This BMJ Leader blog series has been produced in collaboration with the Health Equity Evidence Centre (HEEC). HEEC are dedicated to generating solid and reliable evidence about what works to address health and care inequalities. By adopting innovative methodologies, they efficiently map successful strategies for reducing health and care inequalities, and subsequently empower policymakers and practitioners to make evidence-informed decisions for all.

The blog below has been written by Dr Sash Harasgama, clinical researcher at HEEC.

A shift from analogue to digital is one of the three key shifts outlined in The 10 Year Health Plan to reform the NHS. It was also highlighted in Lord Darzi’s independent report as one of the major ways to fix the NHS, with the advent of artificial intelligence and integrated digital systems.

However, the COVID-19 pandemic revealed how digital exclusion not only affects access to information, but also access to care. There was unequal adoption of COVID-19 digital technologies, with only 33% of black and minority ethnic individuals downloading the NHS COVID-19 app, compared with 51% of people from a white ethnic background. Furthermore, in 2024, 33% of the British public did not have the digital skills necessary for day-to-day life, with 23% and 9% having ‘very low’ and ‘low’ digital capabilities respectively. One in two adults who were ‘offline’ had difficulty engaging with digital services, most commonly government applications.

A survey about attitudes towards technologies deployed during COVID-19 also found that amongst the almost 2,500 respondents, nearly a fifth (19%) said they did not have access to a smartphone, and another 14% said they do not have access to the internet. In fact, the Citizens Advice Bureau found that one million households cancelled or downgraded their internet packages in the setting of the worsening cost-of-living crisis, and affordability is the biggest reason for data poverty in the UK. These economic and financial barriers also disproportionately affect minority ethnic groups.

Digital exclusion is shaped by low digital health literacy (i.e. knowledge and skills), data poverty (i.e. access) and mistrust (i.e. beliefs). NHS leaders play an important role in addressing these. Inclusive digital health starts with making it an organisational priority. Leadership buy-in is essential to influence the culture of everyone, from staff to patients, being motivated to adopt digital health tools, but leaders must leave room for feedback. To approach digital health equitably, the following strategies should be considered:

Train staff to screen for patients with low digital and health literacy

Screening for low digital and health literacy starts with raising awareness (1) and then providing means to identify those at risk in practice. Leaders should train staff to recognise digitally excluded patients through embedding social needs screening and treating digital literacy as a determinant of health. Simply asking patients what their day-to-day interaction will technology looks like is one step towards addressing digital exclusion.

Design and co-produce interventions that are tailored to population groups

Health and care leaders should ensure digital health interventions  cater for everyone (2). Tailoring interventions to the diverse cultural, linguistic and cognitive needs of communities begins by asking patients what they need. Digital tools must go beyond simple translation to product modification with audio-visually enhanced information that can assist patients with poorer cognitive, literacy and dexterity capacities. Free-text fields designed into the digital interface may better address inequalities. Culturally adapting interventions so that population groups who are disadvantaged due to norms and beliefs around digital health interventions, such as older south Asian people, also assists with inclusion (3).

Provide alternative means to digital health interventions for improved accessibility

Health and care organisations should continue to offer traditional methods of collecting data and interacting with patients. QR codes and in-app questionnaires can be used in conjunction with paper-based surveys or SMS messaging, particularly for those who don’t have access to a smartphone. While it is important we optimise telehealth consultations (4), we must also provide face-to-face consultations in tandem. Leaders may appreciate, in principle, that higher adoption of digital health tools by some parts of their patient population frees up time for their staff to physically see more complex patients with unmet need.

Have digital hubs co-located in healthcare settings to provide opportunity to educate

Digital health hubs in healthcare settings, whether it be in hospital or community, can offer assistance and educate patients on the use of digital health platforms. It may also provide a safe space for patients to use technologies confidentially if need be. Engaging the community on finding appropriate local spaces for digital hubs may also improve reach and access, particular for groups that may prefer to gather in venues that are culturally appropriate for them (5).

Raise staff and patient awareness about the value of digital health and data collection, ensuring digital security systems are robust

Mistrust and lack of awareness leads to poor and incomplete data collection (6). Often, patients are hesitant to engage with digital tools because they are unsure how their personal information may be used, and raising awareness on both the value and security of their data is important. Educating staff on the importance of data to prioritise health and care needs in populations is also vital. Finally, leaders should ensure that implementation of digital interventions come with robust cybersecurity and privacy measures. Health and care organisations must take measures to protect health data and should collaborate with information technology experts to ensure no one is left vulnerable.

Tackling patient digital exclusion requires a multifactorial approach, and it begins with NHS leaders committing to narrowing the digital divide. We highlight here several key strategies to ensure that a digitalised NHS is both inclusive and equitable. Health care leaders have an onus to ensure that absolutely no one is left behind when the digital revolution comes.

References:

1. Nutbeam D. From health education to digital health literacy – building on the past to shape the future. Glob Health Promot. 2021 Dec 1;28(4):51–5.
2. Harasgama S, Dehn Lunn A, Lamb D, Gkiouleka A, Painter H, Ford J. Evidence brief: What works to improve health and digital literacy in disadvantaged groups. Health Equity Evidence Centre; 2024.
3. Ramasawmy M, Sunkersing D, Persson DR, Poole L, Patel K, Modha S, et al. “If it all goes digital, we’ll have to learn”: facilitators and barriers to uptake of digital health in British South Asians with cardiometabolic disease. BMC Digit Health. 2024 Jun 3;2(1):32.
4. Evans C, Clancy G, Evans K, Booth A, Nazmeen B, Sunney C, et al. Optimising digital clinical consultations in maternity care: a realist review and implementation principles. BMJ Open. 2024 Oct 1;14(10):e079153.
5. The King’s Fund [Internet]. [cited 2025 Jan 31]. Designing Inclusive Digital Health Services With Communities. Available from: https://www.kingsfund.org.uk/insight-and-analysis/long-reads/inclusive-digital-services-people-communities
6. Bignall T, Phillips J. Improving the recording of ethnicity in health datasets: Exploring the views of community respondents and the healthcare workforce. Wellcome Trust: Race Equality Foundation; 2022 Nov.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests:none