The need for social distancing in light of COVID-19 has led to an unprecedented increase in reliance on digital technologies by both health care providers and patients. While the trend towards digitalisation of health care allows for potential improvements in access, its impact on health outcomes and health inequalities must be carefully considered to ensure they contribute to social welfare and not detract from it.
The outbreak of COVID-19 – declared by the World Health Organisation (WHO) as a pandemic in early 2020 – has affected every aspect of everyday life. In the UK – as in many other countries – social distancing has been implemented as a key strategy in the effort to slow the spread of the virus. While visiting the doctor is technically permitted under these rules, overstretched health systems, along with the need to minimise risk of contagion, means that gaining access to medical professionals has become extremely challenging. This is expected to have significant consequences on overall health outcomes – and thus welfare – not only for those directly affected by COVID-19, but also those for whom vital support from health care providers has been severely limited as a result of the surge in demand.
Digitalisation as a solution
In light of this, there has been an increase in attention towards the potential of digital technologies in the health care space as they offer a means of addressing this problem: for example, in England the NHS app allows patients to take more control over their own health care (e.g. by managing their own prescriptions) thus easing demand on the system. Users of this app doubled over the month of March, reflecting the increased reliance on digital technologies while social distancing measures are in place. Other telehealth services, such as consultations via video link offer a way of maintaining the supply of essential services while avoiding the risk of contagion in waiting rooms. Therefore, the potential of digital technologies to improve access to health care is now – in the midst of COVID-19 – more welcome than ever.
Digitalisation of health care services is not a brand new phenomenon. In recent years there has been an ever-increasing number of mobile applications (apps) being developed and marketed. These range from relatively simple technologies with no measurable patient outcomes, to complex products that guide or even provide treatment (and which may be classified and regulated as medical devices). In 2019, Digital Health Technologies (DHTs) were postulated to go mainstream in the NHS Long Term Plan. This growth in reliance on digital technologies should not be without scrutiny of their safety and efficacy alongside any perceived efficiency gains. The advice provided through the evidence standards framework for digital health technologies by NICE and the NHS assessment of apps and digital tools are useful starting points to ensure that future digital innovations are assessed on evidence for costs and outcomes in a similar manner as other health interventions.
The long-term effects of DHTs on health outcomes are less clear. Although to date there has been little evidence of apparent negative effects from increased use of digital technologies, this may not necessarily hold true in the long run. For example, it is unclear whether consultations using telehealth methods provide the same level of care and patient experience as in-person appointments, which in turn may lead to sub-optimal health outcomes. Alternatively, if a patient becomes overly dependent on DHTs to manage their own health, they may avoid going to the doctor, which has the risk of leading to mismanagement and poorer health outcomes. In light of the increased usage of DHTs during COVID-19, the evaluation of their overall impact requires consideration not only of their direct effects but also of any unintended spill-over effects.
Who will benefit? Who will miss out?
On a wider societal level, there is need to ensure that, where there are benefits to be gained from the digitalisation of health care, such benefits are distributed in a manner that does not exacerbate or create health-related inequalities. Since digital technologies became mainstream, it is well-documented that the uptake of such technologies is not uniform across different groups in society (Brodie et al., 2000). According to the Consumer Digital Index 2019, 4.1 (8%) million adults in the UK are offline, and 1.9 million people (22%) do not have the essential digital skills needed for day-to-day life. Digital disengagement is also found to be higher amongst older people from minority ethnic backgrounds. Thus, there is an imminent risk that improvements to health outcomes resulting from the digitalisation of health care will accrue only to those who are more willing and/or able to engage.
Therefore, digital inequality may lead to DHT-induced health inequalities. Existing health inequalities may become exacerbated, as people who are less able to benefit from DHTs are generally those already in disadvantaged groups. Furthermore, the shift to digitalisation may lead to a redistribution of resources away from non-users of DHTs. Evidence from India suggest that the adoption of digital technologies can come at the expense of non-users as health care professionals change their response in favour of the users (Haenssgen, 2018). It is therefore possible that digitalisation and COVID-19 benefits accruing to one group will come at the expense of other, less well-off groups.
Making it work in the long run
There is no doubt that DHTs bear great potential for improving health outcomes and increasing efficiency in health care markets, especially in times of surge demand. However, more work is needed to ensure the fair distribution of their benefits. This comprises more qualitative research on if and how patients and physicians engage with digital technologies. We need to better understand digitally-induced health inequalities and whether or not digital inclusion can mitigate them. Secondly, quantitative research is required to gain more knowledge about causal relationships of different DHTs used by health care professionals and/or patients, and related health outcomes. In particular, we need to understand how these effects differ between socio-demographic and socioeconomic groups, especially those with protected characteristics.
The NICE evidence framework for DHTs advises innovators to consider the role of their idea with respect to health inequalities. Equality impact assessments are also carried out for DHTs running within the Digital health technologies pilot with the aim to develop dedicated future guidance on DHTs. Given the current ‘shock in digitalisation’ – the time is now to make this role an inclusive one.
Brodie, M., Flournoy, R.E., Altman, D.E., Blendon, R.J., Benson, J.M. and Rosenbaum, M.D., 2000. Health Information, The Internet, And The Digital Divide. Health Affairs, 19(6), pp.255–265. 10.1377/hlthaff.19.6.255.
Haenssgen, M.J., 2018. The struggle for digital inclusion: Phones, healthcare, and marginalisation in rural India. World Development, 104, pp.358–374. 10.1016/j.worlddev.2017.12.023.
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