This is the 5th visit made as a result of my #NHSChangeDay pledge to visit frontline services so that I can understand the challenges of using information and technology in the front-line of care delivery. I’m glad I made the pledge – it’s a journey of learning.
This time I visited some great people in Hull to look at telehealth. I enjoyed my visit but came away with a sense of that we were missing the point and that we were looking through the wrong end of the telescope.
Telehealth is controversial. The Whole Systems Demonstrator Programme attracted attention when studies showed no positive effects on ‘quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months’ (Cartwright, Hirani, Rixon et al 2013) and other studies have shown no cost benefit. In a recent study about the impact on hospital admissions of telehealth concluded that ‘Long term telemonitoring of people with COPD is unlikely to reduce admissions unless it is a lever for enhancing clinical services’ (Pinnock et al 2013).
During my visit to Hull I met Paul, who is a lead nurse for academic cardiology and who leads the telehealth service for heart failure in East Yorkshire. The location was interesting as, of course, telehealth doesn’t need to be located geographically in offices or organisational buildings that symbolise service, indeed there are nurses working on telehealth who work from home. I met Paul in his untidy office, shared with an (untidy) colleague (I feel sure he won’t mind me saying that), none of the usual symbols of a care space – it felt strange to me! Changes to the distance between the practitioner and the patient/client alters the way we do things, it changes practice and requires, if not new skills, a flexing of the skills nurses already have, as many of you have heard me say before it requires a new type of professionalism, digital professionalism; working in digital spaces where the location of professional and patient may be remote.
The conversation between Paul and me rarely crossed into the technology itself, we had a quick look at the screens but what was much more interesting was the conversation about what the patients really thought and what skills staff needed to offer the service. My conclusions are that we have to stop looking at this like it’s an interesting new development that we can all get very excited about and see as a technical service and, instead, think of the patient’s perspective and centre on their care. Paul told me about patients who were happy to use the system as they were able to detect deterioration early and ask for help. Some see it as a lifeline and would never want to give it up once they have it in their homes.
The service in Hull is well established. Their service has supported nearly 300 patients and data from the TEN-HMS study, demonstrated a reduction in one year mortality from 45% with usual care to 29% with telehealth. The heart failure service states that it saves around £1000 per patient per year in avoided hospital admissions. In Hull the patients are supported by visitors from a voluntary sector organisation – Hull Churches Home From Hospital. They provide visits to support patients getting used to the new equipment and dealing with problems in the early stages as they get used to the monitoring equipment.
One of the things that was very striking for me was that we need to make sure we use the skills of staff appropriately – having the right people doing the right work. If the service isn’t offered at scale there is a risk that expert staff will spend lots of time dealing with issues that don’t need their expert skills – Paul showed me long lists of patients with an alert on the system but of course many of these were reporting equipment problems or reporting reasons why they would not be sending results in (for example holidays). This means that services need to be carefully planned and we need to avoid forcing the option on people in order to achieve a critical mass, as people may prefer different alternative options, for example in this instance visits from the health failure nursing team.
Paul also talked about how challenging removing monitoring equipment is once it is in place and how costly this could be. There was even uncertainty about if equipment was re-usable. The result of this may be that people end up on the scheme indefinitely by default rather than by design – clear plans of care are needed that include coming off the equipment as well as patients being offered it. If we don’t do this there is a potential for demand to grow exponentially and become an expensive service that is not related to need.
I also visited Hull University and met with Jonathan Thorpe who is the manager of the Centre for Telehealth. Again our conversations centred on the human dimensions of telehealth and less the technology although I did meet an inspirational PhD student, an engineer who was exploring how technology can help in health. His passion for his ideas and thirst for interesting conversations about the challenges of managing long-term conditions was inspiring – again I was reminded how much of our future relies on young scientists.
All my conversations were about people, ideas, skills and little was about the technology. We need to think about the patients/service users first and see this as an additional tool to help us deliver integrated patient centred care and stop it being about the technology in its own right. My ambition is to mainstream informatics, rather than specialise it! Using information and technology is everyone’s business in care delivery in 2013 and telehealth needs to be considered as part of the portfolio of integrated care options. But we must work in collaboration with patients with an appropriately skilled workforce and infrastructure to get the best from it. We need to stop seeing telehealth as a technical project and start looking at it from the other end of the telescope as an option, part of an integrated care service not as a service in its own right.
All in all it was a great day for reflecting on the emergence of technology in health but my conclusions were it’s not about the kit – it’s about the people!
Cartwright M, Hirani S, Rixon L et al (2013) Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial British Medical Journal BMJ 2013;346:f653
Pinnock H, Hanley J, McCloughan L, et al (2013) Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial British Medical Journal BMJ 2013;347:f6070