The History of Telemedicine in the UK

Date

2021

Advisors

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DOI

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Publisher

International Society of Telemedicine and eHealth (online)

Type

Book chapter

Peer reviewed

Abstract

Introduction The United Kingdom (UK) is located on the north-west extremity of the continent of Europe. In 2018 it had a population of 66.4 million people [3]. The UK is an island nation comprising Great Britain and Northern Ireland. Great Britain is made up of the three countries of England, Scotland and Wales. Northern Ireland is part of the island of Ireland to the west of Great Britain. The UK was the world’s first highly industrialised country. This industrialisation largely took place in the eighteenth and nineteenth centuries and was characterised by scientific advances in agriculture, manufacturing, shipping and other sectors. Relating to these was the occupation (or colonisation) of various territories across the world and the position of the UK as a major player in international trade. The ‘British Empire’ brought considerable wealth to the UK as well as political and cultural influence. The UK has subsequently experienced significant decline. However, links with many of the occupied territories remain within a grouping, established in 1931, known as the Commonwealth. These territories have been the source of much inmigration to the UK and have increased the UK’s ethnic and cultural diversity. The Commonwealth is described as a ‘voluntary association of 53 independent and equal sovereign states’.
This is the context within which the UK is re-defining its place in the world. Its industrial, political and cultural prowess has diminished, leaving a legacy that includes both wealth and relative poverty - with the latter often co-existent with social problems, poor housing and health inequalities [4]. Aspects of this legacy may be exacerbated by the UK having left the European Union [5]. And whilst the scourge of some earlier poverty-related health challenges in the UK (such as tuberculosis and scarlet fever) have been largely overcome, for many people today there are health challenges that relate to relative poverty, low incomes, poor housing and unhealthy lifestyles; and some illnesses, long-term conditions and disabilities that are associated with what has, until recently, been steadily increasing longevity. But despite the extent of inequality and the persistence of relative poverty within the UK, its economy in 2017 (in terms of Gross Domestic Product, GDP) was the 6th largest in the world. With regard to government expenditure on health and well-being, this comprised 9.8% of the UK’s GDP in 2018. The UK’s National Health Service (NHS) consumed the largest portion of this spending.
Coming specifically to telemedicine in the UK, its history and its impact are interweaved with the country’s industrial development and decline, together with (since 1948) both the enthusiasm and the angst associated with the advent, progression and role of the NHS. The history can be described as fitting within five phases, the fifth (associated with and triggered by the COVID-19 pandemic) having already been mentioned (see Figure below). The phases bear testimony to a ‘stop-start’ development of telemedicine that took place over a period of more than a century. A number of themes become apparent in the phases of telemedicine’s development. Two are highlighted here. The first is the ‘fact’ of telemedicine facilitating a decentralisation or ‘devolution’ of services. During the earlier phases, this decentralisation was instrumental in bringing greater service accessibility throughout the UK. Such decentralisation is seen as an ongoing process which necessarily created (and creates) stresses and strains for pre-existing frameworks – raising important questions about the role of the main institutions of healthcare, most notably hospitals. Telemedicine is disruptive. It joins, therefore, other disruptive aspects of health and medicine such as that which relates to workforce change as pointed to in the work of Christensen et al [6]. But Lynch and Fisk [7] noted their work as failing ‘to extend the logic of their argument to points of care that were beyond the local clinic’. In other words, decentralisation was seen by Lynch and Fisk as needing, facilitated through telemedicine, to go further – with the process ending with individuals. Us. The second theme is concerned with the ways in which we are empowered through telemedicine and, emboldened by greater self-awareness and health knowledge, are able to take a bigger role in our healthcare. With empowerment comes changing relationships between

Fig: Phases of Telemedicine Development in the UK

health professionals, practitioners and ‘their’ patients. Here, the word ‘their’ is used reluctantly (and is, in fact, superfluous) because part of the change in relationships is one where empowerment means that the transactions between patients and their service providers will, in the future, need to be recognised as one of greater equity. Is ‘empowerment’, in any case, the most apt of themes? Morley and Floridi argued instead for ‘enablement’ and suggested that ‘promoting digitally enhanced, empowered health care as a techno-utopia is misleading’ [8]. But this chapter suggests that enablement is not enough. Empowerment is considered to give us something more. Empowerment speaks to the way in which we must configure our health services (and a lot more in terms of public education) in order to help build people’s health literacy and motivate us all in relation to the adoption and maintaining of appropriate lifestyles. This chapter calls, therefore, for telemedicine to take a recognised and meritorious place within the range of the UK’s health services, part of which requires a further shift in the balance between, what Morley and Floridi refer to as ‘agency and patiency in (the) doctor-patient relationship’ [8]. Finally in this introduction, it is very worthy of note that the two main themes identified for telemedicine echo two of the United Nations sustainable development goals (SDGs) - Goal 3 (Target 8) which focuses on ‘access to quality health-care services … for all’; and Goal 10 (Target 2) which seeks a reduction in inequalities and to ‘by 2020, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or any economic or other status’. It can be noted, at the same time, that NHS Digital (a branch of the NHS) is concerned to ‘empower the person’ through ‘improved digital access to health and care information and transactions’ and by ‘developing digital technologies that put people in charge of their own health and care’ with apps and ‘personal health records’ part of their focus.

The Five Phases The first phase of telemedicine’s development in the UK extends from a starting point around the 1840s to the outbreak of the First World War in 1914. It was, in large part, a period of rapid industrial development with (for industrial entrepreneurs, engineers and technologists) innovation taking place in multiple sectors – from textiles to transport. But the period, whilst bringing wealth to the UK, was accompanied by the twin scourges of poverty and ill health. Hence it would be surprising if some element of the entrepreneurship and industrial endeavour did not address (poor) health and consider the means of its amelioration. The stimulus for endeavours in this direction were not, however, just philanthropic and/or commercial. They were also self-serving. Many diseases were not respecters of geographical boundaries. The wealthier and generally more educated classes (amongst whom were most of the entrepreneurs) were not immune to having some contact with the poorest, nor to the foul miasma (perceived as carrying infections) that might drift into their neighbourhoods from squalid areas nearby. The second phase extended from the end of the First World War (1919) to around 1970. It covers the whole of the interwar period (including the period of the ‘Great Depression’) and the main period of economic recovery after the Second World War. After the First World War it was still the case that much of the UK population lived in insanitary housing – whether in urban or rural areas. It was with the promotion of better health in mind, therefore, that the then Prime Minister, Lloyd George, called (in reference to the returning soldiers) for ‘habitations fit for heroes’. This heralded a municipally-led house-building programme with accompanying attention to ridding the country from at least some of its slums. But for telemedicine, the inter-war years in the UK (from 1919 to 1939) can be regarded as ‘fallow’. There was little or nothing that might be viewed as a stimulus for telemedicine development. Rather it is the reverse. The health focus was on regularising the roles of doctors and nurses; and establishing and embedding service norms that we see to this day around hospital and GP services. Meeting the needs of patients, furthermore, revolved around the ways that people interacted with the services rather than how the services reached out to them. Besides, telephony networks were poorly developed and telemedicine, if it were to have been considered, could have only involved communication from clinician to clinician or with those patients able to pay for services.
The Second World War meant, of course, that attention to public health issues were put ‘on hold’. But the years that followed the war (from 1945) were very important from a health perspective. They were characterised by an optimism that brought the UK, not just its now iconic NHS, but also other welfare reforms including a national insurance scheme and planning reforms that underpinned the development of ‘new towns’. Such reforms were associated with a sincere and urgent belief among politicians that the people of the UK, after the deprivations of the war, deserved to be able to live better lives and, importantly, access better health services. The impact of the NHS, from the date of its foundation in 1948, cannot easily be overstated. It brought access to health services for all. Its establishment opened a relatively ‘settled’ period for health services where even the most enlightened entrepreneur and innovator might have seen little merit in devoting energy on developing technologies that resembled what we now recognise as telemedicine. The focus of health practitioners was on the establishment and operation of new administrative arrangements in a context of benefit for families and individuals, rich and poor alike. Hospitals became focal resources in every city and GPs became integral to life in every community - with the latter especially being romanticised or immortalised in literature and film. The third phase starts around 1970. Significant from the health perspective was the fact that along with expanded telephone networks, telephony based warden-call ‘systems’ (later more generally known as social alarms, then featuring a part of telecare) were becoming a feature in schemes of municipal housing for older people. These enabled wardens (supervisors and ‘good neighbours’) to be alerted, normally through the pull of a cord, in urgent situations – e.g. after a fall [9]. The image of the ‘fallen’ woman was commonplace at this time in the literature of the companies who marketed such systems (see Plate 1). In this phase, with the ensuing advent of ‘carephones’ (that could be installed in any home with a telephone line), older people could link, with

Plate 1: The ‘Fallen Woman’ Brochure promoting the private Aid Call service, Moreton Hampstead.

the pull of a cord or the push of a radio trigger, to monitoring (call) centres. Systems that had operated within housing schemes became more community-oriented ‘services’. The number community (or social) alarm services increased quickly in the public sector with 301 operating in the UK by 1990. These were driven mostly by the need to give ‘out of hours’ cover for wardens [10]. There were just a handful of services in the private sector. The more recent evolution of such services (see Phase 4) started to bring such services into the wider world of telemedicine. Commencement of the fourth phase can be pinpointed to 1998 – with the publication of the NHS strategy report for England and Wales, ‘Information for Health’ [11] and both the ‘Information Management and Technology’ report and the ‘Acute Services Review Scotland’ [12]. These key reports heralded the greater use of information technology (IT) within the NHS – including promoting the taking of initial steps to develop electronic health records; facilitating the transferability of images and data between hospitals; and the overcoming of what were referred to as ‘data islands’ (i.e. silos). The reports also presaged the establishment of NHS Direct (from 1999), NHS Direct Wales (from 2001) and NHS24 (from 2001) in Scotland. The date of 1998 happened, in addition, to be the fiftieth anniversary of the foundation of the NHS.
The public telephone network was, by this time, extensive - though it was several years before the Internet begun to make its mark on businesses, let alone being accessed by large numbers of people from their homes. It is, nevertheless the time at which there were new, and strong, stirrings around telemedicine. The transfer of images was, for instance, an aspect of telemedicine that was increasingly in use, albeit that this novel aspect of telemedicine was not in ‘real-time’ and did not involve access by patients. NHS Direct (and its variants in the UK) was, by contrast, a new ‘real-time’ telemedicine service - though perhaps not widely recognised as such. It directly responded to patients with an almost infinite variety of concerns. It was proving a success. This fourth phase steadily became characterised by many, many more telemedicine pilots and initiatives in the UK. These related to a range of different health conditions. A key focus was on services specifically responding to the needs of older people - seen as those for whom interventions might give the biggest ‘wins’ in terms of time and cost savings. And while attention, in the evaluations of such pilots and initiatives, was given to the financial ‘gains’ arising from e.g. fewer hospital visits and admissions, shorter ‘bed days’ in hospitals and sometimes reduced death rates; less attention was given to broader well-being gains and/or the greater convenience for patients through the reduced need for them to travel or for them or others (e.g. carers) not needing to take time off work. In addition, but with notable exceptions - see, for instance, Wootton et al [13], little or no attention was given to the potential environmental benefits though reduced travel.
Telemedicine pilots and initiatives did not, however, take place without opposition. The oppositional positions of some clinicians and other health service professionals and practitioners were not to be easily changed. What had been little less than a magnificent contribution of the NHS in the foregoing five decades went, after all, hand in hand with bureaucracies and associated mindsets that were unaccustomed, resistant to, or fearful of change. Telemedicine was a threat to the established order. The NHS was, generally speaking, not ready to consider this threat. Besides, established NHS practices, even with their manifold inefficiencies, carried substantial public support. The fifth phase started with the COVID-19 pandemic. The shape of the NHS and of telemedicine within (or outside of) the NHS is still in large part, therefore, to be determined. Crucial will be the manner in which UK health services, the NHS in particular, responds not only to the numbers of infections (and the death toll) but also to the ongoing repercussions for many of those who have struggled to recover from the virus (i.e. relating to ‘long-COVID’). Herein lies, not so much an opportunity to be grasped by those who favour telemedicine’s further development, but rather a context in which there is growing realisation of it offering another, complementary way forward – linking with public health imperatives that have necessitated a reduction in the extent of personal contact with patients.
What is certain is that we are at the early stage of a transition that will represent the biggest and most profound since the establishment of the NHS. Old affiliations and loyalties will be tested. Some will be broken. New ways of working that hold onto some of the caring and personal nature of our traditional health services, albeit mediated through IT, will be found. Finally, with the NHS facing a time of dramatic change, it can be anticipated that the ‘balance of power’, as health services are further decentralised, will shift away from clinicians. New service norms, that hold on to what is good in the NHS and which include telemedicine, will become established. In the meantime, this chapter attempts to do justice to the multi-faceted nature of telemedicine’s emergence … from its technological roots through the embedded nature of the UK’s health services, to an uncertain future that may be very different to that which has been previously envisaged.

Description

Keywords

Telemedicine, Telehealth, Telecare, mHealth, eHealth, Smart Homes, Lifestyle Monitoring, Activity Monitoring, COVID-19, Health, Social Care, Empowerment

Citation

Fisk, M. (2020) The History of Telemedicine in the UK. In: Jordanova, M. and Lievens, F. (Eds.) A Century of Telemedicine: Curatio Sine Distantia et Tempora. A World Wide Overview: Part IV. Basel: International Society of Telemedicine and eHealth.

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Research Institute

Centre for Computing and Social Responsibility (CCSR)