Our December 2012 report, Telecare and telehealth – a game changer for health and social care, provided a synopsis of the available evidence on the costs and benefits of telehealth and came out firmly in support of the NHS needing to use such technology in its interface with service users. We concluded that technology assisted care provided an equitable way of enabling more people to live independently for longer, while supporting health and social care providers to work differently. (View the infographic used to introduce this report or view the video).
In the past year there has been an unrelenting number of reports, often contradictory, and mostly derived from academic reviews of the Whole System Demonstrator (WSD) remote monitoring trial which have resulted in confusion as to the benefits or otherwise of telehealth. Nevertheless, in publishing the refreshed Mandate to the NHS last week, the Government continued to champion a key objective in the 2012 Mandate, namely that by 2017 'significant progress will be made towards the 3 million people with long-term conditions being able to benefit from telehealth and telecare'. Clinicians and patients, however, appear to have other ideas. Indeed, a recent survey of Clinical Commissioning Groups (CCGs) suggested that delays and lack of interest from clinicians and patients have undermined progress on rolling out telehealth and that some CCGs were withdrawing their investment.
In light of this confusion, I thought this might be a timely opportunity to review what's been happening over the past 12 months and reflect on the Centre's position on this issue. On balance, I remain convinced that the messages in our report remain sound and that there is strong evidence to support the wider scale adoption of telehealth, including how best to implement it and under which circumstances it works best. Of increasing relevance is the fact that the pace of technological development means that the technology supporting telehealth is now almost unrecognisable from what was available at the time the WSD trial commenced. It is far more efficacious and far cheaper; it can be deployed much faster and, for many more conditions, opening up many more possibilities than those in the WSD trial.
There is also much more clarity and experience in implementing the technology. In the WSD trial the two systems were run side by side – one for those in the trial, and one for the rest – leading to increased operational costs. However, providers are increasingly seeing telehealth as part of an overall system change and not simply seen as an intervention. In retrospect, as impressive as it was, there were weaknesses in the way the WSD trial. Furthermore, telehealth Apps can now be downloaded onto a smartphone which significantly reduces upfront costs and provides a mobile, instantly available, service; compared to the WSD, when the telecoms provider had to install a broadband line (and then only once the application form was completed correctly). As a result, telehealth can now be used to facilitate early discharge from hospital much more easily; which couldn't really be contemplated when the trial was being designed and the types of interventions finalised.
The fact that the WSD was a rigorous RCT also placed significant restrictions on selection of patients and subsequent interactions once patients had been allocated to the intervention or control groups. Patient selection also excluded many of the neediest people from involvement in the trial; for example people with existing telecare installations, many of whom were likely to have had the highest need, were excluded because they already had technology assistance. There was also bias in the recruitment process because two of the categories of users who we now believe would have benefitted the most (people requiring 'waking night' care, and people caring for those with dementia that were prone to wander) were excluded.
This inevitably meant that the headline results of the WSD were disappointing compared to the results now being seen from using telehealth as part of a whole system intervention, even though the evaluation method is less rigorous (typically before-and-after). Given the above, I believe that we now need now to move away from a focus on the WSD trial to identifying ways of using the technology more effectively. Continually, looking backwards proves simply that we were at a much earlier stage in technology development and use.
Indeed, all three WSD sites have subsequently mainstreamed telehealth which suggests they are convinced of its value. For example, in Newham the business case was founded primarily on improved efficiencies in the use of clinical staff, rather than the results of the WSD trial. Indeed, helping staff to work differently was the focus of the Centre's Telehealth report and one that we believe remains key to the challenge of meeting the increasing demand for good quality healthcare services from our ageing population.
A main barrier which is often cited as a barrier to the deployment of telehealth is funding; however, in April 2013, NHS England introduced a Remote Care Monitoring Directly Enhanced Service (DES) payment. Survey responses from 71 CCGs suggest 85% of practices will access the DES this year. Whether this shows true faith in telehealth remains to be seen, however, in adopting the DES specification GP practices will soon find themselves fully involved in the telehealth roll-out. They will have the chance to evaluate the benefits and savings themselves and, given that budget pressures are forcing CCGs to get tough on schemes that do not deliver, could result in those schemes which do work being shared more widely.
As things stand currently, three million users is a long way away but the stage is set for telehealth to stand or fall over the next few years. Championed by the English Government, deployed at scale in Scotland and Northern Ireland, the time has come for healthcare to finally embrace a technological approach to providing a more effective, convenient and personalised approach to care. But the questioning by critics over a perceived lack of evidence means it still has the potential to become a divisive issue at a time of straighten budgets and pressured services. If the naysayers prevail, the opportunity to truly transform healthcare and enable it to stand alongside other service industries that have led the way in embracing the technological revolution in their daily interaction with service users, will be lost. However, if the opportunities are embraced at scale, telehealth may finally have its moment in the sun.
Karen Taylor
Research Director, Deloitte UK Centre for Health Solutions
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