Founder’s Statement: Another vision of telehealth
Dr D J Hamblin-Brown, FRCEM
I’ve just visited three patients. One in Birmingham, one in Salisbury and one in Macclesfield – all without leaving my desk.
My patient in Birmingham was panicking – over-breathing, tingling around the mouth – thought he was going mad. But he was too afraid to go to A&E. I gave him some breathing exercises. My Salisbury patient was suffering from COVID symptoms. She and her daughter were in Disneyland in March and had been coughing for several weeks. We discussed the symptoms that would suggest she needed medical attention and how to get this – she was fine with some reassurance. The 40-year-old in Macclesfield had a bad flare-up of his psoriasis and needed to see a doctor in-person to assess his joint swelling. I wrote him a letter of referral for his GP or local A&E department.
Why did these patients need me? Couldn’t the NHS provide this advice? All of them were too was frightened of attending their local surgery or hospital; all had tried and failed to reach 111. All needed help working-out the right course of action for them.
Why is this happening? How could the NHS better help these patients? I think I know. To explain, I need to start in one of the countries of East Asia. I’ve just returned the UK having been working as a medical director there and I have seen this at first hand.
Imagine for a second that your name is Liu Yan. You are a 33-year-old mother, and you live with your 4-year-old daughter on the 48th floor of a block of flats. This is one of 40 identical blocks, in an area in the vast outskirts of one of East Asia’s mega-cities. You’re worried because your daughter is running a temperature. You don’t want to head to the hospital – especially not at this time of night – with news of the pandemic churning on your 24-hr news-feeds.
You turn to your smartphone. You have several apps that can help. You choose one. A list of paediatric doctors is displayed. You agree to pay a small fee (easily deducted from your online wallet) and within moments, you are chatting to a fully-qualified doctor. Within a few minutes, she is able to reassure you and gives you some advice on what signs of deterioration you might look-out for and some simple tips for managing a temperature. You sign-off by providing a rating for your consultation and a short comment about your experience.
This is no fantasy. Something like this is happening tens of millions of times per day in many countries in East Asia – most notably in China, but also in Malaysia, Indonesia, Vietnam. Doctors can earn half their salary from home – often in the evenings – just giving up a few hours to one of the many thousands of platforms that help make these introductions. In China – which I know best – the regulations were strengthened in 2018. They are very clear about the scope of these services: as a doctor you cannot make a new diagnosis, and you cannot prescribe. And, of course, you must only see patients within your scope of practice. The introduction between doctor and patient for healthcare advice is mediated by the technology companies, but the consultation is highly controlled and focused on patient need.
Now imagine we try to do something like this – at real scale – here in the UK.
Today, in the UK, during this pandemic, there has been a huge unsatisfied need for medical advice among families isolating at home and trying to avoid hospital. The waiting times for non-COVID NHS111 appointments has been running between 4 and 6 hours.
There are some online platforms that attempt to replicate the GP experience online. But either they are heavy-handed, asking you to give-up your current GP, for instance, or they are private, and therefore unaffordable for our most vulnerable citizens; the young, the old and the poor.
This leaves most of us in the UK trying to get an appointment with our overworked GP. These GPs are doing their best to take-up the workload. All are offering telephone advice, and many are switching to video consultations. But where possible they must prioritise those reporting worrying symptoms. GPs necessarily screen-out patients who simply want low-risk advice or reassurance.
Add to this the fact that hospitals are largely closed to outpatients and specialist advice is almost impossible to come-by.
I worked at consultant-level in a busy UK Emergency Department for many years. Many of the patients I used to see could be classed as ‘worried well’. According to my A&E colleagues, this cohort has all but disappeared from many of our departments.
Taken together, this means there is a huge, unmet need for healthcare advice and reassurance, building-up behind what you might call “the COVID dam”.
The tragedy is that this group of supposedly low risk patients contains within it a minority who are dangerously sick. Some are seeking help too late and there are reports and statistics which indicate patients are dying for lack of treatment.
And yet there is a paradox. As the pandemic continues, 25% of our medical workforce may be at home, unable to work. Many doctors, dentists, specialist nurses, physiotherapists, pharmacists are available, but unconnected. Many are frustrated since they are well enough to work. And all of these professional groups can provide useful, definitive advice through video-conference.
What can we do to help these patients and perhaps link them to these under-utilised professionals? My response has been to set-up a prototype, pro bono service to try to complement and support the NHS. Doctor in the House allows patients to link easily with at-home doctors and other healthcare professionals, who can volunteer from as little as 30 minutes up to several hours, to see patients via a secure video-link.
Initially, this has been pro bono. Clinicians have been giving their time for free. However, we cannot expect doctors to keep donating time indefinitely, but this model, based on the experience in East Asia, could be one we pursue. We certainly have to find a way to use telehealth to assess patient risk and to give low-risk health advice fast. How we fund such a system within a universal socialised system divided regionally, is currently one of our challenges.
What is clear, is that large-scale online models can be cheaper, more flexible, and more patient-focused than our current systems. The research suggests that they are also well received by professionals who also want choice and flexibility.
This pandemic has provided us with some powerful examples where we can learn from other countries . Large-scale, patient-driven tele-consultation platforms may be one of them.
Our ambition is to bring this to the UK.