Features

The future of practice

05 October 2018

How might current and future technology developments impact on the way you carry out your work now and in the future? And how could this affect your clients? Journalist Peter Crush reports.

The continuing digital revolution is changing how we live our lives: from the way we shop to how we manage our finances, communicate, and much more besides. There are major bonuses to this as well as pitfalls. To deal with both, it is necessary to take steps in making the best use of technology. Healthcare is no different, although it presents some unique issues. As the summary to a recent report on nursing in the digital age puts it: ‘For various and complex reasons, health services in the UK have found it challenging to keep up with the pace of change’ (The Queen’s Nursing Institute (QNI), 2018).

So where do we stand in community practice? What are the challenges of the digital change, and how could technology impact on your role?

When North Manchester Community Service first piloted giving mobile devices to its 120 district nurses in 2017, few could have predicted just how transformative it would be. A year later, the results found a 70% increase in patient contact among all community staff, and a 50% rise in district-nurse-led patient contact (Merrifield, 2018). With each nurse armed with a tablet enabling them to see test results and access and update records in real time, clients receive a better service, and each practitioner saves an estimated hour daily. What about other positive example of practice?

Turning the corner

The North Manchester pilot is only one of the latest in a growing number of technology-driven schemes. In 2012, the use of Breast Start, an app that aims to provide friendly, accessible information and support to breastfeeding mothers in low-uptake area Wirral, resulted in 13% of them still breastfeeding at six months. This is considerably higher than the UK-wide 1% and was a project designed and driven by health visitors, and based on local need. For a small investment of £1500 per year, the app showed how technology could help to improve outcomes (Department of Health, 2015).

Earlier this year, Walsall Healthcare NHS Trust went live with Totalmobile – allowing referrals, dynamic scheduling and visiting information to be inputted via tablets for community nurses.

There is a palpable sense that the future of community healthcare is now catching up with other sectors – with technology at its heart. ‘Community practice is definitely facing its “Amazon-isation” moment,’ argues community pharmacist Sandra Gidley, also chair of the English Pharmacy Board at the Royal Pharmaceutical Society. She says: ‘The ability to be more efficient is certainly attractive, as is better contact with the community with more useful and up-to-date information.’

The other positive news is that CPs are generally supportive of technology. The latest report from the QNI surveyed more than 500 nurses working in the community. It found that 74% of community nurses find IT systems a more reliable way of working than paper-based systems.

However, close to a third (29%) still work largely with paper systems. The report also found that when technology was used, inconsistency arose among employers. And here lies the first issue of the digital age in healthcare: technology needs to be implemented better to make it truly work for both CPs and their clients.

Sue Boran, director of nursing programmes at the QNI, says: ‘One of the key findings of our report was general lack of interoperability in the NHS as a whole. Around a third of people we talked to saw lack of systems being able to talk to each other as a major problem. We found that there were 67 different IT systems in community healthcare, and a real sense from some that CPs want to be carers first, not IT experts.’

She adds: ‘We found less than 80% of community nurses actually have access to information from GPs. Only 57% had access to digital hospital discharge letters, and only 11% had access to social care records, despite nurses in the community often overlapping.

Frustrations will continue to occur if technology is not introduced in a measured and joined-up way and with proper leadership and support

‘For the future of practice to be technology-enabled, technology has to enhance, not frustrate. Frustrations will continue to occur if technology is not introduced in a measured and joined-up way, and with proper leadership and support.’

The human touch?

As use of technology increases, what uncertainties exist around how it’s set to impact CP practice? Potential changes to home-visit dynamics is one.

New technology is great but we must always remember who community work is for and make client ease
the priority

‘You can’t reassure people who are dying remotely,’ says Sue – when debating whether community practice will foreseeably go down the route of virtual GP services, using Skype or similar. ‘You also can’t as easily tell if people are anxious, or show signs that there may be other problems,’ she adds. ‘Those in charge of community practice have to remember that nurses aren’t an emergency service; they’re there to talk rather than provide immediate diagnosis. New technology is great, but while it’s tempting to look at cost savings, we must always remember who community work is for – and it should always be for patient ease over CP ease.’

It’s already the case that studies are examining whether care could begin to be dehumanised by technology from the end-users’ experience. In a Copenhagen study (Vilstrup et al, 2017), the use of tablets by home-care nurses was not only welcomed by those they visited, but positively ‘expected’ because it represented a symbol of professionalism, giving an aura of being in control. In contrast, a study in Switzerland found that when new technology was left at people’s homes, which would activate visits when certain parameters were reached, ‘did not bring real gains to patient care’ (Cohen et al, 2017). In fact, 7% of alerts generated were technical errors, while 55% were judged to have been irrelevant for further investigation.

Sue says that while the promise of tablet-based technology is great, she often hears that CPs still sit in their cars and do any updates out of sight because tapping on a screen interferes with dialogue, and they would rather not mix the two.


74% of community nurses find IT systems more reliable than working with paper-based systems - QNI, 2018


A question of advice

Beyond home visits, technology presents arguably even greater challenges to practice, notably in advising, signposting and supporting. The ubiquity of the internet, social media and apps for personal health research combine to create that most modern of technology problems: ‘fake news’ and misinformation.

While the impact of fake news is well documented when it comes to politics and international affairs, it’s less so for health information say the social change charity Shift and charitable foundation Wellcome (Shift, 2018). They say the spread of health misinformation on social media could be having an impact on the decisions people make about how to keep themselves and their families healthy. So in the summer they began investigating the potential impact (see updates at bit.ly/study_fake_news).

What we do know already is that more people than ever before are choosing to go online to research their health. Data from Oxford Internet Surveys finds the proportion of people doing so rose from 37% to 69% between 2005 and 2013 (Dutton and Blank, 2013). And 2015’s UK digital health report found that 21.8% of people self-diagnosed their symptoms online because they couldn’t get a doctor’s appointment (Push Doctor, 2015).

This can present a challenge to all health practitioners, from GPs to CPs. For instance, anti-vaccination sites were at the top of searches when parents used Facebook to find information about the MMR vaccine or other vaccinations (Hymas, 2018) – a finding Professor Helen Stokes-Lampard, chair of the RCGP, said was ‘deeply concerning’. She said the sites disseminated ‘false and frankly dangerous ideas’.

Both Sue and Sandra say they have both tried to convince people not to take on trust what they have read online. Sandra says: ‘This only enhances the need for more personal skills in the future – to listen to what they have to say, but then tell them that what they think they have is probably not the case.’ She adds: ‘That said, where I do think tablets and more digital technology could help is when CPs use them to show people more trusted sources of information.’

Sandra’s conclusions were similar to those reached by Michelle Moseley in a Community Practitioner article looking at the use of ‘Dr Google’ by clients in the February 2018 issue. Michelle, programme manager for SCPHN (health visiting) at Cardiff University, and Wales chair on the CPHVA executive, revealed she’d been challenged by clients on weaning practices and on vaccinations, particularly MMR. She said: ‘Health visitors have to be well equipped, and respond with advice and knowledge that is evidence-based.’ It was also concluded overall that what’s important is to ensure clients are looking at reputable sites, and that CPs empower clients as much as possible and as early on as possible.


On the ground: A range of views on the use of tech in practice

Nicola Sims, community midwife at East Kent Hospitals University NHS Foundation Trust has found pros and cons:

‘We’ve had a change of system to modernise midwifery, with the ultimate aim of recording all health visitor, doctor or hospital visits.

‘The plan is to do away with the big book of notes pregnant women are supposed to carry everywhere they go but often forget. We were initially given tablets, but they weren’t up to the job because of connectivity issues.

‘More recently, we’ve been given laptops and smartphones, so that in theory, we can create wi-fi hotspots, but I still know of colleagues who have had difficulty connecting. Hopefully it will improve.’

Randeep Kaur, clinical lead for health visiting, Sandwell and West Birmingham Hospitals NHS Trust, has had a largely positive experience:

‘We’ve been quite fortunate with our commissioners. We’re paper-light, so the only record we keep is a reference card that we take out with us to do a new birth visit. Our records are electronic, so staff input directly onto SystmOne records. We do text reminder appointments as well and we’re just going to start doing them via email.

‘It’s time-saving, and just helps everything really [without replacing the human touch]. The only issue we can have is connectivity; for example, when laptops are taken to an area where connectivity is poor it can take slightly longer. But that’s normal, isn’t it? We tend to use recognised apps and those that have been developed by the trust.

‘The only thing we have replaced is when we do the new birth visit; we show leaflets electronically where possible. We’re not electronic with the ‘red book’ yet, but we use technology to show parents information on tablets.’


Getting involved

What’s also apparent is that CPs will need to adapt – and according to Sarah Hayes, deputy chief nurse at Whittington Health NHS Trust, the best way to do it is ensure practitioners themselves are part of the implementation process on any new technology.

For the last five years, the trust has gradually been enhancing what staff can do with mobile devices, not only giving them the ability to edit medical records details on-site, but also introducing better workforce scheduling. This latter element includes matching nurses to patients dynamically, suggesting that different people should visit as people’s health and advice needs change.

Sarah says: ‘It’s involved a massive amount of culture change to ensure the right person visits and no visits are missed. But I can’t emphasise enough how the success of the technology [estimated to be savings of £310,540 for 2016-17 (National Quality Board, 2018)] – has been people leading it from the ground up.’ She adds: ‘People often talk about how you need to do massive amounts of training, but the reality is that the technology is so intuitive, this is not the barrier. It’s more how people change as technology is brought in – and that’s why they need to be involved.’

Currently, the Whittington scheme is focused on district nurses, but Sarah says that plans are already afoot to roll it out to health visiting, and nothing – including Skype-style consultations if that’s what people need – is off the table.

AI and beyond

An important point to bear in mind when assessing the impact of technology is the likelihood that if the NHS doesn’t introduce it, other private sector firms will lead the charge.

At private firm Push Doctor, which offers virtual GP appointments, chief medical officer Dr Dan Bunstone says he’s already eyeing up new areas such as schools and care homes for its services to extend into, which would involve CPs joining forces.

Dan says he’s most excited by where the next level of technology will take things – notably artificial intelligence (AI): ‘While technology like ours isn’t a panacea, there is a real advantage for the community sector from other technology add-ons that can be left on-site – like Bluetooth inhalers.’ He says that such technology could send out alerts if something was amiss.

Robert Smallwood, author of the recently published Information governance for healthcare professionals, adds to this chorus of anticipation. He says: ‘It just feels like we’re at a tipping point. Typically, healthcare is behind in IT from a working practices point of view, but we’ll soon be at the stage where AI could help with checking for some community healthcare professionals. For instance, say a GP has mistakenly flipped a blood pressure reading. AI could compare this to a patient’s history and flag this up to a CP as wrong. Alternatively, AI could even analyse reported symptoms, compare it with millions of records, and suggest a prognosis or other signposting that’s needed.’

The implications could be huge, but the impact on CPs’ work could also be huge – and not always in a way that would be welcomed. ‘Technology can still get things wrong, and this being so, there will be a new requirement for real humans to potentially question what AI might tell them,’ concedes Robert. ‘This means giving community professionals permissions to use their experience to override what their technology might tell them – and this is a big responsibility, which will require lots of safeguarding.’

Sarah adds: ‘There are still issues around data security and sharing data, too.’ Of course, there’s also the unknown factor about how automation may or may not affect CP jobs (see Will you be replaced by robots?, below).What’s clear though, is that once progress starts it’s very difficult to hold back.

Back to the question of the current status of technology in community practice, and a recent report by The King’s Fund, Reimagining community services: making the most of our assets (Charles et al, 2018) notes that current technology usage is confined to innovative projects rather than being more widespread. However, it still concluded that there was great potential out there – to convert what it calls ‘pockets of innovation’ into best practice.

Certainly, the recent QNI report identified various barriers to the best use of tech in community nursing: they ranged from connectivity issues – with reluctance from CPs when it didn’t work – to the fact that ‘IT has not been tailored to community nursing’ and had lacked consultation. Recommendations (beyond more funding) were for service users to have consistent standards in the absence of consistent systems and to involve the workforce more in systems used.

With NHS budgets consistently under scrutiny, a new future for practice – one that embraces and uses cutting-edge technology – may not come as quickly enough for some as it does others. But change is afoot.

The challenge for all CPs is to adapt to the ongoing digital change, take ownership of new roles, and position themselves squarely as people who will lead, rather than follow, this rapidly approaching future.


Will you be replaced by robots?

PwC (2018) has predicted that up to 30% of British jobs could be impacted by automation as quickly as 2030, although different industries and roles will be affected differently.

A new tool from LeisureJobs.com, with the help of intel from Oxford University, has predicted that nurses have just a 5.8% chance of being replaced completely, thanks to their high assisting and caring-for-others score as well as soft skills such as persuasion and ‘social perceptiveness’.

The view from Unite

Such is the predicted scale of automation that the world’s greatest minds were recently debating it at the most recent Davos summit. Ideas discussed included taxing those machines that cause a real person’s job to disappear, and the creation of a Universal Basic Income, which people accept in return for being replaced by a machine. But the idea – to ‘avoid popular backlash’ against the mass unemployment experts believe will be caused by automation – has been derided by Unite.

Sharon Graham, Unite executive officer, says: ‘Work must remain a central pillar of society and automation doesn’t have to mean job losses.’ She adds: ‘Why not have shorter working weeks and better retirements? The next generation of technology is going to generate a lot of wealth so we need to make sure it delivers for society, not just make bigger profits.’


References

Charles A, Ham C, Baird B, Alderwick H, Bennett L. (2018) Reimagining community services: making the most of our assets. See https://www.kingsfund.org.uk/sites/default/files/2018 01/Reimagining_community_services_report.pdf (accessed 12 September 2018).

Cohen, C, Kampel T, Verloo H. (2017) Acceptability Among Community Healthcare Nurses of Intelligent Wireless Sensor-system Technology for the Rapid Detection of Health Issues in Home-dwelling Older Adults in The Open Nursing Journal 2017; 11: 54-63. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5420186/ (accessed 16 September 2018).

Community Practitioner. (2018) Calling Dr Google. See: https://www.communitypractitioner.co.uk/node/685 (accessed 18 September 2018).

Department of Health. (2015) Evidence of service transformation for 0-5s: Health visitor programme. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464916/Case_studies_Sept_2015_v2.pdf (accessed 16 September 2018).

Dutton WH, Blank G. (2013). Cultures of the Internet: The Internet in Britain, Oxford

Internet Survey Report, Oxford Internet Institute, Oxford. See http://oxis.oii.ox.ac.uk/wp-content/uploads/2014/11/OxIS-2013.pdf (accessed 16 September 2018).

Hymas C. (2018) The Daily Telegraph Facebook putting children's lives at risk by reviving spurious MMR claims, say UK health chiefs. See: https://www.telegraph.co.uk/news/2018/07/27/facebook-putting-childrens-lives-risk-reviving-spurious-mmr/ (accessed 16 Septmber 2018).

Merrifield N. (2018) District nurse patient contact boosted by 50% due to mobile tech. See: https://www.nursingtimes.net/news/community/district-nurse-patient-contact-boosted-by-50-due-to-mobile-tech/7024341.article (accessed 12 September 2018).

National Quality Board. (2018) Safe, sustainable and productive staffing. See: https://improvement.nhs.uk/documents/2334/Safer_staffing_District_nursing_appendices_final.pdf (accessed 18 September).

PWC. (2018). PwC economists assess how and when workers will be affected by coming waves of automation. See: https://www.pwc.co.uk/press-room/press-releases/waves-of-automation.html (accessed 18 September 2018).

Shift. (2018) Social media and the spread of health information. See: shiftdesign.org.uk/social-media-spread-health-information/(accessed 12 September 2018).

The Queen’s Nursing Institute (QNI). (2018) Nursing in the digital age: using technology to support patients in the home. See https://www.qni.org.uk/wp-content/uploads/2018/04/Nursing-in-the-Digital-Age-test.pdf (accessed 16 September 2018)

Push Doctor. (2015) Push Doctor's UK Digital Health Report 2015. See: https://www.pushdoctor.co.uk/digital-health-report (accessed 17 September, 2018).

Vilstrup DL, Madsen EE, Hansen CF, Wind G from Metropolitan University College, Cophenhagen, Denmark. (2017) Nurses’ Use of iPads in Home Care-What Does It Mean to Patients?: A Qualitative Study in Computers, Informatics, Nursing 2017 Mar; 35(3): 140-144. See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5348106/5 (accessed 16 September 2018)

Walsall Healthcare NHS Trust. (2018) Walsall’s community nurses engage with mobile technology. See https://www.walsallhealthcare.nhs.uk/walsall’s-community-nurses-engage-with-mobile-technology.aspx (accessed 16 September 2018).

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