Official Report 211KB pdf
I welcome everyone to the 17th meeting in 2008 of the Health and Sport Committee. I remind all members to ensure that mobile phones and BlackBerrys are switched off. No apologies have been received.
I will say something briefly about my background, then speak about our plans.
We have your background details in your biographical and career notes, so perhaps you could just speak generally about telehealth and your plans. That would be useful.
Certainly. I have been in post for two months, and my first impression of telehealth in Scotland—I do not want this to sound like a criticism—is that it is almost defined by the number of pilots that are in progress. Our first task at the centre is to try to decide which telehealth applications might be most useful for development as national-scale services.
Thank you. Do you want to say anything, Mr Hunter?
I have been with the centre for 18 months, so perhaps I can give you a couple of minutes on where we are at and how we got there. We had to set up the organisation in April 2006 from scratch. The first year was mainly about setting it up and recruiting staff, and we have been operational for the past 12 months.
Be careful, because we represent many rural areas—you may be challenged.
My point is that telehealth is as applicable in the urban setting as it is in the rural setting.
I appreciate that neither of you has been in post all that long, but there is nevertheless an element of frustration about this area. Professor Wootton referred in his opening remarks to Scotland being an exemplar. As a member of the previous Government, I had the privilege some six years ago of going to Canada to look at rural service delivery. Matters might have regressed there in the past six years, but I am bound to say that, at the time of my visit, I was singularly impressed by the extent to which telehealth was well embedded in the Canadian concept and used for monitoring—this was Mr Hunter's point—in both urban and rural settings, despite there being vast rural settings in Canada.
We know the Canadian work quite well, because Iain Hunter and I have been over there several times in the past few years.
In Scotland, as in much of the United Kingdom, we are accustomed to an extremely personal health care service. I dread to say this in the company of my colleague, Ian McKee, who is a general practitioner, but GPs have created a genuinely personal element of service. Therefore, I am concerned about the technical issue of how people can be persuaded that the use of the technology is better for their health.
Where we have implemented telehealth solutions, we conduct patient satisfaction surveys to find out what people thought of the experience. By and large, people like the telehealth way of delivering health care. It saves people up in the islands from taking two days off work to travel to Aberdeen or Glasgow. Those people are complimentary about the use of the technology.
Your paper gives as an example of successful telemedicine in Scotland
That is why the Scottish Centre for Telehealth was set up in Grampian. Some time ago, funding was available through the Scottish telemedicine action forum, and Grampian had a particularly successful project. The Scottish Centre for Telehealth was established in Aberdeen because of that work, but there were other pockets of successful work. Paediatrics on the west coast is another good example of a STAF project that is going on to be mainstreamed.
I do not want to interrupt too much, but can you tell me how many patients have filled in your satisfaction forms, so that we get an idea of the scale?
I am sorry, but I cannot answer that off the top of my head. I will come back to you with that information.
In the briefing paper that you sent us, you state:
Human nature is such that people are always suspicious of change. Again, I go back to my previous career. I used to be in the oil industry, where people hated change. In health care, there are patients at the end of the line. People are concerned about patient safety and are cautious when it comes to change. Our role is to try to facilitate change by persuading, cajoling and convincing. If we come forward and do that, we can win the arguments.
So you are saying that there is resistance to change.
I suggest that there is a natural resistance to change.
I have raised in various debates the important question of how NHS 24 fits in with the Scottish Centre for Telehealth. I have been very impressed by the breathing space suicide helpline, which is first class, and as a member for the Highlands and Islands I have also been more than impressed by the superb cognitive behavioural therapy work in the islands, although I appreciate that that is only a pilot. Is that your initiative, or is it the case that, while you are fighting the battle against those who are resistant to change, NHS 24 is moving forward in a positive way?
I think that the language that Mr Hunter is using is a little more tactful than "fighting the battle", but I take your point.
Well, Mr Hunter can use his language and I can use mine. In my opinion, the initiatives that I mentioned are excellent examples of telehealth care for people in remote and rural areas who suffer from depression. Given that they are so successful, I wonder why all that we hear about is problems and resistance.
Perhaps that is the way the briefing note has come across.
It might be just my interpretation.
We are in constant discussion with NHS 24, which is a wonderful resource that can help us to deliver care to patients, and are aware of the two examples that you mentioned. We are also working with NHS 24—we hope to set up a pilot in Tayside on the management of long-term conditions.
But NHS 24 works separately from your organisation. That is what I wanted to establish.
We have strong links.
NHS 24 set up the initiatives that I referred to.
Yes.
I turn to the second page of your submission, which explains why there should be national-scale services in Scotland. I appreciate the need to achieve economies of scale, but the first reason that is given for setting up such services is so that
Of course. I do not have the submission in front of me, but I think that that is an example of a national-scale service. Some pilots are under way on early stroke treatment. As you will probably be aware, it is essential that a patient who is suspected of having had a stroke is considered for clot-busting therapy within three hours of the onset of symptoms. That can be arranged in the major metropolitan areas, but it is much harder to arrange in rural areas.
As an economist, I have a better understanding of economies of scale than I do of thrombolysis. Am I right in saying that such a patient would have to be admitted to hospital to determine what type of stroke they had suffered and that a judgment would have to be made within the three-hour period by a proper clinician? In other words, the diagnosis could not be made by a paramedic, for example, and the patient would have to get a scan.
They would have to be scanned and be seen by a card-carrying stroke physician or a neurologist. The fact that that is hard to arrange in the peripheral hospitals is part of the challenge that we face in scaling up the service.
That is helpful—thank you.
Before we hear from Helen Eadie, I have a supplementary. Our SPICe briefing paper says that your organisation
Absolutely.
A number of years ago, as a member of the Health Committee during the Parliament's second session, I had the privilege of visiting the impressive new hospitals in the Western Isles. I remember the clinicians explaining to us that a big problem was ensuring that when they used the equipment, there would be a consultant or a specialist in place at the other end of the line. To what extent have those managerial and organisational issues been dealt with? As we all know, for the provision of expensive equipment to be justified, it needs to be running efficiently 24/7. If that is not happening, we must ask questions. Would either of you like to comment on that?
I am not sure that I will answer your question. We certainly hear from Orkney, Shetland and the Western Isles that although the equipment is available and ready for use, the issue is having someone to speak to at the other end. We have not managed to address that. We must work on a booking service or a service that allows us to direct someone who needs specialist advice to the appropriate person. Richard Wootton has a vision of how that might work. Such a service would undoubtedly enhance the use of telehealth. If people have nobody to speak to, it ain't going to work.
That is quite worrying for all of us who are enthusiastic about telecare, but that is one reason why we need to probe this important issue.
Telecare in Scotland has been funded to the tune of £8 million in the past two financial years and will receive £4 million of funding in the current financial year. There are 32 partnerships, which involve local authorities and community health partnerships. The partnerships have submitted bids for funding, which has been used in diverse ways. Some partnerships have used it simply to enhance alarm and security systems in patients' homes, and others have expanded the scope to using modern-day telemonitoring equipment in the home. Three pilots are under way—in Lothian, Lanarkshire and Argyll and Bute—and will be evaluated.
Telecare in Scotland has evolved from local authority initiatives such as those involving alarms for when people fall on the floor. As Iain Hunter said, trials are in progress. The world literature on telemonitoring, for example, shows that it appears to work well in some areas. I have colleagues in Harvard University in Boston who speak highly of telemonitoring for patients who have congestive heart failure, because it keeps them out of hospital. Under the American model, it is financially advantageous—much cheaper—to keep people out of hospital rather than to admit them. Monitoring of patients with diabetes who can report their blood glucose values over the phone line to a server somewhere has seemed to work well in trials in Europe. Patients have liked that and GPs have found it useful. However, systematic reviews of the literature do not show compelling research evidence that such measures are cost effective. We all suspect that they might be, but differences between other countries' health systems and ours mean that we need to run formal trials here. As members probably know, the University of Edinburgh has embarked on formal randomised control trials of telemonitoring technology. We expect to have some answers in a year or two.
Your comments are helpful.
I share Ross Finnie's dismay at the lack of progress. My background is as a general practitioner, and I was involved in a telemedicine project in antenatal care 30 years ago. We had videoconferencing and sent results down the line. Women who were out shopping could be informed by mobile phone if monitoring showed that foetal movement or their uterine contractions were abnormal and they needed to seek help from the midwife.
I am familiar with the work to which you refer—it was initiated by Ken Boddy, who was a true pioneer. You are right to say that it did not go into routine service for the reasons that we have discussed. In my opening remarks, I spoke about how we might concentrate on a small number of areas, as you suggest. I have reservations about being prescriptive and telling people how things should be done—it depends on whether one belongs to the carrot or the stick school. On the whole, doctors are a conservative bunch, and rightly so. Telling them to do things is usually unproductive—it would probably be better for us to provide appropriate incentives. In our four chosen areas, we are seeking to identify the right levers for making hospital consultants warm to the idea of conducting teleconsultations rather than automatically requesting that patients front up in their clinics, for example.
I could not agree more. If in five years' time we have 50 pilots up and running, in our book we will have failed. If we have five mainstreamed projects in Scotland, we will have succeeded. Although we are working with individual health boards, we are also working with collaboratives such as the long-term conditions collaborative and the mental health collaborative, with which we have meetings this afternoon. We are looking across health boards to see whether we can approach matters from that direction. If we focus on the 14 mainland health boards, we may end up with a miscellany of pilots, so we must try another approach. I would not like to say whether it involves a carrot or a stick.
I accept that, as Professor Wootton says, it can be counterproductive to force people to do things. Earlier, you spoke about the customer's needs. I had the impression—perhaps unfairly—that your idea of the customer was consultants and GPs. In fact, the health service's individual customers are patients; collectively, the customer is the national health service, and there are plenty examples throughout the national health service of clinicians having to alter their behaviour patterns and act in a certain way because the rules and regulations have been changed on the basis of evidence. I suggest that, unless that can be done, you will not get very far. You probably need help from the wider national health service network outside telehealth. I challenge your statement and would like a further response on whether we can simply wait until everyone is happy before we can proceed with any combined initiative.
It is important not to get hold of the wrong end of the stick and beat yourself to death with it. All the evidence on what the customers think of telehealth is positive, and you are right: the customers, of course, are the patients. All the surveys around the world seem to show that patients are perfectly accepting of telehealth. Even elderly patients whom one might expect would be concerned about talking to the doctor on the telephone do not mind it at all; if they can avoid significant travel and still have a specialist consultation, for example, that is fine by them. I do not have any concerns about acceptability to the patient.
That is a practical suggestion for the committee.
There are three customers—the patient, clearly; the professional clinician; and the organisation—and, somehow, we must create incentives or a business model that can benefit each of them. That, we hope, will help to drive things forward and gain acceptance of the use of telehealth.
If I recall correctly, Professor Wootton, you identified three inhibitors to the development of telehealth: technology, which further discussions have largely set aside because it is fairly advanced and can be brought on stream as and when appropriate; patients, although it appears from your comments a moment ago that most are prepared to engage in telehealth if they think that it will benefit them; and clinicians.
The language is a bit unfortunate. I am not sure that I would describe all the doctors as being reluctant but there is what you might call inertia in the system. Many of my colleagues remain to be convinced, and rightly so. I said earlier that on the whole the medical profession is, with good reason, conservative. What we are asking them to do is see a patient on a TV link, which is an unnatural experience. Why would they prefer to do that than to see the patient in the flesh? Why would they expose themselves to the possibility of making a misdiagnosis because they did not get the full story on the TV picture? We are asking clinicians to practice in an unnatural way, which potentially exposes them to increased clinical risk. The medico-legal basis on which they might be prosecuted if something went wrong is a bit uncertain. There are several good reasons why the medical profession might remain to be convinced about telehealth.
It is right and proper that the clinicians are cautious about telehealth. We have been developing the concept of a medical booth, which would contain videoconferencing equipment and medical devices that the patient could use or someone could help the patient to use. The specialist could be at a distant location. We are trialling that in Aberdeen, where we have an accident and emergency consultant who is a great enthusiast for telehealth. His first reaction was, "We've got to do a safety check on this. How safe is it for the patient?" We have put 100 patients through the booth. The first test was whether the patient would come away with the same diagnosis via a TV screen as they would if they were seen face to face.
That takes me to my second question. I can understand clinicians being cautious about telehealth, given the liabilities that it may leave them open to. In other parts of the world, how effective has it been in ensuring that patients get the right diagnosis and that the time taken to go to hospital to see consultants is reduced? If I were a clinician, how would you persuade me to try telehealth? I presume that telehealth has been practised in other areas, which might have years of experience that we could draw on without—in my view—wasting more time on further trials to persuade people that it is safe.
You are perfectly correct. There is now a fairly extensive literature on many telehealth applications. You will appreciate that if a new application is dreamed up, as Iain Hunter mentioned, various stages have to be gone through, such as testing its feasibility, safety and acceptability to the users—the doctors and patients. Ultimately, we would also want to know about its clinical cost effectiveness. There is a good literature on some of the former aspects in most areas of telehealth; there is only a limited literature on the downstream aspects of clinical cost-effectiveness in many areas. There is good evidence, for example, on store-and-forward teledermatology, which seems to be highly cost effective in many parts of the world. We believe that telestroke treatment is cost effective in the United States—although, the American health care system is so different from any others that it is hard to extrapolate that evidence to what we might describe as normality. There is certainly a literature on the subject—it exists, and nobody wants to repeat feasibility studies unless they really need to be done.
In your opening remarks, you mentioned that there were four potential applications. I picked up that one was psychiatry, which seems quite obvious, given that it is not physical, or does not require a physical examination at any rate. What were the other three? If you mentioned them I missed them.
No, I did not mention them—I was leaving that for your questioning.
Well, we have managed to get there.
Collectively, we at the Centre for Telehealth considered the whole range of telehealth pilot schemes in Scotland that are under way, and some of the more obvious ones that are not. Telepsychiatry was one of those. We used six headings. For the record, they were first, whether or not there was good scientific evidence that the treatment was clinically effective; secondly, practicability, or how easy it would be to scale up the treatment to a national service; thirdly, how well the treatment would conform with the Government's priorities in the chosen area; fourthly, whether the treatment addressed a severe burden of disease and whether the condition was life threatening; fifthly, the potential service profile, in other words how many occasions of service the treatment would be expected to deliver, how big the target group was and whether society had special preferences—for example, society often treats neonates and the newborn quite differently from how it treats geriatrics; and, lastly, if the treatment was to be implemented on a national scale, whether the net cost to the NHS could be expected to be neutral, or whether there would be enormous expense or huge savings.
Ian McKee was saying that such treatment was being used 30 years ago and that it has not moved forward. I was struck by the thought that 30 years is almost the length of someone's career. Could we use training at the very early stages to encourage people, or to remove their fear of getting things wrong? Could training also be given throughout someone's career, perhaps through continuous professional development? Have you considered such approaches for dealing with those real concerns?
Yes. We, too, believe that training is essential. That means continuing the professional training of the people who are in place at the moment and trying to reduce the anxieties of the nursing students and the medical students who will become the next generation of doctors.
I hope so too.
On the whole, the practicalities are fine. Normally, one adjusts one's aspirations to suit the telecommunications available. For data monitoring of patients with diabetes, an ordinary telephone line is fine. Mobile phone networks—I imagine that coverage is available over much of Scotland, but I am not familiar with the details—provide another medium. You are right that there is an intermediate stage between the home and the hospital. Community centres and doctors' surgeries provide locations where individuals might gather for certain kinds of telehealth activity.
I recall the days of the Open University, which pioneered tutorials by telephone so that students did not have to travel.
I believe so. Telehealth is not included explicitly on the curriculum.
Do any medical schools in Europe have telehealth on the curriculum? Unless we start at that level, might the inertia that you are fighting—I should not use such aggressive terms—still prevail?
In Norway, and at the University of La Laguna in the Canaries, telehealth is included explicitly in the undergraduate curriculum. Those are just two examples that I can think of. Informatics is, I think, included in the undergraduate curriculum in Scotland, but I am not aware that telehealth is explicitly identified. As I said, that is a conversation that I would like to have.
When was telehealth introduced into the curriculum in Norway, which is a fairly near neighbour? Has that had a noticeable impact on delivery?
I think that the Norwegians spent quite a long time getting themselves organised, but the subject is also included in a postgraduate course. I think that telehealth was included in the undergraduate curriculum only last year.
I apologise for being slightly late for the beginning of this session.
On that last point, the people in West Lothian are probably leaders in the field. The project is being pioneered by David Kelly and has proven to be very successful. You are right that the evaluations show that admission and readmission rates to hospital have demonstrably decreased. Scotland is leading the field in that sort of example.
I worked in West Lothian for a bit and I understand that a significant number of houses were involved. Do you know the figure offhand?
Sorry, but I do not.
I think that hundreds if not thousands of houses were involved.
Certainly hundreds. It is a good demonstration and Scotland should be proud of it.
Thank you both very much for an interesting session. It will be helpful if you can give us information in writing later about the number of houses involved, which was the issue that Richard Simpson raised, and also the number of people who were treated in that fashion and then took part in the survey, because we are missing data.
Meeting suspended.
On resuming—