With the NHS set to further embrace digital technology to improve the delivery of health care, engaging patients in using technology will be critical. An NHS app is going to be launched later this year, but will anyone use it? And equally importantly, could rolling out new digital health services improve access and care for younger and healthier patients, but leave vulnerable, less healthy and older patients behind?
In this blog, we draw on a number of recent national surveys (see the ‘About the data’ section) and look at common claims about access and use of technology – and who might be excluded if there is a wholesale move to digital health services.
“Older people don’t use technology”
Younger people use more of the internet, but the variation between age groups is reducing, except for people aged over 75 (see chart). In the first quarter of this year, only 38% of women and 51% of men aged 75 and over had used the internet in the previous three months – and the gap relative to young people is growing.
But the relationship between age and digital experience is not straightforward when it comes to health. The youngest age group are not the highest users of online health information, or the most likely to book an online appointment.
In primary care, awareness of online services, such as the ability to book an appointment or order repeat prescriptions, is highest in the 65-74 age group, with nearly half of people aware of these services. And over a fifth of people in this group order repeat prescriptions online – the group most likely to do so. So those in this age group are catching up.
“Digital services are less accessible to people with complex health needs”
Overall internet use is lower among people who are disabled – defined as a “long-standing illness, disability or impairment which causes substantial difficulty with day-to-day activities” – and is particularly the case among older people. However, the gap is greater for some activities than others (see next chart).
For activities where use has plateaued or declined, such as emails, internet banking and social networking, the gap between disabled and non-disabled people is reducing. The gap has grown for finding information about goods and services, and for using official websites. For both groups there has been a decline in booking online appointments.
The gap has also narrowed for social networking, which perhaps reflects the value of social networks and peer support for people with long-term conditions.
Awareness and use of online primary care services by people with long-term conditions are generally similar or higher, depending on the condition, than for people without long-term conditions. There is good evidence that technology can be empowering for patients with some long-term conditions.
But there are important exceptions, such as people with learning disabilities, dementia or sight impairment, for whom both awareness and use of online services are lower.
“Socially excluded people are also digitally excluded”
Health literacy – the ability to use and navigate health and social care information and services – is known to be linked to social circumstances, and impacts on use of health services and patient outcomes. There has also been concern raised about the impact of social circumstances on digital engagement.
Differences in internet use between social grades – a classification system based on occupation – shows that internet use among younger people is similar across different grades, but the gap widens with age.
91% of men and 85% of women over 65 in managerial and professional occupations use the internet. But for semi-skilled and unskilled workers, and households relying on benefits, only 51% of men and 50% of women over 65 do so. People in higher social grades are also much more willing to use a video consultation with their GP (see chart).
People who are economically inactive, such as carers, are less likely to be internet users, but rates of internet use are similar between people who are employed (98%) and those who are not (97%).
“Ethnic groups are digitally excluded”
The gap between ethnic groups in internet use has narrowed over time (see chart). Among younger age groups, internet use is similar between different ethnic groups, but non-white groups have lower rates of use for people over 65. However, the overall use of the internet is now lowest among white people, which reflects the older average age of this group.
“Internet access is worse in rural areas”
While there are undoubtedly variations in the infrastructure for internet access between urban and rural areas, this is not the whole story (see the next image). Portsmouth has the lowest estimated level of internet use in England, with areas in Nottingham, south Yorkshire and Manchester also having low rates of internet access.
Lower rates of internet use reflect disparate factors – poor infrastructure and higher proportions of older people in rural areas, but higher deprivation in urban areas.
Myth and reality?
Internet use overall has plateaued, and many previously less active users of the internet are catching up quickly.
However, those likely to continue to have low digital access are people over 75, carers, those over 55 in lower social grades, and people with dementia, stroke and learning disabilities.
As health and care services increasingly look to digital routes to provide information and services, it is likely that a combination of strategies will be needed to ensure these groups are not further disadvantaged. While initiatives to improve digital skills have been effective, there are significant difficulties in getting and keeping patients engaged in digital services. Non-digital methods of access are likely to be needed for the foreseeable future, otherwise those at greatest risk will be excluded.
Local variations in internet use are striking – the proportion of people who have either stopped using it or never use it is twice as high in Northern Ireland as in London, and there is a six-fold variation between local areas in England. Given the increasing dependence on digital means for delivering services, it is perhaps time to regard low internet use as a measure of inequality.
In future blogs we will consider the implications for patients and services, and look at opportunities for the NHS to engage patients and service users in digital services.
About the data
This blog uses data from the ONS internet users survey, and the ONS internet access (households and individuals) survey, including more detailed analysis of ethnic group and age. Awareness and use of online services in primary care was obtained from the 2018 GP Patient Survey, using the analysis tool to create cross-tabulations by age group and long-term conditions of questions on awareness of online services (Q4) and use of online services in the last 12 months (Q5).
Differences between internet use across social grades were obtained from the IPSOS technology tracker. Variation in willingness to have a video consultation with a GP uses data from an IPSOS poll commissioned for The NHS at 70: Are we expecting too much from the NHS? report.
Scobie S and Schlepper L (2018) "Digital patients: myth and reality", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/digital-patients-myth-and-reality