology, so that user-centred digital content and products are co-designed and deliver excellent patient outcomes
  • Skills and capability so that everyone has the skills to use digital approaches and health services respond to the capabilities of all
  • Beliefs and trust so that people understand and feel confident using digital health approaches
  • Leadership and partnerships so that digital inclusion efforts are co-ordinated and help to reduce health inequalities.

Domains for action

The domains and actions have been informed by evidence on the barriers to digital participation (for example, from the Good Things Foundation, Basis Research and The King’s Fund) and promising practice. It sets out actions across five domains, describes the objective of each domain and the actions the NHS should take in response.

The five domains distinguish between:

  • Actions for all NHS staff that contribute to commissioning, design or delivery of digitally enabled services at national, regional, integrated care system (ICS), primary care network (PCN) and provider level
  • Actions specifically for leaders at ICS, PCN or provider level
  • Actions specifically for leaders at national or regional level in NHS England.

We focus on crosscutting actions, recognising that specific strategies for digital inclusion will need to be tailored to the communities served and the interactions needed.

Access to devices and connectivity

Actions in this domain aim to ensure that everyone can access a suitable device with sufficient connectivity to the internet so that they can use digital healthcare if they choose.

Access to an internet enabled device (such as smartphone, tablet or laptop) is a key step in digital participation. However, some people may not be able to afford an internet-enabled device or have sufficient broadband or mobile data.

Support is available to address these issues so that people are not prevented from accessing health and care services. For example, almost all libraries have internet access points. A growing number of community organisations and local partners offer help to digitally excluded people by providing free devices and free mobile data through, for example, the National Device Bank and a National Data Bank run by the Good Things Foundation. Some internet service providers offer discounted rates for eligible customers in receipt of certain state benefits.

Different models can be used depending on the person, community or service stream required. For example, the Liverpool 5G Health and Social Care Testbed built a publicly owned 5G network to provide connectivity in a disadvantaged and digitally deprived area of Liverpool. Evaluation of this project found a 30% reduction in the number of people who felt they needed to visit their GP and a 16% drop in the average number of their required visits per user.

Partnerships with local government and Voluntary, Community and Social Enterprise (VCSE) organisations are likely to be valuable to make best use of capacity and expertise in the system to reach people that need support. Work by 100% Digital Leeds Programme, summarised at the end of this section, illustrates some of the challenges that families who lack access to devices and data may face.

Actions to increase access to devices and connectivity

Actions for all NHS staff that contribute to commissioning or the design of digitally enabled services

Determine your target populations and decide whether the digital offering will be fully useable on all devices that may be used by the populations, and identify which groups or communities may need additional support including through non-digital channels.

Consider specific provisions to enable access to connected devices for socially excluded groups like people experiencing homelessness and asylum seekers.

Collaborate with other agencies or organisations working in the chosen digital services area to provide access to technology and data.

Ensure service users understand that they will be able to access devices to use digital healthcare when they want.

Actions for senior leaders at ICS, PCN and provider level

Understand which communities might be most affected by digital exclusion using tools like the Digital Exclusion Risk Index to inform targeted activity to promote access to devices and data.

Agree preferred methods and routes to get equipment and connectivity to people who need it, particularly where partnerships with local government and VCSE organisations are required.

Ensure that there is a sustainable approach to enabling connectivity, particularly where devices are provided, e.g., by providing data enabled devices.

Actions for senior leaders in national or regional programmes and functions

Work with NHS colleagues and wider partners to determine the extent of need for access to digital technologies when designing new initiatives, and to facilitate responses.

Case study: supporting families living in digital poverty

The 100% Digital Leeds programme is led by the digital inclusion team in the Integrated Digital Service (IDS) at Leeds City Council, Leeds Health and Care Partnership and NHS West Yorkshire Integrated Care Board.

The 100% Digital Leeds team works with trusted community groups and third sector organisations to make sure they have what they need to support digitally excluded people to get online, develop their digital skills, and understand how digital can help make their life easier.

The challenge:

Lack of connectivity is a barrier to digital inclusion, with a large proportion of families living with data poverty, unable to afford Wi-Fi and reliant on ‘pay as you go’ data, the most expensive way to buy data. For those families that do have access to a device such as a smartphone, one device is often shared by the family, commonly leaving mothers without access. Lack of access and limited connectivity can leave families without the ability to self-manage essentials, such as looking after their finances or managing their health and wellbeing.

Women who are victims of domestic violence are often the most digitally excluded and those most negatively affected by that exclusion, left unable to make calls to the emergency services when incidents are happening, or having to wait until they drop their children at nursery or see an outreach worker.

The approach:

The 100% Digital Leeds team delivered a pilot with Children’s Centres whereby Family Outreach Workers were able to gift a small number of smartphones and SIMs with free 4G data, calls, and texts to families living in data poverty.  The pilot was delivered via Hubbub’s Community Calling project and in partnership with Good Things Foundation’s National Databank.

Insights and impacts: 

Having access to digital devices and data has helped parents be more independent, reducing reliance on, and freeing up the capacity of, Family Support Workers. Families supported with connectivity have been able to work independently to:

  • Look after their finances by managing their Universal Credit and using online banking
  • Manage their health and wellbeing, and that of their families, by being able to make medical appointments and calls to Leeds Domestic Violence Service in private
  • Manage their housing by bidding on social properties and reporting repairs
  • Access learning and development by attending online learning sessions

What people said:

“It’s great to see the women we have been supporting become independent. Mums can contact us when they need support and don’t have to wait until their partner isn’t home or they are allowed out of the home to get that support.” Lisa Holliday, Senior Family Outreach Worker

“Thank you so much for the data code. It’s meant I’ve been able to call the perinatal mental health team and arrange a different appointment for my anxiety and depression. With four children, all of us in a one-bed flat, being able to keep in touch with people makes such a difference to me.” Parent supported by a Family Outreach Worker

“I was in a violent and abusive relationship. When my ex-partner moved out, I was left with no access to a phone, so I was unable contact anyone for help. Since being gifted a phone with data I’ve been able to call services and text the Family Support Worker. I’ve been able to find a nursery place for my two-year-old.” Parent supported by a Family Outreach Worker

Tips for success:

  • Important to ensure that free calls and data could be used by all beneficiaries.
  • Challenge assumptions that younger people are ‘digital natives’ who do not face barriers to digital inclusion.
  • Share ideas of useful digital tools and services to ensure beneficiaries and signpost to digital skills support where necessary to ensure beneficiaries make full use of the data.

What next?

Both Family Outreach Teams involved in the pilot have continued to gift SIMs via the National Databank and the aim is for this to be rolled out at Children’s Centres across the city. Both teams have identified a need for equipment to be made available for use by families visiting their Centres, as well as for Family Outreach Workers to use to support people in home.  This is being trialled using loaned tablets and funding is being identified to support the provision of equipment in the long term.

Accessibility and ease of using technology

Actions in this domain seek to promote effective accessible designs and put in place support to enable people who may face physical, communication or cognitive barriers to using digital approaches to use them and have positive experiences

Digital and assistive technology (which is the adaptation of technological devices for disabled people) can support independence, choice and control for many people and promote health and wellbeing. For instance, 78% of disabled people say that having access to digital technologies is helpful or very helpful, whereas poor design and difficult content that does not respond to people’s real service needs can negatively affect people’s experiences of healthcare. This includes disabled people, people with low literacy levels, or people who do not understand the English language well.

Designing services that everyone can use requires an approach where the digital aspects of a service or pathway are developed with diverse users at the forefront of the design. This helps those commissioning and designing services to understand the potential barriers faced in accessing such services. This was the case in services designed by Midlands Partnership University NHS Foundation Trust in the case study below. It means finding ways to deliver additional support to provide assistive technology or enable people to access help through alternative modes where digital offerings may be unsuitable.

Actions to increase accessibility and ease of using technology

Actions for all NHS leaders that contribute to commissioning or the design of digitally enabled services

Be familiar with and adopt the planned NHS Inclusive Design Framework.

Be familiar with the Accessibility Guidance available in the NHS digital service manual.

Comply with the Accessible Information Standard.

Comply with the NHS service standard.

Ensure that information for the public, including digital technology, is accessible and understandable to people with lower literacy or low confidence in their literacy, and limits the cognitive demand needed to engage with healthcare.

Identify any additional support people may need by ensuring that needs assessments and impact assessments specifically consider the needs of disabled people with different physical, communication or cognitive impairments and people who may face language barriers to accessing digital health.

Remember that 20% of NHS staff are also NHS service users with a disability.

Actions for senior leaders at ICS, PCN and provider level

For PCNs, follow the tips in Supporting digital inclusion in general practice: 10 top tips, including by adopting the tips on Creating a highly usable and accessible GP website for patients.

Make provision within any digital skills or support offers to help people get accessibility software.

Ensure that any digital provision supports any additional amounts of data usage required for accessibility software and the extra time it may take to use the technology.

Invest in culturally appropriate support for those who may have literacy or language barriers.

Consider what specific provision will be made for those who have difficulty understanding the English language and how they will be well supported within pathways.

Case study: reaching digitally excluded people in their homes through the provision of digital technology

Midlands Partnership University NHS Foundation Trust

The challenge:

With the COVID-19 pandemic, and the rapid deployment of standard digital video consultation, several clinical teams worked alongside the digital team at Midlands Partnership University NHS Foundation Trust (MPFT) to identify the barriers to accessing and experiencing the benefits digital technology brings. Barriers for many patients, including older adults and those using the learning disability services included not understanding how to use technology and a lack of connectivity to the internet.

The approach:

It was not possible to find a single product to suit the needs of each group, therefore, the Trust partnered with two suppliers, No Isolation and Konnect to supply two devices, KOMP (which is a simplified one-button computer) and Kraydel (a camera), to give patients more choice on how they can access and progress their care and to help the Trust reduce backlogs caused by the COVID-19 pandemic.

Insights and impacts:

The devices have predominantly been used by people accessing pre-dementia services, learning disability services, and Staying Well Service, which is a service that works with older adults.

  • 49 devices have been actively used across Midlands Partnership NHS Foundation Trust services, and during 2022 this has supported 200 meetings and 110 messages sent for professional clinical purposes.
  • A further 945 calls and 580 messages have been sent for users to connect with their families and friends.
  • A total of 240 hours of online meetings have taken place, for care purposes and social interaction.

The approach has enabled people who previously haven’t been able to use digital technology to access care from the comfort of their own homes, providing more choice in how they access care. The Trust’s research and innovation team identified several benefits from the use of this technology including:

  • Improved access to services for those who are restricted by physical or psychological needs
  • Reduced reliance on others to access care
  • Overcoming the lack of connectivity to the internet through built in data connections
  • Supporting infection control
  • Reducing social isolation by providing an opportunity to reach friends and family.

Trust staff also identified benefits themselves, including being able to see more patients as they reduced their travelling time by using the devices. The devices have also supported winter pressure efforts, especially in supporting recovery workers to deliver care to those who have recently been discharged from hospital.

What people said:

“Our award-winning transformation project provided accessible means of using technology to ensure service users that may not have digital skills, home internet, or access to devices can still join and undertake virtual consultations”

“We are delighted that this innovative and forward-thinking approach to improve the choices service users have in how they access and progress through their care journeys has been recognised at national level”

“The future of the NHS is in the successful transformation and adoption of digital solutions, through more projects like this”

Tips for success:

  • Have a KOMP Champion on board who will encourage the use of KOMP with the clinicians and provide support.
  • Provide virtual training sessions for staff and materials for patients and staff (leaflets and user guides).
  • Produce your own KOMP video to explain to the service user what it is and how easy it is to use.
  • Develop a workbook for Trust Staff to ensure all possible scenarios have been covered to ensure successful installation of the KOMP devices.
  • Highlight the benefits to service users and clinicians during training sessions.

What next?

As the Trust builds ongoing business cases to evidence benefits from the work, the Trust will be able to offer the use of this technology to a broader set of services internally and explore the use with user groups that Trust staff may not have originally thought could have benefitted. MPFT will work with other NHS and non-NHS organisations in Integrated Care Systems to see where we can find joint benefit with these devices so users are able to access a wider set of support services than just our own.

Skills and capability

The actions here are intended to ensure that both staff and members of the public have the skills to use digital approaches and that health services respond to the capabilities of members of the public.

Evidence points to a variety of approaches that can help to improve digital literacy and develop digital skills, such as one-to-one and small groups sessions, peer and intergenerational mentoring, drop-in sessions, and engagement through community hubs, local libraries or in people’s homes or care homes. For example, the Widening Digital Participation (WDP) programme which ran from 2013 to 2020 involved pilot projects aiming to widen digital participation in health and care. Phase 1 (2013-16) focused on improving digital health literacy, using a ‘Learn My Way’ digital platform for free online learning and a Digital Health Information network of hundreds of local providers. Further information about Learn My Way is included in the case study box below. Partnerships with local authorities and VCSE organisations will be particularly essential for reaching communities of need and delivering tailored skills support as needs arise.

Actions to build digital skills and capability among staff, carers and patients

Actions for all NHS staff that contribute to commissioning or design of digitally enabled services

Determine your target population and their needs for skills development in collaboration with VCSE organisations and other partners.

Consider development of tools, scripts or support to enable NHS staff to explain the purpose and benefits of specific technologies or approaches.

Actions for senior leaders at ICS, PCN and provider level

Commission and provide specific training for members of the public, working with local government, VCSE organisations and the private sector.

Commission and provide additional training to support NHS staff with new or updated digital products or systems.

Actions for senior leaders in national programmes and functions

Consider the workforce capability implications of any digital transformations and ensure that any ongoing training and support needs are given attention in workforce plans.

In any communications campaigns delivered through NHS about the digital routes to care and digital inclusion, use the learning for supporting confidence in practices from the evaluation of General Practice inclusive access routes piloted in Humber and North Yorkshire.

Case study: Learn My Way helps people use online health services

Medical practices and others can access free resources when helping people learn how to use NHS and GP online services

Organisation:

Good Things Foundation is a national charity which supports organisations to address digital exclusion in their communities. This includes ‘Learn My Way’ – free bite-sized courses covering online basics, including for health. Any local charity, organisation or service provider can join Good Things Foundation’s National Digital Inclusion Network and access resources (including Learn My Way, mobile data, and devices) for free.

The challenge:

Internet access can make it easier to use health services. But not everyone who wants to or has the confidence to use online health services such as NHS 111 online (www.111.nhs.uk), NHS App or GP online access. Around 10 million adults in the UK lack basic digital skills. Often this is shaped by other factors, such as literacy, language, income, age, and disability. For some people, digital skills barriers are compounded by limited access to a suitable device, or not having enough connectivity.

The approach:

Friendly, trusted support in community settings where people feel comfortable is an effective way to help people overcome digital skills barriers. Common features of support are: starting with what matters most to the person (‘the hook’); helping people experience immediate benefits (‘quick win’) to encourage them to keep going; helping people learn how to adjust their devices for easier use. Embedding digital skills into wider support and Digital Champions (staff or volunteers who are patient and positive about helping others to benefit) also help.

Some medical practices, libraries and local organisations provide patients and carers with digital access and skills support to use online GP and NHS services (‘digital health hubs’). Others have links with community organisations and signpost to support. Good Things Foundation provides free resources for digital health hubs and any organisation helping people to get online. This includes ‘Learn My Way’ with bite-sized topics such as how to use GP and NHS online services, staying safe, and video calling. The charity runs also runs free training and meet-ups for those delivering digital inclusion through its National Digital Inclusion Network.

Insights and impacts:

In a 2019 survey for Good Things Foundation, 83% of people who used the ‘Learn My Way’ health topics (on NHS and GP online services) said they felt more confident about using digital tools to manage their health. Lessons learned from the NHS Widening Digital Participation Programme (2013-20) show how digital access, local support, and inclusive design can enable more people to benefit from digital for health and wellbeing. An early evaluation of digital health hub pilots shows the benefits of this approach in communities. These approach are being rolled out in places such as Leeds and Mendip.

What people said:

“I started Learn My Way a few months ago and still look at it … More confident to access health services – about my health but want to learn more…” (Person supported by a digital health hub)

“We see the potential of the project growing as more people begin to benefit from digital health options and online opportunities for wellbeing and we will be continuing to help, deliver and grow our digital health offer, along with other digital learning, as best we can.” (Digital health hub)

“I’ve learned all sorts! I’m nearly 81 years old, and we always used public telephones. I never thought I could do this” (Person supported by a digital health hub)

Tips for success:

What next? Good Things Foundation is committed to growing and strengthening the National Digital Inclusion Network – so that any local medical practice, charity, service provider, library or other community-based organisation can better support local people to benefit from digital. This includes continuing to provide resources like Learn My Way, alongside devices and data through the National Databank and National Device Bank.

Beliefs and trust

Actions in this domain seek to illustrate ways of creating positive beliefs about the benefits of digital health and building trust among members the public and NHS staff.

Building trust and increasing engagement in using digital health will be an ongoing issue, influenced through the many everyday interactions that people have with the NHS. Research commissioned by NHS England found that key factors influencing the motivation to use digital channels for health and social care among members of the public were:

  • Perceived effectiveness: how digital channels can deliver the expected service (and outcomes) quickly and efficiently.
  • Feeling understood: how digital channels can enable people to communicate their needs and feel heard.
  • Providing control: how digital channels can give people more control over the support they access 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. (Basis Research, 2022)

Actions here seek to ensure that well-designed and flexible digital offerings best respond to the needs of people who may have fears or doubts about using digital and help to build confidence and trust. The case study below on the SuS-IT initiative among older people illustrates how older people’s confidence in using the internet can be built and maintained by working in an informal and responsive working with peers.  

Actions to build positive beliefs and trust

Actions for all NHS staff that contribute to commissioning or design of digitally enabled services

Identify opportunities to make digital services relatable and seen to be used by ‘people like me’, including through use of trusted messengers, and communications using everyday language.

Promote use of lower-risk, transactional touchpoints, e.g., managing an appointment booking, or checking test results online, to give people an opportunity to try out digital services and inform their understanding around safety, security and efficiency for future interactions.

Ensure that new digital health and care pathways are at least as good as alternative non-digital service channels.

Undertake mixed methods research to understand how beliefs or trust affect engagement with digitally enabled pathways.

Actions for senior leaders at ICS, PCN and provider level

Ensure there are routes for users to feedback on their experiences, and that any feedback is considered in appropriate governance forums to shape future action.

Consider opportunities to encourage peer support people to build confidence and trust.

Case study: From digital exclusion to participation in the digital world: encouraging belief and trust in technology among older people

Background:

The ‘Sustaining IT Use by Older People to Promote Autonomy and Independence’ (otherwise known as SUS-IT) venture was a ground-breaking three-year investigation into digital participation of older people and how to sustain IT use in this demographic.

Sus-IT was funded by Research Councils UK i.e., jointly by all five UK research councils: Economic Social Research Council, Engineering and Physical Sciences Research Council, Biotechnology and Biological Sciences Research Council, Medical Research Council, Arts and Humanities Research Council and was part of the New Dynamics of Ageing (NDA) Programme.

It involved a multidisciplinary team of academics from 8 UK universities, with participation of 1,000 older people and 100+ research users.

One of the 30+ participant projects of this study was the Long Eaton 50+ Forum Sus-IT Drop-in and Computer club, which is still providing older people with IT support today and has been running since 2005.

The challenge: 

For many older people, access to digital technology has supported them to live independently, stay included in society and access government and commercial services.  While many older people are enthusiastic and successful users of IT, some find it hard to pick up and sustain digital participation and, when supported to start using digital technologies, experience fear of coping with it at home.

Frequent problems relate to the absence of convenient, patient and regular support to use digital technology, poorly designed hardware and software and difficulty with understanding technical jargon. Older people may also experience physical challenges, e.g., eyesight, hand dexterity, mobility; psychological and cognitive changes such as a lack in confidence, loss of memory.

Older people can be disillusioned with IT classes, which might be short term and delivered by providers that they don’t have a relationship with, and difficult to fit around existing commitments like caring. This led to often forgetting what they had learned – causing fear, upset, frustration, and mistrust.

The approach: 

The 50+ Older People’s Forum in Long Eaton took a different approach to build that trust and encourage sustainable use of IT.  Delivered by retired members of the community, the volunteers took a more relaxed approach and provided a drop-in service with a welcoming local community venue that was readily available and trusted, where participants knew their peers and were comfortable.

The IT support was linked to learning topics selected by users, social activities (often over a cup of tea) and free of time pressures and assessments. Users were given patient, tailored, sustained and ongoing support inclusive of problem solving and troubleshooting. Often the teachers are their own peers who are not highly trained, they just know enough to give that much needed peer support.

Topics included using skype/FaceTime to communicate with friends/family, using mobile phones, printing out digital photos/digital photography, online transactions and shopping, price comparison, accessing public services, how to access self-care videos e.g., keeping fit and planning and booking travel.

Insights and impacts:

Digital technologies can enhance lives of older people in many ways by helping them solve their problems and manage their lives. This results in an enhancement of their wellbeing.  Identifying and meeting such needs is key to encouraging uptake.

The value of the Long Eaton support group is evident from the continued take-up of the services and their continued use. Their ability to offer troubleshooting assistance has been crucial in sustaining digital participation for many of their members. A ‘good’ day will receive around 20 visitors seeking assistance with a friendly welcome. As a result of the support given, members now have the confidence and belief that they now can, for example, book holidays, access online offers, and see grandchildren on FaceTime.

The evidence from this support group (alongside collaborative research conducted with a wide range of relevant stakeholders and older people) has informed a well-developed proposition for socially embedded IT support to facilitate learning and ongoing digital participation.

Tips for success:

  • Avoid practices which can deter people from engaging e.g., inflexible appointments, standardised formal instruction, excessive form filling and assessments, and the use of unfamiliar or intimidating language or terms.
  • Embed the experience of learning as a social process in a comfortable setting by creating community hubs located in welcoming and comfortable local venues that are responsive to local needs and assets.
  • Use familiar language and maintain an ongoing dialogue with users.
  • Provide informal peer support that is readily available, trustworthy and compassionate, free of time pressure and assessments.
  • Ensure a good connection with free or affordable broadband and mobile signal, and supply appropriate hardware devices (phone, tablet, laptop).
  • Use sustainable and ongoing help from local councils, businesses, schools, third sector and other organisations.
  • Work on exploring and understanding user needs.

Challenge your own assumptions and stop creating/maintaining barriers to people going digital.

Leadership and partnerships

Actions in this domain seek to ensure there is clear leadership in place, with an emphasis on partnership working to use the assets in the systems, places and communities to make progress on the other domains of this framework.

Clear leadership and partnership will be essential to set direction and create sophisticated responses to the complex and contextual issue of digital participation.  There is already a range of excellent work going on across the country to promote digital inclusion. The case study in this section is an example of quality improvement work in Cheshire and Merseyside informed by data.

NHS bodies can further build partnerships and collaborative working with national and local government, Voluntary, Community and Social Enterprise (VCSE) organisations, business and industry to support the other domains of action that have been identified. Close collaboration with partners is essential to properly involve a diverse range of members of the public in development and design of services and pathways that use digital. For NHS England and ICBs, the actions in this domain will support fulfilment of legal duties on healthcare inequalities.

Actions to further strengthen leadership and partnerships

Actions for all NHS staff that contribute to commissioning or design of digitally enabled services

Follow NHS England guidance on working in partnership with people and communities in development of digital strategies and digitally enabled pathways to ensure that different voices and perspectives shape new approach.

Ensure that Equality and Health Inequalities Impact Assessments or similar appraisals of policy explicitly consider groups that are at risk of digital exclusion, and include specific actions to mitigate risks in design or delivery.

Collect data and monitor information to assess any inequalities impacting access to, experience of or outcomes from digital healthcare, including by gathering feedback from users about digital offerings.

Actions for senior leaders at ICS, PCN and provider level

Create structures or forums to allow joint work by senior leaders with accountability for health inequalities (Senior Responsible Officers for Health Inequalities at ICS, PCN and provider level) and digital transformation (for example Chief Information Officer, Chief Clinical Information Officers, Directors of Digital).

Consider whether to differentiate or target capacity for general digital inclusion initiatives e.g., provide additional help to services or places where digital exclusion issues are likely to be more common.

Identify which community-centred roles in your system may help to connect people to support for digital inclusion.

Promote use of social prescribing to enable access a free device and data connectivity and support to build digital skills and confidence generally.

Encourage routine recording of preferences for modes of communication.

Consider establishing a Digital Inclusion Lead role to help co-ordinate efforts across health inequalities and transformation leads in the NHS, and lead relationships with wider partnership.

For ICBs: Work closely with ICPs, to develop a digital inclusion strategy that is joined-up with local authority equivalents.

Actions for senior leaders in national programmes and functions

Ensure that any steers to the wider NHS highlight and encourage response to specific digital inclusion issues, including specific responses for groups at risk of digital exclusion.

Consider ways to monitor how digital inclusion is being tackled through specific initiatives.

Case study: celebrating collaboration and coproduction – using a heatmapping tool to identify digitally excluded hotspots across Cheshire and Merseyside

The digital exclusion heatmapping tool was co-produced between Cheshire and Merseyside Integrated Care Board, Cheshire and Merseyside Health and Care Partnership and Thrive by Design.

The challenge:

Using funding from the Digital First Primary Care Programme, Cheshire and Merseyside (C&M) Integrated Care Board (ICB) provided 150 personal computers to residents across their area, on a fair share basis, to support the people of Cheshire and Merseyside with digital access.

To facilitate this delivery, a working group was formed representing organisations across different systems. This included, digital leads from each trust, the local authority, social care, primary care, secondary care, third sector organisations and digital inclusion experts.

After evaluating the kit recycling scheme, it was made clear that to provide personal computers to people who are living in digital poverty, “we first need to know where they are”.

The approach:

Between the working group, everyone had their own lens on how they perceived someone to be digital excluded. Is it due to poor housing and Wi-Fi infrastructure? Or the costs associated with digital tools?

Thrive by Design co-produced a virtual, interactive, digital exclusion heatmapping tool with the working group, using their knowledge of what influences someone to be digitally excluded or not, and using data that exists in the public domain.

“The heatmap is a penetrative view of how digitally excluded somebody potentially could be because of the area they live in” says Jenny Mason, Digital Inclusion Lead at C&M ICB.

Insights and impact: 

The heatmap, developed within six months and finalised in August 2022, has supported several projects across C&M, including, subsequent research into the barriers to digital inclusion.

C&M ICB have since collaborated with VOLA, an organisation that has undertaken research and mapping into digital inclusion activities that are happening on the ground in local communities across the city region. This data has been layered on to the heatmapping tool, allowing people to see what community services they can visit to get digital support also enabling VOLA to identify which areas they can target to put extra resources.

What people said: 

Following the use of the heatmapping tool to support their commissioned research into the barriers to digital inclusion for the people of Cheshire and Merseyside, Karen Swan, Director of Influential, said:

“The digital exclusion heatmapping tool, made it really clear where we needed to focus our resources when it came to interviewing and gaining insight into the barriers to digital inclusion for people across Cheshire and Merseyside. We used the tool to determine the places where we would focus street surveys and pharmacy intercept interviews, to hear the voices of people who are truly digitally excluded, listen to what their barriers are and test ideas for possible interventions to support digital adoption”.

Colleagues from VOLA Merseyside, working with the Liverpool City Region Combined Authority, found the tool to be extremely useful and timely:

“The tool provided data to help target neighbourhoods and areas with the highest risk of exclusion scores for the City Regions new UK Shared Prosperity Fund Digital Connectivity Grants Programme. They described the tool as a really useful data point for charities and voluntary sector organisations.”

Tips for success:

  • “If someone is digitally excluded and can’t access their GP appointments through E-consult, it’s likely they’re unable to access their rent or prescriptions online. If someone is digitally excluded for their health, there is a likelihood they will be digitally excluded for other things” says Jenny Mason.
  • The development of the heatmapping tool relied heavily on collaboration with organisations across systems, taking a holistic and well-rounded approach to supporting digital inclusion.

What next:  

The next phase for C&M is delivering a campaign to improve digital adoption including use of the NHS App. Using the heatmapping tool, C&M ICB will place extra resources in their most digitally excluded areas, with the aim to install trust and confidence amongst the most digitally excluded groups living in C&M.

“The heatmapping tool is welcome to be used and shared as widely as possible, so that when you have a new product, service or programme that has a public facing digital element to it, you can take a look to determine what areas might need more support. The whole point of this work is to get our people digitally connected” says Jenny Mason.

Take a look at the digital exclusion heatmapping tool here: C&M Digital Exclusion Heatmapping Tool and the systems wider work on digital inclusion.

Areas for further strategic action

This section explores the areas where NHS England is taking further action to strengthen the work described in section two. It explains particular areas where national leadership can support digital capability across the NHS and through its partnerships.

National efforts to improve access to data and connectivity

A key barrier for people seeking to access digital healthcare is the cost of connecting to the internet. 

During the pandemic, mobile network operators ‘zero-rated’ NHS and other websites, so that people could access these without paying for data. Ofcom is consulting on the future use of zero rating. The Government has negotiated with internet service providers to offer discounted rates to eligible customers. Known as social tariffs, these provide people in receipt of Universal Credit (and sometimes other legacy benefits and Pension Credit) with the opportunity to get basic broadband for around £15 to £20 per month. Some social tariffs for mobile data are also available. Ofcom’s website has a list of social tariffs. 

Free mobile data is available from community organisations, housing associations, and others using the National Databank. Good Things Foundation’s website has a map of local databanks, and a guide on Supporting People with Data Connectivity. 

NHS England continues to work with partners to examine how best to support groups that may face connectivity challenges.

Supporting accessible services through inclusive design

NHS England recognises there is further to go to ensure the consistent design of digitally enabled services that are inclusive, understood, and accessible to everyone. NHS England is working to ensure every area adopts inclusive design approaches. An inclusive design framework is being developed, drawing on best practice, which will support anyone who is commissioning, designing, or delivering an NHS England product or service to design and deliver services in an inclusive way.

In addition, the User Centred Design maturity model has been updated to include inclusive design and begun to identify staff training requirements on inclusive design principles to inform commissioning of a training programme.

Further NHS England actions in this area will include commissioning a training programme for staff on inclusive design and integrating aspects of the inclusive design framework into the NHS service manual. It will also work to ensure inclusive design is considered at the planning stage for systems and providers.

Guidance for anyone designing and delivering inclusive and accessible healthcare services can be found in the NHS digital design principles and NHS service standard.

Building skills and capability across the NHS

Knowledge management and dissemination of good practice

It can be difficult to navigate evidence-based digital inclusion channels, together with the landscape of existing knowledge and best practice. Ways to consolidate knowledge for policy and practice on digital inclusion will be explored so that it is structured and easier to navigate for end users at all levels of the NHS.

Ensuring a focus on digital inclusion and equity in programme appraisals

Having a clear focus on digital inequalities during work to appraise policies and programmes can be an important means of encouraging a more considered approach. Partners and stakeholders have spoken about the opportunities that formal assessments pose for encouraging appropriate action on inequalities, for example during Equality Impact Assessments, Equality and Health Inequalities Impact Assessment and similar processes.

Therefore, exploratory work on what supplementary support or guidance might enable people to incorporate consideration of digital inequalities into existing assessment tools will be delivered. This will build on existing practice in Integrated Care Systems that have already begun to champion assessments incorporating digital health issues, including NHS Sussex and NHS Cheshire and Merseyside.

Strategic leadership and partnerships

As the NHS begins to implement this framework, NHS England will work across the health system with its partners to undertake strategic actions that support the reduction of digital health inequalities. This includes enabling improved data, research and digital product procurement.

Improving collection and use of secure person-level data

Digital technologies present tremendous opportunities to collect better data on individual characteristics, that reveals health inequalities, including those associated with digitally enabled pathways. Ensuring datasets are secure, complete and timely is an NHS priority for reducing health inequalities. This is set out in the operational planning guidance to inform responses to revealed inequalities. This work has a particular focus on improving ethnicity data, as the pandemic illustrated challenges with the quality of ethnicity data collected in routine health datasets. Action is also needed to improve data on other groups, including inclusion health groups, and to ensure that services consistently and routinely capture information about preferred modes or channels of interaction with the NHS.

Developments like the Federated Data Platform will enhance the NHS’ ability to share data across information systems and create a more complete picture of specific population groups, to support population health management.  Further work at a national level to improve data will include:

  • Enhancing understanding of unequal usage of NHS digital channels by exploring ways to link relevant information about digital channel usage and individual characteristics
  • Developing guidance to support our frontline workers collecting user characteristics information, including ethnicity, during their interactions with patients and carers
  • In the long term, enabling people to self-report their ethnicity, and other personal characteristics in a meaningful way via the NHS App. This will also clarify the users’ ownership of their data and their need for consent to share their data

Health research is integral to NHS’s ongoing development of high quality services. However, the quality and quantity of the existing evidence base to assess the inequalities implications of digital health interventions is limited. 

As the NHS progresses digital transformation, research is needed to understand how to make digital health approaches as inclusive and scalable as possible. This includes research to assess barriers to uptake for different people, including behavioural barriers that may arise during commissioning or prescribing of digital health among commissioners, healthcare professionals, and patients. Research outputs will be used to recommend ways to promote inclusive access to digital health technologies. 

To address general limitations of available evidence on the effects of digital health interventions, NHS England will work with research funders to encourage studies investigating the impact of interventions expressly design to address digital inequalities. Equally we will increasingly need studies that investigate the impact of digital health interventions for different groups and the consequences for health inequalities.

Influencing buying approaches to increase digital inclusion and reduce health inequalities

Ensuring that the digital products the NHS buys directly and indirectly support digital inclusion is a valuable opportunity to support the agenda of this framework. NHS England will explore ways to improve digital buying guidance and wider support to ensure that selection approaches incorporate meaningful consideration of suppliers’ methods to tackle digital inequalities and health inequalities.

Resources

Evidence for action

Other tools and resources

Publication reference: PRN00373

Date published: 28 September, 2023
Date last updated: 1 March, 2024