Public Audit Committee

Meeting date: Wednesday, October 26, 2011

Official Report 411KB pdf

---

Section 23 Report

---

“A review of telehealth in Scotland”

Item 2 is “A review of telehealth in Scotland”, on which I invite Mr Black to brief the committee.

With your agreement, I ask Barbara Hurst to introduce the report.

The report was published on 13 October. It examines how health boards use telehealth, what impact it has on patients and boards, and whether there is potential for it to offer better value for money than more conventional models of care. When we introduced our forward work programme to the committee back in June, some members were quite interested in the report.

It might be helpful if I briefly explain what we mean by telehealth. A recent overseas newspaper article about our report said that we were recommending telepathy, but we are actually recommending telehealth. To put it simply, telehealth is the provision of healthcare to patients at a distance using technology such as mobile phones, internet services, videoconferencing and self-monitoring equipment in patients’ own homes. Examples include using videoconferencing to carry out a consultation between a doctor and a patient at different locations or diagnosing a patient’s condition using images that are sent electronically, such as digital photographs of skin lesions.

Telehealth can help the national health service to treat patients in new ways. It is popular with patients, and nurses and doctors who have been involved in its use also find that it is good. It has the potential to help boards to deliver a range of clinical services more efficiently and effectively. However, it is important to say that it is not appropriate for all patients and all conditions.

As part of the audit, we looked at how the health service has developed telehealth. The Scottish centre for telehealth was set up in 2006 to support the health service in that work, but it had relatively limited impact in its first three years. It has now been integrated into NHS 24 to provide more focus and direction and it has published its first strategic framework, which focuses on developing telehealth on a national scale in four priority areas—stroke, paediatrics, chronic lung conditions and mental health.

As you can see in exhibit 3 on page 14 of the report, telehealth is used throughout Scotland but particularly in the north. That might not be surprising. However, developing and investing in the area has not been a high priority for most boards. We estimate that 70 telehealth initiatives have been introduced since 2006, but most are relatively small scale and cover few patients. Some 60 per cent are still at the pilot stage, are delivered informally or have been discontinued. The remaining 40 per cent are now part of the routine service delivery of the health board. We found that initiatives have often been developed in isolation and are not clearly linked to boards’ wider strategic priorities or long-term financial planning.

As I mentioned, telehealth offers a number of benefits to patients, staff and the health service. Exhibit 4 on page 16 highlights some of the benefits, which include reducing travel, providing a quicker diagnosis and avoiding outpatient appointments and unnecessary hospital admissions. As the use of telehealth in Scotland remains small scale, there are limited opportunities for staff to gain experience in the area. There will be a need for increased training for doctors and nurses as it is rolled out more widely.

Of the 70 initiatives that have been introduced to date, only about 40 per cent have been fully evaluated. Although the results from those evaluations identified benefits from telehealth, the results from three current large-scale United Kingdom projects involving at least 37,000 people will further improve the overall availability of evidence. The first of those, which covers more than 6,000 patients in England, is due to publish its findings later in the year.

As part of the audit, we carried out some interesting and detailed economic modelling to assess whether telehealth can help the health service to provide services more efficiently and manage increasing demand for services. We modelled the costs of using telehealth to monitor patients with chronic lung conditions in their homes. Although there are some uncertainties due to the lack of reliable cost information, which is a recurring theme for us, we estimate that telehealth management of those patients at home could help NHS boards to avoid costs of about £1,000 per patient each year. The saving comes mainly from lower hospital admission rates. As well as creating potential for savings, home monitoring of patients with long-term conditions can benefit the patients by helping them to understand how to manage their condition—with health service support, obviously. Patients clearly value the opportunity that that gives them. There are therefore quality benefits as well as efficiency savings in the area.

The report makes a number of recommendations for NHS 24 and health boards, which are summarised on page 5. We recommend that health boards consider telehealth as an option when they introduce or redesign services. We have developed a list of questions to help them to do that, which can be found in appendix 4.

We are happy to answer any questions.

Thank you. What are the main barriers to more extensive use of telehealth in the health service in Scotland?

The team might come in after my answer. We found that many of the initiatives are developed by enthusiastic doctors. When a doctor is really keen to develop a service and to roll it out more widely in order to provide patients with access from a distance, that is when such services have been most successful. As doctors and other supporting health service staff get more comfortable with telehealth, that should help.

We surveyed medical directors to see what the barriers might be. Sarah Pollock will talk about the survey.

We surveyed the medical directors in the 14 territorial NHS boards and found that clinical preference is an issue. Not all clinical staff like the telehealth approach—they still want to see patients face to face and to have a physical interaction with them, and they really do not want to do that through videoconferencing. Another message that came through in the survey is that much of the work of the Scottish centre for telehealth had been done on quite a small scale and had not been rolled out more widely. The initiatives were quite small and some of the medical directors felt that there had been a lack of national direction on telehealth, particularly in the period when the SCT was being established. In many ways, that has now been addressed through the Scottish centre for telehealth integrating into NHS 24.

Barbara Hurst said that it is down to enthusiastic individuals and you are talking about small-scale initiatives. Are you suggesting that there is a lack of strategic willingness, understanding or commitment? Would a more strategic approach help to develop what you seem to be suggesting is a beneficial initiative?

We found some fantastic examples of where telehealth is being used to great advantage. Through the report, we are trying to push the idea—and we are already having some success—that telehealth is not something that should be at the behest of individual doctors but a strategic issue for the health service. Of course, we need doctor buy-in, but we also need buy-in from managers in order to develop different ways of delivering services and to manage demand in increasingly pressurised areas. Sarah Pollock could give you more detail on the situation in NHS Lanarkshire. That is a fantastic example of how, even in the central belt, telehealth can be used to increase the speed at which patients receive treatment according to priority.

Before I open up the debate, I will ask a specific question about chronic obstructive pulmonary disease. You say that there are more than 100,000 people in Scotland who have the condition and that monitoring patients with COPD could avoid costs of around £1,000 per patient per year. Do you know whether all those 100,000 people would benefit from that? If they did, we would be talking about saving £100 million a year, which is staggering. If there is a potential saving of around £1,000 per patient even in this limited part of the health service, why is more work not being done on it?

We could have aggregated that figure up and claimed a massive saving from monitoring patients with COPD, but we were pretty cautious in the economic modelling because of issues to do with the reliability of some of the data. We were trying to use it as an example of the savings that could be made. The modelling was a detailed exercise involving experts from across the range of COPD services and we are pretty confident that it is as robust as it can be, but we did not want to make huge claims about the savings that could be made, because telehealth might not benefit some individual patients among those 100,000.

Even if only a very small percentage of patients—only 1,000, say—-would benefit in the way that you suggest, telehealth could still result in savings to the health service of at least £1 million. Even in a worst-case scenario, substantial savings could still be made, so why are we not seeing more commitment to using it?

10:15

We agree that there are savings to be made, which is why we did the exercise. NHS 24 has been very interested in this area of work and now that it might be driving some of the work, it may well try to promote the benefits of the approach more widely.

COPD is one of the priority areas for the SCT and NHS 24 in the SCT’s strategic framework. As Barbara Hurst said, four areas have been identified in which the SCT wants to prioritise, pushing more national projects as well as more projects across the country, and COPD is one of those priority areas.

It strikes me from reading the report and from the discussion with the convener that this is very much a spend-to-save initiative. Obviously, there would be up-front costs in establishing telecare—sorry; I mean telehealth, as telecare happens at a local authority level, of which more later, I am sure. However, when telehealth is up and running, savings can clearly be achieved.

I have two questions. I notice that on page 13 of the report, you talk about

“resistance or uncertainty among clinical staff“.

There is often resistance to change, but is the block to broadening the use of telehealth resistance among clinical staff or a lack of understanding at the board and senior management levels? Obviously, decisions on the deployment of resources come from the top down. Is the problem as simple as resistance among clinical staff, or is it about a lack of understanding at board level?

Secondly, on page 14 you identify what appears to be a clear north-south divide, apart from a couple of exceptions, in the use of telehealth. We might explain that by reference to the remote communities in Highland and Grampian, but the Borders and Dumfries and Galloway have remote communities, too. I do not think that the explanation is that cut and dried. What is the rationale behind the reluctance to roll out telehealth in some of the other board areas that have remote communities to serve?

I shall kick off and then, perhaps, I will ask Sarah Pollock to come in.

On your second question, part of the explanation might be no more than that the Scottish centre for telehealth was initially based in NHS Grampian and was seen as a way of giving people in rural and remote areas more ready access to services. Clearly, however, boards such as NHS Greater Glasgow and Clyde also provide services to people on the islands. As the benefits start to become obvious—we are getting some interesting examples from the central belt—people will see that telehealth is not just an issue for rural and remote communities. Things should improve.

On your first question, we agree that the block is about both clinical resistance and the need for managers to buy into the idea. An individual enthusiastic doctor can go only so far; the approach must be properly embedded in the work of the health board. We are very keen on the idea that, when boards are looking into different ways of delivering services, they should always consider telehealth. It might not be appropriate in all cases, but it should be part of the strategic thinking about how to change and redesign services.

Let me follow up on Mark McDonald’s question, looking again at the map in exhibit 3 on page 14. It is interesting that there seems to be no pattern at all in the development of telehealth. Some areas have a wide range of telehealth initiatives, such as Grampian, Highland and Argyll, as we might expect, and also greater Glasgow and Clyde and Lothian, but other areas that we might have thought would have benefited more—Tayside, Dumfries and Galloway, and the Borders—do not. The pattern seems to be completely piecemeal. Is that a fair characterisation? It seems that there is no particular logic to the development of telehealth and that it is very much ad hoc.

That is a very good point. That is probably true, and it reflects how initiatives have been developed. There has not been huge national direction or a huge national drive in the early years, as there was no national strategy for telehealth. It was really for boards to say, “Here’s an area in which telehealth might work for us and, more locally, here’s an enthusiastic clinician looking for an area in which they think it could add value for patients.”

That is interesting.

The redesign of services is covered at paragraph 30 and onwards. Paragraph 30 says:

“Telehealth is not generally considered as an option when NHS boards are planning or redesigning the way a service is delivered.”

The clear message from the report is that it should be considered as an option, as it can result in patient benefits and cost savings.

Paragraph 32 is about the Scottish Government’s efficiency and productivity framework for the NHS. Is there sufficient impetus from the Government or the NHS nationally to drive forward that framework?

There is probably more impetus now than there was a few years ago, and there is probably much greater understanding. I think that the evidence base is starting to be strengthened and that it will be strengthened much more by the three large-scale initiatives that are being run in the UK. One of the difficulties in the early days has been that there has not been the evidence base to say that telehealth is the right way to go, that it will result in benefits in the longer term, and that it will be cost effective. Very little work has been done that shows that, from a financial perspective, it is more cost effective to go for a telehealth initiative than conventional care.

I am very interested in the checklist in appendix 4 for NHS boards that are considering redesigning services and bringing in telehealth. Will you be encouraging the audit function in the NHS to consider how it is being followed?

The checklist will be applicable at many levels. We are mainly thinking about a clinician who might want to introduce an initiative working with management—they can say, “Here are some of the things that we need to think about before we can put in place a telehealth initiative.” The checklist gives the questions that need to be asked to evaluate whether telehealth has proved to be more effective than carrying out the service through conventional care.

Would you clarify something that you said to Murdo Fraser? You said that there was no national strategy. Is a national strategy now in place?

Yes. When the Scottish centre for telehealth and telecare came under the wing of NHS 24 in April 2010, it put in place a strategic framework that in essence is now the national strategy for telehealth. That covers the four priority areas of COPD, mental health, strokes and paediatrics, which are the areas that NHS 24 is considering prioritising over the next few years.

Have there been any significant improvements since that strategic framework was put in place?

The report highlights the work that has been done on strokes in particular and the successful development of telestroke throughout Scotland. I refer members to case study 1, on page 9. We looked at telestroke specifically in the south and east of Scotland, but it has been rolled out nationally, and NHS 24 has very much been behind that development. It has done work on developing a strategic framework for mental health, and it is driving forward home monitoring initiatives, which we talked about earlier, in the area of COPD. It is also increasing opportunities to put in place pulmonary rehabilitation classes for patients. I refer members to the third case study in exhibit 4. Patients with COPD in Pitlochry had to travel to Perth royal infirmary for rehabilitation classes, but that facility can now be provided in their local community hospital. NHS 24 is working nationally to roll out that approach in other areas.

The report is very useful. One aspect that jumps out at me is the potential for the duplication of services. I recognise that there is a difference between telecare and telehealth, but there seems to be a lot of crossover in the functions that are carried out under each heading. I am aware that, in my area, East Lothian Council and Midlothian Council have spent millions on a telecare system that may or may not be able to slot into a telehealth system. That is an area that would benefit from more exploration. I think that Barbara Hurst touched briefly on the possibility of duplication, but I wonder how much exploration was done of that in developing the report.

When we first scoped the report, we wondered whether we should broaden it to include telecare. However, we decided that we would do telehealth initially because it would give us a clear way in to look at potential efficiencies. Since we started the work, the strategic oversight of telecare has moved from the Scottish Government to NHS 24, which will now have oversight of both telehealth and telecare. Part of its support role will be to try to help health boards and councils to integrate some of the systems, although it is very early days for that.

Telecare is a gleam in our eye for possible investigation. However, we want to wait to give telehealth a little time to bed in before we come back and review what is happening in the area and expand that to look at telecare services. Colin Beattie is right that some of the monitoring could cover everything. We are keen to look at telecare services, but we want to do it as part of our second look at telehealth.

I am pleased that you are thinking about looking into telecare, because millions must be getting poured into telecare services right across Scotland as part of the effort to deal with the ageing population and avoid expenditure on care homes by keeping people in their own homes, which is all commendable. However, there must be considerable potential for duplication. We need to be alert to that. I hope that you will audit the area at an early point.

I am not quite sure what “early” is, but—

Soon.

We have certainly got it in our medium to longer-term plans. Sarah Pollock has been doing some work on the issues that we might examine when we bring it forward.

Paragraph 4 of your report refers to the Health and Sport Committee’s 2010 report “Clinical portal and telehealth development in NHS Scotland”, which said that no significant progress was being made although there were good examples, which sounds similar to the result of your report. That led me to think about what has changed since the 2010 report, and the obvious thing is the integration of the Scottish centre for telehealth with NHS 24. That sounds great, but paragraph 24 of your report states:

“Half of medical directors felt that the integration of SCT and NHS 24 had no impact on the delivery of telehealth within their board.”

Can you expand on what you heard from medical directors about that? If the Health and Sport Committee were to take another look at telehealth this year, would it just publish the same report again?

I ask Sarah Pollock to talk about the survey of medical directors.

The survey highlighted the way in which telehealth has evolved in Scotland through small initiatives and enthusiastic clinicians. We found that much of the interface was between those individual clinicians and the SCT. Strategically, medical directors perhaps did not have oversight of what was happening in their boards around telehealth. In addition, there was no national strategy for telehealth in the early days between 2006 and 2010.

The SCT was integrated with NHS 24 in April 2010. When we did our audit, we were looking at the situation less than a year after that integration, so it is fair to say that it was quite early days to evaluate what NHS 24 was doing more generally on a national level to drive forward telehealth. It has started to put in place initiatives such as the champions network, which brings together clinicians from across Scotland to share best practice, and it now has a much greater focus on the evaluation of initiatives and what can be learned and shared by NHS boards. Progress has been made, but it is still quite early days.

10:30

I accept that the integration is new, but we are talking about established organisations, so I would have expected to see a bit more progress, given the sums that the convener mentioned could be saved.

You said that it was enthusiastic clinicians who were pursuing telehealth. That says to me that there must be enthusiastic clinicians out there whose small-scale projects are not being developed because they are meeting barriers. Did you get much of a sense of what the frustrations are for those people?

With some of the small initiatives, we found that there probably was some frustration, because a number of initiatives have been discontinued. In some cases, that may have been for clinical reasons. We looked at an initiative in Fife on eye conditions where the quality of images was not good enough, so it was discontinued on information technology grounds. It is often the case that clinicians manage to get funding for a small-scale pilot, which they run for two years or so, after which it is discontinued. That might be because it did not fit with what the board was doing more widely, on a strategic level. A clinician might have developed an initiative but then not engaged with other people to find a way of taking it forward.

In paragraph 22, you say that only half of boards’ local delivery plans refer to telehealth. Did you get the sense that that will change? As a result of the strategic framework, is the Government now being clear with boards that telehealth needs to be part of their local delivery plans?

It is hard to be definitive about that. Boards are starting to see the benefits of telehealth. When the evidence comes through from the large-scale initiatives that are being run just now, particularly the whole systems demonstrator programme, that will strengthen the evidence base, but NHS 24 will still need to provide considerable drive to promote and encourage the use of telehealth, which will involve working and engaging with boards.

I recently visited the Glasgow School of Art, which has a digital media hub in Glasgow’s digital quarter. It has Europe-leading laser scanning technology, on the use of which it is linking up with Greater Glasgow and Clyde NHS Board. It is looking to generate income from that, in partnership with the health board.

Did you get a sense from any of the health boards that they see telehealth as an opportunity to generate income? Patient care must, of course, be at the centre of everything, but the great thing about a lot of telehealth initiatives is that their potential is not restricted to Scotland. Experts who are based in Scotland could treat conditions all across the world. Did you get a sense of that potential? I did not get any sense of it from the report. Maybe it is early days because the technology is still to be developed and we are talking about small initiatives, but you would think that that would be worth exploring.

The focus of our work was to look at the specific benefits to patients and the efficiency savings. Income generation was not a focus. I do not think that we asked any questions about that, so I am afraid that we cannot answer your question.

Do you think that it might be a motivating factor for some health board chief executives? It would be interesting to look at that.

Do any of the health boards have data on the uptake of telehealth initiatives by patients? Do you have any data on that, or do you know of any health boards that have such data?

We certainly have data on how many patients were involved in each of the initiatives but, as we have said, they are relatively small-scale initiatives, so we are talking about only 30 or 40 patients per initiative.

Okay. It would be interesting to see such data. Do you think that the health boards would have that information?

I am sorry—I just need to check something with Sarah Pollock. Do we have the detail of how many patients were involved in each initiative? If so, we could provide members with it.

Yes. We found information on 70 initiatives that have been put in place since 2006. From that, we know how many patients were involved. The average figure was about 34, but some initiatives involved slightly more patients and others involved as few as five or six patients. Therefore, we know how many patients were involved in the telehealth experience in those initiatives.

Did you notice any discernible pattern? I am making a complete assumption, but I assume that perhaps people in a younger demographic would be slightly more willing to take part in telehealth initiatives, although it might well be that people from an older generation would need the service more because of mobility issues.

It is interesting that the perception is that, particularly among older people, there may be more resistance and fear around the use of technology, but a number of the initiatives were around home monitoring of patients with chronic conditions such as COPD. It is interesting that patient satisfaction with the initiatives was very high. There was initially some concern along the lines of, “Will I be able to use the technology? Will it be difficult? Will I have problems?” However, problems did not happen because a lot of the home monitoring equipment is very simple to use. It came through strongly in the report that age was not a barrier to people feeling that they could use the technology.

That is good to know.

My attention was drawn to page 18 and case study 3, on the national videoconferencing project, which began in October 2009. With reference to my colleague Mark McDonald’s comments, there seems to be a focus on the northern health boards in the early stages of that scheme, which might explain the difference between the north of Scotland and the south of Scotland in engagement with telehealth services.

Do you get the sense that, as we develop telehealth in Scotland, the public are fully ready to embrace it? I note with interest your comments about the use of broadband for delivery of some of the services. We can all talk about access to and the availability of broadband and broadband speeds throughout the country. Do you think that we are geared up and ready for telehealth and that the public are more ready to engage with it as a means of improving their own health?

It is hard to speak for the public, but patients who see the benefits for themselves are positive about telehealth—I am thinking of benefits such as a patient not having to travel from the island to the mainland for an out-patient appointment or being reassured in their own home that what is happening to their blood pressure is not a cause for real concern. The more that the health service can do around promoting such initiatives, the better.

I suspect that it is only when you need telehealth or you can see the benefits to yourself that you become very positive about it. It is a difficult issue. I imagine that there may be some scepticism, but that would be quite easily dispelled when the benefits were considered.

As Sarah Pollock says, once we get the evidence from the large-scale evaluations, that will give us a much more solid evidence base on which to go out and say, “This can really deliver benefits to you as patients.”

Can you clarify the experience that a patient has with telehealth? Is it with a local health centre or hospital? Do patients experience a direct link from the home to the telehealth service?

Home monitoring equipment is used, but for videoconferencing—Sarah Pollock can come in with more detail—the patient would need to go to a health facility. In some ways, if someone is having a consultation, they want to be in a health facility, because if anything comes up through the consultation that they want local healthcare support on, they want to be able to access that.

Clearly, people do not all have videoconferencing facilities in their own home. I am not a technical person, so I have no idea what will happen in five or 10 years’ time, but at the moment there are real benefits from the technology, which we think could be used better, or more effectively.

The application of technology can easily deliver that technology now—a person can receive some advice and some services directly at their home rather than via a local health centre or even a hospital that is distant from where they live. Perhaps that is a wee glimpse further into the future.

My second question is on evaluation. You made some comments about that. I know that there is a low number of pilot studies and so on, but even within that, the amount of evaluation is quite low. Is there a reason for that? Have some boards not done any evaluation of telehealth services? If so, why not, given that there is a national strategy in place to assist with the delivery of telehealth?

Perhaps that takes us back to Mark McDonald’s question about whether telehealth is properly integrated into the management of services locally. Individuals who are doing things with telehealth might evaluate them, but they might not be bought into locally as a way of redesigning services. We are pushing appendix 4 to our report hard and saying to boards, “Please use these questions every time you think about redesigning services, because it might help patients and save money.”

I call Mark McDonald.

Thank you for allowing me to come back in, convener. I had a minor epiphany when Colin Beattie asked his question, because I recall that, when Audit Scotland outlined its work programme, I raised a point about the auditing of telehealth and telecare separately and asked whether it would not be better to integrate them in an audit. You appear to be saying that, had you known then what you know now, you might well have looked at doing a combined audit, given that telecare appears to have moved since then.

However, telecare is in your longer-term programme—I assume that you are talking about years rather than months—so might you consider publishing an overarching report on both areas of work? That would allow you to revisit some of the issues that are covered in the telehealth report and would provide for a more holistic audit, rather than your auditing telecare and then having to go back and audit the two areas of work together at some point in the future. Is that something that you would consider?

Yes. On whether we could have focused more widely in this report, we would probably still have gone for telehealth, because it was a definite decision that we wanted to look at efficiencies in the health service. When we revisit the area, there is a strong possibility that we will want to look at telehealth and telecare together, particularly given the drive towards more integrated health and social care services for older people. It strikes me that that would be a good way of considering the integration of those systems.

I thank you and your staff from Audit Scotland for contributing to an interesting and full discussion. Telehealth clearly has the potential to make a contribution not only to the quality of healthcare in Scotland but to financial savings. It will be fascinating to see how much commitment is made to it in the future.