As digital health technology becomes more widespread, is it truly advancing equitable access to healthcare or widening existing gaps? Should technology itself be considered a social determinant of health?

In this thought-provoking webinar, our panel of experts will examine the impact of healthcare technology on equity through the case study of wearables. Do these innovations empower individuals and communities with real-time health data to live healthier lives, or do they unintentionally contribute to health anxiety, strain healthcare systems, and deepen disparities in access? Join us to explore the promises and pitfalls of wearables in the digital health revolution.

Experts:

• Sam Shah, CMO, The Ivory Clinic
• Elizabeth Anderson, CEO, Digital Poverty Alliance
• Stefan Buttigieg, Specialist in Public Health Medicine, Ministry of Health and Active Ageing in Malta
• Adam Abbs, Medical Director, Hurdle
• Keyrellous Adib, Technical officer, World Health Organisation

Transcription:

Welcome to this webinar as part of the series hosted by BMJ Future Health. I'm Sam Shah and I'm your host for this episode. Thank you for so many of you joining both online and of course, I'm here at BMJ at BMA house in the studio.  BMJ Future Health brings together the ecosystem to engage in the rapidly changing world of digital health. 

Their mission is to bridge current gaps between problems faced out there in society and the solutions that are available and that can be delivered.  You can join us in person on the 19th and 20th of November at the conference that BMJ Future is hosting.  In this episode, we're going to focus on the public health dimensions of technology.

Is it excluding? Is it empowering? Hopefully, by the end of this session, you'll be able to tell us what you think, and you'll have heard from some experts on their views on this important topic that affects us, not only in Europe, but of course, globally.  I'm joined today by some experts from around the world, and they really are representative of the ecosystem.

They're policymakers, change advocates, Industry leaders, and of course, agitators,  will be considering whether technology should be considered as a social determinant of health. I'm joined today by my esteemed panel, Elizabeth Anderson from the Digital Poverty Alliance, Kerala Siddib from the World Health Organization, Stefan Buttegig, who is from the Ministry of Health Malta, and Adam Abbs, who is an expert and leads that comes to us from Hurdle. 

A warm welcome to my panel. And just to get us started, I'd like to bring each of you in just to introduce yourselves and describe a little bit of what you do and I guess why this topic is important to you. Just to start us off, Elizabeth, I'd like to bring you in. And of course, you're joining us from the Digital Poverty Alliance.

And the irony is not lost on me today, that we are all joining on a webinar with probably some of the best tech and kit going. And we're here speaking about inequalities in health and technology. Elizabeth Overtune,  please welcome.  

Thanks so much, Sam, and absolutely fantastic to be part of this webinar and part of this wider series looking at where digital fits in to health. 

The Digital Poverty Alliance is a charitable institution. We are working with government, we are working with local authorities, we're working with charities, we're working with health trusts, companies, big and small, all towards a shared goal of ending digital poverty. Once and for all, whether that's around affordability, infrastructure, skills, and much more.

We do this through advocacy, and we also do this through direct delivery. So we talk to thousands of people each year about how digital poverty is affecting them in a range of different areas, growingly, including how they access healthcare here in the UK. So I'll dive into that in a little bit more detail during the conversation, but hopefully that gives you a flavour of what we're doing.

Thank you, Elizabeth. It really seems like you are in an organisation that is listening to the needs and views of the people closely affected by this issue. But another organisation that does lots of listening at a global level is the WHO. And Carolus, would you like to introduce yourself and tell us a bit about yourself, your work, and I suppose what it is about digital health that's important to you? 

Thanks,  my name is and I'm a technical officer for data science and digital health at the European regional office. This office says 53 member states, not only the EU, but also some other countries in Western Asia and Central Asia. When we refer in. My talk to W2 Europe or Europe that's going to be including the 53 member states.

That's a disclaimer. Our work as a team is mainly about data evidence and digital health. So like the whole continuum, basically from data and data governance all the way to AI and AI governance. Our areas of focus is basically. Setting guides norms and standards, and this is 1 of the main activities and I will touch today on 1 of the scoping reviews regarding the equity in digital health and capacity building and net.

Building new networks, which is the third, and the fourth is main, mainly horizon scanning and scaling up. So we look into what's working, what's not working, what's not working, et cetera.  

Fantastic. Very much looking forward to hearing, especially about those things that may not be working for how we solve them.

For somebody who likes solving lots of problems and is never short of any words. Stefan, please introduce yourself and not only your work in Malta, but your work across Europe please.  

So hi, everyone. I'm not your typical doctor, of course. So  I have a medical doctor. I'm a medical doctor by background. But of course, then I decided to explore the public health world because there isn't like a specific digital health specialty in medicine.

But this journey basically brought me as well in connection with the European Public Health Association, where I'm lucky enough to be the vice president. On the section of digital heads and artificial intelligence. And over the years, I've been involved in multiple organizations, multiple meetings, really discussing the impact  of digital health as well on public health as well on global health.

Here I am to really share a bit of that part of the journey and to see how that's also fit in a local context where I work as the manager of the national contact point for E Health.  within the Ministry for Health and Elective Aging. Back to you, Sam.  

Thank you, Stefan. And Adam, last but not least, please introduce yourself and share with everyone what it is you do, but also a little bit about the expert series that you curated for the BMJ. 

Thanks, 

Sam. So I'm Medical Director at Hurdle, and Hurdle is a company that aims to make biomarker testing more available to people. So moving testing away from hospitals and healthcare institutions into people's homes.  . At Hurdle, I'm responsible for ensuring the safety and medical appropriateness of that service.

I'm responsible for everything from the test request all the way through to the test result. My background is in remote consultations and digital health. I'm proud to say that predated COVID-19. And I'm also a GP working in the NHS and I also wrote the remote consultations education  program on on BMJ Best practice.

At some point in our discussion, I'd like to come back to that, because that is the very junction of telehealth inequalities. So I do hope we can talk about that a bit more, and what it is that you can do to support colleagues in solving that, especially when we think about the people that Elizabeth knows only too well. 

With that, I'd like to start our conversation, and Elizabeth, come over to you first of all.  I guess as a starting point, Digital poverty. Why does it matter? And what is it really? Because we might all have conceptions of it.  What is it from your perspective?  So when we talk about digital poverty, we use a definition around the inability of an individual to access online services when, where, and how they need to. 

And actually all of those words are really quite carefully Chosen. So if you think about maybe you're on this webinar, as Sam, you said, everybody here is all techied up, we've got all the kit we need,  but if you took a piece of that puzzle away, so you didn't have the internet at home or you didn't have a device and you needed to travel somewhere, you could only do that at certain times a day when that happened to be open and whether that meets up with when you can get somewhere, for example, or when you need to access a service,  those locations and that timing. 

And how you need to do that is an app better, is a keyboard device better, do you need to be filling in a long form, which is going to be laborious if you've only got a tiny little, quite ancient smartphone.  So it's that inability to access these digital services when, where and how you need.  And there's lots of different pieces to it.

There's the affordability of kit and connectivity. So you've got to buy your device in the first place. You've then got to pay either for mobile data or broadband data.  We are talking to older people and families regularly who can't afford broadband anymore. So they are ending up just on mobile, which of course can run out mid month. 

We've got infrastructure challenges within there as well, so if you're in an area even within the UK that doesn't have strong internet connectivity or has a really poor mobile signal, that's another consideration.  And then there's the skills, there's the confidence, there's the trust. And there's also the accessibility of services.

Are they built to meet the needs of all users? So there's lots going on in there. Around 19 million people are impacted by this. So this is a big scale. We're not talking about just a handful of individuals.  And when we think about those people who are affected by digital poverty,  paint me a picture of who, who I should be thinking about when I have to characterize what somebody might be, because we've got lots of people online who are going to be listening to this and watching this.

And by the way, those people joining us online, feel free to post your questions in the Q and A, because I will be coming to you a little bit later on. and posing your questions back to our panelists. So do feel free to pose them. But and of course the rest of our panelists will also interject as we go through this.

I think about who those people are and if I'm seeing them in my practice or out there who am I looking for?  So one of the big things to remember is actually it could be anyone, so lots of people are affected in a variety of different ways. Whilst it is a bit of a cliche, older people are actually the most impacted by digital poverty, and remembering often it's older people who are most accessing health services, that's incredibly important. 

The next most impacted age group are young working age adults, so people who've just come out of the education system. are actually the second most likely to be in digital poverty.  But generally speaking, it is people who are on low incomes, people who are unemployed, half of the people in the UK who are in  either low income jobs or supported by the state.

are experiencing digital poverty and the women are up to 22 percent more likely to be in digital poverty in the UK. So it is really mixed, but if you're an older woman, for example, you're much more likely to be in digital poverty than say a middle aged man  a working situation.  Carolus, I can see you're nodding in agreement with some of the points there Elizabeth's made.

Probably a great time to bring you in and also get your reflections and perhaps some of the outcomes from the scoping review.  So I can echo Elizabeth fully. That's why I was nodding pretty much in all I have a list from from basically from the scoping review that we conducted and we looked on something, a framework called progress plus, which is place of residence and race, ethnicity, occupation, gender, education, socioeconomic status, and social capital.

And the plus is the age disability and minority group, whether like. Person falls into minority group or not. And basically, Elizabeth touched pretty much on both of the results and in even a quantitative way. That by looking mainly for this is just to give a brief introduction about the scoping reviews, scoping review of reviews.

So this kind of more of a breadth rather than an in depth review looking into 400 reviews only 22 included in the final stage. Again we use the progress with, I just referred to right now, but across 3 domains. So we looked at the access, the use and the engagement. And basically, we wanted to locate whether there are evidence around the access use and engagement across all the progress items that we mentioned.

In a nutshell to give a brief about the result  place of residence plays a big factor still and that's mainly in the use site. There's some mixed results around the access, but mainly the use and for the use is not only the Internet connectivity or the ICT infrastructure. It's also the social demographic. 

Characteristics of the people living in rural area versus urban areas and their level of digital literacy in terms of engagement. There was no evidence around engagement in that sense. And unfortunately, across pretty much the engagement section for all the items, just to avoid saying engagement and all of them.

It's either missing or it's mixed results, so we don't know much around the degree of satisfaction, for example.  For people who are older age with digital technology, and this comes to the fact, basically, if we looked at the age, which is going to be my 2nd point  is that the access is also like missing in terms of evidence, but the use we have some evidence that young people are using a digital interventions and digital services more than older people.

Although older people are. The ones who are in need for these services. It's interesting you make this point, Carolus, because if I think about all the many events and conferences that we probably all go to around health tech all across Europe and the UK and elsewhere. Whenever I am asked about surely this isn't a problem that older people can get on.

And someone will give an example that their grandparent, their relative is using the internet to go and buy something called CRGP. It almost feels like the evidence is telling us a different story. To perhaps some of the the very supportive and promotional messages i'm getting around access to telehealth.

Let's say what are your thoughts on this? Do we are we living in two different policy environments?  I would say it is different from one country to another, and this can take us to the governance part, which is the start of any discussion or like this kind of the bread and butter of what we are doing. 

It's looking into digital health inclusion plans, whether basically while having an overarching digital health strategy in the country, is there is a measure of of equity. Are they who are they looking for? Who are the key priority? Population where these services should be targeting and what kind of programs are there for them.

Are there something like digital health literacy program targeting older age group? Is there is a peer learning among older adults?  Is there's also like some sort of training for healthcare professionals to guide older people to navigate like how they can book, for example, starting even from the booking, this can be actually blocking.

This is actually the problem with digitalization. It's basically exacerbate any kind of inequalities already existence or existing or, at the same time, it can be a solution. So it's really dependent on what kind of strategy you have as a country to, to overcome this inequality. I'm going to come back to Elizabeth and then perhaps to Stefan on this, but Elizabeth, I'm sure you have to advocate and speak to lots of politicians, policymakers, others about the very same points that Carolus has made, the ones that you already articulated around the groups who are most affected and the strategies you might need to solve this.

How often though are you faced with the argument that everyone seems to have a smartphone, they're on social media, is this an issue you have to deal with?  Yes, it is. Very frequently the Everyone's connected by using a mobile device is the argument that comes back what we are starting to see but international viewers, we recently had an election and a major change of government within the UK, and we are starting to see some growing awareness that actually that's not necessarily enough. 

Now, something that we're working to understand is actually how do we evidence  that a mobile device doesn't provide you, even as an older person looking to access healthcare. That doesn't give you what you need. You need a stronger device. You need that mobile network. You need the support network to help you use it. 

But we're starting to make a bit of progress.  So it seems like a bit of recognition that it's not just about some basic connectivity, but it's connectivity that's actually effective and that can, that has some sort of effect. That sort of takes us on to perhaps some public health principles. And Stefan, you've obviously heard the discussion so far, you're working across Europe, you're involved in lots of policy development and strategy implementation. 

Isn't digital and digital health, Just another wider social disturbance. Don't we have to tackle it in the same way with housing, water, sanitation, or am I missing the point?  I don't think you're missing the point. I think we really need to work harder, as hard as possible, to involve all stakeholders in the, let's say, in the co creation of.

Of an additional intervention, so if we want to achieve the ultimate success, let's say, on the highest level of optic, we really need to bring everyone into the picture. So this is not nothing new in reality. Even when we had services that were ultimately based on paper, let's not forget that paper, technically speaking, is a technology. 

And now we're continuously evolving and taking things to the next level.  And during the time when we were based on paper, there were even literacy issues. People even being unable  to write up a form. Now we're facing new kind of literacy issues, which are digital health related. And yes, we need to provide the support there.

So I would advocate full blast, for example, for head healthcare professionals within the community, supporting individuals to onboard digital health solutions right there in the community, in their village square, where they can reach out to that person, and they will help them and guide them. And I think this could also potentially You know be one of the different ways to tackle this, but  of course, I had to wear a bit of a more of a public health cap here.

We really need here inter ministerial interventions. That means maybe the government could consider, for example, introducing a subsidy on getting a smartphone to start off with as a, like a first layer. And then you have an onboarding mechanism for those who have brought in the smartphone, for example, to be onboarded on digital health services.

This could be really thought through. And I think here there is an opportunity that  We really need to advocate for governments to have in mind digital health for all. In the same way that we have health for all, we need to also think about digital health for all. That means that everyone has the right to have their health records in a digital format.

It's really interesting you mention that, right? Because obviously in the UK in the last couple of days and and of course this is at the moment in October, the last few days there was only an announcement that everyone should have access to their medical records. How's that working in Europe and is that changing or reducing health inequalities by giving access to that technology?

Does it empower people in a different way?  I think first and foremost, we're always, we're forgetting that many people already have a digital personal health record.  Many of them. So if you have a smartphone, technically speaking, you already have a person had to record right on you right there. So the barrier has already lowered down, of course, as mentioned before, not everyone might even have a smartphone in the first place, but once you bring that in the picture, you already have a person and record. 

So I would say that.  The goal might not be even ambitious enough because we need to look at not only just having a digital health record or an electronic health record, but how about a comprehensive? and accurate record. Now those done out, that's a big aspiration that we really need to look forward to because we really need to ensure  that even those who are in different levels of income and different levels of digital poverty, we ensure that we make the right decisions.

for them. That means that if there is someone who, was in a specific type, let's say specific group that is prone to digital property, that we don't make incorrect head decisions just because they didn't have the opportunity to curate their head data. We need to help them on their, on this journey as well.

I think let's not forget that even Europe has digital decade indicators, and by 2030, one of them is for 100%, so to speak, electronic health records. So we're already on the way there, I would say, but we need a bigger push, I would say. You just made a really good case there for healthcare professionals.

And perhaps family physicians, GPs being more involved and careless. There mentioned earlier on some of the needs there we have around around the workforce as part of this. So Adam over to you. It'd be great to hear your thoughts on this because you've been dealing with this problem for a long time.

You've been launching services that are designed to help people use technology to get better access to care. Some might say though. it adds a barrier. Now you work in the UK, in Ireland, in Spain, so you understand a lot of clinical practices and a lot of different systems. What's your perspective? What are your thoughts on this?

This is interesting that Stefan said that he would like not just health for all, but digital health for all. I'm looking forward to the day when we don't talk about digital health anymore, because digital health is an integral part of health and it's nothing new. It's a standard across the board. 

But as Clive McIntyre said in the group here, not everyone will use a device. There needs to be there always needs to be an alternative. I think we need to be pragmatic and realize not everybody wants to use digital health. Not everybody will. Not everybody can. We should enable those who would like to use it. 

to use it, but there will be always need to be parallel systems. So we didn't in the 1880s stop using telephones because some people wouldn't be able to call the GP. We enabled those who walked down to the GP to see the GP to do that still. And we we enabled people to speak to the GP on the telephone and it's the same with digital health as well. 

And it's also worth remembering that one person's tool for increasing access is another person's tool for excluding access. For example, if we have CGMs for people with diabetes, those patients who can't leave the home have suddenly had a revolution and they can have their clinician see their, Glucose readings day to day, month to month, year on year, or home O2 sats readers for patients with COPD.

They're incredible for patients who have difficulty in getting to the GP. But those patients who can't use those things for, because they have problems with their sight, or because they're technically not quite there,  then that  reduces access.  You're always going to get people who want a different route to healthcare.

And we need to make sure that we don't  get blindsided or  too focused on digital health is the only way. We should put forward with digital health, but also remember the other routes. And patients, you still speak to patients and consult with them. Do you feel that the issue of digital poverty is just so broad and that these are people in their lives that are facing other problems, they can't afford their rent, they're finding it difficult to get into whether it's employment or education.

And on the other side, we're driving towards health systems across the whole of European region of WHO, which is more digital, digitally orientated. Does that change? You know who it is that can really access these services. Can we truly make a difference if we're facing the real problems that society has out there?

The ideal is that we use digital health in such a way that those who can use it And as many people have access to it as possible and that makes the service more efficient But we also need to remember that we have patients who just want to speak to a GP and the resources that are made available from making things more efficient, hopefully through digital health should then open up appointments and face to face clinics with, between the patient and the GP.

You get many patients who come to urgent care because they say, I just can't see my GP. I just want to see a doctor. And they're people who may be digitally literate, may have the latest smartphone, but we need to remember there are different routes into care that should all, should stay open. 

Elizabeth, just reflecting on what Adam said there and thinking about the many people that your organization, speaks to, listens to and really tries to help solve their problems. Have you come across situations where people have come to you or reflected their experiences of difficulty in access to things like the NHS?

Does that happen?  Definitely. It does. And choice is a word that a couple of people have mentioned, and that's incredibly important because actually we do have to. Maintain the fact that actually, for a lot of people, as you say, Sam, if they're dealing with a lot of other things in their lives, learning to use the internet, which is a frequently used term for people who are perhaps a little bit older, isn't necessarily a big priority. 

But there's also so much to learn. There's so many different apps, there's so many different routes if you're going online. There's e consult, there's RQX, there's  patient portal, there's all sorts of things that. People are coming to us seeking help for,  and being able to streamline that would actually bring a lot of benefit because yes, people come to us, they're confused, they actually, sometimes they want to be able to use these systems, they can see it would bring a lot of help for them.

We know from widening participation research actually it can really improve mental health, knowing you can manage your own health online.  But it's a complicated thing to learn. So even if you've got the device and the connectivity,  particularly if you're older, if you're vulnerable, it's quite a scary world going, what is this that I need with all these codes and different bits?

And right now we've had an announcement from a minister only days ago around access to technology. From your perspective at the Digital Poverty Alliance, do you think There's something that you could ask the minister to enable as part of the action plan to make this a reality. What would you be asking for?

What would you want the the Secretary of State to do, not only in, in England, but across the UK, to help the people that you are effectively representing?  There's so many things and actually one of the things that we need is a joined up cross governmental approach for the UK because you can't sit just in the Department of Health for dealing with health, literacy and digital poverty. 

But actually, if we had more awareness of digital poverty within GP practices and within hospital staff, if people could ask some of those prompt questions. Do you have a laptop at home? Do you have broadband? Do you feel comfortable using an app? Actually, that would help a lot because then we'd have the awareness and we would have the understanding and then we could be targeting support. 

I can see Stefan nodding there and bringing him in. Go for it. Yeah, in fact it reminds me about a smoking cessation toolkit.  Very simple. It was like three, three. In fact, I can't remember right now. And I'm sure that my, if my mom would see this, she would tell me, listen, to be a bit more careful because she was a smoking cessation professional herself.

But I remember that there's sometimes just questions. I even remember  a colleague of mine who set up a sticker right outside the GP practice asking me about the Jupiter.  Did it work? Simple sticker. I think it was Dr. Bert and Meko, who actually was sharing these stickers to ask GPS to stick it out on their office door so that if someone, it might be, they might be shy, they might say, no, listen, I don't have access to this because of this and this.

Just a simple sticker or just a simple offline intervention can really convert a person from someone who might be taking a step back. Simple off. shyness or simply because of digital poverty and enable that person to say, listen, ask the right questions.  And get the right answers for them to be able to access these digital health services.

So you'll be surprised how many ingenious solutions are available out there for people to really access health services, in different ways. But, ideally, at least one of the ways to be considered and prioritize, I would say a bit as well, is the digital approach because it can bring so many things together. 

Carolus, what are your thoughts in terms of what's happening across your members? Stefan has just mentioned, at least one really useful intervention there, but are you seeing different types of actions that are changing this in different member states at the moment?  Thanks. I think I would like to say that To what Stefan mentioned around, for example, digital literacy among healthcare professionals is key and this is they are the proxy agents basically for many patients to help them navigate.

And 1 of the things that that we looked at is looking into to what extent countries already have digital education plans and whether they are included in the mandatory training for for for medical students. Or even as a continuous professional development training, and it's shocking almost half of the countries only have the digital education plans only 52%,  and when it comes to basically what what Elizabeth mentioned earlier around looking into different groups and issues related to gender, culture, minorities basically again, like the scoping review say is saying the same thing, but like, when we look at what countries are doing only 56 percent of them have like digital health inclusion plans, although. 

In the overarching digital health, their digital health, the 75 percent of them say that they have a measure of equity. So equity is something that's really important pretty much for all countries.  But I think to the 2nd layer of what we are going to do about it in terms of action, it's still like maturing.

It's not up to, the scale of the need first, and also like to the required course of actions is like, there's a lot to be done.  And I wonder whether at a very micro level, when we've got global players in digital health, the companies working in digital health, the organization Adam's with, is a global player.

They exist across different member states, different parts of the world. So I suppose even if we take action in one part of the world, the organizations delivering these services exist across the globe in terms of the people who work in them come from different places. The very nature of digital, we have digital nomads.

Adam, I wonder with that what is it that you can see that would be useful at a workforce level to help with the mindset of product developers and others when thinking about how to solve this problem? Is there something you can see that would be useful amongst healthcare professional colleagues, but also amongst those working in digital health? 

Yeah, there's several things that we could do. We need to make sure the next generation of doctors are ready. So as it has been discussed already, medical school needs to have it as Part of the curriculum. And, sorry, to reiterate the point, but we need to stop separating digital health from health and see it as an integral part.

So just in the same way you get taught communication skills, you should get taught digital skills because it is just another way of communicating between patient and healthcare facilities and doctors. And I remember my,  how many years ago now? Eight years ago now, in my GP training the, one of my.

One of my senior colleagues still was typing his consultations like that with index fingers. And I think now if he had one of those stickers outside his door, ask me about digital, he  would know what to say if a patient asked him. So we need to upskill the existing workforce. And to bring them up to speed because things are happening so quickly. 

We can't just wait for the next generation. And as Stefan touched on before, there isn't a specialism in digital health. It still hasn't developed as a profession yet. And I think that's something else that we need to do. Having a GP with a special interest in digital health, just like you have a GP with a special interest in women's health, and each GP practice would be wonderful.

They could upskill their colleagues. There's different routes that we need to take, but the longer that we,  the longer that we leave it the more behind people are going to get. So I think we need action as soon as possible to upskill the general workforce. I could keep on talking forever and commandeer our entire webinar, but we've got an amazing audience that's posed some questions to us and I can see the questions are coming in and the comments coming in.

So I'm going to turn to the questions that we have and I hope our panelists feel free to. Answer freely and feel free to interject over one another as well. But our first question is from Dr. Elliot Roy Hiley, who some of you might know recently published the paper on drink awareness type products, alcohol reduction apps and perhaps dark apps and so forth that he mentioned there.

And his question as someone who's a digital expert really is what are the most effective policy levers for reducing the health impacts of digital poverty? And a part of that question, should the focus really be on increasing and maintaining non digital routes to health interventions, which we've touched on already, but I might ask Stefan first to come in on this particular question. 

I think it's a very valid question. I think we really need to look across the board. You'd be surprised, for example, how different digital health systems work in different countries. For example, in Malta, having an EID  is quite an appropriate authentication method.  But in a country like Poland, for example, in order to increase access, they allow people even to use their bank digital authentication. 

Now banking, it's related to our financial. It has a high incentive, high level of incentive. So all of a sudden, rather than limiting people, to just accessing like digital health services through, their national  document ID, you have given him the possibility to link, let's say, their national digital identity to their bank.

Authentication and they will access the head, the digital health service. So we really need to have across the board approach to really enable this kind of access. I'm not sure how it is in other countries. I'll be honest with you, but I've even noticed in Italy, for example, that they allow people to access their digital health apps through different authentication  methods.

All of a sudden you have a federated approach and opening up there. But that needs to be ingrained in the strategies and the policies that implemented that they know ah, okay, there's this authenticator. Let's use this method as well. And I guess that's really helpful, right? In that, that omni channel approach is helpful, but here lies the problem.

I guess somebody needs, first of all, access to the digital tools and mechanisms for that to happen. Elizabeth, what are your thoughts on this? Because I suppose you're coming at it from their foot of. First stage perspective of, is there even digital access?  We really are. And we know that the reality is that the millions of older people, they don't have that access.

And even if they do have the access, they don't have the skills. So really focusing in on the question.  Absolutely, we need those interventions that can reduce digital poverty. So we have many fewer millions of people who are without the device, without the connectivity, without the skills. We need to do that, though, in such a way that we are not taking away.

existing services, we're not shutting phone lines, we're not stopping face to face contact. So people can make that choice, or if they can't make a choice, they can choose, they can opt for the only option they have, which is the non digital approach. But that doesn't mean that we shouldn't be trying to chip away at it in the meantime. 

And another comment that's come in, Elizabeth, and you might be the best person to respond to this, is that it seems shocking, almost, that young graduates are being exposed to digital poverty. Is this something you're seeing? Is it increasing at all?  It is. It would be reasonable to partly relate this to the cost of living crisis that we're seeing at the moment.

Young people, more than ever, are struggling to find employment. If you're struggling to find employment, you will be struggling to find the funds that you need to access digital tools. But also, digital skills aren't routinely taught within school anymore, so people are not necessarily leaving with that digital confidence.

as well.  Accessing social media does not mean you are digitally included.  And it's interesting that you mention that because given that now so many jobs are remote in many parts of the world, especially across the European region, where people are expected to connect and work remotely, are we excluding a whole segment of society from the workforce simply because of the way in changes which on the one side are very positive have now been adopted by most organizations. 

We certainly are. And within the UK, the House of Lords found 90 percent of jobs are only ever advertised online. So you've got a hurdle before you even get going if you can't write a CV on a keyboard and then apply for the job. But if we're not giving people the skills within the school environment, which we're not,  absolutely we're blocking them off from a whole range of career and future career options. 

And it's interesting, let's say we address some of the issues of accessing technology. There's another comment that another colleague Dylan Sykes has made, which is really about excluding patients and primary care through the way in which local policies may be made up around access to digital, but also the varying digital maturity in the organizations.

Are you, all of you, are you seeing this where Different providers of healthcare themselves have such variable degrees of digital maturity. This is a barrier itself to citizen access. Has anyone got any views on this? 

I might ask Stefan to start and I might ask Adam. Oh, Adam actually come in. You've got your you work in the NHS. I fear ever hear about people struggling to find out their GP's email address. Yeah I think one of the challenges is in the NHS, nobody has taken the brave steps to centralize things and to move things forward.

And bringing the NHS digital app or NHS app is moving forward. But there are so many different apps, there's so many different routes into healthcare which varies by, by city, by county, by GP practice, and.  Each to expect each condition to know, each 1, each patient to know, each 1 is it just makes it the hill much, much steeper.

And I think if somebody was brave enough to integrate it into 1 single app  on a national level. It would be expensive, but it over time, we would see rewards and that more people would have access. It would be easier to be more straightforward. In the analog world, none of us really close our letterboxes or place where our post comes to in different parts of the world, right?

We don't nail it shut and say, nobody can put any more letters through our letterboxes. But it seems in the digital world, people switch on and off digital providers, which takes away the ability for citizens to Put things through the digital letterbox. They email might be switched off or these e consultation systems might be switched off at six o'clock in the evening and not switch on again until eight something in the morning, but in a digital world, is that even reasonable?

If we've got people who can only access the internet through their work and not at home, what do they do after six o'clock? If they need to access a doctor, for example Elizabeth, is this something you've come across or heard about?  Yes, and it goes the other way as well. If you only have access when you can go to the library, but the e consult form is only open at a certain time of day, that becomes a massive challenge.

This is why, certainly for those people who choose and want to be able to access digital tools, this is why we need those policy interventions that can help. actually tackle this affordability and the infrastructure that sits alongside it too.  Carolus, are you seeing this infrastructure issue manifest across different member states, the different people having infrastructure problems that themselves are a barrier to empowering people with technology?

Yes, definitely. Like again, like the infrastructure is very different across the region because the region is quite big. What are the extremes? Tell me about some of the extremes that we see. So basically, if we looked into a sub regional level, the Still the ones that we are looking into infrastructure as a key is especially in rural areas is going to be around Central Asia.

Central Asian Republic is, but still we have some countries, that they are still have the struggle for the proper infrastructure for for the digital health services. So that's that's 1 area. And 1 of the things also that I think Elizabeth Touched on is like relate to the Internet connectivity with people's time as well, which is something that we touched on or wrote about in the review, basically regarding like what we can do about it.

And 1 of 1 of the solutions can be like. Providing community based Internet through hubs and like hubs resources and adjusting the digital health services to accommodate people's time. Again exactly what you mentioned earlier regarding those people might not be able to book and a GP appointment unless they have access to Internet through their work.

This is actually something that we look at, so basically, infrastructure is still important, still something that is there mainly in the ruler settings, I would say pretty much in many countries, but to a great extent in Central Asia, if you want a sub regional level country specification, yeah. 

Switching tack slightly, and Stefan's going to come in here. In fact, I'll let Stefan come in first. And Stefan, I've got a specific question for you based on one of the comments from another public health colleague. But first of all, I'll let you come in.  Thanks, Sam. Just, I just want to point out that overall, I think, like in this conversation, we might have not mentioned that the idea of representation  and developing a support system, I think that is critical in developing, and. 

increasing uptake. That means, for example, let's say, for example, our national head, digital health portal, which is called MyHead, we have representation features, which is both for minors and also both for adults as well. Those have really helped. the uptake of digital health. And I think that they could definitely be considered for other communities, other health services, this idea of representation to help bridge the gap if anything.

And then thanks to this, because I, this is the classic, where I'll ask my daughter, I'll ask my son to help me out. And it's true. There really is an opportunity. But now, do we see the same, for example, coming for health professions? You're not going to ask someone to represent you there.

You have to take your own decisions but  they can use things like, for example, scribes. They can use things like, for example, assisted. In fact, I just read the chat on the chat. That's, someone is struggling with this.  But I really hope that possibly his trust here is ICB ICB and I'm always forgetting, sorry about that,  could consider providing him, for example, with a voice recorder and a transcript.

So there are opportunities out there, but we really need to  bridge this gap, provide this bridge. I guess coming back on this though, and there's a question about this, and you're probably a good person to have a view on this. In public health, we generally think about, what's the most cost effective thing that we can pose to the biggest population to get the most impact, right?

We often have big population health Programs on screening, immunization, public health messaging, cessation, all of these things. But in digital, sometimes those segments in the population that are going to need the most help, where the benefit is perhaps greatest, is also going to be a greater cost.

What are your thoughts on, how we grapple with this? Because policymakers and public health systems, publicly funded systems, will be thinking about a large volume of people, but the large volume are not necessarily people where. But most of that targeted resource needs to go. How do we address this, Stefan?

What are the strategies for dealing with this?  I think overall, we need, as digital health professionals, I would say, we need to constantly improve our communication skills.  That's like a for starters and how would you do that is by understanding that  first of all,  that we really communicate very well.

What are the benefits of digital heads? You know that we need to be, we need to be, we need to be stars really because people are really depending on us to really communicate this to the best of our ability. And I think overall, we need to learn from other industries to see what effective tools they have used to communicate the value of digital health.

Now, there are a couple of different tools available for us. Of course, you can use the classic economical tools, but of course, when it comes to health, it's not just about economics only, it's about improved health outcomes. And I think much more research there has to happen and we need to create.

a new generation of digital health researchers who really bring this out.  So I'm glad you mentioned industry there. And in the past, when we've had industry involvement in digital health and telehealth, there's been criticism on both sides, whether it excludes Whether it empowers. Adam, I might bring you in at this point.

A few years ago, in the UK, was probably one of the first big digital health providers of primary care. And when this happened, there was an argument these providers are cherry picking. They're taking on the youngest, fittest population. But what do you think? Is that really true? Do you think this is a manifestation of digital poverty?

Do you think it's cherry picking? Is COVID era?  Oh, interesting one. I think if we want innovation and if you want innovation, then we need to motivate people to innovate and to motivate people to innovate in from and in a private sector, then people need profit  and that's going to drive people to shareopic that's going to drive the organizations, the private companies to choose where the most, where they will make the most money.

In that particular scenario, it seems unfair, but what happens then is they're driven to innovate,  they develop new systems, they develop new IT software, they develop new protocols and new standards, and that then feeds down to the wider population.  It's a double edged sword really, so it seems unfair at the beginning, but then the second wave.

Benefits from the private sector investment, and then that feeds into the public sector. So a lot of the things that the NHS are now doing were spearheaded by Babylon et al.  If it wasn't for them,  then we wouldn't have progressed as much as we should, because the NHS wouldn't have been, wouldn't have been as brave or maybe as ruthless, if you could put it that way, as Babylon were.

I think that's really interesting. It's a really helpful perspective that we need this partnership between industry, between policy makers, between governments and organizations to try and make change happen. You touched on something there around how the mechanisms by which people may get to these organizations and new entities.

And Stefan, you touched on something related to this earlier. And we've got a question that was posed to us online earlier today around social media. So we're all be very familiar with the use of social media. I'm sure many of our listeners and viewers as well. It acts as a promotional tool. Some people might say it's a form of Digital social marketing, you might argue.

Others might say it's purely promotional and promoting particular apps and resources. I guess I'd like to come to each of you on, is social media really something that's empowering public health, or is it excluding individuals and is it driving a bigger divide to social media?  Widening inequalities, narrowing them.

Who wants to start first? And Stefano, I bring you on this first of all, because you use social media so much. 

You might be still, there we go. Just trying to I really want to give space to everyone, but  I think overall what is the challenge here is that.  We're facing the age of, let's say, misinformation and disinformation. Let's not forget about that.  So I think overall though, if I ask someone, let's say, who to use when, what's, what are my thoughts about using social media is that I would prefer hearing your credible  voice as a healthcare professional  rather than let someone else do that for you. 

That's really interesting. It's super interesting because I know the WHO have done an incredible amount of work on solving this. Ferulus, I know that WHO with some of those big organizations have managed to come up with a way of reducing this problem of of poor credibility. What are your thoughts on how we make sure we take the best of those things the WHO have worked out and bring them into a way of using social media to really empower people? 

I think collaboration with private sector and tech companies that manage social media is really key. And that's something that having more or less like a co regulation of what kind of content.  From the discussions with many companies, basically what we usually hear is that it is quite difficult to take down content in certain ways.

But as Stefan mentioned earlier, like they can promote the reliable and incredible content. Content so basically some platforms already have more a tag for this is coming from a reliable source or this is coming from a source or from the Ministry of health, or especially around covid time, because there was a lot of misinformation and disinformation circulating in the media.

Especially around video content, for example, this is usually having this tag, basically saying that. This information comes from the public health and the National Public Health Institute in this country, or. Or a or a credible health institution over time. That has been a really interesting discussion with four absolutely fantastic guests that I've had today.

The audience have been great. You've been engaging and thank you for your comments and questions. And sorry that I couldn't get to every single comment in question, but I'm really grateful for the thought and time that you put into them and sharing them with each other.  That brings us close to the end of this session But first of all, I'd like to remind you all that on the 19th and 20th of november We'll be meeting in london for the bmj future health conference please do join us if you are able to and if you can we have two more webinars in this series that are taking place and the first of which is on the 29th of October.

And I think that follows on nicely from the topic that we have just spoken about and the use of social media. But with that, I would like to thank my entire panel. Thank you, Elizabeth, for sharing your thoughts, views, and educating us on digital poverty. Thank you, Carolus, for telling us about the work of the WHO and what is happening across the entire region.

Stefan, thanks for sharing your thoughts, your insights, new experiences, and Adam for telling us about your work, but more importantly, what has happened there in the world of general practice and how we can solve some of those challenges. So most grateful and look forward to seeing you all again, seeing you in person.

We'll On the 19th and 20th of november at bmj future health. Thank you for joining today. Goodbye