interviews

Telehealth: the ‘quiet storm’

David Morgan is a consultant otolaryngologist and clinical director of ENT Services at Heart of England NHS Foundation Trust, as well as an associate professor at the Clinical Research Institute at the University of Warwick. Nine years ago he founded a company, Safe Patient Systems (where he is now medical director), which has become the top provider of telehealth technology to the NHS. NHE spoke to him.

Safe Patient Systems grew out of the Heart of England NHS Foundation Trust in 2005, and it is the patient-first vision it shares with the NHS that has helped the company become so successful, according to its medical director David Morgan, a consultant surgeon at the trust.

The company recently became the technology provider to BT Cornwall, a ten-year partnership between BT, Cornwall Council, Peninsula Community Health and Cornwall Partnership NHS Foundation Trust. That contract covers the supply of 1,200 of its smartphones with its Safe Mobile Care platform installed, to be used by patients.

That is one of four new contracts that bring the number of patients being supported by its telehealth and mobile health systems to 7,000. According to the latest annual Government Procurement Service report, the company is the UK’s biggest provider of telehealth technology to the NHS.

Problems with the Whole System Demonstrator

NHE asked Morgan for his views on the development of telehealth in recent years, and how he would characterise what happened with the Whole System Demonstrator (WSD) studies into telehealth. “A disaster!” he said. “Where I sit, the WSD always seemed a bit bizarre. I know why the NHS does this kind of big-bang research, [but] they were using apples and pears in terms of the comparisons. It’s a bit like me saying, ‘let’s do a drug trial to show that drugs work, and we’ll use a penicillin, a cytotoxic, and a lipid lowering drug’. You’re not talking about the same technology.”

The involvement of 12 academic institutions further increased overheads, he added, and said: “They selected patients just because they had a diagnostic code against them, not how severe they were. Why would you monitor someone who’s got asthma but who’s never been to hospital? They’re not going to see any benefit. The selection was faulty, and my own view from a clinical point of view is that rubbish in equals rubbish out.”

An initial 2012 analysis of WSD results found that telehealth cut hospital admissions by 18% and deaths by 46%. Value for money is a different matter, however. Researchers writing in the BMJ in 2013 concluded: “The QALY (quality-adjusted life year) gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.”

But Morgan said: “We’ve got to accept that although the people who did it had the best intentions, it wasn’t really set up in the best way. They came at [WSD] almost like a drug trial, but to me, telehealth is an enabler of normal practice. It makes normal practice more efficient and cost-effective. It’s not a new treatment.”

Freeing up hospitals to do what they do best

Morgan said that although the NHS is facing increased costs, he is confident in the vision of new NHS England CEO Simon Stevens, whose experience with foreign healthcare systems means he can “bring a unique assessment of how we can do things better”.

“Simon Stevens, like most people who work in the NHS, realises that we have to get patients being treated at home, being more empowered to look after their own health to allow the hospital to do what it’s good at doing – acute trauma, paediatrics, oncology and so on.

“If you wander around any A&E department in October, it will be full of people on nebulisers due to exacerbation of their COPD (chronic obstructive pulmonary disease). Why is this happening, when they can be better looked after using enabling technology at home, preventing the exacerbations?

“Telehealth is very much a quiet storm, allowing a paradigm shift but supporting the strategic view of the NHS – that more needs to be done at home than in hospitals.

“The problem is that some commissioners have fatigue from the experience of Connecting for Health, where people tried ‘big bang’ solutions. That doesn’t work with technology: you need a crawl, walk, run approach, making sure you have the budget, once you’ve learned to crawl, to go on to the run.”

From reactive and disease-centric to pre-emptive and patient-centric

Morgan is keen to stress that the benefits of telehealth in terms of cutting emergency admissions is just one aspect: it also allows much better use of nursing resources, for example.

He said that in most cohorts of patients – regardless of the nature of their precise long-term condition, whether CHF (congestive heart failure), diabetes, or COPD, for example – about 5-8% of them ‘alert’ per day.

Telehealth monitoring allows the nurse to focus on those patients who alert and need their time the most. Morgan said: “This is using technology to enable, to focus, and to convert what is traditionally a reactive healthcare process into a pre-emptive, proactive process that is, importantly, patient-centric and not disease-centric.”

Morgan added: “Obviously the nurse can still see the patients who are not ‘alerting’, but they can focus on those who need it most. Focusing on those avoids the emergency admissions which clog up your beds and mean you can’t do your elective surgery.”

Helping patients help themselves

Telehealth is not just about remote monitoring and alert systems – it can also improve self-care and encourage self-treatment.

Morgan said: “Patients know their health better than their doctor. That’s something I say to patients a lot, as I did when talking to a mum and her child at a clinic just this last weekend. A doctor will interact with them for say 10 minutes every six months, while the patient lives with their health 24/7/365.

“There are some patients who want someone to look after them, but I’m sure the vast majority of people know when their health is deteriorating. “The health service hasn’t been good at supporting them in looking after themselves, and helping them with decision-making. Once again, technology is about enabling this change: patient empowerment and self-education.

“We have e-learning pathways on our [device] so patients are not only being monitored but also being educated at the same time. With any individual patient, then in time, the alerts go down, as they become better at self-educating and self-treatment.

“Telehealth is not one-size-fits-all; there’s going to be some people who never really want to engage with it, but our experience is that’s a small minority. The average age of our users is 75 and the oldest we’ve had is 104. So, that’s the other thing – getting over the resistance of doctors as regards patients looking after themselves, and the ability of the elderly to use this technology, which they absolutely can.

“The basic platform is completely customisable and localisable into different languages,” Morgan added. “This type of technology can allow empowerment of people who have been marginalised. We’re now looking at areas such as mental health. If there’s one area where the NHS fails dramatically, it’s engaging with people with mental health problems.”

End-to-end solution

The Safe Mobile Care system (the company also offers ‘Safe Mobile Multi Care’ and ‘Safe Text Care’) is a platform installed on a phone or tablet and supplied directly by Safe Patient Systems, which also supplies the back-end server software and support. It is not currently available as a downloadable app, partly because the company wants to ensure it is used on MHRA-accredited devices, but also to ensure it can be easily controlled and updated and communication with the server can be guaranteed. “That’s why we’ve always gone for an end-to-end solution,” Morgan said. “There are some possible risks with someone using a downloadable app.”

The phone can be used for calls, but that is strictly controlled. “All the functionality of the phone is controlled by us,” Morgan said. “Patients can’t use it to phone Australia, because the NHS is paying! They don’t want to pay for communication charges that are not medically useful.”

He called the Cornwall system a “fantastically innovative model”, because so many stakeholders are joined up on one IT system with transparent data. “It’s a fantastically brave move by BT that has gone down exceedingly well with the stakeholders, and it’s important because it’s a real scale operation. It’s not about doing 100 [devices] here, 200 there – it’s got to be a population-level deployment.

“Our solutions vary from supporting children with spina bifida to the classic CHF, COPD and diabetes. It’s important that we’re able to deal with multiple diseases with the same patients.”

Morgan noted that of the 21 CCG areas where its solution is in use, 13 are for multiple diseases, often when commissioners see its effectiveness for one disease state and see how it can be expanded to cover others.

Its contracts so far have come from competitive procurement processes, which Morgan said is important: “It should be a competitive arena, so the NHS can have the best pick of what’s available, and we would always welcome open competition. In the past, people have been leveraging previous relationships in telehealth, but we’re very keen that any opportunity comes from a procurement rather than any other methodology.

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