Covid-19 is magnifying the digital divide
The covid-19 pandemic has precipitated a digital boom in healthcare, with radical digitisation reported in countries around the world.  As the initial peak declines, the NHS is relying on technology enabled remote solutions such as telephone and video consultations to play a key role in returning non-urgent services to pre-pandemic capacity. 
Most GP consultations are now remote, primarily via telephone, but with a significant minority via digital pathways such as online text or video, though the latter is likely to be an underestimate due to poor data quality. [3,4] While this may support social distancing, infection control, improve service efficiency and expand healthcare access for some, it will undoubtedly exacerbate marginalisation of some already-vulnerable groups. Even before the pandemic, there was evidence that moving services online disadvantaged certain population groups. 
Although penetration is high, 7% of UK households remain without any internet access.  The most financially vulnerable are particularly excluded: 29% live in households without internet access, 12% have fixed-line telephones only, and 2% don’t use any form of telephony, preventing access to text messaging, video or even telephone consultations. Additionally, the most recent data show that internet non-users are disproportionately disabled, women, and aged over 75. [5,7]
Social factors including insecure housing and domestic abuse also undermine remote healthcare delivery. In England, approximately 3.65 million people live in overcrowded accommodation, and around 400,000 are homeless, or at risk of homelessness.  Unsuitable accommodation can mean a lack of private space for consultations, while many rough sleepers never access the internet and most do not go online for health purposes despite generally high phone ownership.  An estimated two million people experience domestic abuse, and only 1 in 5 surveyed survivors said their online activity was not monitored by their partner. 
Shifting to digital services also assumes people have the skills and ability to engage. The most recent figures available estimate 10.7 million people in the UK have limited or zero digital skills, and 20% of households without internet cite this as the reason.  Further, 1 in 6 (16.4%) adults in England and Northern Ireland have “very poor literacy skills” , and 0.9 million people cannot speak English well or at all. [11,12] This poses obvious challenges if patients are required to read anything other than simple text or graphic information, or complete online questionnaires. Moreover, there are 1.2 million people with a learning disability in England who may equally struggle with information in digital formats. 
Though decreasing, one in ten people still have difficulty paying for communications services, particularly younger consumers and those with long-term mental illness.  Counter-intuitively given people with disabilities are more likely to be unemployed, financial constraints are a major barrier to those with sensory impairment accessing assistive technology. [14,15].
Finally, among many already-excluded groups, the perception they do not need to engage digitally is a significant barrier in itself: 61% of households without internet access say they do not need it, highlighting that exclusion is defined by cultural and behavioural factors too. 
Digital exclusion will only ever affect a minority of patients: most will embrace new ways of accessing healthcare and benefit from the change. For example, geographically isolated rural communities; those in insecure employment who may not be able to take time off to attend appointments in person; and those with mobility issues for whom travel is difficult, are likely to benefit.
Nonetheless, it is clear that some will be significantly disadvantaged by the expansion of remote pathways, and the NHS has a legal duty to reduce health inequalities across nine “protected characteristics” including age, gender and disability, as well as dimensions such as socio-economic inequalities and educational attainment. Solutions to reducing digital health inequalities must first start with healthcare commissioners and, separately, providers gaining an accurate understanding of the communities they serve to identify vulnerable groups and quantify potential exclusion. Second, they will need to identify mitigating actions to level-up health outcomes across these groups. Finally, they must work at scale (e.g. integrated care-system level), and in close partnership with excluded communities, to identify issues of inequality, and co-design meaningful and sustainable solutions. Examples of approaches implemented to date include digital skills training and donation of unwanted devices by businesses and other organisations to excluded groups. [16,17].
While rapid service-redesign decisions were initially required, the on-going covid-19 crisis cannot justify ignoring the need for equalities impact assessments: the experiences of black and minority ethnic (BAME) communities underscores the fundamental importance of an equitable approach. Messages urging people not to attend medical services in person, but instead seek online or telephone advice, may already have disproportionately excluded the digitally-disconnected population. It is now vital that health systems across the world assess the specific needs of vulnerable groups to mitigate any potential for either creating or exacerbating health inequalities.
Azeem Majeed, professor of Primary Care & honorary consultant in Public Health, Department of Primary Care & Public Health, School of Public Health, Imperial College London
Edward John Maile, NIHR academic clinical fellow in General Practice, Department of Primary Care & Public Health, School of Public Health, Imperial College London
Sophie Coronini-Cronberg, honorary senior lecturer, Department of Primary Care & Public Health, School of Public Health, Imperial College London
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.
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