Good call: why telehealth is so important to patients with long-term conditions

Telehealth has struggled to move into the mainstream, despite a string of successful small-scale trials. All eyes are now focused on the outcome of a big national trial that will report later this year – and whether it will help to overcome some of the barriers to adoption many health communities have encountered.

The whole system demonstrator sites in Kent, Cornwall and the London borough of Newham have put telehealth equipment into thousands of homes to monitor and transmit readings from patients and looked at the outcomes. Although the full results are still being analysed, it is likely they will show that cost savings from adopting telehealth can justify the original investment – although how it is implemented is likely to be key to realising savings.

If the final analysis is positive, it could be the biggest boost yet to telehealth adoption in the UK. On paper, telehealth frequently saves money and can make better use of skilled staff. Patient satisfaction is high, even among the over 65s. Yet only 6,000 to 7,000 patients are currently using the equipment.

Delegates at a conference run by the Telecare Services Association last year were asked what barriers were preventing adoption: 42 per cent said resistance to change by frontline staff and 35 per cent said it was a lack of commissioning knowledge. But more than a fifth pointed to the difficulty in turning estimated savings into quantifiable or deliverable ones.

And where some health economies have invested in telehealth, the equipment has been left in cupboards. Last year cash-strapped NHS North Yorkshire and York was pilloried for only using 135 units out of 2,000 it had spent £3.2m on. GPs suggested it had taken a risk on something “we don’t know will work” and the system would put extra pressure on community nurses.

This problem of expensive equipment languishing in cupboards due to problems with adoption appears common. Nick Goodwin, a senior research fellow at The King’s Fund and an expert in telehealth, describes seeing “60 units in a cupboard which were two years old”. So why is this expensive kit not being used? Very few of the problems in introducing telehealth relate to the technology; implementation is key. Acceptance of technology among patients has been encouraging, but the problems often lie in healthcare professionals being reluctant to accept changes to their way of working.

Mr Goodwin puts some of the issues down to the inertia within the system and the difficulty in changing culturally embedded ways of working. He says telehealth is on a knife edge with some areas pulling back, because they cannot justify the perceived risks.

National leadership

John Cruikshank, who worked on a telehealth report for health thinktank 2020health, argues that some form of national lead is necessary to prompt widespread adoption. He suggests the Department of Health or the National Commissioning Board could be involved in this. Another idea is to provide a menu of telehealth services at different levels, to match the needs of the patient, which consortia could then buy. Large scale adoption is also likely to drive down prices.

“There is a whole maelstrom of change which is going on at the moment, which makes initiatives like this – which take a while to deliver benefits – quite difficult,” he says. While the cost benefits may become clearer once the whole system demonstrator report comes out, implementation may still be an issue. But large scale adoption could make telehealth disruptive and bring about changes in care pathways, which are difficult to implement when only small pilots affecting a handful of patients are running.

This problem of small scale trials with the rest of the system going on as normal has been the standard situation up to now. The large whole system demonstrator sites go some way to addressing this and may give some hints of how telehealth could fit into the broader health system. In Newham, the monitoring was originally carried out by a specialised team, but this has been dissolved and replaced by community matrons and other staff trained to do the work. Telehealth is becoming normalised – and the primary care trust is now looking at how it can enter the mainstream.

Difficult future

But though telehealth has made huge strides – and the publication of outcomes from the whole system demonstrator trials should raise its profile even further – it faces a difficult future. “It couldn’t have come at a worse time,” says one manager involved in telehealth. With PCTs dwindling on the vine and consortia at very early stages, getting telehealth commissioning will be a challenge – and many PCTs’ financial situation will not make it any easier.

GP support will be vital once they hold the commissioning purse strings, but their commitment is uncertain. Of 200 subscribers to a newsletter on telehealth issued by The King’s Fund, only five identify themselves as GPs. Some of the trials have found it hard to engage GPs in direct involvement in telehealth – a pilot which ran in Kent between 2005 and 2007 found significant differences in results for models that relied on GP input and those using community matrons, who were more enthusiastic.

“Engagement of the GP community was challenging and participation poor,” an evaluation found. GPs who resent being involved in telehealth or who feel it puts extra burdens on their staff are unlikely to support spending money on it.

Lack of GP engagement has been a crucial factor in York. Some practices have become involved and around 350 units out of 2,000 are now in use. Kerry Wheeler, assistant director of strategy at the PCT, says a pilot scheme involving 120 units had been successful. Practice based commissioning groups were keen to see wider implementation and had produced business cases for investing savings in telehealth. But GPs were concerned it might involve additional work for them or their staff. 

With 50,000 patients in the area with long term conditions, the PCT is keen to see its investment fully utilised. One possibility is using the equipment with patients who are at risk of declining and making more extensive use of services in the next six to 12 months. Telehealth could help clinicians pick up early signs of change and intervene to keep them stable and at home.

Positive experience

In Cornwall, another whole system demonstrator site, the experience of telehealth has been positive and it is now being rolled out more widely – potentially including patients with conditions other than those in the demonstrator sites; chronic obstructive pulmonary disease, diabetes and heart failure. Around 1,000 units have been installed so far.

It helps that telehealth complements the PCT’s aim of moving care closer to home; cost savings have not been the main driver.

The model of care involves 80 per cent of patients being monitored by a dedicated telehealth team and the remainder by community matrons and their teams. There is some GP involvement, but telehealth does not add greatly to their workload and support has been strong from them.

Another consideration is likely to be ensuring the cost of equipment is minimised and it is used appropriately. Richard Stubbs, programme manager for the demonstrator site in Newham, says different units may be appropriate for different patients. Someone newly diagnosed may benefit from a unit offering an educational package as well, while a stable patient used to self-care could have a simpler, cheaper model.

Leasing units rather than buying can reduce the initial cost and allow the lease cost to be offset against savings in the cost of care. For example, the community matron only having to respond if a previously stable patient has abnormal readings. And leasing could also make it easier to upgrade as smaller, more advanced and more mobile units become available – or mobile phone technology takes over, allowing readings to be taken on the move.

“We know that people are better off if they go out more, so we don’t want a situation where people don’t go out because they need to take their readings,” says Mr Stubbs. The NHS may not be the only purchaser of “simple” telehealth, Mr Cruikshank points out. As costs become lower, these may be purchased by users or their families. Self-monitoring equipment is widely advertised to the public and apps measuring physiological signs have begun to appear for smartphones. One challenge may be how to integrate readings from these unofficial sources into patients’ care.

Ultimately, telehealth services may be integrated with existing technologies, such as mobile phones, and purchased as software rather than hardware. But just as the first mobile phones were quickly eclipsed by smaller models with improved features, so the equipment today will quickly look dated. Knowing that what is purchased now may be obsolete tomorrow could put off purchasers in the short term. “Commissioners don’t want to be buying Betamax,” says Mr Goodwin.