Economic growth is increasingly driven by the skill of the local workforce and more specifically confidence and competence in using digital technologies.

This is one driver both of the significant success of India in recent years compared with Pakistan, and the desire of our own government to address the skills deficit in the British workforce, particularly in the "workless".

So it should be frightening that 39 per cent of the population does not use the web and only 50 per cent of homes have internet access. Perhaps more frightening is that in healthcare, with the best of intentions, we recognise this divide and then reinforce it. We enhance a two-tier system in which as we develop services we design them for the IT literate while maintaining secondary systems for those currently excluded.

Work in health inequalities has taught us that interventions not designed to address exclusion will reinforce it. As the middle class and articulate are early adopters of new services and emerging knowledge, they tend to make full use early of NHS freebies. Smoking cessation interventions are a salutary example of how we often first maximise inequalities, before realising we need to target, design and market services if want real impact for those most at risk of ill health.

Likewise if we do not begin to develop applications of digital technology designed to address inequality we shall reinforce the digital divide by default.

A key challenge is often that surely access to technology would come higher on Maslow's hierarchy of needs than the basic concerns of housing, wealth and health which dominate many people's lives. Increasingly, digital technology will become key to them, starting with wealth, or at least work.

If we are complacent about the digital divide we reproduce the NHS fallacy that by definition poor populations generate poor health and poor services. To make a difference to health status, health outcome and health experience, we need to use every tool available to us, including the virtual ones.

But there is still a considerable overlap between social exclusion and digital exclusion. So we need to be creative in developing targeted digital applications in health if they are to help bring people into the digital age rather than act as a further barrier to service use.

Our organisations need to commit investment in the use of digital technologies to tackle inequality, including partnerships with those more skilled in adapting digital to new markets than we are. We will have to invest in technology beyond the limited interventions of the national IT programme.

It is not uncommon for frontline clinical staff to share desks with five or more staff, while British Gas engineers visit our homes with laptops and portable printers.

Our high-risk groups for coronary heart disease and sexual health conditions tend not to respond to letters yet we do not routinely use and update telephone numbers, even though locally the take-up is 90 per cent when we contact patients that way.

A key issue is that in recent years technology in the NHS has tended to be "pushed", with compulsory national interventions and uptake targets incorporated into punitive performance regimes. Not generally recognised in the literature as the way to achieve significant adoption of new tools and ideas, those areas of high uptake of IT have tended to be where clinical systems are developed to meet the expressed needs of particular groups. Try to separate most GPs from their favoured system - and then consider early retirement as an option.

Some of the core standards required by NHS Connecting for Health are long overdue, but how much greater might impact and take-up have been if the national programme had been designed to be compelling rather than compulsory?

The issue of generating interest and desire in the user becomes crucial once we consider digital applications with patients and the public.

Initially the digital divide focused on differential access to hardware and more recently broadband, but this area is falling to market pull. The "one laptop one child" initiative has invested in developing $100 computers for the developing world, city authorities are investing in public wi-fi and handheld game devices include connectivity as standard.

The new barrier is basic IT skills, now being addressed through voice technology, increasingly intuitive technology and assertive investment in schools, with 90 per cent of 16 to 24-year-olds now IT familiar if not fully literate.

The key barrier now is attitude and interest. Our most disadvantaged communities are often our most disappointed, with learned low expectations and limited appetite for new experiences. We really need to understand what the added value of new technology might need to be, for people to want to use it.

If this sounds obvious, why is HealthSpace, the personal health organiser, going to be one of the last components of CfH and, as it comes online, why are we making giving away one's organs the big opportunity?

As a specialised commissioner I am all for active promotion of organ donation, but as a patient I'm not sure that I want to be confronted with that as one of my first digital health interactions. This is a sign of a site designed in the interests of health providers, rather than responding to potential users.

While digital technology has a huge amount to offer everyone, paradoxically it could have disproportionate benefit for the currently disadvantaged.

If we do not set out to tackle current prejudice about the digitally deserving and Luddite dinosaurs, we will reinforce exclusion and only begin to make a difference when we start to design for the interests and foibles of our patients rather than ourselves.