WSDAN Roadshow 30 June 2010 - round-up of presentations
Prepared by Mike Clark for WSDAN
All slides at:
1 Telecare and telehealth – economic issues
Professor Martin Knapp (email: )
London School of Economics and Political Science (Personal Social Services Research Unit (PSSRU))
The economic questions
Following on from the recent WSDAN events in Manchester and Stansted, when Stan Newman and Anna Davies covered aspects of telecare and telehealth evaluations, we were pleased that Martin Knapp, another member of the WSD evaluation team, joined the Newcastle Gateshead event to discuss some of the economic issues facing organisations currently implementing technology-based services.
In introducing his presentation, Professor Knapp considered the developing context, which is one of growing user and patient needs, rising aspirations, real budget cuts, and widespread calls for greater efficiency.
When looking at specific developments in health and social care, economists ask themselves the following questions:
· What does it cost?
· Will it pay for itself?
· Is it worth it?
To consider this in more detail, Martin Knapp posed a series of further questions: do interventions such as home care, extra care housing, case management, community health care, telecare and telehealth lead to improved outcomes such as independence in daily living, improvements in quality of life for users and carers, and behaviour changes for people with long-term conditions? Do these interventions and outcomes also produce cost savings, eg, lower use of health and social care services? An example of a potential saving may be in the future use of health services or in a carer being able to return to work.
The cost question becomes more complicated when people with long-term care needs are involved, as they need access to a range of co-ordinated services from different providers, which are often derived from different budgets.
At a time when budgets are being tightened, the cost offset issue becomes more important. Decision-makers are looking to see what will happen to overall expenditure by rolling out a new service. An important question is: can the costs of services be offset by savings? Sometimes the biggest impact is in another area of activity.
When it comes to cost-effectiveness, if the clinical/care question is ‘does this intervention work?’ then the economic question is ‘is it worth it’? This is the approach taken by organisations such as NICE (National Institute for Health and Clinical Excellence). It includes examples where costs could be higher but the outcomes are greatly improved.
For long-term conditions, economists are interested in the costs, outcomes and impact over the long term. This often means that some form of modelling is necessary to consider the cost-effectiveness beyond the typical 3–12-month research period.
One recent literature review (Bergmo 2009) provides some indication of progress with establishing the cost-effectiveness of telehealth. However, the evidence is limited.
Bergmo (2009) ‘Can economic evaluation in telemedicine be trusted? A systematic review of the literature’. Cost Effectiveness and Resource Allocation, vol 7, no 18,
Areas to beware of
Professor Knapp considered that the financial context is now more challenging. There is an urgent search for affordable, efficient, cost-effective ways to meet needs, but organisations need to beware of the following:
- There has been much emphasis on the 3 Es over the years – economy, efficiency and effectiveness – but not so much on equity. This is important, as people with long-term needs and conditions are disproportionately represented in the lower socio-economic groups.
- It is important to focus on outcomes (the impact on people’s health, well-being and quality of life) and not solely outputs (eg, how busy you are, how many people are supported by telecare or telehealth).
- Retrenchment could encourage retreat into narrow self-interest (‘silos’), whereas many service users and their families have wide-ranging and multiple needs. Individuals are interested in improving their lives and are not concerned with the boundaries between services. There is a growing emphasis on joint working and co-production to provide a wider range of support and services. It will be more difficult to break down silos as budgets get tighter.
- Keeping a long-term view is important – hard-pressed decision-makers may be more concerned with short-term pay-offs rather than long-term results. User needs are long term, so services need to be structured accordingly. Some initiatives may be ‘cost increasing’ this year but ‘cost-reducing’ in the future (for instance, NICE will try and look at longer-term impacts).
- Research is usually expressed in terms of averages (the ‘average user’ or ‘average patient’). However, it is important to understand individual variations in outcomes and costs – people are spread very widely around the average. Services cover the whole span of people and their needs, whereas research programmes will often restrict access for various reasons.
- Many research samples in the telehealth/telecare areas are too small (eg, because of expense). This makes it quite difficult to generalise from the results. ‘Cost-effectiveness’ studies require larger samples than just ‘effectiveness’ studies.
- It is easy to suggest that another (untested) approach is better, without providing sufficient evaluation or evidence. Technological change is needed, but it must be evidence-based.
- Finally, it is important to be wary of luddites (eg, some people will see extra cost or risk associated with initiatives), lobbyists (eg, commercial, voluntary sector or user groups, who may cherry pick results from recent literature to support their case), ‘snake-oil’ sellers and obsessive scientists (important to have good research). Research should be valid, impartial, pragmatic, proportional, ‘good enough’, generalisable and well communicated.
2 Telecare in Scotland – Progress and shared learning
Telecare Programme Manager
Joint Improvement Team (JIT), Scottish government
Background to the programme
The Telecare Development Programme in Scotland commenced in 2006. Its main aims are:
- to help more people in Scotland live at home for longer, with safety and security, by promoting the use of telecare
- to provide the foundation on which telecare can become an integral part of community care services across Scotland.
The initial objectives included increasing the overall number of telecare service users, including people with a diagnosis of dementia. In addition, the programme aimed to reduce care home and hospital admissions as well as improving the quality of life for users and reducing the pressure on carers.
Following initial and updated business cases in 2006/7 (based on the Northamptonshire and West Lothian studies), a telecare strategy was developed in 2008. This covered some of the areas that needed to be developed nationally, eg, training, standards, assessment and review practices. Services have been subject to considerable monitoring and review since 2006 (eg, York Health Economics Consortium (YHEC) evaluation 2008, and annual progress reports by Newhaven Research). Strong governance arrangements were established from the outset through the gateway review process. Additionally, the Scottish government and partnerships have learned from a recent carers report with Carers Scotland and Sue Yeandle (University of Leeds).
By March 2010, all 32 local partnerships were implementing telecare programmes. More than 29,000 people had received telecare services, with £10 million of the £14 million allocated (75 per cent) being spent. Additional users have been recruited through match-funding arrangements. Self-reported, indicative gross benefits have been estimated at around £48 million. These are based on the partnerships’ experience of what would have happened to a person if they had not installed a telecare service.
There has been positive feedback from users and carers (see appendices to YHEC report on the JIT website). Partnerships set their own local targets, and monitoring activities show progress on outcomes and efficiencies.
Quarterly telecare learning network events, survey questionnaires and other communications are used to gather data and disseminate information on progress.
There needs to be a healthy balance between mainstreaming and innovation, including convergence with telehealth. Three demonstrator projects are under way in Lothian, Lanarkshire, and Argyll and Bute.
Some sites are carrying out ‘health at home’ monitoring (eg, Argyll and Bute, Lanarkshire, and Lothian), prevention and management of falls (Falkirk, Ayrshire, Perth and Kinross), development of local training and awareness raising (Fife, Edinburgh, Falkirk) and housing and care models (Highland, Inverclyde, West Lothian).
Practice guides are available for some areas of activity, eg, learning disabilities.
A recent self-assessment survey (March 2010) has established the extent to which organisations are planning on mainstreaming their services as government funding ends. Sixty-six per cent report that local telecare services will grow once the funding has ended. Around 50 per cent are planning investment in call centre capacity, with 53 per cent planning investment in responder services. Sixty-three per cent considered they were reducing care home admissions, while 66 per cent were phasing out or reducing sleepover or wakened nights cover. Significant numbers of sites had included telecare within their strategic planning documents, although there was still scope for progress. Partnerships were also ensuring that processes and protocols were in place to cover eligibility, assessments and reviews, maintenance, and response services. Around 22 per cent of sites were considered to be at or near the point of mainstreaming, with 63 per cent progressing towards this aim. Around 15 per cent of partnerships were still operating on a pilot basis.
A number of challenges remain in Scotland:
- There is a need for a more co-ordinated strategy as well as leadership and investment at both local and national levels.
- In some areas, there is still a project mentality, instead of seeing a significant opportunity for service redesign.
- There is a need for greater integration of equipment and data.
- Some programmes were initially slow but are now gathering momentum.
- Telehealth and telecare are at different stages – there is a need for more integrated community services.
Overall, a great deal of progress has been made since 2006/7.
Priorities for 2010/11
The priorities for 2010/11 include the following:
- Reaching a further 13,000 service users (at a cost of approx £120,000) – but with ‘telehealthcare’ now rather than ‘telecare’. Again, partnerships are matching funding at a local level.
- The development of a five-year action plan for telehealthcare with the Scottish Centre for Telehealth/NHS 24 linked to key policy agendas.
- Implementation of a telehealthcare education and training strategy.
- Identifying options for more effective procurement.
- Embedding telehealthcare within care pathways (eg, dementia, falls, management of long-term conditions, medication management, support for carers)
- Continuing to monitor progress and share evidence.
- Exploring funding opportunities to develop ‘at scale’, integrated service design.
For more information about the programme, visit the JIT website: www.jitscotland.org.uk/action-areas/telecare-in-scotland/
3 Telehealth Regional QIPP Programme (Yorkshire and the Humber)
Paul Rice ()
Associate Director Care Partnerships, Regional Telehealth Lead
Yorkshire and the Humber Strategic Health Authority
A high-performing chronic care system
Paul Rice made reference to Chris Ham’s ‘Ten characteristics of the high-performing chronic care system’ in setting the context for his presentation. These include the following:
- Priority is given to patients to self-manage their condition with support from carers and families.
- People with chronic diseases should be stratified according to risk and offered focused support commensurate with risk.
- Care should be integrated to enable primary health care teams to access specialist advice and support when needed.
- The potential benefits of information technology should be fully exploited.
- Care should be effectively co-ordinated.
- These characteristics should be linked into a coherent whole as part of a strategic approach to change.
Technology should be part of a comprehensive and sophisticated solution for the management of people with long-term conditions. Technology was not a substitute for people-based case management but would help in refining such programmes. Service reconfigurations would be an important factor going forward, together with the incentives and reimbursements that drive whole-system change.
Chris Ham (2010) ‘The ten characteristics of the high-performing chronic care system’. Health Economics, Policy and Law, vol 5, no 1,
Paul described the current progress in the region as a ‘living lab’ – a mixed economy. Two of the organisations have moved to large-scale deployment of telehealth (North Yorkshire and York, and Barnsley). A number of other organisations are in the ‘post’ pilot phase (50, 100, 150 telehealth users). Little work has been done on co-morbidities – people have tended to segment patients into single long-term conditions. As with telehealth, there will be a span of deployment activity for telecare.
Work is being carried out across the region to bring together services, system suppliers and change management resources. The main components of the regional QIPP (Quality, Innovation, Productivity and Prevention) telehealth programme are:
- change management
- service and technology
- hub services
There must be new efficiencies, including moving away from old systems of working. It must be a comprehensive and sophisticated approach. Any one of these elements on its own will not secure success.
Main areas of interest within the regional telehealth programme include:
- telemedicine/TEMPiS (Telemedic Project for Integrative Stroke Care) focusing on stroke (video-to-video resources)
- teleconsultation – focusing on high-intensity users and co-morbidities
- telemonitoring – focusing on high-intensity users, COPD, CHF, diabetes
- telecoaching for supported discharge – focusing on long-term conditions
- e-care planning – focusing on long-term conditions
- medicine compliance – focusing on long-term conditions
- social networking/wellness and behavioural feedback – focusing on long-term conditions.
Although of interest, some of the latter items are not currently financially supported.
A telemonitoring service model has been developed that considers how users/patients are recruited through risk stratification, predictive modelling and patient segmentation.
The ‘emerging offer’
From the work carried out across the region, an ‘emerging offer’ has been developed, which includes:
• full spectrum of high-tech to low-tech telehealth required
• high-end telemedicine resource valued but not vital (TEMPiS valued+vital)
• initial focus on low-tech telemonitoring to deliver quick wins, cash-releasing savings – opportunity for scale and pace, building on local visions and concrete plans
• credible weighty regional partner to attract commercial sector and cross-government investment in conjunction with business and local authority partners
• expertise in change management, procurement, business case development, evaluation and technical interoperability
• need to integrate technology into workflow management and realign the rewards and incentives.
Provision of a regional ‘hub’ resource
Some of the areas being covered at regional level include:
• predictive modelling and risk stratification tools to identify high-risk and high-volume users
• intelligent procurement with ‘risk sharing/incremental cost’ models developed with suppliers
• local/sub-regional telemonitoring centre(s) to allow PCTs to join patients to proven service models at incremental per-patient cost
• regional co-ordinating centre to act as umbrella to co-ordinate change management, learning and support
• horizon scanning of technology-enabled care; QIPP opportunities for patients with multiple co-morbidities
• consistent evaluation methodologies/research, education, training and workforce development collaboration
• resource to promote and publicise regional activity and attract inward investment
• regional procurement of high-end video consultation capability for ‘virtual outpatients’ model – triage/specialist nursing/consultant physician – 24/7/365
• technical interoperability to ensure incorporation of telemonitoring information and ‘end-to-end’ patient care record/plan
• credible return on investment models to enable ‘cash-releasing’ savings (beds and workforce) to be identified and secured.
4 Heart failure telemonitoring in Hull: saving lives, improving care
David Barrett ()
Lecturer in Telehealth
University of Hull
Heart failure (HF) is the failure of the heart to pump the volume of blood required to meet the body’s demands. As many as 1 million people in the UK may have heart failure, and it accounts for approximately 2 per cent of all health care costs. Patients hospitalised with HF have a 23 per cent chance of readmission within 30 days of discharge, and the five-year mortality rate exceeds 40 per cent.
Telemonitoring (the remote monitoring of signs such as weight and blood pressure together with monitoring of symptoms using technology) can be very effective in supporting people with heart failure. In the TEN-HMS (Trans-European Network-Home-Care Management System) study, one-year mortality fell from 45 per cent with ‘usual’ HF care to 29 per cent in telemonitoring patients. A 2009 meta-analysis concluded that remote monitoring reduces mortality and hospital admissions, and a 2010 Cochrane Review is expected to reinforce the benefits of remote monitoring.
Cleland et al (2005) ‘Non invasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death’. Journal of the American College of Cardiology,
Polisena et al 2010 (‘Home telemonitoring for congestive heart failure: a systematic review and meta-analysis’. Journal of Telemedicine and Telecare,
The potential benefits of telemonitoring
The potential benefits of telemonitoring for heart failure include:
Improved clinical outcomes
– early recognition of deterioration
– increased speed of medication titration
Improved quality of life
– enhanced understanding of condition
– reassurance from clinical support
– reduced health care utilisation
– workload optimisation
The heart failure telemonitoring service in Hull was originally supported by research funding and is now funded through NHS Hull. Products used for heart failure monitoring include Tunstall Genesis and Philips Motiva.
Headline activity information
The headline activity information from the current Hull heart failure programme is as follows:
• More than 100 patients were receiving telemonitoring by the end of 2009/10.
• The total number of patients who have benefited is approaching 200 (in addition to those recruited to TEN-HMS).
• Set against registry data, the service has saved around 0.1 all-cause admissions per patient per month.
• Around 84 all-cause admissions were saved between July 2009 and March 2010.
• An estimated net saving from the service of more than £46,000 in 2009/10, based on reduced all-cause readmissions alone.
The way forward
The aim is to use a wider telehealth approach in future, not solely telemonitoring. There would be closer links with long-term conditions services and telecare. The aim would be to provide person-centred care. In addition, a quality of life study is planned, together with increasing the robustness of the financial savings model.
5 Telemedicine – Outpatients and beyond
Richard Pope ()
Airedale NHS Foundation Trust
Richard Pope covered two areas – prison health care using telemedicine (videoconferencing) and the use of video-telephony in the home.
Prison health care
Health care in prisons is particularly difficult to deliver – for instance, providing access to specialist opinions. There are issues of security in taking people out of the prison environment, as well as disruption to the hospital. There are issues of dignity for the individual if accompanied by prison staff at private consultations. Costs are high for taking people out of prisons. PCTs have a vested interest in getting a grip on the costs of these services.
Telemedicine can help in the prison environment, but it is only in recent years that it has taken off because of the availability of videoconferencing facilities.
Following prototyping in HMP Full Sutton, the prison health care programme is now live in eight prisons. It will be extended further throughout 2010. It no longer matters where the prisoner is and where the doctor is – they can be one mile apart or 250 miles apart. The equipment is an off-the-shelf, videoconferencing set-up, with an additional high-resolution camera for looking at wounds, etc.
In 2009, 550 elective calls were dealt with – the vast majority were assessed or treated without transfer. A number of recognised specialties are covered such as teledermatology and, most recently, physiotherapy services have been provided. There is very high patient satisfaction with the process. There is continuity of care in cases where people move from one prison to another. Staff satisfaction is also high. Costs are reduced (the saving is a minimum of £300 per case) and there have been no clinical incidents. Far fewer cases were dealt with as emergencies compared with elective consultations.
Challenges and next steps
It has been a very difficult journey. There is a lot of red tape to work through in the prison service. There are differing levels of acceptance for a new way of working. It has taken five years to achieve the progress to date. It is important to deal with consultations in a timely way to meet targets. Different relationships have had to be developed with different trusts around the country as the programme has been rolled out.
There are opportunities to extend the programme to cover teaching, podcasts and links to health records. The role of telemedicine in stroke is another area that can be developed.
The second area covered by Richard Pope was a project funded by ALIP (Assisted Living Innovation Platform, Technology Strategy Board) on video-telephony for use at home. The television is used as the display device with a standard broadband link that allows telemedicine consultations covering potential hospital outpatient and urgent care services.
The ‘mark one’ version is being deployed and is already in use for diabetes. The ‘mark two’ version is an improved design of the set-top box. Plans are in place to test this with 120 people from late summer 2010. This will allow the scheduling of outpatient activity and the provision of information prescriptions through the TV.
The response system requires outward-looking clinicians who are able to deal with problems that may arise. Other applications could include nursing homes, post-op checks, and paramedic home visits, with links to an A&E consultant for decision-making. Other modalities can be overlayed, eg, social support, and contact with family members.
A blended solution is needed, where patients are able to take control of their records with improved understanding of their conditions and the range of responses from health services.
The electronic shared health record becomes the glue to hold the different telehealth approaches together.
Although some UK sites are working towards 2,000 patients using telehealth, this is still only small scale. There needs to be a critical mass of activity. Some form of co-ordinating centre or hub is required to operate at scale. When it comes to managing change, the key issues are often about culture rather than technology – system change is a huge challenge. Some modelling with YHEC (York Health Economics Consortium) suggests that a COPD patient with two to four admissions per year could yield a net £4,000–5,000 saving per year from the system being developed.