The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.
Dr Julian Tudor Hart, 1971
Tudor Hart’s analysis remains a pertinent reflection on the difference between demand and need, and the tendency to inequality when healthcare provision is left to supply/demand (market) forces. Yet health & wellbeing inequalities have been allowed to worsen due to market forces dictating access to digital connectivity. Access to a mobile phone network and the internet is increasingly being viewed as a ‘basic need’, and yet there is a wide variation in this access across Scotland. We are now at a point where unless the issue is taken more seriously, this digital divide between the ‘most and least connected’ threatens to create a very real inequality within Scotland.
Ten years ago, it may have been assumed that those living in rural and remote areas should not be surprised to miss out on the opportunity to use their mobile phone for calls and texts, never mind email and internet video. However, now the poverty of connectivity in rural Scotland is no longer an acceptable fact of rural life.
The threat that poor coverage now poses to rural areas, is such that this deserves to be a high priority issue at corporate and government levels. The ‘digital divide‘ – the difference between those who have access to fast broadband, 3G/4G cellular coverage and ‘always on’ technology; and those who don’t, has become a driver of numerous subsequent inequalities – access to information, business development, freedom of speech, the right to be heard and interaction with services essential to everyday living. It is now commonplace for certain services – from both commercial and public organisations – to offer only online ways of interacting, with the assumption that this is universally available across Scotland.
Even on stripping the necessities for communication right down to functions commonly viewed as ‘vital’ – such as summoning and co-ordinating emergency care – there is a paucity of acceptable network coverage. For example on the Isle of Arran, we see the following examples of the difficulties presented by poor mobile phone coverage:
- Difficulty in contacting on-call staff including medical and midwifery staff. Our system is as safe as we can get it – we carry radiopagers which have improved coverage, but this offers no means to respond to the one-way message that this can send, nor any confirmation that the message has been received.
- Difficulty for our ambulance First Responder teams – both in missing calls and subsequently volunteers naturally losing interest as they are either tied to their home phone, or have to relinquish their commitment to volunteer on a regular basis
- The great benefits offered by SMS callout of our Mountain Rescue Team (allowing rapid assessment of who is immediately available) are overshadowed by poor coverage throughout the island – and in particular for the volunteers who live in Lamlash which is a particular blackspot. This is dependent on 2G only, in an area that includes hospital, ambulance, lifeboat, coastguard, medical, local authority and other centres, including Arran High School.
- The Emergency Medical Retrieval Service from Glasgow have invested heavily in making the most of iPads and iPhones to achieve and maintain gold standards in critical and transfer care of patients. However, as our community hospital in Lamlash has no mobile phone coverage, it is impossible to access these unless sticking to offline content. In addition, this also makes it very difficult for the EMRS team to stay in touch with their base, and maintain phone availability to other rural centres who may also have critically ill patients to discuss with them. This example is detailed more fully in the NoBars section of this website, and is replicated across rural hospital sites across Scotland.
A number of emergency teams on Arran can make use of a basic 2G signal to find the position of a phone during emergency situations. For example, ambulance service resource tracking (including availability of BASICS GPs) is reliant on GPS-units which continue to send a GPS position over the 2G network. When a medical emergency arises, ambulance control can quickly pinpoint who is available, and where they are. Without 2G, this function is lost, and this is the case throughout much of Arran and other rural areas in Scotland.
Another example is in the case of finding a missing person, for example lost walkers on the hills of Arran. In certain circumstances, Police Scotland can trace the signal from a mobile call, and work out its location. This information allows emergency teams, for example the mountain rescue team, to rapidly reach the missing person or casualty, saving vital time in preventing ongoing injury or hypothermia.
Without any mobile coverage, these functions are simply impossible.
Smartphones are smart
Smartphones are now so commonplace that they bring an almost-universal access to their other key functions. Email, maps and key documents whilst on the move can all be facilitated by 3G access, and the vast majority of phone customers are already on 3G contracts. In being prevented the use of 3G functions whilst away from home wifi, this simply causes an even greater void between what is now currently possible, and what is available to folk living in rural areas.
Access to social media is also increasingly important to form and maintain professional networks, as well as keep up to date with medical news and advances. In my own experience, much of this is possible through Twitter – our colleagues in Australia have been particularly active on this front – and yet, during a typical 8am-7pm day at work it is not possible to engage with social media due to having no connection.
The situation is further exacerbated by the barring of social media sites by many employers (in my case, our NHS IT team) for fear of activating virus activity from online contacts. With professional and social isolation being a considerable risk and concern in rural practice, this lack of appropriate phone connectivity does nothing to improve social contacts with colleagues elsewhere in the country and further afield.
What about wired broadband?
In addition, we have seen a similar divide develop with access to hard-wired internet connections. With urban areas now seeing access to rapid fibre-optic connections, many rural areas still lumber on with fixed copper-wire, offering no more than 6Mb/s – and often the connection is as low as 2 Mb/s. So on both accounts (mobile and fixed networking), we are seeing the digital divide widen at an exponential rate.
Hotels now rely on online bookings and customer review sites. GP practices rely on networked access to results, records and reporting systems. Commercial and charitable organisations rely on cloud-based document storage. Schools rely on adequate IT access to ensure that students are IT-savvy for the wider world.
Scotland, as a forward-looking country, needs to realise the widening disparities being created by differences in digital connectivity.
The double-whammy of 4G
For many of us working and living in rural Scotland, we will look to Germany with some degree of envy. When 4G technology came along – promising broadband-speed mobile connectivity – mobile network providers were keen to bid for licences, in order to rollout of this service to urban areas where the money was easiest to make (no problem with that in the context of business).
Germany, at this point, realised the prospect of widening inequalities in access to digital connectivity. The German Government therefore began their 4G licensing process by prioritising rural areas for 4G licences first. Only after providing 4G to these areas , could mobile providers then move on to obtaining licences for more urban areas. This, I understand, has been successful in closing the digital divide, but without significant penalty to those in cities, as high-speed fibre-broadband was generally already available.
In addition, 4G could rapidly become a surrogate for hard-wired broadband access. The increased costs in laying fibre-optic cable across rural geography is a prohibitive and costly factor for bringing faster broadband to rural communities. There is some realisation even within the industry, that implementation of decent 4G roll-out to rural areas would improve internet connectivity – as well as the advantages in mobile phone coverage.
Why the concern now?
If this has long been the case, why the concern now? Until relatively recently, mobile applications were new, and most folk living in rural areas have come to expect (justifiably) that digital rollout tends to happen in more urban areas first. That is where the larger consumer-base is likely to be found, and so it makes sense on many levels, including for profit.
However, the last five years have seen a rapid expansion of the opportunities to network at professional, personal and social levels by having access to 3G coverage or more. Along with this we have seen it become increasingly important to have an internet connection in order to engage with systems – road tax, online shopping, news and media, and especially professional networks. The loss of local post office services has exacerbated this dependence on online public services. Videoconferencing is commonplace, and virtual collaboration is essential for progressing with initiatives and projects. Poor connectivity simply stifles this productivity.
In 1971, Dr Julian Tudor Hart’s work on describing the ‘Inverse Care Law‘ raised awareness of the fact that in order to benefit those who need it most, healthcare should not blindly follow market forces, and that demand does not equal need. Whilst the telecommunications industry is rightly a highly competitive and demand-led consumer business, it must be realised that telecommunications per se are an essential component to successful, healthy and productive communities. Scotland needs more effective action to tackle this inequality if it is to benefit from the vibrancy, innovation and productivity available from more rural areas of the country. It is vital to close this digital divide.