3 Public Policy and the eHealth Vision
This section provides a brief overview of the public policy setting for eHealth, and sets out the eHealth Vision and Aims.
3.1 Public Sector Policy
In September 2011, the Scottish Government set out its response to the Christie Commission Report on the Future Delivery of Public Sector Services. It stated a commitment to intensify public service reform based on:
- a decisive shift towards prevention;
- greater integration of public services at a local level driven by better partnership collaboration and effective local delivery;
- greater investment in the people who deliver services through enhanced workforce development and effective leadership;
- a sharp focus on improving performance, through greater transparency, innovation and use of digital technology.
Clearly, the commitment to digital technology affirmed the importance of eHealth. However, these proposals also gave rise to a requirement for eHealth to reflect integration with local government and third sector partners and, wherever possible, contribute towards the prevention agenda.
Alongside this the Government published its response to the McClelland Review of ICT Infrastructure in the Public Sector in Scotland, where it highlighted the Review's recognition that 'the health service… is somewhat more advanced than the public sector in general in its adoption and deployment of ICT for enabling internal processes and in areas of service delivery' and also that 'there is a strong track record of sharing ICT and other capability'. In its response the Government restated its expectation of collaboration and more active deployment of ICT to support on-line provision of public services, to unlock further operational and delivery efficiencies, and to respond to demands from service users.
Scotland's Digital Future: Delivery of Public Services was published in 2012 and placed an emphasis on innovation in public service delivery. It promoted a "digital first" approach wherever possible, utilising digital technology to redesign existing services and enable better information access and online transactional services for the public. National approaches and collaboration were proposed across a range of areas including governance structures, ICT procurement, data storage, information assurance and workforce development.
Since 2012, developments have taken place from which the eHealth programme will benefit including:
- development of the mygovscot portal infrastructure to simplify and better signpost access to public services information and online transactions;
- the Citizen Account structure and system (myaccount) to enable members of the public to verify their identity and register for online services;
- the cross public sector Scottish Wide Area Network (SWAN) contract for communications infrastructure. This is the first time such an all-embracing contract has been awarded in Scotland. As the major partner, NHSScotland led the procurement. SWAN will support sharing of services and integration within the public sector through providing SWAN users with common, shared Virtual Routing and Forwarding technology. The contract will also deliver significant financial savings;
- the Next Generation broadband programme which will provide both patients and mobile health and social care staff with improved coverage and data speeds to access eHealth systems;
- legislation to enable NHS National Services Scotland (NHS NSS) to provide technology and procurement services not just to NHSScotland but across the entire Scottish public sector.
In summary, digital delivery of services is front and centre in the Government's plans for developing and sustaining public services for citizens. Healthcare is recognised as a leading sector in both its current use of digital technology and its plans for future digital enhancement of services, and is encouraged to progress rapidly within an environment of cross public sector collaboration.
3.2 Health and Social Care Vision and Strategy
The Scottish Government's 2020 Vision sets the strategic narrative for the delivery and development of healthcare in Scotland:
Our 2020 Vision
Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.
We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.
The 2020 Vision provides the current context for implementation of the Healthcare Quality Strategy for NHSScotland which sets out the Quality Ambitions:
The Quality Ambitions
Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision making.
There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
Achievement of the 2020 Vision through delivery of the Healthcare Quality Strategy is brought together in the Route Map to the 2020 Vision for Health and Social Care. The route map describes the challenges facing NHSScotland over the next decade including:
- projections of the impact of demographic change on the volume of demand for health services suggest there might be an increase of 22% between 2012 and 2032 if healthy life expectancy does not change. For health and social care services the projected increase is 29%;
- a continuing shift in the pattern of disease towards long-term conditions, with growing numbers of people with multiple conditions and complex needs such as dementia;
- relatively little progress to date in addressing health inequalities in Scotland despite the effort undertaken.
A key development has been the focus on integrated service provision, which was a clear recommendation of the Christie Review, both within NHSScotland and with social care and other service providers. The objective is the delivery of person-centred services, and implementation has been taken forward through the legal requirement for greater joint working between NHSScotland and Local Government, manifested in the new Health and Social Care Partnerships, and enabling NHS National Services Scotland to service both parties. The Health and Social Care Partnerships are still in the early stages of their development. However, they will deliver revised models of care for patients with long term conditions as well as increasing management of acute patients by community staff with hospital outreach support. It is absolutely clear that integrated services can only be delivered in the context of shared information and clear communication.
Substantial work has been ongoing to enable this to be achieved in the context of the recommendation from the recent review chaired by Dame Fiona Caldicott that 'the duty to share information can be as important as the duty to protect patient confidentiality. Health and social care professionals should have the confidence to share information in the best interests of their patients'. The results of this work are set out in the recent report from the Information Sharing Board and place a responsibility on eHealth to facilitate the required information sharing to enable service integration to be successful.
Other key initiatives supporting the 2020 Vision and the quality agenda include:
- Prescription for Excellence which describes a model of pharmacy care where pharmacists work in partnership with patients and health and social care professionals to obtain optimal outcomes with medicines and eliminate adverse events whenever possible;
- The National Telehealth and Telecare Delivery Plan for Scotland which sets out Scotland's approach to deploying these technologies to enable integrated health and social care.
Finally, in addition to the above challenges, there is no obvious or single endpoint to the improvement of health and social care. Technology will continue to drive both incremental and disruptive improvements leading to increasingly stratified and personalised healthcare through fields such as genetics, molecular pathology, immunology, sensors and robotics, and the analysis of complex data to evaluate outcomes and identify opportunities. This will be accompanied by changes in the organisation and delivery of care in multiple locations by larger, more highly trained teams of health and social care professionals. In turn this will place continuing demands on eHealth in relation to growing complexity of information recording, retrieval and display, decision and process support, and information analysis and governance.
3.3 The eHealth Vision
The role of eHealth is to support the achievement of the 2020 Vision and the Healthcare Quality Strategy. Indeed, eHealth is a key enabler for NHSScotland's Quality Strategy ambitions for safe, effective and person-centred health and social care. Consequently, it will be fundamental to delivering the 2020 Vision.
Primary and secondary care services depend more than ever on secure, resilient and reliable ICT systems. This dependency also reaches beyond NHSScotland as NHS Boards work in integrated partnerships with local authorities and the third sector. Health and social care workers require access to the right information, whenever and wherever they need it, to inform their decisions and ensure the best possible care is given to each individual. The move to seven day working will require NHSScotland to enhance its current infrastructure, and the associated support services, to provide much broader "always-on" capability.
Whilst much has already been achieved, the demands of delivering the 2020 Vision will require considerable further progress over the intervening period. In recognition of the crucial role of eHealth in delivering the 2020 Vision, the Scottish Parliament held a debate in March 2014 during which the following motion was endorsed.
Scottish Parliament Motion, March 2013
That the Parliament recognises that innovation through technology is vital in delivering Scotland's 2020 Vision for health and social care, whereby everyone is able to live longer, healthier lives at home or in a homely setting; considers that enhanced home-based monitoring services are instrumental in reducing levels of hospital readmission; acknowledges that digital healthcare should be a catalyst for people interacting with services and information online, building on examples such as the Key Information Summary and the internationally acclaimed Emergency Care Summary, and recognises that Scotland has a clear opportunity to be a leader in the growing global digital healthcare market, following the establishment of organisations such as the Digital Health Institute, welcomes innovations such as WardView, which can help to reduce the length of patient stays, improve patient safety and make more efficient use of clinicians' time; believes that technology will play an important role in meeting the challenges of the future, especially from the growing population of older people and the extra healthcare that they will need; further believes that Scotland should establish national-scale telehealth services, and would welcome the establishment of a specific HEAT target for NHS boards to mainstream the use of telehealth in the delivery of patient care.
As a result, a refreshed vision has been developed for eHealth that is consistent with the 2020 Vision for Health and Social Care, the Parliamentary Motion, and the Cabinet Secretary's subsequent commitment that patients will have access to their own Personal Health Record by 2020.
The eHealth Vision
By 2020 eHealth in Scotland will:
- Enable information sharing and communications that facilitate integrated health and social care across all settings from the patient's home to the hospital.
- Provide information processing, analysis and intelligence that supports and complements the work of health and social care professionals and improves the safety and quality of care.
- Support people to manage their own health and wellbeing and live longer, healthier lives at home or in a community setting.
- Contribute to a partnership between the Scottish Government, NHSScotland, the research sector and industry to enable Scotland to be a long term leader in digitally enabled care.
3.4 The eHealth Aims
A set of six eHealth Aims were developed as part of the 2011 eHealth Strategy. These remain appropriate for the next period of eHealth development and, together with a seventh aim specifically in relation to innovation, are consistent with NHSScotland's 2020 Vision.
The eHealth Aims
1. To enhance the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality.
2. 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.
3. To contribute to care integration and to support people with long term conditions.
4. To improve the safety of people taking medicines and their effective use.
5. 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.
6. To maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money.
7. To contribute to innovation occurring through the Health Innovation Partnerships, the research community and suppliers, including the small and medium enterprise (SME) sector.
3.5 Achievement of the eHealth Vision and Aims
There is no doubt that eHealth has massive remaining potential to assist clinicians to do their job better and to provide citizens and patients with better information and services. To meet these demands eHealth will need to continue to address several complex areas:
1. A focus on integrated person-centred information. Data and information about any individual patient may reside in different NHSScotland organisations and in different systems. Together it comprises that patient's information which documents their health history over the course of their life and their current known health status. In principle, whenever and wherever (from the home to the hospital) a patient has an encounter with health and social care services this information should potentially be available to the health and social care practitioner and the patient. In practice all levels of detail may be unnecessary, and indeed excessive, and accurate, up-to-date summary information will suffice, whilst viewing of some information may be restricted for reasons of privacy and confidentiality. However, the principle should be that organisational and system boundaries should not prevent person-centred care which requires integrated person-centred systems and management of information.
2. Many vital pieces of patient information are still held on paper which frequently makes them unavailable when needed. Patient information in digital form can be accessed immediately from multiple locations and reused without delay for multiple purposes, thereby greatly enhancing its value and its contribution to the quality of care. The ongoing process of full digitisation of patient information must be completed, with minimal resort to paper which needs to be scanned in order to be added to the electronic record. A key principle of this digitisation is the importance of using structured and coded formats whenever possible. Whilst this can be a burden and time-consuming for front line practitioners, it results in much more valuable data which will have benefits for patients, through enabling more intelligent support from systems, and for research.
3. Digitised information will ultimately provide the basis for a comprehensive Electronic Patient Record which can, in principle, follow the patient between services and across organisational boundaries, and be shared between health and social care professionals. In addition, it can also be viewed by the patient as their Personal Health Record, and they can add information that they wish to share with their health and social care professionals.
4. Digitised information and associated electronic communication must be exploited to organise, co-ordinate, monitor and evaluate inputs to the patient's care. Information and tasks can be more quickly and effectively shared between care team members who can be facilitated to work together through shared directories and calendars for easy identification and referral, secure messaging and system based workflow, so staff are fully informed about the patient and the wider care context. This needs to include patients who can be kept informed about their care electronically, as well as exploiting this capability to electronically order repeat prescriptions, book appointments, message with their carers, and access healthcare information.
5. Healthcare is characterised by vast volumes of research and guidance that in theory can be applied to individual patient care decisions to improve outcomes. In practice, health professionals who see a vast variety of patients cannot be up to date with all this information, and typically they have to rely on their training and memory, and developments such as the SIGN guidelines, whilst working under significant time pressure. The value of digitised patient information is that this knowledge base, with appropriate, and complex, design of rules and ergonomics, can be applied electronically to provide clinicians with reliable, automated advice and support that is sensitive to a patient's specific circumstances and can be integrated into existing clinical working practices (so called clinical decision support). To be effective at the most sophisticated levels it will require coded and consistent patient data which can be processed and analysed to produce intelligent support, with the objective of reducing some of the cognitive load on clinicians and supporting less experienced staff.
6. Digitised information with associated intelligence provides options to evaluate and, where appropriate, significantly redesign some care processes. The most senior and experienced staff need to be reserved for the most complex cases, whilst other staff care for simpler situations with intelligent support. Ideally, this will mean that clinicians can focus and spend more time with those patients who have complex problems, whilst quickly and effectively providing the required service to those who need more standard care. Patients can also be provided with, or acquire themselves, measuring devices or sensors and associated intelligence that monitors the results and determines whether any escalation or intervention is required (home health monitoring). Although healthcare is definitely not a factory environment to be automated, it still has opportunities to increase capacity and productivity, and reduce cost, through the application of eHealth, whilst always ensuring that new models of care are evidence based, carefully trialled, and at least as good, and preferably better, than those they replace.
The above areas are challenging, not only in terms of technology, but particularly in respect of the organisational, process and cultural change that they entail, and it will take considerable development and time to address them to their full potential.
Email: Alan Milbourne