Telehealth's time may finally have come, with three demonstrator sites spending £12m on the technology to help patients manage their conditions, writes Daloni Carlisle

The telehealth world is on tenterhooks. This summer£12m was at stake as three councils and primary care trusts nominated as whole-system long-term condition demonstrator sites decided who would provide their technology.

These projects, the latest in a long line of pilot schemes, will be the largest tests of telehealth in the UK. They are moving up a scale from tens of patients to several hundred, potentially heralding a move into the mainstream.

In the next two years across Kent, the London Borough of Newham and Cornwall and Isles of Scilly, a combined total of 3,000 patients with long-term conditions such as chronic obstructive pulmonary disease, diabetes or heart disease will receive machines to monitor the biological parameters of their disease as well as answering a series of clinical questions.

They will feed the answers into a computer and their condition will be monitored remotely, triggering intervention if their measurements fall outside set parameters. That might be a phone call from a nurse or a home visit.

Small victories

That's the theory. The general idea is that telehealth empowers patients to manage their disease and reduces hospital admissions, thus reducing costs and improving quality of life.

So far it has worked well in a number of small-scale projects, with between 30 and 50 patients run jointly by PCTs and telehealth providers such as Docobo, Tunstall, BT and others. Their pilot schemes have reportedly achieved multi-million-pound savings based on projected reductions in emergency admissions and bed utilisation. But up until now the evidence has not been compelling enough to prompt widespread take-up.

That is where the whole-system demonstrator sites come in. They were proposed in the white paper Our Health, Our Care, Our Say to test the benefits of integrated care. In December 2006, the Department of Health invited NHS/local authority partnership bids for schemes for combined telehealth and telecare (remote social care), covering their whole population.

The winners were announced in May and throughout the summer they set up project boards and sub-groups with the aim of delivering a framework to the DoH in early autumn 2007. Meanwhile, a research and evaluation group led by Professor Chris Ham, director of Birmingham University's Health Services Management Centre, with input from King's Fund policy director Jennifer Dixon, had its first meetings.

Matt Marshall is director of health for technology providers Tunstall. He says: 'We have been active in telehealth for the last two years and it's always been an uphill struggle but in the last six months take-up has really increased. The whole-system demonstrators are a major catalyst to the market and while there are only three winners, there were another 25 PCTs and local authorities that put in bids and they are out there, still talking to us and wanting to do something.'

Adrian Flowerday, managing director of Docobo, which is working with 14 PCTs and trusts to develop telehealth services, agrees. 'It's gone beyond the study stage. About 10 per cent of PCTs are now rolling it out.'

Managerial grip

What is less clear is how well the NHS can manage large-scale telehealth introductions and whether PCTs can get the clinical buy-in they need to make it a success.

'It's the service redesign that's tricky,' says Mr Flowerday. 'It's the staff training and helping community matrons to understand where it fits as a tool.'

Mr Marshall adds to this, saying he has been in meetings where community staff start with their arms folded, but end up suggesting particular patients who the service might suit.

Mr Flowerday calls on PCTs to get a managerial grip. 'It needs PCTs to manage staff and say "this is what we are going to do", then identify the patients and give the technology to community matrons as a tool.'

All of which is in the forefront of Carol Williams' and Debbie Lindon-Taylor's thinking. Both are PCT managers involved in developing the demonstrators, Ms Williams in Cornwall and Isles of Scilly and Ms Lindon-Taylor in West Kent.

In Cornwall, hopes are high. It's a rural area where patients can travel 50 miles just to get to an outpatient clinic. Forty community matrons are already comfortable with the PARR2 predictive tool, which they use to select patients for their caseload.

'Telehealth will be key to reducing dependence on outpatient appointments,' says Ms Williams, the PCT's director of service improvement. 'This is very much about empowering the patient to manage their own condition and knowing they have the additional support if they need it.'

Change is the biggest challenge, she admits. 'It's all about clinical engagement and working hard with our clinical staff so they see it as one of the tools they use routinely.'

She is putting structures in place to make that happen, appointing the lead community matron as manager of the programme. The IT staff for the project are now co-located in an office with the project leads and clinical design team.

Ms Lindon-Taylor, West Kent PCT's assistant director of adult services, agrees that clinical engagement is a challenge but defends beleaguered community nursing staff. Kent has the biggest telehealth pilot in the UK, with 220 patients enrolled. The last data gathering before final evaluation took place on 30 July this year.

She says: 'From a health perspective we would want to use it as a tool to empower patients to manage their diseases. There is an element that believes nurses need to log on to a computer every day for every patient. That conflicts with what this is about.

'We need a system that flags up when a patient's measurements are outside their normal parameters. Surely that's something that can be done by a skilled IT person.'

Not so, says Kent County Council telehealth evaluations manager Matt Rye. He agrees telehealth is all about putting the patient at the centre; do anything else and you rapidly start to lose any savings you might make.

But the role of the skilled, senior clinician in evaluating data is crucial. 'As soon as you start removing senior clinicians with the relevant competencies you will miss things,' he says.

'I would also raise the question of whether you want somebody who is not clinically competent to look at your data and manage your condition. That's slightly unethical.'

There is still a lot of detail to thrash out and these and other questions will exercise the minds of managers, providers, academics and clinicians alike for some time to come.

Telemedicine: the specialists' tool

It is not just telehealth that is coming of age. Telemedicine - in which clinicians use mobile technology to talk to each other - is also developing rapidly.

The digital picture archiving and communications system has been a big success, but earlier this year NHS North West reported on their major trial of cardiac telemedicine, carried out with Broomwell Healthwatch.

It involved placing telemetric 12-lead ECG machines in 15 GP practices and two walk-in centres in Cumbria and Lancashire.

Patients with suspected heart disease could have tests done on-site. The results, instead of being analysed by a non-specialist GP, were transmitted wirelessly to a call centre where a team of clinically trained staff were available 24/7.

Specialists communicated by telephone with the clinical staff attending the patient.

The results were dramatic, showing that 82 per cent of patients did not need a hospital appointment. Patients and primary care staff loved the technology and found it easy to use.

The strategic health authority audited 55 patients treated using the system and found that it saved 16 accident and emergency attendances and four hospital admissions. Offset against the costs, the six-month pilot scheme saved£3,965.

Nationally, that would amount to 90,000 accident and emergency visits, 45,000 admissions and£46m saved.

The report can be downloaded from www.lsccardiacnetwork.nhs.uk. The Royal Society of Medicine's TeleMed and e-health conference is on 26 and 27 November. Go to www.rsm.ac.uk/academ/tee101.php