• 1 Collective term for telecare, telehealth, telemedicine, mobile, digital and health services

2Significant advances in health care in recent years provide the potential to transform health care provision in the form of Technology-Enabled Care (TEC)1 and Artificial Intelligence (AI) for diagnosis. Moreover, the Covid-19 pandemic has enabled the NHS to implement a fully online service, which had been the objective of the government and NHS governance bodies for many years. But these recent advances in health care delivery have also underlined some significant challenges which this paper will analyse. The public health care system in England has encountered limits to the provision of a fully digitalised service: inadequate funding, and outdated infrastructure. A fully digitalised health service has also exposed some vulnerable populations to the risk of exclusion from health care provision, namely the elderly and other socially disadvantaged people. This paper will start by examining the digitalisation of health systems and it will underline the significant nature of digital transformations in health care in England, some of which are common to most developed countries, but with some specific features which are unique to the universal health care system in England. It will then consider the challenges raised by the recent transition to online health services and other digital transformations. In particular, it will focus on health care exclusion as a result of digitalisation. The paper draws on a wealth of literature, government reports, academic papers and CSO research to synthesise current research on the issue, which is timely given the extent of digital disruption in the wake of the health crisis. It will specifically focus on England, given that the United Kingdom has a national health service or three quite distinct national health services and health policies since devolution to Scotland, Wales and Northern Ireland in 1999.

• 2 OED online

3According to the Oxford English Dictionary (OED), the term “digitisation” is “the action or process of digitizing; the conversion of analogue data into digital form”. “Digitalisation” is, on the other hand, defined as “the adoption or increase in use of digital or computer technology by an organisation, industry, country, etc.”2 The advances and processes described in the post-pandemic period are mainly concerned with digitalisation processes although some are also new conversion processes, so both terms are relevant. In any case, such processes of disruption have transformed health services and their delivery.

• 3 European Parliament, “The rise of digital health technologies during the pandemic”, European Parlia (...)
• 4 Ibid.

4The acceleration in digital health devices and usage since the outbreak of the pandemic has been significant. Digital health incorporates a wide range of technology, including that used in telemedicine, teleconsultation, remote monitoring, connected devices, digital health platforms health apps, health data analysis, application in systems based on big data in epidemiological research and AI-enabled diagnosis support.3 Digital technologies were extremely important during the Covid pandemic to ensure continued health care, such as medical consultations from home and telemedicine technology to diagnose and treat patients. E-prescriptions and repeat prescriptions were processed online to avoid catching and spreading the illness among patients and doctors.4

• 5 Richard Bodell, H. Dominic Covvey and Christina Fader, “Achieving a ‘therapeutic dose’ of IT,” Stud (...)
• 6 Theo Lynn, Pierangelo Rosati, Edel Conway, Declan Curran, Grace Fox and Colm O'Gorman, Digital Town (...)

5Transformations as regards e-health and online patient care have been particularly significant since the outbreak of the Covid-19 pandemic5. These include telemedicine and telecare (disease management, remote patient monitoring, telecommunications, home care); clinical information systems: Electronic Health and Medical records (EHR), Computerised Decision Support Systems (CDSSs); integrated regional and national information networks, associated electronic referrals and prescriptions (e-prescribing), disease registries and other non-clinical systems (used for education, public health, patient/disease-related behaviour and healthcare management), mobile health (medical and public health provided via mobile phone such as health information, patient screening, monitoring illnesses, providing direct care, patient education), personalised devices (wearable or implantable), micro and nano-technologies, therapy delivery devices for health and social care delivery and, finally, Big Data which implies integration and analysis of large amounts of data.6

• 7 WHO Regional Office for Europe, “European Programme of Work: united action for better health in Eur (...)
• 8 United Nations General Assembly “Transforming Our World: The 2030 Agenda for Sustainable Developmen (...)
• 9 Gov.UK., “Health and Social Care Secretary speech on Health Reform”, 8 May 2022. https://www.gov.uk (...)

6At an international level, the digital health transformation is supported by the World Health Organization’s (WHO) European Programme of Work for 2020-257 and the United Nations’ 2030 Agenda for Sustainable Development.8 Beyond the crisis, cost cutting has been essential and online services can help make significant savings in health care provision. It was recently estimated that the NHS could save £12.5 billion a year by fully automating routine and administrative tasks.9

• 10 European Parliament, “The rise of digital health technologies during the pandemic”, European Parlia (...)
• 11 Ibid.
• 12 Jo Bibby and Cara Leavey, “Learning from lockdown: how can we build a healthier future post-COVID-1 (...)
• 13 NHS England, “2022/23 priorities and operational planning guidance”, 2021: 26 https://www.england.n (...)

7Remote health care services have increased and remain in place despite moving to endemic status. Indeed, 58% of countries around the world have replaced face-to-face appointments with telemedicine since the outbreak of Covid-19 in 2020. Teleconsultations have been vital to avoid contamination and to diagnose Covid-19 under safe conditions. 5G has also provided the potential for new interventions including remote and robot led surgeries.10 AccuRx produced a video chat tool in March 2020 which is now used widely across the UK in 6700 doctor’s practices.11 It was reported that online consultations doubled from around 900,000 to over 1.8 million during the pandemic.12 Similarly, teleconsultations have been widely conducted. Advances have been made with the NHS Apps Library, NHS state Wifi, the NHS App NHS 111 online, allowing for GP records, booking or appointment and registering for organ donation to be made via a computer or smart phone. 93% of GP practices in England now use the Electronic Prescription Service, and 67% of prescriptions are delivered by this service which enabled the NHS to make savings of £136 million. Online hospital bookings have also saved the NHS more than £50 million a year.13

• 14 Department of Health and Social Care, “The Future of Healthcare: Our vision for digital, data and t (...)
• 15 NHS, “The NHS long term plan”, 2019. https://www.longtermplan.nhs.uk/ (accessed on 7 November 2022)
• 16 Review of NHS computer systems commissioned by Secretary of State for Health Jeremy Hunt and carrie (...)
• 17 Emma Stone, “Digital exclusion & health inequalities”, Good Things Foundation, 2021 https://www.goo (...)
• 18 NHS England, “2022/23 priorities and operational planning guidance”, 2021: 26 https://www.england.n (...)

8There was much momentum to expand and improve digital health even before the pandemic. In October 2018, the Department of Health and Social Care published The Future of Healthcare which led to the establishment of NHSX the following year.14 In February 2022, this institution integrated the Transformation Directorate NHS England to work with NHS Digital to help the NHS to move to a completely digitalised system. The NHS Long Term Plan of 2019 reiterated these ambitions.15 Previous to the NHS Long Term Plan, the Five Year Forward View and the Wachter report16 had set forth ambitions to provide new or enhanced digital and technological services. The Integration White Paper also underlined the objectives of using digital health tools, remote monitoring and digital health apps (NHS App and NHS.uk). By 2024, all patients should have a single digital health care record. Moreover, in June 2022, the government published a report on the integrated digital plan, which proposes to provide a digitalised system for the delivery of both health and social care17. The NHS is aiming to ensure digitalisation across all secondary care and electronic patient records (EPRs) in 90% of NHS trusts by December 2023 and 100% by March 2025. Other objectives include 80% of adult social care services to be provided using electronic records by March 2024.18

• 19 BMA (British Medical Association, “Technology, infrastructure and data supporting NHS staff”, 2019 (...)

9But some localities do not have the necessary technology (particularly in primary care) to achieve such objectives. A quarter of doctors (22%) responding to a British Medical Association (BMA) survey mentioned inadequate IT systems in their place of work and especially the ability to run Electronic Medical Records (EMR) and operating systems.19 The other issue is enabling a declining and inadequate workforce to adapt to digital systems. Many different systems exist which make a whole and integrated system difficult to achieve.

• 20 European Parliament, “The rise of digital health technologies during the pandemic”, European Parlia (...)
• 21 Justine Alford,  “NHS cyber-attacks could delay life-saving care and cost millions” Imperial Colleg (...)
• 22 Ibid.
• 23 Ibid.
• 24 Lizzie Roberts, “GP made end-of-life care recommendation after incorrect video diagnosis”, The Tele (...)

10Liability and cybersecurity are also significant issues, with incidents of cyber attacks on hospitals and concerns regarding the safety of transferring personal health data.20 For example, in 2017, the WannaCry cyber attack on NHS hospitals in England is estimated to have cost almost 6 million pounds because of cancelled appointments and reduced activity.21 The EU is currently working on the GAIA-X project to ensure secure usage of health services and security of data and applications. Such innovations could also be introduced in the UK.22 But further advances are also needed in the process of digitalisation of health care. For example, the transfer of telemedicine to 5G will be important and may raise a number of issues in terms of technological transferability. Prior to the pandemic, digitalisation of health care was less advanced than in other areas, so health infrastructure needs to go through a further catch-up process. Investment needs to be greater with European healthcare providers only investing between 2.9% and 3.9% on capital equipment.23 Moreover, most users’ access to health care devices is via mobile phones, which are not necessarily the most appropriate means of health care delivery, especially digital health treatment. The other problem is in terms of the reliability of digital devices to detect illnesses and disease and also the effectiveness of diagnosis via online consultations. There have been a number of incidents of misdiagnosis, such as the one reported in The Daily Telegraph, whereby a GP made a wrong diagnosis of organ failure after a video consultation and recommended end-of-life care for a 92-year-old.24

• 25 The Patients Association, “Patient experience before the omicron wave: the storm before the storm”, (...)
• 26 Healthwatch, “Locked Out: Digitally Excluded People’s Experience of Remote GP Appointments”, 2021 h (...)

11In addition, the merger of NHSX and NHS Digital is supposed to enable digital care to be provided in a more holistic fashion. However, in practice a number of patients have encountered challenges in accessing services via online systems. A Patients Association survey reported that respondents had encountered difficulties in getting in touch with their GP practice, getting in person appointments and also had to wait much longer for an appointment. One in four were unable to obtain access to any kind of service.25 A Healthwatch study collected stories on GP services during the pandemic and found difficulties in finding alternatives to remote booking systems or appointment via e-consult or reception. It was particularly those with low digital literacy or language barriers who found it difficult to make appointments. Staff also noted significant problems with the moving online of services and exclusion issues, which the next section explores in more detail.26

• 27 Emma Stone, “Digital exclusion & health inequalities”, Good Things Foundation, 2021 https://www.goo (...)
• 28 Ofcom, “Connected Nations Update”, 15 May 2020 https://www.ofcom.org.uk/__data/assets/pdf_file/0028 (...)
• 29 Simeon J. Yates, Elinor Carmi, Eleanor Lockley, Alicja Pawluczuk, Tom French and Stephanie Vincent, (...)
• 30 Ibid
• 31 Hannah Holmes and Gemma Burgess “Digital exclusion and poverty in the UK: How structural inequality (...)

12The digital divide can be observed not just in health care but in a variety of settings which can have an impact on health and wellbeing. According to Stone (2021),27 there are three main areas in which exclusion has been observed: access, use and engagement. Access will depend on available infrastructure at home or via mobile servers and this is most likely to be more difficult for people living in rural or deprived communities. Use and engagement relies on skills but also trust of technologies and privacy issues. Such problems can be related to locality (rural/urban) (even though 98% of households have the infrastructure necessary to obtain broadband access28) or socio-economic divisions (reduced access owing to poverty or digital illiteracy). There is a rural/urban divide which has been identified and is especially linked to poverty. In addition, a regional and inter-regional divide, again linked to socio-economic disadvantage, has been highlighted. A study was conducted by Yates et al. (2020)29 which distinguished between those who have full use and access and those who have limited use and access to online services. While 49% of the population had full access to the Internet in the South East, only 18% were connected in the North East and 31% in the North West.30 In addition, factors related to age, gender, income, employment and education can have an impact on the digital divide. More generally, marginalised groups have been found to have particularly limited or no access to online services.31

• 32 Digital Economy and Skills Unit, “The digital economy and society index 2020 – Methodological note” (...)
• 33 Ofcom, “Connected Nations Update”, 15 May 2020 https://www.ofcom.org.uk/__data/assets/pdf_file/0028 (...)
• 34 Ibid.
• 35 Ofcom,” Digital Exclusion: A review of Ofcom’s research on digital exclusion among adults in the UK (...)
• 36 Ibid.
• 37 Ibid.
• 38 Ibid.

13This divide was quite significant even before the outbreak of the pandemic. In 2019, it was estimated that approximately 15% of European households had no access to the Internet.32. The UK fares better than the European average with only 6% not having access or not using the Internet.33 The main cause for non-use was lack of skills (44%), followed by lack of equipment and finally inability to pay (24%).34 Yet as Ofcom (2022) underlines, the number of adults unable to use or access the Internet steadily declined in the lead up to the pandemic, even if since then the necessity to have access and use Internet has increased. In the UK, the number of households benefiting from internet access at home increased from 76 to 89%.35 Since this period the number of households without Internet access has decreased once again from 11 to 6%. Ofcom notes that with the decline in the number of people unable to use the Internet comes further exclusion for the minority who still do not have access or the ability to use it. Since affordability is identified as a major barrier to home Internet access, Ofcom is concerned that rising costs due to current inflationary pressures may have an impact on the ability of lower income households to maintain Internet connection.36 Moreover, Ofcom identified narrow Internet users, that is those using their mobile phone to access only a limited number of services, as at risk from exclusion. They reported 21% of users to be in this category.37 As mentioned previously, beyond access is the ability to navigate appropriate services with 8% of users reporting difficulties and lack of confidence in navigation.38

• 39 Health Foundation, “The Health Foundation Covid-19 Survey. Ipsos Mori”, June 2020 https://www.healt (...)
• 40 Ibid.
• 41 Public Health England,”Beyond the data: understanding the impact of Covid-19 on BAME Groups”, Londo (...)
• 42 Emma Stone, “Digital exclusion & health inequalities”, Good Things Foundation, 2021 https://www.goo (...)
• 43 Anca Elena-Bucea, Frederico Cruz-Jesus, Tiago Oliveira and Pedro Simões Coelho. “Assessing the role (...)
• 44 Thomas N. Friemel, “The digital divide has grown old: Determinants of a digital divide among senior (...)
• 45 Barbara Barbosa Neves, Jenny Waycott and Sue Malta, “Old and afraid of new communication technologi (...)
• 46 Leonieke C van Boekel, Sebastiaan Tm Peek, and Katrien G Luijkx, “Diversity in older adults’ use of (...)

14Education seems to be a strong factor in exclusion too, as well as competency in the English language. A Health Foundation survey reported that 9 million people were unable to use the internet without assistance. This was found to be related mainly to educational levels. The survey looked into the ability of users to download the Covid-19 contact tracing app and 71% of people with a degree said they were able to do so, but only 38% without formal qualifications could.39 So not just access but also the notion of digital health literacy is very important. Digital health literacy can be defined as the personal and social resources which need to be employed by individuals to access, understand, appraise and use information and services in order to make decisions about health and access to health care.40 Improving digital health literacy is therefore an essential tool to reduce health inequalities. Those with the poorest digital health literacy tend to be those in the disadvantaged groups we have already established: lower income, low education, elderly, minority groups, etc.41 Complexity of health systems with digitalisation requires people to be able to read health information online, use devices and be able to search online for the correct e-health information.42 Age has also been reported to be negatively associated with the use of e-services including e-health.43 Friemel (2016) explains that each additional year in age, decreases the likelihood of using e-services by 8%.44 Barriers to use of services for the elderly include both attitudinal (interest, anxiety), functional (not considered as useful) and physical factors (health difficulties preventing manipulation and general use of digital services).45 Older adult use of the Internet tends to be more basic than younger generations and the preference for older generations tends to be in person and telephone rather than online service provision.46 It should also be pointed out that this category of the population is less likely to have been in contact or need to be in contact with a computerised device than younger individuals.

• 47 European Parliament, “The rise of digital health technologies during the pandemic”, European Parlia (...)
• 48 Maria Merisalo and Jussi S. Jauhiainen, “Digital divides among asylum-related migrants: Comparing i (...)

15Other categories of the population that may suffer from the digital divide are minors, disabled people, those with serious illnesses or mental disorders and recently arrived migrants or immigrants.47 In the UK, a disability digital divide was found to be significant among refugees, displaced people and asylum seekers,48 and this divide has increased since the outbreak of Covid-19.

• 49 Hannah Holmes and Gemma Burgess “Digital exclusion and poverty in the UK: How structural inequality (...)
• 50 Sabrina Bunyan and Alan Collins, ”Digital exclusion despite digital accessibility”, Tijdschrift voo (...)
• 51 Amy Bach, Gwen Shaffer and Todd Wolfson, “Digital human capital: Developing a framework for underst (...)
• 52 Pierre Bourdieu,. “The social space and its transformations Distinction: a social critique of the j (...)
• 53 Gabe Ignatow and Laura Robinson, “Pierre Bourdieu: Theorizing the digital”, Information, Communicat (...)

16Holmes and Burgess (2022) underline that poverty can have a significant impact on digital exclusion. They posit that the pandemic has raised the stakes of exclusion and drawn more attention to it.49 Bunyan and Collins (2013) found that low income households have a decreased likelihood of having Internet connection at home compared to higher income households50. Other research has also shown that digital exclusion is less linked to motivation or skills levels and more related to poverty and structural inequalities51 In the literature, there has been significant attention given to digital exclusion owing to socio-economic status and class, based on Bourdieu’s class habitus concept. This relates to the internalisation of class conditions and the impact it has as a result of an individual’s position in society.52 More recent publications have used this idea and extended it to what they have called a digital habitus.53 This concept relates to how individuals use IT resources according to their social status and scarcity of resources but also, more generally, the usage which is related to social status and being in society. It can also depend on quality of access and necessity. Those from lower class backgrounds will only tend to engage with IT if it is absolutely necessary. Related to level of usage and poverty is housing. Adequate infrastructure is essential to avoid exclusion.

• 54 ONS, “Coronavirus and the social impacts on disabled people in Great Britain”, February 2021 https: (...)
• 55 Joseph Rowntree Foundation, UK Poverty 2020, Online. 2021. https://www.jrf.org.uk/report/uk-poverty (...)
• 56 GP Patient Survey Infographic 2020 and Analysis Tools; Emma Stone, “Digital exclusion & health ineq (...)

17During the pandemic, and with increased pressure to use technology to manage health care, disabled people reported that the lack of skills and home support for the use of technology had an adverse impact on their health (35% of disabled people reported such effects).54 Poverty and disability are often linked. Half of all those living in poverty either have a disability or live with somebody with a disability.55 They have significant expenses linked to their disability and lower rates of employment. Many disabled people also receive state benefits. They may also have lower levels of education and skills. It has also been found, from analysis of GP Patient Survey data, that Black, Asian and minority ethnic communities have also had significant issues using online GP services.56

• 57 Hannah Holmes and Gemma Burgess “Digital exclusion and poverty in the UK: How structural inequality (...)
• 58 Martyn Frank Warren, “The digital vicious cycle: Links between social disadvantage and digital excl (...)
• 59 Ibid.

18Digital exclusion also evolves over time as technological advances become more significant.57 This means that those who are only introduced to digital devices very much later in life, or unable to adopt technologies, may be left behind, especially faced with new digital processes.58 As Helsper (2017)59 underlines, digital exclusion is neither an individualistic nor fixed condition but changes according to evolving structures and processes.

• 60 Adam Tinson,. Living in poverty was bad for your health before COVID19, The Health Foundation, 2020 (...)
• 61 Ofcom, “Connected Nations Update”, 15 May 2020 https://www.ofcom.org.uk/__data/assets/pdf_file/0028 (...)
• 62 Julian Tudor Hart, “The Inverse Care Law”, The Lancet 297(7696), 1971: 405–412.

19The move towards online services since the pandemic, apart from highlighting digital exclusion, has also brought to light how digital exclusion and health inequalities are related. Those who have had to shield and self-isolate are those who are most at risk and have become excluded. People who are most in need of health services are those who are digitally excluded (either offline or have difficulties navigating health services online). The link between poverty and lower health performance has been well established. The bottom 40% of households in terms of income are twice as likely to report bad or very bad health compared to the top 20%.60 So health inequalities and digital exclusion are both linked to poverty levels. There are no national datasets to link digital exclusion, access to digital healthcare and health inequalities, however it is possible to link health inequalities to poverty levels and then make correlations with the same populations suffering from digital exclusion.61 Such factors therefore reinforce already existing inequalities in access to essential services. There is thus concern that there may be a digital inverse care law emerging. Such observations are based on Tudor Hart’s 1971 observation that disadvantaged groups who most need health services actually have the most difficulties accessing those services.62 This would seem to be even more so the case in the digital age.

• 63 Qualitywatch/Nuffield Trust, “The remote care revolution during Covid-19”, 2020, https://www.nuffie (...)

20A specific example of how these disadvantaged populations suffer from exclusion in England is in relation to the triage system, which was introduced during the first lockdown in spring 2020. Following guidance issued by NHS England, GP practices have started to put in place a “total triage model”. Patients are triaged remotely by telephone or online by a doctor. Doctor’s practices should only proceed to face-to-face appointment when it is considered to be necessary by the physician treating the patient and otherwise prioritise telephone or online consultations. This led to 48% of appointments being carried out online in April 2020 compared to 1 in 10 between January and March 202063

• 64 Healthwatch, “Locked Out: Digitally Excluded People’s Experience of Remote GP Appointments” https:/ (...)

21A survey carried out in 2020 which included interviews with vulnerable populations flagged up a number of issues with the new system and barriers to health access.64 First of all, the need to access the online video conferencing platform Zoom represented an additional barrier especially for older participants who were not interested in using technology or prioritising new skills. Online communications were also considered to disrupt the relationship between the doctor and patient with the online experience being impersonal. Older participants who do not use the internet or mobile phones found manipulation of new systems difficult. Significant reliance on family and friends thus became necessary to book and attend appointments, which also led to privacy issues. Sometimes technology would work on one occasion but not the next, resulting in reduced confidence especially again for the elderly and other vulnerable populations. Difficulties to explain digital devices across generations was clearly an issue.

• 65 Ibid.

23Access and affordability issues were also raised as barriers to the effectiveness of the triage system. Older versions of mobile phones and computers were not effective enablers of digital interactions, which meant that upgrades to newer devices may be necessary. Moving to digital services for all populations has meant it is very difficult to get an appointment especially for those who try to book appointments online because they are unable to use or manipulate the AskMyGP app. Overall, the message from this survey, which interviewed both vulnerable people and carried out more general interviews, was that whether people preferred remote appointments or not, because they encountered difficulties, they should be allowed to choose the form the appointment takes (online or face to face). From the health care providers’ point of view, however, this may raise issues of organisation. A massive shift to online services has enabled GP practices to work more efficiently, save time and allow for forward planning.65

• 66 Ibid.

24Following the survey, several recommendations were made to improve the triage system. The overall recommendation was that there was a need to have more support from staff for patients who have difficulty using digital tools. NHS guidance specifically indicated that support should be available when this system was introduced. Providing easier access to face-to-face consultations for vulnerable populations is essential. Proactive responses from practices need to be offered for making remote appointments. Practices should respect patient choice for face-to-face care.66 The present author would also recommend that vulnerable persons or, at least, those with recognised disabilities, should be able to bypass the phone or online access phase. They should be able to simply state their disability and be fast-tracked to an in-person appointment if this is their preference.

• 67 HM Government, “Get help with technology” https://get-help-with-tech.education.gov.uk/ (2021); Hann (...)
• 68 DCMS (Department for Digital, Culture, Media and Sport). "Digital Lifeline: A qualitative evaluatio (...)
• 69 DCMS (Department for Digital, Culture, Media and Sport), “No Longer Optional: Employer Demand for D (...)

25Solutions to alleviating digital exclusion have been the focus of government policy, with the distribution of laptops and data routes to disadvantaged school children and the promotion of social tariffs for broadband in low income families.67 One of the main policies that the UK government has put in place is Digital Lifeline, which has been set up by the Department for Digital, Media and Sport to assist people with learning disabilities to make the transition to online services.68 The charity Mencap has also set up support via the Digital Unite and Good Things Foundation, providing devices and training in digital skills for people with learning disabilities. In addition, the government has established an Online Media Literacy Strategy to help the disadvantaged navigate online. The National Strategy published by the Department for Work and Pensions, the Disability Unit and the Equality Hub in July 2021 makes access to public services a priority and includes policies to improve accessibility to digital services.69

• 70 Emma Stone, “Digital exclusion & health inequalities”, Good Things Foundation, 2021 https://www.goo (...)

26In addition, the Widening Digital Participation programme was created to help people develop skills to access information and services online. Such a programme was run even before the pandemic. The first phase of the programme ran between 2013 and 2016 aiming at improving digital health literacy in local communities. Phase 2 ran from April 2019 to March 2020 and looked more deeply at the barriers to accessing information and services online. It explored how these barriers could be overcome in a more holistic fashion. Online learning contact was made available free of charge, awareness campaigns were led and digital “Pathfinders” developed to co-design and deliver services for those who were digitally challenged. Some of the underlying conditions which affected access were related to trying to deal with the more complex socio-economic conditions of users such as homelessness, substance abuse, older people with care and support needs, etc. The programme also incorporated “digital health hubs” and specific interventions. For example, Seaview, which provides support to the homeless and insecurely housed, intervened via their outreach workers by taking photos of injuries and sending them to St John’s Ambulance for a clinical opinion. The outreach staff at Seaview found that tablets and equipment provided as part of the Pathfinders project helped this charity provide more effective health services online. Other pathfinders were conducted in the 999 Club in Lewisham and Addaction in Wigan and Leigh with similar success stories. Associations supporting asylum seekers and refugees, who apart from poverty issues often need language support, were included in this initiative. For example, Ashra, a charity based in Stoke which assists asylum seekers and refugees who suffer from significant economic, social and language barriers was able to use the Digital Health Peer Support to train refugees and asylum seekers to access services.70

• 71 Hannah Holmes and Gemma Burgess “Digital exclusion and poverty in the UK: How structural inequality (...)
• 72 Siobhan Stevenson “Digital divide: A discursive move away from the real inequities”, The Informatio (...)

27However, as Holmes and Burgess (2022)71 underline, digital exclusion is treated in exclusivity to other problems. Other issues related to online and offline inequalities in health need to be addressed more holistically. The authors recommend focusing on health inequalities in a broader setting to include other issues such as housing inequalities and welfare support. The authors argue that focusing on digital exclusion in isolation is part of a more general neoliberal ideology to distract attention from more general structural inequalities (Stevenson 2009; Holmes and Burgess 2022)72. This argument is justified by underscoring that solutions are often market-led responses. Some policy proposals by charities in England were rejected by the government, such as social tariffs for Wifi, because it was considered to interfere in the supply and demand of the market. The government considered that market competition for Internet access already allowed for the supply of affordable broadband. The authors conclude by reiterating that it is important to consider the broader aspects of inequality including the spatial, material and temporal dimensions related more generally to housing inequality and poverty.

• 73 Mind (2020) Briefing from Mind, https://www.mind.org.uk/media/6693/briefing-digital-services-during (...)

28The charity Mind has made several recommendations regarding exclusion of those with mental health issues, but in fact they could apply to all excluded and vulnerable persons. Mind notes that professionals should consider that remote services may make interaction difficult and obstruct care provision. Therefore, they recommend offering in person support alongside remote services. Outcomes of services provided online should be carefully monitored. Lack of access to health services during and after the pandemic should also be carefully monitored by NHS England. More research and efforts should be made to reduce digital exclusion by the government in the long term (Mind 2020)73. Unfortunately, few recommendations have been put forward to solve the digital divide for the disabled. The major problem is that this covers a very heterogeneous group. More tailored services and interventions are therefore necessary for disadvantaged groups.