Dr. Claudia Pagliari, Senior Lecturer in Primary Care, University of Edinburgh

In the UK patients with cancer are generally well served in terms of access to palliative care services, including hospice facilities. There is less provision for people with other terminal illnesses (e.g., COPD, heart failure) and the very elderly. This is partly due to strategic prioritisation by the National Health Service (NHS). Specialist home care for patients with terminal illness tends to be provided by non-profit organisations such as the McMillan Trust and the Marie Curie Foundation, which provide trained nurses. Supply of these nurses is insufficient to meet demand. Changes in the organisation of out-of-hours primary care services in the UK mean that patients are unable to access their own general practitioner out of working hours and are instead routed to a call-centre- based telephone triage service. This raises issues around continuity of care that may be particularly acute for those with terminal conditions.

In the homecare context, telehealth tools have the potential to provide both practical and social support to patients and carers as an addition to face-to-face support from health professionals. They may be particularly useful for accessing primary care services out of usual working hours and for those in remote locations. For the health professional, they can offer a means of obtaining peer-support, accessing evidence-based medical information and monitoring patients remotely. Video-supported interactive telehealth tools offer certain advantages over telephone support, such as the value to the patient of seeing a human face (especially if mental impairment is an issue) and for the professional of being able to see a patient's expression or observe some practical task being carried out. However limitations include the fixed location and cost of equipment as well as privacy issues. Computerised symptom monitors, home-based sensors and drug dispensors may also play a role, although these have not been widely exploited in the UK. Increasingly centralised and web-based electronic health records are likely to become more useful as a means of improving interdisciplinary palliative care in the community.

UK experiences of telepalliative care delivery are still limited, although there are groups delivering telephone-based palliative care services. A recent qualitative study by members of our group (Worth et al BMJ 2006: 56:6-13) explored the responses of cancer patients, carers and professionals to the new centralised NHS out of hours telephone service, which questioned the ability of such generic services to meet the primary care needs of palliative care patients (e.g. perceptions that it as impersonal).

We are planning to mount a multicentre trial of home video-visits by palliative care nurses and are currently consulting with key stakeholder groups to assess the acceptability of such a system in preparation for this.

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