8. Recommendations
Telehealth has entered the national agenda, with pockets of pilot projects appearing across Scotland, and greater numbers of Health Boards enthusiastically using telehealth applications with support from the SCT. Telehealth technology is clearly enabling rural Boards to deliver specialist health care services through teleconsultation with specialist centres, and enabling patients to receive treatment closer to home. It is reducing unwarranted travel to specialist centres and unnecessary referrals to emergency departments in some areas. Therefore, it is unsurprising that there is almost unanimous support from stakeholders for the continuation of a centre of telehealth expertise.
The SCT has had significant successes in various discrete clinical areas including the ongoing development of a Scottish Telestroke Network, a Paediatrics Network, and minor injuries and out of hours services in NHS Grampian and NHS Tayside. It has made considerable progress in improving access to specialist services in remote and rural areas e.g.NHS Orkney and NHS Highlands. It is clear from this review that the SCT has performed a central role in each of these examples, with some Boards relying heavily on the support and expertise of SDMs.
Telehealth (and telecare) are evidently popular with patients and their clinicians. Drivers such as demands on service provision resulting from demographic changes, and the need to develop services that encourage and enable self care and self management will require service re-design, which will incorporate telehealthcare applications. Growing pressure on Health Service budgets will be a significant incentive for service providers to seek more efficient and cost effective delivery models. Telehealthcare technology has the potential to deliver significant efficiency savings and reduction in Carbon emissions, without compromising quality of treatment.
We recommend that a centre for telehealth expertise in Scotland should be retained
Governance and accountability
Poor communication, confusion over the SCT's role and purpose, and the absence of a clear strategic direction have arisen as particular concerns.
Poor internal and external communication is affecting not only the SCT's success and influence, but its management and governance arrangements, and, most importantly, its staff moral.
The SCT's governance arrangements are particularly poor, with split accountabilities between NHS Grampian and the Executive Group, and questions over the size and membership of the Executive Group.
It is apparent that problems with the SCT's governance are contributing to the organisation's lack of strategic direction, confusion over its role and purpose, and poor corporate communication.
The failure of the SCT's Reference Group to meet for over a year is of concern, as this group forms an essential part of the organisation's governance arrangements. The purpose of the Reference Group was to shape and formulate ideas with input from clinicians and key stakeholders from across the NHS. Crucially for the SCT, the Reference Group was its forum for communicating with stakeholders and ensuring that its work programme was relevant. It is unsurprising that many interviewees felt the SCT lacked direction, was working in an "ad-hoc" way and failing to communicate effectively, as there was no opportunity to come together as a group and receive regular updates on the organisation's work.
Staff morale within the SCT was particularly poor, with staff anxious about deteriorating communication, lack of effective line management and a culture of "silo" working. Many felt that the organisation's management was disinterested in their work and views on the SCT's future direction. There was an overall feeling of lack of leadership. The SCT's low staff morale is particularly concerning and damaging. If it is allowed to continue, it will have an increasing impact on the SCT's overall effectiveness, and make retention of existing staff and future recruitment more difficult for the Centre.
Problems with internal communication, silo working and ineffective management are contributing to external perceptions that the SCT lacks direction, is working in a "piecemeal" or "ad-hoc" way, and is sending an inconsistent message. Poor internal communication is leading to stakeholders receiving mixed messages and, on occasion, contradictory information from the Centre's staff on various issues e.g. evaluation.
We recommend that the SCT's governance arrangements should be streamlined and improved
If the SCT was to be repositioned as part of a national NHS Board, the Executive Group may be re-constituted as an Advisory Group and its membership augmented with additional representatives from NHSScotland and other key stakeholders. These changes would make the Executive more representative of its key stakeholders and may help the Group, through greater involvement with the SCT, obtain a better understanding of the organisation's business and challenges. SCT staff, who are not members of the Management Team, may have the opportunely to routinely attend Executive Group meetings, which may be held in public. The SCT's Reference Group may be re-launched, with the group re-visiting its membership, constitution and the frequency of its meetings. However, given the size of the SCT (8 full-time and 3 part-time employees), making this number of changes might be disproportionate in terms of the additional resources required to implement them. There is no guarantee that these changes would bring about the necessary improvements.
The telehealthcare landscape
The Scottish Government has made it clear that effective government may be best achieved by:
- simplifying the landscape of public sector organisations in Scotland, through simpler structures that support the delivery of national strategic objectives and local priorities
- transparent and clear service decision making with streamlined scrutiny and control regimes
- an overall reduction in the number of "arms length" bodies at national level
- improved collaboration and joint working between public services
Its policy drive is based on ensuring public services, which are focused on:
- the users of services and the development of ongoing personal relationships, rather than anonymous one off transactions
- outcomes and monitoring real improvements in services
- delivering value for money through public services that drive up efficiency and ensure best value
Any future changes to the SCT's governance arrangements and structure must be assessed against the Scottish Government's policy on public bodies. Currently, our operational environment promotes the simplification of the organisational environment with improved collaboration between public bodies. Therefore, it is consistent with the wider policy context to question the SCT's continued independent status.
Many of the interviewees questioned the SCT's independence and suggested that it should have better links with NHSScotland. There was unanimous support for simplifying the telehealthcare/eHealth landscape, and calls for the SCT to increase the pace of its collaboration with the JIT. A small number of stakeholders specifically suggested that the SCT should lose its independence and become part of a national board structure, for example NHS24 or NSS.
We believe that it was correct to establish the SCT utilising the pre-existing expertise in NHS Grampian. However, the role of the SCT is evolving and the SCT's location may be a factor in the relatively slow adoption of Telehealth on a national basis in Scotland. We understand that some of the expressed concerns are based on widely held perceptions. However, a more central location may smooth the progress of the development of national telehealth solutions. Of particular significance were the comments from some very influential individuals, who were actively involved in the SCT, they felt that the time was appropriate for the SCT to become part of a National (Special) Health Board.
The integration of the SCT into one of the National (or Special Boards) would bring about significant benefits. It would be consistent with government policy (see above) and with the views of many of the SCT's stakeholders (and some of its staff). It acknowledges the SCT's chief role of supporting NHSScotland in developing telehealth solutions, in the same way that Special Boards work with territorial Boards.
The SCT would no longer require its own governance and management arrangements, with the costs that these incur. It would sit under the Special Board's existing governance structures, with links into the Scottish Government through its Board and Chief Executive, and representation on eHealth Programme Board. Crucially, the SCT would have the opportunity to become a truly national resource, with improved leverage and influence, and better opportunities to work in collaboration with other parts of the NHS in Scotland.
We recommend that Scotland's telehealthcare landscape be simplified with the SCT joining one of the Special Boards. We recommend the best fit is to reposition the SCT within NHS24, recognising its potential as a service delivery and improvement organisation.
The two most appropriate National Boards to host the SCT are NHS24 and NSS. Of the two, NHS24 appears the best fit with the SCT. They share a strong clinical focus, both rely on IT infrastructure, and NHS24 is active in many complementary areas of health care service delivery. For example, both organisations are working on: improving health; unscheduled care; and improving access to NHS services. Both organisations are specifically supporting patients with Long Term Conditions and Mental Illness, and both are utilising technology to expand options for the public to access services in the future. Although headquartered in Glasgow, NHS24 has 3 national and 5 local centres throughout Scotland.
There is an argument for retaining the SCT's Reference Group, albeit with a revised membership and remit, as this may continue to provide a forum for communicating with a large range of stakeholders and guiding the SCT's work at grassroots level. Unlike other parts of the health service ( e.g. eHealth, eCare and telecare), Telehealth does not have a network of professionals and specialists, currently delivering services using Telehealth, to encourage diffusion of innovation and develop recommendations, guidelines and standards. This may be delaying development and learning in Scotland as, out with annual conferences, there are few, if any, opportunities for people actively involved in telehealth to come together, share their experiences and develop national approaches.
There may be greater potential in the creation of a new "telehealth network", with "telehealth co-ordinators" or "telehealth champions" nominated by each NHS Board and the SCT's key stakeholders. This may be modelled on, either the existing Scottish Government sponsored eHealth Leads Groups or the Telecare Network, which is supported by the Dementia Centre and considered by the JIT to work particularly well. If established, the telehealth network would have the opportunity to meet and liaise with the eHealth and telecare groups, which would improve communication, mutual understanding and delivery, and progress telehealth/telecare convergence.
We recommend that a "telehealth network", with "telehealth co-ordinators" or "champions" (nominated by NHS Boards, the Scottish Government and key stakeholders) should be established with a view to integrating telehealth and telecare
Telehealthcare terms and definitions
There was unanimous agreement amongst interviewees for the simplification of the terms and definitions currently in use. In particular, it was clear that the terms telehealth and telemedicine, and to a lesser extent telehealth and telecare, were being used interchangeably, with some individuals using the term teleconsultation when referring to telehealth solutions in general. In addition to the terms (and definitions) causing confusion within the sector, many stakeholders were concerned that the number of "tele" terms was particularly bewildering for service users and their carers.
The vast majority of interviewees had no strong preference for any particular overarching definition. Three possible nonspecific terms were suggested: Telehealthcare; eHealth; and eServices. Of the three suggestions, telehealthcare received the most support. A small number of interviewees felt strongly that the term eHealth should not be used.
It is important to reach a consensus on an overarching term. Not only are a number of different terms in use, but there are also a number of different definitions being used by the various delivery organisations, including the SCT and the JIT. Furthermore, as the technologies converge, the distinction between telehealth and telecare will become increasingly irrelevant.
The priority must be to ensure that telehealthcare receives a higher profile within Scotland and any barriers to its increased use ( e.g. confusion over terms and definitions) should be removed.
We recommend that the terms (and definitions) used should be simplified, for example Telehealthcare, eHealth or eServices
Projects and other activities
The Scottish Government is committed to funding telehealth in Scotland. The evidence suggests that, if less ad-hoc project work is to take place, the SCT's focus must shift from short-term projects to strategic long term national, or regional, telehealth solutions. The SCT should continue to support Boards in implementing Telehealth solutions but must prioritise its work programme.
The SCT must communicate what its role is more clearly, if it is to avoid raising expectations, which are unable to be delivered with its existing resources. In particular, it should be communicating more clearly its clinical focus and clarifying its role, if any, in providing technical advice and guidance to Boards. When negative comments were expressed on the SCT's advisory role, they were all concerned with the lack of technical advice from the SCT and its failure to underpin its clinical vision with a technical strategy.
Currently, the SCT spends the vast majority of its time working with Boards on pilot or local projects. Of the appropriately fifteen projects the SCT is current supporting only two may be classed as national ( i.e. paediatrics and stroke), with an additional two regional projects ( i.e. out of hours care in Grampian and Tayside). However, the majority of Boards value and appreciate the work the SCT is doing with many interviewees stating the SCT's involvement had been critical to their projects' success. Furthermore, pilot projects are an essential tool in identifying and trialling new telehealthcare initiatives.
The first challenge for the SCT should be to prioritise its workload of local and pilot projects, and to free up time and resources to take forward national telehealth solutions.
The SCT seems to lack formal exit strategies for their current projects, often continuing involvement until the project becomes part of mainstream service delivery. Before agreeing to support pilot projects, the SCT should be clear on the extent of its involvement and the timescale. The impression formed during the review is that the SCT often drifted into projects, with the time and resources allocated at the discretion of the relevant SDM, resulting in a dilution of the SCT's "vision" resulting in mixed messages being sent to stakeholders.
The second challenge for the SCT should be to develop exit strategies for projects where it no longer has a central role, with transfer of responsibilities to the relevant Boards/partners.
National telehealthcare solutions
Currently, the SCT is considering four areas (stroke, mental health, COPD, and unscheduled care and minor illnesses) for development of national telehealth solutions. Interviewees broadly supported an increased emphasis being placed on national initiatives, but questioned the process by which the SCT had determined the number and nature of its priority areas.
There is broad consensus that stroke (and in particular thrombolysis for Hyperacute Stroke) is an excellent priority area for development of a national telehealth solution. The Scottish Telestroke Programme is already up and running in NHS Lothian, Grampian and Lanarkshire, and project teams have been established in another four Board areas. The Programme is sensitive to the different needs of each Board area and allows for differences in service delivery. Given the excellent progress to date combined with the significant buy-in from stroke clinicians across Scotland, it would be logical for the SCT to support this Programme by facilitating a national telehealth solution; particularly as stroke remains one of the Scottish Government's priorities.
The other clinical area where the SCT should support and facilitate existing activity is telepaediatrics. The Scottish Paediatric Telemedicine Network is already employing telehealth to facilitate the delivery of specialist paediatric care across Scotland. Each of the four children's hospitals is being equipped to: undertake teleconsultations; send and receive incoming referrals; and host and broadcast meetings or case conferences. Eventually, these facilities will allow the specialist centres to support the delivery of paediatric care in: hospitals without specialist paediatrics services; minor injury facilities; out of hours centres; NHS24; and the Ambulance Service. The SCT should lead in accelerating the role out of this programme; working with the four children's hospitals and the existing regional network of staff to formulate plans for its further implementation.
We recommend that the SCT should become more strategic and initially focus on one or two clinical areas moving them from projects to universal use ( e.g. building on the existing paediatrics and stroke networks)
Interviewees unanimously agreed the SCT must become more strategic. The absence of a comprehensive Strategy is delaying the implementation of telehealth in Scotland and presenting a confused message to stakeholders. An immediate priority for the SCT is the development of a telehealthcare strategy, in consultation with its key stakeholders. This strategy should be underpinned with a parallel IT infrastructure plan.
The SCT requires a telehealth strategy which is underpinned by an IT infrastructure plan
Information technology
Interviewees repeatedly commented on problems with IT particularly video conferencing, band width and bridging services. It was felt the SCT should have taken an early leadership role in highlighting band width problems, particularly in remote and rural areas. A considerable number of stakeholders were of the opinion that the SCT had done little in terms of technological support or in developing wider IT standards. However, it was clear that there has been little progress in developing a national infrastructure for telehealth delivery and the current disagreements about the provision of video conferencing and bridging services was unhelpful.
It is not within the remit of this review to make detailed comments or recommendations on Telehealth technology, other than to identify the pressing need for a number of national and/or regional agreed approaches. Scotland requires immediate action on video conferencing and bridging services, and eHealth, in collaboration with eHealth Leads, the SCT and other relevant stakeholders must develop technical standards and guidance. The delivery of video conferencing and bridging services must be addressed. For example, these services could be outsourced, with the SCT (or eHealth, NHS24 etc.) retaining a "virtual" lead on the development and implementation of such services.
The SCT should advise NHSScotland about options for improving video conferencing and bridging services
The SCT effectively performs the role of Scotland's telehealth champion and has held a number of very successful conferences, raising the profile of telehealth within Scotland and beyond. We recommend that the SCT continues to champion telehealthcare and host regular conferences.
Other areas of activity
Currently, the SCT is working with the higher education sector on the development of telehealth modules for inclusion in under graduate and post graduate courses. Work on this is in its infancy and has so far been limited. However, if telehealthcare is to become part of everyday service delivery, it will be necessary for all health care professionals to receive appropriate training throughout their career. The routine use of telehealthcare will require significant cultural change within NHSScotland. There is evidence that some clinicians and health care professionals are reluctant to implement telehealth solutions due to their resistance to change, and considerable work will be required to change peoples' behaviours and attitudes to telehealth applications. Developing tools, in collaboration with higher education and other training providers, is a substantial task but one that the SCT should have a role in along with other parts of the NHS in Scotland e.g.NES.
The SCT, in collaboration with NES, and other training stakeholders, should develop telehealthcare education tools
There was some criticism of the SCT for failing to take the initiative when dealing with suppliers and manufacturers. A number of stakeholders believed the SCT should be guiding and advising suppliers on NHS requirements of Telehealth technology rather than being reactive to the market. However, it is very likely that, even had the SCT taken a leadership role, its influence would have been limited due to the relatively low and fragmented use of telehealthcare applications in Scotland. Nevertheless, if the SCT moves from telehealth pilots to national solutions, it may develop a role as part of a larger and more influential organisation with greater bargaining powers.
A considerable number of stakeholders stated they would look to the SCT for advice on procurement. Many were frustrated that, in the absence of such advice Boards had no alternative but to procure equipment locally, with the risk of future incompatibility between systems and NHS Boards. They felt the SCT (or eHealth) should be helping with the procurement process and may be able to negotiate volume savings for NHSScotland. To date, the size and scale of telehealth use in NHSScotland has not required any one organisation to take on this role. However, as the SCT moves from pilots to national telehealth solutions, there will be a requirement for national procurement or a national procurement strategy.
We recommend that the SCT takes a more pragmatic role in procurement processes for Telehealth equipment
Service Development Managers
As the SCT's focus changes from pilot projects, and raising awareness, to facilitating delivery of national telehealthcare solutions, then the role of its SDMs must change correspondingly. In theory, the SDMs currently combine project work with geographical responsibilities. However, in practice their project role takes priority. Frequently, the SDMs are diverted from their project development role by having to undertake routine, relatively minor hands-on tasks for individual Boards. The SCT should ensure it delivers national coverage rather than the current situation of rural and remote Boards receiving the benefit of the majority of the SCT's resources. A more central location with in NHSScotland may assist the SCT in achieving this, as will the development of a strategy and the prioritisation of its workload. However, it is important that NHS Boards requiring support with implementing telehealth applications may contact the SCT and receive timely assistance. Becoming part of a considerably larger organisation, with call handling capabilities, would help the SCT to provide advice, whilst maintaining its core business. In time, and given the required demand, such as advice service may develop into a telehealthcare support centre for professionals using a range telehealthcare applications; e.g. from clinicians in a hospital setting to health care support workers looking after older people in the community.
The SCT should achieve equitable national coverage of Scotland
SDMs were concerned that they rarely had the opportunity to meet with colleagues to discuss common problems. They, and a small number of stakeholders, expressed concern at the silo culture of working within the SCT with very little team working amongst SDMs. Becoming part of a larger organisation, with more mature communication systems, an intranet and better management processes, should assist in improving communication amongst SDMs and the wider SCT. In addition, we recommend that SDMs should meet regularly to share experiences and increase the opportunity for shared learning. We genuinely believe the SDMs are looking to become more involved in the operation of the SCT and should have a key role in developing the organisation's strategy.
Team meetings should be held regularly and all staff should be give the opportunity to raise issues for discussion, and to contribute fully and openly
SCT funding
We consider the size of the organisation to be appropriate at present (8 full-time and 3 part-time employees). However, it lacks sufficient technically trained IT staff. Therefore, we propose that one or more of the IT vacancies, in the SCT's current organisational structure, should be filled as matter of urgency to further support NHS Boards with existing technical difficulties.
In light of the previous years' underspend, and our recommendation that the SCT should remain approximately the same size, we do not anticipate the SCT requiring additional funding from the Scottish Government for its running and staff costs in the immediate future. Furthermore, as part of a larger organisation there may be opportunities for efficiency savings and/or for resources to be diverted into projects and Telehealth activities. Future funding will be informed by an approved Telehealth strategy (see above).
Telehealth funding
There must be clarity on the funding available (or likely to be available) for telehealth projects, so Boards may set affordable priorities and expectations can be managed. Interviewees were unclear as to how the SCT was funded (or to what degree), and commented on the absence of dedicated funding for telehealth compared with telecare, and the existence of limited eHealth funding from the Scottish Government. There was frustration that although the SCT was not a funding body that it had at times provided funding from its underspend.
There should be clarity on the funding available for telehealthcare, so affordable priorities may be set and expectations managed
The vast majority of stakeholders felt that, if the Scottish Government was genuinely enthusiastic for Health Boards to invest in telehealthcare, it should demonstrate its commitment with dedicated funding. A number of interviewees suggested there should be a centrally funded, national telehealth programme with bids scrutinised by a Programme Board. However, others suggested the SCT should have its own "national" budget. All agreed that the current arrangements required change.
We recommend consideration be given to the introduction of an element of core funding for national telehealth solutions
Estimates of the amount of central funding required for national telehealth initiatives must await agreement of national Telehealth priorities between the SCT, NHS Boards and the Scottish Government, and the production of a telehealth strategy (incorporating an infrastructure plan).
Whilst, we recommend consideration of the creation of a national programme with some core funding, the SCT or the Scottish Government should not fund local projects and initiatives within Health Boards. Local projects should continue to be funded predominately by Boards (and their partners), as part of service re-design and continuous improvement initiatives.
Whilst, the SCT doesn't routinely fund local projects, it does support and provide substantial resources through its SDMs. The resource it allocates to projects varies considerably, with some projects receiving additional and on-going (often hands-on) support for some months after they have become part of mainstream service delivery. There should be a clear transition from funding or resourcing of pilot, or development, projects into "business as usual" or mainstream service delivery. This would enable the SCT to become more strategic, focusing on national initiatives, whilst retaining its key advisory role.