1. Unanswered questions in telehealth. The
lessons to be learnt from the WSD trial
Evaluating the impact of telehealth: where next for research beyond
the Whole System Demonstrator trial?
2 October 2012
Nuffield Trust, London
James Barlow
www.haciric.org

2. 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

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

4. The idea has been around a long time
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

5. 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)

6. There are many
industry case studies
and other reports

7. There have been many trials ...
Diffusion of telecare in Surrey 1998-2005
COPD Project
Brockhurst Dementia unit
LAA: Safe Thames Ward, Molesey Hospital
At Home
Columba MEWS Hospital Discharge project
NEECH videophone pilot
Leatherhead Hospital
Mid Surrey Falls Project Dormers SMART House
Guildford Falls Project
Dray Court Telecare flat Mid Surrey Wristcare pilot
Tandridge Telecare Flat
COPD at Home Project
Community Alarm Teams,
Elmbridge, Guildford, Mole Valley
7
& Runnymede

8. Even before WSD there was a
large evidence base
• 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 Bulk of studies are
evidence is limited targeted at diabetes and
heart disease
Source: Barlow et al (2007)

9. Which? (Feb. 2009)
Remote care is
entering the
public awareness

10. And yet …

11. The remote care adoption pattern in the UK
Adoption Spread Mainstreaming
Level of
uptake
Time

12. So how much remote care is
there in the UK?

13. 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
350000
With Scotland &
300000 Wales
250000
200000
150000
100000
Assumes 15,000 remote care
50000 users (2005) and 5000 users
(2000)
0

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

15. Half a million, one million … or three million?
Assumptions:
• UK population aged 75+ is
c4.9m (2010)
• c85% of older people wish
Actual remote Potential remote care to remain at home as long
as possible
care market 2010 market 2010 • 1/3 needs remote care at
350,000 1,400,000 any given time
Source: based on CQC
returns, JIT (Scotland) data,
Potential and authors’ research for
telehealth WAG. Telehealth figures
Actual telehealth market
market 2010 from Minutes of the Strategic
2010 Intelligence Monitor on
450,000
22,500 Personal Health Systems
[SIMPHS] meeting,
Brussels, 17-18 November
2009.

16. We don’t know:
How many people could
benefit at a given
snapshot in time or over a
year (what is the rate of
“The Department of Health
‘churn’?) believes that at least three million
people with long term conditions
and/or social care needs could
Which population groups benefit from the use of telehealth
can benefit most? (top of and telecare services.”
http://3millionlives.co.uk/about-
the ‘pyramid’, next tier, 3ml#background
which conditions?)

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

18. All those pilot projects COPD Project
have told us LAA: Safe
At Home
Brockhurst Dementia unit
Thames Ward, Molesey Hospital
Columba MEWS Hospital Discharge project
something about the NEECH videophone pilot
Leatherhead Hospital
organisational and Guildford Falls Project
Dray Court Telecare flat
Mid Surrey Falls Project
Mid Surrey Wristcare pilot
Dormers SMART House
Tandridge Telecare Flat
economic factors COPD at Home Project
Community Alarm Teams, Elmbridge,
which influence Guildford, Mole Valley & Runnymede
implementation of
remote care

19. The challenge is not the
technology!

20. Financial support has helped stimulate
activity at a local level
Adoption Spread Mainstreaming
Level of
uptake
Enthusiasts
Pump priming
Grants
Time

21. We understand much about the organisational
factors that influence implementation
Adoption Spread Mainstreaming
Level of Leadership
uptake
Project management
Champions
Enthusiasts
Pump priming
Grants
Time

22. WSD has highlighted questions about the need for
evidence and a business case
Adoption Spread Mainstreaming
Business case
Evidence
Evaluation
Level of Leadership
uptake
Project management
Champions
Enthusiasts
Pump priming
Grants
Time

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

24. 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

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

26. 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’

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

28. 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

29. But what about
the business
models for
remote care?

30. 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

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

32. Do they have the capacity /
• How to engage with the expertise / inclination to plan and
coordinate the implementation of
part of the health system remote care?
that has the bulk of the
budget – CCGs
• What is the role of the Many would like to move from a
‘box provider’ to ‘service
supply side? provider’ role … but how to do
this?
• What financial and
contractual models for
What PPP arrangements work
remote care are the most and what do they embrace?
• infrastructure only
effective? • infrastructure + monitoring
• infrastructure + monitoring +
clinical care

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