In total, we included 87 policy documents in the qualitative content analysis (see Supplementary Material Appendix 4). Policies we included targeted multiple stakeholders: system-wide aimed at health and social care, or public health (n = 40), health data and digital health (n = 15), digitisation (n = 6), cardiometabolic disease (n = 4), COVID-19 (n = 4), public health or other health conditions (n = 2) and related to inequalities, including health (n = 15) (see Appendix 4). Health is a devolved power in the UK; 17 policies specifically stated they were UK-wide (specifically stated); the remainder related to Scotland (n = 15), Wales (n = 9), Northern Ireland (n = 7), local authorities or NHS regions (n = 4) and England (n = 34).

Analysis of these documents set out the context for existing policies. We considered the extent to which the three areas relating to digital health, ethnic inequalities and cardiometabolic disease are considered together within existing policies. We explored these under the following five themes: policy context for digital health inequalities; representation of ethnicity and ‘marginalised’ groups; addressing digital accessibility, skills and literacy to enable digital health; and the potential for digital in cardiometabolic health conditions. Embedded in each of these themes is the impact of COVID-19, which emphasised ethnic inequalities in health and prompted government action and policy.

Policy context: digitisation of health is embedded in policy and action.

This theme describes the broader context underpinning the specific policies pertaining to each of our three areas for inclusion (cardiometabolic disease, digitisation and inequalities/minority ethnic groups). During the period covered in this review, we observed a continued focus on these three areas of interest in high-level strategy documents for the whole of the health care system (n = 32) (see Supplementary Material Appendix 4, Sect. 1). For example, the first mandate from the Government to NHS England from April 2013 to March 2015 set out expectations and objectives for delivery of health and care in England. This highlighted the need to increase use of technology to help people manage their health and care; the importance of prevention, diagnosis, treatment and management of cardiometabolic disease; and the legal duties of NHS England to tackle health inequalities and advance equality [17]. Similarly, the first objective of the first PHE ‘Our Priorities’ document for 2013/14 was to reduce preventable deaths and the burden of ill health associated with smoking, high blood pressure, obesity, poor diet, poor mental health, insufficient exercise and alcohol; and elsewhere the document referenced the need to tackle the wider determinants of health [18]. The first mandate to Health Education England highlights the role of health and care staff in addressing health inequalities[19]. In subsequent years, government developed these aspects further. In 2017, the NHS mandate included the role of commissioning in tackling health inequalities [20]; and in 2018, both the NHS mandate and PHE remit highlighted the potential of embedding prevention of ill health (including of cardiovascular conditions and obesity) as a way to reduce health inequalities [21].

Against this backdrop, we identified four main ways in which documents described the origins of specific policies: system drivers, such as a move to digital in other national institutions; new and emerging evidence; availability of funding; and public or stakeholder opinions. For example, the creation of the Commission on Race and Ethnic Disparities, supported by the Race Disparity Unit of the Cabinet Office, took place in a context of increased discourse and public concern about ethnic health inequalities during the pandemic, and in the wake of Black Lives Matter protests.

Policymakers have embedded digitisation of health in policy development since 2010, with specific policies introduced across England [22], Wales [23] and Scotland [24]. We identified six strategies related to digitisation of public services highlighting health and care as a key area for change [25,26,27,28,29,30]. The COVID-19 pandemic has driven creation of policies focused on health digitisation at both regional and national levels [27, 28], and use of the NHS apps to support patient access to data [31], and for patients to organise and manage their own health and care [32]. The NHS has embedded these policies into practice including data linkage between primary and secondary care [33], use of electronic booking systems [34], digital consultations [35] and increased uptake of the NHS app [36]. In addition, COVID-19 has also resulted in planning beyond the pandemic, with optimism surrounding the continued inclusion of digital tools within the NHS: “The pandemic has shown the positive changes we can make to how and where we deliver healthcare, and we must lock that in. By accelerating the transition to a new model of community NHS care and supporting the digitisation of services, such as NHS Near Me, we will ensure people get the right care, in the right place, at the right time” [35].

In subsequent sections, we consider the limited focus on ethnicity within policy documents, and given this context, approaches to addressing digital inequalities to enable digital health, and the intersection between cardiometabolic disease, digital health and ethnicity (see Fig. 1 for a timeline of the key policies related to our areas of interest that were published in this period).

Fig. 1

Timeline of the key policies related to cardiometabolic disease, digital health, and inequalities

Representation of ethnicity and ‘marginalised’ groups

This theme focuses on consideration given to specific ethnic groups or communities within policies related to digital health and cardiometabolic disease. We explored this through analysis of language and context, and the degree to which documents included specific and culturally tailored examples of good practice.

Prior to 2020, no documents focussed exclusively on ethnicity and health. Their drafters used the term ‘BAME’ (Black, Asian and Minority Ethnic) in nine of the total documents [14, 37,38,39,40,41,42,43,44], with no or limited focus on specific ethnic groups in the UK. Policy drafts used ‘BAME’ interchangeably and in conjunction with other terminologies such as ‘disadvantaged backgrounds’ [45][46][47,48,49,50,51]; in Northern Ireland, this focuses on regionally relevant characteristics related to inequalities, gender and geographical area, as at the last census, less than 2% of the population identified as belonging to a minority ethnic group [52].

The impact of COVID-19 on minority ethnic communities in the UK prompted shifts in language and a renewed focus on ethnicity. Ethnicity and health were key areas of interest for both the Commission on Race and Ethnic Disparities (which called for the end of the use of the term ‘BAME’ in Government [42,43,44]) and for the PHE report on Disparities in the Risk and Outcomes of COVID-19 [41]. Actions included publication of the first Advancing Mental Health Equalities Strategy in October 2020, development and testing of a Patient and Carers Race Equality Framework [53], and increasing support for research in “more diverse and under-served populations” [54]. A number of responses to a call for evidence from the Commission on Race and Ethnic Disparities considered racism a cause of ethnic disparities in healthcare, policing, education and employment, and identified actions they would like to see from national and local government [55]. Additionally, a number of COVID-19 policies targeted improving outcomes in minority ethnic groups, including the following: establishing a dedicated team to support effective communication with minority ethnic staff in the NHS [56], creating an Equalities Board for inclusive vaccine delivery based on the principle of inclusion [56] and showcasing local engagement with minority ethnic communities [57]. Given the limited focus on ethnicity within the documents identified in the review, the remaining themes focus on the broader consideration of digital and health inequalities.

Addressing digital accessibility, skills and literacy to enable digital health

This theme focuses on digital inequalities and captures the extent to which the policies show consideration for the digital requirements (in terms of both the physical infrastructure and the individual) to support the roll out of any new initiatives. This sets out a broader digital context in which digital health approaches in cardiometabolic disease are proposed and implemented. We identified content regarding the quality of the available general digital infrastructures, access to digital resources (in health and other areas), barriers to access as well as any examples of the types of digital resources currently available.

The Department of Health and Social Care (DHSC) Information Strategy in 2012 set out actions to achieve improvements in the collection and use of information in the health and care system, noting that it must be ‘digital first’ (rather than ‘digital by default’), meaning that while digital methods should be adopted to deliver healthcare, face-to-face contact with health and care professionals are an essential part of care [22]. In the same year, they announced their ambition to become a ‘Digital First’ department, leading a culture change in the health and care sector [58]. More recent government publications, such as the PHE ‘digital first’ strategy, do not define this term [5].

Several policies demonstrated awareness of the need to improve digital access [14, 28, 30, 32, 59]. For example, the NHS (England) Five Year Forward View published in 2014 identified a need to develop “partnerships with the voluntary sector and industry to support digital inclusion” [32]. In Wales, the digital strategy explicitly mentioned digital inclusion; the document recognised lack of internet affordability as a barrier to inclusion [30]. Beyond cost, it identified a need to “understand the links between digital exclusion, data poverty and financial and social exclusion” [30]. Recognising that some of the population cannot use digital services because they lack the skills and competence, the Welsh government ran a digital inclusion programme, ‘Digital Communities Wales’, from 2015 to 2019, focusing on the most deprived areas. The strategy explicitly stated an intention to “ensure no one is left behind as we embrace a digital first approach, keeping digital inclusion at the heart of all we do” [30]. The COVID-19 pandemic has also accelerated the need to increase digital access to ensure equitable service provision across society [30, 35].

Some policies aimed at improving digital access have also focussed on professional groups and settings in health and social care [35, 60]. Leeds City Council specified the importance of digital access for healthcare professionals; the Leeds Care Record (an electronic resource to improve access to patient records for professionals) that operates across health and care services aims to provide the most comprehensive and up-to-date information about patients to clinicians, thereby reducing the number of times patients are required to divulge sensitive information [60].

The potential for digital in cardiometabolic health conditions

This theme focuses on policies that address cardiometabolic disease in the digital space. Four policies explicitly targeted cardiometabolic disease, including specific delivery plans for diabetes [61] and heart conditions in Wales [62, 63], and policy actions for diabetes, heart disease and stroke in Scotland [64]. England set out ambitions for care for cardiovascular disease, stroke and diabetes in the NHS (England) Long-Term Plan [65] and other broader documents. For example, in 2014, NHS England’s ‘Five Year Forward View’ suggested that remote monitoring of patients with congestive heart failure with biosensor technology could improve outcomes and reduce hospitalisations [32]. Similarly, ‘Advancing our health: Prevention in the 2020s’ describes plans to utilise new digital resources to improve the cardiometabolic risk of patients [66].

Additionally, eleven documents that looked at the wider benefits of digitalisation in health highlighted cardiometabolic disease as a clinical area in which digitisation could improve patient experiences [23, 27, 29, 33, 35, 36, 58, 59, 67,68,69]. In 2017, PHE’s digital strategy showcased the digitisation of the Diabetes Prevention Service Programme as an example of how a tailored digital resource had reduced visits to a healthcare provider by up to 25%. In it, theChange4Life Sugar Smart mobile app uses the camera on a mobile phone to scan barcodes on food and visualise added sugar content, and One You addresses health risks in mid-life [5]. NHS Lanarkshire’s digital strategy highlighted hypertension, obesity and diabetes as common conditions for which patients could be supported through Technology-Enabled Care (TEC), with overall aims for TEC to reduce the need for hospitalisation, improve the quality of life, reduce instances of relapse and help to reverse the condition [67]. This aligns with the wider strategy for Scotland where digital improvements included an electronic monitoring and early warning system for cardiac arrests, a clinical decision support system for diabetes [27], a diabetes management patient portal ‘My Diabetes My Way’ [70] and scaling up of remote blood pressure monitoring [35].

The association between cardiometabolic diseases and broader health inequalities was well understood. For example ‘‘… the population is also suffering from the burden of chronic preventable conditions, like obesity, diabetes and heart disease, which are often concentrated in the poorest sections of society” [41], female-specific risk factors [71], and increased risk of some minority ethnic communities of developing type 2 diabetes [66]. Cardiometabolic disease-specific policies also highlighted the need to address these inequalities in service provision, for example in the Diabetes Delivery Plan for Wales states: “Diabetes prevalence is higher in areas of greatest deprivation, and amongst minority ethnic communities. Services should be designed to reduce this health inequality” [61].

The Diabetes Delivery Plan in Wales also highlighted the use of integrated electronic health record data as a route by which prevention programmes can be “targeted at more deprived areas” [61]. However, the Plan presented limited evidence of addressing health inequalities in the design or implementation of these digital opportunities: a case study presented within a scoping review commissioned by Public Health Wales on digital technology and health inequalities demonstrated how health exclusion in diabetes management could be addressed through co-design of a website to support young people self-managing diabetes [14].