Analysis: Is telehealth a busted flush?
As new studies question the evidence base, and CCGs struggle to get pilots off the ground, Caroline Price looks at telehealth’s uncertain future
Just 18 months ago, telehealth looked set to transform the landscape of primary care, helping patients with chronic conditions to stay out of hospital and freeing up GPs to focus on other things.
Initial headline findings from the Government’s Whole Systems Demonstrator pilot showed telehealth and telecare brought impressive reductions in mortality, and the Department of Health announced the ambitious ‘3millionlives’ campaign to give patients with long-term conditions access to the new technologies by 2017.
Yet fast forward to the present and a very different picture emerges, with three further studies from the WSD pilot reporting equivocal findings and huge costs, and CCGs tasked with pioneering telehealth struggling to get ‘pathfinder’ projects off the ground.
As GPs in England prepare to spearhead a rapid expansion in the use of remote monitoring equipment under a new directed enhanced service, is telehealth something the NHS can afford to bet on?
Successive governments have invested heavily in assistive technology over the past 15 years. According to health policy expert Professor James Barlow, from Imperial College London, at least 20 government reports have called for remote care since 1998, and over £200 million of public money has gone into such remote care since 2006.
The outlay was justified on the basis that costs for GP and secondary care services would fall, but only very small pilots attempted to test the theory. To try to close the evidence gap, the DH set up the WSD programme in 2006 to evaluate the effectiveness and cost-effectiveness of both telehealth and telecare.
The randomised trial included over 6,000 patients across Cornwall, Kent and Newham in east London. Initial results for 3,000 patients with COPD, diabetes or heart failure showed a 45% reduction in mortality and 20% fall in emergency admissions as a result of the telehealth interventions used.
However, when this study was published in full, the researchers concluded that a £188-per-patient reduction in hospital costs between cases and controls was not statistically significant – and further studies have also cast doubt on the expected savings.
London School of Economics researchers last month published a paper calculating a cost per QALY of £92,000 – above the usual NICE threshold for cost-effectiveness of £20,000–£30,000 per QALY.
A study looking at the pilot’s telehealth arm found no benefits in terms of patients’ quality of life or psychological wellbeing, while another found telecare had failed to cut care home or hospital admissions or GP contacts.
Lead WSD investigator Adam Steventon, senior research analyst at the Nuffield Trust, says the lack of cost-effectiveness could be down to the difficulty in adapting the use of technology during a clinical trial.
He says: ‘The most likely thing is that there were no improvements in quality of life, anxiety and depressive symptoms – it might be that the equipment wasn’t designed in the right way for patients.’
If I was a CCG, I’d be trying out telehealth cautiously
Adam Steventon, Nuffield Trust
Despite the unclear evidence base, he insists the best way to evaluate telehealth will be through rolling it out more widely. He says: ‘There have been quite a few randomised trials now, I’m not sure that another is going to tell us that much.
‘If I was a CCG, I’d be trying out telehealth cautiously and evaluating it as I went along. The evidence is quite mixed and there’s no guarantee you’ll replicate it when you implement it in your area because it depends which patients you choose, how you do it and what your other services look like.’
But others are less circumspect. Dr Mark McCartney, a GPC member and GP in Pensilva, Cornwall, says: ‘It is the wrong time to be putting new money into telehealth, given that the evidence isn’t entirely conclusive, at a time of financial constraints and uncertainty.’
The DH has yet to show much caution in its approach, and is putting GPs at the forefront of the most ambitious drive yet to roll out telehealth across England under a new DES.
The DES – funded by the retirement of organisational QOF points – will require practices to agree on a local ‘priority’ condition for remote care monitoring with their CCG and pay them 21p for each patient they sign up this year ready to start on the service in 2014/2015. In total it will be worth up to £1,478 for the average practice.
The DH claims this will free up GP time ‘by reducing unnecessary routine attendances’, but the GPC has said there is little evidence for this from the WSD trial.
Simply ploughing on… is not a sensible use of money or GP time
Dr Chaand Nagpaul, GPC negotiator
GPC negotiator Dr Chaand Nagpaul says: ‘The use of telehealth should be based on evidence of benefit and cost-effectiveness, not ideology. We have concerns that this DES is being linked to the Government’s political agenda for telehealth.
‘Simply ploughing on with a target to roll out telehealth across the NHS without pausing and thinking about its merits is not a sensible use of money or GP time.’
Pulse has also discovered that even the most enthusiastic CCGs are struggling to roll out the scheme. Of the seven pathfinder areas announced by Jeremy Hunt at an Age UK conference last November, two were unable to provide any figures for the number of patients benefiting from telehealth. The remaining five, which were able to provide figures, have between them signed up only around 8,000 of the 100,000 patients the DH promised would benefit from telehealth this year.
None of the pathfinder sites has received funding to set up its projects, and precisely how they are purchasing equipment and reallocating existing funds is unclear.
NHS Kent and Medway and NHS Cornwall and Isles of Scilly, which both participated in the WSD pilot and so have well established telehealth services, reported they currently have only 500 and 900 active telehealth users respectively.
In Worcestershire, some 6,000 patients are currently supported by a mixture of telehealth and telecare. But NHS North Yorkshire and York, which is part of a joint pathfinder with Humber PCT cluster, still has only 650 patients using telehealth, despite previous efforts to boost uptake in an earlier pilot launched in 2010.
In Bassetlaw CCG, which is part of a joint pathfinder with NHS South Yorkshire, just 21 patients have signed up. NHS South Yorkshire and Humber PCT cluster were not able to provide separate figures for their part of each pathfinder, while the two remaining pathfinders, NHS Merseyside and Camden CCG, were also unable to provide figures.
Dr Tamsyn Anderson, GP in Newquay and clinical lead for long-term conditions and urgent care at Kernow CCG, says there are benefits from telehealth, but that it is a technology searching for a reason to exist.
She says: ‘The biggest difficulty is that the evidence doesn’t provide sufficient confidence to allow our clinicians to be able to take this forward.’
‘Patients really enjoy having that improved knowledge and confidence in managing their own symptoms – in the main it’s a positive thing.’
The evidence doesn’t provide sufficient confidence… to take this forward
Dr Tamsyn Anderson, Kernow CCG
‘It sort of feels like the technology is there and we’ve said, “which patients will fit it?” Rather than saying “here’s the patient, here’s their situation, is there a technology that will work for them?” ’
She adds: ‘Obviously, we’re very aware of the financial situation… you have to be confident that you’re investing in the right thing.’
Despite the apparent pragmatism from the CCGs supposed to be spearheading the scheme, the Government says it remains committed to rolling out telehealth according to plan.
A DH spokesperson told Pulse the WSD trial shows ‘economies of scale and lower unit costs’ are needed to ensure the technology becomes cost effective.
She said: ‘There is work going on as part of the Year of Care tariff development, CQUIN and QOF to support the wider implementation of telehealth and telecare services. We are also working with professional bodies and the sector skills councils to raise awareness of what is possible and how to deliver services.’
CCG leaders in areas beyond the pathfinders remain unconvinced about the cost, even though they are positive about telehealth. Dr Sarah Baker, GP and chief clinical officer at Warrington CCG, says it has telehealth in its strategy for elderly care, but funding is the stumbling block.
She says: ‘We’ve got an IT strategy with telehealth right in the middle of it – but it’s just an intention at this point in time.’
She says that as technology gets more ‘agile’ and costs come down, it is something the CCG wants to look at.
‘We would try elements of it, see what worked with the change in the service specifications. I don’t think we’d be going for a wholesale, we’re-going-to-do-this, big bang. It would be “let’s try it in one area, see how it works, learn lessons”.’
She adds: ‘We haven’t got any money – we’re the second-lowest-funded CCG in the north-west. Trying to get the headroom to invest is a challenge – we’ve had to get the context right before we can start changing services.’
Telehealth pathfinders - progress so far
Currently 6,000 patients supported with assistive technology
Will start enrolling patients from September, aiming for up to 18,000 users
North Yorkshire & York and Humber PCT cluster
Around 650 patients currently using telehealth
CCGs responsible for rolling scheme out further from this month
NHS South Yorkshire & Bassetlaw
21 telehealth users in Bassetlaw
No other patient numbers available
Builds on established scheme delivering telemonitoring to patients with long-term conditions
Kernow CCG and Cornwall & Scilly Isles PC
Around 900 people currently using telehealth
Mainly patients with COPD and heart failure, and pilots for UTI and postural hypotension monitoring
1,700 users expected by the autumn
NHS Kent and Medway
Currently around 500 patients using telehealth, involving GPs at 270+ practices
Next phase of roll-out to begin from April, aiming to reach 10,000 people by March 2014
Camden CCG and NHS Merseyside were not able to supply any information on their schemes