NEW CARE MODEL
Integrated Primary and Acute Care Systems
Project partners: University Hospitals of Morecambe Bay NHS Foundation Trust; Cumbria Partnership NHS Foundation Trust; Blackpool Teaching Hospitals NHS Foundation Trust; Lancashire Care NHS Foundation Trust; North West Ambulance Service NHS Trust; NHS Morecambe Bay CCG; Lancashire County Council; Cumbria County Council; North Lancashire Medical Group (GP federation); South Cumbria Primary Care Collaborative (GP federation).
The Better Care Together telemedicine project seeks to reduce unnecessary journeys taken by the public and ambulances between the South West Cumbrian town of Millom and Furness General Hospital, which takes approximately one hour on a rural road. Millom has a population of just 8,500 and generates over 22,900 journeys to the hospital each year, which is over 1,000,000 miles travelled.
The project team believe telemedicine has the potential to help services overcome the challenge of providing health and care in a rural part of the country, where the population is spread over 1,000 square miles, as well as staff shortages in some specialties.
The intention is for telemedicine to account for 20% of outpatient activity at University Hospitals of Morecambe Bay (UHMB) Foundation Trust within 2-3 years, with patients receiving the same level of care but in more convenient locations.
HOW ARE THEY HARNESSING TECHNOLOGY?
One of the Better Care Together projects has been to set up a video link between a GP surgery in Millom and Furness General Hospital Emergency Department. The project involves an integrated approach by various health providers. If a patient seen in Millom is not in an immediately life threatening condition, clinicians at the emergency department can carry out a triage remotely via video link. If travel to the hospital is required, this is immediately arranged.
Virtual out of hours appointments are also now being offered by video link between Millom Community Hospital and GPs at Cumbria Health on Call (CHOC) based in Carlisle. Patients who call NHS 111 on Saturdays between 9am and 1.30pm and require clinical attention will be offered the option of a consultation with a GP via video link. The out of hours GP can virtually assess the patient and agree the best course of action, which may include a prescription being sent electronically to a local pharmacy. This initiative is helping some patients avoid travelling to attend face-to-face appointments at Furness General Hospital.
A telehealth link between the Category C prison and Furness General Hospital is also allowing prisoners to be assessed with this technology, similarly avoiding the need for travel in suitable cases.
Further applications have included a single gastroenterology pilot clinic, rheumatology clinics, psychiatry clinics, and linking three maternity labour wards so senior midwives can support junior midwives and women ‘at distance’. There is potential for links to tertiary service clinical advice further afield, such as between the primary care assessment service at Westmorland General Hospital and renal and neurology services based in Preston.
Cisco was selected as the supplier for the telemedicine project; a decision that was strongly influenced by UHMB’s existing Cisco network equipment. Telemedicine simply sits on top of the existing infrastructure. Around 20 video consultation units have been installed as part of the project. Otoscopes (ear, nose and throat) and Dermatoscopes (examining the skin) are attached to the patient-facing units and provide very high resolution images. The team are also using thermal imaging cameras help to diagnose conditions such as Raynaud’s disease.
The telemedicine solution is integrated with an advice and guidance tool, a software platform developed in-house that allows GPs to pose questions to clinical specialties. Cisco presence technologies will enable real-time video conversations between GPs and consultants in the future.
The team have concentrated their return on investment thinking on wider socio-economic benefits and workforce utilisation, rather than looking only at income from the tariff. This is an important consideration as the evidence from the project is contributing to sustainability and transformation partnership (STP) planning about how Lancashire and South Cumbria network might use the technology to deliver efficiencies.
Reduced cost of transport, and reduced travel time for patients and staff are clear aims for the telemedicine project. A dashboard now shows mileage saved per patient based on outpatient appointments. The team are also looking at tracking mileage and travel time reductions for clinical staff who no longer have to travel as frequently as they did previously from their base location to a remote clinic.
The project team recognised that patient and clinician involvement in the project was crucial to its success. Each organisation sent questionnaires to their members, supplemented with surveys in outpatient departments. The team then held a patient focus group comprising people for, and against, the project.
This allowed the project team to get under the skin of the project and explain its potential value. Two patients from the focus group have continued to work with the team to trial a new, virtual waiting room project, which will allow video consultations with health care professionals to take place from patients’ homes.
WHAT HAVE THEY LEARNED?
A key feature of the Better Care Together programme is that telemedicine takes place within existing clinical settings, where the technology is controlled and staff are on hand. This has meant the barriers to adoption by patients and clinicians are reduced. Telemedicine has also delivered an additional role for the local community hospital.
Negotiating connection to each others’ networks and the ability to use equipment owned by another organisation is starting to become less problematic now installs are live and working, though the team say that they underestimated how much time this aspect of the roll out would take.
The thorniest challenge has been navigating the contractual arrangements in commissioning models for telemedicine activity. “We’re trying to find the right internal market in which this can fit,” says Paul Charnley, chief information officer at University Hospitals Morecambe Bay, “else you have a very perverse incentive to drag people to an outpatient appointment just because we get paid for seeing them face to face, and might not if we see them on camera.”
The project team recognises that they are still in the early stages of technology and acceptance by clinicians. Their approach has been to work with natural early adopters, such as the chief clinical information officer, who was the first to trial a clinic using telemedicine. Three initial remote clinician pilots in gastroenterology, rheumatology and mental health got clinicians engaged in the idea and generated interested in the potential for telemedicine.
In January 2017 Cisco Jabber Guest was installed at UHMB, which will enable video consultations over the internet and is allowing the UHMB team to roll out a virtual waiting room. Deployed in outpatient clinics, care homes and GP surgeries, patients receive a unique, time-bound link via email. On clicking the link, a web browser displays a simple call button that connects the patient to the receptionist who checks quality the quality of the connection and explains the process. Films and information can be displayed to the patient prior to meeting the clinician, and during the consultation the clinician can share images such as x-rays and self-care information.
The project team hopes to extend telemedicine to neighbouring areas and also believe that organisations could make use of telemedicine for webinars and staff supervision.
For further information, please visit www.bettertogether.co.uk
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