Learning from the Whole System Demonstrator Programme – the future of telehealth in England

How to get off the Roundabout: Making a success of an ageing population!

LSE – 8 April 2013

Mike Clark@clarkmike

www.telecarelin.org.uk

From 1 April 2013, 211 Clinical Commissioning Groups (CCGs) took over from 151 Primary Care Trusts (PCTs) in England to provide healthcare to

their local communities.

Will they achieve better outcomes for less money?

@clarkmike

The total NHS Budget for 2013/14 is £108bn.

The PCTs had £85bn pa - CCGs will have £65bn pa

(some specialist commissioning has moved to NHS England – around £12bn).

@clarkmike

There are over 15 million people with long term conditions in England - they use around 70% of the

NHS budget.

We know that increasing numbers of people have multiple/complex co-morbidites.

Cost of long term conditions = £70bn paTotal CCG Budget = £65bn pa

@clarkmike

Healthcare systems in England are not sustainable in their current form. Social care services face

major funding problems and are limiting eligibility.

We can expect to see more financial failures, mergers and other problems arising in health and social care organisations over the coming months unless there is fresh thinking about how services

are provided.

@clarkmike

Around 30% of hospital beds are thought to be occupied by people who probably don't need to be

there.

Most of the easy part of the £20bn QIPP efficiency challenge (£5bn+), has been found.

It now gets tougher without major service transformation and the best use of the skilled NHS & social care staff, drugs and technologies that we

have available.

@clarkmike

Emergency, out of hours and urgent care services are under pressure. Bed occupancy remains high and some waiting times appear to be increasing.

There are increasing numbers of people with dementia, diabetes, some cancers, heart disease.

More care and support needs to happen at the right time in the right place - at the earliest stage

where possible to avoid complications. Some conditions may be preventable, some may benefit from self-management. Some services are being

transformed – eg early stroke response.

@clarkmike

Within the coming years, we may have whole genome testing for personalised cancer

treatment…..

Yet it is still difficult for people to have conversations with health and care professionals by telephone, e-mail, video link or remote self-management support. Access to online health records is limited. Few services are 24/7. If you

self-track your health you may end up being labelled as ‘a bit strange’.

@clarkmike

If health and social care budgets were aggregated and used differently is there more scope for

improved outcomes for the same overall cost?

Yes, probably, if we coordinate and integrate services to reduce duplication, unnecessary

bureaucracy and release frontline services to do what they can do best at the right time and in the

right place.

It makes sense, but defining an effective, universal model is not easy.

@clarkmike

Can technology help?

Yes, if we adopt a sensible, pragmatic approach. Avoiding claims and hype, looking for evidence of

where it works well to maintain, improve and transform services and free frontline staff to

provide personal care. Careful and timely use of health & care data could lead to better individual &

whole system outcomes…

but it may cost more initially to get the big breakthroughs.

@clarkmike

Typically healthcare innovations can take 15 or more years for adoption.

e-mail ubiquitous by early 90s Skype available since 2003

UK telehealth remote monitoring from 2005, as was You Tube

Smartphones and social media have been around for 5+ years and tablets for 3 years

Some web portals have been around 10 years, most apps have been available for the

last 1-4 years@clarkmike

If we do nothing, what could happen?

There would probably need to be a debate in health about rationing of services, co-

payments, self-payment and top ups (it already happens in social care). There could be more complaints, legal cases, disputes,

inquiries. Consumer expectations could increase placing further demands on

services.

@clarkmike

We don't yet know whether it is cheaper to support people in the community or closer to

home, but….

We do know that in the future, people will expect to have some choice and will probably want to

access support or advice via multiple platforms in a range of locations around the clock.

We also know that many people are experts in their conditions and are able to self-manage given the right support and information. They will know

when they need more/less support.

@clarkmike

As regards the Whole System Demonstrator (WSD*) Programme, we have learnt much since the early trial

discussions (from 2006), the regional events (from 2009-10), the conferences and the 6 papers published so far (From

2012).

We know the constraints of RCTs and how the trial impacted staff working at the sites, we know the service costs from five

years ago, we know that health records still need to be improved, we know that diagnoses are not always

confirmed, that data sharing and consistency of records is not easy. We know that single disease pathways may not suit

people with complex conditions, that there is duplication and unnecessary bureaucracy.

We know that there will always be champions for change and some people that will never be convinced.

*List of WSD Papers: http://storify.com/clarkmike/updated-list-of-wsd-papers-published-22-march-2013@clarkmike

But, there was no difference in the quality of life between the two WSD trial groups for telehealth

and the £92k QALY is too high...

We know that certain technology support will benefit some people and not others. We know that

where telehealth does not work well, people can still have support to help them. We know that technology and service prices are reducing and

business models can include low cost or risk sharing options. We now know that even if people respond positively to the new services, it does not always mean their quality of life will improve over

time.@clarkmike

Is there more we could do in the future around quality of life when using remote support in the home?

Yes, we know there are links between loneliness, isolation, depression and some long term

conditions - we need to think more about support that is personalised for the individual. Peer support through

local and online communities and the use of social media could work well alongside existing telehealth approaches. We also need to think about joined-up

consumer options that could be accessed via personal budgets and self-payment. People are social - health is

social, care needs to be connected.

@clarkmike

In 2005/6, when the WSD trial was first discussed, telehealth options were few.

There are now many. Outside of the dementia village at the recent NHS Expo (March 2013), the

majority of the stands were digital health, telehealth, apps and health records. The formats

are increasingly mobile, based on smartphones and tablets as well as home TV – they may fit better

with lifestyles. There is more choice & flexibility to meet a diverse range of user needs. Any new approach has got to be easier for patients &

clinicians to be adopted at scale.

@clarkmike

The 3millionlives initiative provides opportunities to transform services that could make a difference

for people with long term conditions.

But, like any fresh approach in healthcare (‘paperless’ NHS, online access to health records,

e-mail and video consultations, electronic prescriptions*) it has to overcome the challenges of austerity, inertia and historically slow speed of

adoption. It is important to continue to gather good practice examples and evidence from UK &

around the World.

*NHS Mandate: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127193/mandate.pdf.pdf

@clarkmike

So, seven years on from the announcement of the WSD Programme, what more can we do?

Given the financial situation, we need to move quickly, evaluating as we go, generously sharing

knowledge of what works and addressing quality of life improvements where we can. We still need to be better at case finding, responding to needs

and establishing likely beneficiaries from the range of telehealth and self-management apps. We need

to engage patients and their families through support networks as well as clinicians through honest discussions about what is achievable.

@clarkmike

Cont……..

We need to focus on improving outcomes for communities and look at better ways of organising

care. With multiple co-morbidities, we need personalised care plans as disease-specific care

pathways may no longer be relevant. We need to ensure health and social care systems are

coordinated and electronic records are integral. Most of all, we need to recognise and engage

patients & communities along with frontline staff as the most important resources for better health

and wellbeing in the future.

@clarkmike

So, What is the future for telehealth in England?

We are still in the first generation of telehealth, telemedicine, mobile health, health

apps, patient portals, self-tracking and self-management, the engaged and empowered

patient as a resource, personalised pathways, risk stratification, skill mix adjustments, the use of big

data to improve outcomes, coordinated health and care services.

The potential remains strong but so are the challenges of commissioning & providing services in a different way. ‘Telehealth’ needs to become

simply ‘health’. @clarkmike

Unfortunately, we do not have time to wait 15 years for technology adoption and we do not have the money to continue on as we are with increasing

demands on health and care services.

Cost of long term conditions = £70bn paTotal CCG Budget = £65bn pa

It will not be an easy time if you are in one of those 211 CCGs starting out on your journey without

carefully considering how technology and innovation can help transform and improve services. CCGs will

need to be bold with their plans.

@clarkmike

Thank you

@clarkmike

www.telecarelin.org.ukhttps://www.rebelmouse.com/clarkmike/