How do we improve inclusion in the age of digital health?

Christina Sothinathan, Clinical Transformation Fellow at NHS England and Improvement (London) and Clinical Lead Physiotherapist & Advanced Practice Physiotherapist at King’s College Hospital, is part of the current cohort of the DigitalHealth.London Digital Pioneer Fellowship programme. In this blog, Christina shares her thoughts on ensuring inclusion in a post-pandemic NHS.

Before the pandemic, I was a Physiotherapist working in the NHS with a passion for digital innovation. Although the NHS Long Term Plan recommended digital solutions, it wasn’t until the pandemic that rapid implementation occurred. Digital solutions have shown lots of benefits but ensuring inclusion continues to be a challenge. As we move forward in the NHS post pandemic, we must bring patients and staff along the journey with us or risk leaving them behind.

Introducing video consultations

As far back as 2013, we started to do pre-appointment online screening and I’ve always been inspired by the work of Melanie Martin in remote monitoring of rheumatology patients as well as Ben Wanless’ adoption of the GetUBetter app and I have been keen to implement similar digital health solutions.

I started work on video consultations in 2019 and my own experience has been very positive with patients reporting high levels of satisfaction in a local service evaluation. I often used virtual appointments to enhance triage and I experienced patients with severe anxiety who would not normally leave their homes therefore this suited their needs. Patients frequently expressed a reduced financial burden associated with virtual appointments, particularly where employers would not provide paid leave to attend hospital appointments and this commonly affected patients who work in lower paid industries such as care homes. Given the significant financial burden of attending appointments for these patients, I would often wonder what value I was adding and whether the same quality of care could be delivered virtually. With examples such as these, I felt providing virtual appointments were improving inclusion.

Dealing with digital exclusion

Whilst virtual appointments were beneficial for many, I became aware that not all my patients could access these due to lower levels of digital literacy, lack of device or internet leaving the only option being a telephone appointment. With higher satisfaction levels for video compared to telephone consultations by both patients and clinicians, digital exclusion became a reality and reflections cited by Anthony Gilbert et al resonated strongly with me. Some clinicians expressed their preference for face-to-face appointments despite a significant proportion of patients preferring virtual over face-to-face appointments (see graph). I overheard clinicians stating they didn’t feel like physios anymore and their job felt like working in a call centre therefore affecting their sense of professional identity. This made me worry about our future workforce.

In my new Transformational role within NHSE/I (London Region), I am keen to grow innovation whilst ensuring inclusion. Exploring barriers as well as co-designing solutions will be essential including digital hubs as piloted by Dr Annie Murphy. In addition, enhancing personalised care within virtual appointments to mirror face-to-face appointments may improve patient and staff satisfaction. My experience highlighted variation in clinician enthusiasm when delivering virtual appointments and patients have described the ability of a clinician delivering a virtual appointment as a skill. There is no doubt that supporting clinicians with resources and digital competencies such as Chris Tack’s Framework will go a long way in addressing workforce challenges. Joining the Digital Pioneer Fellowship has allowed me to connect with leading innovators across the NHS, to share experiences and learning in co-design and optimising implementation.

The balance of innovation and implementation is challenging and as we have experienced over the last year, sometimes it is best achieved under immense pressure such as a pandemic. With growing demands on the NHS, it is important we continue to innovate post-pandemic and my personal experience tells me we may need to push people out of their comfort zone to achieve true innovation.

The increased use of digital technology offers an opportunity to expand digital solutions whilst simultaneously ensuring inclusion. Although addressing healthcare inequalities is a priority for the NHS, finding solutions is proving challenging. The real question will be, in a fast-moving world of digital solutions, just how far are we willing to truly grow innovation at the risk of leaving people behind?

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