Examination of Witnesses (Questions 20-39)
PROFESSOR CARL
MAY, MR
BALJIT DHEANSA,
MR JOHN
WILKINSON, PROFESSOR
SIR JAMES
UNDERWOOD AND
MR TONY
RICE
3 MARCH 2005
Q20 Dr Taylor: It is particularly with
examination of the brain where that has to be fixed for weeks
and weeks?
Professor Underwood: Yes.
Q21 Dr Taylor: So could that speed up
examination of the brain?
Professor Underwood: No, not of
the brain but it could make the post-mortem examination more informative
and therefore motivate physicians and surgeons to request them
more often.
Q22 Chairman: Professor May wants to
come in.
Professor May: I think one of
the things that we need to remember is that incorporating these
new technologies into clinical practice actually requires that
the hospital departments re-engineer their business processes.
For example, in some work that we did on a telepsychiatry service
we found that the pressure on consultants to be in a particular
place at a particular time to see a patient on a video link created
real problems in the distribution and organisation of other work.
So a problem for NHS departments that want to use these systems
is thinking about how to integrate the hidden work of delivering
healthcare, the things that none of us think of in terms of professional
practice because we see a doctor at work on a patient and we neglect
the work that goes on to deliver that service in a flexible way.
Some of these systems can be quite inflexible for clinical users
and that has led to some resistance. One further point to make
of course—and I know also that you do not want to discuss
the National Programme—is that for many IT professionals
in the NHS a real problem with these systems (and there are many
of them) is concern about whether they will be compatible, whether
they can be compatible with the new information spine and the
work that different contractors are doing on NPFIT clusters,
Mr Dheansa: At the Queen Victoria
Hospital we have successfully introduced a telemedicine system
which is a store and forward system, which looks at plastics trauma
patients and burns patients, and it has been successfully introduced
and it has been incorporated into the daily use of the hospital
because it has changed the way that we manage patients, to avoid
the unnecessary transfer of patients, to safely triage patients
at a distance and to plan their appropriate surgery without unnecessary
visits to our hospital. Because it is a regional trauma centre
it covers a population of four million people, and patients may
have to travel up to 80 miles to see a plastic surgeon. With the
use of telemedicine pictures one can make much more appropriate
decisions, thus avoiding late night transfers, which can sometimes
be unsafe and also make appropriate operative decisions, such
that a patient can come directly to theatre rather than making
a visit and then having to wait unnecessarily.
Q23 Chairman: Just before you carry on,
I was very interested in what you have done because I have a burns
unit, as you know, in my part of the world. In 1999 what actually
kicked off the idea of introducing this approach? What were the
factors that resulted in huge interest?
Mr Dheansa: It basically stemmed
from patient safety. We had a patient who was referred to us,
we were informed that they had a very large burn, they needed
to have immediate transfer to enable their safe management, intravenous
fluids and what have you. On the information we were given from
the referring hospital we felt that the only way to get them to
us quickly was to use a helicopter. Helicopters are very useful
in transferring patients quickly but they are also very, very
cold and relatively unstable. If a patient becomes very unwell
in a helicopter transfer then it is much more difficult to manage
them. This patient came over, we assessed them and they did not
have a burn; they went home in a taxi that day.
Q24 Chairman: In other words, if you
could have seen them it would have avoided all the expense.
Mr Dheansa: That is right. To
some extent the cost to us was not significant but the cost to
the NHS as a whole was massive.
Q25 Dr Naysmith: If I could just come
in here, Richard? It is a question I was going to ask Mr Dheansa
later on but this is a very good point to ask him. One of the
criticisms often made is that it is quite hard to produce links
between primary care and secondary care and between specialists
and non-specialists. You seem to have solved that problem at the
Queen Victoria; you have very good relationships with everybody
you need to have a relationship with. Why have you managed that
and are there lessons that other people can learn later on?
Mr Dheansa: The first thing was
identifying the problem and the problem was that patients were
travelling long distances and sometimes unnecessarily. We then
found the means to avoid those unnecessary trips, and at the same
time we had an increasing number of referrals and we were filling
up to capacity, so we needed a safe way of triaging and changing
our practice to enable a vast number of patients to come through,
and explaining this to our colleagues in the Accident & Emergency
Departments and then providing a clinical champion. So we provided
support in the form of a clinical champion and also identified
the clinical champion within those Accident & Emergency Departments.
Providing that support enabled doctors in those units to see the
benefits of those cases where telemedicine was useful, and in
fact it has become so useful now that patients' photos are sent
to us before they actually get on the phone, to make it even easier
for us. It is the constant support so at that A & E Departments
do not have to worry about having to maintain the system because
we will provide that support and, equally, legitimising its benefits.
The doctors and the nursing staff can actually see the benefits
of doing that because it means that their referrals are quicker
and easier and it means that patients are happier because they
do not feel unhappy about travelling long distances when they
do not need to.
Q26 Dr Naysmith: Forgive me, Richard,
this will be the last one. Is that because you have a very specialised
area of medicine that you are involved with in burns surgery,
and that sort of thing, or could it work with other things too?
Mr Dheansa: It works in two ways.
For instance, in burns critical care, where we have a very large
burn, someone has had smoke inhalation, where they have potentially
life threatening conditions, it is a situation that A & E
doctors do not come across very often and it is something with
which they need as much help as possible. So it means that I can
start managing the patient right from the beginning. I can say,
"This patient may well be safe for transfer with the clinical
information you provided over the telephone and the photographic
evidence I have before me." So in situations where doctors
feel out of their depth and rarely treat a situation it is very,
very useful. Equally, there are situations where there are benefits
to be had from much more common injuries, so finger injuries where
some specialised treatment may be necessary in certain situations
but not in others. Equally, it is also useful within the hospital
because it means that consultants who are, for instance, in an
operating theatre can also help manage patients in the rest of
the hospital whilst still in theatre. A good example would be
that I was operating on a large burn the other day, I had a patient
who had a wound break down in dressing clinic and I also had an
outside burns referral, all of which needed expert opinion, which
the junior doctor wished me to be involved in, and I was able
to do all three to some extent without leaving theatre, without
compromising any of their care. These sorts of things are quite
useful, not just outside of hospitals but within. So transferring
pictures of wound breakdowns for general surgeons, for instance,
or for orthopaedic surgeons and X-rays.
Dr Naysmith: Thank you very much.
Q27 Dr Taylor: I think your specialty
is one that lends itself ideally to this sort of work. In your
memorandum, Professor Underwood, you said that there was often
a reluctance to use the new technologies; that it was more difficult
to look at a section on a video screen rather than down the microscope.
Professor Underwood: Yes.
Q28 Dr Taylor: How can you overcome that
reluctance?
Professor Underwood: Through training.
We train with microscopes and I daresay that in 50 years' time
histopathologists like me will be using flat screens on which
the images will be projected, perhaps the histology slides will
be digitised and therefore transmissible more widely. The other
thing is that, in seeking second opinions, it is much easier in
this country to put the histology slides into a padded envelope
with a referral letter and send them by post and to get a full
and reliable expert opinion than to get a partial opinion more
quickly by telepathology. Often the opinion that we are asked
for does not have to be given so quickly that it needs telepathology.
It is not like burns, which is a very acute situation. We are
dealing with cancer diagnoses, which, apart from the intra-operative
situation, do not necessarily have to be made within a few hours—often
a day or two to get a very reliable interpretation is better for
the patient.
Q29 Dr Taylor: To someone who was not
used to looking down a microscope it would appear to me to be
far easier to look at a huge screen with everything magnified
even more times than just peering down a microscope.
Professor Underwood: Yes, I suppose
it is like the difference between driving a car and flying a plane.
I can drive a car but I would find it impossible to fly a plane,
but pilots have no problem with that because they have been trained
to do it. If we are confident that in 10 or 20 years' time colleagues
of mine will be diagnosing off flat screens then we had better
start training them to do that now. The other thing is that the
technology has improved considerably over the last decade or so,
the resolution that one can achieve with digital microscopy is
far superior now to what it was even five years ago. So it makes
it more realistic and feasible to consider diagnosis off screen.
Q30 Dr Taylor: So it is a question of
training, practice and usage?
Professor Underwood: Yes, and
developments in technology that make it feasible.
Q31 Dr Taylor: I want to move on to regulation
because POCT—Point-of Care-Testing—
Professor Underwood: Or Near Patient
Testing, it is often called.
Q32 Dr Taylor: You are suggesting either
a single regulatory framework must be applied to all diagnostic
tests, whether Point-of-Care Testing or laboratory based, or
that somehow laboratories have to somehow take the responsibility
for controlling the point of Point of Contact Testing.
Professor Underwood: Yes.
Q33 Dr Taylor: What do you want us to
recommend on those lines?
Professor Underwood: It is important
to bear in mind that point-of-care testing includes a wide spectrum
of patient testing. Your wife is a diabetic, so is mine; so our
wives do blood glucose tests frequently, and that is point-of-care
testing—the patients test themselves. We do not envisage
that that test ought to be regulated by a local pathology service
and quality assured and that sort of thing. But where in a hospital
testing is being done at the bedside or in the operating theatre,
we believe it should be done to the same quality assurance standards
as the same test done in the laboratory. It is perhaps even more
important it should be quality assured to the same standard because
if it is being done at the bedside the clinical action that is
likely to result is going to be very immediate, so we need to
make sure that that action is based on the most reliable result.
Q34 Dr Taylor: What about chemists' cholesterol
levels?
Professor Underwood: I have concerns
about that, from the pre-analytical, analytical and post-analytical
aspects. On the pre-analytical aspect I went into Boots
recently and I found a leaflet that said on it that three out
of four adults over the age of 45 have high cholesterol. What
does the ordinary man in the street conclude from that: that only
25% of people have a normal cholesterol? I think that is grossly
misleading information that is given to patients, motivating them
to have a test, which is 75% likely to show that they have, by
Boots' standards, a high cholesterol, which then results
in over-the-counter sale provision of simvastatin. So I am concerned
about the probity aspects of that and the quality assurance aspects.
Q35 Dr Taylor: So it is a very good way
of increasing sales?
Professor Underwood: I am not
unhappy for you to say that. Then there is the test itself and
its quality assurance. If the patient has a high result it could
be because they genuinely have a high cholesterol or because there
is a problem with the test itself. In hospital-based testing we
know whether it is a genuinely high cholesterol or a wrong result
because we quality assure the method. I do not know if Boots
and other high street chemists do that.
Dr Taylor: Thank you; that is very clear.
Q36 Chairman: Could I ask one more question
before I bring in Doug Naysmith. Going back to Dr Dheansa, one
concern that I have had raised with me about down the line consultations—and
frankly this is nothing new, I can recall 35 years ago when I
was training in social work I was going into hospitals where we
were doing sessions where a consultant psychiatrist interviewed
a psychiatric patient in front of a camera and a roomful of people
saw the outcome, and we discussed the diagnosis and all this sort
of stuff, so this has been going on for a long time—is that
where you have people going down the line, maybe in primary care,
and someone like you in a tertiary hospital or wherever, looking
at that patient, there is some anxiety on behalf of the patient
about who is seeing them down a camera, particularly if they are
showing their more private parts, shall we say. Is that an issue
that you have addressed and how do you deal with those anxieties?
Mr Dheansa: It was actually integral
to our development of the whole system because we have certain
regulations, Data Protection Act, Human Rights issues and what
have you, which we pull together with the general act of patient
dignity and privacy that we all need to address, and we have developed
quite a comprehensive photographic and video recording policy,
which includes getting the patient's consent but explaining to
the patient where those images are going to be used.
Q37 Chairman: I appreciate that this
is quite a complex area and if it is possible for you to give
us some follow-up information on exactly what is given to patients,
that would be very, very helpful.
Mr Dheansa: If you would like
I can actually forward the policy we have developed.
Chairman: That would be very helpful;
I am most grateful.
Q38 Dr Naysmith: I want to follow up
with Mr Dheansa an aspect of the fact that you are giving advice
fairly widely to people who ask for it, and you have good links
with other Trusts, and so on, partly because of the success of
what you have done at the Queen Victoria. But do you suffer a
financial disadvantage in any way because you are offering this
service? How is it paid for?
Mr Dheansa: To some extent we
have had a financial disadvantage. We have been very cost efficient
in developing this system. To date, since 1999, we have spent
£85,000 on developing a system that has transformed our management
of 3,000 patients a year, and we have not been reimbursed for
that cost. The advantages that it gains to the Trust in terms
of efficiency and appropriate theatre and bed utilisation is such
that we can treat more patients; and also to the NHS in general
in terms of avoiding inappropriate transfers, and more importantly
to the patients. So although there are cost benefits the hospital
itself has not realised those cost benefits except by more efficient
usage of the facilities that they have already.
Q39 Dr Naysmith: Is this then an inbuilt
disadvantage or disincentive to do things because spending money
on developing new systems means that you actually spend the money
and you do not get any reimbursement for it? So some Trusts are
making use of your facilities and not paying for them.
Mr Dheansa: There is and certainly
that is an issue in terms of payment by results issues, in terms
of commissioning for patient care. To some extent we feel that
it is important that those costs are reimbursed because on a wider
scale it would be cost inefficient and even in the States, where
telemedicine is utilised on a wider scale, those costs are not
reimbursed and it is detrimental.
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