The recent plan for digital health and social care has reaffirmed NHS goals around digital transformation, taking account of the pandemic and the significant role that digital technology can play in improving health care. But the NHS digital journey has not been straightforward. The last 10 years in England or so have seen a multitude of strategies, plans and targets, new organisations and shifting governance structures, with criticism for the NHS at its progress.
But what is the case elsewhere in the UK? With all four countries emerging from Covid-19 and embarking on ambitious digital health programmes, we wanted to understand the approach that each country is taking. In Scotland, Wales and Northern Ireland, new digital health care strategies have been recently published or are in development, new organisations have been established, and digital transformation projects are underway accompanied by significant investment. The four countries provide us with a unique way to see how policy impacts on practice, forming a natural experiment where health care is devolved but many similarities between the countries remain.
It is not just all change for digital – among the flurry of wider health care policy activity, including the proposals for a National Care Service in Scotland, the establishment of integrated care systems (ICSs) in England and the universal challenges of Covid recovery, the significance of technology cannot be underestimated. Aligning goals around digital transformation with this wider context is important.
This explainer draws on a review of policy documents, data analysis and stakeholder interviews to take stock of the key features of digital health care policy across the UK, to provide insight for policy-makers and researchers.
What is digital health and care and how can it help?
“Digital health” is an umbrella term that refers to the use of digital technology to improve the operation and quality of health care systems and services, as well as individual and population health. The topics included within digital health care are extensive, encompassing the collection and use of data, patient-facing apps, electronic systems for prescription, appointments and patient records, and telemedicine.
The four UK countries face many shared health and social care challenges, such as an ageing population with increasing and complex long-term conditions, pressure on health and social care funding, workforce shortages and widening health and care inequalities. Digital technology has the potential to address some of these challenges by improving health care system efficiency, widening access to services and increasing the ability of health care professionals to provide early intervention and high-quality care. For example, integrated care is a shared ambition for each UK country, and effective digital and data systems are pivotal in supporting this.
Who is responsible for digital health care across the UK?
As health care is devolved, responsibility for digital transformation in health care rests with each country. Reforms have recently aimed to consolidate disparate leadership, clarify roles, and ensure accountability. Outside of England, this has been reflected in a shift towards greater leadership and oversight of digital health care policy within government, following criticism of a lack of clear governance within digital health care. In Scotland, for example, a 2018 Committee inquiry noted a disconnect between the Scottish government’s approach and the delivery by local boards. Similarly in Wales in 2018, reports from groups including the Public Accounts Committee (PAC) highlighted several issues, including governance.
In Scotland, leadership for digital health care is provided by the Digital Health and Care Directorate within the Scottish government. Other key stakeholders include NHS Education for Scotland (NES) – one of Scotland’s national health boards – which is responsible for training and educating the health and social care workforce, including developing digital capability and leadership. The Local Government Digital Office (LGDO) was set up in 2016 to help councils accelerate their digital transformation.
Digital Health and Care Wales (DHCW) came into being in April 2021, replacing the NHS Wales Informatics Service (NWIS). This followed a series of reports and reviews recommending several changes to digital health care governance in Wales. The focus of DHCW’s work is on engagement and working collaboratively with local partners to facilitate change across the system, and it has its own independent board and chair. Overarching leadership for digital health care in Wales rests with the Welsh government, which includes a Chief Digital Officer for health and care.
Digital Health Care Northern Ireland (DCHNI) brings together the digital functions from across government, commissioning and delivery, under the leadership of a Chief Digital Information Officer within Northern Ireland’s Department for Health. DCHNI oversees digital health and care strategy and investment, and commissions digital projects to support health and care services.
In England, integrated care systems are taking responsibility for developing digital capability within their area, and are expected to deliver on a number of digital targets. At a national level, most recently following an independent review, digital has become more aligned with the wider transformation agenda at NHS England.
What are the ambitions and priorities for digital health care across the UK?
The table below illustrates (non-exhaustively) some of the key digital health care policies and programmes in each UK country. There are many shared ambitions such as improving the quality and use of data, increasing patient access to health care, and workforce development.
Key digital health care ambitions for the four countries of the UK
- The plan for digital health and social care (2022) provides an updated vision for digital health care, consolidating digital health targets within the NHS Long Term Plan, clarifying the responsibilities of the newly established ICSs, and including ambitions for digitising the social care sector.
- The social care white paper committed £150 million over three years to delivering a programme of digital transformation for the social care sector, recognising the need to improve quality and collection of data, integration with NHS systems and better internet connections in care homes.
- Ensuring the safe and effective use of data in supporting health and care has also been reflected in Data saves lives: Reshaping health and social care with data (2022).
- The 2019 GP contract outlined support for practices to deliver ‘digital-first’ approaches for patients, such as digital access to medical records and digital prescription services.
- The Digital health and care strategy (2021), published jointly by the Scottish government and the Convention of Scottish Local Authorities (COSLA), reflects the importance of digital transformation across both health and social care.
- The Independent Review of Adult Social Care (2021) noted the importance of digital and data in improving the social care system.
- Public Health Scotland identified four digital priorities in its Digital Strategy (2021) – engaging and empowering the public; creating actionable insight across the public health system; leading digital collaboration; and accelerating digital innovation for the public health system.
- The Technology Enabled Care (TEC) programme launched in 2014 to support citizen and service technology adoption. Their current strategic priorities are set out in the Digital Citizen Delivery Plan 2020/21, and include addressing inequalities and exclusion (particularly in social care), digital mental health care and exploring what the ‘digital front door’ means for patients and the public.
- NES has been commissioned by the Scottish government to deliver a workforce development programme to increase digital capability across four main areas – leadership, specialist workforce, wider workforce, and future workforce.
- Wales’s most recent dedicated digital health care strategy, Informed health and care, was published in 2015. A Healthier Wales (2018), which sets out the long-term plan for the NHS in Wales, highlighted data and digital as key enablers.
- DHCW is leading on multiple projects. This includes the Digital Services for Patients and the Public (DSPP) programme, which aims to develop an NHS Wales app allowing patients to access a range of services such as booking appointments or viewing their health records, e-prescribing and the National Data Resource programme. Rolling out the Wales Community Care Information System across health boards and local authorities is also a priority.
- TEC Cymru (Technology Enabled Care) was established in 2018. Funded by the Welsh government and hosted by the Aneurin Bevan University Health Board, it encompasses three main areas – video consulting; telehealth; and telecare and assistive technologies. It has a remit to provide oversight and the coordinated scale up of TEC, built upon an evidence-based approach.
- The SAIL (Secure Anonymised Information Linkage) databank is hosted by Swansea University and is funded by the Welsh government and Health and Care Research Wales. It contains data from across public services and allows researchers to access anonymised, linked data for projects that aim to improve the health and wellbeing of the Welsh population.
- Northern Ireland has recently published a new digital health care strategy: Digital Strategy Health and Social Care Northern Ireland 2022-2030. This is closely related to Health and Wellbeing 2026: Delivering Together, Northern Ireland’s health and social care strategy. The aim is to ensure that the digital health and care strategic objectives are viewed as integral to service delivery and better outcomes, rather than presenting digital as an addition to normal work.
- Alongside this, there are strategies for cybersecurity, data and innovation.
- The flagship programme is Encompass – the aim is to develop an electronic health and care record across the whole of Northern Ireland involving secondary, tertiary and community care delivered by Epic. Building capacity in data analysis – both growing talent within the workforce and developing the infrastructure – is also a priority.
What factors influence digital health care in each country?
Country context is important for understanding the development of digital health care policy. Health care in Northern Ireland is jointly commissioned by six health and social care trusts, and social care has been a significant part of the approach. Similarly in Scotland, strategies have been published jointly by the Scottish government and the Convention of Scottish Local Authorities (COSLA), reflecting the need for a holistic approach to using digital to improve wellbeing and support the delivery of health and care services. This contrasts with England where, until the most recent iteration, social care had been largely absent from NHS digital plans.
Like elsewhere, challenges delivering care in remote and rural areas have acted as a catalyst for the adoption of digital technologies. In Scotland, the use of Near Me – the video consultation platform – was originally rolled out to support those living in remote and rural areas to access health care, although its use has since expanded far beyond that. In Northern Ireland, the decision to implement one record across the country via the Encompass programme was considered more appropriate given their smaller population.
Processes and attitudes around the use of health care data also vary. In 2019, the Scottish government worked with Nesta to undertake a series of ‘Data Dialogues’ with Scottish citizens, which explored public attitudes and ideas on sharing health care data, and provide basis for effective public engagement on digital health care.
The SAIL databank in Wales has been in operation since its pilot in 2007, and provides a secure way of accessing anonymous data for research to improve health, wellbeing and services. Public engagement is a key aspect of how the databank works. Stakeholders noted how high-profile controversies (such as that surrounding the GPDPR in England in the summer of 2021), can have a knock-on impact on public confidence in data, despite countries having separate systems.
What has been the impact of digital health care across the UK?
Measuring the impact of digital technology on health care can be challenging, both in measuring success at a policy level and the impact on individual patients and staff. A 2018 inquiry in Scotland noted that previous strategies had not set out clear measures of success, which made monitoring progress difficult. Stakeholders noted the importance of accompanying strategies with implementation plans to set out clear actions and how they relate to wider health care outcomes.
Although there is limited comparable data across the UK, there is evidence on the use and experience of digital in health care within countries. For example, in 2019, the Scottish government conducted a digital maturity assessment (DMA), which showed there was variation across health boards regarding digital maturity. This highlighted the need for better vision, support and resources at a national level to support integration.
In Scotland, a survey on the use of Near Me found that 87% of the public and 94% of clinicians thought video consulting should be used for health and care appointments, provided it is appropriate for the consultation. Similarly in Wales, the Video Consulting Service Evaluation found that 92.4% of patients said that the quality of the video consultation was excellent, very good or good, and 91% reported that they would use video consulting again. Although we found no comparable data for Northern Ireland, stakeholders noted multiple benefits of remote consultations for patients and staff, such as improved access and convenience.
What has been the impact of the pandemic on the use of digital health care?
Like in England, there has been an increase in the use of remote consultations across multiple health care settings, with all four countries seeing rapid scale up during the pandemic. In Scotland, investment in infrastructure, training and staff and patient engagement for remote consultations prior to the pandemic meant that they were able to expand the service at pace and scale.
In the first five months of 2021, the Scottish GP Activity Survey estimated that 60.8% of appointments were by telephone, 30.6% were face to face, 0.4% by video, 6.1% asynchronous (where there is no real-time interaction), and 2.1% home visit (data provided by Public Health Scotland). In England, NHS Digital’s experimental statistics showed that an average of 41.2% of appointments were by telephone and that 54.4% were face to face in the same period.
Countries also used technology in their pandemic response, supporting test and trace services and developing contact tracing apps, although there was divergence in approaches as a result of particular country context and policy objectives.
What action are countries taking to support digital transformation outside of health care?
Integrating digital within wider public services is a key lesson from countries that have made significant progress on digital health care. Across the UK, there has been a similar shift towards greater focus on digital across wider public policy.
Scotland and Wales published updated digital strategies in 2021, with the publication of the long-awaited UK Digital Strategy in June 2022. As well as this, the roadmap for digital and data: 2022 to 2025 sets out a government-wide vision and programme of work for using digital and data to improve public services.
The value of digital has been highlighted during the pandemic, but at the same time there is concern about an increasing “digital divide”. Despite an overall increase in the numbers of people using the internet between 2020 and 2021, this varies across the UK. Wales has a lower level of digital engagement (13% of Welsh population had not used the internet in the last three months) compared to Scotland and England (4% and 5% respectively).
This is important given the relationship between digital technology and health inequalities. A survey by Public Health Wales showed that those of older age, least affluent or with poorer self-reported health were all less likely to engage with digital technologies for health purposes.
In Scotland, the equality impact assessment (EIA) on the use of Near Me recognised that video consulting should remain optional, rather than be the default. Despite acknowledging multiple benefits of video consulting, it also noted barriers including connectivity, as well as concerns about people who might be digitally excluded such as homeless people, rural and remote communities, and those from low socio-economic backgrounds. All health boards are expected to review the national EIA and modify it to suit their local circumstances.
Cwmpas (formerly the Wales Co-operative Centre) has been delivering digital inclusion programmes for the Welsh government since 2005. The current programme – Digital Communities Wales – is run in partnership with the Good Things Foundation and Swansea University. The Digital Inclusion Alliance Wales was established in 2020, and aims to address digital inclusion across different sectors. In March 2021, the Alliance published its own ‘agenda’ in the lead up to the Welsh government election, which outlined five priority areas.
Digital inclusion is also a key mission of Wales’s digital strategy. The Welsh government has recently created a Centre for Digital Public Services, which has published public service standards for digital, focusing on user needs and service design.
The standards are closely linked with the ambition to improve Wales’s social, cultural, environmental and economic wellbeing, as set out in the Wellbeing of Future Generations Act (2015). The digital strategy also includes a goal to develop a “shared ambition” for health and care, to reassure citizens about how their health and care data is being held and used, and to consult on a wider set of principles for the use of data in the public sector.
Digital inclusion is also a theme of Scotland’s overarching digital strategy (2021). Continuing the Connecting Scotland programme (which was initiated during the pandemic to connect people to devices, data, skills and support) is an important part of this. The Scottish Approach to Service Design sets out a framework that emphasises discovery and design in solving problems using digital. The Digital First Service Standard also exists as an assurance framework for the design of public sector digital products, including across health and social care. Organisations such as the Digital Health and Care Innovation Centre, which looks at how digital tools can address societal health care challenges, also play a key role. Their focus is on user-centred design, with a particular focus on adoption and scaling.
What does the future hold?
Given the impact of Covid-19 on digital health care, now is an important time to consolidate progress and set clear objectives for the future. Stakeholders felt that the pandemic has led to a greater acceptance of the use of technology within health care, and improved collaboration within services. Building on this with the right infrastructure, sustainable resources and research to ensure that it is being implemented in the best way for staff and patients will be crucial if each country is to deliver on their ambitious goals.
As there are significant initiatives underway across the UK, sharing learning across the four countries about what works well will be invaluable. Given what history has shown us, achieving digital transformation in any UK country is unlikely to be plain sailing. Learning the lessons from the past, and working with patients, the public and health care professionals to get the most out of technology will be essential if the four countries are to reap the benefits of digital health care.