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Saturday 1 October 2016
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Evolution, not revolution

Feature: Telehealth

Telehealth is transforming services for patients with long-term conditions. The key message from policymakers and pioneers is 'keep it simple'. Jenny Sims reports...

Health Secretary Andrew Lansley says the NHS could help improve the care of more than 15 million people living with long-term conditions (LTCs) and reduce the number of unnecessary trips to hospital if the most innovative work being pioneered in parts of the NHS were adopted nationwide.

The number of LTCs is set to rise to 18 million within 20 years, and new ways of delivering services are urgently needed.(1) But as far as telehealth innovations in primary care are concerned, many commissioners, practitioners and practice managers are holding back. They want more evidence.

"Commissioners and providers have not been reassured their investment will be a wise one," Stephen Johnson, Deputy Director of Long Term Conditions at the Department of Health (DH) admitted at The King's Fund's telehealth summit in June, organised in partnership with the Technology Strategy Board.

That's why DALLAS (Delivery Assisted Living Lifestyle at Scale) is being set up. The DH is currently sifting through applications for the £23m project, which will involve up to five communities of 10,000 people each, including one community in Scotland, to "show how assistive living technologies and services can be used to provide top-quality health and care, enabling people to live independently."(2)

Telehealth and telecare (see Box 1) can boast plenty of small-scale pilot successes, but will they work large-scale? DALLAS and the results of the government's £31m Whole Systems Demonstrator Programme, due to be published in November, should provide some answers.

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Meanwhile, practice managers can find plenty of advice from primary care pioneers on the benefits of introducing assistive technologies into general practice, as well as the pitfalls.

The main benefits are claimed to be: reduced hospital admissions, better management of patients with LTCs, improved patient self-care and confidence, cost savings and more GP and other healthcare staff time freed up. However, some schemes have found the introduction of assistive technologies has led to increased staff workloads, with more telephone calls and patient visits, and no cost savings either.

The key message from experts is "keep it simple" – from the type of monitoring equipment and devices used by patients to the telecare communications systems used by both patients and staff.

Care-home video consultations
Dr Shahid Ali, a Yorkshire GP and the DH's Intelligence for Commissioners National Clinical Lead, is a passionate advocate of patient empowerment and is currently leading a telemedicine pilot project linking his practice with a Bradford care home.

The aim is to see how technology can provide more efficient care to patients, lead to fewer hospital admissions and save the NHS money. A high-quality audio and video link from the surgery to a consulting room at the care home enables the GP to offer a more immediate clinical opinion than a visit to the care home, or a visit to the surgery by the patient. An electronic patient record (EPR) is available during the consultation; the GP can give a prescription if necessary, call the patient in for a surgery consultation or advise they go to hospital.

The project is currently being evaluated but in future Dr Ali and colleagues hope to extend the scheme to another five care homes and also to people with LTCs living in their own homes.
Dr Ali believes that up to 80% of calls for home visits could be dealt with via telemedicine, and that everyone with an LTC should have a personalised care plan, access to support groups and know how to use equipment to help them live more healthily and stay independent.

At a recent telehealth summit organised by the Royal Colleges of GPs (RCGP) and 2020health, he said telehealth could bring "enormous benefits to patients, clinicians and the NHS as a whole."(3) But he added: "The future of healthcare is dependent upon clinicians changing the way they work by becoming more patient-centred and with greater immediacy in delivering care."

Dr Ali's advice to practice managers is: "Don't be afraid of new technology and don't assume it's difficult to use until you've tried it."

However, some telehealth champions, despite their enthusiasm, have more tempered views. Professor Ruth Chambers, a GP and the RCGP's Practice-Based Commissioning Clinical Lead, says: "Delivery in general practice is much more complicated in reality than some would lead you to believe." And in her locality, GPs have opted to give all the kit back.

Phil O'Connell, 'inventor' of the multi-award winning NHS telehealth innovation Simple Telehealth (STH), says feedback from around the country shows that some systems are technically complicated to use and have actually increased healthcare staff workloads, rather than reduce them.

False alarms
One issue is that some self-monitoring devices – for example, for blood pressure and oxygen – trigger too many unnecessary alerts and alarms, resulting in increased calls and visits to the GP.

"One size does not fit all and in some instances the business case does not stack up," says Mr O'Connell. But on the plus side, telehealth can lead to increased productivity and quality, can be inclusive and available to everyone, is low cost and can produce a high return on investment.

For example, the Simple Telehealth project is designed to enable thousands of patients to take responsibility for the monitoring and management of their own condition or treatment, and allows multiple healthcare teams to share patient information.

The project is currently undergoing academic evaluation in multiple trusts across the West Midland and in a health foundation SHINE (Serving the Health Information Needs of Elders) project in Stoke-on-Trent, specifically focusing on the control of hypertension in general practice. It includes 800 patients and examines ease-of-use and clinical impact. Early practice nurse case studies from the SHINE project show improved patient compliance and satisfaction, and fewer feelings of social isolation.

Mr O'Connell's advice to anyone contemplating setting up a telehealth project is to frame it over 12 months, stressing: "It must benefit the patient, provider and local health economy in line with QIPP" (the Quality Innovation, Productivity and Prevention programme – see Resources)."

Paradigm shift in care
But potential telecare adopters should also take heed of the current patient mantra, 'No decision about me, without me'. Dr Amir Hannan, a Hyde GP and IT lead at NHS North-West, certainly does. Passionate about encouraging patients to take more responsibility for their own health to achieve better outcomes, he says: "Telehealth has the promise to enable them to achieve that."

He points out there has been a "paradigm shift" in the way healthcare is delivered, with the self-managing patient supported by clinicians and technologies at the top, and "healthcare professionals as authorities" at the bottom.

His practice at Haughton Thornley Medical Centre has been involved in an NHS Tameside and Glossop telecare pilot for patients with chronic obstructive pulmonary disease (COPD). It aims to make savings of £1m from its LTC budget and meet its QIPP target.

The trust serves a population of 240,000, and in 2009-10 heart failure and COPD resulted in 1,024 emergency hospital admissions, costing about £2.7m. And that is set to rise to £3.5m annually over the next decade.

So far, the telehealth technology has been provided to 60 patients. It allows them to check their blood pressure, oxygen levels, weight and temperature, with the hardware also asking a series of health-related questions on a daily basis. It's hoped that helping patients to manage their conditions more effectively at home can reduce hospital admissions.

Dr Hannan says feedback so far has been positive and they hope to roll out the scheme to other patients with LTCs, including heart failure.

Early feedback and findings from the Whole Systems Demontrator Programme has also been positive, according to government officials. But practice managers may find it prudent simply to wait for the business case before acting on Mr Lansley's advice on being innovative.