In the north of Scotland, there is a driving route called the North Coast 500. It makes its way through beautiful empty lands of dramatic mountains and rugged coastlines with white sand beaches. It’s little wonder CNN named it one of the world’s top 10 road trips.
But for people who live in this remote part of Europe, it can mean driving for hours to a hospital appointment. If you’re relatively healthy, this is an inconvenience. For someone who is frail or in pain, the journey is a huge challenge.
Annette lives in rural Caithness and is very busy with a litter of puppies at home. She has a long-term condition that requires regular reviews with her hospital specialist in Inverness. “It used to be a six-hour round trip,” she explains. “With my condition, I suffer from fatigue, and it would take two to three days to get over that trip.”
It was because of people like Annette that NHS Highland created NHS Near Me. It enables patients to attend appointments by video from home or a local clinic. Although NHS Near Me was developed to address a rural need, the benefits are just as relevant for people in urban areas who, for example, are frail or find it difficult to get time off work. In short, health care needs to stop expecting patients to fit their lives around health care appointments.
More Than Technology
Video consulting is not new in health care. In fact, in some places around the world, it is used extensively. For example, Intermountain Healthcare in the US provides a fabulous telehealth service that I was fortunate to see in action as part of a Scottish Quality & Safety Fellowship study trip. But this success isn’t replicated across all health care providers. One reason is because simply giving clinicians access to a video system is not enough.
In creating NHS Near Me, we took two key decisions. First, because this was new to patients, clinicians, and the NHS, we co-designed the service with everyone involved. Second, NHS Near Me had to be embedded into how we provided outpatient appointments, and that meant taking a whole-system approach.
We sought feedback from every patient who had an NHS Near Me appointment during the first six months. We went to patient and public forums to collect ideas, and we recruited a patient group to co-design written materials.
We made many changes in response to patient input. For example, they told us emailing them a link for each clinical specialty was confusing. Instead, they asked for a single point of entry website for all specialties.
We also acted on feedback from clinicians. One said it was unusual for this to happen. This may explain why we started receiving 10-point emails about all the improvements they wanted!
Finally, we worked with every staff group involved in outpatient services, covering areas like appointment booking, system coding, reception functions, and clinical support. The key was to look at the whole system to understand every aspect that would be affected by introducing video consulting. Providing an appointment by video had to be as easy as providing an appointment in person — not just for the clinician — but for the entire staff.
One Size Does Not Fit All
It’s essential to recognise that certain consultations cannot take place by video, so we had to ensure that clinicians — with patient input — could decide on an individual basis whether to use NHS Near Me. During testing, we identified a group of people who could not connect due to poor internet connectivity or because they lacked a video calling device at home. Consequently, we have nearly completed a network of 15 clinic rooms located in our rural areas where people can use our devices. In some cases, they're supported by a local health worker who can provide checks like blood pressure or blood tests.
During the development phase, we carried out over 100 tests of change before we reached a standard process for delivering NHS Near Me. A big challenge was pressure from the public and NHS management to grow the service faster. Keeping it small meant it was agile; we could quickly respond to suggestions and test changes. Investing time in co-design enables quick scale up because it ends up being faster than rushing out an untested service that you spend months fixing.
Where are we now? Our first test clinic was in January 2018, so it’s still early days. But we have a clear standard process which is embedded in our outpatient service. We have 22 clinical specialties offering NHS Near Me, and two of these are already providing about 15 percent of their total outpatient appointments by video.
More important than any of the statistics are the patient stories. Annette no longer has to take those six-hour trips. “It’s made a huge difference to me,” she says. Instead of a three-day recovery, “it’s all done in a morning.” Another patient said, “I wish this service had been in place when my husband was alive. We spent the last year of his life driving up and down to Inverness for hospital appointments. Avoiding this would have given us much more quality time together before he died.”
Effectively implementing telehealth is about more than just technology. It’s about co-design, using a whole-system approach, and ultimately about delivering person-centered care.
Clare Morrison is the NHS Near Me Lead, NHS Highland.
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Keynote One at the IHI/BMJ International Forum in Glasgow, Scotland on March 28, 2019 (by Jason Leitch, National Clinical Director, Scottish Government and Derek Feeley, CEO, President, IHI) highlights the work of NHS Near Me.