Presentation at LSE event (European Knowledge Tree Group) on 8 April 2013 on Learning from Whole System Demonstrator programme - future of telehealth in England

1. 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

2. 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

3. 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

4. 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 pa
Total CCG Budget = £65bn pa
@clarkmike

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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
@clarkmike
last 1-4 years

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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
@clarkmike
simply ‘health’.

22. 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 pa
Total 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

23. Thank you
@clarkmike
www.telecarelin.org.uk
https://www.rebelmouse.com/clarkmike/