Loneliness and telehealth

Loneliness is endemic.  There are people who live alone, and who will see someone else rarely. Often, people who are lonely can’t get out much – unsteady, lacking confidence, afraid, anxious – and rely on relatives or rare visitors to help with shopping or outings. Many people – often older people – will still dress up to come to the doctors.  There are people in waiting rooms who chat, there are babies to admire, there is weather to discuss. When patients and doctors talk, there is an exchange of information, a touch of conversation. Many doctors are part of the community where they live and work; many say that they get back as much, if not more, than they give, a kind of living exchange.

I am also a fan of the internet. Social media has enhanced, not diminished, my friendships in the world at large. I have met people and had conversations with folk I wouldn’t have met otherwise. But here is Jeremy Hunt, declaring that GPs and district nurses should be doing more by ipad and Skype; the assertion that 2.9 billion could be saved ‘almost immediately’ by having online rather than real life consultations. Where this figure has arrived from is unknown; whether this new direction could work or be dangerous may be rightful concerns but have fallen by the policy over evidence, technological wayside. This latest initiative is staggering for it’s unreasoned nature and ignorance of what currently happens in the world of primary care.

I’ve been in practice for over a decade, and have never worked in a practice where the telephone wasn’t a vital part of communicating with patients. It does, however, have serious shortcomings. I can’t listen to the patients’ chest or check reflexes in the legs. But I can discuss results, plan for follow up, or explain hospital letters or tests. Used well, it can help continuity of care, and promote an ongoing relationship. Often a phone appointment is the most useful and efficient way of seeing a plan through. But I can’t do everything by phone. The very most difficult, rewarding, and essential part of general practice – and what we are trained to do- is to pick up on cues, to notice the unsaid and the almost unseen. It’s about understanding what a person is worried about and why, what symptom they may be almost too uneasy to disclose, what is behind and around what we say and the gestures that we make. This isn’t some kind of bizarre parapsychological nonsense – it’s about listening and responding in a human interaction.

When people consult with doctors, they tend to discuss more than one problem. What and why they are raised is a matter of urgency and trust, and of the space to speak being allowed. I have been a doctor for almost twenty years, and I am still a little nervous when I see my own doctors – I expect that many others do too. We are vulnerable, we want to discuss matters which are important to us, we have questions, and we may be afraid. The issues which are discussed are not simply functionary, but are packed with information which may seem inconsequential, as thin and slight as tissue paper, but are multilayered, explaining and aiding the story not just of this pain, but of where it came from, how it is being dealt with, but where it shall be endured. Some home visits could perhaps be dealt with by telephone, but there are many people – again, often older – who will try their best to minimise their symptoms, and where a visit will explain more about their social circumstances and illness than half a ton of technology ever could. Mental illness is a large portion of GP workload: I would want proof that Skype consultations were not harmful before proceeding.

For in the brave new world of telehealth, with multiple tests results being monitoring, and protocolised healthcare, it would be easy to think that one day your healthcare will be possible without needing to see a doctor or a nurse. Your symptoms or measurements will be fed into a computer which will calculate the tests that need to be done and the actions that are therefore required. This was revealed with NHS Direct, which has been noted to use multiple protocols and produce many vast over reactions to symptoms which appropriately qualified humans have been able to deal with far more nuance and less inappropriate ambulance intervention. Telehealth costs vast sums in terms of equipment, but is hoped – by the government – to eventually reduce staff time in directly caring for patients as well as to reduce hospital admissions. We do not have enough good evidence that this is the case, but policy dictates that we should do it anyway. Yet computers cannot attend to personal hygiene, offer a spoon to the lips, lift a person to the commode. Telehealth will not be able to sit down and have a cup of tea or fetch a pint of milk. There will be no point in wearing a pressed suit for a computer monitor, and there will be no conversation to be made in when we press a button to send our results down the line.

We can already do much healthcare without the patients’ presence in the room, by simple use of the telephone. The people who will gain from bigger technology spends the government plans are the companies who manufacture them, and the politicians who can say they are investing in them. Only some patients will gain. People who were capable and mobile to start with also have lower need of monitoring or consultations, and will paradoxically be more likely to use them. People who find technology difficult, or who are frail, or who need human care more than they need their blood pressure numbers extracted and transmitted down a wire will lose out.

Spending on unproven technology continues despite carers often being paid at minimum wage and with barely enough time to do essential tasks.  We need science and technology to help us provide the best care for patients. But we also need humanity. Jeremy Hunt, proceed at your peril.

15 Responses to “Loneliness and telehealth”

  1. Mike November 25, 2012 at 7:47 pm #

    Excellent blog, Margaret. Would you agree that the best way to protect our NHS in Scotland is to get a divorce, not just from Westminster rule, but also from the flawed mentality which has allowed the NHS in England to be dismantled. I’m thinking not just of the political ethos but also about the media indifference, if not complicity, in the disaster. I fear it’s already too late for England and Wales. It’s not too late for us. I know it’s a devolved matter but the austerity cuts will bite deep into Scottish NHS.

  2. Mandy Hall November 25, 2012 at 8:52 pm #

    Excellent blog, Margaret. There are many, many issues in the middle of this supposed policy statement that make me wary. I agree that there are many methods of contacting patients and some more efficient than some GP surgeries use at the moment. However, the processing time is what is important here – GPs will still have to sit down and look at the results and say normal / abnormal – that is what takes the time! The communicating (or not) is usually done by much lower level staff. Does the Govt really know what happens out there in GP land?

    My surgery still refuse to leave messages even to say that they rang – quoting confidentiality, I can see them having fifty fits about texting results out (even negative ones) !

    And I agree many attenders at GPs surgeries are there more for the *chat* than anything else.

  3. Jon Chanter November 25, 2012 at 8:59 pm #

    I think that those of us who are trying to explore the ways in which telemedicine can be used would always want to see it as complimentary rather than competing with face to face consultations.

  4. Jess Madge November 26, 2012 at 8:19 am #

    This is another glittery bauble that has caught a minister’s attention. Neither evidence, nor thinking through an idea and working out the finances seem to feature.
    Telehealth might work for the younger working population – but many of older population do not have a computer or smart phone and have never used even email. Goes back to the point you made in your book about spending money on helping those who need it least.
    My long -suffering mother in law has a long list of serious medical problems, including, her latest symptom, a leaky leg. District nurses doing their stuff – how could you treat conditions like this by computer!

  5. steve November 26, 2012 at 9:28 am #

    Hi Margaret – excellent blog with which I wholeheartedly agree. I thought it might be worth posting here a wee blog I wrote about telehealth about 18 months ago:

    “Here, in my neck of the woods, we are being asked to participate in the expansion of a scheme which initially kicked off in Argyll, in south-west Scotland. There they found that by linking vulnerable elderly people to equipment that could remotely monitor things such as blood pressure or oxygen saturation and relay the results via computer to another location (the local medical centre?) they could intervene earlier and thus reduce hospital admissions.
    I am almost pathologically sceptical by nature and I have a significant degree of scepticism about the BP/sO2/glucose thingymajig – BUT the people from Argyll claim that they have substantially reduced hospital admissions (though I am not really sure what the quality of their research is).
    But are we running the risk of over-medicalising things, especially in old age, and is that perhaps symptomatic of the whole of primary and secondary care in the UK which seems to have lost its patient-centred approach in favour of chasing numbers and boosting the profits of big pharma?
    So now we see people in their 80s and 90s with diabetes, hypertension, CKD, IHD and AF and all the other normal features of normal senescence coming out of hospital on two or three antidiabetics, one or two antihypertensives (including the almost obligatory ACEI), a statin and warfarin (or an antiplatelet or two) as we try to chase ideal HbA1C levels and BP readings and prolong their lives by perhaps a few weeks or months (and while we’re at it cancer care is little better for a lot of people).
    It’s just downright bad medicine in my view.
    I am concerned that this”Bluetooth” rush (which has already happened in the USA) is based on an assumption that it has to be good for patients. But where is the evidence that collecting numbers and then acting on them without actually clapping eyes on the patient is a better way to deliver care?
    Of course, it could be argued that it will reduce the number of consultations and therefore allow consultations to be longer and kept for those with “real disease” – and that is certainly the argument that comes out of the USA.
    But what we are at risk of doing, in my view, is depersonalising the service and treating the numbers not the patients.
    In the USA this movement is driven by deep commercial interests – technology companies wanting to sell the technology; insurance companies wanting to save money; etc. But that is in a country where health care is NOT about looking after people’s health first and foremost but rather it’s about income generation and income capture.
    Ultimately, if we go too far down this road of technology having the answers, we end up with a situation where the numbers we are measuring at home in remote areas get sent via Bluetooth and home computers to some central hub where management decisions can be taken and then acted on locally by more poorly trained, poorly qualified, poorly paid (and therefore cheaper) health workers. You might live in Lochinver but your GP is in front of a computer screen 200 miles away in Motherwell. It might sound like science fiction but it’s already fact in the USA.
    Let’s not beat about the bush. The health reforms planned for England will allow some private insurance companies to come along and say “it costs the NHS £200 per annum per person to provide primary care – we can do it for £175″ and they get the gig.
    I really think people have not woken up to the true implications of the English White Paper and what it means for primary care. The effects will be particularly felt in rural areas in which the use of teletechnology in tandem with low paid local health workers would allow big savings to be made in the primary care budget. Afterall, each GP post reduced would save the NHS about £150,00 per annum. Very tempting if your are trying to balance the books”

  6. Sian Jones November 26, 2012 at 10:42 am #

    The link between healthcare technology and loneliness is an interesting one. With the government pushing the 3millionlives programme to increase use of telehealth, the implications of potentially reducing face to face contacts needs to be understood. However, with pressure on clinical staff to take on more and more, is it the role of expensive health professionals to provide tea and a chat? If use of telehealth flags up a need for social visits, surely it would be better to look at alternatives such as befriending services that the voluntary sector might provide, rather than continuing to use community nursing services inappropriately. Telehealth should be used to compliment existing healthcare practices, as an additional ‘tool’ to manage the increasing number of people that will need to be cared for outside of hospital. It does not replace face to face, but can make sure that these valuable and important contacts are used to maximise clinical outcomes. The clinical team can then manage their time to spend more with those with greatest clinical need.

  7. dearieme November 26, 2012 at 2:10 pm #

    Increasingly when I visit the doctor he (or she) scarcely looks at me and very rarely asks me to take off any clothing so that he can inspect more of me. The medical eye tends to be on the computer screen, reading … what, messages from other medics, test results, and so on?

  8. Ian S. Rickard November 27, 2012 at 10:49 am #

    Enforcing telemedicine because we think it might save money or, help to use money supply more effectively, is not a good enough reason to roll it out. In my view, it is only worth investing in if we believe that improving the range of consultation approaches is likely to improve peoples’ health and that enough patients will want to use it.

    Ideally, it shouldn’t be an either /or. Some people will prefer home-based tele-healthcare, particularly if it is an adjunct to face to face primary care, rather than a replacement..

    For example, people could send bio-feedback information in to their GP, specialist nurse, or medical consultant and get more timely guidance, bringing all the benefit this implies. Others might want to undertake Skype-type calls from work or home, particularly if their journey to and from their doctor’s is a long, costly or tiring one.

    However, home-based tele-healthcare shouldn’t be considered by politicians and health care executives to be a Silver Bullet in the fight to cut costs; because electronic information congestion and poor information security is going to continue to be a developing feature of wireless interaction for some years to come. This means that tele-health care users, clinical practitioners and health care mangers will have to accept that, no matter how secure or reliable tele-health care is supposed to be, there will remain a trade-off between confidentiality and convenience, which, at the moment, we are not able to estimate as a potential cost and benefit.

  9. Harry Longman November 27, 2012 at 10:52 am #

    There is grave danger in the DH drive for telehealth as a cost saving measure. All the comments and the popular papers headlines reflect this. There is grave danger for both patients and doctors in undermining their relationship. But we need to grab hold of this agenda from the profession, and say there are ways of doing better, giving better care to more patients.
    That’s why I’m proud to be working with GPs around the country who invented the Patient Access model, led by improved service, which just happens to use the humble telephone as a useful bit of technology (134 years old). The point is, service led not technology led. This is not setting a telephone consultation against a face to face. This is a whole system whereby the GP decides with the patient, who to see and when, meaning all patients can be helped, all day, every day, enhancing the doctor-patient relationship and with measurably better continuity. Most patients struggle to see their GP, and most GPs are either blind to this or are tearing their hair out trying and failing to meet demand.

  10. Alasdair Morrison November 27, 2012 at 1:49 pm #

    I would like to point out that the use of video to converse with a patient or service user does not have to be made using a computer / tablet or smart phone. TV is a way of using video (when and where this appropriate) as part of a complimentary package of technology (all encompassing term for Telecare / Telehealth / AT etc) support or care. technology will not never replace the need for physical contact but should be deployed as part of a complimentary mix of the above.
    I would also like to point out that we have deployed PC to TV video communication to homes in Sandwell as well as providing the same system from the GP surgery to a residential nursing home. This has reduced the number of visits that GPs have to make to the building by 75% but has not meant that patients can not have a physical visit from the GP if and when they need / ask for it.

  11. Chris Johnson November 28, 2012 at 6:57 pm #

    I would like to be in your practise. After many decades I have yet to be called by a GP to tell me I have missed an appointment or to be informed about test results. I am tired of waiting in line in the surgery, already sick and feeling vulnerable, along with several people who have “god knows what”. I would be happy to take a Skype call occasionally and agree mutually to take a physical appointment if needed.

    I resent the inefficiency of having to take a half-day off to visit the hospital either on my own behalf or with relatives to learn there is no trouble found. Even when there is a problem we have to make another appointment for a proper explanation.

    So while I buy your touchy-feely interpretation of the GP job, I do feel many aspects could be managed much more productively.

  12. Rusty Solomon November 28, 2012 at 10:27 pm #

    Thanks for sharing this idea interesting blog, Please continue this great work.
    Rusty Solomon

  13. Jim Ward November 30, 2012 at 8:56 pm #

    Great to see so much discussion around this interesting and important issue. Most important thing is to listen to the patients who in my experience are overwhelmingly positive about alternatives to face to face consultations if the experience is positive and adds value.
    Will be worth training Junior docs to consult and recognise cues by vc and phone, it can be done and this is coming.

  14. John B Dick December 6, 2012 at 6:44 pm #

    Dearieme: My experience too, but I’m confident that I get appropriate treatment including telephone consultations, easy access, continuity of care despite half a dozen practice staff being involved. The only improvement I can imagine is an extra manned telephone line at certain times of day.

    Mike: When I was in hospital for a triple bypass earlier this year I was visited by the mother of a GP who had the same concerns as you. I passed on the assurances I had previously received from my then constituency MSP Jim Mather, then a member of the Scottish cabinet, and also the fact that the confidence I had in the reliability of his assurances was because of the way he expressed them as assurances about the competence and character of the then minister. Though the DFM’s new role will surprise nobody, I complained to my current MSP that as someone at the stage of my life when I need the NHS most, I had hoped she would be in charge of the NHS as long as I need it.

    Without independence the Barnett formula should boost the Scottish Government income, for no matter how much the private sector is funded other than from taxation, the extra costs of the insane market system will cost the exchequer more.

    With or without independence we should be able to fill any niche specialty vacancy with ease.

    Prescriptions are not a “Universal benefit” in Scotland for there is no such thing, and I deplore SNP spokesmen’s uncritical adoption of the value laden terminology of their opponents.

    The FM frequenly tells us that “sovereignty comes from the people” in Scotland, not the Queen in Parliament.

    An arcane historical debating point? No!

    A benefit (cognate with benefice) is something granted by the grace and favour of the ruler, landowner, bishop or factor. If your boss takes the staff out for a drink to mark the end of the project or financial or calender year, that’s a benefit. If colleagues go to the pub for a night out and put money in the kitty, that’s a collective purchasing arrangement.

    The real definition of what is called a “Universal Benefit” is something now free but paid for within living memory in England or America.

    So too with tertiary education. In England secondary education is assumed to be necessary but enough for the plebs to enable them to service the elite but is not spoken of as a “Universal Benefit” because it would call into question what principle is involved in making the distinction.

    In Scotland a reformation duty for householders (women included) to provide daily religious instruction to all under their roof, together with a misinterpretation of the parable of the talents made it a sin to fail to take maximum advantage of the opportunity to educate yourself. Church, state and public opinion ensured that the opportunity existed.

    The respect for public health, water and sanitation and the higher level of funding of the Scottish NHS is not as widely known in England as it could be. Both derive for the success of the response to 19thC Cholera. Thatcher dared not privatise Scottish Water. The pretext of morbidity and sparsity as a justification for higher funding is not the reason it is there, and is in any case obviously false.

    But the best thing about the NHS in an independent Scotland, from the point of view of those in England, is that notwithstanding EU contracting rules, it could be a key ally in putting Humpty Dumpty back together again, and you would get a better deal on that than you will for oil, renewables or water.

    “ANY willing provider?”

    The best thing for you, unless that is, eiher you or those you love, happen to need cardiac surgery.

    Believe me, I can tell a good hospital from a bad one. I was once part of the management team for what was officially recognised to be the worst hospital in Scotland. My wife, a midwife, had a bad experience in another country.

    The quality of the service in the Jubilee hospital, with a catchment of 2m with the worst heart disease in Europe was astonishing. Staffing levels, skill, equipment, nursing practice, and yes, compassion and crucially, morale and job satisfaction were as high as you could possibly imagine.

    Waiting lists? No need to game the targets. The target from referral to admission is 18 weeks. From first recognising that I was ill, and making a GP appointment till discharge from hospital, took 14 weeks, and that over Christmas.

    We didn’t need to take advantage of it, but the reimbursement of patient travelling expenses could have included overnight acommodation in an on-site four-star hotel for my wife. The after discharge support from three hospitals and a health centre was faultless.

    The leader of the orchestra my wife and I play in had the same operation in the same hospital with the same surgeon. “You’ve landed on your feet” was his comment when I told him. Now, at the break in rehearsals, two old men on diuretics can be found in the toilet enthusing about every aspect of their shared experience, even the view of the river from the windows. The food, though was only good.
    You will have got the impression that I am in favour of a wholly free NHS, but it is not only because of the things I have written above. I am old enough to remember being ill before the NHS, and my caring and not poor parents sat up by my bedside all night but would not call the doctor. Later I respected many fine colleagues, in administration and finance too, who had worked in health before 1948. I have told my GP in the presence of my wife that I will in no circumstances will I accept private treatment.

    And yes, I’m voting YES.

  15. Michelle December 19, 2012 at 12:49 am #

    100% agree, technology most certainly provides its advantages but when it comes to health care we should proceed with care. After going through a bit of a tough time I went along to my dr for one reason but during my visit got quite emotional. The dr recognised I was stuggling a bit and helped me address concerns I had. I am usually very good at holding things together and without that face to face contact would never have let my guard down. An area of grave concern to me was addressed and did not then manifest had this been a Skype consultation there is no way I would have let that guard down.

    In my area of work we are being pushed into home working. The importance of face to face contact not only with the public but with collegues seems to be getting lost.

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