Four key takeaways for advancing digital inclusion

It is already well documented how in response to the COVID-19 pandemic, NHS trusts adapted and adopted digital ways of working to meet the needs of their staff, patients and service users. With these rapid changes underway trust leaders are rightly reflecting on the need to address digital exclusion. That is the lack of digital skills, connectivity or accessibility which can fundamentally affect an individual's ability to engage with health and care services. The scale of the challenge can be articulated in numbers:

• around 2.6 million people in the UK have never used the internet
• 14.9 million are considered low internet users
• but 1.5 million people came online for the first time during the pandemic.

Digital exclusion fundamentally results in poorer health outcomes and quality of care. Board action is therefore vital to mitigate digital exclusion and ensure that digital transformation can equitably improve patient outcomes and quality of care for all.

NHS Providers recently hosted a digital inclusion panel discussion to explore some of the key lessons for NHS board leaders. Facilitated by digital transformation consultancy Public Digital, the discussion featured expert insights from Victoria Betton, PeopleDotCom managing director, Helen Milner OBE, The Good Things Foundation group chief executive, and Denise Sterling, Calderdale and Huddersfield NHS Foundation Trust non-executive director. To follow are four key considerations for board leaders looking to improve digital inclusion. These are based on the expertise shared by our panel, and as one leader described it this is about "business better than usual". You can access a video recording of the session at the end of this blog.

1. Take a holistic systems approach
   
   First and foremost, digital inclusion is about better health and wellbeing. Much like digital transformation more generally it cannot be considered an add on. Boards need to balance their focus on the accessibility of individual services and products, while also working with local partners to maintain a wider view of the social determinants of health inequality. Those digitally excluded are also most likely to be socially excluded. In this way, digital exclusion acts as a compounding factor of poor health and as a proxy for health inequality, and so should underpin the wider work of the place-based agenda.
   
   Connecting digital inclusion to your organisation's wider strategic ambitions can embed digital inclusion across all work programmes. Boards should consider what evidence is available to demonstrate this is happening. The mistake often made is to ask the question "what is the project for the 20-30 people we think will be excluded", instead of asking "what is the digital inclusion element within all our transformation programmes?".
   
   
   
2. Strategic engagement with community partners
   
   Digital inclusion is a shared agenda that is not confined to the NHS and trust boards may look to harness the benefits of strategic local partnerships. Improving digital inclusion will involve building stronger place-based networks of care with local authorities, charities and community organisations.
   
   There is no such thing as a "hard to reach group", and so the NHS may want to work with those organisations already embedded within communities. This is sometimes called "bonding and bridging", going to where users are, such as cafes, local hubs and community centres. Trust leaders have an opportunity to work with those already embedded in communities, although experience suggests there is no quick fix and it is important to develop strong partnerships built on trust. A first step for boards may involve taking stock of the resources already available to the organisation, and then looking to join assets with others to the benefit of the wider health ecosystem.
   
   
   
3. Co-design services with patients and staff
   
   A comprehensive understanding of user experience is integral to designing and implementing services that reduce digital exclusion. There is a wide diversity of digital users – from patients to carers to clinicians – with a range in levels of digital literacy, connectedness and motivations for using or not using digital.
   
   Mapping the patient and staff journey to identify the pain points and barriers can reveal when and why patients risk being excluded. Boards may want to reflect on the purpose of service changes. Why and when will patients, service users, use a service – the answers to both may explain why some are digitally hesitant.
   
   It is important to break down assumptions about users and instead gather meaningful evidence from user research so that mindful, simple and effective services can be designed and sustainably adopted. As an example, when designing solutions for children and adolescent mental health services, one trust had a preconception that 'digitally native' young people would favour high-tech solutions, such as having treatment resources available through a smartphone app. After engaging directly with the young patients, it became clear this group did not have the data and broadband necessary to connect to an app at home. For this digitally literate group, the reality was that the most appropriate tool to deliver health services was found through the co-designing of a low-tech solution.
   
   
4. Create a digitally inclusive culture
   
   Boards can look to establish a culture of sustainable digital inclusion. In order to do this, they may want to start with three key areas:

• categorising the problems - is it hardware, access to data, digital literacy, confidence?
• identifying people who are currently excluded or at risk of exclusion
• prioritisation – there will always be a limit on resources.
  
  Evidence suggests organisations should then start small, iterate and be bold. The first step may involve identifying and supporting digital inclusion champions within the trust. Look for people and departments that already have an enthusiasm for digital where you can pilot new ways of working. Learn from these pilots and make changes as you continue to develop.
  
  When done right, pilots build out into programmes and then eventually into sustainable system change that is anchored within your teams and services.

Health outcomes are fundamentally impacted by the level of digital inclusion faced by individuals and communities. The pandemic has exposed and exacerbated digital exclusion over the last year. Boards must take action now to address these challenges but also articulate the vision for the future sustainability of their services.

The above learnings gained from the digital inclusion panel event are a part of the wider offering from the NHS Providers' Digital Boards programme. For more information on digital inclusion, please see our two-page Digital Download containing useful information for boards.