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Unanswered questions in telehealth. The lessons to be learnt from the WSD trial

James Barlow

Evaluating the impact of telehealth: where next for research beyond the Whole System Demonstrator trial? 2 October 2012 Nuffield Trust, London

Outline

• Lesson 1. Taking stock. What progress has been made in deploying remote care in the UK?

• Lesson 2. How big is the potential UK market for remote care?

• Lesson 3. Crossing the brick wall – mainstreaming remote care

• Lesson 4. Evaluation, evidence, policy and scaling up

• The questions we now need to address

Lesson 1 Taking stock. What progress has been made in deploying remote care in the UK?

Practice by Telephone The Yankees are rapidly finding out the benefits of the telephone. A newly made grandmamma, we are told, was recently awakened by the bell at midnight, and told by her inexperienced daughter, "Baby has the croup. What shall I do with it?" Grandmamma replied she would call the family doctor, and would be there in a minute. Grandmamma woke the doctor, and told him the terrible news. He in turn asked to be put in telephonic communication with the anxious mamma. "Lift the child to the telephone, and let me hear it cough," he commands. The child is lifted, and it coughs. "That's not the croup," he declares, and declines to leave his house on such small matters. He advises grandmamma also to stay in bed: and, all anxiety quieted, the trio settle down happy for the night The Lancet 29 Nov 1879, Page 819

The idea has been around a long time

There is political support Successive UK governments have bought into the remote care story

• Since 1998 at least twenty government reports have called for remote care

• Public finance (£200m+ since 2006)

• ‘3 Million Lives’ initiative (2012 – 2017)

There are many industry case studies and other reports

There have been many trials ... Diffusion of telecare in Surrey 1998-2005

7

Columba

Brockhurst Dementia unit

NEECH videophone pilot

Mid Surrey Falls Project Guildford Falls Project

Dray Court Telecare flat

COPD at Home Project

Dormers SMART House

LAA: Safe At Home

MEWS Hospital Discharge project

Mid Surrey Wristcare pilot Tandridge Telecare Flat

Community Alarm Teams, Elmbridge, Guildford, Mole Valley

& Runnymede

Thames Ward, Molesey Hospital

Leatherhead Hospital

COPD Project

Even before WSD there was a large evidence base

Source: Barlow et al (2007)

• Very large number of studies around the world (now 10,000+ published reports?)

• Clinical / QoL benefits have been shown in trials in a variety of circumstances

• Robust economic evidence is limited

Bulk of studies are targeted at diabetes and heart disease

Remote care is entering the public awareness

Which? (Feb. 2009)

And yet …

Adoption Spread Mainstreaming

Time

Level of uptake

The remote care adoption pattern in the UK

So how much remote care is there in the UK?

Growth in remote care users in England (with many assumptions) Source: Based on CQC returns, JIT

(Scotland) data, and authors’ research for WAG. Includes LA and other agency services. Assumes 30% drop-out rate each year

With Scotland & Wales

0

50000

100000

150000

200000

250000

300000

350000

Assumes 15,000 remote care users (2005) and 5000 users (2000)

Lesson 2 How big is the potential UK market for remote care?

Potential remote care market 2010

1,400,000

Actual remote care market 2010

350,000

Potential telehealth

market 2010 450,000

Actual telehealth market 2010

22,500

Source: based on CQC returns, JIT (Scotland) data, and authors’ research for WAG. Telehealth figures from Minutes of the Strategic Intelligence Monitor on Personal Health Systems [SIMPHS] meeting, Brussels, 17-18 November 2009.

Assumptions: • UK population aged 75+ is

c4.9m (2010) • c85% of older people wish

to remain at home as long as possible

• 1/3 needs remote care at any given time

Half a million, one million … or three million?

We don’t know: How many people could benefit at a given snapshot in time or over a year (what is the rate of ‘churn’?) Which population groups can benefit most? (top of the ‘pyramid’, next tier, which conditions?)

“The Department of Health believes that at least three million people with long term conditions and/or social care needs could benefit from the use of telehealth and telecare services.” http://3millionlives.co.uk/about-3ml#background

Lesson 3 Crossing the brick wall – mainstreaming remote care

All those pilot projects have told us something about the organisational and economic factors which influence implementation of remote care

Columba

Brockhurst Dementia unit

NEECH videophone pilot

Mid Surrey Falls Project Guildford Falls Project

Dray Court Telecare flat

COPD at Home Project

Dormers SMART House

LAA: Safe At Home

MEWS Hospital Discharge project

Mid Surrey Wristcare pilot Tandridge Telecare Flat

Community Alarm Teams, Elmbridge, Guildford, Mole Valley & Runnymede

Thames Ward, Molesey Hospital

Leatherhead Hospital

COPD Project

The challenge is not the technology!

Adoption Spread Mainstreaming

Time

Level of uptake

Enthusiasts

Grants

Financial support has helped stimulate activity at a local level

Pump priming

Adoption Spread Mainstreaming

Time

Level of uptake

Enthusiasts

Grants

We understand much about the organisational factors that influence implementation

Pump priming

Champions

Leadership

Project management

Adoption Spread Mainstreaming

Time

Level of uptake

Enthusiasts

Grants

Pump priming

WSD has highlighted questions about the need for evidence and a business case

Evaluation Evidence

Business case

Champions

Leadership

Project management

Lesson 4 Evaluation, evidence, policy and scaling up

It is often hard to pin down healthcare ‘innovation’ … remote care is no different

An innovation with seemingly straightforward objectives and using relatively simple technology can be:

• highly operationally complex

• with a large number of stakeholders and

• perverse economics

• often evolve through process of adoption

So evaluating the impact of telehealth (and especially telecare) is very hard and leads to ambiguous, context-specific findings

Yet there is a perceived need for very ‘robust’ evidence

• ‘Pilot-itis’ – lessons learnt from projects are not disseminated or accepted locally

• ‘The largest RCT of remote care’ to date

• Background discourse on ‘evidence-based policy’

Is an obsession with evidence beginning to stifle experimentation and innovation, and slow scaling-up?

The future landscape is apparently promising

• Government and industry ambitions are high – 3 Million Lives

• DH is encouraging – adjust tariff, look at incentives

• We know what the organisational barriers are and what to do about them

But what about the business models for remote care?

Suppliers have been searching for business models for years: • market segment, i.e. users to whom

the offering is useful and for what purpose

• value chain required to create and distribute the offering

• cost structure and profit potential

• position of supplier within the value network

• competitive strategy to gain and hold advantage over rivals

Finally, the questions we now need to address (apart from continuing to work on the WSD data)

• How to engage with the part of the health system that has the bulk of the budget – CCGs

• What is the role of the supply side?

• What financial and contractual models for remote care are the most effective?

Do they have the capacity / expertise / inclination to plan and coordinate the implementation of remote care?

Many would like to move from a ‘box provider’ to ‘service provider’ role … but how to do this?

What PPP arrangements work and what do they embrace? • infrastructure only • infrastructure + monitoring • infrastructure + monitoring +

clinical care

WSD research team: James Barlow, Jane Hendy and Theti Chrysanthaki Based on several projects funded by EPSRC and Dept of Health