Scotland has the potential to become a world leader in mainstreaming telehealth, but progress, despite concerns about a rapidly ageing population, has been slow. James Ferguson, lead clinician for the Scottish Centre for Telehealth, explains why, and what the NHS needs to do to move things forward and avoid being swept away
Whilst speaking at a recent conference on care of the elderly at the Royal College of Physicians of Edinburgh, one of my co-speakers referred to the ‘silver tsunami’. This refers to the increasing number of patients with long term medical conditions, approaching or already in retirement. This cross section of the British public is fast becoming a major issue for government, who must address the health and social care needs of a rapidly expanding elderly population.
Issues such as demographic and social changes in the general population, as well as the impact of the largest global recession in over 80 years, means the NHS is currently facing its most challenging period of development since its inception. Financial and resource constraints are making it increasingly difficult to treat the elderly and long-term ill within the traditionally secondary care based model.
The reality of this oncoming tidal wave of an increasingly aged population, combined with the very real threat of NHS funding cuts, mandates a change in the way healthcare services are delivered across the UK. Current traditional pathways of care are likely to be overwhelmed. Redesign to improve efficiency and implement innovative, effective pathways of care is urgently required to maintain care and support for the elderly, many of which suffer from chronic conditions.
The upshot is the NHS must focus on achieving healthcare delivery and value for money by shifting the emphasis on care from hospitals to community-based care. Patients with chronic conditions require increased support to help them manage their conditions at home or close to home. If more efficient ways of managing long-term conditions are not put into practice, the NHS is in danger of being engulfed by the wave.
It is widely acknowledged that advances in modern technology have had, and continue to have, an enormous impact on the quality, delivery and efficiency of public healthcare services. Telehealth home monitoring systems, supplied across Scotland by a variety of providers including Tunstall Healthcare, offer a potential solution.
Telehealth enables patients to stay at home, helps prevent avoidable admissions, supports early discharge and improves quality of life for patients. This benefits patients from a clinical point of view and helps alleviate the organisational burden on the NHS.
One of the key advantages of telehealth is the potential to deliver high quality healthcare to patients in, or close to, their own homes, reducing the need for travel to hospitals to receive care and treatment. This is relevant for all elderly patients and particularly for those living in rural and remote areas of Scotland.
Telehealth in Scotland
In 2006, the Scottish Centre for Telehealth (SCT) was established to support and guide the development of telehealth for clinical, managerial and educational purposes across Scotland. This involves working across boundaries, with industry, academia, local authorities, NHS Boards etc, to develop models for redesigning care.
The Centre’s role is to provide support and advice to NHS Boards and help evaluate and implement the benefits of new technologies, with the aim of making Scotland a recognised global leader in telehealth.
The geographical spread of Scotland with its widely distributed population has always made the delivery of healthcare challenging, but telehealth technology has made this task easier. Its value in assisting clinicians to manage patient’s long-term conditions, as well as saving on secondary care costs to the NHS, has long been recognised and has been demonstrated through numerous pilots and projects carried out across the country.
The SCT identified the potential use of telehealth in the management of Chronic Obstructive Pulmonary Disease (COPD) in Scotland as a priority area of work and commissioned a report to: 1) review key reported studies, 2) detail the COPD telehealth projects known to be ongoing both in Scotland and elsewhere, 3) introduce, examine and propose options for the use of telehealth nationally to manage people with COPD in Scotland.
In 2009, an evidence session held by the Scottish Parliament’s Health and Sports Committee with the SCT reported that excellent work was being undertaken across Scotland on telehealth development. Telehealth systems had been widely used in Aberdeenshire and The Highlands, with one project leading to a 100% reduction in emergency admissions for patients with chronic cardiac conditions.
However, concerns were raised that progress with widespread implementation was not occurring at a rapid enough rate. Nearly all the applications reported had been on a small scale and a lack of large-scale evidence meant reliable measurement of the potential benefits was unavailable.
There was varying feedback on the benefits of telehealth and, whilst some pilots may say that telehealth has been 100% successful, others have indicated that workload was increased by its use.
However, despite the lack of widespread usage and quantifiable results, the majority of applications report discernable benefits in various areas, including patient and carer satisfaction and secondary care admission reduction. To truly observe, derive and measure mass scale benefits from telehealth requires its usage to transform from pilot studies to mainstream usage.
A national agenda
To drive this agenda, the SCT is planning to establish a national home telemonitoring service for COPD patients to monitor and record the effects of telehealth on a wider scale.
Initially, existing telehealth users from a number of different areas across Scotland will be recruited to pool together data to give a better picture of its current effectiveness.
Parallel to this, the first phase of a national telemonitoring service will be constructed consisting of four health boards reflecting urban, rural, semi-rural and island areas of Scotland.
Once established, if this platform proves to be effective, the remaining health boards will have the opportunity to join the service, creating a truly nationalised service.
Obstacles and vision
It is not enough just to plan the widespread uptake of telehealth. An important element of progressing the telehealth agenda in Scotland centres around overcoming obstacles to telehealth implementation, which currently exist within the NHS.
Examples of barriers to implementation include cultural resistance and fear of change, lack of training amongst clinicians and health professionals in telehealth technology, protection of vested interests amongst certain health professionals and a narrow focus on traditional ways of delivering healthcare.
Many clinicians are unaware of the non-clinical benefits of telehealth, such as cost savings, and so are not incentivised to change the way they work. Awareness of the tangible benefits to patients, healthcare professionals and the organisation in general must be raised to encourage integration of telehealth into their working practice. Clinicians must be convinced and confident that telehealth is best practice in their sphere of influence.
A major factor slowing progress is the lack of clinical confidence in telehealth. Many clinicians raise concerns that patients may feel that the level and quality of care they receive via telehealth will be inferior to the care they receive face-to-face.
In fact, the vast majority of patients, who have participated in telehealth, have proven to be enthusiastic and satisfaction is very high. One tactic to drive the agenda forward will be to recruit patient groups to present their positive feedback to clinicians.
It is not solely clinicians who need to be convinced. Organisational confidence to buy in to telehealth is required for telehealth to go mainstream. A significant driver here is the economic climate.
To engage health boards and other bodies, business planning must be undertaken clearly demonstrating the potential long-term, clinical, organisational and cost benefits resulting from mainstreaming telehealth across Scotland.
Driving the agenda
What drivers may push the telehealth agenda forward? Two factors highlighted by the SCT are:
• Incentivising health boards and clinicians to adopt telehealth
• Ensuring telehealth is mainstreamed into the education and training of all health care professionals.
The approach adopted by the Government to encourage health boards to use telehealth systems has, to date, been largely unsuccessful. There is ongoing frustration at the continued failure of telehealth projects to achieve the critical mass required to become mainstream options for the delivery of care by health boards.
Whilst, many boards have undertaken effective pilot projects, there has been no real incentive to ensure telehealth development overcomes the cultural resistance which has prevented its widespread use.
In light of this, a two-year strategy has been developed by the Joint Improvement Team, in association with the SCT, which outlines the first phase of an approach to develop and deliver telehealthcare education and training opportunities in Scotland.
Stakeholders, who have been identified as potentially benefitting from telehealthcare training include; senior strategic and operational managers, GPs, nursing professionals, social workers, allied health professionals, equipment installers, home carers and service users.
The strategy will involve a two-pronged approach:
• The inclusion of training in telehealthcare in the core curriculum of the emerging telehealthcare workforce
• The development of accessible, Scottish Qualifications Authority (SQA) accredited training and CPD opportunities for staff already working within telehealthcare services
As telehealthcare education and training is new ground, robust review and feedback mechanisms will be employed during this two-year strategy to enable the approach to be adjusted and refined as necessary.
The power to make a difference
Scotland has the potential to be a world leader in telehealth. A major problem for the SCT in driving forward the telehealth agenda has been the advisory nature of its original remit. A review by the Scottish Government of the SCT undertaken in 2009 identified it being hosted by a regional health board, rather than being part of a nationwide NHS body, as possibly creating a perception that telehealth is only relevant to remote and rural health services. This may have limited the SCT’s credibility in encouraging clinicians and health boards to take up telehealth as a mainstream delivery tool.
A recommendation from the review was that the SCT integrate with Scotland’s answer to NHS Direct, NHS 24. This integration occurred in April 2010 and will provide the national platform required to ensure telehealth is given the focus it deserves within health board planning, and should lead to more innovative solutions to redesign healthcare in Scotland.
During the 20th century, the biggest challenge facing the healthcare industry was what to use to diagnose, treat and cure ill health; this resulted in the discovery of medicines such as Penicillin and imaging techniques such as MRI.
The challenge we face in the 21st century is not what we use to deliver healthcare, but how we deliver it equitably, and advances in communications technology have presented us with a solution.
Telehealth technology has a vital role to play in revolutionising healthcare in Scotland, and it is this point that needs to be driven home. The question is how will the NHS in Scotland harness this technology to deliver efficient and sustainable services for patients?
The healthcare environment is ripe for Scotland to move forward and become world leaders in mainstream telehealth deployment. The continued failure of the NHS in Scotland to capitalise on successful telehealth pilot projects has been very disappointing. However, if the measures outlined here are successful, then Scotland could become the first country to establish national-scale telehealth services.
Scotland has the opportunity to lead the way and we need to grasp this opportunity as the silver tsunami is coming, and healthcare, like it or not, is changing. In the words of the great singer song-writer Bob Dylan, “You better start swimming or you’ll sink like a stone. Because the times they are changing.”