Feature / Smart medicine

Technology promises much as NHS organisations seek to increase quality and efficiency, particularly by helping patients remain in their own homes. Seamus Ward reports

It’s one o’clock in the morning and Edward, an 85-year-old care home resident, is not feeling well. He is a diabetic and, together with a member of staff, he checks his blood sugar. It’s fine, but the care worker notices his breathing is shallow and rapid. ‘Would you like me to call an ambulance?’ she asks. ‘No,’ he replies. ‘Let’s call the video nurse instead.’

Within minutes, his laptop has booted up and he is talking to a nurse in a telehealth hub. Thankfully, it’s nothing too serious – he’s worried about going to his granddaughter’s wedding the next day and is having a panic attack. The nurse talks him through coping strategies, both for the anxiety and keeping his blood sugar levels in the normal range. Reassured, he settles down to sleep.

While this is not a common scenario in today’s NHS, the use of technology to support people to remain in their homes and improve quality and efficiency of care – in this case, avoiding an ambulance call and a possible A&E attendance – is growing. All four UK nations are developing telehealth models (see box). And they are arming community-based staff such as district nurses with familiar technology such as laptops and smartphones to help them provide better care, more efficiently.

The nomenclature around this technology can be confusing. Telehealth is an overarching term covering all electronic means of providing healthcare services. Sometimes it is used to refer to telemonitoring: the remote capture of clinical information, such as pulse and blood sugar levels. Telemedicine is the provision of clinical consultations via secure, encrypted video technology.

Airedale NHS Foundation Trust is one of England’s pioneers of telemedicine, having started a service eight years ago. It has a telehealth hub that allows patients with a range of long-term conditions to video call nurses or specialist clinicians 24/7 if they are worried or for a scheduled appointment.

To develop its telemedicine services, last July it formed a joint venture with technology firm Involve in a the partnership known as Immedicare. It can now provide a full end-to-end service – the clinical service and the technology – to nursing homes, patient homes and prisons in the region and nationwide.

Rebecca Malin, the Airedale trust deputy director of strategy and business development, says the partnership makes sense as it allows the trust to offer remote clinical and technical services to patients in its own community and around the country.

The partners’ services aim to allow patients to live at home. While its telemedicine services were local until quarter three last year, she says, Immedicare now has contracts to provide services to 222 nursing and residential care homes around the country. The service has gone live in 108 homes and Immedicare supports about 3,200 patients in their own properties and nursing and residential homes.

Locally, it has launched a service for 75 patients with chronic obstructive pulmonary disease (COPD) and heart failure and it is piloting telemedicine units for patients at the end of life. The latter project enables these patients to spend their last few months at home and is funded by independent charity The Health Foundation.

The trust is just starting another project with local clinical commissioning groups across Bradford and Airedale and Bradford Teaching Hospitals NHS Foundation Trust, connecting 80 patients with chronic heart failure to specialist heart failure nurses in its telehealth hub. This will allow patients to access planned and unplanned care to support them to remain in their own homes wherever possible.

Extended services

The partnership has expanded and is hoping to go further. As well as its local base, including 33 care homes in Airedale and 50 in Bradford, it also provides services to patients in Calderdale, Cumbria, Dartford, Coventry, Macclesfield and Lincoln.

Having services in a range of areas creates challenges, Ms Malin acknowledges. ‘We need to understand the services in each area and we invest a significant amount of time on this in the build-up to going live. We need to know which skills are in each locality, so we can facilitate on-the-ground teams if necessary.’

The telemedicine services are funded by CCGs in some areas and by acute trusts in others. Trusts fund telemedicine for a number of reasons – to reduce demand for A&E, to provide clinical support to smaller hospitals and to stimulate discussion in their health economy. In the latter scenario, typically a trust will fund the service for 12 months and use the evidence to engage commissioners to fund the service going forward.

Ms Malin says there are two cases where commissioners and providers have come together to fund the service, recognising the benefits are across the health economy.

Airedale will continue to assess the impact of its work as it seeks to build evidence in favour of telemedicine. ‘One of our challenges is that we find that people talking to us about implementing telemedicine want evidence from this country. Even though we provide telemedicine services to 3,200 patients, it is still small scale when you think about the national picture,’ Ms Malin says.

The Department of Health whole system demonstrator produced evidence that, at scale, telehealth and telecare (for people with social care needs) could improve patient outcomes and reduce the use of hospitals and care homes. However, it was unlikely the Department’s claim that it would save £1.2bn over five years would be realised. The demonstrator covered around the same number of patients currently looked after by the Airedale partnership.

Last summer, an internal audit looked at the impact of the telehealth hub on services in Airedale. It found a 35% reduction in hospital admissions on the previous year (without telemedicine).

The audit was based on hospital episode statistics for around 2,000 residents in 23 local care homes. It also found A&E attendances fell by 53% and acute bed days were down 59%.

They saw the same downward trend in use of hospital facilities when they drilled down into specific groups of patients. For example, among 26 COPD patients living at home, there was a 45% reduction in admissions, a 69% fall in A&E attendances and bed days were cut by 50%. Length of stay fell by 9%.

‘These figures are staggering,’ Ms Malin says. ‘When we started, we had a slight concern that if we gave people the opportunity to have a face-to-face consultation 24/7, then it would be used 24/7. We don't find that at all. The message we hear back constantly is that patients and carers feel assured just by having access to telemedicine from their home and knowing that if they need to see a nurse they can at the touch of a button.’

Call volumes are not large – the hub generally gets between 100 and 200 calls a month.

‘The test would be if people were going to A&E rather than using telemedicine,’ says Ms Malin. ‘The data for our catchment area suggests that's not the case. Equally, has it changed the patients’ use of primary care? I am having discussions with the CCG and primary care colleagues about whether they have seen a difference and how they can manage their capacity. GPs say much of their home visits are to care homes, so anything we can do to relieve that is a good thing.’

A local GP has been using telemedicine to deliver consultations to nursing and residential care homes and reports a 70% fall in GP visits.

North West pilot

The North West Coast Academic Health Science Network is one of three of the academic networks focusing on telehealth.

Liz Ashall-Payne, programme manager for digital health at North West Coast, says it is supporting a wide-ranging project in Liverpool to promote independent living. This includes a telehealth pilot covering patients with heart failure, COPD and diabetes, which produced cost savings through reductions in hospital admissions, A&E attendance and community matron visits.

It is also supporting a project with Cumbria University to introduce telehealth on the Wirral that aims to help people stay at home and be well for longer. Though still in the planning stage, it aims to allow patients to input their vital signs regularly – heart rate or blood glucose, for example, or even how they feel. This will be assessed at a hub and if outside the normal range a message can be sent to a community clinician, such as a district nurse.

‘It means they will have the ability to monitor more patients and should hopefully avoid the patient having to go into hospital,’ says Ms Ashall-Payne.

Tariff concerns

The current payment mechanism could be hindering the advance of telehealth. ‘An acute trust loses income by reducing admissions but we know it is the right thing to do to reduce inappropriate admissions,’ Ms Malin says.

‘Tariff continues to be a challenge. It needs to be turned on its head to a tariff for outward-facing consultations or for telemedicine where a whole health economy gains from reducing admissions.’

Though she believes there is evidence telehealth can have a positive impact, she does not believe it can act as a silver bullet for both quality and efficiency. ‘It’s one piece of the jigsaw. It means patients decide when they need to be seen, not when they are called for an outpatient appointment and are feeling fine.’

Keeping patients out of hospital does not necessarily mean a telehealth hub is needed. Giving community-based clinicians access to the same levels of patient information enjoyed by their hospital-based colleagues can enhance patient care and be more efficient.

The government has a Nursing Technology Fund to support nurses, midwives and health visitors to make better use of digital technology in all care settings, in order to deliver safer, more effective and more efficient care. In the first round, announced in February, 85 projects, many aimed at supporting patients in their own homes, shared the £30m pot.

Staffordshire and Stoke on Trent Partnership NHS Trust was one of seven trusts that received the top award of £1m from the fund.

It is using the funding to provide its nurses, health visitors and local social care workers with technology to enable remote working.

Jonathan Tringham, the trust’s director of finance and resources, says: ‘The additional funding will allow staff to record and access information, order equipment and prescriptions, as well as send referrals while out of the office and in real time when with patients and services users. It will save their time and ultimately improve the patient experience.’

Chief information officer Amy Freeman says, historically, district nurses and community matrons had unequal access to IT, meaning they had to go to the office in the morning to pick up their list of calls for the day and then return to base later to update clinical records. By providing these nurses with laptops or smartphones, the trust is able to send job lists out electronically, while records can be updated on the spot via a 3G or wifi connection to the trust network.

‘We’re not saying to them that they cannot come into the office any more. It’s vital they have the opportunity to get support from each other face to face. The technology means they don't have to come in one, two or three times a day,’ Ms Freeman says.

‘It will improve the quality of care to patients by reducing waiting times. And by having more information about the patient, such as their allergies, in real time they can make better decisions.’

Perhaps the biggest saving will be in travel costs – the trust estimates a reduction of £1m over three years. It will also gain more information about community service activity.

Clinical system

However, Ms Freeman believes that the biggest gains will be made when the trust introduces a new clinical system, which will include a new electronic patient record and streamlined methods of capturing patient information, next year.

Pennine Care NHS Foundation Trust also received £1m from the fund to improve community staff access to information on the move. The trust’s ICT director, Barbara Hoyle, says: ‘Approximately 75% of our workforce provides care in a community setting and having access to mobile working technology will completely change the way we deliver care.

‘In addition, mobile working assists the organisation in meeting the challenge to be paperless by March 2018. The £1m funding will enhance the work of our community staff, helping them to provide a safe, personalised and efficient service for patients.’

That is, of course, what it is all about. Technology is a means to an end, a facilitator of better, more efficient services. Though it is not yet at the scale required to achieve this, the NHS has made a start.