The NHS has ambitious goals for digital services to transform how care is delivered. The Long Term Plan aims for digitally supported service changes to cut up to a third of face-to-face outpatient appointments, and reduce A&E attendances for children and young people. And the recent GP contract already requires practices to offer a quarter of GP appointments as online consultations.
The technology exists to make these ambitions a reality in the NHS, as they are in retail and banking, and there are examples of NHS services that are already on this journey.
However, this won’t be the first time that policy-makers have embraced development of new service models to try to take pressure off existing modes of delivery – and the track record is mixed.
Sometimes offering more costs more
NHS Direct, 111 and minor injury units were all conceived as services to divert activity from high-cost hospital A&E care. But over the last decade we have witnessed a huge overall growth in urgent care activity. The new services are being used in addition to existing ones, rather than replacing them.
Digital service developments are following the same pattern. Analysis of telehealth services shows an increase in hospital admissions and outpatient appointments, not the reduction that was hoped for. And an evaluation of the digital first general practice service GP at Hand has found that its patients are using more care than would be expected given their age and health status, suggesting that easier access is translating into greater activity.
This is not to say that the drive for digital service delivery shouldn’t happen.
Patients are pulling ahead
There is evidence for an increasing interest from the public themselves in digital routes to engage with health services. In 2019, 63% of people had used the internet to look for health-related information in the last three months, an increase from 54% in 2018. We know from the GP patient survey that both awareness and use of online NHS services are increasing. Currently, though, awareness is moving faster: over a half of people know that they can book appointments, order prescriptions or access their medical records online, but only a quarter have done so.
But at the same time there is consistent evidence that people who are most vulnerable and have the greatest health needs are least able to access digital services. Using technology to replace conventional services won’t be an option for these people. Recent national surveys report that:
- Under half of people (47%) over 75 have used the internet in the last three months, although use is increasing for people aged 65-74 (now 83%).
- Households of only one person aged 65 plus are least likely to have internet access (only 73% v 93% for all households).
- Concerns about cost and lack of skills have grown dramatically as reasons why people don’t use the internet, suggesting those already left behind will find it more difficult to catch up.
- People who are unemployed are less likely to be aware of, or use, online services at their GP practice, and people from non-white ethnic groups are more likely to find their GP practice website difficult to use.
- People with no qualifications are much less likely to use the internet to search for information and decide what to do before going to A&E than people with a higher level of education.
Focus on meeting people’s needs
We need a realistic view of what the benefits of digital are going to be, in terms of redirecting activity away from other routes. There are two reasons to think we are in danger of overestimating these.
First, the pace of uptake of digital services in the NHS has historically been slow. Given the limited investment available to develop IT services, and the current level of digital skills in the workforce, this is not going to change quickly.
Second, even if digital targets are met, this won’t necessarily result in improved care for those patients who actually require the most health care. For example, even if GP practices are already offering 25% of appointments online, this may not help practices to support patients with complex social needs and multiple long-term conditions. There is a risk of giving extra services to those who had good access to the care they needed to begin with, raising costs while leaving people most in need no better off.
To really benefit both patients and itself, the NHS must address the digital engagement of these most vulnerable patients. The sustainability and transformation partnerships and integrated care systems that bring NHS and local government bodies together should make this a priority. It will often be the same group of people who risk being excluded from digital services across health and social care, not to mention benefits, housing and other public services.
The implementation framework for the Long Term Plan doesn’t address digital exclusion, but there are resources which the NHS can draw on. Digital technology probably won’t deliver the miracle cure of doing more for less any time soon – but if we get it right, it really can help patients who are most in need.
Scobie S (2019) “Will a digital NHS reap the rewards policy-makers are aiming for?” Nuffield Trust comment.