Pioneers and policy makers claim telehealth is the solution to solving the management of long-term conditions; but the advice is to ‘keep it simple.’
Community nurse-led telecare and telehealth projects throughout the UK are transforming the treatment of patients with long-term conditions (LTCs). Most are small scale and few have been adopted into mainstream services – but that could be about to change. The final report of the government’s £31m Whole Systems Demonstrator Programme (WSDP), due to be published in November 2011, is expected to provide commissioners with the hard evidence they need to prove the benefits will be worth the investment.
Early findings from pilots involving 6,000 patients across England have already shown that telecare can reduce unelected hospital admissions for COPD patients, improve patient care and cut NHS costs.
Telecare and telehealth have had the backing of several health ministers, including current Health Secretary, Andrew Lansley, who recently admitted that care of the UK’s 15 million people with LTCs could be improved and hospital admissions reduced if “the most innovative work being pioneered in parts of the NHS were adopted nationwide.”
While the WSDP report (the world’s biggest ever randomised, controlled trial (RCT) into telecare) is awaited, the innovators – pio- neers and policy makers – have been pitching their case at a spate of national conferences, urging nursing, health and social care managers to engage with the new technologies. Their key message: “Keep it simple.”
North Yorkshire and York Primary Care Trust (PCT) has “a huge LTC problem”, which includes 50,000 patients with chronic obstructive pulmonary disease (COPD) and unelected admissions costing £10m a year. It is one of the pioneers who has had the courage to scale up a successful community nurse-led telehealth pilot and incorporate it into the trust’s main services.
Community nurse ‘advocates’ or ‘champions’, including community matrons, district nurses and case managers, play a key role in referring patients to the telehealth service. They also act as a key point of contact for everyone involved in telecare and are able to nip problems in the bud.
Patients with heart failure, diabetes, COPD and other LTCs are provided with a telehealth unit in their own home so they can record their own blood pressure, airflow and other measurements. The readings are sent down their telephone lines to a software centre, and anything outside the normal parameter readings, reported to clinical staff for follow-up, result in a telephone call or home visit.
One myth that has been dispelled by the pilot is that patients might become more isolated and have less contact with nursing and other health and social care staff. This finding ties in with evidence from other pilots, including the WSDP.
An early teething problem experienced by the PCT was that there were too many ‘spurious alerts’ from readings, leading to unnecessary nurse and GP visits. However, these problems have been resolved and new clinical protocols have reduced them to 3%. The trust has procured 2,000 units costing £3.2m in total, which it hopes will be in use by March 2012. “We’ve had a 35% reduction in non-elective admissions and savings of £400-500 per patient,” said Julie, in reference to the 600 units that have been in use since the service was launched in August.
In a testimonial to the service, one user said: “Before the device was fitted I would worry my blood pressure was too high and whether my body could cope with the things I had to do that day. Now I feel I have the confidence to get on with my daily activities without that thought being constantly in the back of my mind.”
To encourage a greater number of referrals to the service, Julie, who helped draw up the pathways, was also involved with developing clinical guidelines for GP practices, which were published in August. “We wanted to encourage more practices to get involved with telecare, to start them thinking about it and to simplify it for them,” she said. The guidance was developed following a survey of GP practices, which revealed that many were unclear about how to start referring patients for telehealth and were worried about a potential increase in workload from managing alerts. Some GPs were also sceptical of the benefits the technology could bring to patients.
Dr David Hayward from Haxby Group Practice in York has been referring patients to telehealth since 2010, and suggests one barrier to uptake was the general feeling that new initiatives in primary care led to “a significant increase in workload”.
However, an evaluation of an early pilot at his practice found the opposite was true and, in fact, 50% of the patient cohort didn’t need to contact the surgery at all during the project. As a result of the North Yorkshire and York trust’s successful pilots, new pathways for COPD including telehealth as a normal part of the service were adopted on 1 April 2011 and are now included in acute hospital contracts.
One size does not fit all
Although telehealth can lead to increased productivity and quality, and can be inclusive, available to everyone, low cost and produce a high return on investment, Phillip O’Connell, inventor of the multi-award winning NHS telehealth innovation, Simple Telehealth (STH), warns “one size does not fit all.” He says feedback from around the country shows that some systems are technically complicated to use and have led to increased workload for staff.
The ‘Simple Telehealth’ project is designed to enable thousands of patients to take responsibility for the management of their own condition or treatment. It also allows multiple healthcare teams to share patient information and assist patients in the management of their own care. It is currently undergoing academic evaluation in multiple trusts across the West Midlands and a Health Foundation SHINE project in Stoke on Trent. It includes 800 patients and examines ease of use and clinical impact.
O’Connell says: “Early practice nurse case studies from SHINE show improved patient compliance and satisfaction and less feelings of social isolation.”His advice to anyone considering setting up a telehealth project is that they frame it over 12 months and should remember that “it must benefit the patient, provider and local health economy in line with QIPP”.
Mainstreaming in Kent
Kent has been piloting telecare since 2004 and had several successes before taking part in the WSDP pilot in 2008 involving people with COPD, heart failure and diabetes. So successful was the WSDP led by community matrons that Kent went mainstream with telecare for these services earlier this year. Now that they have a template they hope to extend telecare for other conditions and services.
Hazel Price, Programme Manager, says: “For their nurses, telecare is just another tool in the bag.” She adds: “To make telecare successful you need knowledgeable and skilled staff with the right competencies and attitude. You also need patients to regularly lay data and staff regularly monitoring it”.
Scotland telecare action plan
The Scottish government has actively promoted telecare technolo- gies since 2006, and services are gathering momentum. The country’s vision is “to support as many people as possible to live at home for as long as they want to, in comfort and safety, with the best possible health and quality of life.”
To achieve this, the government is making telecare and telehealth systems an integral part of community health and social services throughout the country, and has developed the concept of ‘telehealthcare’. This is “the convergence of telecare and telehealth to describe a range of options available remotely by telephone, mobile, broadband and videoconferencing.”
Partnerships have been set up covering every area for the provision of home-based monitoring, the lead role in many of them taken by health. These include:
- Falls management programmes.
- COPD projects.
- Home pod units.
- Diabetes monitoring.
- Fitness in older people.
The Scottish government has also spent £20m priming a Telecare Action Plan to monitor people at home, but they expect to get their investment back by 2012 and reap gross benefits of £48m, says Moira Mackenzie, Scotland’s Telecare Programme Manager.
Mackenzie says she is “waiting with baited breath” for the WSDP report, and is “very encouraged by the early findings”. In fact, she expects the RCT to tell them what they already know: “But because it’s an RCT, it will give us reassurance, overcome the barriers that have held us back and enable us to make the changes we need to make. It’s not just about cost efficiencies; we will simply not have the staff to deliver services in the way we do now,” she said.
Carmarthenshire chronic conditions management demonstrator
An integrated approach to implementing telehealth and telecare is being trialled in Carmarthenshire between the Local Health Board’s respiratory telehealth team and the council’s telecare team. Set up by the Welsh Assembly Government, the cost effectiveness of the 24-month, crossover RCT of telehealth technologies is currently being evaluated.
The service is being undertaken jointly between the Local Health Board’s respiratory telehealth team together with the council’s telecare team and monitoring centre. They are comparing two telehealth devices in 240 patients with COPD to see if telehealth reduces costs to the NHS in terms of emergency admissions, lengths of stay, A&E attendances, GP practice and community COPD specialist nurse consultations. It will also assess any differences in quality of life.
Leo Lewis, Project Director, says: “In addition, we are assessing information on the costs of installing the devices, training patients and remote monitoring; comparing two models; where the telecare team respond directly to technical issues and incomplete data leaving the clinical team to act only on medical alerts compared to a delivery model using specialist nursing staff for all monitoring.”
Long-term conditions are a ticking time bomb. It is predicted that by 2050 there will be a 252% increase in people aged over 65 with one or more. As a telehealth and telecare champion, Andrew Lansley points out: “The NHS cannot afford to stand still if it’s going to cope with these increasing numbers.” Today, between 1.6 and 1.7 million people in England benefit from telecare services, and the number is growing. In contrast, there are only about 5,000 users of telehealth services – many still in pilots. Mainstreaming of telecare and telehealth may be the only solution.
1. The King’s Fund. Technology and Telecare.
2. Whole systems demonstrator Programme Simple telehealth www.stoke.nhs.uk/simple