Will CCGs ride a telehealth wave – or stay on dry land?
The Government has thrown its weight behind telehealth in a bid to cut costs. But do CCGs share the enthusiasm?
The futuristic vision of the long-term sick being treated in their own homes and monitored remotely from ‘radar centres' is understandably high on the agenda for a Government trying to slash NHS costs. Opponents say telehealth is unproven and no substitute for face-to-face contact with doctors and nurses.
But the latest NHS Operating Framework, published in November, left no room for doubt about the Government's intentions: ‘PCT clusters working with local authorities and the emerging CCGs should spread the benefits of innovations such as telehealth and telecare as part of their ongoing transformation of NHS services.
‘They should also take full consideration of the use of telehealth and telecare as part of any local reconfiguration plans'.
Momentum has also been sustained by recent encouraging results from the £30m Whole System Demonstrator (WSD) programme launched under the previous government in 2008.
In January, headline figures from the 179-practice, 3,230-patient programme showed a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions and a striking 45% reduction in mortality rates for patients using telehealth services.
Care services minister Paul Burstow responded by announcing a concordat between the Department of Health and the telecare industry titled ‘3millionlives' to ‘develop the market and remove barriers to delivery' – spearheading a drive to bring telecare to three million patients with long-term conditions and complex care needs.
The initiative followed last year's launch of a four-year, £23m project – DALLAS, or Delivering Assisted Living Lifestyles at Scale – set up by the Government's technology strategy board to establish up to five communities of 10,000 patients across the UK to illustrate how assisted-living technologies can be used to enable people to live independently.
Detailed results from the WSD programme published in the BMJ in June confirming the headline findings have added further impetus.
Professor John Cleland – professor of cardiology at the University of Hull, who has been researching telemonitoring for a decade – describes the findings as ‘really rather positive': ‘Put simply, WSD confirms we should be going down this route. It's a question of engaging patients in their own management, putting the facts at the patients' fingertips and empowering them.'
But there are, of course, caveats. An editorial accompanying the WSD findings in the BMJ by Dr Josip Carr, director of the Global eHealth Unit in the department of primary care and public health at Imperial College, London, suggests the jury is still out: ‘Does the WSD trial provide convincing evidence for commissioning a national rollout of telehealth? The findings reported to date suggest not, although we recommend caution until the full data are released.'
Dr Carr is also equivocal about the 3millionlives project: ‘Policy makers, commissioners and guideline developers should help ensure the research agenda focuses on areas where telehealth shows most promise. There is great potential, but also still much to be done.'
King's Fund figures suggest 1.7 million patients are currently using the technology, but academic criticism such as this – coupled, in places, with outright opposition from grassroots GPs – has threatened to rain on the Government's telehealth parade.
Commenting on the WSD findings in our sister paper Pulse, Dr Mark McCartney – a GP in one of the programme's pilot sites of Liskeard, Cornwall – claimed participating had meant the loss of ‘low-level' care visits for vulnerable patients in his area as part of ‘a saving process for the local authority'.
‘Many patients have lost their regular visit, which provided a social and human contact,' he says.
‘I would argue that these contacts provide much better value for money than a remote technological link. In a time of economic difficulty, it would seem prudent to take care with extending NHS investment in telehealth monitoring until we have a clearer view of the benefits and risks, both financial and clinical. The NHS has a poor record of procurement in new technologies, and this is another area for concern.'
Pilot schemes where PCTs have bought into telehealth without consulting local GPs have faced difficulties getting GPs engaged – cash incentives for participating practices have had limited success.
Dr Paul Cundy, chair of the GPC's IT subcommittee, takes this as evidence telehealth should not be imposed in a top-down manner: ‘The Government may have to rethink the whole thing. Your average GP needs substantial convincing that there is any benefit to telehealth – and this is a very good argument for putting GPs in charge of commissioning.'
Evidence from areas where GPs are in the driving seat on telehealth backs this up. Dr Ian Greaves, a GP at the Gnosall surgery in Stafford, set up a management scheme for patients with dementia involving telemonitoring that has expanded into other areas of healthcare – turning a £300,000 overspend at his practice into a £1.4m underspend. The project involved putting patients' care and treatment plans, medicines management and personal details on specialised elderly care tablet hardware.
The network and tablets are sold directly to patients' families so they can use them to monitor and performance manage the inputs of the providers.
‘We basically stopped a whole lot of "-ologist" appointments and enabled transfer of power away from the institution and back to the patient,' Dr Greaves says.
Tunstall – a leading provider of telehealthcare solutions, which has struck high-profile deals with PCTs in Gloucestershire and North Yorkshire to provide telehealth services to benefit 4,000 patients – feels confident enough about the financial benefits of telehealth to offer CCGs risk-and-reward options in its contracts.
The CCG takes the ‘risk' of investing in systems, processes and technology up front to support deployment of the service. As a ‘reward', the CCG is able to pay for these investments over a longer period of time and also has potential shares of future savings in hospital admissions or length of stay.
‘We and our NHS partners are confident of the financial case,' says David Cockayne, Tunstall's UK director of health and social care. ‘We're offering clients varied commercial options including risk and reward. That's going to become more and more part of the deal we offer them.'
But as many critics point out, savings don't necessarily equate with cost-effectiveness because of the high cost of outlay for equipment. And this is likely to be a key determinant for CCGs thinking of making the investment.
NHS Gloucestershire – which contracted telehealth services for 2,000 patients from Tunstall, alongside ‘pump-priming' from consultants Ernst & Young – is reporting a reduction in admissions of around 30% in the first three months of the scheme, with only around 400 units deployed.
The PCT's director of commissioning Linda Prosser says that having made the initial outlay to secure the service redesign, the PCT is now preparing to transfer its Tunstall contract to the local CCG by partly renegotiating it onto a cost-per-case basis.
‘It's a three-year deal, so it will have a year to run when the CCG takes over and we are working with them to ensure what novates to them is cost-effective,' she says. ‘We're discussing changing to a cost-per-case basis, but that doesn't mean any change to our ambition. We still think 2,000 is about the right level for our population.'
Tunstall's UK and Ireland managing director Simon Arnold is aware that CCGs will be looking for value for money: ‘The way we're doing things fundamentally changes the burden on the NHS. The traditional model was that you bought a lot of equipment. Now it's more of a strategic partnership involving GP engagement, pathway redesign and upgrading and maintaining the technology. The commissioner does not own the equipment and can pay on a revenue basis per patient, per month.'
Professor Cleland takes a long-range view of telehealth's cost-effectiveness: ‘In the long run, telehealth is likely to be highly cost-effective. It doesn't require more staff, and may require fewer. The equipment cost, compared with more drugs, is not so high. People forget that in the NHS, the most costly thing is people. And in patients monitoring themselves, you have a large workforce coming at no additional cost whatsoever. We're still at the very beginning of the technology. I can easily see every house having some kind of telehealth capability in 10 to 20 years.'
Alisdair Stirling is a freelance journalist