Telemedicine in the United Kingdom
The UK’s health care systems
The health care system of the United Kingdom consists in fact of four healthcare systems: the National Health Service (England), the Health and Social Care in Northern Ireland (HSCNI), the NHS Scotland and NHS Wales. They all share certain characteristics: they are principally funded through taxes and provide a comprehensive range of health services, of which most are free at the point of use (at least for citizens and residents of the United Kingdom).
Beyond the common characteristics, the four systems are quite independent, and operate under different management, rules, and political authority. The following discussion will focus on the NHS Scotland.
Scotland’s health and care system organisation
The health and social care system in Scotland is a devolved responsibility which is overseen directly by the Scottish Government’s Health and Social Care Directorate. The Directorate also allocates resources and sets the strategic direction for the National Health Service in Scotland (NHS Scotland) and is responsible for the development and implementation of health and social care policy. NHS Scotland is responsible for ensuring that everyone in Scotland receives the health services that they need, with well over 90 per cent of all healthcare provided by the public sector.
Scotland has an integrated healthcare system: all its hospital and community health services are delivered by 14 regional Health Boards. To bridge the gap between primary and secondary care, and between health and social care, regional health boards have established Community Health [and Care] Partnerships (called CH[C]Ps). The CH[C]Ps work in collaboration with 32 local authorities, that are represented at a national level by the Convention of Scottish Local Authorities (COSLA). These local authorities (also known as councils) are responsible for social care, support, housing, education, transport and environmental and community planning.
However, under legislation recently presented to Parliament (the Public Bodies (Joint Working) (Scotland) Bill), as from 2015 the regional Health Boards and Local Authorities will be required to set up a jointly-accountable Health and Social Care Partnership to deliver integrated Health and Social Care. Such a partnership will, as a minimum, cover a single local authority area, replace current CHP arrangements and have a single budget.
Primary care services are overseen by the CH[C]Ps and are provided by a range of health care professionals (such as general practitioners, nurses, midwives, and health visitors), and allied health professionals in a variety of non-hospital settings. These professionals are usually the first point of contact with the NHS, and have a ‘gatekeeper’ role in relation to secondary and tertiary services. Indeed, an estimated 90 per cent of patient contact is with primary care, and most patient journeys begin and end in primary care.
Secondary and tertiary care are provided mainly in hospital settings on an inpatient, day-case or outpatient basis (“day-case” procedures e surgical procedures performed in a single day, without admitting the patient for an overnight stay). This type of care is provided almost entirely by the NHS. Some care is provided through outreach services, for example in rural areas.
There are currently 30 district general hospitals in Scotland (ranging in size from hospitals with fewer than 30 beds to ones with over 600 beds), seven teaching hospitals providing tertiary care for more complex or rare conditions, five single speciality hospitals providing tertiary children’s, maternity or dental services, and one national centre for elective orthopaedic surgery and cardiothoracic services.
There is a very small independent health care sector, both private and non-profit-making. The private sector focuses largely on cosmetic surgery and healthcare for those with private medical insurance (around 8 per cent of the population), along with a number of mental health services. The non-profit making sector includes local hospices’ providing specialist palliative care.
The total number of people receiving home care from independent providers has grown every year over the past decade, from less than 10 per cent ten years ago to over 30 per cent of clients today. In 2012, for the first time, more hours of home care were delivered by the independent sector than by local authorities. A small number of these services are privately funded, with the vast majority contracted by local authorities; the same applies to care homes that provide nursing care (of which there are over 500) and, to a lesser extent, residential care homes (of which there are nearly 800).
The Quality Strategy is the approach and shared focus for all work to achieve the aims of delivering the highest quality healthcare to the people of Scotland and ensure that the NHS, local authorities and the third sector (which includes voluntary organisations, charities and community groups) work together, and with patients, carers and the public, towards a shared goal of world-leading healthcare, in support of the 2020 Vision.
At the core of the strategy are three Quality Ambitions:
• Safe – There will be no avoidable injury or harm to people from healthcare, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
• Person-Centred – Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
• Effective – The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
This vision, with its focus on quality healthcare, provides the context for all strategic and operational decision-making across NHS Scotland.
Scotland’s health and care system financing
The health and care system in Scotland is publicly funded and is financed almost entirely out of general taxation. Per capita public spending on health in Scotland is just over £2,000 a year. It accounts for 10 per cent of gross domestic product, and more than one-third of the Scottish Government budget – well over £11 billion.
All health services and almost all social services are provided free at the point of delivery. Local authorities may charge a small fee, based on the individual’s ability to pay, for non-residential and domiciliary care.
The Government of Scotland receives a funding allocation from the United Kingdom government. However, the responsibility for health and social care lies entirely with the Scottish government.
The provision of health and care services in Scotland is governed by a number of legal frameworks. It is guided by strategy and policy designed to ensure sustainable services which are safe, effective and person-centred (see the description above). The Health and Social Care Directorates Management Board aims to provide strategic leadership to NHS Scotland.
Scotland’s telemedicine strategy and legislation
While there is no specific legislation covering the use of technology in health and social care in Scotland, increasing attention has been paid to patient-related IT systems. The first eHealth strategy was published in 2008 and covered the period up unto 2011. It had two main strands: a number of national systems and collaborative working among groups of boards.
Central to these two strands, and a key patient safety measure in its own right, was the universal use of the unique patient identifier: The Community Health Index (CHI). Use of CHI on clinical communications is mandated across NHS Scotland with few exceptions. The CHI number is a fundamental building block to future Scottish Government health initiatives.
In support of future developments, a national technical architecture (pdf, 260KB) has been assembled and the Scottish Government has been working with boards to promote safe, effective and appropriate use of information through publication of an information assurance strategy and core guidance.
A second eHealth strategy was published in 2011 (and refreshed in 2012). It outlines how digital technology will enable patients to become more directly involved in the design and management of their individual care. Its aims, that are focused on the achievement of the three quality ambitions (see the description – above – of Scotland’s health and social care organisation), are to use information and technology in a coordinated way, to assist people to communicate with the NHS and manage their own health, contribute to care integration, support people with long-term conditions, and improve the safety of people taking medicines as well as the effective use of these medicines. The strategy has also provided a framework within which NHS Boards across Scotland are agreeing outcome-based eHealth plans. It runs to 2017.
In the autumn of 2012, the Scottish Government published a report entitled Scotland’s Digital Future – Delivery of Public Services. This document sets out a vision for a Scotland in which digital technology provides a foundation for integrated public services that cross organisational boundaries, delivers services to those people who are most in need, and also enables services for businesses that promote growth.
A National Telehealth and Telecare Delivery Plan for Scotland to 2015 was published in December 2012. It was developed in conjunction with partners across services as diverse as health, social care, housing, the third sector and the independent sector. It provides continued strategic direction for the use of Telehealth and Telecare within Health, Social Care and Housing in Scotland. (NB Telemedicine in Scotland comes under the overall umbrella of Telehealth and Telecare.)