Official Report 278KB pdf
Agenda item 3 is our inquiry into the clinical portal programme and the Scottish Centre for Telehealth. The committee will take evidence on the development of the clinical portal project in NHS Scotland and then follow up the evidence session that it held in June 2008 with the Scottish Centre for Telehealth. The evidence-gathering process will conclude next week, when we take evidence from Scottish Government officials. The intention is to follow up any issues that arise via correspondence with the Cabinet Secretary for Health and Wellbeing. Any such correspondence will be published on our website.
I am a consultant anaesthetist and one of the two joint e-health clinical leads in NHS Tayside. The other e-health lead is a general practitioner.
I work for NHS Greater Glasgow and Clyde as an emergency medical consultant in the accident and emergency department of the Southern general hospital. I am also one of the health board's clinical e-health leads.
I am a consultant in the high-dependency unit at Edinburgh royal infirmary and a part-time Scottish Government e-health clinical lead for secondary care.
I am a consultant colorectal surgeon and clinical lead for e-health in NHS Highland. I am also co-chair of the clinical change leadership group.
I am a GP in Clydebank and chair of the primary care information technology committee in Glasgow. I am here to represent the British Medical Association.
I am knowledge and research manager at the Royal College of Nursing Scotland. I am here to give evidence on behalf of nurses, midwives and allied health professionals as part of the e-health leads network.
I thank the witnesses for the papers that they have provided to the committee, which are helpful.
May I ask you a question, convener?
Yes, if you want to. I was trying to start the discussion.
I was not going to say anything before the eminent people in front of us did, but I want to be sure about something. Most, if not all, of the papers mention telehealth and telemedicine. Will we talk about only the clinical portal project today or will we stray into other areas?
We will do both. I hope that we will clarify what the different terms mean.
That is fine.
The papers tried to tease out matters for us. Language gets intermingled and things get difficult, but I hope that the public as well as committee members will begin to understand the terms.
A clinical portal is a system that sits above several other systems. We have many systems, which all have bits of the electronic patient record, but no system has the complete picture. The clinical portal sits above those systems and knows which ones hold parts of the clinical record for any patient. It can interrogate the systems and then present the information that it gets from them as if it were a single electronic patient record. The clinical portal is therefore a virtual electronic patient record that takes its feed from many different clinical systems.
Is that a particular computer programme that is designed to do that?
Yes. It is a computer application.
We need to get away from thinking that the clinical portal is a single IT system that we can procure and that everyone will then implement. As Cliff Barthram described, the mechanism for delivering information can be developed in a number of ways. Health boards have several different options for delivering information using clinical portal technology, but each board will have the opportunity to deliver that in a way that suits its own purposes.
I see. I could not therefore just buy a programme off the shelf and put it into my computer to extract the required information.
A clinical portal is not just a static view or window into the information in various systems. Portal technology will also allow us to move into the system and interact with it without having to reselect a patient. It is a sort of seamless integration with the underlying feeding systems and is not just a view—I have heard it described as a view and do.
As Dr Kelly pointed out, the clinical portal is not just a single piece of software; it is more a methodology of looking at information. It works only if the underlying feeds for the data are indexed correctly and have what are called metadata attached to them, which tell us what type of information it is and how it fits into our index. Without that, whatever technical solution we purchase to provide a portal view will not function.
I know less about the technology. However, from a GP's perspective, when I come in in the morning, I switch on my computer—
I am beginning to like your language. I was getting lost as well. I like the bits beginning with switching on the computer—that is a start.
I just switch on the system that I use to look at my patient records. At the moment, that is just my system, and no one else looks at it. In theory, however, I could come in in the morning, switch on the computer and go in through the clinical portal. I would still have my clinical system, and I could type in everything about a patient and look at information that I have added. However, I could also look at, say, Dr Gordon's system if my patient had been to accident and emergency the night before, and I could find out what he had done with the patient. If my patient had been admitted to hospital, I could see that, too. If the system was switched on to let it happen, I could see the patient's hospital appointments, results from their hospital attendance and so on. The portal would therefore allow me to see information that is not in my computer but in someone else's.
A further example of what the clinical portal could mean is that nurses will be able to access a range of information that is currently not available in electronic form. A district nurse will be able to look at, for example, a patient's discharge letter or their medication history. For people in an acute setting, the nurse will be able to look at a range of information and make much easier and better decisions for patients. It will also enable a much clearer understanding for the patient care that nurses, allied health professionals and midwives can deliver.
It is important to point out that that information is not freely available to anybody; it involves controlled access by authorised users only. There is an audit trail of who has looked at what, down to the level of individual items of information. For example, if Dr McDevitt looked at a letter from the A and E department for a patient who had been there the day before, it would be logged on the system that he had done that, even if he did not add anything to the system at that point.
Do committee members have any questions?
I am having difficulty getting my head around what you are saying—the system sounds like a huge Google for health records. According to the information that we have, the GP record to which Dr McDevitt has access is the fullest electronic record that is available. Can someone in A and E change and update the GP record? Will the GP record eventually become the main record, which people can update from wherever they are, or will the system be for people to update a record that is viewed by the GP but is not part of the GP record?
There is no intention to allow anyone other than the GP to update the GP record. Most clinicians would not want someone else to change their record, as it is important that the clinician who creates the record is responsible for its content and able to justify what is there. At present, it is not intended that people should be able to change the information that is on someone else's system. The portal is more about how we share what we create. Each clinician creates their own record but allows other people to see that record when it is relevant and they are authorised to do so.
As Dr McDevitt said, clinicians must be authorised to see records. Let us take the example of a stroke patient. As a colorectal surgeon, I would see a summary of the patient's stroke episode. However, if I were the stroke physician, I would be able not only to see that record but to access the stroke system and make changes to that. As a colorectal surgeon, I would not have access to that system. People are responsible for the data on the system. As Dr Gordon commented, everything must be authorised. As a colorectal surgeon, I will be able to look at certain things but not to alter them. If there were a surgical system, I would be able to alter that and there would be a full audit trail.
It is clear that clinicians generally do not need or want access to all information that is held on every system—they want a summary of essential information. The national survey that we undertook revealed clearly that it is important to share certain aspects of the GP record, such as drug history, information on allergies and past medical history, but that it is neither relevant nor appropriate for clinicians in secondary care to know everything that has been discussed with a GP. The point of the portal technology is that certain types of information can be presented in a format that can be shared through the portal. It is not necessary to provide access to everything that is held on every database.
I understand that it may not be necessary for some other person in the health service to see information, but who makes that decision? You cannot decide what information you do not want if you have never seen it.
Some of the information that is currently held—for example, on a patient's psychiatric history, which may include a history of depression—is held confidentially and relates to discussions with the GP. It is relevant for me, as a secondary care clinician, to know that someone has a history of depression and what treatment they are receiving, because that may influence the treatment that I give to them. It is less important for me to have a detailed description, based on someone's discussions with a psychiatrist or the GP, of why they may be depressed. It is clear from the survey that we carried out that clinicians do not want to be bombarded with lots of information—they want a summary of information that is essential for them. There are certain key elements that are critical to making safe clinical decisions.
You have indicated why you do not want the information, but you have not answered my question. Who takes it on themselves to look at the record, to decide what information you will not want—without necessarily asking you—and to provide a summary?
The survey that we carried out identified core pieces of information that clinicians across Scotland said are important to them. That is the information that we want to concentrate on delivering in the first phase of the portal.
We dealt with the question of who gets access to what information about 18 months ago in NHS Tayside. We have an information governance group, which has representation from among GPs, allied health professionals, IT security people, secondary care clinicians, managers and, most important, patients. All those people are stakeholders in the information. Questions of what information it is appropriate to share and to allow to flow are decided by that group. Then, we have to communicate the decision to clinicians and make it happen in practice.
I have a point on the same topic.
We will hear from Dr McDevitt first—and Ian McKee is ahead of you.
That is fine.
In an ideal world, the patient would decide exactly what information is shared. We are constrained only because that would be time consuming and technically challenging. As it is, the rest of us have to come up with the best option. Discussions on the issue have been going on for some time in both England and Scotland in relation to emergency care summaries. We have been cautious in Scotland about the nature of the information that is shared and how it is shared. There are divergences of view even in that, and the issue has challenged us at times.
I am interested in what I would call the electronic footprint of the patient. The information might not be desperately confidential, but it might reveal something. For example, somebody may be concerned about a sexually transmitted disease but not want to go to their GP. If a consultant does a haemoglobin or other test, the laboratory results will be recorded, and if the GP looks to see what tests have been done on the patient and finds that someone who is not him—or her—has done a haemoglobin test, they will find out where their patient has been. There might be other similar circumstances in which some fairly innocent information will show what someone has been doing.
As well as those two questions, it might be helpful if I gathered up Dr Simpson's questions before I ask the witnesses to respond. We will then hear from Ms Kiely, Dr Gordon, Mr Docherty and Dr Barthram—in that order.
As a clinician, I experienced the problem at the other end when we tried to get shared information from social work and voluntary organisations that were pertinent to the patient's care. We ended up with a 75-page protocol document, which was being discussed when I left. If such protocols are being reinvented across every health board, is that the most efficient way to go about things? Should we not have some nationally agreed protocols? I entirely accept we should not go down the route of having a national spine, as has happened in England. I like the concept of a portal that can interrogate individual systems, and I like the idea of patient control.
I will also allow a question from Helen Eadie, who has been waiting quite a while.
My question is on how NHS staff members will access the portal. The BMA Scotland submission expresses concern that the sharing of passwords and user names, which happens to quite an extent within the NHS, could lead to information about patients being shared inappropriately.
I think that Mary Scanlon also has a question. Is it also about confidentiality?
No.
That is okay. We will come to Mary Scanlon's question next.
The clinical portal technology project should improve the security of patient data because staff will have a single log-on identity rather than multiple log-ons. That should go some way towards removing any reason to share any log-on details.
Perhaps I can quickly answer Dr Simpson's question on whether we are using the portal—the answer is that we are. In NHS Greater Glasgow and Clyde, we currently have 1,300 users logged on per week. Users within the health board areas that have access to our portal access more than 65,000 results and almost 20,000 documents per week.
If an individual patient wanted you to have greater access to their records, and authorised that, could you do it for that one patient?
No. At the moment, the only thing that I can get is their medication history, which is restricted to an emergency contact with secondary care. Under the current confidentiality rules, if a patient comes to an out-patient clinic or is admitted as a routine, that information cannot be accessed.
Why?
Dr McDevitt should perhaps answer that.
That is not currently possible as the technology is not in place. There is the alternative technology of the emergency care summary, which extracts information from GP systems on everyone's records unless they have opted out of it. It allows anyone—usually in emergency care situations—to ask the patient whether they can look at their record and, if so, provides a list, mainly of medication and allergies.
I would like to pick up on a number of points. Dr McKee talked about haemoglobin being checked in a sexual health clinic. There is a national sexual health system. If I turn up at a sexual health clinic, I will be asked my name. Many patients use Joe Bloggs—they do not give their real name. They can give their real name if they want to, but they can say that they do not want their GP informed, and they will be given a unique identifier on the national sexual health system. Their haemoglobin will go to the labs and the results will come back to the local repository, which is the Scottish care information store. The results will be anonymised—no one else will be able to look at them; they will be available only to the sexual health clinic.
What do you mean by a direct clinical relationship?
If a GP phones me up, says that Donald Duck has these blood results, asks whether they need to send them to me for an opinion, and I look at the patient's blood results on the electronic system and see that they have had an ultrasound scan, I have a direct clinical relationship with that patient. Although I have not physically seen the patient, I have been asked by their GP to get involved. However, if I have no clinical relationship with Sally Duck, and I look up her results because she is my next-door neighbour, that should be picked up, and I should be censured. In future, NHS Scotland must pursue high-profile cases against folk who breach confidentiality. We must be able to catch them and prove that they have done wrong—they have broken all the codes of practice and must be punished. If that were done in high-profile cases, people would stop sharing passwords.
Do your computers not shut down after a short time? Ours do if we leave them.
No. The computers in a ward never get time to shut down, because there is usually someone looking over your shoulder asking, "Are you finished with that? Can I get on there?" That is why we need the technology to be able to log people in and out very quickly.
You have helped greatly with my first point, but I need a bit more convincing—I am sure that you can convince me—about the ability of the software to detect illegitimate use. Suppose that you were in a hospital and you looked up your next-door neighbour's details for your own purposes. How would the computer tell that you did not have lawful access when you would have had it if the patient's GP had telephoned and asked you to look up the data? Is it sophisticated enough to sort that out?
I will pass that to Cathy Kelly, because she has more input.
That is fine. It will take one off my list.
In Wales and NHS Lothian, an automated system is being piloted that can produce exception reports. It is possible to ask it to audit how many times the results of people who are not currently in-patients or out-patients have been accessed. That mechanism reduces the time that is spent manually auditing access to information. For example, if a VIP patient came in, we could find out how many times somebody accessed that person's information and manually see whether they had a relevant clinical relationship with them. Similarly, it would be possible to see whether members of staff with the same postcode as a certain patient were accessing that patient's information. Different types of report can be set up in each organisation, taking away the need to spend hours manually processing information.
I can understand how that would work if Tiger Woods came into your hospital.
I wonder why you picked that name.
However, it would be more difficult if it was an old friend of a staff member.
If somebody is currently not an in-patient or out-patient, there is little reason why a staff member would need to access their clinical record. No system will ever be 100 per cent fail-safe, but we try to put safeguards in place to ensure that any abnormal activity is picked up early and can be followed up manually in a way that allows the limited number of staff who are available to do that using resources appropriately.
It would be a mistake to focus entirely on technical solutions to confidentiality. It is more important that we have training and support and ensure that everyone has a username and password. Those need to be obtained immediately prior to somebody commencing work within the NHS and not some time afterwards, which is frequently a problem, because the support mechanisms are unable to cope with the rapidity of changeover, particularly of junior doctors, and the increasing number of locums that we have to use nowadays. We also have to spend more time educating junior and, unfortunately, senior members of staff about their professional responsibilities in relation to confidentiality and computers. Those responsibilities are no different from those that apply to paper records.
It is important to put the issue in context. With paper notes, there is no audit trail to show who has looked at what. Someone with no relevant clinical relationship with a patient can look at their notes and nothing is left behind to say that that has happened. With an electronic system, there are electronic fingerprints all over what is done. Password sharing is a big problem, as that breaks the audit trail. If someone looks at notes that they should not be looking at but they have borrowed someone else's password, that breaks the security trail and two people are potentially in trouble over the accessing of those records.
I agree with a lot of what Dr Gordon and Dr Barthram have said. Predominantly, GPs expect to share information with other professionals rather than take information in, but that is because we have had the luxury of quite good IT systems so far. We need to know who is accessing the systems, but we know that the current methods of doing that are not right. That is probably true even in my practice. At the moment, 24 people can look at my patient records. I do not know why they would all want to look at them; they might be looking at their neighbours' records. They would be sacked if we found them doing that, but it is sometimes hard to detect. That is the situation with only 24 people; in theory, everyone in the NHS in Scotland could look at a patient's file.
With regard to securing the best for patient care and taking forward clinical portal technology, I reiterate Dr Gordon's point about training and support. Training helps clinicians to understand and engage with the new technology and ensures that, with issues such as access and signing on, the required professional practice is reinforced.
Did you say that patients were going to be represented on the board?
Yes.
I point out that a director of nursing from NHS Lothian is a member of the clinical portal programme board, so nurses, midwives and allied health professionals are represented on it.
I return to information governance. Delivering health care by using a system that eliminated trust would be a tall order. An element of trust will always have to exist between health care professionals and patients about how we deliver good practice.
That is helpful. Mary Scanlon has been patient; she can ask her questions now.
I have only three questions.
I knew that—that is good—but the questions will be in several parts.
It is worth putting it on record that I read all the papers last night, and they were interesting but alarming. One submission says:
It does.
Oh—it does now. I was told that that was up for grabs.
I am never disappointed, Mary.
The answer is that there will not be one single system, as that would not be appropriate. If we tried to have a single electronic patient record, we would run into even more issues about information governance and data sharing, so that is not the plan. The work in Tayside and Glasgow is not a pilot—the health boards in those areas have chosen to do that work to satisfy their business needs, and they will continue to do so. The national clinical portal programme is looking at the lessons from Glasgow and Tayside. It is considering why they have chosen to develop their portals in that specific way. The programme is considering whether we can use that work for other health boards in Scotland.
In the NHS Lothian internal audit report on the e-health strategy, the overall evaluation is unsatisfactory, and for objectives C1 to C3 the rating is unsatisfactory. We are told that the board has purchased
I wonder how the official report will deal with those comments on Viagra and impotence.
Accurately—verbatim.
I do not mind that malapropism being recorded.
For the benefit of those who were not present, we had a discussion before the meeting about what the official report does. The word "verbatim" was mentioned. What was the other expression?
Substantially verbatim.
I will let Mary Scanlon in again on the same point after we have heard from Rhoda Grant.
I have a short supplementary. I am surprised by the information that Dr Kelly has given us, and I wonder how interactive all the different systems will be. Many people like me live in one part of the country for half the week and in another for the rest of it. People travel around. If I were run over by a bus in Edinburgh, I would want the hospitals in Edinburgh to be able to track down any important information on me that was stored at home.
Richard Simpson summarised my concerns. When Dr Kelly talked about the plethora of systems, the one thing that she did not say was when the patient will have their own electronic record. I would like to know that.
I want to take all the questions together. Michael Matheson has the next one.
Staff training has come up as a key issue for the effectiveness of the system: a computer system can only be as effective as the information that is put into it. I am interested to find out how much training was given to staff in NHS Greater Glasgow and Clyde and NHS Tayside as the portal was being developed. Was training sufficient to ensure that the portal would be used effectively, or have deficiencies been highlighted that have resulted from a lack of training on how to use the system most effectively?
We have had questions on a single system and on training for a variety of systems and the difficulties that that would impose on NHS boards and individuals.
The interactivity of systems is dictated not by the portal technology but by the underlying systems that feed it and their ability to deliver information that is correctly indexed to information services division standards. We need to put more effort into that. Provided that the data that we want to look at in the portal can be exported from the generating systems with the appropriate indexing information attached to them, it will not really matter what we lay over the top. It will not matter how many systems we have; we will be able to share data effectively across all the systems.
I have not forgotten that Mary Scanlon has more questions to ask. We will hear our medical professionals first and then come back to Mary.
Dr Gordon has covered a lot of what I was going to say about the single system and the training that is required.
I think the committee perhaps misinterpreted what I said earlier about the fact that we would eventually move towards one or two systems. That was not to say that nothing is happening in the meantime. The results of the discovery project, which will tell us exactly which components we have for developing clinical portals in other boards, will be available at the end of this year, in the next few weeks. On the basis of that, we will identify the other components that we need, whether that will involve a full procurement or whether we already have access to some of them. That will happen early in 2010.
In the remit that we gave the developers when we were working on our portal was that, if they came up with something that needed a manual for training, we would not accept it. The system had to be absolutely intuitive: one had to be able to use it without having ever seen it before. That is important in terms of transferable skills, because we have a very mobile junior workforce in the NHS. There is a national standard—the NHS common user interface standard—for how clinical systems should look and behave. Most of the system suppliers are now looking at that in terms of how they build the pages with which clinicians interact. We hope that that will start to eliminate some of the training needs that we had in the past, when lots of systems had different looks, data-entry screens and ways of navigating. I think that such differences will start to disappear.
I would like to respond to Dr Simpson's points. IT will not solve all the errors that he mentioned. It will certainly help a lot, but it is about how clinicians use that information and are able to recognise it for what it is. For example, if someone sees a list of the medications that I think someone has been taking, then gives them all to the patient when they go into hospital even though they have not been taking those medications for six months, there is a danger of harm.
I am going to move on to Mary Scanlon's second question.
My third question will be about telehealth; I would like a discussion on that before witnesses leave today.
The technology that makes clinical portals possible also has an application for patient portals, and some complementary developments are happening at the moment. The knowledge services group in NHS Education for Scotland has been involved in developing a number of patient information portals and is tackling some of the issues to which Mary Scanlon referred so that patients can access information that will help their decision-making. For example, one of the roles of nurses could be in knowledge transfer to enable patients to access suitable information and to help them to make sense of what might now be available to them electronically.
Were you at the launch of the managed knowledge network in April 2008, and are you part of the integrated national health information and support service that was launched in April 2009?
No. What I am referring to is—
I appreciate that but I am honestly trying to understand this.
I am afraid that I am not able to comment on that.
I am sorry; I was slightly distracted when that line of questioning was going on. Mary, maybe those questions would be better put to the civil servants who will come to the committee. From the reactions that we are getting just now, they are probably not questions that can be answered by today's witnesses. They are on the record now and we will ask the officials when they come before the committee.
It is national health information.
Before we leave the subject of the transfer of information, can I ask one more question?
Certainly.
I want to ask about the exchange of information, although the point that was made about lab reports has answered part of my question. I visited a GP's surgery where the staff were laboriously typing in lab results that had been printed from a computer somewhere else, which I thought was one way of getting misinformation. Is there a way of transferring that information electronically, as perhaps happens with prescriptions? If there were a computerised system, people could copy and paste the information rather than printing it out and retyping it or scanning it.
There are systems that can transfer the electronic information, not just a picture of it. At the moment, we tend to scan in a picture of the result, but that does not allow the numbers to be searched for. If we want to search the information, people have to scan in or type in the information from the pictures.
Dr McDevitt has said most of what I was going to say. General practices have access to their patients' information on the Scottish care information store, which is a repository of common laboratory results and radiology results. Each health board has at least one store.
Ross Finnie and Richard Simpson have questions, which they will ask sequentially, after which you may, if you wish, answer Mary Scanlon's question on telehealth. If you feel that you do not want to comment on telehealth, that is fine, because our next panel will deal with that issue.
This has been an extraordinarily interesting discussion. Are cost restraints inhibiting the development of the portals across the country? Can you provide information—now or in writing later; I appreciate that the information might not be readily available—about the cost of developing the portals in Greater Glasgow and Clyde and Tayside? That would enable the committee to form a view about the overall cost of developing the portals, given that the initiative is not going to be rolled out but will involve work being done by elements within health boards. Once we have an idea of the overall cost, we will be able to take a view on the suggestion that it will take 10 years to implement the initiative across the country. Mary Scanlon and Richard Simpson both recoiled immediately at the suggestion that another decade might pass before we move into the 21st century.
Dr Gordon's opening remarks are fundamental. We have developed a system in which everyone has been doing their own thing and has their own pieces of software at local level. Although the systems are being merged and there are now some national guidelines, we have a long way to go before the old systems are no longer in place.
It is infectious.
The general practice administration system for Scotland—GPASS—is, in effect, being dumped after 25 years, and we are going to have EMIS and Vision. I understand that those systems have extremely clunky back ends.
That is a technical term.
It is very technical. Will those systems be capable of being interrogated by the existing portals in Greater Glasgow and Clyde and Tayside?
I ask you to respond to the question about funding and the technical question about clunky back ends. Who is driving the work so that we do not continue to have clunky back ends? I think that that is where Dr Simpson was going.
On the costs, my financial colleagues have been struggling to tease out the costs of the portal for us in Tayside because it has been part of our e-health strategy for so long. The bottom line is that I cannot give you a figure because it has been an incremental process and the cost has been low. We did not go out and buy portal technology. We did the work as a collaborative development with In Practice Systems Ltd, and it delivered what we need. I am sorry that that is probably an unsatisfactory answer.
I will back up what Cliff Barthram said. The technical people who have been involved in the clinical portal programme feel that moving to the new GP IT solutions of EMIS and Vision will allow much more flexibility to share information than we have with GPASS and the other GP systems that are in use. Similarly, health boards' moving on to use the new patient management system—Intersystems TrakCare—will make it much easier to share information. Although we plan to implement the portal technology in all health boards in the near future, how that is done and the mechanism through which information will be shared might well change in time.
You cannot, however, provide us with any figures.
The clinical programme board estimate is between £10 million and £15 million.
Unfortunately, I have no information on costs that I can share with the committee. The GPASS system will be respectfully retired in 2012. It has served us and the patients of Scotland well—to say that it has not would be to do it a disservice—but it has had its day. We are moving on to two new systems, EMIS and Vision. The two commercial companies that are responsible for those systems have joined together in partnership to deal with issues of information transfer, to ensure that they can transfer information to our other systems easily. The new systems are much more technically able than GPASS was, although they are also more complex in other ways. We can look forward to that change. It will not make the process any harder—it should make it much easier.
Unfortunately, I cannot give you precise figures for costs for NHS Greater Glasgow and Clyde, partly because we have been as opportunistic as possible in how we have developed our portal. Most recently, we have had a big push on and a big improvement in content and usage, by linking portal development to the opening of the new ambulatory care hospitals at the Victoria infirmary and the Stobhill site in Glasgow. Some of the IT that was necessary for those institutions facilitated development of the portal. We were able to offset some information provision against their development.
As a final point, does anyone have any comments to make about the use and development of telehealth? Do not feel obliged to comment.
My practice participates in telehealth on a small scale in that we have links with the GP hospital in Campbeltown and a variety of other community hospitals on the west coast of Scotland. The GPs contact us about patients and we can facilitate discussions with those patients by providing access to their X-ray images, for example. The ability of portal technology to provide more information than simply X-ray images—such as background information about those patients—would enhance the consultation process enormously. The portal has a lot to add to the concept of telehealth and telecare.
In NHS Highland, telehealth has the potential to have a great impact. We use it to a degree at the moment. The picture archiving and communications system is probably one of the best examples of telehealth that is available in Scotland at the moment. Very few hard copies of X-rays are now printed—they are all digital. If I break my leg in Edinburgh and go back to Inverness for treatment, the folk in Inverness will be able to look at my X-rays there and then. We use PACS extensively for supporting remote and rural surgeons in carrying out cancer surgery. We also have a multidisciplinary meeting on gastrointestinal cancers on a Friday afternoon. Raigmore hospital has been the main site, but the meeting involves clinicians in Wick, Belford hospital, in Fort William, and Stornoway, in the Western Isles. The clinicians all communicate by videoconference, sharing images and pathology. We then design a management plan that we recommend to the local clinicians for when they speak to the patients. That is a good example of telehealth.
Was it a technical failure?
Yes. The problem is that it is difficult to get hold of someone in St Andrew's house to fix the connection. I phoned the local bloke in Raigmore hospital and he told me that it was a busy line and that we needed someone in Edinburgh to fix it.
That is the story at the Parliament building, too—it is hard to get someone to fix the link.
Meeting suspended.
On resuming—
I welcome our second witness panel: Iain Hunter, general manager, and James Ferguson, clinical lead, from the Scottish Centre for Telehealth. Thank you for your written submission. I think that Mr Hunter wants to refer us to paperwork with regard to a matter that was raised earlier.
Yes. At the end of the previous witness session, Jim Docherty mentioned that he had examples of the use of telehealth. The Scottish Centre for Telehealth has a catalogue of initiatives that are going on now. If you like, I can send your officials a copy of that before the next committee meeting.
That would be very helpful. We will circulate it to members before the next meeting. As your written submission is very full and you have been patiently waiting, for which I thank you, we will move straight to questions.
Members of the previous Health and Community Care Committee visited the then Western Isles Health Board area a few years ago, and I remember an issue that was raised then. I would like to know how things have moved on and whether improvements have addressed that issue. There was concern about ensuring that, for telehealth consultations, appropriate consultants were available at the other end of the line—for example, in Glasgow or Edinburgh—who would respond timeously to clinicians in places such as the Western Isles when they used the new technology, so that photographs or other images could be beamed down in connection with particular problems that patients presented with. Are you confident that all that is well organised?
We have several on-going projects in the Western Isles, but we certainly do not have national systems set up yet for every specialty. We have moved forward with the ear, nose and throat specialty and speech therapy, which do not involve emergency situations and for which appointments are scheduled on a clinic basis anyway. I suppose the most important project that we are moving forward is the telestroke project. That is being arranged regionally, so that some epilepsy clinics can be supported as well. We are still at the early stages of developing the systems. Much of the work has been about developing the equipment and seeing how it works on a pilot basis, so the work is by no means ubiquitous yet.
The vision is that you would be able to sit in the Western Isles and see who is available, where and when. You could therefore route your inquiry to, say, Glasgow or Aberdeen—whichever was appropriate. We are slowly leading towards the use of technology that will identify not just what equipment is available and where, but who is available and what skills that person has. However, that is some time off.
I just clarify that the issue in the Western Isles was not with the technology, which was spot on and bang up to date, but with the personnel at the other end of the line. That problem was identified four years ago; I am just concerned to know whether it is an on-going issue.
In which specialty or particular clinical application was that the problem?
I do not know. The issue was raised by the consultants who showed us round the fabulous hospital that had been built in the Western Isles and all the tremendous new technology there. They said that, across the board, the problem appeared to be that they did not have the consultants at the other end when they needed them. That is a scheduling issue, and if patients present with an emergency it becomes a problem. However, I presume that, given the number of hospitals across Scotland and the number of consultants who are on call, it should not be beyond the wit of man or woman to organise a system that addresses the issue. That problem was identified four years ago and I am disappointed to learn that it is still on-going.
It is interesting that the technology appears in this case to be reliable and robust, but something simple such as the scheduling of available people is not quite there yet.
It is worth saying that the use of telehealth is not routine among most senior clinicians. One major problem that the SCT is having to address is that telehealth is currently a hobby for the majority of clinicians. A few clinical leads have seen the potential of telehealth and are leading projects, but in no way is it widely used by consultants as part of their daily work. One of our challenges is to ensure that, in future, telehealth delivery of services is routine, with face-to-face delivery the default if telehealth cannot be used, but we are a long way away from that.
I want to look at telehealth for self-management when a patient has a CardioPod, which is used in places such as Argyll—I realise that there are many other uses for it, such as for patients with diabetes. I understand that the evaluation of the Argyll pilot study was phenomenal and that the number of emergency admissions of patients using the CardioPod is zero, so there are obviously savings to be gained from the system. There is no doubt about the benefits of the technology, particularly in the Highlands and Islands, which is the area that I represent, but where do we go from the end of the pilot? Let us assume that the system is 100 per cent successful. How can we ensure that appropriate patients throughout Scotland are given access to the technology? There seem to have been some excellent pilots, but when they end people say, "That was wonderful. Cheerio." Will moving the SCT into NHS 24 be a way of rolling out these excellent, innovative products that are hugely beneficial to patients?
I will respond to the question on the move into NHS 24 while James Ferguson contemplates the answers to your other questions.
I think that Mary Scanlon was saying that, basically, this is about homecare and how we manage long-term conditions. The SCT can have the biggest potential impact in monitoring the care of patients with long-term conditions. The problem that is holding things up is that nearly all the applications have been on a small scale. Although one pilot says that telehealth is 100 per cent successful, others are saying that it has increased clinicians' workload and that it costs more for little benefit. There has been no one big study into that.
I am trying to understand the process, so can we start again? Let us assume that we have a first-class telehealth system that has been piloted for three years and has led to greater empowerment of patients, better management of conditions, savings to NHS accident and emergency services, and a report that says the pilot has been 100 per cent successful. I am concerned that someone is saying, "That works in Argyll, but it won't work in Edinburgh." As the previous witnesses said, we could have 14 or perhaps 20 or 30 separate telehealth systems running in Scotland. Is there someone in Scotland or in NHS 24 who can say, "That's a wonderful way to manage long-term conditions, from diabetes to asthma and all the rest, so let's roll it out in all the areas of Scotland where people think that using it would be appropriate"? Is such a system in place? If there is, I have not seen it.
The simple answer is no.
Why not?
Because the projects are still at the pilot stage.
I am sorry, but if a patient management system works on the Isle of Bute, surely it will work in the Western Isles, Orkney and Shetland and the remote areas of Sutherland. I simply cannot understand why there is pilot after pilot. People will get fed up, think that no progress is being made and go away. I was hoping that you would say that, if we find a first-class system that is hugely beneficial for patient care, we have the methods to move it forward so that patients in Scotland will benefit, but I have heard only what the problems are.
The simple answer is that there are systems that can work; the problem is how to implement them within health boards' current systems of delivering care. We can get this or that information, but we must remember that these are only pilots and, when they end, everyone reverts to what they did before.
Oh dear.
We can tell you that this or that system works; the question is how it is implemented.
As James Ferguson has pointed out, we are only an advisory group. We cannot say, "We have the most wonderful evidence from the Western Isles that this or that system works, so implement it now across Scotland." However, we are in discussions with NHS Quality Improvement Scotland about whether we can drive the use of telehealth by embedding it in clinical standards.
I am hearing gasps all around me from committee members.
I share other members' frustration about the time that it is taking for telehealth to be introduced. It seems like it has been around for a very long time, if the number of times that the committee has discussed it is anything to go by. I suppose that whether it works or not all depends on the enthusiasm of individuals.
That has been recognised. For example, the health department's recent review of telehealth and, in particular, the SCT identified the need for improved training and education, and we have been charged with, where possible, working the issue into our discussions with NHS Education for Scotland and academic institutions.
But are the training bodies involved in those discussions? What influence do you have over them?
I could not agree more with your previous comment. Everyone uses IT in their daily lives, but it has never been included in training. I certainly think that telehealth should be covered at medical school and nursing school level. Although we have interacted with various bodies, including nursing colleges and NES, the issue is still regarded as an add-on when it should be seen as absolutely necessary. We all have to use computers, so why are we not being taught how to deliver telehealth?
Your comment that you do not have any teeth is important. We accept that you are an advisory board and that you can offer practical help, but you cannot go in and impose anything.
I want to pursue that point, because I think that it is fundamental.
You are giving us lovely evidence—you are quite right.
My question to the witnesses is: how would you drive telehealth into the system if you had an untrammelled, unfettered opportunity to do so? That is what Mary Scanlon was asking. How would you drive that approach into the system so that the system adopts the things that work? I am thinking about the A and E project in Aberdeen, which is fantastic, given the number of patient journeys that you have saved. I understand that about 17,000 or so such journeys were saved, as I am sure you will tell us.
We need to split up the different drivers. Over the past year we have been discussing how to start applying some pressure. Until now, we have been saying, "This is a good idea. Please use it," but we really want to say, "Guys, you really should be using this." The next stage is to ask, "If you're not using it, why not?" Boards could be penalised in some way—there should be at least some way of driving the system forward.
The committee is taking evidence on telehealth because we want to drive things forward. Before we move on, I advise members that it is open to the committee to deal with the matter in a letter to the minister, having heard from officials next week, or in a short report. There is nothing to stop us doing that. The committee can be part of the drive to make progress. We understand that this is not in the SCT's remit, but we could put pressure on officials, the minister and the cabinet secretary to take up some of the ideas that have been aired by Richard Simpson and the witnesses. Telehealth is a good idea, but it often just gets parked.
Does the SCT have access to, or any connection with, the change and innovation fund, which I think is now called the health improvement fund? It has been used primarily in relation to waiting times, but it should be about driving innovation, too.
Several of our projects, for example in teleneurology and ENT, were initially funded with money from the centre for change and innovation.
To be blunt, I did not follow the answer to Mary Scanlon's question about the SCT moving in with NHS 24. If the Scottish Centre for Telehealth cannot operate in Aberdeen, God save us. I simply do not accept that the Highlands and Islands and the Borders can forget it unless you operate from the central belt. Should we be saying that the Food Standards Agency is wholly ineffectual because it operates out of Aberdeen, and that Scottish Enterprise's food promotion function, which also operates out of Aberdeen, would be far more effective if it operated out of the central belt? That is just nonsense, so I did not understand that answer. Does that mean that the SCT is simply a nameplate? Have you simply moved to a more convenient and more prestigious location in the central belt, or are you being integrated with parts of NHS 24? If you would just give me a simple answer to that, I will ask about that integration.
I cannot answer that because we are in the middle of transition. The first meeting with NHS 24 took place at the beginning of November, and the transition will be complete by 31 March next year, so I have no—
Is the purpose only to have a nameplate that avoids the embarrassment of your being in Aberdeen, as you put it?
No. I am sorry; I withdraw the comment about Aberdeen. I said that it was a perception.
It is a perception that any service might attract, but it is up to the SCT, which operates the service, to operate efficiently and effectively and to get a reputation that makes it clear that the Scottish Centre for Telehealth is a Scottish body. With respect, you should not denigrate Aberdeen for causing a problem that can be caused only by the people who run the centre.
I am an Aberdonian and I quite like the SCT being in Aberdeen, because it means I am at home. The move is not really about us physically moving to the centre. I think that we have given you the wrong impression. The real advantage of the SCT going into NHS 24 is that we are talking about a national telemedicine system, and any national solutions to telehealth will need some sort of call centre technology to support them.
I will get to the more substantial point—I am glad that we have moved away from the frippery. The committee is uncomfortable with your advisory role—that is not because of you but because of the difficulties that that role produces in relation to implementation. We might want to develop that point.
I have always had a problem with NHS 24 because it uses only the telephone, which is a limited, if useful, technology. I see the SCT moving forward on the remote delivery of care using extended techniques. There are many multimedia systems out there. I have always had a problem with the fact that NHS 24 offers to phone you back. Why not offer to Skype, videocall or text you back? A variety of options should be available. At the moment, someone who calls NHS 24 can speak to a nurse adviser or, perhaps, a GP, be sent to the accident and emergency ward or have an ambulance sent out to them. There have to be other services to which that person can be referred.
So NHS 24 would develop into an overarching, 24-hour-a-day service, rather than being an out-of-hours service. You had difficulty defining telehealth, telemedicine and so on. NHS 24 started life as an out-of-hours service, but your vision is that it would replace a huge amount of other work, as it would become the major call centre for 24-hour care.
Absolutely.
Earlier, Mary Scanlon spoke about the difficulty of getting people to take up advances that are acknowledged and proven. That is something that is well beyond the field that we are talking about. It has always been a problem in the NHS and, probably, in the health services in other countries. As I have said to Iain Hunter before, I was involved in a telehealth scheme years ago that was not taken up. The problem was not that the technology let it down, but that other clinicians simply were not interested and allowed it to wither on the vine.
I agree with you 100 per cent. Many of the barriers that we face are around clinician engagement. Some of that is unwitting, as their working pattern has always involved patients coming to them for primary and secondary care and they assume that, because that has been the system for the past 50 years, there must be a benefit to it. Part of the issue is also that some people are not really comfortable with change.
My question is whether the pressure should come from the Scottish Centre for Telehealth, which should be, if you like, the saviour of practitioners. Should not the pressure come via local health board managers saying that the current situation is unsatisfactory and needs to be sorted out? Hopefully, practitioners would then come to you for solutions and you would not need to sell solutions to them.
Absolutely. We hope that we act as a catalyst to inform the debate, but health boards must ultimately take ownership of the situation in which they find themselves by looking for creative ways of redesigning services. I keep saying that we are an advisory body that does not have money to dish out to this or that project. We go out to cajole and persuade health boards of the concepts that we are talking about, which we try to get boards to implement wherever possible.
We will take evidence next week from Dr Kevin Woods, Derek Feeley, who is director of health care policy, and Paul Rhodes, who is the e-health programme director. We will be able to raise our concerns about the business of driving change by encouraging NHS boards to be more proactive.
Apropos the point that Ian McKee made, last Wednesday we had a series of events in the Parliament that involved skin care clinicians from all over Scotland. Between 60 and 70 people attended, including Mary Scanlon, Ian McKee and various others. The clinicians said that malignant melanomas, which are the type of cancer that has had the highest increase—42 per cent, I believe—in Scotland and the United Kingdom, are an absolute candidate for a telehealth solution. The problem is that it can take up to 130 days before the patient receives a diagnosis. If the appropriate triage that James Ferguson suggested was available, we could use digital imaging—provided that the consultant was appropriately scheduled at the other end of the camera—to ensure that the patient gets a faster diagnosis. We were told that that would cut the death rate fantastically.
I will speak about teledermatology at the meeting in the Parliament tonight. When I was making up my presentation, I found an old presentation from 2000 that cites evidence that telehealth solutions can reduce attendance by 85 per cent—
Did you say 85 per cent?
Yes, 85 per cent. That evidence has been around for a long time and is also available from Scotland. Teledermatology is perhaps the best example. We know that it works, but we have not implemented it. One could say that part of the reason is technological—we have problems with the infrastructure and so on—but, at the end of the day, the reason is clinician resistance. That is the best evidenced example of telehealth in the world, but we cannot get that system up and running. As far as I am concerned, everyone should be seen initially using a telehealth referral from the GP before we select which patients should come in—
I am sorry to interrupt, but the clinicians want it, so it must be the health boards or someone else who is resisting. Certainly, Jimmy Ferguson and all the clinicians at that event were desperate to have the system.
With a name like Ferguson, obviously he is a good guy, but—
Only if he has one s.
He is a Jimmy as well.
Yes.
Consultants are happy with the television system for diagnosis. Dennis Canavan's son died from a melanoma. Everyone knows about the urgency and that if someone is diagnosed within two weeks that increases their chance of survival. In my opinion, the system is an imperative and it must be driven.
We had some provocative comments towards the end. I thank both our witnesses for their evidence. On behalf of the committee, I give an assurance that we will not just watch the pilot succeed and then go away. The committee is determined to make progress on the issue and to bring it to ministers' attention, either by a report or by an extensive letter. It might very well be a report, given the way things are going.
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