We know that rural health care is complex and that, despite many shared challenges, every region is also unique. What are the particular issues in your area?
JH: We’ve got an ageing population, with multiple co-morbidities and complex health needs, and high levels of mental health problems. The data shows that the more remote you are, the higher your elderly population. East Kent also has a unique geography compared to other rural areas. We're surrounded on three sides by water, which restricts where we can recruit from. We’re limited by our local infrastructure with single lane roads, limited public transport and poor broadband provision in some areas, and travel times between sites can be lengthy.
MB: When I'm on call in the centre of Canterbury I have to be careful which buildings I go into because the signal is not great. Our patients face the same issue – their broadband speeds are not what you might expect from urban cities. We’re also spread across three acute sites with five hospitals, which makes transferring people between sites and coordinating care more complex.
What role could technology play in addressing those challenges?
MB: Technology brings choice. Not that everything should be virtual or face to face – it’s how we manage that hybrid approach. Some patients may want a video consultation, some over the telephone, some in person. It’s the same for different conditions. A good example is blood pressure monitoring, where you could run a whole virtual clinic because you just need to talk to the patient on the phone and speak about their blood pressure, which they monitor at home. Someone going for complex surgery may need to be physically examined, so 100% of their consultations may need to be in person.
How have you used technology during the pandemic?
MB: At the beginning, our IT department said “what can we give you to help you do your job in a different way?” It’s been so much easier to innovate, to change the way we work, and do it at speed. I look after renal transplant patients, who are clinically extremely vulnerable and who we haven’t wanted to bring to hospital. We set up a virtual clinic where we can do home blood pressure monitoring, blood testing, urine testing – a whole virtual consultation. We haven't been able to have visitors, and technology has really helped us to have conversations with family members, and for patients to have that support.
JH: Mike and I are very positive about technology, but nationally there’s been resistance in terms of “do we really need this?” Those attitudes have changed dramatically because they were necessary to help reduce the spread of Covid. We’re moving towards a digital note-taking system for ward rounds and handovers, and digital prescribing. Communication was really key, whether with colleagues or with patients and their families.
How far have patients been willing to use digital tools?
MB: It’s had a massive benefit – there are still times you need to see patients in person, and we're not removing that. But for patients who we don't, they're not having to travel from their home. One thing I've noticed is that lots of patients put the telephone on speakerphone and have the family all there. We talk about patient-led care but it’s a whole team effort.
JH: Family involvement has been really key. There's traditionally poor retention of information after a consultation, and having family members help recall information and discuss afterwards will be hugely valuable. I think our trust is really committed to taking forward co-design, co-production and patient involvement, and we’re about to relaunch our innovation strategy incorporating those principles.
Thinking about your area in particular, what has worked well?
MB: IT infrastructure – simple things like headsets, laptops and docking stations, so staff can work anywhere. We've created outpatient pods, where clinicians can have a virtual and face-to-face clinic environment. Another thing that's been brought to the forefront during Covid is the importance of access to information at the point of care, and how we share that information across providers and within a region. We're about to launch our local care record, which is going to be key as we go forward.
It’s not just availability of information for the clinician, but also the patient. We’ve also seen more use of wearable technology – we have to find how to efficiently feed that into the patient's records to make it available to the clinician. The pathway to innovation has been accelerated with Covid and that's one thing we must take forward. Clinicians have had innovative ideas, we've acted on them and the innovations have been seen in real time very quickly. We've got to take that forward.
JH: It’s an emphasis on making things clinically led. Digital innovation, clinical leadership and roles like the Chief Clinical Information Officer are massively important. But people are tired, and there's a huge challenge in terms of mental health. We need to be careful that we're not saying “use this technology”. It's about getting that buy-in and support, and people seeing the benefit for themselves because it just works.
There seems to be a consensus that we won't go back to how things were before. What do you think your local area needs to do to be able to make the best use of technology?
JH: We need to look again at the possibility of a rural health care strategy. It’s about getting the basics right, and we need to pay greater attention to broadband and access to data – that is essential for providing services in a rural health system.
To get buy-in for patients and clinicians, education is hugely important. The simpler we make our interfaces and the interoperability of our systems, the better. We need greater support for organisations who are in relative digital infancy – creating a culture of digital excellence across the whole NHS, rather than centres of excellence. We need huge levelling up of digital provision for patients to make sure that we're not leaving people behind. It’s about moving away from institutional care to “how do we provide the best care for the patients in our area?”
MB: One thing that needs to change is tariffs and payments – funding needs to catch up and facilitate clinical change in terms of technology. That's one massive change that would have made us use virtual environments a lot sooner. Covid has made it happen, but it must now become business as usual.
What do you think are the risks if some of these issues aren't addressed?
JH: We can’t just talk about “the patient” – it’s such an all-encompassing term. The digital patient or the patient of the future could be a young diabetic who is quite happy to interact remotely. At the other end of the scale might be someone who's living with dementia, who is elderly, and who has poor mobility. Conversations need to be tailored to different groups. There are assumptions about the reality on the ground in Canterbury versus somewhere like Romney Marsh, where mobile phone signals are non-existent. We can't assume there's a level-playing field for everyone. We need to make sure people aren’t being left behind.
MB: It’s also how we communicate with patients – they need to know what choices there are and how they can access care. Even simple things like how to book your blood test using a QR code, but we have patients who have never heard of a QR code. We need a combined approach, ensuring that our services are accessible to everyone.
Which priorities do the NHS need to focus on to make the best use of technology?
JH: Workforce. We know that burnout rates are high, particularly post pandemic, and we need to look forward to how technology can help staff. For example, if someone wants to move away from the front line, how do we retain that individual and is technology something that might help us do that? It’s about flexible working and ensuring that we incorporate technology into looking after our staff as well as our patients.
MB: There is a question nationally about how we draw all of our datasets together, particularly with new apps being developed every day. It's how we use that rich source of information and bring all the data together, to get a complete picture of the patient. More monitoring blurs the focus around clinical consultation – should it be a regular consultation with your specialist, or when you clinically need it? As we use more wearables and have real-time data collection, we might intervene more rapidly when something is wrong, rather than a rigid structure of “I'll see you in the clinic in three months’ time”.
You mentioned recruitment as a distinct challenge. Is there potential for technology to alleviate some of those issues too?
JH: Absolutely. Given the challenges of providing services across three acute sites and five hospitals, offering the possibility of interacting with colleagues and patients remotely is a huge win for us. I think we've got huge opportunities on working across some of those organisational barriers and taking more of a population health view, providing the best possible care for our patients. Technology will be a huge enabler of that.
Dr James Hadlow is the Associate Medical Director for the Remote and Rural Strategy at East Kent Hospitals University NHS Foundation Trust, and Dr Mike Bedford is the Chief Clinical Information Officer at East Kent Hospitals University NHS Foundation Trust.