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NHS 24 X GSA

NHS 24 LOCAL 01.02.18

NHS 24 LOCAL

14.05.18

alternative now

facilitating experiences that feel supported, appropriate and personalised to rural and remote areas.


TEAM MEMBERS

table of contents

ALTERNATIVE NOW NHS 24 LANDSCAPE/ DEMOGRAPHY ENGAGEMENT NATIONAL AND REGIONAL INFRASTRUCTURE KEY INSIGHTS DIRECTION NHS 24 LOCAL COMMUNITY SPACES LOCAL AMBASSADOR SCENARIOS LOCAL PROFILE CONCLUSION

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team mem-

ELENA CIPRIANI

CAT BINNIE

WEIRONG ZHONG

bers GUARONG DAI

XIAOFEI HUANG

Throughout this project, we have been exploring how NHS 24’s services exist within rural and remote areas of Scotland and how they can be tailored to support the health needs in these areas through proactive and preventative health care.

QIAOZHI ZHANG

and with people who live in these diverse communities to understand how NHS 24 could better support their geographical circumstances. Our proposal is NHS 24 Local, a system that shifts NHS 24 from delivering individual, isolated journeys to driving social, collective journeys. We have created a framework for this, consisting of utilising people and places, to create a system that ensures more accessible health touchpoints, creates new support networks forming and strengthens community resilience.

One of the reasons for taking this direction is that within NHS 24’s remit they have stated that self-management of care is a key strategic priority and a key area where the national infrastructure and capability of NHS 24 could deliver benefits. Within this project we have engaged with a number of key stakeholders

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alternative now The Stage Two project ‘NHS 24 Alternative Now’ brief was a live project with NHS 24. We were to explore how NHS 24 can expand upon its current offer, envisioning how their services may exist in the future. NHS 24 fit under the larger umbrella of the NHS, and as an organisation they focus providing telehealth and telecare services to the whole of Scotland. Currently they offer a number of different digital touch points, however at the moment they are somewhat limited. NHS 24 want to expand upon their current service offering and also envisions widening the organisations remit. Within this, we have been challenged with exploring people’s behaviours and interactions around NHS 24.

This in turn will allow us to gain a deeper understanding of people’s lives and in turn create a framework to address current needs and speculate new, innovative and alternative ways of living. We were to explore and question what additional features, needs and services could NHS 24 offer. As part of this brief we were assigned the sub-topic of ‘robots.’ With robots being utilised in other industries, we were to explore how robots could be used to mediate our relationship with NHS 24 by introducing new ways of thinking about remote access to healthcare. We can explore how they could be a point of access through physical and digital interactions in response to emerging health needs. This meant understanding if their existing offering could be rethought to provide a different offering, which would be more meaningful for individuals or groups. Therefore, our project looked at what we might do differently today that may reframe possibilities. We explored how alternative scenarios may exist and we designed in response to these. We did not aim to design futures, but to think about how existing and emerging technologies can be used to connect innovative personal/social behaviours and interactions. Through these innovations, NHS 24 aims to improve the NHS 24 health and care system as a whole.

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“..to gain a deeper understanding of people’s lives and in turn create a framework to address current needs and speculate new, innovative and alternative ways of living.” 5


NHS 24 Exploring an overview of NHS 24’s services highlighted the challenges they face as an organisation and what their strategy aims to do over the next five years. The key aspects to us were the following: a drive towards creating a more efficient preventative as opposed to reactive health service, the push to combat significant health inequalities across the country and the important role NHS 24 plays in mediating the pressure on the wider health care system. As a result of this meeting, it was clear there were a number of areas to examine and interact with moving forward and it was invaluable experience to get an insight into NHS 24’s responsibilities as well as their aspirations moving forward.

1. NHS 24, Our Local Delivery Plan 2017-18 Scotland’s Landscape

Exploring an overview of NHS 24’s services highlighted the challenges they face as an organisation and what their strategy aims to do over the next five years. The key aspects to us were the following: a drive towards creating a more efficient preventative as opposed to reactive health service, the push to combat significant health inequalities across the country and the important role NHS 24 plays in mediating the pressure on the wider health care system. As a result of this meeting, it was clear there were a number of areas to examine and interact with moving forward and it was invaluable experience to get an insight into NHS 24’s responsibilities as well as their aspirations moving forward.

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“Self-management of care is a key strategic priority for NHS 24 and a key area where the national infrastructure and capability of NHS 24 could deliver benefits... and help reduce demands on primary and urgent care 1 services.�

Within their strategy, we found the rationale of ensuring rapid access, equity of access and the idea of collective management interesting and fruitful topics to explore further within our project, especially as our brief was focused around remote access to healthcare.

We felt that this demand can be mediated through shifting the focus to proactive and preventative health care provision. There are several key challenges facing the system that we identified, such as demographic changes, health inequalities and geographical challenges. Our focus was upon the geographical challenges, and how this affected those who live in rural and remote areas in accessing NHS 24’s services.

When focusing further on the various services they offer, we determined that 111 works as their key and most in demand service, as it has the most healthcare professionals involved and has a high level of usage and calls received. In relation to this, we sought to examine within our project how NHS 24 can ensure this increased demand is mediated.

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landscape To highlight the complexity of the task faced by NHS 24, it is vital to understand how Scotland’s landscape presents a unique challenge to ensure health services are accessible. 20% of the

population live across 98% of the land ², and within that you have people who live on remote islands to people living in more accessible rural areas leading to logistical issues due to the centralisation of many health services. NHS 24 have already been exploring how to ensure increased access in these areas through their work with the Scottish Ambulance Service and the Attend Anywhere software they have created, which allows people to speak to their GP or health professional via webcam. We felt it would be a further area to examine to see if these developments currently already meet the needs of these rural and remote communities. 2. Scottish Government, Rural Scotland Key Facts, 2015, http://www.gov.scot/Publications/2015/03/5411/1

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demography According to The Scottish Public Health Observatory, the population in rural

areas is growing at a faster rate than the rest of Scotland, whilst also having a higher ageing population than the rest of the country.3 Within the National Clinical Strategy, they speak about this having a great impact on core health services in rural and remote areas due to increased demand. This is due to the fact that as we get older, we will tend to need more prescriptions medications, more GP appointments and develop more health conditions that need to be managed. Alongside the higher number of elderly people living in rural and remote areas, a Citizens Advice Bureau report highlights how these people are more likely to be digitally excluded.4 This then creates a barrier for them accessing any health support and information online. Looking at NHS 24 and their services, there is a wealth of information online, however it may not be utilised by this demographic. Therefore we saw it as a priority that within NHS 24’s agenda they need to ensure their services are mediating this extra strain on the wider health care system and on their services.

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3. The Scottish Public Health Observatory, Rurality: data, http://www.scotpho.org.uk/life-circumstances/rurality/data/ 4. Citizens Advice Bureau, Disconnected: Understanding Digital Inclusion and Improving Access, 2018


engagement

The Alliance Carmen Paputa Dutu Digital Health and CareAssistant

Glasgow University Dr Nai Rui Chang Social Scientist Links Worker Programme

Aberdeen University Professor Philip Wilson Director Centre for Rural Health

Rural Gps, Pharmacists

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Scottish Rural Action Fiona Thompson Volunteering and Compaigns Coordinator

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These organisations covered those who worked specifically for rural health, such as the Centre for Rural Health and Scottish Rural Action, and academics who gave an overview of the health system and context they work within, such as the Health Institute at Glasgow University.

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From this, we hoped to build a richer understanding of the issues and concerns in relation to health delivery in these areas.

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With this basis of understanding and exploration, our next stage was to speak to a wide range of organisations who work within the context of NHS 24, rural health and, most importantly, those who live within these diverse areas of Scotland.

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Remote and Rural Patients Group (Facebook Group)


national and

Could increased presence in these communities support self-management and collective management of health?

We explored how NHS 24 is structured and how they work as a national organisation. We found that nationally they have four central offices, which act as the main points of contact. They then expanded their presence regionally, with each health board having its own NHS 24 contact centre. These decentralised offices cover vast areas of land that are made up of diverse rural and remote communities and we saw this as an area to examine. We wanted to understand how NHS 24 currently have a presence in these areas and if they currently meet the diverse needs of these communities. There was an opportunity to explore how they can move towards a more dispersed model of service delivery, rather than decentralised.

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We were able to able to speak to a broad range of people, however there were several interviews that proved to be the most insightful for our project. Here we highlight some of these key interviews:

Professor Philip Wilson Centre for Rural Health

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rofessor Philip Wilson is the Director of the Centre for Rural Health in Aberdeen, which develops and evaluates interventions to improve the health of people in rural communities. They work on a number of innovative projects and we were lucky to speak to him regarding our focus on NHS 24 and rural and remote areas. The key highlights from this interview were that he felt currently the perceptions of NHS 24 were poor: people feel that it is a service that was not designed for rural areas, but rather focused on supporting those who live in urban areas of the country.Through his experience of being a GP, he knows that GP’s feel reluctant in using NHS 24 as the point of contact out of hours (OOH) as they feel it is not suitable for the geographical circumstances of rural and remote communities. He felt that one of the greatest challenges is NHS 24’s 111 service not providing adequate, accurate information during 111 calls and that this therefore makes people reluctant to use the service again in the future.

He felt a really important change would be to create local profiles that would give call handlers a broader understanding of these communities.

“The feeling is that NHS 24 is a service for those living in urban areas, it’s not for rural areas.”

Fiona Thompson Scottish Rural Action

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iona Thompson works for Scottish Rural Action, a charity that seeks to make the voice of rural Scotland heard, by bringing people together to discuss issues that affect them. They run the annual Scottish Rural Parliament which highlights the issues and concerns arising across rural and remote Scotland. She works as the Volunteering and Campaigns Officer, and gave us an insight into work they had done around NHS 24 and issues that people had with the service. (continues next page >)

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She felt that people did not have a real awareness of NHS 24 and their services. Whilst people know about the 111 service, there is a lack of understanding of when to use it. Outside of the 111 service, people tend to have a low awareness of the other services NHS 24 offer. She felt this awareness should be increased, and that an important point to highlight was that there are a lot of other services that exist that can support health care delivery. The topic of geographical and logistical issues were highlighted, in that there are issues with public transport and being able to use centralised health services.

acts as an online space for people living across rural and remote Scotland to connect and share issues with healthcare in these areas. She was extremely insightful, with a connection to many of the issues that had already arisen in our research. She was able to connect us to GPs and people living in these areas who had experiences of using the 111 service. Her feeling was that NHS 24 staff should have a greater awareness of the geographical circumstances that people living in these areas have, in order to ensure they provide the correct information.

“There is a low awareness of NHS 24 and the services that they provide.”

“The geography thing is so significant. I was facilitating a discussion about the GP contract and one of the young mums said NHS 111 just don’t ‘get’ that we don’t have a pharmacy a few minutes away.”

Karen Murphy Rural and Remote Patients Group

K

aren runs a Facebook group called Rural and Remote Patients Group which

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During our engagement we were able to speak to a number of GPs and people who live in rural and remote areas. These are some of the key points they mentioned:

“Nhs 111 just don’t get that we don’t have a pharmacy a few minutes away, that there are no buses into town from many places (and if there are they don’t run at convenient times).” Resident, Carradale

“Our present gp doesn’t let us use nhs 24/111 because it does not work for our part of the world. It’s ok for urban populations but not rural they don’t understand our issues and remoteness.” Resident, Ross of Mull

“The logistics of travelling by ferry creates a lot of barriers to access.” GP, Luing

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“I worry that, when we have to use nhs 24/111, they won’t understand our situation and will give inappropriate advice.” Resident, Ross of mull

“The person didn’t know from their screen where the ambulance was - they told her it was in balloch... When it was actually a few minutes down the road in ballochair (they said they couldn’t pronounce the places)” Resident, Carradale

“Local policy is contrary to the advice nhs 24 gives out... The patient may therefore avoid using nhs 24 the next time they need help.” GP, Luing

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key insights Lack of Awareness One of our key insights was that people feel like NHS 24 isn’t tailored to support them and the geographical situation they live within. For example, one woman we spoke to, living rurally with two children, was recommended by 111 to ‘pop to the pharmacy’ to treat a minor issue. This woman had issues with transport, had two children to take care of, meaning the advice from 111 wasn’t very helpful. So she ignored this impractical advice and booked a GP appointment, to solve a problem that did not require this level of service. This example, highlights how people might not make use of NHS 24’s services again in the future and therefore put unnecessary pressure on the wider health care system.

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Social and Geographical Isolation Another key theme that stood out to us was how socially isolated people felt in these areas, as well as geographically. They felt cut off from health support but also from the support of other people. This was particularly evident for people who had existing health concerns and who were older. We felt it was an issue that would increase as the ageing population increased in these areas. These were the three key insights we identified during our research and sought to challenge with our design proposition. Therefore, our focus became how can NHS 24 reshape their service offering to these areas to ensure that NHS 24 supported both self-management and collective management of health, moving away from the current perception people have of the service.

Logistical Issues A significant recurring theme, was logistical issues. Due to the centralisation of many health services, there is a greater struggle for people to ensure they can reach the services NHS 24 may recommend. This is important as it highlights people are being disadvantaged in their efforts to manage their health issues. This in turn can increase pressure on NHS 24 and wider health care services when minor issues become more serious.

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direction Therefore we want to propose a shift in NHS 24 from promoting individual health care experiences, to becoming a social enabler that facilitates supportive journeys. We explored ways in which we could create this shift, by introducing new touchpoints within local communities that ensure NHS 24 has a greater presence in people’s everyday lives to support management of health and create new support networks to create social, supportive journeys.

NH S 24 p ro m o t e i nd i v i d u a l , i so l a t e d j o u r neys

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NHS 24 LOCAL So we propose the creation of an NHS 24 Local system that would move away from these isolated experiences and engender social experiences and this localised system would be an extension of NHS 24’s current service offering. Therefore, it would build upon their current offering by creating more accessible touchpoints that ensure management of health and localised support. Alongside this, we wanted to utilise what currently exists within these rural and remote communities to help facilitate remote access to health services.

NH S 24 promo t e s o ci al , s u p p o r t ive j our ney s

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Local means a system that facilitates experiences that feel supported, appropriate and personalised to their geographical location. It means more accessible health touchpoints that enable NHS 24 to have a greater presence in people’s lives. And it means resources that are more readily available to support rural health needs and utilising and facilitating community resilience.

NHS 24 LOCAL There are three key aspects of NHS 24 Local, that consist of utilising people, places and events.

NHS 24 LOCAL AMBASSADORS These are people in the community that signpost other community members towards resources. They have a strong local knowledge and understand the health needs in their area.

COMMUNITY SPACES Community spaces can act as existing infrastructure that can be utilised as a space for Attend Anywhere to be facilitated. Alongside this, there can be an automated dispensing machine for medication, both over the counter and prescriptions. This is a space that the local ambassador can utilise for running new support groups and resources.

LOCAL PROFILE The local profile will be used to provide accurate, informative and supportive information to people living in rural and remote areas. These profiles can be utilised during 111 calls and will be created and maintained by the local health board and local ambassador.

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local NHS 24 Local Ambassadors

Community Spaces Looking at community spaces, they would be central to how NHS 24 Local would run and the delivery of more localised support networks. According to the Scottish Government, around 80% of community spaces are owned in some part by the community, and due to the decline of many other local assets such as shops, banks and post offices, they act as centres of the community. Therefore NHS 24 Local would utilise these spaces and provide the Attend Anywhere software and automated dispensing machines that provide medication to be based here.

The ambassadors will be a person present in the community who has a strong understanding of existing local health services and the needs of the community. This would be a flexible role that would shape to the health needs within each community.

Local Profile Finally, to ensure NHS 24 have an increased awareness of the geographical and social setting within these areas, local profiles will be created to ensure accurate and supportive information is given out during both 111 calls and on their online services. It would therefore be building upon the current knowledge management system they use.

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people places events ecosystem So these three aspects would work together to create an ecosystem of people, places and events in local areas that create a greater sense of locality to NHS 24’s services and how people are enabled to experience collective health management.

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community spaces Looking at community spaces, they would be central to how NHS 24 Local would run and the delivery of more localised support networks. According to the Scottish Government, around 80% of community spaces are owned in some part by the community, and due to the decline of many other local assets such as shops, banks and post offices, they act as centres of the community. Therefore NHS 24 Local would utilise these spaces and provide the Attend Anywhere software and automated dispensing machines that provide medication to be based here.

Providing Attend Anywhere here would be particularly important for an ageing population in rural and remote areas, where many people may not own computers or the software needed to facilitate this at home but need more regular access to appointments to manage their health. Following these remote GP appointments, they can pick up their prescriptions from a dispensing machine that is based outwith the building.

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local ambassador Their roles would cover facilitating the services offered at the community space, being a present source of support in the community and having a strong local knowledge of the current services available in their area and working towards creating new events and support networks. They would sign up to become an ambassador through accessing the NHS 24 Local section of NHS 24’s website. There would be both voluntary positions and paid positions available, depending on the need and demand in the area. When first signing up they would receive a welcome pack delivered to them at home, with information on their new role, resources they may find useful, ways in which they can recognise health needs in their area and create new health connections amongst the community. The benefits of signing up as an Ambassador would be to receive local incentives such as a NHS 24 Local discount card, that would allow them to access discounts at various stores. For example, this could be at shops such as the Co-op.

One of the most important aspects to NHS 24 Local is the creation of Local Ambassadorial roles, which would enable these social and collective journeys to form. These roles would be open to anyone within the community to apply for. Ideally, these positions would be promoted towards younger people who have the digital skills needed to support those using the Attend Anywhere facilities and to promote intergenerational connections within the community. This would act as valuable voluntary experience, or paid work in larger areas.

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#1 scenario

Attend anywhere This system can unfold in different ways within the community. For example, ambassadors can be available to help people to use the Attend Anywhere package at the community space. They can also be present to guide people through how to access the dispensing machines for medication and picking up prescriptions. The dispensing machines would require them to enter their Community Health Index number to dispense the medication. Minor ailment medication and repeat prescriptions can also be picked up from this point.

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“I don’t get out of my home as much as I used to. Is there anything happening locally I could attend?”

“Did you know that there is a weekly meet up that runs in the community hall?”

Local Ambassador

#2 scenario

Specific events and preventative health workshops can be tied into this. This gives the Ambassador an opportunity to begin to understand the health needs in the area they work within, and try to fill in gaps in health support.

Part of the role of the Ambassador would be to support emerging health needs in the area they work within. For example, they may notice that in their area there is a high number of elderly residents who live alone and are increasingly socially isolated. Therefore, they may set up a weekly meet-up in the nearest local community space for people to discuss issues relating to their health, facilitating a new way for people to connect regularly and feel supported. This can also be a space for the Ambassador to recommend other local services they may benefit

For example, if someone in the community has a specific health issue, such as diabetes, but there is no current support network in the area, the ambassador can link them to other people in the area who have the same condition. This can enable and support collective health management.

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#3 scenario

Home delivery Another way this can unfold within the community, is supporting those who are elderly in picking up prescriptions and medication from the community space’s dispensing machine and delivering it to their home. This can be where people in the community look to the Ambassador as a local point of support, who they can call and request this to happen. This aids the idea that there will be an increasing number of elderly people who may need more prescriptions and support.

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local profile

So for example, when someone calls 111 with an issue that requires self-care, the call handler can utilise a local profile related to the person’s post-code, and point them in the direction of their local community space and ambassador. This could be to find out about local support groups and events or using the dispensing machines. In turn, this would build a more trusting and supportive relationship with NHS 24.

Another aspect of this role would be to provide a more detailed profile of the area that the Ambassador works within, this would enable more accurate information to be provided by NHS 24 during 111 calls and supportive information relevant to the area. This profile would consist of information such as any issues with public transport, the support provided at the community space, who the local ambassador is and local policies.

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conclusion To summarise, this NHS 24 Local system will facilitate a shift from people in rural and remote areas feeling increasingly geographically and socially separated from support that ensure health management, by introducing more accessible touchpoints that begin to become a part of their everyday lives and create a new sense of collective health management. This system utilises people and places to create a framework that can shape to the needs of each individual rural and remote area. There are opportunities to build upon our proposal, perhaps by utilising existing voluntary initiatives such as First Responders, to create a pool of volunteers who already take on a role of responsibility within their communities. Overall, we see this system as one that could take shape differently within different communities, depending on emerging health needs and concerns but ultimately it would act as a more accessible point of support within the community facilitating social, collective journeys.

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NHS 24 Local: Alternative Now  
NHS 24 Local: Alternative Now  
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