Special Report: Mobile and remote working in the community


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Everybody can see the case for getting community nurses and other staff mobile; but there have been significant barriers, from resistance to new ways of working, to contracting mobile networks, to a lack of integration between the core systems to which staff need access.

Daloni Carlisle reports on the progress that some healthcare communities are making, and the challenges that still need to be addressed, with a focus on work underway in Surrey [case study 1] and Locala [case study 2].

The road to mobilising the community nursing workforce has been strewn with obstacles; sometimes it must seem that as soon as one is overcome another crops up.

A few years ago, it was nurses who were the main barrier, as they fought the adoption of new technologies tooth and nail, arguing that they could not be replaced by a computer.

Now that battle has been won, with most community nurses seeing technology as an answer to their daily battle to meet rising workloads and remove paperwork and admin from their job.

In fact, today they are more likely to demand mobile working solutions – and not just any solution but one that works for them and integrates with the wider health economy. Both are proving a challenge.

Problem: connectivity

Brian Hickey, who is head of product management for Totalmobile, agrees with this analysis. A survey by Totalmobile in September 2015 highlighted how the majority of community nurses spend less than half their time with patients and how most see mobile working as a way to improve that.

In the case of community nurses in Surrey, it’s proven true (see case study 1). But mobile working is not just about handing out the technology.

“The technology itself should not get in the way of delivering care,” he says. “It should be a tool rather than something that becomes an impediment. So we mobilise the nurse first and try to remove all the things that get between the nurse and the patient.”

The two major barriers cited by everyone in this space are connectivity and interoperability.
First, connectivity. Online working is the ideal but Totalmobile’s solution, in common with others, is designed to work offline where there is no signal. At best this is a short term fix.

Hickey explains: “We have heard about nurses in Cornwall who leave the office on a Monday morning and can spend the whole week without hitting so much as a GPS signal until they get back on Friday. That is not good enough.”

David Roots, executive director for health and social care at Civica, says this is a complex issue and tells a cautionary tale from Cardiff and Vale University Health Board, where a five year investment in mobilising the community workforce was predicated on more widespread 3G and 4G signals.

“Recent telecoms mergers have meant a reduction in the number of masts,” he says. “Because devices are locked down to particular networks, it has meant a massive project of bringing in all the devices and swapping SIM cards.”

The board is now working with the Welsh Government on making use of commercial wi-fi – a complex issue given the need to secure personal information.

He is not convinced that NHS organisations have fully understood the limitations of offline working – or how to manage it. Off the record, sources say that nurses commonly use patients’ home w-ifi when there is no phone signal.

“I’m not trying to be critical,” says Roots. “But too often we see trusts coming to the end of their national contracts and needing to focus on getting a new electronic patient record. Then they have thrown mobile working into the requirements and not fully understood it. They have made decisions based on cost and not got anything useful.”

Policy drives change

Part of this is stimulated by the government’s new models of care programme outlined in its ‘Five Year Forward View’ in 2014. That outlined two models for re-organising healthcare systems, Multispecialty Community Providers (MCPs) and Primary and Acute Care Systems (PACS).

Broadly, one builds out from GP practice while the other builds out from hospital, but both aim to provide integrated services, with a probable end goal of being funded on a capitation or list basis. Both are being tested by a vanguard scheme.

MCPs are to consist of groups of practices covering a minimum list size of 30,000. The government wants MCPs to deliver the majority of outpatient consultations, potentially run community hospitals and have admitting rights to hospitals.

The MCP vanguards are tackling this in different ways. Lakeside Health in Northamptonshire is one of the largest ‘super-practices’ in the NHS with more than 100,000 patients.

It is using TPP’s SystmOne to support its service redesign which includes an urgent care model, an ambulatory care service to divert care from the hospital front door, a long term condition management service for the frail elderly and a GP-led complex care management service.

Problem: interoperability

In his view – and it is one that is widely shared if not universally practiced – mobilising the workforce is a transformation project (see case study 2).

“We are working with Southern Health and Care Trust in Northern Ireland and the starting point is to understand the requirements of care workers,” says Roots.

They have begun slowly with a pilot project with community tissue viability nurses, who have a complex job that requires access to the care record, to assessment forms and images.

“The real challenge is getting seamless operation together from EPR through to the mobile,” says Roots. “It is a transformation project and you must understand how it is going to affect the EPR.”

Some say that the connectivity challenge will be solved as mobile network infrastructure improves. Everyone agrees that the interoperability challenge is proving a tough nut to crack.

Paul Cooper is research director for IMS MAXIMS and vice chair of TechUK’s Health and Social Care Council which last summer launched an interoperability charter that now has more than 80 signatures. He is more hopeful than most.

“What we wanted to do as a supplier community was to say ‘we want to make our solutions more open’ and as a first step to publish our interfaces so any supplier can write an interface with any system,” he says.

It’s beginning to happen. IMS MAXIMS, as an open source system, is already committed to this model; in February EMIS Health announced that it had implemented new open standards for interoperability in the NHS.

It’s a move that George Thaw, managing director of Advanced Health and Care, says is long overdue.

“As an industry we have to collaborate,” he says. Failure by big suppliers to support interoperability is a law of diminishing returns, he argues. “Ultimately the customer will walk if they do not get what they want.”

Disruption already on the way

The other trends emerging recently are the advent of the app in community working and the rise of patient information.

Commontime specialises in developing mobile app technologies, including in healthcare. Among their recent innovations is a smartphone app for mobile oncologists who work from various bases around the North West and refer patients into Clatterbridge Hospital. It is in a trial phase, but the idea is to allow mobile clinicians to refer patients electronically.

Steve Carvell, head of healthcare at Commontime, says disruption is on its way in mobile working. He predicts the end of the laptop in favour of the smartphone and tablets and points to the NHS Test Beds and the King’s Fund’s predictions of technologies that will change health and care. Wearable devices are maturing rapidly.

Pete Kerly, who is managing director of Microtech Group’s Telehealth Solutions, says it is already here. While telehealth and mobile working could be considered quite distinct, Kerly says that they are getting closer.

In Surrey, one of the largest telehealth implementations in the country, patients are managed from a central hub – but now community nurses and GPs also have access to patient-generated observations via their smartphones.

But again, interoperability is proving a barrier. “We are absolutely open to integrating our data with any clinical system,” says Kerly. “The challenge is with some of the clinical systems and with individuals in clinical commissioning groups who are not open. We have to jump through hoops.”

Mobile working in the community remains a reality for many, a benefit for some, and just a dream for others. Questions remain as to how well the lessons about clinical transformation leading technology development will be learned and the twin challenges of connectivity and interoperability will be addressed.


Case study 1
Community Nursing Service, Surrey

Community nurses in Surrey went mobile in December 2013 and now spend more time with patients and less on paperwork.
But introducing the Totalmobile solution to 350 community nurses who work in Virgin Care’s Surrey Community Nursing Service was way more than a technology project, says Marie Cummings, clinical management specialist for the mobile working programme.

Technology, she says, is an enabler for transformational change. “Our starting point was wanting to reduce the administrative burden for our staff, increase the time they spent with patients and improve patient safety,” she says.

“When we looked at our baseline data, we found that nurses were spending one third of their time with patients. That was because so much of their time was taken up chasing poor referrals or retrieving information around scheduling.”

A new end-to-end solution from Totalmobile included not just the mobile nursing solution but also referral management and on line scheduling.

Implementing all this was a major change project – and one that was clinically led, says Cummings. “We developed and fine tuned the solution in conjunction with clinicians. We had a user group, a reference group, clinical redesign groups and a group of early adopters.”

Surrey’s community nurses now spend 59% of their time with patients and there has been a 61% reduction in the time they spend inputting clinical records.

“We now have electronic forms – so all the demographic details are pre-populated, for example – and we can extract data much more easily,” says Cummings. “The feedback from nurses is really positive.”

The Totalmobile system is also integrated with the service’s back end system, RiO, and with EMIS Web; meaning GPs can tap into the community nursing data.

“We are still a long way from the 360 degree integration across multiple systems nationally,” says Cummings. “VirginCare has an exciting strategy to achieve this in coming months. Our work in Surrey is just the start.”

Case study 2
Locala Community Partnerships

In 2012, Locala Community Partnerships in Kirklees undertook a root and branch review of mobile working in the community. Today more than 1,400 clinicians and managers are equipped for mobile working.

“We started by asking our clinicians for their top ten needs in terms of information,” says director of transformation Jim Barwick. “Then we did a top ten of what people needed to receive that information. So we did the information flow first and then the kit before we did the market testing.”

Locala secured a contract with Dell to provide a managed system with a hybrid cloud service to provide access to non-clinical tools such as Skype for Business and the Microsoft suite and a secure direct line via N3 to the clinical record and SystmOne.

“It means everyone can access the information they need to do their job wherever they are,” says Barwick.

They opted for light weight, robust lap tops to give mobile workers the key boards and battery life they needed to work effectively.

Today, almost everyone who needs to be mobile now is. In addition to using the system in people’s homes, clinicians and managers now use Skype for Business for virtual meetings with colleagues in partner organisations such as the local mental health trust and local authority.

“We are also seeing community nurses use Skype for Business to seek help from more experienced professionals,” says Barwick. “So they might be at home with a person whose condition is deteriorating and set up a virtual meeting with the patient and with a therapist or senior nurse. It works very well and patients are involved in a three-way conversation.”

Barwick says there are three pieces to making mobile in the community work: culture and behaviour of staff; the design of clinical services for a mobile world; and making sure the technology does the job. “If you have all these three pieces in place, the chances are you will have effective digital mobile working,” he says.

The challenge of connectivity remains but is improving as wi-fi becomes more prevalent. Integration remains a challenge as currently SystmOne and RiO, used by different primary and community services, do not talk to each other.

For anyone setting out on a similar journey, he has a warning: do not underestimate the challenges of training the workforce and rolling out the kit.

“The logistics of swapping out the kit for 1,400 workers is no mean feat,” he says. “It requires a proper plan and takes skill.”