NHS Choices may increase inequality

Tags: Choice Community GPs NHS Choices

22 Jun 2009

Relying on online sources such as NHS Choices to deliver information to patients could lead the NHS to sustain or even increase health inequalities, a new report warns.

The authors says the government’s policy is to give patients better access to information but that the internet may not be the most effective way of doing so.

The report from Birmingham University’s Health Services Management Centre, Supporting patients to make informed choices in primary care: what works? , says that older people, ethnic minority communities and those on lower incomes are most likely to have literacy problems and least likely to use the internet.

Jo Ellins, the report’s author, added: “Evidence shows that alternative ways of delivering information are far more successful at reaching these groups. More effective alternatives include telephone helplines, digital television and community education programmes.”

The report says around one in five British people do not have basic literacy and struggle to read and one third of households do not have a home internet connection and are therefore unable to access or understand information which could help them choose and use health services effectively.

Ellins added: “The way in which this information is provided restricts opportunities for informed choice to more educated and affluent patients. There is a very real danger that this is sustaining or even increasing health inequalities.”

The report also concluded that many health professional are not signposting patients to reliable sources of information.

Shirley McIver, co-author of the report, added: “Some people will need support to help them find, understand and use information about local services. While GPs are ideally placed to provide this help, our research found that many are not doing so.”

Links

Supporting patients to make informed choices in primary care: what works?

Fiona Barr

Reader's Comments

Lazy thinking

22 Jun 09 17:06

This sort of lazy thinking drives me nuts: some people can't yet use or access a virtually free and omnipresent media, so lets scrap it and go for carrier pigeons with translations into pictures and 20 languages instead….

In two years, NHS Choices has grown from 1m to 7m visits a month, making it by far the biggest health info site in the UK. More than 90% of its users say they would recommend it to a friend and its user profile is heavily skewed towards women (who manage family healthcare) and the working (rather than middle or upper) classes. In addition to written articles, it has video and audio for those who find words difficult. Its bright, easy to use and attractive… and it’s the first time the NHS has ever had a proper ‘front door’ through which people can access all the info they need on keeping healthy, choosing hospitals, treatments etc – and all within just a couple of clicks.

So might NHS Choices widen health inequalities? I very much doubt it. And certainly there is no evidence for that. The NHS has an army of doctors, nurses and care workers on the ground throughout the country. Surely the one in five who it’s claimed (but not proved) may not be able to access websites will be picked up by these guys – indeed that’s what they are there for.

And what about all those 7m who we know are now being better informed about their health by NHS Choices every month? Might they not be passing on what they have learnt to the less able? Might in fact services like Choices gradually be raising people’s understanding of health overall? Might they actually be reducing health inequalities? Already its Behind the Headlines news service seems to have taken the spin out of a lot of tabloid news coverage, for example.

The latest market research on Choices shows that two thirds of its users are not sick themselves. Instead they are looking up info for less able dependents, relatives and friends who are… mums looking for info on angina for doddery father in laws; second generation immigrants looking for information for their non-english speaking parents; teens checking up on safe-sex advice their parents have failed to impart….

Just because 1 in 5 struggle with literacy does not mean that digital services like NHS Choices will widen inequalities. As Ben Goldacre puts it in his book Bad Science: the reality is just a little bit more complicated (and interesting) than that…

Lazy thinking! - the bleeding obvious

NHS.Patient@ntlworld.com

23 Jun 09 01:06

Of course "Choice" increases inequality, that is its purpose.

Those better able to make judgements are empowered to get a better service. Those who do not, carry some of the responsibility on themselves for making a poor choice.

If all is equal, then choice is meaningless!

Alice in Politicsland

23 Jun 09 12:06

A. Equality of provision at national level / NICE / elimination of 'postcode' prescribing etc.

B. Commissioning of services at PCT or Practice Level

C. Patient choice

Your mission...

1. Reconcile these three mutually exclusive policy goals

2. Build a single computer system which integrates the myriad of organisations charged with delivering them - and deliver all three

P.S. Make sure you achieve this before the next General Election

P.P.S. Any edict or NHS organisation can be changed, reorganised or boundaries redrawn at a soundbite's notice.

Olde Theme

24 Jun 09 08:06

This social problem was discussed, in depth, using BT data models from real trials and supporting trials from canada and sweden in the 1990's for my degree.

There's nothing new here -just someone re-hashing something which we already know and consuming NHS cash to do so.

Digital Exclusion

24 Jun 09 08:06

It is completely unacceptable to increase health inequalities by favouring those who are well-off and well-educated. If internet based information is to predominate, then the NHS must put significant resources into enabling internet access and use by those who are currently digitally excluded. Whilst the Digital Divide is closed then alternative ways of obtaining information have to be maintained.

Hitting the right target

24 Jun 09 12:06

The government is already trying to bridge the digital divide through a range of other policies which may or may not be effective. It's most certainly not the job of the NHS to do this. Like many people, I'm convinced that the choice agenda will exacerbate inequalities. But I think the role of the Choices website in all this is actually quite marginal.

Setting aside the parts where you can compare Trusts (apparently usage is extremely low), most of the general health information is very good. It's really useful to have it provided on the web, because most people that are going to use it, will already be connected. The problem is that some people won't use it no matter how easy it is to access, because there are a range of other barriers (usually social and educational) preventing them. But again, it's not the job of the NHS to solve people's social and educational problems.

Information for all

roger.hook@nuneatonandbedworth.gov.uk

24 Jun 09 14:06

It is the job of the NHS to ensure that information about its services, and how to access them, is available to ALL. Providing information only in a way which is known to exclude a major portion of the group which needs the NHS most (older people) is a dereliction of duty. Either information must be provided in other ways, or internet access must be facilitated for older people. Otherwise, the internet becomes a new and iniquitous means for rationing services.

Heads in The Cloud

24 Jun 09 16:06

“Give a man a fish; you have fed him for today. Teach a man to fish; and you have fed him for a lifetime”

There are a few hundred social determinants of health to consider before broadband internet access for pity's sake! Is this merely gov.uk's version of "never mind the cholera, here's a laptop".

If you have a reasonable level of literacy, housing, mobility, a job etc. you organise the broadband yourself!

My personal opinion is that "Choices" is primarily eye candy for the worried well in the voting classes.

I suggest our resident armchair socialists ask people who actually step foot inside today's NHS (patients or workers) whether they want spending on Web 2.0 gimmickry or on more capable staff and non-virtual facilities.

Roger Roger

24 Jun 09 17:06

I think I'm with you most of the way Roger. But given that the government is already spending lots of money on things like the People's Network, Learn Direct centres, and providing free computers to excluded groups, it seems a bit over the top to suggest that the limited NHS budget should be used to do this too.

On top of that, I'm highly sceptical that even if the NHS managed to ensure people had access to this information, the choice agenda would still exacerbate inequalities for a whole host of other reasons.

Piecing together information from a variety of sources, I'm pretty certain that most people don't want to shop around for their healthcare - they want to be able to go to the nearest hospital that the service is available and be sure that it will be clean, efficient and that the staff will be polite and helpful. I'll bet that's the case in Nuneaton and Bed'uth too.

So why is that so difficult to achieve?

Reducing health inequality

roger.hook@nuneatonandbedworth.gov.uk

25 Jun 09 11:06

The NHS has as one of its key policies "the reduction of health inequalities". If some of the ways in which it does things are actually exacerbating inequalities, then it has to address the issues which are causing that inequality. In this particular case, it is for the NHS to decide whether to offer suitable alternatives for non-internet-savvy paitents or whether to enable them to become internet users. But it cannot simply ignore the issues as if they were irrelevant, or "someone else's problem".

It is worrying that some of the wider messages about health promotion seem to have missed some NHS Practitioners!

Compare to paper

26 Jun 09 11:06

OK, so not everyone has a computer, or finds their way to the library, or has the skills to drive a web-browser. But in my area silver surfers are a very active phenomenon, and there are these other initiatives to increase Internet access and confidence for the population at large in a variety of community settings.

Yes they may be predominately the worried well, and have some money, but there are other people - advocates, relations, even NHS staff who can print some of this information out, and we all get sick irrespective of literacy or income.

The alternatives seem to be paper leaflets, or long face-face discussions. Paper leaflets fall out of date all the time (or stock runs out, or is not everywhere), and there are studies that show patients don't remember much of what they are told, and need time to reflect and raise follow-up questions.

It is important to try and ensure that we meet the needs of all, but surely the NHS should also support the majority who do either have access, or the motivation or support to go somewhere that has access to the Internet. The explosion of information that is "out there" is a phenomenon.

I'm lukewarm about NHS Choices, but for shopping, holidays, diy, gardening, all sorts of things, much of the population now uses the Internet as their first port of enquiry. Why not health, and why should the NHS not seek to improve the health of those who can access too ?

Choices branding

26 Jun 09 11:06

Anyone see the brief piece about Choices on page 8 of this weeks HSJ? Apparently the DH are thinking about how Choices branding 'fits' with NHS Direct. Could it be that NHS.UK becomes NHS Choices, takes over the NHS Direct website, then...goes back to being NHS Direct?

The wheel of politics turns...

information at the point of care

glen.griffiths@interactivhealth.co.uk

26 Jun 09 16:06

.. which for the majority is at their General Practice.

Providing a Practice Portal allows Doctors to stay ahead (or at least alongside) the information curve by providing a validated source of information from a variety of trusted sources including but not exclusively NHS Choices.

This example www.htmc.co.uk - Haughton Thornley Medical Centres in Hyde, Cheshire provides a comprehensive gateway to Health and other useful information with links to local as well as national resources. The site also supports patients who have opted in to accessing their full health record online as well as other online services often discussed in these pages

The portal directs patients and the public to information from hundreds of sources and all within the Practice context.

Information sources include BBC Health, patient.co.uk, Map of Medicine, Citizen's advice bureau, Greater Manchester Transport, NHS Choices, Health Protection Agency and local hospitals as well as highlighting Practice performance with QOF data. Links to Choose and Book with supporting information written by patients is also provided.

I would agree with some findings of the report that helplines as well as other forms of information delivery are important for those people who are not online however we must also take into consideration the role of friends and family in the dissemination of information.

The final para of the EHI piece included this

"The report also concluded that many health professional are not signposting patients to reliable sources of information.

I would suggest that htmc is a good example of where this has been done and the uptake and acceptance of the site by patients has been very good.

Declaration of interest: My company developed the Practice Portal platform used by htmc and also collaborated on the initial information provision. Content on the site is fully managed by the Practice.

glen griffiths interactivhealth plc

health2.0 for good measure

glen.griffiths@interactivhealth.co.uk

29 Jun 09 12:06

re: Information at the point of care;

I should also have mentioned that htmc.co.uk also promotes http://www.healthtalkonline.org/ and http://www.youthhealthtalk.org/ which are both excellent resources for patients to share experiences on particular conditions - this service is provided by DIPEx. There is also a moderated blog for the Practice as well which patients and the public can participate in.

According to the Picker Institute in their 2007 report 'at a crossroads without signposts', there are reported to be in the region of 60,000 sources of health information in the UK - the vast majority of which have a web presence. General Practices that provide good signposting also then have the opportunity to print out information available from the web for their patients who may not themselves be on-line or able to use the web. I re-iterate the role of family and friends in the dissemination of information and potential increase in health literacy.

glen griffiths - interactivHealth