James Barlow - unanswered questions in telehealth 121002
Unanswered questions in telehealth. Thelessons to be learnt from the WSD trialEvaluating the impact of telehealth: where next for research beyondthe Whole System Demonstrator trial?2 October 2012Nuffield Trust, LondonJames Barlowwww.haciric.org
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
Lesson 1Taking stock. What progresshas been made in deployingremote care in the UK?
The idea has been around a long timePractice by TelephoneThe Yankees are rapidly finding out the benefits of the telephone. A newlymade 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 dowith it?" Grandmamma replied she would call the family doctor, and would bethere in a minute. Grandmamma woke the doctor, and told him the terriblenews. He in turn asked to be put in telephonic communication with the anxiousmamma. "Lift the child to the telephone, and let me hear it cough," hecommands. The child is lifted, and it coughs. "Thats not the croup," he declares,and declines to leave his house on such small matters. He advises grandmammaalso to stay in bed: and, all anxiety quieted, the trio settle down happy for thenightThe Lancet 29 Nov 1879, Page 819
There is political supportSuccessive UK governments have boughtinto 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)
There are manyindustry case studiesand other reports
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
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)
Which? (Feb. 2009)Remote care isentering thepublic awareness
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
Lesson 2How big is the potential UKmarket for remote care?
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.
We don’t know:How many people couldbenefit at a givensnapshot in time or over ayear (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 couldWhich population groups benefit from the use of telehealthcan benefit most? (top of and telecare services.” http://3millionlives.co.uk/about-the ‘pyramid’, next tier, 3ml#backgroundwhich conditions?)
Lesson 3Crossing the brick wall –mainstreaming remote care
All those pilot projects COPD Projecthave told us LAA: Safe At Home Brockhurst Dementia unit Thames Ward, Molesey Hospital Columba MEWS Hospital Discharge projectsomething about the NEECH videophone pilot Leatherhead Hospitalorganisational and Guildford Falls Project Dray Court Telecare flat Mid Surrey Falls Project Mid Surrey Wristcare pilot Dormers SMART House Tandridge Telecare Flateconomic factors COPD at Home Project Community Alarm Teams, Elmbridge,which influence Guildford, Mole Valley & Runnymedeimplementation ofremote care
Financial support has helped stimulate activity at a local level Adoption Spread MainstreamingLevel ofuptake Enthusiasts Pump priming Grants Time
We understand much about the organisational factors that influence implementation Adoption Spread MainstreamingLevel of Leadershipuptake Project management Champions Enthusiasts Pump priming Grants Time
WSD has highlighted questions about the need for evidence and a business case Adoption Spread Mainstreaming Business case Evidence EvaluationLevel of Leadershipuptake Project management Champions Enthusiasts Pump priming Grants Time
Lesson 4Evaluation, evidence, policyand scaling up
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
So evaluating the impact of telehealth(and especially telecare) is very hardand leads to ambiguous, context-specific findings
Yet there is a perceived need forvery ‘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’
Is an obsession withevidence beginning to stifleexperimentation andinnovation, and slow scaling-up?
The future landscape isapparently 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
But what aboutthe businessmodels forremote care?
Suppliers have beensearching for businessmodels 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
Finally, the questions wenow need to address(apart from continuing to work onthe WSD data)
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
WSD research team: James Barlow, Jane Hendy andTheti ChrysanthakiBased on several projects funded by EPSRC and Dept of Health