Trust and confidence in technology-enabled care

A joint analysis with Q

Progress with digitisation and technology adoption in health care, often hailed as holding the potential to help the challenges facing the NHS, has been slow. In his Independent Investigation of the National Health Service in England, Lord Darzi said that the NHS is currently ‘in the foothills of digital transformation’ and recommended ‘a major tilt towards technology to unlock productivity’. In response to the review, UK Prime Minster Keir Starmer pledged a move ‘from an analogue to a digital NHS’.

As the new government focuses on solutions to address some of the long-term productivity and workforce challenges in the NHS, a lot of hope is being placed on the role technology can play in reshaping how care is delivered and freeing up staff time. 

To realise the benefits of technology-enabled care, national policymakers and health care system leaders need to focus on and invest in successful implementation and adoption, not just the technology itself. Technological solutions do not operate in isolation; they are deployed in complex systems and interact with people, processes and other features of the health and care environment. For technology to fundamentally change or improve the way care is delivered requires good design of the technology itself, the processes that sit around it and the roles and ways of working that will be needed. This also needs to be supported by planning to understand how freed-up time will be used. Health Foundation research shows such planning is currently variable or not done at all. 

Change will not be possible unless technology is designed well and the people who need to use it – such as staff, patients and other users – are motivated by and believe in its potential benefits. In work from the Health Foundation and HDRUK to understand the factors that support the successful implementation and adoption of technology the Q Lab programme delved deeper into:

• what influences staff and service users to trust new technology
• how trust and confidence influence motivations and attitudes
• how to build trust and confidence to support the adoption of new technologies. 

During the pandemic, Q members saw huge changes in how technology was being used to support remote care – with the rise of virtual wards in secondary care and video or telephone consultations in primary care. Many of these changes were made through necessity, where the balance of risk and reward was temporarily altered. 

Q’s collaborative insight work during this time unearthed a wide range of factors influencing the speed and success of video consultation adoption. These factors were often interconnected, impacted by context and effected staff trust and confidence.

Q wanted to explore how the factors that influence trust and confidence would evolve as the health service returned to more ‘normal’ circumstances for digital change. Between 2021 and 2023, the Q Lab programme – which brings people together to tackle complex challenges and build scalable solutions – worked with four teams developing and implementing technology-enabled remote monitoring. Specifically, the programme explored the factors that increase trust and confidence.

Here, we draw together lessons from the work of the Q Lab teams. While evidence and guidance are emerging on the role trust and confidence play in the adoption of new health technologies, there is a clear need to strengthen the evidence base further. 

Previous Health Foundation research shows that trust in technology-enabled care can vary depending on the type of technology and who is managing the data. The Q Lab teams all reflected on the importance of having a solid foundation around things like data accuracy and safeguarding, though they highlighted that this alone is likely not enough to ensure trust and confidence.

The four projects supported by Q Lab programme highlighted several important factors that are likely to influence trust and confidence in technology-enabled care, including:

• its potential to enhance existing care 
• clinical risk associated with specific conditions
• intersections with health disparities
• the interconnection between staff and patient trust.

These factors can inform the strategy needed for digital change, who needs to be involved and where best to start. As such, it is essential to consider them before beginning the tasks of procuring, developing or implementing technology.

Potential to enhance existing care 

Previous polling found that the public is generally more supportive of technologies that support them to look after their health and increase their connection with the health service (such as self-monitoring devices); support is lower for technologies regarded as potentially ‘coming between’ people and their health care service provider (such as chatbots). 

The technology-enabled remote monitoring used by the four Q Lab teams aligns more closely with the former category. However, it is still important to consider how a technology may affect patients’ relationship with their health care providers and their overall care, and what this means for their trust. 

For example, a project from What Works Centre for Wellbeing looked at how remote kidney monitoring devices could be designed and deployed to maximise patient and staff trust and confidence. They found that the long-term therapeutic relationship developed in kidney care is often what patients and clinicians value the most. This is fostered over many years due to the need for long-term follow up with a dedicated kidney specialist. This highlights that any technology needs to enhance, rather than remove, this aspect of care if it is to be trusted, valued and therefore successfully adopted. 

When you put digital devices into care pathways… it shapes the relationships that you have with a patient. In kidney care, that therapeutic relationship is hugely important. Many patients will see the same professionals over a long period of time... Putting digital into that space can change that. 
Joanne Smithson, Head of Implementation and Learning, What Works Centre for Wellbeing

Through their early research, the team understood that technology would only be successful in kidney care if it sustains the therapeutic relationship and enhances other aspects of care. Using novel research methods from Thiscovery, the team employed this knowledge to develop a guide that describes what good remote monitoring looks like as well as a set of service principles that highlight what to consider when designing a digital service. These can be used by any commissioning team or technology developer to ensure that new technologies respond to what matters to patients and clinicians, both of whom have varying needs, such as in terms of what level of information or assurance they need to trust a device. 

[Device manufacturers] need to know how they can tailor around these factors so that [a device] works for patients in their lives. We give a device developer a rich insight on the features that their device would need to have to make it most likely to maximise trust and confidence and be successfully implemented in practice.
Joanne Smithson, Head of Implementation and Learning, What Works Centre for Wellbeing

This learning from the Q Lab is consistent with and adds further nuance to previous Health Foundation research on the importance of the human dimensions of care, and echoes findings from a survey study that one of the biggest risks for technology adoption is the prospect that it might make health care more impersonal.

Clinical risk associated with specific conditions 

Trust in technology-enabled care is also influenced by the levels of clinical risk and how users perceive those risks. It is important that any digital solution is suitable for the situation at hand, and this will vary across conditions. For example, a project between Aneurin Bevan University Health Board, Technology Enabled Care Cymru and school staff and pupils in South and West Wales developed a model for remote health monitoring in schools. They initially planned to use the technology to better support pupils with, or at risk of developing, eating disorders. Through working with young people and families, they identified a range of concerns with remote monitoring of eating disorders and so changed their plans to pilot their work with a different condition, attention deficit hyperactive disorder (ADHD). 

Families were quite nervous [about remote monitoring of eating disorders at school]… ‘What if the weight is wrong? What if I don't get it right?’ It was like, fine. Let's do ADHD because… it's not life threatening, you can always pick up the phone or chat to the doctor. 
Alka Ahuja, Consultant Child and Adolescent Psychiatrist, Aneurin Bevan University Health Board

Choosing a clinical area where the users felt comfortable with the proposed care model was important for securing the buy-in and support needed for the work to succeed. The team enhanced trust further by building in choice. The young people involved were made aware that they could continue to access in-person appointments at the clinic if they preferred, meaning that the new service would not compromise their existing therapeutic relationships.

Interestingly, the rhetoric of the NHS being in crisis has been cited by teams as having a negative impact on their work. The current context has led some patients to believe technological change is motivated by reducing costs rather than improving services. 

People think the moment you say digital, you [are] almost fobbing them off and saying that, you know, we’re so short of doctors and nurses and other professionals that we'll do this, because that's the way that we [are going to] deal with the waiting list crisis and what is happening in the NHS.
Alka Ahuja, Consultant Child and Adolescent Psychiatrist, Aneurin Bevan University Health Board

Intersections with health disparities 

Issues with trust in technology-enabled health care can be closely linked with people’s trust in technology more widely, as well as their confidence in their health care provider or existing tech literacy. 

Research undertaken by the Ada Lovelace Institute in partnership with the Health Foundation has shown that an increased use of digital solutions risks increasing inequalities, an issue also highlighted in a House of Commons report. The Health Foundation’s research investigating public and staff attitudes to health technologies shows support is significantly lower among people who experience inequities or barriers to accessing health care, including those on low or no income. It is therefore important to understand how digital technologies may impact different demographic groups and interact with health disparities to ensure that any digital change projects are developed with inclusion as a central principle.  

A project between Chelsea and Westminster Hospital NHS Foundation Trust and Hounslow Council explored potential inequities introduced in their service through the rapid implementation of virtual wards (also known as hospital at home) during COVID-19. They worked with trusted local charities to engage with seldom-heard groups to better understand issues with trust and how to address them. They identified digital literacy and confidence using technology as significant barriers, with many residents relying on family support, and explored a range of interventions. These included bringing health literacy into existing technology literacy sessions at local libraries and supporting digital champions across Hounslow who volunteer to help the local community with fundamental digital skills and overall confidence in online tools. 

The interconnection between staff and patient trust

Staff trust is an enabler of patient trust, as it is often staff who present the technologies to patients to use. If staff do not trust digital solutions, they may be more cautious, find workarounds or duplicate tasks – all of which have the potential to reduce or eradicate the potential benefits, as well as patient uptake, of technologies. 

A collaborative project between Healthcare Improvement Scotland, Cohesion Medical and the National Rheumatoid Arthritis Society has developed a Citizen Wallet smartphone app to manage the patient and clinician interface for people living with rheumatoid arthritis. User testing found that patients were highly willing to trust the app, much more so than some of the clinicians they had engaged with. The team also saw how trust goes two ways – seeing patients’ positive experiences with the app allowed clinicians to see its potential benefits and the latent demand it would address, encouraging buy-in. 

Digital change is often understood simplistically. Too much focus is put on the technologies themselves rather than how to redesign care models or the testing and iteration required to derive the benefits new technologies can deliver. To truly enable digital transformation, services need to work with patients, staff and the developers to ensure technologies are user centred and challenge driven. They must also run iterative change processes to reconsider the many elements that make up existing services. There should be a focus on how technology can enable an improved model of service delivery rather than digitising the status quo or simply adding technology into existing pipelines. This would be enabled by robust co-design with all key beneficiaries, focusing on what challenge technology is trying to solve and what value and benefits it will deliver. This work is more likely to succeed if it draws on the expertise of improvement experts, industry and voluntary and community sector partners. All of this will take time, skill, energy and resource.  

Invest in co-design to build coalitions for change 

Co-design plays a dual role of ensuring that technology meets the needs of stakeholders (including technology partners, improvement teams and patient organisations) while also building the support and ownership among end users (including patients, service users and staff) critical for technology adoption.

It is important to work with a range of end users from the outset. This ensures that issues of trust and confidence are addressed at the earliest stage of development rather than during implementation. Meaningfully involving staff could also contribute to an overall sense of feeling valued and appreciated, thereby increasing their uptake of the technology.

Co-design should focus on understanding what matters to the relevant stakeholder groups and how to develop and implement technologies that will meet these needs. In doing so, trust and buy-in will be increased. 

By co-designing the Citizen Wallet app with people living with rheumatoid arthritis, the team was able to respond to patients' needs in a more meaningful way. What the app does and how it is used were heavily influenced by the views of people living with rheumatoid arthritis. 

What we really wanted to do was… empower patients to design the solution for themselves… that they were in charge of, that they could shape what it was… a bit like plasticine to allow them to decide what features were important to them… They began to say, ‘Actually, it would be really good if we could do this, if we could do that. I’m less bothered about that. Could you explain that more to me?’ It allowed us to build in… more personalisation to individual context, expand and refine the whole self-management tool that we made available.
Euan Cameron, CEO, Cohesion Medical

The co-design process led to the inclusion of features that had not been considered, enhancing the product and ensuring it would meet people’s needs. For example, the original model was to support a dialogue between a patient and a consultant. Through co-design, it was expanded to also enable connections with voluntary and community sector support, a community pharmacy and other touch points like occupational health. The addition of these elements provides a much more connected model of care. 

Ideally, co-design processes should allow different stakeholder groups to work together to develop ideas and build collective ownership. Health Foundation work on developing learning communities offers some suggestions for how to include diverse voices and build trusting relationships in co-design.

Often, technology is developed away from the contexts in which it will be used. The need to involve staff in the development process is supported by recent Health Foundation research, which highlights how staff are often frustrated when technology solutions are not driven or informed by their knowledge of the service needs. Engaging stakeholders in the process builds a coalition for change. 

Establish a dialogue about the benefits and challenges 

Technology will not reach its potential if it is used purely as an add-on to existing services. It is important to understand what parts of an existing care model are working well and valued, whether a challenge is amenable to a tech solution and where there is potential for improvement using technology.  

The teams supported by Q Lab often found that patients and service users wanted to protect the human elements of care. 

We didn’t hear from patients that they were worried about tech giving wrong results. I think there was enough assurance that there were safeguards in place that any tech they would be using would have passed all the required safety checks. It was much more about the introduction of tech would take away the opportunity and time to talk with a health professional about how they were doing, how they were feeling. In terms of trust, it was, ‘How will I just not become a number?’ For many people living with kidney disease, the interactions with health professionals, that time to actually talk about how you’re doing, was highly valued. 
Joanne Smithson, Head of Implementation and Learning, What Works Centre for Wellbeing

Technology is more likely to be seen as trustworthy when there is an open dialogue around the overall benefits it can bring to care, as well as any limitations or risks it may introduce.

Bring in expertise and resources from a range of partners

Having a range of partnerships and collaborations can enable success. There is a wealth of expertise and capacity in the voluntary and community sector and in industry bodies that is often underutilised by the NHS. Additionally, different organisations can help secure the support of and build confidence with different stakeholder groups. 

The partnership between Healthcare Improvement Scotland, Cohesion Medical and the NRAS is an interesting example of this. The NRAS were critical in galvanising patient support for the rheumatoid arthritis app as it was being developed, brokering links with people who could test the system in its early stages and enabling a level of engagement often hard for NHS teams to facilitate. 

Putting the citizen right at the centre and giving us parity with clinical health professionals… really has worked well. The whole-system thinking has just widened the opportunities that we’ve had. Often, NHS projects are clinician or commissioner led. It was really exciting for NRAS to be such an important part of a project and really have our voice heard and listened to.
Ailsa Bosworth, NRAS Founder and National Patient Champion

The central role NRAS played in the partnership led to them taking on responsibility for running it. Alongside NRAS, Cohesion Medical, the technology developers, were integrated into the core team. This meant they were able to lead the co-design process, drawing on their existing user-centred design skills. Too often, NHS organisations find it difficult to work with industry, meaning they do not get the benefit of the expertise and resources industry partners can contribute to technology development, implementation and adoption.

The partnership between Chelsea and Westminster NHS Foundation Trust and Hounslow Council provided a springboard for better collaborative working in the borough. The team were recently given the MJ Achievement Award for taking ‘a whole-team approach to tackling health inequalities’ in this project.

Utilise expertise in embedding, scaling and spreading change 

The work of the Q Lab teams has demonstrated the important role improvement experts can play in understanding what is needed to embed, scale and spread innovative ideas. Too often, digital change efforts can be siloed or disconnected between digital, innovation, transformation and/or improvement teams. But embedding, scaling and spreading technology requires a truly interdisciplinary and collaborative approach. This idea is communicated succinctly in Healthcare Improvement Scotland’s model for enabling improvement within clinical teams, which highlights the need to align process, technological and workforce innovations. There is a wealth of expertise from improvement that already exists in our health and care system. This is demonstrated by the thousands of members who make up the Q community, which can support this work. The challenge for leaders is to make sure this expertise is well utilised in the significant task of digitising the NHS. 

 The Q Lab programme saw how improvement science enhanced the work of early technology innovations. The teams benefited from thinking through their theories of change and distilling what is core and what is customisable, incorporating learning from previous Health Foundation work on enabling the spread and scale of innovation.

Building trust and confidence is a key part of successful digital transformation. Specifically, it is important that both staff and patients trust and feel confident using the technology and feel it enhances their experiences.

The learnings from the four successful Q Lab teams provide real-world insights into the approaches and considerations needed to support trust and confidence in tech-enabled care. These findings add to wider evidence on this and suggest the following recommendations to support the ambition of ‘a digital NHS’.

• To enable the effective design and implementation of technological interventions, policymakers need to provide support and resources beyond simply funding procurement and development – including involving users in these processes. The Q Lab teams found that coaching, peer learning and working with people with diverse perspectives supported them in developing and implementing technology. 
• Opportunities should be improved for the NHS to work with industry on technology-enabled care – and policymakers, along with wider stakeholders, have an important role to play in facilitating this. The Q Lab teams that included an industry partner from the outset were able to ensure that user needs and challenges informed the technology’s design from the very start and that its development also considered how it would be implemented.
• Those leading digital transformation and implementation in the NHS should embrace a culture that centres patient and staff experiences and values co-design and co-production. Proactively engaging staff and patients from the outset will help surface issues around trust, help address these and gain buy-in from users. Doing this well requires dedicated time and effort.
• Those leading change in the NHS should establish a dialogue around how digital transformation can enhance existing services. This will highlight its benefits as well as encourage openness and transparency about any challenges it may bring for staff and patients and how these can be addressed. 
• Senior leaders in health care must help set a culture that supports collaboration and enables experimentation with new partnership arrangements. This will create flexibility around how individuals and organisations work together, including industry and voluntary and community sector organisations, and enable better and earlier collaboration among diverse teams and areas of expertise. This process will foster a sense of shared ownership of the outcome. 
• Senior NHS leaders should also invest in improvement expertise to support digital transformation. This is critical to effectively implement and optimise new uses of technology and make sure changes meet the needs of users, including those at risk of health inequalities or facing particular barriers.