Digital first: inclusion by design, or exclusion by default?

Recently, we were invited to the HETT Leaders Summit in Leeds to lead a roundtable we called “Digital first: inclusion by design or exclusion by default?”. Hosted by Fiona Maher and Angela Maragna.

These are the sessions we love, not because anyone’s trying to catch anyone out, but because people show up with real stories, real constraints, and a genuine desire to do better.

What made this conversation feel different was how honest it was. There was a shared acknowledgement that digital inclusion isn’t hard because people don’t care, it’s hard because healthcare is busy, messy, and under pressure. And when you’re stretched, the things that take extra thought (or extra minutes) are the easiest to lose.

A tiny moment that changes someone’s access to care

One story that stayed with the room was about repeat prescriptions.

A grandmother asked at reception for a paper form. She was told, “It’s all done online now.” In theory, there should be alternatives. In practice, the receptionist is doing multiple jobs in a stretched environment, and the app route is the fastest route. It avoids printing forms, manual data entry, and extra steps. It’s not laziness. It’s survival in a system where time is rationed.

But that one “tiny” moment had a big impact. It meant the grandmother no longer had equal access to the service, and had to go through a family member as a proxy. That can be supportive for some people, but it can also create real issues around privacy, control, and dignity, especially if the health need is sensitive, or something they simply don’t want to share with family.

And then came the next layer, the wider system. In that local area, pharmacies had signs saying they wouldn’t accept paper prescriptions. Again, not a “gotcha,” just an example of how a decision made in one place can make the “digital first” pathway feel like the only viable option everywhere else.

It’s a helpful reminder that inclusion isn’t just about what’s technically possible. It’s about what happens in real life when people are tired, busy, and trying to get through the day.

Translation can be an enabler, but it has to be joined up

Language came up as another area where digital can genuinely help. There’s a lot of work happening on translation across systems, and the potential is huge. Digital can be a ladder, not a barrier, for many people.

But the group also talked about how translation has to work across the whole pathway. If an app is translated, but the in-person appointment or pharmacy interaction isn’t, the experience can fall apart at exactly the moment someone needs support most. And it can even become riskier if people receive translated information in one part of the journey but can’t communicate effectively when it matters.

So the point wasn’t “don’t translate.” It was: translate properly, and plan it as a service, not just a feature.

“It’s not for us” and who quietly struggles

Another big thread was about who digital-first decisions tend to work best for.

We often build for people who look and live a bit like the people in the room making the decisions. That isn’t malicious, it’s human. But it’s why representation and lived experience in teams (and in research and datasets) matters so much.

We heard a powerful example from someone working as a product manager with multiple access needs, describing how “digital convenience” can become a barrier when there’s no option to say: I’m disabled, I need an in-person appointment. When the only alternative is phoning at limited times, or fighting for access via an 8am rush, the system quietly selects who gets served.

We also talked about staff. There’s an assumption that everyone in a hospital is tech savvy and well set up for digital tools. In reality, many frontline staff don’t have their own workstations, don’t have time for training, and are asked to adopt new tools in already overloaded roles. When people are supported and shown how to use tools well, adoption improves, but without that support we’re designing “efficiency” that can actually add burden.

Inclusion starts before the digital bit

A line that landed: the breakdown often happens before we even get to the technology.

If patients and communities aren’t in the room when we decide what problems to solve, what to fund, and what “good” looks like, then bringing them in at the point of “will this product work for you?” can feel too late. Not because co-design isn’t valuable, but because the direction has already been set.

We heard an example from a HealthTech Research Centre acting as “gatekeepers” at the idea stage. A company brought a calorie-recognition app that worked well in their own context, but it had been trained on a narrow set of diets. The conversation wasn’t “bad app,” it was “this will fail in the UK unless you do the work with the people who will actually use it.” The same discussion touched on a very real behaviour too: even tech-savvy people delete apps after a few weeks. So inclusion includes adoption, relevance, and payoff, not just interface design.

The culture bit (because it always comes back to culture)

One of the most human parts of the conversation was how quickly good intentions can be squeezed by culture and incentives.

In academia and in healthcare, people described a familiar pattern: leaders talk about inclusion, but day-to-day structures don’t support it. There’s an unspoken “I cope, so you should cope” attitude that can squeeze out flexibility, time to think, and time to do things properly. And once trust is lost, it’s hard to rebuild.

We even talked about the signals organisations send internally: if your everyday templates, tools, and ways of working aren’t accessible by default, it quietly tells people with access needs that they’re an afterthought. That matters, because how can we build inclusive products if inclusive people can’t thrive in the organisations building them?

What people wanted to stop and start

In the “stop/start” part of the session, one thing came through clearly:

Please start defining the problem before defining the solution.

And alongside that, practical ideas like:

• Ask people how they prefer to communicate, rather than assuming one format works for everyone (Zoom isn’t accessible for everyone, and neither are online-only feedback loops).

• Make everyday artefacts accessible by default, templates, forms, the basics, because it sets the tone.

• If you want better engagement, don’t frame inclusion as “extra,” frame it as adoption, trust, staff experience, and better outcomes.

The pledge we’re taking forward

We ended by making pledges, and one resonated because it felt doable even in a pressured system:

Do a little more every day.

A few extra minutes. One more question asked. One more assumption checked. One more effort to include the people most likely to be excluded.

Not as a grand gesture. As a habit. As something we can do today, and then again tomorrow.

If you were in the room, thank you for bringing your experience and your honesty. And if you’re working in digital health or care, what’s your “little more” going to be this week?

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OHT Leeds is funded by the West Yorkshire Combined Authority as part of its Inclusive Growth initiative