Professor James Ferguson is explaining how the emergency department can be a useful barometer for how the health service is working.
“If you are getting good preventative care, good home care, and good monitoring at home, that tends to mean there are less people coming through the emergency department and less patients coming to the hospital,” he says.
“So by providing better quality day to day support for patients using telehealth and telecare, care plans, etc, all of these things, if they are implemented well it means the system operates better and therefore the pressure cooker, which is the A&E at the front of the hospitals, works better too.”
Ferguson is the clinical lead for the Scottish Centre for Telehealth and Telecare (SCTT) and a consultant surgeon in Emergency Medicine at NHS Grampian, so it is unsurprising that he views the topic through that particular lense. Later this month, Ferguson will open Holyrood magazine’s annual Telehealth and Telecare conference in Glasgow where he will discuss the overarching value of telehealth and telecare and the difference it can and is already making to unscheduled care.
Ferguson was seconded on a half-time basis to the then newly established Scottish Centre for Telehealth in 2006 and has been an ardent, and persistent, advocate for its potential ever since. And it appears his hard graft is paying off. While he expresses his frustration at the “immense inertia to change”, which he says exists in most public health organisations, he argues there is an increasing acceptance of both the need to redesign how we deliver care and also the key role that telehealth and telecare can play in supporting that.
“The fundamental change in the last few years has been a growing acceptance, I think, from the NHS and other organisations, but mainly the NHS, that regardless of the arguments over whether individual aspects of telehealth and telecare are right or wrong or better, actually, we are the only game in town.
“We can’t continue to do what we are doing at the moment. Our hospitals are overcrowded, the patients aren’t getting as quality care as is potentially available, we can’t afford to just keep throwing money at this. It is not good for the organisation, it is not good for patients, it is not good for doctors,” he states.
“...So it is our time, I think. No doubt about it.”
Scotland has “won the battle” over whether telehealth and telecare works, Ferguson says, but he admits the next step is to start doing things on a bigger scale. It is a challenge that is perplexing many, but one that Ferguson believes Scotland is ideally placed to deliver on.
“Not many people have managed to do many things on a big scale. So I think that is where we find Scotland is leading the way across Europe because we are a population of around five million, we are a nice size, we’ve got all the elements – rurality, big cities. So actually, we should be able to implement this on this sort of level.”
Ferguson says the move to NHS24 in 2011 has helped the centre to move into a phase of implementation.
“I think the change over the last four years, the big thing has been it is all about integrating because that is what the technology can do. It allows you to interact with people in and out of the hospital and improve services generally. So, I think, the best steps for us in Scotland have been things like the increasing working relationships between the ambulance service and NHS 24, because that is the front door.”
As part of this closer working relationship, they will soon launch a common triage tool, he says.
“We’ve got a vision that you will make a phone call and whichever bit you hit of the service it is not in isolation. If you hit the wrong place, we will transfer you to the right one rather than putting the phone down on you. So that has been a major step forward for the integration of frontline services.”
Improving the links with social and home care and increasing uptake of telecare will also be key if we are to deliver more care in, or as near to, a patient’s home as possible, rather than defaulting back to using expensive emergency care inappropriately, he says. However, he is aware that achieving this will require greater buy-in from clinicians.
Clinician engagement has, and continues to be, a central part of Ferguson’s role and, while there has been movement, others remain to be persuaded that they could provide better quality care, for more patients, for less cost if they are willing to do things differently. However, here, he argues that decision support models – for example, greater use of video conferencing – could help reassure healthcare professionals and ensure that decisions about resources are not being made in isolation of the bigger picture.
He explains: “There was an article in the New York Times about a year ago comparing hospital chains to restaurants. Every time a meal goes out in a restaurant there is a guy who double checks it before it goes out the front door...there is a little bit of variation allowed by the cooks but it is kept at a standard.
“And that is what we are really talking about. At the moment we allow practitioners to independently make the decision whether to use expensive resources and send a patient into an environment that may be hostile for them. And that then comes right down to whether that person has the knowledge, experience and understanding of the system to be able to do that. And that is variable. What telehealth allows us to do is reduce variation. Variation in any system is disastrous. You don’t want everybody sending every patient into hospital, and equally, you don’t want people being kept at home who actually need to go to hospital. And the answer to that is to actually have links to the team that are going to look after the patient and asking the question before you take that action.”
Ferguson says the centre is about to start a project delivering paediatric decision-making support for unscheduled emergency situations, which will provide 24-hour access through a single point of contact to a rota populated by consultants with both emergency care and paediatric experience.
“Everybody is scared about children and people tend to default and send the patient in, to the point, in my own hospital, something like 80 per cent of the patients, when we did an audit a couple of years ago during the really bad weather through which these patients had to travel, around 80 per cent of patients remained in the hospital for less than a day. Now, some of those patients did need some treatment. But a large number of those patients were just coming in to be sure, to be safe. And what is safe about driving with your kids through really bad snow?”
Over-referring can be costly in more ways than one, he explains, pointing out that there are now clear links between hospital overcrowding and higher mortality rates, particularly among the frail and elderly. And so, he argues, we should be taking a tougher line with those who ignore this evidence.
“Nobody has ever highlighted the fact that pushing people into an overcrowded hospital actually increases their chance of having a negative outcome. Now, that is not to say that you don’t use a hospital. But what you should do is select the patients who are going to benefit from that. And if you send someone who is not getting clear benefits, you are doing them a disservice and somebody should come back and rap you over the knuckles. Because what you’ve just done is said it is easier for me to send them.”
In December the Scottish Government, together with COSLA and NHS Scotland, published their joint National Telehealth and Telecare Delivery Plan for Scotland to 2015, which sets out their intention to drive improvement, integration and innovation. It’s an important piece of the puzzle, says Ferguson.
However, he adds in order to achieve the vision it sets out, reluctance to change “is probably the biggest single barrier that we’ve got left to overcome”.
“I think most people are happy with where we are saying we are going. I think it is the right direction. We are going to see more home care, we are going to have all these projects, and we are going to have more interaction with Europe and be building on a bigger scale, we are going to try and integrate more services – all of that is great.
“My job, mainly, is trying to get recalcitrant members of the organisation to actually do that, rather than just give it lip service, and start delivering it.”