Chris Subbe is a Consultant in Acute, Respiratory & Critical Care Medicine. He is a Service Improvement Fellow with the Health Foundation. He does research on patient safety at Bangor University. He tweets @csubbe
Unsurprisingly many of us have more medical needs as we get older. While some people manage to stay remarkably fit, for others it is getting more difficult to get around town or worse across country. The hike around an overflowing car park of an inner-city hospital does surprisingly little for mobility, and most people get little value from sitting in an outpatient waiting area to wait while their medical team is struggling with the application of queuing theory to healthcare.
A few years ago, when granddad was sent a follow-up appointment for his cardiac surgery several months after the operation, I was suspicious. I rang the secretary of the colleague who had done an amazing job on his heart to ask for the reason for the review. “An important part of quality assurance: we like to make sure that everything has gone well”. I explained that granddad had been in hospital, survived prolonged rehabilitation, and had already been followed up by an excellent local geriatrician and one of our brilliant cardiologists. He felt well. I suggested cancelling the appointment.
A month later grandma and granddad were picked up by an early morning ambulance. The long trip across rural North Wales to the big city, then a lunch in the hospital canteen, a long wait in outpatients. Finally granddad was asked in as the last patient of the afternoon by a junior doctor who he had never seen before and would never see again. A review for ankle swelling and a look at the scar, an evening cruise along the Welsh coast, a late night and granddad wiped out for days. Arguably not a great day out and of fairly limited benefit, even for the doctor in training.
It made me think. In a meeting with over 80 senior colleagues we discussed our outpatient clinics. We come from a broad range of medical specialties. We look after very different patients and have different personal styles. On the first appointment when we see a patient for the first time we like to have some time with them. We take a history, we examine our patients, we discuss the plan forward, we order tests and adjust treatment. The next time around we discuss results, adjust the prescription, occasionally order further investigations or get a colleague involved. “How often do you physically examine a patient on the second appointment?” “Rarely.” Yet patients travel to see us for both the first appointment where we often require physical examination and to all subsequent appointments.
Fast forward to 2015: As a team from North Wales we were successful with the application for the first round of demonstrator sites for the Future Hospital Programme of the Royal College for Physicians. With the help of high-quality video technology we can now offer patients the choice to see their specialist in a local surgery or community hospital after a short trip to the next village. Thanks a million for high definition video technology! CARTREF (CARe delivered with Telemedicine to support Rural Elderly and Frail patients; CARTREF is the Welsh word for home) used experience from other groups for virtual follow-up but worked together with patient representatives from the local community and the RCP to adapt it to the needs of frail older persons living in rural North Wales. And given that most of our patients have more than one problem we have additionally streamlined their follow-up. Rather than being seen by multiple clinics they are now seen by a single specialist in care of the older person.
Supported by the brilliant Future Hospital team we did collect data on patient satisfaction. The oldest patient was over 100 years old. Good feedback!
Not being in the same room with the doctor had not jaded patients’ opinion of the clinic experience. And all this with less strain on patient time, and the need for a carer or friend to take a whole day off. And if global warming matters, then we did also show a dramatically reduced carbon footprint of the service. We have, over the last three years, undertaken specialist clinics in rheumatology, chest medicine, geriatric medicine. But unfortunately spread beyond this has been slow.
There were considerable concerns from colleagues when we started. Would older patients be suitable for the ‘modern’ technology? Would families be worried if their grandmother told them she had seen the doctor on television. No problems yet. And why should there have been? These days many grandparents keep up with their family via Skype. They read the news on their tablet and order the shopping online. It is healthcare professionals (and their managerial colleagues) who are lagging behind the times. Fewer and fewer professionals are using travel agents, bookshops, etc. etc. Yet healthcare is 100% Victorian in its approach to communication technology.
Technology can now facilitate appointments in patients’ own homes, via secure online connections, telephone or e-mails. In settings where patients are allowed to hold their own records they are able to prepare better for the encounter.
The fact that services in many areas have not moved with the times helps nobody. Being stuck in the past might ironically be worst for our oldest patients.