eHealth can be the key enabler for the transformation of health and care services in Scotland
The latest Registrar General’s Annual Review of Demographic Trends, published in August, emphasised the greatest challenge facing Scotland’s health and care services today and in the future. Like many countries across the world, Scotland’s population is ageing.
Life expectancy of those born in Scotland in 2013 is now 77 years for males and 81 years for females. This is an increase of 8 and 5.8 years respectively from those born just thirty years ago. Thirty years from now the number of people aged 65 and over is projected to rise by 59 per cent, from 0.93 million to 1.47 million.
These are staggering figures. But, hidden within those statistics, there are some other significant trends. Life expectancy in Scotland is improving more slowly than in the rest of the UK and elsewhere in Europe, and major health inequalities still exist in parts of Scotland.
Increased longevity can be expected to mean more people will be living with chronic and multiple conditions and with complex health and care needs, such as those associated with dementia. We know people who have long-term conditions use the greatest proportion of Scotland’s health and care services. It is projected the increase in demand for health and social care services in thirty years’ time could be 29 per cent.
The current situation is simply not sustainable.
The Scottish Government’s 2020 Vision for health and care - that everyone in Scotland is able to live longer healthier lives at home or in a homely setting - sets the strategic narrative for the delivery and development of healthcare in Scotland for the next five years, and all strategies, policies and actions flowing from it are focused on addressing these challenges, including eHealth.
To understand Scotland’s strategic approach to eHealth it is necessary to view the eHealth strategy not as a point-in-time initiative, but instead to recognise it as a continuum of managed change brought about through a sequence of consistent strategies.
These strategies don’t focus on technology products, services and their suppliers. Instead they focus on the benefits and outcomes experienced by health and care professionals, by helping them to work with patients to re-design and improve services. The people of Scotland then benefit from these improvements.
We published the latest eHealth Strategy (2014-2017) in March of this year. This strategy is the third in a series started in 2008 and, although the focus of each has shifted significantly between each publication, many of the strategic principles remain unchanged.
The 2008-2011 eHealth Strategy was fundamental as it recognised the cornerstone of delivery had to be nationally co-ordinated, collaborative at all levels, and closely aligned to clear priorities at both a national and a health board level. It acknowledged Scotland had already made some valuable investments through developments such as SCI Store, SCI Gateway and the Emergency Care Summary.
These enabled a vital but nonetheless basic level of information sharing. But beyond these national developments many systems were, in effect, information silos within health boards. To deliver the objectives of that strategy, and to enable Scotland to move forward more quickly and effectively, a collective governance structure was established.
That structure exists to this day and is the bedrock of eHealth delivery. It harnesses the resource, knowledge and expertise around NHSScotland and brings it together in the form of governance groups with representation from all the health boards and all health professional groups.
This collective governance – for example, where the CIOs for all 22 health boards meet monthly – is something many other health organisations would wish to implement, but their size, geography or fundamental service structure does not allow it. With the recent introduction of Integrated Joint Boards in Scotland, and their responsibility for fully joined-up health and social care services, this collective governance is being enhanced with the addition of leaders from social care.
The period of the first eHealth Strategy focused on investing in and rolling out further key foundation capabilities, including a common Patient Management System; a national Picture Archiving and Communication System; a national ePharmacy system; one of a choice of two General Practice Systems; and the universal use of the Community Health Index as the single identifier to be used across all eHealth systems. In parallel, many health boards started to implement clinical portals drawing together relevant information from various systems and display the information health and care workers need whenever and wherever they need it.
Perhaps the most notable aspect of the investments made at that time was that these systems have functionality used directly by health and care professionals as an integral part of their clinical duties. By the end of the decade the shift was being made from purely administrative systems to clinically-rich ‘eHealth’ ones.
The second eHealth Strategy (2011-17) saw a significant shift in emphasis to person-centred services, recognising self-care and self-management approaches have the potential to reduce the impact of long-term conditions on NHSScotland resources. It also introduced the six strategic aims which continue govern all significant eHealth developments at local, regional and national levels. These are:
- To enhance the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality.
- To support people to communicate with NHSScotland, manage their own health and wellbeing, and to become more active participants in the care and services they receive.
- To contribute to care integration and to support people with long-term conditions.
- To improve the safety of people taking medicines and their effective use.
- To provide clinical and other managers across the health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery.
- To maximise efficient working practices, minimise wasteful variation.
These six aims - along with a 7th one “To contribute to innovation occurring through the Health Innovation Partnerships, the research community and suppliers, including the small and medium enterprise (SME) sector” - are also the backbone of the current eHealth Strategy (2014-17).
The current version of the eHealth Strategy was planned to be simply an update of the one published in 2011. But in the three years between 2011 and 2014 significant policy developments in Scotland for health and social care, and for citizen-facing digital services, meant the current eHealth Strategy needed a further shift of emphasis – this time to delivering secure digital access to health and care information to a much wider set of professionals and providing more services and information to people through digital channels.
The impact and pace of technology advances has been unparalleled in very recent years. Digital technology is now part of our everyday lives and evidence builds daily that everyone’s health and wellbeing can be better supported through greater use of technology innovations – providing fully person-centred care which fits seamlessly within an increasingly digital lifestyle.
When the first eHealth Strategy was published in 2008 only 49 per cent of adults in GB accessed the Internet every day, and only a quarter of adults used it to access health information through websites similar to NHS Inform, according to the Office for National Statistics (ONS). In 2015, 78 per cent of adults access the Internet every day and almost half use the Internet to find health information online. Today, 80 per cent of UK adults are able to receive a superfast broadband service and there are 23.6m 4G mobile subscribers in the UK, according to Ofcom. Smartphones have become the hub of our daily lives and are now used by two thirds of UK adults.
The quantity of clinical information recorded in NHSScotland’s systems is estimated to have more than doubled in the last three years. With more clinically-focused systems now in everyday use, the clinical richness of data is improving immensely.
Challenges addressed by the current eHealth Strategy are multifaceted. They include maintaining the resilience of systems needing now to be available 24/7/365; ensuring availability of funding for replacement and modernisation of an increasing ICT estate; filling gaps in electronic information coverage and systems integration (most significant being Hospital Electronic Prescribing and Medications Administration); further reducing variation in systems, infrastructure and applications; opening portals through which people can access their health and care information; providing secure interfaces between consumer health and care products/tools and core health and care information systems; building capability development for business intelligence and predictive analytics; and introducing information governance that balances the need to protect with the need to share.
We have a related 2020 eHealth Vision that everyone’s health and wellbeing can be better supported through greater use of digital technology. eHealth is the key to how we access, use and share information within and across health boards and with partner organisations in order to deliver integrated health and social care; how we support patients and their carers to make informed decisions to manage their health and wellbeing; and how we use health data appropriately to improve the effectiveness of services and treatment and make significant advances in medical research.
eHealth can be the key enabler for the transformation of health and care services in Scotland. Progressively through to 2020, people, in addition to their face-to-face care, will be able to use a patient portal to access their Electronic Patient Record and make their own contributions to the record, have structured access to information about prevention, order repeat prescriptions and book appointments online, use secure two-way electronic communication with their health and social care providers, and access a portfolio of proven technology enabled solutions such as home health monitoring, tailored to match their conditions and circumstances. This will enable them to undertake a much larger role in managing their own health care.
Health and care professionals and third sector partners will be able to quickly access an Electronic Patient Record providing the information they need to make their contribution to the patient’s care, electronically record their findings and share these with the rest of the care team, and quickly and easily initiate care processes, such as investigations, referrals, and treatments, and generate clinical correspondence.
Managers, planners and researchers will have better access to appropriately anonymised and summarised data, arising from the myriad of patient contacts taking place across NHSScotland. This will enable individual and teams of clinicians to analyse, better understand and improve their clinical practice. They’ll have support from immediate information that enables them to take operational decisions on an hour-to-hour and day-to-day basis that can improve patient flow and the management of outpatient, inpatient and community services; a greater capacity to analyse and understand specific patient populations, whether by geography, age group or condition(s), and undertake risk stratification and predictive analytics that can inform prevention measures and early intervention with a view to improving health and reducing unplanned admissions.
As a result of all of the above, eHealth will enable care and treatment in Scotland to be more personalised and continuous. People will be healthier for longer and when they have health problems these will be predicted and managed more effectively and more efficiently, benefitting not only the patient, but also the overall sustainability and total capacity of the health system.
Eddie Turnbull is head of eHealth for the Scottish Government.