Comment

What can the NHS learn from the VHA?

Julia Manning, chief executive of independent think tank 2020health, discusses the lessons in long-term condition management emerging from the USA.

At present, the NHS spends 70% of its budget on the 15 million individuals who have one or more long-term condition. This number is expected to increase by 23% within the next 20 years due to our ageing population.

The current NHS delivery of care for patients with long-term conditions is widely accepted as unsustainable in regards to cost and quality of care.

Awareness of these alarming figures demonstrates how important it is to review current procedures and to consider alternative methods that could be adopted to create a system that is more effective for its users, and more cost-effective for its payers.

In 2010, 2020health published the report ‘Healthcare without walls: a framework for delivering telehealth at scale’, which outlined how telehealth services could improve the cost and quality of care within the NHS. The report highlighted numerous proposals on how to implement these ideas at scale. On January 19 2012, on the day that the government launched its ‘3 million lives’ telehealth programme, 2020health produced a follow-up white paper, ‘Telehealth – what can the NHS learn from experience at the US Veterans Health Administration?’ This built on the 2010 report, with more detail from the evidence and experiences of the Veterans Health Administration (VHA).

Telehealth at scale

The white paper was based on interviews that took place with VHA chief executives and clinical leaders as well as research that had been previously published on organisations’ use of telehealth at scale. Once again, 2020health’s paper sought to make key recommendations on telehealth implementation that could inform NHS leaders, policy makers and commissioners.

The VHA is a major part of the Department of Veterans Affairs, which delivers federal benefits and patient care to veterans of the armed forces. Its mission is “to keep patients healthy”, and to that end, it employs 225,000 staff in 153 hospitals and a num-ber of other centres, delivering healthcare services to 23 million veterans (2009 figures). In 2010, the VHA’s annual budget for medical care was £30bn, which is approximately a quarter of the NHS’s budget.

The VHA was failing as a healthcare system in the 1990s. President Bill Clinton appointed an experienced physician, Dr Ken Kizer, as the VHA’s new Under Secretary for Health and he immediately began to reorient the system away from hospitalbased care. Central to this was the installing of the Care Coordination / Home Telehealth programme to improve nationwide healthcare, providing “the right care in the right place at the right time”.

The initial purpose of the programme was the vigorous control of long-term conditions and post-traumatic stress disorder (PTSD), but has now been expanded to primary prevention of the above conditions along with, for example, an obesity management programme and for additional conditions such as programme for those requiring palliative care, acute heart disease and dementia.

The VHA has 21 areas for regional service delivery and these were all allotted $1m for the equipment needed to launch their telehealth programme. These areas were asked to supply telehealth for five conditions which included chronic heart failure, chronic obstructive pulmonary disease, hypertension, diabetes mellitus and PSTD. These conditions were targeted because they consume the majority share of healthcare resources. Patients who had enlisted for this programme were provided with ‘care coordinators’ who assessed patients during the enrolment process, selected the appropriate technology, trained the caregiver and the patient, assessed telehealth monitoring data when it is updated and provided active care management.

The results were stunning: a 20-56% reduction in patient utilisation of services depending on the disease group.

In 2004, when the national Home Telehealth programme was inaugurated, its purpose was to provide care for non-institutional patients (patients who had deficits in three or more activities of their daily living and who were at risk of being placed in a nursing home), and individuals who needed long-term condition case management. Telehealth allowed the care services to be brought to the patients. This programme assisted with the organisation and continuity of care as well as reducing clinic visits and hospital admissions, and resulted in a reduction in costs associated with chronic condition management and an improvement in patient outcomes. Telehealth also allowed the patients to take control of their own health and changed the relationship between the patient and the healthcare system, putting the patient at the centre.

Referral system

When the programme first commenced, the recruitment of patients for the telehealth programme was completed using risk stratification. The first individuals recruited were patients who had health costs that exceeded $100,000 in the previous year and/or had contact with the care service multiple times or for an extended period of time. Currently, telehealth patients are recruited via referrals from physicians; however, some patients may refer themselves or are referred by other patients in the programme.

The VHA has been highlighted for its excellent delivery of healthcare. Even in the early years of Dr Kizer’s tenure, a 2004 RAND corporation study noted that the VHA was superior when compared to the other division of American healthcare in 294 measures of quality. The British Medical Journal mentioned in 2007, “the VHA has recently emerged as widely recognised in quality improvement and information technology. At present, the VHA offers more equitable care, of higher quality at comparable or lower cost than private sector alternatives”.

Due to the success of the programme, the VHA provides numerous lessons that the ‘3 million lives’ (3ML) NHS programme needs to learn as it creates a new telehealth service.

It’s good news that the Department of Health has indicated it is working on a new ‘year of care’ tariff that will at least provide a currency for future commissioning of telehealth, but there are further steps that are vital to success.

Business case

With investment into central programmes on the whole a thing of the past, the key now lies with persuading commissioners of the business case for new telehealthenabled services. The Whole Systems Demonstrator results (the large trial of telehealth that preceded the 3ML announcement) – and other relevant evidence – will need interpreting to help commissioners frame new services and decommission others; in particular, of course, for diverting acute resources into community care.

Added to this, while commissioning at the local level remains in flux, the National Commissioning Board will need to show leadership and consider what will really drive large-scale uptake – in addition to the requirement of the use of technology as directed in the Innovation Strategy. Clinical leadership will also be essential. We need to turn enthusiasm at the national level and in organisations such as the RCGP into clear endorsement for local GPs to refer patients, provided telehealth-enabled services meet key clinical standards, and possibly also have central accreditation. There is a lot to learn from telecare too, which is well established in many local authorities, and there could well be opportunities to converge systems and costs. Personal health budgets could be an additional driver here.

The story of the VHA tells us that this is an exciting opportunity, one that could transform the lives of a huge number of people living with long-term conditions. Government mustn’t let the waste and embarrassment of the NHS IT programme mean that they neglect to provide the central support that is vital to the success of the 3ML telehealth programme.

Tell us what you think – have your say below, or email us directly at [email protected]