“We started with a problem”, Clare Morrison, who is clinical health lead at NHS Highland, explains. “NHS Highland is a remote and rural health board, it covers 40% of the landmass of Scotland yet only has 8% of the population so it is a large area which is sparsely populated, and this really brings a couple of problems”;
It has long been the mantra of those working in health and care services in Scotland that living in a remote or rural area should not deprive an individual of their right to access high-quality healthcare services. Now the innovative Pharmacy Anywhere initiative is bringing clinicians closer to being able to square the circle of ensuring that patients, whether they live in Torridon or Tongue, can access the services they need.
It’s doing this by using technology to overcome the vast distances and let residents access high-quality support from their pharmacist.
Although the area’s remoteness attracts so many visitors to the Highlands every year, healthcare has had to innovate to overcome the challenges of geography. The first problem, according to Ms Morrison, speaking at the Celtic pharmacy conference earlier this year, is recruitment.
“Recruiting pharmacists to work in rural areas like that is really hard and yet we do recruit some, but the nature of the workload means they spend a lot of time driving between communities…which really is such a waste of clinical capacity at a time when we are stretched as a profession.”
NHS Highland’s senior clinical quality lead and NHS Near Me lead outlined a journey that began with securing charity funding for the new venture from the Health Foundation in January 2017, followed by three months of planning and then small-scale testing.
Ms Morrison reflected: “It seems quite strange to me now looking back, but at the time what we were doing just had not been done before, that remote access in and remote consulting…Now to me, this feels routine but back then it was really, really new.”
Remote access and consultations
Previously, collaboration with dispensing practices had involved pharmacists physically working in a practice.
“We know dispensing practices supply the medicines but often don’t provide the pharmaceutical care and expertise that a pharmacist can provide…what we tried to do was take that model and approach of regular annual medication reviews that had been provided by pharmacists in dispensing practices, and provide it remotely rather than in person”, Ms Morrison says.
“We used two forms of telehealth”, she explains, “the first one was remote access to patients’ medical records, so this allowed the pharmacists from a laptop to have full read and write access.
“I think it’s fair to say that when we started, vision anywhere wasn’t up to scratch in terms of what we needed it to do…The vision anywhere team were fantastic and worked with us and we managed to get it working”.
Video consulting via the attend anywhere platform was used, and, in light of connectivity issues that exist in some areas, telephone calls were used where a video link could not be established.
“In the initial phase we developed a process so we had a clear written process for how the consultations should be delivered, and that was jointly developed by the pharmacists who were involved in this and the GP practices.
“The process was to start off with the GP practice staff identify the patients who were due a medication review; some GP practices just for patients when their annual review was due, and one actually picked out the most complex patients to maximise the benefit of pharmacist input.”
GP practices would contact patients to offer appointments and explain the different options of a video or telephone consultation.
Another consequence of patients living in remote rural locations is a higher reliance on purchased medicines. A lack of community pharmacy facilities has meant many increasingly purchase some of their medicines online.
Clare Morrison explained: “The medication review process was very much based on the NHS Scotland seven-step framework but we had a real focus on purchased medicines as well. People who don’t work regularly in dispensing practice don’t realise patients in these areas just don’t have access to community pharmacy at all.
“They do rely on the internet to buy their medicines so it was really important for us to ask patients about every single medicine, including those they had bought on the internet.
Reviews can result in advice on purchased medicines, reductions, increases or alterations in prescriptions and referrals to other members of the general practice team for extra support.
“So the results”, Ms Morrison went on, “As a six-month pilot with ten pharmacists, the uptake was pretty high: 85% of patients who were offered an appointment accepted.
“We did have 57 refusals and telehealth was the reason for 36 of those; not one single patient despite the fact they had never had a pharmacist support before refused because it was review with the pharmacists.
“I think that shows just how much the public and the patients and these practices value the support that they were getting in the pharmacists.
“94% of consultations used telehealth successfully. In the early days, we did have a lot of problems with internet connections…interestingly since this pilot’s been done there’s been quite a massive improvement in the fibre broadband coverage in Highland and I suspect we would get very different results if we did it now.
“The consultation methods did end up being more telephone-based but I think that’s okay. I think we did definitely identify that there are values in improving and using video because, for example, patients could hold up their medicines and staff could see them. We recognise the value but at least they were getting a pharmacist input, which they weren’t normally getting, by phone.”
70% of patients who took part required some sort of clinical intervention – “a massive number”.
In terms of the savings, the licence for the software used to provide the service was £1980 a year, compared to the £8,400 approximate cost of a pharmacist delivering the same service in person by driving to different practices across the Highlands.
“Patient acceptability [of the service] has been positive,” Ms Morrison says, before extolling the benefits for staff.
“Enabling us to provide care to remote locations in this way is just fantastic; it provides a better work-life balance for pharmacists. These are teams who suddenly find they are not spending all their time driving and that’s a really big thing.”
An improved patient experience
“Thirdly, it provides a more responsive and sustainable service. In terms of responsiveness, we provide medication reviews when patients are referred rather than waiting until the next time the pharmacy team was going to be in the GP practice.”
“If we get a referral we can dial into the patient’s records immediately, and the service becomes so much more sustainable because if one pharmacist is off sick and something urgent still needs to be done somewhere else, we can act remotely and provide a replacement service.”
“The project comes with two caveats” the audience at the Celtic conference was informed. “Caveat number one is that telehealth isn’t suitable for all consultations. Some patients will need in-person appointments and we have to recognise that”.
“Caveat two relates to the video consulting part – not every person is as addicted to smartphones as we are, so remember they may need some support.”
Initial reactions informed the adoption of a single point of entry into the system, as Ms Morrison says:
“What patients really hated when we started off was having one service for diabetes and one service pharmacy and one service for respiratory and so on where patients had to enter in a different way for each condition. That was really hard for patients – they got confused, they got the wrong place and they gave up.
“To make it easy for patients we developed a single point of entry. Our system works by starting a video call, patients are then greeted by a real person who transfers the patient to the clinical service they are attending.”
So successful has the initiative been, that what started off as a charity funded project has led to the establishment and integration of an NHS service.
“Pharmacy Anywhere led to the establishment of NHS Near Me – a video consulting service for all outpatient appointments in NHS Highland. We have 19 different clinical specialities now providing appointments with this way and patients either have an appointment at home because we recognise connectivity issues and we have put the kit in for patients to use in local NHS clinics.
Feedback from patients frequently highlighted the importance of time saved if a remote consultation could be carried out, often giving them more time with loved ones. Before embarking on this project, Ms Morrison said she thought “telehealth was second best…but actually, it’s not. For a lot of patients, this is the preferred service”.
This story was supplied as part of our partnership with healthandcare.scot.