Beyond Digital: Planning for a Hybrid World Contents

Chapter 3: Health

The impact of the pandemic on the use of digital technology

92.One of the areas where we have seen the greatest change in how services are accessed, as a result of an increasing reliance on digital technology during the COVID-19 pandemic, has been the provision of healthcare services. Almost overnight services that have traditionally been provided face-to-face have been provided remotely, via telephone or video. While this was, undoubtedly, a suitable urgent response to a global pandemic, there is now a need to develop a more considered approach to digital healthcare services. As we have stated throughout our report, the future will be hybrid, and the future of healthcare provision is no different. In the future, services will be provided both remotely and face-to-face, with some patients preferring remote services, others preferring face-to-face services, and some preferring a mix of both. We believe that digital capacity should be used as an effective new tool in providing some healthcare but can never be seen as a universal solution. There are undoubtedly some medical appointments that cannot, or cannot effectively, be provided remotely. The Royal College of Nursing (RCN) gave the example of needing to be able to smell wounds if infection is suspected and, in some instances, being able to use touch to discover what kind of pressure elicits pain to help staff ascertain adequately the patient’s health problem.100 Therefore, the challenge will be ensuring that all patients receive the best possible healthcare services regardless of the mode in which it is delivered and in line with their choice about the mode.

93.According to the RCGP, prior to the COVID-19 pandemic, approximately a quarter of GP appointments were carried out remotely.101 Since the introduction of COVID restrictions, approximately 70 per cent of GP appointments have been carried out via video or telephone. Dr Mistry emphasised that it was important to note that the statistics on remote consultations differ depending on the “digital maturity” of the organisation in question,102 and that there was a marked difference in pre-pandemic access to remote healthcare between digitally enabled GP practices and those struggling to provide remote services.

What we have learned

94.Chris McCann told us that Healthwatch had interviewed patients about their experiences of remote healthcare provision and had found that “for many people, remote consultations offer a convenient option for speaking to a healthcare professional,”103 although only where the quality of communication did not compromise the quality of the interaction. Chris went on to explain that patients appreciate the quicker and more efficient access, not having to travel, less time taken out of their day, and the ability to fit an appointment into their general lives. Mind agreed, and also noted that a key benefit of digital delivery of mental health services is that online digital mental health programmes allowed people to access support more quickly, with 65 per cent of the people surveyed able to start using the support immediately.104

95.Mind also told us, however, that some people struggled to access services when they were provided remotely. A fifth of those surveyed at the beginning of the pandemic had tried to access mental health services in the last two weeks, but almost a quarter of those people had been unable to access services.105 The main difficulties experienced in accessing support were difficulty contacting a GP or Community Mental Health Team (24 per cent), feeling unable or uncomfortable using phone or video call technology (22 per cent) and appointments being cancelled (22 per cent).

Box 5: Digital consultations

I have met an entire range of patients, from those who absolutely love using digital technology and find it great either to speak on the phone or to speak via a video call right through to people who have found it a really unpleasant experience to engage in those ways. As a clinician, I have had some excellent consultations with patients … However, in some cases I have just had to hang up the phone, get in my car and go to the person’s house and see them face to face.

Source: Q 53 (Tom Foley)

96.The pandemic has also highlighted the need for greater investment in the technology needed for digital healthcare. A BMA survey found that 46 per cent of doctors said that internet speed/bandwidth was a barrier to providing remote consultations and nearly six in every 10 doctors (56 per cent) feel that current IT infrastructure significantly increases their day-to-day workload: a quarter (27 per cent) reported more than four hours per week were lost due to inefficient hardware/systems. Dr Jameel explained how issues with digital technology might affect a patient’s experience:

“I have seen a patient in general practice and referred them on to secondary care. Their referral should be with the secondary care team, because now we have a lovely electronic referral system. My understanding is that in some trusts the team responsible will download it off that system, PDF it and upload it on to a different system, and then the consultant might print it off at their end and review the referral. That sounds like an awful lot of steps and a waste of time for a lot of people.”106

97.COVID-19 resulted in a dramatic shift to healthcare services being delivered online. While this was driven by necessity, some people have benefited from this approach and will want it to continue. Digitally delivered services also present opportunities to save time and treat more people; given the significant existing pressures on mental health services, for example, which are only expected to grow as a result of the pandemic, the increasing adoption of digital interventions may be the only realistic way of providing a service to those who need help, but always ensuring that face-to-face consultations are available as an alternative when clinically preferable or desired by patients.

98.The Government must commit to ensuring health professionals have the training and equipment needed to deliver digitally effective services in the most appropriate way.

Potential future uses of technology

99.While the pandemic required a shift from in-person to remote healthcare appointments, digital healthcare interventions were being developed and used before the pandemic, and have the potential to play an increasing role in future.

100.A number of witnesses told us about the potential benefits of ‘wearables’.107 Dr Mistry explained that “there is a growing evidence base” for their effectiveness, and that some of the technologies that are “ready for uptake”108 include:

“apps for health monitoring, what are termed digital therapeutics, which can provide cognitive behavioural therapy through digital means, and wearables that can give you a precursor for a deterioration in well-being, which can then be supported through remote monitoring.”109

101.Dr Mistry then highlighted the role of wearable technology in ‘nudging’ people to monitor their own health, such as an app that tells the wearer when pollen levels or air pollution levels are high, which may cause a flare-up of their asthma.110 However, Dr Mistry then noted that while such nudges can help people to self-care, it tends to be people who are highly educated, and who already know a substantial amount about their health conditions, who use such technology.111

102.SimplyHealth also noted the potential for digital technology to raise awareness and early treatment of mental health issues through the ability of smartphone apps and digital wearables to provide ‘nudges’ and mental wellbeing self-management advice in real-time in addition to access to remote consultations with a psychiatrist or counsellor.112

103.Dr Ruth Chambers, from Staffordshire Sustainability and Transformation Partnership, gave detailed examples of pilot projects where wearables have been used successfully, including a project where 400 AliveCor devices were posted to patients to discover if they had an irregular heart rate (atrial fibrillation). Each patient borrowed the device for two weeks, and would use it intermittently to monitor their heart rate, and check whether they had atrial fibrillation.113

Box 6: The cost-saving potential of digital technology

I would price a stroke up as £30,000, which is common with atrial fibrillation, either because of their hospital stay and the fact that they have lost their job or because people are looking after them. That is what we have saved the country. It is easy to price up how these wearables, if we were to target them at scale, could save the resources of the NHS.

Source: Q 33 (Dr Ruth Chambers)

104.Witnesses also emphasised the role of existing technology, such as Facebook, in improving health outcomes. Dr Chambers explained that a pilot project had established a closed Facebook group for socially isolated people with multiple sclerosis in North Staffordshire.114 The group gave people the opportunity to socialise online and share their experiences. A nurse would post health messages to the Facebook group once or twice a week, to provide health ‘nudges’. While the pilot project was a success, Dr Chambers expressed frustration that such successful pilots are not rolled out nationally.

105.Dr Chambers also highlighted the importance of supporting patients to use digital technology, giving the example of providing vulnerable people with an Alexa Echo Show, and the support of a “buddy” to learn how to use it. She emphasised the importance of working with people and respecting what they are prepared to do, rather than “dismissing them because they do not have a smartphone.”115

106.Any increasing role for digital technology in providing healthcare services may raise concerns about data sharing. Chris McCann explained that HealthWatch England commissioned a poll in 2018 about data sharing in the NHS, which found that, overall, most people are positive about sharing their patient data. Approximately 73 per cent of respondents stated that they would be happy for the NHS to use their information to improve healthcare treatment for themselves and others. However, he went on to emphasise that “the key thing here is public confidence, and that any mis-steps involving the use of personal data really negatively affect public trust in data sharing.”116

Box 7: Existing digital technology

We see headlines about exciting new avenues of research and high-tech ideas that have potential for mental health services, but what we are more likely to see implemented over the next few years, and what resources are needed for, are services that make the best of technologies already widely accessible and ways of working that already have a mature evidence base. That will include a need for services to deliver confidently a more blended approach that draws on technology that many people already have access to, adding what is special and supportive in digital technology to well-established, evidence-based practice in face-to-face working.

Source: Q 51 (Professor Kate Cavanagh)

107.There is clearly significant potential to improve our health and wellbeing by harnessing both the day-to-day technology that many of us use and by developing healthcare specific products and tools. However, some people may be wary of such technology due to concerns about data privacy and data sharing. As highlighted earlier in this report, these benefits will only be realised if there is a robust system in place for developing, testing and evaluating such approaches, and if significant progress is made on tackling digital inequality and making these technologies accessible to all.

Preparing for the hybrid world

108.Many witnesses suggested that future healthcare provision should ensure a blended approach, whereby patients can access services both remotely and face-to-face, depending on their circumstances. Dr Jameel explained that there are some elements of healthcare that can only be delivered by examining and seeing a patient face-to-face, and that clinicians must choose the right consultation method based on patient interaction, patient preference and the patient’s needs.117

109.A number of witnesses also expressed concerns that an increasing reliance on providing digital healthcare, particularly consultations, may mean that some symptoms or conditions are missed. Dr Jameel told us that there were a “number of times”118 when “I listened to a chest and spotted a mole that I just did not like the look of which I then sent off for specialist review.”119 Dr Jameel explained that the patient had booked an appointment to discuss other issues, and would not, necessarily, have booked an appointment specifically for advice on the mole. Carnegie UK Trust made a similar point, stating that telephone or virtual consultations led to a tendency to focus on the specific health problem being presented, rather than the health of the whole person.120 While Dr Mistry agreed that there are concerns that “something will be missed” by offering remote appointments, they also suggested that technology can mitigate some of these risks, by using innovative devices, such as e-stethoscopes.121

110.Alongside thinking about which services are best suited for digital or face-to-face delivery, witnesses repeatedly emphasised the issue of digital inequality in accessing healthcare. Chris McCann, for example, raised concerns that any increasing role for, or reliance on, digitally technology in providing healthcare services could exacerbate existing inequalities122 and that there may be a risk that people without access to technology will receive poor-quality care.

111.Other witnesses focused on specific communities or groups that may face increased inequality in accessing digital healthcare services, with Professor Gurch Randhawa, from the University of Bedfordshire, referring to research that suggests that older people, people from lower socio-economic groups, and people from Black and Asian communities are less likely to utilise phone or online healthcare services.123 The RCP suggested that older people and people from lower socio-economic backgrounds may have worse health outcomes because their communication with their doctor is affected by their lack of digital skills or the quality of their devices.124

112.Dr Emily Peckham, from the University of York, suggested that people with severe mental health issues are at an increased risk of being unable to access digital healthcare services.125 Dr Peckham explained that over a third of people with severe mental health issues do not use the internet for daily activities, compared to 10 per cent of the general population, and that some people had expressed concern that mental health symptoms can make accessing digital services harder and symptoms can be made worse by the experience (voices, paranoia about social media or being online), and this may lead to people not accessing services that are delivered remotely.

113.Mind highlighted similar concerns, and also told us that young people were more likely to find it difficult to access mental health support using digital technology, and less likely to feel comfortable accessing mental health support over the phone or on a video-call.126 Almost a third of young people (30 per cent) who accessed or tried to access support said that the technology was a barrier to doing so.127

114.We heard from witnesses that some conditions may be missed during remote consultations, while other medical specialisms may not be suitable for virtual appointments. However, digital technology and patient data can also be used to help ensure that a patient’s medical needs are understood more fully. As such, we believe that the hybrid healthcare service must be underpinned by an acknowledgement of the potential opportunities and current shortcomings of digital provision in certain circumstances and a commitment to ensure that all patients receive the very best healthcare service.

115.As part of its new hybrid strategy, the Government should work to develop a genuinely hybrid healthcare service. In implementing a hybrid healthcare service the Government should work with the NHS to evaluate what treatments are suitable to be offered digitally, and provide further funding to research new digital interventions for those specialisms that currently cannot be provided remotely. The Government should also work with the NHS to ensure that current, and future, healthcare systems and processes reflect the new hybrid reality, including the importance of face-to-face provision, and enable patients to move seamlessly between online and offline service provision.

116.The digitally hybrid healthcare service in England should be underpinned by a code of practice giving patients the right to receive services online or offline, as well as guaranteeing a minimum service standard for both online and offline healthcare services, including a right to contact their doctor digitally. In developing this code of practice, the Government should undertake a review of patients’ rights in hybrid healthcare provision, including its impact on accessibility, privacy and the triage between face-to-face and digital provision.

100 Written evidence from the Royal College of Nursing (LOL0022)

101 Royal College of General Practitioners, ‘General Practice Will Not Become a Remote Service Post-COVID’ (2 July 2020): [accessed 11 February 2021]

102 Q 26 (Dr Pritesh Mistry)

103 Q 27 (Chris McCann)

104 Written evidence from Mind (LOL0087)

105 Mind, ‘Mental health charity Mind finds that nearly a quarter of people have not been able to access mental health services in the last two weeks’ (7 May 2020): [accessed 11 February 2021]

106 Q 28 (Dr Farah Jameel)

107 Wearables, or wearable technology, are smart electronic devices that are worn close to and/or on the surface of the skin, where they detect, analyse and transmit information.

108 Q 26 (Dr Pritesh Mistry)

109 Ibid.

110 Q 31 (Dr Pritesh Mistry)

111 Ibid.

112 Written evidence from Simplyhealth (LOL0065)

113 Q 33 (Dr Ruth Chambers)

114 Q 31 (Dr Ruth Chambers)

115 Ibid.

116 Q 26 (Chris McCann)

117 Q 27 (Dr Farah Jameel)

118 Ibid.

119 Ibid.

120 Written evidence from Carnegie UK Trust (LOL0096)

121 Q 27 (Dr Pritesh Mistry)

122 Q 32 (Chris McCann)

123 Written evidence from Professor Gurch Randhawa (LOL0007)

124 Written evidence from Royal College of Physicians (LOL0073)

125 Written evidence from Dr Emily Peckham et al (LOL0042)

126 Written evidence from Mind (LOL0087)

127 Ibid.

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