Photo by Giu Vicente on Unsplash

Making a list of ‘pros and cons’ is the first analytical technique most of us encounter. The internet is full of templates and guidance, but the basic approach has changed little since Benjamin Franklin recommended it to Joseph Priestley in 1772: make a list of pros; make a list of cons; compare the two; decide what to do.  

Some experts cast doubt on this as a decision making technique. But it is difficult to deny the fundamental premise: all courses of action have upsides and downsides; and good decision making means thinking this through.  

This basic insight is frequently overlooked. The idea for a project on ‘digital downsides’ came about because this seems to be the case when it comes to the use of digital technologies in health and care services. 

Peter Spilsbury’s foreword in the resulting ‘discussion document’ (see below) notes that:

“It is obvious that digital technologies bring both gain and loss. We are reminded of this every day. We might feel the joy of easy access to endless entertainment, while simultaneously regretting the smartphone’s effects on our attention…

[But] In policy, in strategy, in programmes, in organisations and systems – the emphasis is almost exclusively on the upsides and benefits that digital has to offer”.

In the paper, we make no attempt whatsoever to dispute these upsides. Time, experience and evaluation will show what gains digital technology has to offer. 

Instead, we focus exclusively on digital downsides. And we do so primarily from the perspective of ‘person-centred care’: a concept that our partners, and the funders of this work, the Health Foundation have done so much to promote. Our aim is to bring balance to a lop-sided conversation.  

The project was a pleasure to run. A quick skim down the list of experts we interviewed (Annex A of the paper) shows why: it is hard to imagine a more diverse and thought-provoking group to consult with.


We used a wide lens. Rather than focusing down on specific digital technologies, we took a broad definition and sought to examine more general risks and challenges. 

Findings were illuminating – and challenging. To give just a flavour of the experts’ views (and quotes), cited downsides included: 

  • Making care more transactional: ‘With triage through an algorithm you’re only allowed to have one [problem]…It forces consultations to be very transactional’.
  • Compounding disadvantage: ‘Having multiple interacting disadvantages makes it harder to keep with the pace that digital access to care is going at’.
  • Creating disadvantage: ‘We are creating the inverse data quality law: the availability of high-quality data varies inversely with the need for healthcare’.
  • ‘Blaming’ individuals: ‘We use digital products to say to people ‘you should lose weight’ or ‘you have a gambling problem’ – and this puts systemic issues back onto the individual’. 
  • Making Evidence Based Medicine harder: ‘When I tried to get data about how many people were using it [an app they were evaluating], and at what times of day, and then how much it costs to provide, how many staff were doing what – I was told I couldn’t have this data because it was commercially sensitive’. 
  • Attraction to the ‘cutting edge’ rather than the basics: ‘You’ve got finite resources. Do you spend on bytes versus bricks, for example? So, where you invest in cutting edge technology, that might be expensive, and that means you’ve got less to spend on physical infrastructure to deliver care in’.
  • Fuelling mechanical thinking: ‘I’m not so much worried about machines becoming more like us…what I worry about is people becoming more and more like machines…Our work [as clinicians] has become less fulfilling as it has been taken over by mechanistic thinking’. 

The paper describes these and other downsides at three ‘levels’: the Relational, the Organisational, and the Environmental. It concludes by asking whether there is a deeper trade-off: does digital technology promote the technical and transactional elements of care at the expense of the contextual and relational? 

The project was pleasurable, but it was not definitive. We hope to stimulate and open conversation, rather than settle or narrow it: and we hope that anyone with an interest in digital and care finds the paper useful. 

Light brings shade. Advantages contain drawbacks; and we don’t achieve greater benefits by ignoring their costs. And so, by illustrating some items for the ‘cons’ side of the list, we also hope that our paper helps improve decision making when it comes to digital. Can we see what is lost, even when we gain?  

‘It is usual (and typically required) to consider risks to successful delivery; why not risks from successful delivery?’