Data from the Whole Systems Demonstrator Project suggests impressive reductions in mortality (45%) and in hospital admissions (20%). This data is being used to promote a massive roll out in the provision of remote tele-monitoring of patients with long term conditions.
These figures somewhat contradict earlier evidence from studies which have been dubious about the cost effectiveness of these type of interventions.
Unfortunately the headline figures were released long before the publication of the data, so academic debate has been difficult in a political environment where roll out of the technology has proceeded in the form of the ‘3millionlives’ campaign and the announcement of a concordat between the government and the telehealth industry.
The study sets itself up to prove the effectiveness of remote tele-monitoring, but I have a handful of concerns already about the way the study has been carried out.
- There are concerns about the control group. It is not clear how the placebo effect (of the presence of the support and technology) has been accounted for.
- Randomisation is done by ‘cluster groups’ of patients were allocated to two different interventions on the basis of their registered control practice. The interpretation of cluster randomisation trials is difficult.
- The group of patients studied is quite heterogeneous – not linked to a specific condition. Interpretation of the results from these sorts of study requires a degree of caution.
- This is more of a ‘before and after’ study than a true randomised controlled trial. The projections of possible savings are pure speculation.
- The interventions were introduced at a time of organisational and structural change in the NHS – other factors which could have confounded the final results.
I have no doubt that remote tele-monitoring will benefit significant numbers of patients – the anecdotal stories provided by the members of the Whole Systems Demonstrator teams are very positive and heartening.
However it is very hard to establish if these patients benefitted from the increased clinical input to their care, to their increased understanding of their condition or to the presence of the technology.
Whether tele-monitoring needs to be delivered by an expensive NHS model such as the WSD is another matter. Computer technology, smart phones and apps are moving ahead at a phenomenal speed and these potentially offer new opportunities for patients to monitor their health and access advice on self-care or when medical intervention might be required.
In Cornwall we have a very well managed telehealth team, judging by their success in this trial and their ability to secure potential funding for expansion of the project. We have also seen changes to social care in Cornwall, with the loss of ‘low level’ care visits for vulnerable patients as part of a saving process for the local authority. Many patients have lost their regular visit which provided a social and human contact. 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.
It is also hard to see how the proposed savings from telehealth will be achieved as a resource to finance the cost of the service. The only way of extracting the secondary care savings would be to close hospital beds and there is no evidence that this will be possible on the back of a telehealth programme. There are also concerns about the increased resources required to support the telehealth programme in terms of community nursing and GP care.
We need more evidence and more experience of using remote tele-monitoring before increasing the financial investment to the levels suggested by the ‘3millionlives’ campaign. This does not reflect scepticism of the possible benefits, but the reality of how these things can be implemented in the NHS in our current economic situation.
Dr Mark McCartney is a GP in Cornwall.