The next chapter

Scotland is moving into the “next era” of telehealth and telecare. In this new chapter, Professor George Crooks, director of the Scottish Centre for Telehealth and Telecare and medical director of NHS24, says telehealth is no longer regarded as a “Cinderella, nice-to-do, additional service” and is instead increasingly being recognised as a key way of delivering and supporting core, day-to-day health and care services.

In its recent review of telehealth in Scotland, public spending watchdog Audit Scotland argued that telehealth provides an opportunity to treat patients in new ways and help manage rising costs and demand, and urged the NHS in Scotland to do more to consider it when introducing or redesigning services.

Crooks acknowledges that some critics and sceptics are still to be won over, but nevertheless feels that a corner has been turned. “I would be kidding myself if I actually sat back and thought we had convinced everyone - because we haven’t,” he says.

“But I think we are very close to the tipping point where in fact more people understand the opportunities and benefits.” A lot of hard work has gone into preparing the groundwork for telehealth and telecare to thrive in Scotland, Crooks says, and rightly so.

“We have had examples in the past where we have driven forward change, not bringing people with us. That is really no way to deliver sustainable services in the future. So sometimes you do want to prepare the groundwork.

“But you can only prepare the ground for so long. Once it is fertile, you do need to plant those seeds and let them grow.”

Crooks praises Scotland’s “foresight” for investing in a national centre to support territorial health and care providers to understand and use these technologies appropriately. The Scottish Centre for Telehealth was established in 2006 to support NHS boards in developing telehealth. Initially hosted by NHS Grampian, a review of its work that was published by the Scottish Government Health Department in 2009 recommended repositioning the centre within NHS 24.

The transition took place in April 2010 and a year later the national programmes for telehealth and telecare were brought together to form the Scottish Centre for Telehealth and Telecare.

The merger was “not so much of a challenge as an opportunity”, says Crooks. The agendas were already closely aligned and so bringing them together formally felt like a natural progression. Now, it is working on its first joint strategy, which Crooks says will be ready to go to the next meeting of the Scottish Government’s national e-health strategy board by June. In the strategy, Crooks says the centre will be seeking to set out how it can support some of the major services changes that have been happening across the NHS in Scotland.

One example will be looking to continue to support long-term condition management. While another will be looking at how telehealth could actually better support the delivery of health and care services for people in Scotland’s prisons, he says.

“One of the key areas of work will be mental health services in prisons, both in terms of assessment and treatment, because, of course, if you deploy technology like videoconferencing, for example, into prisons to deliver mental health services you can, therefore, suggest that you could use the same equipment to deliver other aspects of care.”

This could include services that at the moment require prisoners to be taken from prison to attend, he says.

“That is particularly challenging, not only for the delivery of custodial requirements of the prison service, but actually, when we talk to prisoners, they often find those types of hospital visits particularly uncomfortable and challenging because they are escorted, they often are easily identifiable as prisoners because they are sometimes restrained by handcuffs, etc.

“So it is not simply that you are using these technologies to make it easier for the system, you actually are recognising that it could be beneficial for the individual as well. In other words, a win win.” They are also keen to explore the way technology can be used more broadly to improve wellbeing.

“We are not going to develop technology that will only do one thing - in other words, manage a disease or simply have a health focus,” Crooks explains.

“We are looking at using technology that will not only help care but also support wellbeing and carers as well as the service users themselves. Not only to access health and care services, to manage long-term conditions, but allow them to be active participants within their own community. Because everyone has got a contribution to make and technology can allow you to do that.

“So if I am allowing someone to manage their COPD, for example, why does that technology not also allow them to interact with the grandchildren in Australia or New Zealand if that is what they want to do?”

They are also now at the stage where they are fit to deploy at scale, he says.

Last year it was announced that a joint project between the Scottish Government and Technology Strategy Board will see £10m invested over the next four years to improve care by growing the Scottish telehealthcare sector. As part of the UKwide Delivering Assisted Living Lifestyles at Scale (DALLAS) programme, the Scottish Assisted Living Demonstrator will involve at least 10,000 users in Scotland with a view to demonstrating how assisted living services could be provided to millions across the UK.

“Continued investment in both telehealth and telecare is a crucial factor in helping our health and care services to meet the aspirations and needs of Scotland’s people,” Health Secretary Nicola Sturgeon told Holyrood.

“By adopting an embedded and creative approach to the use of technology, I am convinced we can support more people to remain safely at home in their communities, avoid unnecessary hospital admissions and enable people to be better connected with their families, carers and friends.”

And according to Sturgeon, the return on these investments is already reaping dividends.

“Investment in the telecare development programme has already shown positive impacts with almost 9,000 unplanned hospital admissions, and 4,000 care home admissions avoided between 2006 and March 2011.”

Similarly, when Prime Minister David Cameron announced in December last year that three million people are to be given access to telehealth technology in their homes as part of the Government’s Life Sciences programme, he said that telehealth has been proven to be a “huge success” after trials and will make an “extraordinary” difference to people’s lives.

The initial headline findings from the Whole Systems Demonstrator (WSD) programme - the world’s largest randomised control trial of telehealth and telecare services - showed that the trials had resulted in a 15 per cent reduction in A&E visits, a 20 per cent reduction in emergency admissions and a 45 per cent reduction in mortality rates.

Crooks believes the evidence base is strengthening month on month and there is now a “groundswell” of validating evidence.

In addition to DALLAS and the WDS programme, which is expected to report in full soon, Crooks highlights the Telescot programme in Lothian, which is evaluating home monitoring of people with long-term conditions.

Professor Brian McKinstry, a Professor of Primary Care E-Health at the University of Edinburgh who leads the Telescot programme, agrees it has an important contribution to make.

“I think one of the things that has been difficult with telehealth over the years is what are you actually comparing. So, for example, it is seldom just telehealth that is put in. It is usually telehealth plus community matrons and all sorts of additional things in with the telehealth. So it can be quite difficult to unpick which of these bits of the intervention have actually made the difference.

“The Telescot trial, the one we are involved in with chronic obstructive pulmonary disease (COPD) actually does unpick that. So we are comparing a variety of different types of ways of delivering healthcare to people with COPD, plus telehealth. That is the comparator and it is quite a strict comparator, so we are hoping that we will be able to unpick that.”

The programme, which is a collaboration between public, private and voluntary sector organisations, is investigating telemetric supported self-monitoring of a number of long-term health conditions, such as hypertension, COPD, congestive heart failure and diabetes.

The response from patients in general has been “very enthusiastic”, McKinstry says.

“Obviously we are a bit coloured in that the people who choose to take part in our studies are more likely to be more enthusiastic anyway. But if you take COPD, for example, almost 60 per cent of the people who were eligible to take part in the study took part so it is actually a very high response rate for a trial.”

For others to be persuaded, McKinstry argues that a strong evidence base will be important. The technology must also be as simple as possible and integrated with normal care so that it is not perceived as an add-on.

“The problem is that what you are asking people to do is something new and to an extent it is proven but not very strongly. Doctors and nurses, they don’t have much time, they are very busy, so what you are effectively saying to them is you have to stop something else to do this. So they have to be pretty confident that what you are asking them to do is worth stopping something else for.” In conditions such as heart failure, telehealth can reduce a heavy workload and so is a “no brainer”, he says.

“While conditions like COPD, these patients weren’t desperately well looked after before and so you brought in a system that undoubtedly improves their care. I have absolutely no doubt about the fact that their care is improved by it. But even if that takes half the workload that a traditional approach to it would take, it is still more than they were getting before. So inevitably, you are asking people to do a bit more albeit improving the quality of care.” That, for McKinstry, is the real success of telehealth.

“I think, really, that is what telehealth does more than anything. I think it has been touted very much as something that is going to save money and save time; I think it is more that it improves the quality of care that people get.”

Alongside these health benefits, others argue that telehealth and telecare could also prove to be a real asset to the Scottish economy.

Scotland is already considered to be a world leader in this emergent sector. When Neelie Kroes, Vice-President of the European Commission met Health Secretary Nicola Sturgeon in February this year, she described Scotland as “a forerunner in Europe” when it comes to investing in ICT solutions and promoting eHealth. With governments around the world expected to increase their use of digitally delivered healthcare as they strive to meet the challenges of the future, Dr Steven Dodsworth, Head of Life Sciences, Highlands and Islands Enterprise, is keen to see Scotland capitalise on its reputation and growing expertise in this field and ensure it is positioned to take advantage of this accelerating market.

In the Highlands and Islands, with its mountainous terrain and geographically dispersed population, the relevance of technology-aided healthcare is clear. But this is also a “global phenomenon”, says Dodsworth.

“Three years ago, we did our homework as we were looking at the global trends and drivers and picked up that this will be a global phenomenon. So what was relevant in the Highlands would be relevant across the globe whether you be in a remote community or actually in the middle of a city,” he says.

Having identified this as a key interest, HIE has pursued it with “considerable vigour”, says Dodsworth. Now, it has created what it believes to be the world’s first digital health cluster.

Dodsworth explains: “For us, digital health is ICT enabled health and care with a very forward thinking view. What we’ve seen since 2009, when we had six active organisations, is we now have in excess of 40 and they naturally cluster around the Inverness and Elgin area. So there is no denying we have a geographical cluster.” He says there are “early but good signs that there is truly a networked cluster”.

He continues: “We have organised meetings every six months since May 2010 just to provide a coffee shop or local where people can gather, find out who is doing what and build new relationships. And not being in the least parochial; it is an open door policy, so we welcome everybody.” Much can be achieved when people from different professional walks of life start working together, he says. One example has seen SMEs working together with healthcare professionals to develop phone apps. They also have a growing strategic relationship with NHS 24, which Dodsworth says has been very important for developing interests across Scotland.

“These partnerships with enterprise organisations, SMEs, government and the academic community help us play to our strengths and are key to maximising the benefits for everyone in Scotland,” agrees Crooks. “By coordinating our efforts we can make Scotland an ‘ideal’ place to drive forward this agenda,” he says.

“Technology companies are investing billions of pounds into this key growth market. If we make Scotland a very attractive place for these technologies to come and work with our health and care providers designing the next generation of these technologies ...we can actually grow the economy of Scotland. And if we grow the economy of Scotland, we know that generating wealth actually also delivers better health and wellbeing outcomes as a byproduct.” To achieve this, however, we have to broaden our horizons, Crooks argues.

“That is also why we are also engaging with like-minded regions across Europe so that we can learn lessons from other regions in Europe and likewise, they can learn lessons from us. For so long we’ve had this mistaken belief that unless it is invented in Scotland, actually, unless it is invented in our own region in Scotland, then it is no use. Well, we don’t have the time and we don’t have the finance and, quite frankly, we don’t have the manpower to have those options.

“We need to work much smarter, in a much more collegiate, joined-up way across Scotland, and with partners across the UK and Europe, learn the lessons where there are lessons to be learned and share successes where there are successes to be shared. Then we’ll all benefit.”

Safe walking

“I have this vision of people looking out through their curtains thinking, ‘I want to get out there,’” says Sharon Ewen, telecare manager, Bield Response 24.

For people with dementia and other cognitive disorders, a fear of wandering or getting lost can leave people trapped in their homes.

And yet modern technology could help overcome some of these challenges.

Bield, in partnership with the City of Edinburgh Council, is exploring how the latest Global Positioning System (GPS) technology can be used to give people with dementia the freedom to roam and walk safely in familiar neighbourhoods.

While there are various products on the market, Ewen says they selected a Vega GPS bracelet for its Safe Walking service.

“When people have cognitive issues or beginning stages of dementia they won’t remember to take a device like a mobile phone with them. They won’t remember to put a buddy device in their pocket. So the reason we use the bracelet is that it is put on them like a watch,” explains Ewen.

A ‘safe’ zone is established by working with the individual and their family. If an individual goes beyond their agreed geo fence, an alert is raised.

It can also save police time, she says. Before the pilot began, Ewen reports that one of the ladies, who is now part of the study, went missing from her home sparking a police search. She was eventually found four hours later, nearly two miles from her home.

The pilot currently has seven clients and is hoping to get up to as many as 20 people, Ewen says, adding that for those families already involved the service has been “life changing”.

European Code of Practice 

Developing a European Code of Practice With the speed with which telehealth technologies are emerging gathering pace, work is already under way to produce a European Code of Practice for Telehealth services.

A draft was published last month and will be tested during the summer and refined ahead of its final publication in April next year. Dr Malcolm Fisk, Senior Researcher and CoDirector of the Ageing Society Grand Challenge Initiative, Health Design and Technology Institute, Coventry University, who has been working on the European Commission TeleSCoPE project to develop the code, says the intention is to establish benchmark standards for services across the European Union.

This has been no mean feat, Fisk explains.

“That in itself presents a huge challenge, first of all because there is nothing at the moment that really does help to establish that benchmark. And secondly, when we talk about telehealth, it embraces a wide range of things.”

There is a far wider range of dimensions to telehealth than people may realise, he argues, as, along with the more familiar vital signs, monitoring it can also include things like health training, medication compliance and activity monitoring.

Through the code, he says they also hope to give “a fairly strong nudge” to encourage a rethink of the way services are traditionally offered to people.

There is, he believes, “a moral case” to move forward on telehealth.

“We focus too much on the cost savings, or potential for cost savings, when actually, the big issue is the way we deliver our services, the way we deliver, empower, engage and support the autonomy of users.”