Over the last couple of years, my work on the Whole Systems Demonstrators (WSD) trial, has reinforced my view that our treatment of long term conditions is fundamentally a problem of changing the behaviour of patients and health care professionals.
Patients must take responsibility for self care and self management and health care professionals should be trained to facilitate behaviour change and empower and support patients to manage their condition. It is only through these types of changes that the sustainable system of managing long term conditions will be achieved in the NHS.
Two myths, two models
The question then is what is the potential role of telehealth in long-term conditions (LTCs)? At the moment, two common myths exist about TH – and not just among GPs but also other clinicians, politicians and the public. The first is that it’s a treatment in itself. It’s only an instrument to assist in the management, planning and organisation of care. The important question is how it is used in the care pathway for patients with different conditions and levels of severity.
The second myth follows directly from the first in that even when it works effectively, telehealth isn’t about the equipment – the key to its sustainability is about creating behavioural and organisational change in switching the emphasis of our care for long term conditions to one that monitors, informs and supports patients and health care professionals about the ongoing management of the LTC (or LTCs).
Careful attention needs to be paid to the care pathway that includes telehealth. Crudely, there are broadly two models of telehealth. In both, the patient transmits their data to the health care professional. What follows is important. Excluding an emergency, if the health care professional is making all the decisions about their patient’s care, based only on the data and without informing the patient of their readings or explaining and interpreting any unclear data, it certainly is not empowering to the patient. In this model, the doctor is effectively interpreting the data using technology. It is not providing care that is inclusive and empowering to the patient and in the long term it’s not sustainable. This approach does in some ways sit comfortably with the traditionally paternalistic nature of the NHS.
In another model, the data that the patient transmits is analysed and presented to both the patient and the health care professional. This shared data can then be the subject of a conversation initiated by the health care professional or the patient that may, where appropriate, include the patient’s informal carer. In this way the monitored data assists patients to manage their long-term condition. The doctor might nudge them to act in a certain way or take more recordings, but ultimately it has the potential for the patient to recognise that they are crucial to the effective management of their long-term health condition.
Evidence to date
There have been a number of publications from the WSD trial and it may be useful to summarise some of the findings. Although complicated in interpretation the study has found significant reductions in mortality and emergency admissions. These are important as they suggest that telehealth can lead to improvements in key outcomes for some patients.
Some people appear to have expected an improvement in general quality of life in the trial. While this is not an unreasonable expectation there are important factors to take into account. Firstly, it was argued by some before the trial that the introduction of telehealth would lead to patients becoming isolated and this would in turn lead to those with telehealth having a reduced quality of life. The findings showed that there were no differences between those who received telehealth and the controls in quality of life or psychological well being.
The second issue in relation to the quality of life findings is that telehealth, unlike many other healthcare interventions, is not in itself a treatment. The issue that needs careful consideration is whether including telehealth in the care pathway of managing LTCs has a direct impact on quality of life. Measures of quality of life include a range of questions that attempt, when assessing generic quality of life, to cover the whole range of areas in ones life. Whether a management change has a clear impact on all these aspects of quality of life is questionable.
Some people have suggested that because of the reduction in hospitalisation in the telehealth group we should expect an improvement in quality of life. Although we found lower rates of hospitalisation among patients using telehealth not everyone was hospitalised and also that instances of hospitalisation may have occurred some time before the quality of life was measured. It remains a question, but perhaps not that interesting, as to whether those who were hospitalised had a lower quality of life than those who were not.
Using the DES
I didn’t see the telehealth DES until last week. Whilst this provides some level of financial incentive for GPs to use remote monitoring for patients with LTCs, it is very loose in its specification of the care pathways and the ways in which it will encourage patients to self manage and thereby reduce the number of GP visits. This lack of detail may seem unsatisfactory to many GPs but it also leaves open the possibility of designing a system to fit the particular practice and its ways of working with patients with LTCs.
There are a number of ways to configure the role of telehealth in GP surgeries and some GPs have already introduced systems and services which both they and the patients are very satisfied with. For example, patients with a condition such as diabetes can have their consultation over the telephone if both the GP and the patients have access to shared data. This will mean that the patient does not need to travel to the surgery which for patients who work can be a real bonus.
It is essential that any new system incorporates sharing and additional analysis of the data provided so that both patient and health care professional can learn something new. An example would be the daily pattern of blood glucose control cumulated over an extended period.
One of the concerns GPs express about telehealth is that it will increase their workload, and that may be a concern for those undertaking the DES. The findings we produced in WSD study, with its model of managing long term conditions, showed telehealth was neutral in terms of GP workload. Other systems may be able to reduce the workload whilst some may lead it to be increased. Careful design of the system, what the different responses by the surgery are and models of treatment escalation need to considered. The objective of any pathway that uses telehealth should be to provide better quality of care, first of all, but should also be introduced with a view for some cost savings.
Change for the future
For telehealth to work as an instrument in the NHS, there has to be more training for GPs and other health care professionals involved with the management of LTCs. A sustainable model will be one that ensures patient empowerment and behaviour change are embraced and that health care professionals are trained to facilitate behaviour change in their patients. Recognising that patient behaviour is a key to the management of LTCs means that we need to consider our training of health care professionals and incorporate facilitation of behaviour change for people with LTCs into our curriculum for both doctors and nurses and other health care professionals.
Its important that we recognise that with an ageing population and the predicted increase in chronic disease we’re on a ‘burning platform’. While we may not have the perfect solution for the management on long term conditions, we do need to change, as carrying on in the same way we have done in the past is simply not sustainable. Add into the equation the saving expected in the NHS and the need for change is undeniable.
I understand that many GPs will feel resistant to the way telehealth is being promoted – perhaps because of the politicisation or misunderstandings that impact on its correct application. But buy-in from the clinicians using telehealth models is key to its success, so it’s crucial that GPs engage with the evidence and the debate and have their say in the way it is (or isn’t) introduced into local pathways.
Professor Stanton Newman is Dean of the School of Health Sciences at City University London and was the research lead on the Whole Systems Demonstrators trial