HC Deb 04 May 2000 vol 349 cc387-96

Motion made, and Question proposed, That this House do now adjourn.—[Mrs. McGuire.]

7.1 pm

Dr. Howard Stoate (Dartford)

I feel fortunate to have obtained an Adjournment debate on a subject which I believe is of great importance and sits well with Government policy on the health service.

Telemedicine means medicine at a distance. It has been defined by the American Medical Association as: the provision of health care consultation and education using telecommunication networks to communicate information. Currently, the telephone is the simplest and most common form of telecommunication and, therefore, of the telemedicine medium. It is used every day by every GP in the country and is now, I am pleased to say, employed by NHS Direct—a 24-hour nurse-led helpline that can offer triage, information and other services to patients, wherever they live and at whatever time of the day or night they choose to phone. However, telemedicine can be far more sophisticated. Almost every day, it brings the introduction of more sophisticated systems that extend the range and scope of such services. That is one of the reasons why I requested this evening's debate.

Telemedicine has the potential to deliver improved access to health care to the whole nation and greatly to reduce pressure on the acute sector by bringing specialist knowledge and expertise to the heart of communities, and even directly into patients' homes. The key function of telemedicine is assessment and diagnosis. It has the capacity to speed up diagnosis and the referral procedure, thereby reducing the need for patients to travel and enabling more efficient use to be made of hospital time and resources.

That is of particular benefit to isolated and rural communities. For example, in Australia and the United States of America, which contain large tracts of land with extremely low population densities, the use of telemedicine video-imaging to make emergency diagnoses is well established. Although such problems are far less pronounced in this country, many communities, both urban and rural, are poorly served by certain medical specialties. Telemedicine offers one means of tackling such underprovision.

We all know that there are shortages of certain specialists. I am pleased that the Government are tackling that by dramatically increasing the number of specialist training places available, but gaps remain and it will be many years before enough specialists are trained to meet all the needs of every community. Therefore, it is vital that such resources as the NHS has are used to the best possible effect and in the most efficient way.

Let me give an example drawn from my locality, which prompted me to raise this subject. The Lions hospice operates in my constituency and that of my hon. Friend the Member for Gravesham (Mr. Pond). Last year, the hospice was faced with a problem: it had working for it a full-time palliative care consultant, Dr. Peter Harper, who was able to provide first-class treatment directly to patients in the hospice. However, Dr. Harper decided to take a post in Cornwall, thus leaving the hospice without a palliative care consultant. As I said, there is a shortage of palliative care specialists in Britain. Despite the fact that more are being trained and will be available in the future, there is a gap.

The hospice found it extremely difficult to recruit a replacement for Dr. Harper. Moreover, on examining its resources, it found it difficult to justify employing a full-time consultant at a hospice of moderate size. It simply was not the best use of NHS resources. It seemed wrong to take up the time of a full-time consultant at a hospice that did not need one. When I spoke to Dr. Harper, he mentioned that he was doing jobs that were not within his field of expertise, so he felt that his time was not being used to the best possible effect.

The hospice therefore invested £7,000 in telemedicine equipment—a couple of monitors, a couple of high-quality video cameras, six ISDN lines and the necessary electronics to link all the equipment together. That enables the hospice to communicate directly with Dr. Harper—the same NHS consultant, who is now in Cornwall. Three times a week, case conferences are held with him through a live TV link. The quality of the system is so good that he can assess scans and X-rays directly over the system and can participate directly in patient care, as if he were in the room. I have had a conference with him over the equipment, and I was astounded by the quality of the link and how well the system worked for the hospice.

Although the hospice has no consultant, it has access to a consultant exactly when he is needed. He is available three times a week on a regular basis, and can be contacted at other times in emergencies, if necessary. He can provide a first-class service to patients in my constituency, even though he is 200 miles away.

That seems a splendid way of ensuring that the NHS gets the best value for money out of the system. The only on-going costs are those of the hospice's contract with the consultant's current employer and of the telephone links, which are very small compared with the cost of employing a consultant. Although the hospice has not had a consultant for the past year, it has access to a first-class service.

Such an innovative response to the problem of local under-provision can only be applauded. Not only is it more efficient and cost-effective than other systems, but it increases the level of responsibility and expertise of locally based nurses and other health professionals who liaise with remote consultants. A colleague of mine in Dartford, Dr. Roger Peppiatt, has taken a sabbatical from his GP practice specifically to examine the breadth and scope of telemedicine, and is researching that very area. I shall be interested to hear what he has to say when he returns from his sabbatical.

Telemedicine is one way of developing the role of the nurse, which fits well with the Government's primary care strategy. The kind of consultant-led, nurse-managed system that operates at the Lions hospice could act as a model for many other parts of the health service.

The education function of telemedicine should also be emphasised. It could provide significant opportunities for primary care professionals and GPs to develop new skills and build on their existing knowledge, enabling them to offer new services to local people.

In Ireland, for example, the advent of a video conferencing link between the island of Inishmore and the department of psychiatry at University College hospital, Galway, gave patients on the island their first opportunity of direct psychiatric assessment. Before the link was established, the majority of new cases were admitted directly to hospital, as there was no qualified professional on the island to assess properly the severity of each case.

Not only did direct assessment reduce the number of hospital referrals, but it gave health care professionals on the island a more sophisticated understanding of the nature of psychiatric conditions. That entailed an appreciation of how to identify and manage such conditions, and therefore enabled them to give the appropriate support to psychiatric professionals on the mainland.

Video conferencing as a teaching tool has great potential. It could enable local health practitioners to learn from leaders in their field through interactive classes, and the internet, which has allowed patients to obtain a greater understanding of their condition, offers even more potential.

Improving local health care services has the direct consequence of reducing the need for hospitalisation in many cases. That is good news for hospitals and their staff, but even better news for patients, who, given the opportunity to stay at home, can enjoy a much better quality of life. A good example of that is the pilot programme involving patients with chronic illness, which is being conducted by Newcastle City Health NHS trust in partnership with Newcastle city council and the regional medical physics department.

The trial involves the installation of telemedicine monitors in a patient's home, allowing his or her condition to be remotely monitored by a local control centre. Any change in the patient's heartbeat, respiration or temperature can be recorded and monitored. If there is a change, the GP, nurse or other specialist can be notified. So far, the results have been favourable, encouraging the belief that such social alarm monitoring services may in the future provide a realistic alternative to hospitalisation for thousands of people.

As the national beds inquiry showed, many people in hospital, including the elderly and those with long-term chronic conditions, have no clinical need to be there. Indeed, an extended stay in hospital may actually be of harm to them. Methicillin-resistant staphylococcus aureus, which is an extremely unpleasant bug and difficult to treat, exists only in hospitals. It is virtually impossible to catch it in the community. I know of only one case in the world of a patient who acquired MRSA from a community infection. It is sometimes bad for one's health to be in hospital. Therefore, anything that can reduce the number of hospital admissions or the length of stay must be applauded, not merely as a way of saving money for the NHS, but as a way of improving patient care.

However, certain provisos remain. Telemedicine cannot be phased in on a wider scale until its long-term effectiveness has been demonstrated conclusively to the wider community of health professionals and patients. We must establish that patient monitoring can be performed reliably and safely to ensure that such trials can be extended.

We need a way of ensuring that people are reassured, that patients feel that they are receiving good quality medicine, and that doctors feel that their expertise is being best used. We must ensure that pilot studies are properly evaluated, and that all the benefits can be seen by everybody so that they can decide for themselves whether telemedicine should be developed further. That is why we need proper training specifically designed for telemedicine practitioners and the regulation of telemedicine itself. Those are vital issues which the Government need to address and for which they need to provide a proper framework.

The Government have a major role to play in that. Undertaking a review of telemedicine and its role in the health service would serve to resolve some of the issues that are preventing the wider use of telemedicine. As a recent guidance note from the NHS Executive stated: The full benefit of telemedicine and telecare may only be realised in the light of managerial and organisational change within the health service.

The Government have already made a commitment to modernising the NHS and increasing the role of IT across the health and social care system. Promoting telemedicine and producing guidance documents for health authorities on how telemedicine can be incorporated more fully into the health care system is one way of achieving that goal.

That is why I hope that today the Minister will be able to take a lead. An evaluation of whether the quality of care and diagnostic accuracy being delivered by telemedicine is equal to that delivered in person would help to tackle the misguided belief that telemedicine is a second-class form of medicine. A review of the law to ensure that the interests of telemedicine practitioners and patients are adequately protected would also serve a useful function. For example, whether a remote consultant who examines a patient's case is subject to the same regulations as an in-house consultant is a question frequently raised by experts in the field. Establishing just who is liable for a mistake or misdiagnosis and creating a proper control for telemedicine, governing the interaction between different institutions and different specialisms, is clearly necessary.

There is no question but that within every health authority there is greater scope for the practice of telemedicine. For example, health authorities could consider setting up telephone contacts between the health service and recently discharged patients to monitor their progress. That is an obvious, cost-effective form of telemedicine, which would undoubtedly benefit patients and could be delivered through existing systems, such as NHS Direct.

The use of electronic referral letters and electronic medical records, creating virtual outpatient departments, is another form of telemedicine that could easily be developed and progressed. For example, a number of internet-based projects have been set up around the country linking hospital dermatology departments and GP surgeries. The quality of images available over such systems is good enough to allow a dermatologist many hundreds of miles away to make an accurate diagnosis and offer appropriate advice and treatment.

There is also the possibility that the internet and telemedicine could be used in developing countries, so that experts from one country could establish links with experts in a different country, diagnosing and training.

However, some significant ethical implications need to be addressed. We must ensure that the systems are confidential and secure. The internet has already been shown in many cases to be an insecure medium. There also needs to be a change in the attitude, work practices and organisational structure of the NHS if we are to see telemedicine developed. I should like the Government to encourage all health authorities to draw up a telemedicine strategy with specific targets for the adoption of telemedicine in their areas and specific proposals for its use.

An NHS in which telemedicine is widely practised is one in which there will be greater communication between health professionals and between health professionals and patients, forming new partnerships across service boundaries. It would also be a service that respects the idea of lifelong learning, committed to the use of new technologies in providing opportunities for its staff further to develop their skills.

Breaking down interdisciplinary boundaries and encouraging a fresh look at how skills are utilised in the health service will help to create the modern, efficient NHS which the Government are determined to build. Telemedicine has enormous potential to reduce medical inequalities in Britain and to bring services back to areas that, in recent years, have seen gaps in, or a lack of, services. That is one powerful reason why we should be looking to invest more in telemedicine during the next few years.

7.14 pm
The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)

Information is the key to the modern age. The new information age offers possibilities for the future limited only by the boundaries of our imaginations. I quote the Prime Minister in "Our Information Age" and I congratulate my hon. Friend the Member for Dartford (Dr. Stoate) on securing a timely debate on telemedicine.

Last month, I was delighted to open officially a telemedicine system, which links the accident and emergency departments at Bolton, Burnley and Bury with the maxillofacial and oral surgical unit in Blackburn royal infirmary. Experts at Blackburn can now quickly assess patients with facial injuries. Treatment begins immediately under expert supervision without the need to travel long distances. Patients are transferred to the in-patient unit at Blackburn only when necessary. For many patients, that will mean avoiding the 20-mile round trip to the specialist unit, and allow them to remain close to their families. It is a fascinating example of the NHS using new technologies to improve patient care.

Before I explore the use of telemedicine further, let me explain the wider need for change. The Government are committed to building a new NHS, which is faster, fairer and more convenient for patients and fit to face the challenges of a new millennium.

The extra resources that the Budget made available to the NHS give us an excellent opportunity to modernise its services. We have set out a 10-year modernisation programme to renew and reform the NHS. It aims to transform services, widen access, foster quality and modernise government.

We have achieved a lot: we are modernising every casualty department that needs modernising, getting more doctors and nurses into the NHS, setting up new additional services like NHS Direct and walk-in centres. Of course, we are providing the extra resources that the health service needs. We have been turning the NHS around and, in the process, laying the foundations for modernisation.

We have announced the modernisation action teams, which will consider the variation in practice and performance in the NHS and provide a unique opportunity to work with patients and professions to modernise the NHS and reinvent it for the new century.

The teams will devise solutions and work towards the creation of a national plan for the NHS. The national plan will embrace all those who share a commitment to the founding principles of the NHS but who have an equal determination to modernise its practices.

One of the ideas from the initial meeting of the teams was the potential use of a patient-held smart card to enable patients to gain access to their medical history. That is an example of the innovative ideas that emanate from the teams and will be taken forward in the coming months.

Telemedicine and telecare will play a vital part in modernisation. They are not new medical disciplines but tools that allow services to be delivered in a new way. They will provide services for patients, when and where they need them. That is happening at Blackburn.

People often associate telemedicine with video conferencing and perceive it simply as a patient in a remote location connected to a doctor by a video link. However, it is much more than that. It is about using simple as well as complex technology to ensure that patients get the right treatment at the most convenient place, from doctors and nurses who are able to make the best use of their specialist skills. Telemedicine and telecare can potentially be applied to all aspects of the NHS.

My hon. Friend the Member for Dartford vividly described examples in his constituency. Good work is being done throughout the country. I shall outline some examples to show the range of options that telemedicine offers. In Lewisham, a specialist mental health team is using telepsychiatry to link to a local GP. Video conferencing is partly used in place of referral to a specialist unit. The patients remain in the care of the local team that they know and trust. Equally important, the stigma that is sadly often associated with attending a specialist mental health unit is avoided.

In Bradford, the Anchor housing trust is working with British Telecom on a telecare system that monitors people who are at risk in their homes. Alarms are automatically generated for the carer should something go wrong. That enables people who have such a system to lead a more independent life, secure in the knowledge that they will get help if they need it.

In Cornwall, the A and E centres at Treliske and Truro support a number of nurse-led minor injury units in the community using video conferencing and teleradiology links. Patients have access to specialist care where they need it and avoid the long journey in to one of the main A and E units. That is especially important in rural areas.

The needs of patients must ultimately drive developments in telemedicine and telecare. Building on the work of recent years, they are increasingly seen as real options for effective health care delivery. Clearly, the evidence base is still being established, but a lot can be done now. For example, Peterborough hospitals NHS trust has links from eight local GPs to the specialist dermatology services. Images and e-mail referrals can be sent via the NHSNet for diagnosis and triage for referral. I was interested to hear my hon. Friend's concerns about confidentiality, but the NHSNet provides a much more secure system than the web. Patients avoid unnecessary referrals and journeys and receive a quicker diagnosis, reducing the stress associated with waiting for results.

My hon. Friend has also described the work in Newcastle, where a telemonitoring service is being used in the home to monitor patients suffering from chronic illnesses. That is a perfect example of social services and health care providers working together for the benefit of patients. The patients have said how much they value the reassurance the system gives them; they know that someone can help them if there is a problem, especially at night.

Key to the wider development of telemedicine and telecare is our belief that they should be implemented only where there is good evidence that they are a safe and appropriate solution to the clinical needs of patients. We are building on the earlier work in telemedicine, ensuring that patients receive the best care in the right place at the right time from the right people.

Under the pathology modernisation programme, the United Bristol Healthcare NHS trust is setting up the Avon virtual pathology laboratory service and using telepathology to provide faster and more reliable access to a range of laboratory services, allowing quicker resolution and better consensus for difficult diagnosis.

Under our A and E modernisation programme, North Bristol NHS trust is developing a telemedicine link by which X-rays and other images can be relayed between hospitals. East Kent hospitals NHS trust will link minor injuries units at Buckland and Deal hospitals to two full A and E departments, using telemedicine to provide access to specialist advice. In another innovative development, Avon ambulance service is linking ambulances to A and E departments using telemedicine. The national database of telemedicine provides many more examples of the excellent work that is being done to provide real benefits for patients across the country.

Telemedicine and telecare have the potential to transform a patient's experience of the health service by reducing inconvenience, shortening journeys and avoiding unnecessary referrals. They also present new opportunities to deliver and configure services and, as my hon. Friend has said, new opportunities for professional development. I recognise what he said about the need for changes in attitudes and work practices if telemedicine and telecare are to flourish. If we are to realise their full potential, we must be willing to communicate and work across professional and organisational boundaries.

The health service has made real progress in recent years, and I pay tribute to the enthusiasts whose energy and vision have carried us so far. Telemedicine and telecare are already being promoted and used in many examples such as NHS Direct, the information strategy, the national service frameworks, the A and E and pathology modernisation programmes, walk-in centres and the health action zones innovation fund.

We recognise the need for further research and I understand my hon. Friend's desire to ensure that telemedicine is evaluated. Our health technology assessment programme is evaluating two telemedicine applications and on-going research is being carried out to underpin both "Information for Health" and telemedicine policy development.

My hon. Friend will be aware of the national beds inquiry, which we published for consultation on 10 February. It shows that, in any scenario, it is probable that the number of beds in the whole system, including those in intermediate care, nursing homes and residential homes, will need to increase. It suggests that the trend of the past 30 years—more hospital bed reductions—can no longer keep pace with the changing needs, additional activity and new services that the NHS will provide. It takes a whole-system perspective and considers hospital beds in the context of developments in primary care, community health services and social care as well as hospitals.

The facts revealed by the inquiry support the Government's plans to build a new bridge of NHS care for older people between hospital and home by developing a wide range of intermediate care services to prevent avoidable admissions, enhance rehabilitation and enable as many people as possible to maintain or regain functional independence in their own homes.

The Government have looked critically at telemedicine and telecare to see what can be done to bring about further development, and will continue to do so. We want telemedicine and telecare to be seen as options for service delivery. We have already said that, from 2000, all health improvement programmes and associated strategies will need to demonstrate that telemedicine and telecare options have been considered. We hope that that will be one way of ensuring that they are involved in the development of the health service, and will be introduced if they prove to be a way of including it.

I was struck by my hon. Friend's observation that the system in itself does not always involve a huge amount of capital investment. The necessary service can be provided at relatively low cost, but with tremendous benefit to patients.

Telemedicine and telecare are likely to play an important part in the addressing of national priorities. They will also have an impact on the provision of health-care information, providing links to NHS Direct, the national electronic library for health, the NHSNet and the electronic patient record.

In building a modern NHS and improving services for patients, we are focusing on the real opportunities that telemedicine and telecare represent. They will make it possible to deliver services more effectively, to move specialist expertise out of hospitals and into primary care, and to create the framework that is necessary to ensure that specialist skills are more widely accessible. The challenge will be the requirement to harness the information revolution to ensure that patients receive the best treatment, at the right time and in the most convenient place.

Our vision is of an NHS in which services are shaped around the convenience of patients. That means embracing technology to provide faster services. It means direct booking of hospital appointments, shorter waiting times for treatment, more rehabilitation services and more use of telemedicine, the internet and NHS Direct to bring care closer to home.

It is easy to underestimate the true impact of new technology. Two years after inventing the telephone, Alexander Graham Bell made a famous prediction: he firmly believed that one day all cities and all companies would have telephones, and people would be able to talk to each other on them. That was greeted with cynicism at the time. In the same way, some people now feel that telemedicine may be a cheap option, and that it may not be possible to deliver such a service.

My hon. Friend, however, has seen the quality of the images being transmitted, and knows about the consultation that is possible between specialists who can exchange ideas and experience. When telemedicine is implemented well, the patient will often receive almost a better service, because that service draws on a much wider range of resources and expertise than is possible in conventional medicine.

Telemedicine is an extremely useful example of what we mean by modernisation. It also illustrates the fact that all the changes in the health service have a single aim: to improve the service to the patient by harnessing the skills of all NHS staff, while also harnessing the new technology. That may sometimes mean that certain people must take a deep breath and realise that technology is moving on, but it is in all our best interests.

I am grateful to my hon. Friend for raising an issue that is often overlooked. I am delighted to have been able to support his commitment to telemedicine. I assure him that the Government are determined to support that commitment, and will continue to do so.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes past Seven o'clock.