A first glance NHS policy statements at local and national level could give the impression that services are being transformed out of all recognition with the use of new IT technology and “digital first” systems.

However research by NHS Executive magazine on the scale and growth of spending on IT across the various English regions suggests that the reality is much more modest – and recent data on services during the Covid pandemic shows that old-style telephone contact is favoured over more fancy new digital and video links for remote consultations with GPs and hospital services.

The NHS Executive survey shows a total IT spend of £3.8 billion in England in the 4 years from 2016 to 2019  – averaging less than £1 billion per year, and therefore less than 1% of NHS England’s budget: more than half of this was accounted for between just three regions – London (29%), the West Midlands (13.6%) and Yorkshire & Humber (11.2%).

Regional increases in spending over that same period ranged from just under 19% in London to a hefty 166% in the South West (confusingly positioned in the South East on the NHS Executive graphic): but the 166% increase is not as interesting as it sounds – it means an increase from a minimal £32.8m in 2016 to a slightly less minimal £87.4m in 2019.

The accompanying NHS Executive article waxes wordily enthusiastic about these relatively trivial sums, claiming that “it ensures the UK remains world-leading in the healthcare it can provide,” and quoting Matt ‘the App’ Hancock, who predictably sees the need to involve the private sector: “companies, entrepreneurs and innovators who come up with many of the world-beating ideas which we have and are rolling out in the NHS.”

However there was visibly less enthusiasm and more scepticism about the state of play  in the National Audit Office survey of ‘Digital transformation in the NHS’ in May. The NAO pointed out the level of investment was running well below the level needed to facilitate the planned changes, and as a result

“The NHS has not made the expected progress since 2014, including against a headline target to achieve a ‘paperless’ NHS.”

The NAO states “NHSE&I expects the NHS will need around £8.1 billion to deliver its digital transformation ambitions.” This includes £5.1bn from national bodies between 2019-20 and 2023-24, of which £2.2bn of revenue is already committed, and £2.9bn of capital funding which is dependent on spending reviews). The other £3 billion has to be funded by trusts between 2019-20 and 2028-29.

It’s clear from the current level and trajectory of spending that the NHS is well below the pace required for its plans: but it’s also questionable whether some of the “innovations” to be financed through this splurge of spending will achieve what they are supposed to do: some seem likely to further deepen already gaping inequalities in health.

The move towards a “digital first” system for GP consultations and many outpatient appointments might seem appropriate during the peaks of the Covid pandemic, but they are less than ideal for many consultations.

Health Foundation research has shown an increase in remote consultations and a sharp reduction in the proportion of face to face primary care consultations between March 1 and June 30 – based on a remote consultation supplier which had only 38% of face to face consultations before the pandemic. But the extent to which this involves cutting edge research is limited. Despite NHS England urging GPs to invest in video systems, and more than 90% of practices now able to offer video appointments, the most growth in numbers in 2020 has been in telephone and online messages: in the Health Foundation data video consultations increased 50-fold … to just 0.5%.

While arguing that its findings “suggest the NHS should continue to invest in digital-first primary care,” the Health Foundation also admitted that many doubts remain:

“Research is required to answer questions about the impact of remote consultation on the quality of patient care, patient experience and access, and workload.”

Here the right questions are seldom asked, let alone answered. Digital enthusiasts consistently postpone any research that might show up how many people are excluded from the new systems, whether through lack of digital access, or through visual or hearing impairment, learning disability, lack or decline of literacy skills, and lack of confidence to express themselves clearly in a remote consultation. Some people with serious health needs are resistant to consultations that do not offer any in-person human interaction.

The scale of “digital exclusion” is huge: 1.9 households have no access to the internet – and almost 30 million people rely on pay as you go services for calls, messaging and data. Those most likely to suffer digital exclusion are also among the vulnerable and deprived sections of society most likely to suffer chronic ill-health.

One organisation that has set out to establish the scale of such problems is Derbyshire Healthwatch, which has published a very informative booklet Experiences of Virtual Appointments during Covid-19. But even this is limited, in that the survey involved 118 telephone interviews – which requires the interviewees to have access to a phone, and the speech and language skills to respond to the interviewer. Other data came from social media, virtual engagements and comments from health professionals. There appears to be no mechanism to reach out to those who are left out of these networks.

Of course many people have found remote consultations to be more convenient and safe, especially  at a time of fears of infection: “there were benefits of appointments being held virtually. For many people, it was far more convenient to access services virtually than having to attend in person and was felt to be the safest way to access services during the pandemic”

However even from its relatively limited survey the first and most telling conclusion from Healthwatch was:

“Virtual appointments did not work for many participants for a variety of reasons and at times were inaccessible to participants in specific groups who are digitally excluded. Careful consideration will need to be given, and actions taken, to ensure that these groups can access services and are not disadvantaged.”

That means a very different approach from the case study in the report, in which a woman was asked by a GP practice whether she had booked online, told them she had no computer and could not do so – but was sent away and told … to book an appointment online!

With a growing elderly population, many of them with restricted ability to us technology and limited access to it, and increasing levels of unemployment and poverty, it’s clear that alongside the investment of billions in IT and digital solutions NHS England needs to lead a major reality check … to ensure that there are sufficient ways for the army of digitally excluded to access the care they need. Failure to secure this aspect of health care is likely to store up many bigger and more intractable problems for A&E and other services when people’s health deteriorates to crisis point.

With every NHS England, CCG and Integrated Care System document binding on at huge length with empty phrases about the need to address health inequalities, it’s high time they took themselves seriously, and took notice of this glaring omission of the new systems they are putting in place.

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John Lister
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