It is inarguable that the process of change has already started, and the seeds we are planting now will determine the future of digital health and care. It’s difficult, perhaps impossible, to predict the future especially considering the health and care system is complex. I’ve been wrestling with some questions to look deeper at the seeds being sown and so try and understand where digital health and care is heading.

Is the development of digital tools being driven by the needs of staff and patients?

If users (staff and patients) don’t drive the selection and use of new digital tools, it’s likely these tools will not solve the key problems facing the health and care system and they may not fit workflows, creating inefficiencies and duplication. Currently, at best, a small subset of users are involved in selecting new digital tools. This means only a subset of user priorities are driving technology selection, making it unlikely solutions will fully address user needs. If the technology selected does not work for users, time and effort goes into developing workarounds, adding more complexity to workflows and cognitive burden.

Are we developing digital tools that makes life easier, better and more effective for patients and staff?

For digital technologies to be the go-to solution they need to work well for all staff and patients. This also creates a culture more readily accepting of an increased use of digital technologies. Currently persistent basic problems mean there’s high levels of continued dissatisfaction with digital technology. This can perpetuate a reluctance to engage in digital change.

The design and implementation of technology has a strong determining factor on how it affects staff. Research shows electronic health records (EHRs), a key technology for digitalisation of health and care, can have below acceptable useability. This is linked to increased cognitive burden and burnout due to non-intuitive implementation into pathways. But we also know digital tools like EHRs can drive improvements in patient safety, safeguarding and medicines optimisation. Similarly data driven systems can improve population health and resource allocation, while AI can improve accuracy, reproducibility and speed of services. But the technology also has knock on implications by placing new demands on staff, with data driven care meaning a need for higher quantities and quality of data but the limitations of digital systems risks highly skilled clinical staff becoming data clerks.

NHS Digital Academy and local training programmes are creating a digitally competent workforce, increasing staff confidence to use and engage with the development of digital tools and pathways. However, the tools supplied need to work for digitally competent staff without them becoming technical experts.

Is technology helping or hindering greater equality in outcomes and access?

How technology and digital healthcare information are designed and implemented can exclude or include different groups of people based on the complex interplay of numerous variables, such as device access, skills, culture and language. For example, a patient portal gives patients access to their health and care information, but are often designed with a narrowly defined user in mind and instead of empowering people, they exclude many. Researchers of data driven tools have concerns that their effectiveness depends upon data quantity and diversity, which can be highly non-representative. This means it’s very unlikely that a single solution will work effectively for each individual within a diverse community.

However, providers and services commonly demonstrate preference for a single tool for a specific task. It's likely the combination of procurement approaches and scarce resources incentivise this. National procurement sets a price cap but allows for local purchasing agreements, so the price can be negotiated locally often for exclusivity locking in selecting a single tool. Whereas a diverse range of tools for diverse patients and staff could lead to better outcomes. Incentivising use of a single digital tool and the difficulty of interchanging tools means settling for a digital tool that has unequal performance from one demographic to the next. This could mean unequal care services risking an exacerbation of inequalities and unequal care.

Is there a sustainable supply of good value digital technologies?

The Secretary of State recently highlighted the financial sustainability of the NHS as a challenge and in the long-term we need to consider the role technology has to play. The common assumption is digitalisation will cut healthcare costs but this is only true if certain criteria can be met, including benefitting from consumer technologies, interchangeable tools and preventing incumbent legacy tools. One of the many drivers of digital health transformation is the consumer technology boom. But consumer technology develops at a much quicker pace than medical and health technologies - robust regulation and evidence are essential to ensure safety, efficacy, and value but this takes time. The military and defence sector invests heavily in technology and has been caught by the increasing cost of trying to maintain legacy technology. A long-term strategy for digital health needs to ensure the health and care system is able to have a vibrant supply chain at national and global levels to keep costs competitive and encourage innovation while avoiding embedding incumbents.

A vibrant supply of digital tools must be complemented by a dynamic implementation environment - arguably one cannot exist without the other - but the NHS struggles with scale, spread and adoption. The digital health technology ecosystem is both incredibly fragmented and consolidated in different parts. Historic approaches to digitalising in siloes and by tasks has created a health and care system which is beset with technologies that are siloed with varying degrees of overlapping functionality. This constrains the supplier market dynamics, as the incumbent systems grow in complexity and capability becoming more difficult to replace. New entrants have higher barriers to entry which stifles innovation and reduces the leverage alternative solutions enable. This creates a supply chain where suppliers face significant challenges becoming established and/or scaling.

Today’s seeds turn into the fruits of tomorrow

The vision for digital health and care is compelling. We’ve seen and experienced how transformative it can be in each sector that digitalises, sectors as diverse as banking, media and transport. We’ve learnt about it’s potential in health and care, and while it's yet to be realised there’s been tantalising glimmers of potential.

However, in our rush to digitalise, the seeds we are planting today are not necessarily the ones that will grow the fruit we aspire to have in the future. Instead we may have tools that poorly suit the problems we are seeking to solve, add burden on staff, become increasingly expensive while increasing inequalities. Focusing on achieving digitalisation isn’t enough, there’s an equal need to scrutinise the future state of digital health and have a more active role shaping how digital tools are developed, supplied and implemented.

Dr Pritesh Mistry, Policy Fellow for Digital Technologies at the King's Fund, UK.