The reality of, and potential for, digitally enabled care in the community
As digital technologies have developed, there has been a slow but significant shift in people using digital tools to access health and care services – and in health and care services using digital tools to deliver services.
With many health and care services under intense pressure, people using and working in those services have high expectations about the potential of technology to help meet patients' needs and improve quality of care. To date, most technology transformation has been focused on hospitals, with innovations in community settings, such as 'virtual wards', seen as a vital tool to help bring down elective care waiting lists and support people to avoid hospital visits.
Digital technology could help to deliver the long-held but unrealised ambition of moving care closer to home. This ambition would not just reduce the need for people to access already over-stretched hospital-based care, but would also provide more effective, higher-quality care in the community to enable people with ongoing care needs to live independent and full lives. Funding and support programmes, such as the Adult Social Care Technology Fund and the Better Care Fund, can facilitate the use of digital technology in community settings. But is the health and care system realising these technologies’ full potential?
This long read shares the findings of our research (see Methodology below) into the current reality of digital technology use in community services, and what the future could – and should – hold.
About this report
This work was commissioned and funded by Nourish. This output was independently developed, researched and written by The King’s Fund. Nourish has not been involved in its development, research or creation and all views are the author’s own.
The King’s Fund would like to thank roundtable participants, the people who draw on services who participated in our research and external reviewers.
Why is digitally enabled care in the community important?
Health care services located in the community are as important as the acute services located in hospitals. People with multiple long-term conditions need services that support them to manage their health and care needs throughout their lives; a visit to hospital won’t cure or ‘fix’ them. Community and primary health and care services can meet people’s needs closer to home and support them to take charge of their health.
Demographic changes also mean that the UK will face the challenges of an ageing population. Many older people will be living with more than one long-term condition and so will have complex care needs, potentially further increasing demand for care in community settings that can support them to live as full and independent lives as possible.
People who draw on services from the NHS and social care often want to have their care delivered in the community.
I have no confidence. If I went into a general hospital, I would not receive the care I needed or would come out with a pressure sore.
Person who draws on services
Technology can often be seen as a solution to the challenges facing the health and care system – for example, a solution to increasing demand, insufficient access, low productivity and workforce shortages – but it also has the potential to improve care experience and outcomes. Better digitally enabled care in the community has the potential to improve quality of life for many people who have ongoing care needs, such as people living with neurodiversity, people living with physical disabilities, and people with complex long-term conditions.
In addition to demographic shifts and people’s changing expectations, technological shifts create an additional driver for change. New emerging technologies have the potential to change where and how care and support can be provided; this will have implications for community service providers, staff and people who draw on services.
Here we bring together the lived experience of people who draw on services and the staff involved in care delivery, national developments and literature to consider the present landscape and potential future of digitally enabled care in the community.
Current use of digital technologies in community care
Connecting systems and co-ordinating care
We've got a population feeling the inconvenience of integration not being where it needs to be.
Senior leader (occupational therapist)
Listening to people who draw on services in the community recount their experiences, it is clear there is a great deal of frustration around the disjointed approach to care services. We also heard about patient safety failures, people feeling like they have no control in their care, and the impact of poor technological implementation.
Technology can be an important enabler of joined-up care in the community, but people’s experience of communication and shared care information is highly variable. When medical information cannot be shared digitally, there is a continued reliance on letters. This can create safety risks or lead to people experiencing needless harm, such as spending significant periods of time in pain.
Why can’t that letter be emailed to the GP practice? It took three weeks for the consultant letter to get to the GP and meanwhile my health issue is getting worse.
Person who draws on services
One individual recounted how they were seriously unwell following the use of an incorrect dye for a scan. Before the scan, general practice and hospital staff communicated by post: one of the letters, which contained safety-critical information from the GP, was not received by the hospital, resulting in harm to the person.
A second individual recounted how they hold their own medical information in patient-held records, then download this information and email it to the hospital before an appointment. This approach avoids repeated questions and improves the care experience but creates additional burdens on people who draw on services.
I want all the staff to be able to see my health data.
Person who draws on services
Interoperability – where health and care information is accessible and available to individuals who need it – is an ongoing challenge in the health and care system. Some integrated care systems (ICSs) are trying to improve interoperability by creating additional systems that link all electronic records. However, these efforts can be hindered if some hospitals and social care providers do not have digital record systems. In other areas, the siloed nature of the health and care system and behaviours of the technology suppliers impede the transformational potential of technology and data.
The problem with suppliers is they want to keep information in their own ecosystem; there’s a number of different technologies that can help and trying to link them all in is possible – but that doesn’t happen and so services can’t change.
Senior leader (care provider)
This echoes findings from earlier work by The King’s Fund, but there are also actions that providers, integrated care systems and central government can take to start to address the interoperability challenges.
There are clear benefits to having well-established digital technologies, such as shared records and digital communication, but these are not being realised nationally. Joined-up, accessible information enables fully informed conversations between patients and staff, which facilitate good experiences of care, support positive outcomes, and ensure patient safety.
Before the appointment the lead nurse reads the notes from the GP, so she has access to any health information prior to the procedure.
Person who draws on services
We heard multiple examples of joined-up care information being used to provide high-quality care in the community, with good access to care information enabling person-centred care – for example, social care providers being able to access an individual’s GP record. This approach means care staff are fully informed of changes to an individual’s medications and care needs on the occasions when the people they care for are admitted to hospital. However, one roundtable attendee commented on how there seem to be many more poor examples than good ones.
Some services are embracing more advanced technology, such as apps and patient portals, but the continued lack of joined-up systems affects individuals’ experiences of care. We heard from a digitally confident and capable person who is very frustrated.
I have five medical apps on my phone because the different hospitals have different systems. Why can’t I just have one?
Person who draws on services
NHS App development plans aim to improve data sharing across apps. However, it is unclear whether this will improve patient experience or whether people with complex care needs will still have to juggle multiple apps. It begs the question: if the technology isn’t working even for digitally capable people, who is it working for?
Currently, use of digital technology is mimicking silos in the system, and people are frustrated at having to piece their care together. This fragmentation is partly due to the funding and approaches to digitalisation replicating organisational silos in the system and the technology then copying this.
Personalised and inclusive digital tools for health and care.
Technology doesn’t work for everyone, and people can find themselves digitally excluded for multiple reasons. In England 75% of the population are confident internet users, using technology for many everyday digital experiences from shopping to banking. Research shows that the public has different expectations of the NHS compared to private companies. But members of the public do make comparisons between the two and NHS technology often compares poorly to people’s experiences of technology in other parts of their lives. For example, during our roundtable both staff and citizens commented that parcel delivery services use a combination of emails and text messages to keep people fully informed and in control of communications and deliveries; in comparison, simply keeping track of appointments in the NHS is a challenge.
Technology has the potential to improve patient experience. Currently, people can wait at home for a district nurse, only to wait all day and not receive a home visit because of staff shortages. Simple, well-established and mature technologies, such as location tracking and notification alerts, could dramatically enhance this type of experience. Similarly, simple options, such as giving a preference of morning or afternoon visits to an individual and their circle of support, can empower people to direct their care needs.
Good-quality, person-centred digital technology can enable individuals to be more confident and knowledgeable when it comes to managing their own care needs. At the roundtable, several participants mentioned how a lack of patient input into tailoring services and technology drives exclusion through hard-to-use services. By working with partners, providers can address many digital exclusion barriers with support from policy changes.
What we hear from people is there’s a problem with the way technology is just prescribed and not tailored. That needs to change.
Co-production lead
Instead of a standardised approach to implementing digital technology, there is a need to start from people’s existing capability and build digital health and care support from there. This might mean some people have an app on their phone; for others, a better option might be a tablet acting as a display for simple notifications.
We need to start from what people can do, not thinking about what they can’t.
Person who draws on services
When staff are empowered, it can empower people who draw on services. For example, social workers in Hertfordshire have £500 one-off budgets to spend for people who draw on services. This money is used to support people to live independently, and can often include purchasing technology. However, there is a lack of awareness from both staff and those who draw on services as to what funding and technology are available. Personal health budgets are another example of support that is available, but not many people are aware of them or know how to access them. Even when people know about personal health budgets, they can feel overwhelmed by choice combined with uncertainty as to what is a suitable technology to meet their needs. These accessibility and confidence challenges mean people are unable to purchase technologies that work for them. Some local authorities are testing the use of AI to help people identify assistive technologies that could be purchased with personal budgets.
When [technology is] used it’s very traditional, but there’s lots we could do with digital to really maximise the independence of people to live well.
Social worker
Simple technologies that identify people who could use personal health budgets, communicate with them and pre-complete application forms can improve accessibility. Similarly, recommendation technology that can match individual needs to available technologies could improve the personalisation of technology-enabled services through better use of existing funding.
Co-development is a good way to engage meaningfully with people who draw on services to ensure digitally enabled care meets their expectations and needs. Organisations that support inclusive co-design, such as Think Local Act Personal, start by asking: how can technology enable people to live better lives? And it is not just about people’s expectations – the Care Quality Commission’s single assessment framework incorporates quality statements on how people and communities are engaged and at the centre of services.
To improve and tailor services, some providers and ICSs now have staff dedicated to the digital patient experience. As part of the digital solution development process, these staff work to improve services by engaging proactively with people who draw on services. Integrated care board (ICB) and provider plans are in the early stages of implementation, so staff sometimes feel they are not doing user-centred design as well as they could – and could do more.
We’re making progress but there’s so many quick wins that we could do that we’re not doing and that’s so frustrating.
ICB digital user engagement lead
Additionally, allied health professionals involved in care provision believe they have much more to offer in helping to create personalised digitally enabled care that is tailored around the individual.
We can help with how you build solutions in a way that suits the individual’s learning needs, suits the individual’s environmental considerations, and suits the individual’s health and care needs… keeping the application of the technology centred on the end user I think is the potential value that occupational therapists bring.
Senior leader (occupational therapist)
Collaborative leadership approaches are needed to ensure staff are supported to tailor digital services to an individual and have easy mechanisms to provide feedback. Technology has the potential to change an individual's level of need for care: well-designed technology could help people live more independently with less need for care from services or paid or informal carers.
Health and care staff experiences of digital tools
Staff are just as frustrated about their experience of using digitally enabled services as the people who use services. For example, district nurses we spoke to expressed frustration that the most basic requirements of technology are not being met.
Patchy connectivity, so using laptops to facilitate mobile working is sometimes not the solution it is thought to be, leaving nurses making decisions in the dark. Often that’s on top of old or inadequate hardware.
District nurse
Research shows that three-quarters of district nurses struggle with connectivity issues, poor battery life and heavy laptops. The electronic records software that is currently used interrupts workflows, and district nurses sometimes need to duplicate tasks due to different digital systems used by different provider organisations. For example, an interviewee described staff having to duplicate work by entering similar information three times into systems because providers have three different systems running.
This isn’t limited to district nurses; occupational therapists told us they also struggle with the basic technology needed for day-to-day working.
There’s a lack of some of the basics, such as a personal device, so staff are finding themselves waiting to use a shared device, trying to remember multiple details or jotting on paper until a computer is available.
Senior leader (occupational therapist)
Currently, technology can be designed for hospitals without sufficient engagement or understanding of community requirements. We heard how staff are frustrated with systems that are built for hospitals but need to be used in the community, which has a completely different context. We also heard that when technology is commissioned in hospitals but used in community settings, community staff can find themselves unprepared and unsupported to integrate the technology around the individual. For example, homecare workers are asked to support people on virtual wards but do not receive appropriate training or support on how best to use the technology and empower the individual.
Staff who use digital tools and technology in the community are rarely involved in developing or selecting systems. As with centring the expertise and experiences of people who use services, we heard how there is a missed opportunity to tap into staff expertise when it comes to developing technology that’s needed, so it is more likely to be welcomed as a useful tool.
It’s not all negative. There are bright spots where great technology is being developed with staff – for example, a supplier of rostering software has worked with staff to develop their software.
Providers are now using a rostering platform that ensures you have the right number of nurses with the right skills at the right time. It also takes into account the local demographics and clinics so that you are then able to plan the workforce of the future.
National leader (district nurse)
Staff in community care settings are mobile and distributed over large geographies; they are confident at working remotely and take flexible approaches well suited to digitally enabled care. Technology should support staff but, as we’ve shown, that’s not the reality. Research shows staff in the community can be hesitant about using technology but also that they are interested in using it, and many district nurses have good digital literacy skills. When designed and working well, technology can benefit staff by reducing their workload and so benefit patients by creating more staff availability.
Simply digitalising a lot of the ways in which we work means digital technology can increase our patient time within the existing capacity that we have as a workforce.
Senior leader, occupational therapy
Technology has the potential to support staff to improve the workplace. Referral and triage technologies are already deployed in some settings, such as general practice. These types of tools could support better service access, especially where people are less aware of the support other health and care professionals can provide.
Digital capability of health and care providers
Community providers report that they struggle to access funding for innovation and digital transformation. The community sector is often overlooked in national digital priorities and funding streams, which exacerbates the variation in digital capability affecting how services can be improved or transformed.
We’re definitely seeing that certain care homes are better equipped around digitally enabled care.
Senior leader (occupational therapist)
When funding is accessible and there is adequate infrastructure, provider organisations can support their staff to embed digital tools into their roles and thereby improve staff and people’s experience of digitally enabled services.
The national commitment to digitalise social care records means increasing numbers of care providers are doing so. But that doesn’t necessarily mean providers are using the technology and data to transform care services and experience.
We were early adopters of digital records. Over the last eight years, more providers are using digital records, but the ‘so what’ hasn’t followed on… we have all of this data as a care provider – start times, timetables, how much travel time between locations – so someone should be able to see that their carer will arrive in 15 minutes.
Senior leader, care provider
In our research we heard how the drive towards more digitally enabled acute care in the home, for example virtual wards, rarely includes specifying minimum staffing levels for allied health professionals and care workers. So although virtual wards are gathering evidence that they support patients with acute needs, it remains to be seen whether this approach can be extended to support long-term independent living. Meanwhile, community providers have developed strategies to harness digital technologies aligned with the NHS Long Term Plan, but there’s insufficient evidence to understand how community providers are working with secondary care providers to leverage virtual wards for longitudinal care needs.
Potential for the future of digital in community care
A vision and incentive for digital in community care
ICSs and their provider organisations have an important role in driving digitally enabled care in the community by creating capacity and a collaborative culture. Cross-system working needs common vision, shared leadership, strong relationships and joint commissioning. However, centrally driven priorities for ICBs risks digitally enabled care in the community being lower priority.
Digitally enabled care can be a profoundly human-driven aspect of our work. I am performance managed by NHS England by looking at the impact of what we do on emergency care attendance. It doesn’t look at whether the people living are well, their outcomes and quality of life.
ICB chair
Our report Making care closer to home a reality found that there is a lack of data on community care activity. In the roundtable, people criticised the focus on tasks not outcomes.
The system is orientated on traditional care with a focus on time and task, so this technology for this task means we don’t talk about outcomes and the life people want to live.
Social worker
Using digital as an enabler for transforming care in the community means it needs to be a national priority.
We need to shift mindsets; the instinct of ministers is to go and visit hospitals, they need to instead check in with patients who are at home with remote monitoring, or the voluntary sector who are doing incredible digital work with patients.
ICB chair
New possibilities for digitally enabled care in the community
Greater collaboration between social care and health care could enable pathway transformation and help to address care gaps. There are some examples of good innovation and digital transformation in community settings across the NHS and social care. The Care City test bed demonstrator is one such example. The test bed shows it is possible to innovate in the community across NHS and social care boundaries using technology to support staff and people who draw on services. Another example is work in Tameside and Glossop, where work across the NHS and care homes has upskilled, supported and empowered care staff to do more for people who draw on services and prevent worsening health. In some areas, community nurses can send a photograph of a patient’s ulcer for diagnosis through an app, empowering staff to make decisions about care and potentially avoiding a hospital visit or GP appointment.
These examples show the potential for a wider range of staff to support more of people’s care needs through the use of technology. National initiatives such as the Topol Digital Fellowships can support individual staff to change services with technology and so improve working conditions, give greater support to individuals, and reduce demand on hospitals. However, staff need to be supported and enabled within the provider organisations, too.
However, basic technology capabilities, as well as expectations from staff and people who draw on services, are not being met. There is potential for significant improvement: the focus should be on getting the fundamentals right and this is achievable now.
It is also important to look to the future. As technologies continue to develop, many digital tools will become faster, more efficient, smaller and able to do more. This means newer technologies will be used in different ways and for different things, creating new possibilities to further improve care in community settings. AI will be a key enabling technology and could power future capabilities.
Below, we touch on a range of technologies that could enable a different approach to digitally enabled care in the community.
Remote supervision and support are already possible with video consultations, but the visual range is limited to a single webcam. With augmented reality (AR) technologies, the ease of use and direct replication of what the user sees could unlock improvements in care. AR combined with AI to visually highlight features of note could support clinical decision-making and digital care planning. For example, a district nurse on a home visit concerned by something unfamiliar could use AR glasses to receive remote support from a community matron who would be able to see what the nurse is seeing.
AR technologies could also help to support staff with more diverse and accessible training opportunities, improving their knowledge and skills. For example, experienced GPs could use AR glasses so that a range of staff, eg with differing levels of expertise, could observe, train and learn.
Diagnostics are becoming smaller, enabling more diagnostic investigation and monitoring in community settings. For example:
point-of-care ultrasound probes are already very mobile, can connect to tablets and smartphones, and use AI for identifying relevant parts of an image
MRI scanners that combine low magnetic fields with AI to create portable scanners are being developed. These scanners are being tested in hospital settings but could enable more care in the community in the future
digital stethoscopes combined with AI analytics have the potential to support diagnosis or for the information to be shared with remote experts, supporting care givers to do more.
3D printing is growing in use in the health and care system. In the future it could provide personalised support for individuals to enable them to live with increased independence. For example:
researchers are testing 3D printed gloves to reduce tremors in people living with Parkinson’s disease
occupational therapy can provide better and cheaper assistive aids
it is feasible for care homes to support residents overcome denture loss using 3D printing
3D printing can be used to support home modifications that can improve the independence of people who draw on services.
Robotics have the potential to help provide physical, cognitive and social support by promoting mobility, improving memory, providing companionship and assisting daily living activities. Robotic technologies such as exoskeletons have the potential to support people who draw on services and their carers.
However, these technologies pose social, cultural, evidence and impact, and affordability challenges. The examples given have proven feasible and indicate benefits, but further assessment and development are needed before they can be used at scale.
Summary and recommendations
Digitally enabled care in the community is currently limited by low levels of investment and siloed approaches. There are examples of good implementation and use of technologies, but these need to become the norm not the exception. To capitalise on future technologies, there needs to be substantial improvements to digital infrastructure and the use of basic technologies, in addition to growing the capability and capacity in community settings so that technology and new skills can be integrated.
More work needs to be done on this topic to drive forward digitally enabled care in the community. We recommend more work in the following areas.
National vision to guide local decisions: a Department of Health and Social Care vision co-created with people and staff that puts digitally enabled independence and dignity at the centre of care in the community. A guiding national vision, with local flexibility as to how it is achieved, will help to align the efforts of technology innovators, health and care providers, and leaders designing improved community-based services. This vision should use technology horizon-scanning to help direct technology innovators, and facilitate ICSs and providers in developing infrastructure, workforce and services.
Boost investment and capability: increasing the distribution of funding and support for innovation and digitalisation into community orientated services through NHS England working with ICSs to support them to have autonomy on how funding is spent, and prioritising community care and joined-up services.
Strategies for co-developing digitally enabled services: integrated care partnerships and ICBs, with support from NHS England and the Department for Health and Social Care, should work to better understand the existing co-development and patient engagement approaches in the system, support sharing knowledge across ICSs, and develop a strategy for co-development and patient-led service design that will help to direct digital service development and strategy.
Shifting culture to embrace the public’s digital capability: leadership training from NHS England and professional bodies for all health and care leaders to support a culture shift away from focusing on what people can’t do to instead taking a strength-based approach of enabling services based on what people can do, based on staff training and more flexible service design so that services can be tailored around individuals’ strengths.
Support staff to embed technology in their roles: ICBs and leaders within provider organisations need to support and enable staff to grow their own roles and careers with technology and personalised technology-enabled pathways. This should be facilitated and supported through national networks, and arms-length and professional bodies.
Joined-up procurement to ensure the compatibility of digital tools: supporting ICSs to improve interoperability by creating joined-up procurement approaches that adhere to data and digital standards. Achieving this will require leaders to drive improvements in cross-organisational working relationships. As well as procuring the right tools, provider organisations and senior leaders also need to create staff capacity to implement and embed changes to digital systems.
Create cross-NHS and social care environments that enable innovation: NHS England, with support from ICSs, needs to review local innovation initiatives that are working across boundaries, use this information to share potential successful models, and support ICSs to cultivate the creation of innovation initiatives across NHS and social care boundaries.
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