09.04.11
Chronic disease management and the future of telehealth and telecare
As the recession bites, grant funding for new innovations is likely to cease and NHS and local authority finances will become heavily squeezed. This may prove bad news for telecare and telehealth, says Nick Goodwin
With an ageing population and the ever increasing prevalence of both chronic and long-term illness a challenge has been established for the management and integration of health and social care. The need for new care models and new technologies to support long-term care needs has never been greater whilst the management challenge requires the fostering of new forms of clinical and inter-organisational partnerships and networks and the promotion of care support strategies within the home environment.
The urgency of making this shift in the balance of care settings is being driven by the dramatic upward trend in costs. It is a truth that if we do not engage with keeping people healthy, independent and out of institutional care (both long term care and hospital care) then total expenditure will rise to potentially unsustainable levels as utilisation rates increase exponentially 1.
We can also expect the current economic downturn to exacerbate the demand for health and social care services in the short-term since we know that the health and wellbeing of populations suffers during times of recession 2.
Emerging technological innovations such as telecare and telehealth have the potential to enable and support long-term social and medical care in people’s own homes.
Telecare, for example, is characterised by continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living.
Telehealth is the remote exchange of physiological data between a patient at home and medical staff at hospital or GP surgery to assist in diagnosis and monitoring. Amongst other things, it comprises home units to measure and monitor temperature, blood pressure and other vital signs for clinical review using phone lines or wireless technology.
Telecare and telehealth have been promoted vigorously by a government eager to find a cost effective remedy to rising demand and costs. For example, the Darzi Review identified telehealth as a ‘core’ preventive service in supporting people with long-term chronic conditions whilst £80m was injected into councils in April 2006 in the form of a preventative technology grant to help initiate telecare innovations to help maintain the well-being and independence of 160,000 older people in their own homes whilst reducing avoidable admissions to hospital and residential care.
The emerging international evidence – of which there are hundreds of pilot or trial project on ‘remote care’ worldwide - shows some cause for optimism for these strategies.
Many studies show that telecare and telehealth can positively affect clinical outcomes, client independence, reduce visits to the emergency room, lower admissions to hospital, reduce lengths of stay and lower the utilisation of GP services.
However, a characteristic of the evidence is that it is spread across such a diverse range of technologies, care systems and client groups that any form of generalization of outcome from a specific innovation is problematic - an issue also related to the variable quality and depth of research studies 3,4.
More importantly, there is a lack of evidence to conclude that telecare and telehealth innovations are cost effective - a fact that has the potential to limit the funding of innovative new technologies as commissioners seek to ensure their financial investments are made wisely.
Whilst there is an underlying belief that new assistive technologies should help reduce costs in the long-term, advocates face real problems with developing and sustaining such innovations due to the lack of cost-effectiveness data.
The business case for investment is thus often unable to reassure commissioners of performance improvements in terms of reduced hospital utilisation rates, health gain or contribution to savings targets.
Organisational barriers related to integration of care between care providers have also slowed or precluded uptake, not least due to budgetary or professional protectionism. As a result, pockets of excellence have not spread beyond the enthusiasts and innovators within whom only vision and belief is enough.
In truth , pilot projects are rarely sustained and telehealth and telecare have yet to become a mainstream part of the delivery of chronic care. An ‘evidence chasm’ exists since, despite the growing evidence for the clinical effectiveness of some specific telehealth and telecare applications and the growing belief in their utility, the lack of cost-benefit evidence has been stifling.
A good case in point is the potential for home-based telecare to enable people with dementia to be supported with technologies that help keep them safe and independent in their own homes and so reduce both the burden on carers but also the burden on the health and social care system.
The long-awaited National Dementia Strategy published in February 2009 highlighted the need for people with dementia and their carers to have access to telecare – but only as ‘evidence emerges’. The decision in the strategy to give an ‘amber’ rather than ‘green’ light to telecare applications appears to be appropriate given the existing evidence but has meant that innovators are left one step short of a mandate to invest and run with such new services. Nonetheless, this is one area where evidence has not seemingly stopped the ability to innovate – as a result, new evidence from pilot approaches is emerging on a regular basis 5.
The history of health and social care integration is littered with well-meaning and often effective new partnership schemes built on shared development funds and government grants that subsequently founder as health and social care organizations look inwardly to protect their own budgets . The investment histories of commissioners would suggest ‘non-core’ or speculative ventures where outcomes and investment returns are uncertain are the ones most likely to be frozen or discarded as expenditure is cut and prioritised 6.
For telecare and telehealth to thrive rather than perish in a cold economic climate it is vital that new innovations are actively encouraged with minimal delay and are linked directly to generating a sound and emerging evidence-base.
It is for this reason that the Department of Health has been keen to develop the evidence base through an ambitious randomised control trial of telehealth and telecare that seeks to examine 6,000 service users over two years in a real-time study comparing ‘intervention groups’ (with advanced assistive technology) with ‘control groups’ receiving ‘usual care’ 7.
In addition, an action research network - called WSDAN (Whole System Demonstrators Action Network) - is developing an integrated point of access for published materials on the evidence base as well as to support the generation of evidence and promote evaluation amongst its membership 8.
It launched an ‘evidence database’ in July 2009 which currently has summaries of over 225 reports and articles – a number set to at least triple by the end of the year 9. Moreover, WSDAN has committed to undertaking some ‘translational’ work in respect of such evidence, turning it from academic language that is difficult to understand and interpret in favour of evidence that provides clarity and guidance to those seeking to develop business cases or to commit to new innovations.
Despite the importance of developing an evidence base to inform decision making, the future reality is that the development and survival of local telehealth and telecare innovations will rely as much on local ‘champions’ (such as medical directors and councillors who have the power to earmark commissioning resources) and through commitments made in strategic plans such as Local Area Agreements and Local Development Plans.
It is highly unlikely that the WSD Programme will provide the definitive evidence for this, yet there is the growing reality that commissioning organisations are not taking on the responsibility to innovate in this area until it does – a bit like Waiting for Godot.
Government policies and national targets and guidance for the roll-out of new technologies may prove to be highly influential. It’s not as if a lack of evidence has been a barrier to government policy initiatives in the past – and in many ways we already have the evidence staring us in the face.
We know the current system is not geared up to meeting the demands of an ageing population with increasing long-term care needs and that system redesign – one that shifts the balance of care settings from institutions to the home environment – is essential if we are to reduce the future cost burden of delivering care.
Moreover, you cannot achieve choice and the personalisation of care services without first freeing people from the shackles of institutional care in hospitals and nursing homes.
Even so, it is likely that sustaining innovation in home-based telehealth and telecare services may prove problematic in the face of financial realities. This, of course, represents a curious paradox as it will be through schemes such as telehealth and telecare that the necessary strategic objective of developing care support strategies within the home environment has the most potential.
Nick Goodwin , PhD is senior fellow, health policy, King’s Fund, London, W1G 0AN, UK, [email protected]
A version of this paper was first published as an editorial in the Journal of Care Services Management – Goodwin N (2009) Will telehealth and telecare thrive or perish in a cold financial climate? J Care Services Management, 3(2):116-118
References:
Coyte P, Goodwin N, Laporte A (2008) Policy Brief. How can the settings used to provide care to older people be balanced? WHO Regional Office for Europe, Denmark
Appleby J. ‘The credit crisis and health care’, BMJ, 337, 1022-1024
Dellifraine J, Dansky K. (2008) ‘Home-based telehealth: a review and meta-analysis’, Journal of Telemedicine & Telecare, 14(2): 62-66.
Barlow J et al (2007) ‘A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions’, Journal of Telemedicine & Telecare, 13(4): 172-179.
Bowes A, McColgan G (2009) Implementing people for telecare with dementia: supporting ageing in place in West Lothian, Scotland. J Care Services Management, 3(3):227-243.
Goodwin N (2007) ‘ Developing effective joint commissioning between health and social care: Prospects for the future based on lessons from the past’, J Care Services Management, 1(3), 279-293
Department of Health (no date) ‘Whole System Demonstrators’ available at http://www.dh.gov.uk/en/Healthcare/Longtermconditions/wholesystemdemonstrators/DH_084255, accessed 31 st July 2009
WSD Action Network (no date) ‘About WSDAN’ available at http://www.wsdactionnetwork.org.uk/about_wsdan/index, accessed 31 st July 2009
WSD Action Network (no date) ‘WSDAN Evidence Database’ available at http://www.wsdactionnetwork.org.uk/resources/evidence_database, accessed 31 st July 2009
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