Written evidence submitted by The Nuffield Trust (DHS0032)

Government Commitment under evaluation

Was the commitment met overall or, is the commitment on track to be met?

Was the commitment effectively funded (or resourced)?

Did the commitment achieve a positive impact for patients and service users?

Was it an appropriate commitment?

POLICY AREA: The care of patients and service users

Commitment 1: “Our aim is that, by 2024, 75% of adults will have registered for the NHS App with 68% (over 30 million people) having done so by March 2023.”

According to the most recent press release, as of September 2022 there have been 30 million ‘sign ups’ to the NHS App.[2]

Detailed data on how the NHS App being used is available to those working in the healthcare system (via the NHS App Dashboard).

There is a risk that too great a on targets around the use of the NHS App compounds existing concerns around digital exclusion and access to care. Our research shows that some groups tend to be left behind when access to care becomes digital.[3]

Furthermore, several other apps are in use by GP practices to support triage, e-consultation and appointment booking/ prescription requests. The interaction between these and the NHS App is unclear.

POLICY AREA: The care of patients and service users

Commitment 2: “By increasing digital connection and providing more personalised care, we can support people to monitor and better manage their long-term health conditions in their own homes, enabling them to live well and independently live longer.”

This is an unquantified commitment without a clear measurable definition. Notwithstanding this, there has been recent progress on using digital technology within healthcare.

During the Covid-19 pandemic there has been an increased use of technology across multiple aspects of healthcare including support at an individual level for people to manage long-term conditions. There was also a rapid increase in the amount of care delivered remotely. In 2020, GP appointments carried out via telephone or video/online rose from 15% in February to 48% in April, decreasing slightly to 36% in October.[4] Similar increases have been seen across outpatient services which within some specialties have been largely maintained.[5]

However so far, less progress has been made at a system-level using data for population health management in part because of limitations around interoperability, data quality and the ability to use data beyond the initial purpose of providing clinical care. This should be an important role of the ICSs.

Increased use of digital and data can bring positive improvements to patients and service users. However, to make the most of these opportunities it is important to understand how best to support digital engagement, and address issues of inequality.

Multiple complex factors can influence patient uptake and engagement with digital tools, such as the wider clinical context, people’s individual attitudes towards their own condition, motivation and privacy concerns.

Although the public’s attitude towards remote care was largely positive during the pandemic, difficulties accessing GP appointments in particular are causing frustration.[6] Our research suggests that the implementation of virtual primary care in its form to date is not enabling equal access to care and – because of this – much of the potential for digital care to help mitigate inequalities in health care is being lost.[7] Nuffield Trust analysis of the GPPS 2020/21 data showed that patients at GP practices in England who were of Asian or Black ethnicity, living with a disability, and providing unpaid care of 50+ hours a week (N= 61) were: four times less likely to try to book a GP appointment online via an app or website (4% vs 19%, respectively), and one third more likely to be dissatisfied with the choice of appointment offered (25% vs 17%).[8] Findings from the NIHR funded Remote by Default care in the Covid 19 Pandemic study highlight inequalities and tensions that occur when staff use overly rigid approaches to digital care which do not account for the variation in patients’ abilities, attributes and problems – from deprived communities with limited English skills, to mothers who cannot look after children while having a video consultation with a doctor.[9]

Too great a focus on digital tools without recognising the need for alternative approaches risks creating a “digital inverse care law” where those most in need - often patients who are less well and already materially disadvantaged - find it hardest to access care they need.[10]

But, technology also has the potential to address inequalities by providing alternative routes of access for people. International evidence shows that choice of different modes of consultation can empower patients previously disadvantaged by traditional face-to- face primary care for example by breaking down geographical barriers to health care[11], and by promoting patient autonomy.[12]

Although it is appropriate to recognise that digital solutions can act as an important enabler to healthcare, they are not a solution on their own. Our international research showed that countries which have made significant progress, also benefit from having an overarching policy focus on digital. Digital health is inseparable from the wider approach to digital in both public policy and society, with a clear link between digital health and wider societal and health care goals, wellbeing and prosperity.

It is important that at a national level, the use of digital technology is driven by particular problems and needs of the NHS, and not the technology itself.

To reduce the risk of making inequalities in access to care worse, there needs to be a stronger focus on inclusive and flexible routes for accessing health care (particularly primary care) - a one-size-fits-all approach is not satisfactory. It is essential that this is also reflected in any national policy commitments around the use of digital healthcare.

POLICY AREA: The care of patients and service users

Commitment 3: “Roll out integrated health and care records to all people, providing a functionally single health and care record that people, their carers and care teams can safely access, enabled by a combination of nationally held summary data and links to locally held records, including shared care records.”

Progress towards achieving this commitment is ongoing. The extent to which it will be achieved remains to be seen given that previous similar targets have not been met. Most recently, the DHCP set a target for all NHS trusts to have an electronic patient record (EPR) system by March 2025 (90% by December 2023 and 100% by 2025), and 80% of CQC registered care providers to have a digital social care record system in place by March 2024. However, the ability to share information between settings is still limited.

Importantly, interoperability (essential for integrated care records) is limited by the wider state of digital capability, which is still variable across the NHS and social care with variation between the systems in use across different organisations and specialties.

Promising examples of Shared Care Records exist at a local level (for example developed through the Local Health and Care Record Exemplars) but coverage is not universal.[13]  There is also variability between different settings, which affects the effectiveness of data-sharing initiatives. Due to the vast and fragmented nature of the social care provider market and poor data quality, a squeeze on funding which has limited investment in technology and digital, social care has traditionally lagged behind.

Previous attempts to introduce electronic care records have been accompanied by different approaches to investment. The Global Digital Exemplar (GDE) programme, which provided funding for the most digitally advanced trusts to accelerate their digital transformation plans, has been beneficial. However, the evaluation of this project called for action to address the risk of a widening divide between the most and least digitally advanced trusts.[14] The most recent approach has been to provide funding to trusts to reach the ‘core level’ of digitisation, and funding was announced in the 2021 Spending Review to support this.  

The social care white paper also committed £150 million of new funding over the next three years to deliver a programme of digital transformation for the social care sector, recognising the need to improve quality and collection of data, integration with NHS systems and internet connections in care homes.[15]

Our research noted that although this initial funding is important, long-term, sustainable investment is required for organisations to maintain this progress and react to the latest digital advancements.[16]

If Integrated Care Systems (ICSs) are to achieve their objectives they need to take a comprehensive approach to improving digital skills, capability and the use of data across both health and social care. The emphasis now should be on the support provided to organisations across Integrated Care Systems to put these systems in place. Importantly, this must recognise that digital projects are a change process requiring leadership, workforce engagement and funding.

POLICY AREA: The health of the population

Commitment 1: “Through the Data for Research and Development programme we will invest up to £200 million to transform access to and linkage of NHS health and genomic data sets for data- driven innovation and inclusive clinical trials, whose results will be critical to ensuring public confidence in data access for research and innovation purposes.”

During the Covid-19 pandemic, there has been considerable progress on using data for research, such as the OpenSAFELY platform.[17] This allows researchers to submit code to run on patients’ data, then receive the results without data needing to be transferred. The development of Trusted Research Environments (TREs) such as that being developed by NHS Digital is a valuable step and this is currently in the beta phase of public testing.[18]

There is value in applying some of the lessons from the pandemic to how we use public health and surveillance data for other diseases but there are still significant gaps in the data which limit its use. For example, ethnicity is not always routinely collected, or records are of poor quality, which limits our ability to understand and address for example the experiences of different ethnic groups. 

The Data Saves Lives strategy outlines several other important commitments and plans to improve the use of data within healthcare, which must be considered alongside the investment in data infrastructure.

Engaging with the public on data is not just about defensively communicating assurances on data security. Effective communication and public engagement on the purpose and value of data-sharing within health care, as well as having a robust and effective infrastructure for collecting, storing and accessing data is key.[19] High profile controversies such as those relating to the GPDPR – a system for collecting data held within GP practices - in summer 2021, continue to risk damaging public confidence and trust in the use of health care data.[20]

Providing the infrastructure is just one part. Effective communication with patients, the public and professionals to ensure there is trust and confidence in the use of data is essential, as well as making it accessible and transparent.

Our research into the experience of other European health systems showed that a society-wide approach to using digital across multiple areas of public life has been important for providing an infrastructure and fostering a culture of trust and confidence more widely.[21] Collaboration between government departments to address issues is desirable, and stakeholder groups which influence the public need to be reached as well as the public themselves.

POLICY AREA: Workforce literacy and the digital workforce

Commitment 1: “We will co-create a national digital workforce strategy with the health and care system setting out a framework for bridging the skills gap and making the NHS an attractive place to work.”

This commitment was most recently set out in the DHCP, alongside other goals for supporting the workforce such as improving digital skills and confidence across the NHS and social care. Although the status of this strategy is unclear, other initiatives exist (this includes the Digital Academy, NHS Providers digital boards programme and Health Education England’s Digital Readiness programme (previously Building a Digital Ready Workforce).

It is also essential for digital to be considered within other plans for a long-term workforce strategy, work which is still ongoing. It is unclear how far digital skills development and needs will be considered within these wider workforce plans. 

Workforce is no doubt key to achieving digital transformation, and having a commitment is valuable, but the skills and support needed are multi-faceted and any strategy must emphasise this and be backed with appropriate support for implementation.

Importantly, education, training and support should not only focus on how to support the workforce use specific technologies (such as those highlighted in the Topol Review), but more widely on how the increased use of technology impacts workforce roles. This must be considered alongside the need to develop digital leadership, and non-clinical digital professionals (such as data analysts).

For example, our research from the NIHR Remote by Default study has identified that in primary care, in addition to skills in assessing which technologies suit a patient, health care staff – such as receptionists– need skills in negotiating with patients balances the patient’s needs, their own preferences and the capacity available.

It is also important for digital skills to be considered more widely as part of workforce development in both health and social care. We examined digital skills in remote monitoring for social care staff and highlighted the potential of using digital technologies as opportunities for skills development.[22] Using remote monitoring technologies can help staff develop a variety of skills that can improve job satisfaction and help them move towards new career pathways. The development of ‘digital’ skills was seen as a gateway to broader skills including the medical knowledge and communication abilities needed to monitor the health of service users as well as delivering social care. Given the specific issues surrounding recruitment and retention within the social care sector, increased use of technology offers an opportunity to create a more attractive career pathway for social care staff but it is important to consider the specific needs of this group.