NHS drivers, such as the NHS Long Term Plan (NHS, 2019a), are steering a major reform to shape the way that healthcare is delivered across the service. Although change is inevitable and constant in the NHS, the plan is to address long-term change with a focus on efficiency and sustainability. Digital technology features heavily, as more is needed to progress tailored care approaches that deliver person-centred care. To achieve this, the Topol review identified the growing need to develop a digitally skilled workforce, as the benefits that technology can bring to patient care both now and in the future continue to progress at pace (Health Education England, 2019).
Engaging with new opportunities to develop these skills is fundamental to meeting contemporary healthcare needs, and for the workforce, choosing to engage is no longer an option. The Queen's Nursing Institute (2016: 6) offers a very poignant message, advising that not developing these skills ‘would be as unfair as denying a patient modern medicines’. However, for nurses, being able to foster new ways to deliver high-quality patient care will, in itself, be a very powerful motivator.
Technology in general practice
In general practice, nurses have been using technology to record patient consultations for some time and familiarity with software has enabled a higher level of record-keeping and more thorough audit, which has improved patient benefits. Technology has become part of everyday routines, including accessing tablet devices and mobile phones with apps and downloads.
With demand for consultations becoming ever greater in primary care, the ability to diversify and find smarter ways of working is crucial (British Medical Association and NHS England, 2019). Stepping outside of comfort zones and embracing new technology may be the first step in widening the consulting remit. For patients, this creates new and empowering opportunities through shared-decision making approaches. Identifying the right digital support that is valued by the patient and tailored to their needs can be a powerful adjunct to face-to-face appointments.
There is a wide range of technology enabled care services (TECS), where patients can learn more about their own conditions. This enables the patient to become more confident and self-reliant in managing them, thereby reducing contact with nurses or GPs. Additionally, their interactions with clinicians are likely to be more focused and informed. Although this can feel a challenge to health professionals, it does not need to be a problem. Patients may know as much, if not more, than their nurse or doctor about how to use their smartphone for their own purposes, but they need the expertise and guidance of their local clinician to make sense of the wealth of material that is available.
Health apps
There are over 318 000 health apps now available worldwide, with more than 200 health apps being added each day (Aitken et al, 2017). There is concern about the effectiveness of these apps, and although many have been evaluated, the quality of the research has not been high enough to enable them to be prescribed (Toelle et al, 2019; Wisniewski, 2019).
Several apps recommended by the NHS can help patients with long-term conditions such as diabetes, asthma and hypertension
However, this situation is gradually improving: for example, a recent randomised controlled trial of an app for back pain showed greater benefits for patients than physiotherapy with online support (Byambasuren et al, 2018). The NHS Apps Library (NHS, 2019b) has developed its own evaluation criteria that will help to ensure which apps are of a quality that can be recommended to patients. If they wish, patients can download any app and if they want to, may come to the surgery with a list of measurements they have recorded over the previous weeks. When trying to get their asthma, hypertension, weight management or diabetes under control, apps can be very helpful, especially if this is done alongside a jointly agreed plan, which the clinician has helped them formulate. The clinician and patient become partners in the management of the condition and the patient is empowered by having an app that they have chosen to help them achieve their goals.
Directing patients to apps
If the nurse's role is to signpost their patient towards suitable apps, they need to do some background work in finding apps that are appropriate. Many apps do not reflect the current thinking of NHS clinicians, therefore a good starting point is to go to the NHS app library (NHS, 2019b) where there are at least 70 apps that have been assessed by criteria described on their website. Even here the apps should be treated with some caution – the list includes some that either require a payment from the patient or are only available where local NHS authorities have paid a subscription to enable widespread use. Some apps require personal details to be provided and although this enables the information to be appropriate for the participant, patients may be suspicious about how that information will be used. Therefore, your recommendation will need to take into account whether it is really available for your patient, if a charge is required, and whether the developer of the app is about to recoup their costs by allowing adverts to appear frequently, or by passing patient data on to third parties.
Lifestyle changes
Despite these negative considerations there are an overwhelming number of positive reasons to recommend some apps. The Change4Life campaign uses several apps aimed at improving the eating habits of families and children with inspiring recipes (such as Smart Recipes) or learning about ingredients (the Change4Life Food Scanner). Public Health England's One You apps are also reliable, providing support for lifestyle changes. These include Easy Meals, Active 10, Couch to 5K, NHS Weight Loss Plan, Drink Free Days, Drinks Tracker, or Smokefree. NHS focused apps can be found at www.my-therappy.co.uk, which recommends a number of apps that are suitable particularly for patients who have had a brain injury or stroke, but can be used more widely too.
The free Manage Your Health app, produced in collaboration between the NHS and Keele University, covers asthma, chronic obstructive pulmonary disease (COPD), type 2 diabetes, hypertension, stroke, atrial fibrillation and back pain. Developed following the results from patient focus groups, using clinical experts with health literacy oversight, the app includes avatars demonstrating inhaler technique and diaphragmatic breathing methods. Once downloaded, the app does not need internet access.
Diabetes
There are many diabetes apps, some of which are not wholly applicable to the UK. However, if patients are advised about possible inconsistencies, there are some interesting recipes to try out. National organisations such as Diabetes UK also provide links to apps via their websites, or manufacturers of glucose meters will use apps to support their product. Recording measurements to help control their condition using ‘Diabetes PA’ or ‘My Therapy’ (which also can be used as a medication reminder) enable the user to recognise progress.
Noting readings or symptoms can be a useful resource for patients to have when consulting their health practitioner. The Cleo app is intended to do this for patients with multiple sclerosis, while the Keele Pain Recorder allows patients with chronic pain to record their symptoms.
Mental health
There are many apps aimed at mental health, such as Beat Panic, Feeling Good, Thrive, Mood Tools, Well Mind or What's Up?, as well as numerous others aimed at specific age groups such as Blue Ice or Chill Panda. For advice about managing health problems or health concerns, the Student Health app provides reliable health information and First Aid by British Red Cross has advice and videos. The new NHS app can also help people by using algorithms to decide the seriousness of their problem and appropriate action to take.
Smart watches or smartphone apps, usually chosen without professional guidance, are widely used for daily exercise. These can be a great incentive to maintain enthusiasm for a programme and bringing about significant lifestyle changes.
Goal setting and assistance
Clinicians may need to advise about appropriate goal-setting. The NHS app, as well as providing some answers to health questions, also links with patients' own GP surgery computer systems and can be used to make appointments, order repeat prescriptions, view test results, and see one's own medical records. To ensure confidentiality the initial registration for the service is laborious and may deter some patients as they need to provide their NHS number, driving licence or passport, which they must photograph and upload, then read some words aloud while recording on video, which will be compared to the identity document before the application is approved.
Patients who may only use their phone to communicate may need help downloading apps and help to register for online access to their surgery, which can be even more complicated. GP practices will need to find innovative ways to help their patients adopt this technology, whether through patient participation groups, dedicated admin staff, or having a readily accessible tablet in waiting rooms for a technology novice to try out. Without assistance, patients may not participate at all, thereby missing out on new ways to manage their health.
Skype
Using apps can be a great way of introducing technology into the workplace and a means of building digital confidence. However, with the right support and guidance, more clinicians are using opportunities to progress to interactive applications such as Skype. The benefits of Skype consultations are vast and varied, including enhanced access to appointments, reduced waiting times, and improved non-attendance rates and travel efficiencies. Embedding Skype as an alternative consultation method will require some set-up time; however, as seen in the case study, the benefits more than capitalise on the time invested.
This account demonstrates how using Skype as a ‘ward round’ approach in a care home can result in these improved efficiencies. Further benefits include greater multi-disciplinary working between health and social care staff and increased confidence of care home staff to manage the patient's care. The programme being referred to is part of the nationally funded NHS England pilot project General Practice Nursing – Developing Confidence, Capability and Capacity, for delivery of technology enabled care (NHS England, 2018; NHS, 2019c).
Case study
Being approached to become a digital champion on a pilot programme was a perfect opportunity to trial something new in the knowledge that support and assistance would be available. At the time I was visiting a residential home on a weekly basis and following up by telephone as required. I was spending a considerable amount of time, both at the care home and at the surgery afterwards, completing documentation and planning care. On the programme, I was inspired to look at using a form of technology that would benefit my patients; however, I saw an opportunity to do far more.
The pilot provided me with access to a tablet computer that gave me the ability to download apps, such as Emis Mobile, that linked in with the system at the GP surgery. This enabled the patient's records to be transferred securely for the purpose of home visits. One of the positive aspects of this was the ability to conduct a safer consultation by having access to the patient's medical history, consultations and test results. The additional advantage was being able to document the consultation there and then, thus saving considerable time and alleviating the issues I initially had when having to complete documentation once back at the surgery.
The second and most innovative part of the programme was realising the usefulness of Skype for consultation purposes. With the assistance from the project team, the programme facilitated the residential home to be supported with the technological ability needed to use Skype. The clinical governance surrounding Skype consultations did require some initial planning, but this was negotiated and provided alongside the digital champion training and in the residential home. Questions regarding indemnity insurance were also answered and supported, enabling the initiative to become a reality.
Preparing for the Skype consultations became an important issue. The staff in the home were not clinical and therefore a need for training was identified. For this to work, the staff would become my hands during the consultation. With this in mind, training sessions were planned and conducted, teaching staff basic skills such blood pressure monitoring, pulse oximetry and the recording of an accurate temperature. The staff were proactive in this role and, along with some simple documentation charts, they were able to prepare in advance for the consultations.
Patients and their families were introduced to the process of Skype by the care home staff; again, clinical governance and confidentiality were covered and policies were put in place. When the Skype sessions went live, the residents in the home were shown the computer tablet and they were amazed to see their regular nurse on the screen. Having support staff assisting the patients in a quiet, private room allowed patients, including those with a diagnosis of dementia, to participate.
The Skype consultations began to form part of a weekly visit format where patients could be reviewed for various reasons including medication reviews, chronic disease monitoring and some aspects of minor illness assessment. Alongside the weekly review, Skype created a further opportunity for patients to be reviewed on a more urgent basis. This enabled decisions to be made as to who would be the most appropriate member of the team to visit, or if the patient should be transported to the surgery.
Like with any new advancement, there were teething problems. One of the main issues was that the internet connection was not always reliable, which prompted a review of alternative providers. However, none of the issues were insurmountable and once the initial concerns were overcome, including individual consulter confidence, the true value of Skype started to be appreciated.
Benefits for the practice included a reduction in visiting times and in some instances a physical ‘ward round’ to the home was only conducted fortnightly, as a result of staffing and consultation efficiencies. The benefits for patients were that they received prompt treatment in the comfort of their home with a regular health professional who knew them.
There was increased satisfaction gained by the care home staff and also by me. The project proved that although patients may have complex needs including dementia they were still able in the majority of cases able to embrace the Skype process, with most finding it enlightening and satisfactory. I would advise anyone thinking of embracing technology and considering an alternative consultation approach to give it a go, have patience, think it through and plan yours and your peers' training needs.
‘Technology is all around us and it is important that we capitalise on new digital advancements. This may be as simple as starting off with introducing apps or engaging in video consultations’
Conclusion
Technology is all around us and it is important that we capitalise on new digital advancements. This may be as simple as starting off with introducing apps or engaging in video consultations. However, what is important is taking that leap of faith and embracing change.
For more information on starting to use technology, please visit http://www.clinitecs.uk. For more information on the NHS England digital clinical champions programme please visit https://future.nhs.uk/connect.ti/GPFV/view?objectID=15218352
KEY POINTS
- Contemporary healthcare requires a digitally skilled workforce
- Using apps can be a great way of introducing technology and a means of building digital confidence of professionals and patients
- Identifying the right digital support valued by the patient and tailored to their needs can be a powerful adjunct to face-to face appointments
- More clinicians are capitalising on the benefits of Skype consultations including enhanced access to appointments, reduction in waiting times and improved non-attendance rates and travel efficiencies