Are the Whole System Demonstrator trial results a watershed moment for the rise of telehealth?

On Monday, David Cameron launched the government's Life Sciences Strategy, which seeks to attract investment to support the discovery, development and delivery of medical innovations.

As part of this strategy, there is a commitment to increase and speed up the use of telehealth technologies – such as home-based equipment that can send the vital statistics of at-risk patients direct to clinicians. The delivery of this technology will be done in partnership with industry and will aim 'to improve the lives of three million people over the next five years'. This could help to position the UK at the forefront of global health care in this field.

At the same time, the Department of Health published its headline findings from the Whole System Demonstrator (WSD) programme – the largest trial of telehealth and telecare ever conducted, with almost 6,000 participants. We already knew these results would be positive, but the findings show that – if 'delivered properly' – telehealth could achieve an impressive 20 per cent reduction in emergency hospital admissions; a 14 per cent reduction in elective admissions; another 14 per cent reduction in bed days; and an 8 per cent reduction in tariff costs. Most strikingly, the evaluation demonstrated a 45 per cent reduction in mortality rates.

These impressive results will surpass the expectations of many in the private sector who have found the UK telehealth market (particularly in England) a tough nut to crack. Talking to the chief executive of a major telehealth service provider at a conference last week, we both agreed that the difficulties in mainstreaming telehealth services in England were probably insurmountable unless there was a directive 'from the top'. Moreover, while we felt that remote technologies would be used routinely in caring for people with chronic illnesses within three to five years, we could not predict when it would take off and whether the long-delayed results of the Whole System Demonstrator trial might act as a catalyst.

The government's plans to involve industry in its Three Million Lives campaign (a statement of intent rather than a target) indicates that they are serious about providing national leadership, strategic direction, and advice to NHS and social care organisations to help create a market and to deliver change. So it is tempting to conclude that the government has reached the watershed moment when the deployment of new technologies will increase exponentially.

However, it is clear in the Department's short report that the best results will happen only where telehealth is delivered properly, and that this requires a more integrated health and social care service. As I discussed last month, if we are to make telehealth a reality, we need a clearer understanding of the operational processes that are required at an organisational, clinical and service level to ensure that users and patients feel the benefits of these new technologies. For this to happen, the Department of Health and policy-makers will need to accept and prepare for the consequences of such a change. Significant investment is needed to improve skills and enable primary care providers to deliver and co-ordinate care in the home.

It is inevitable that this agenda will require some 'double-running' costs in the short term and the subsequent down-sizing of activity undertaken in acute hospitals in the medium term – neither of these are particularly palatable concepts politically or economically. The government's strategy is to use a large chunk of private sector capital to inject the necessary impetus into the system. However, the NHS market is volatile, bureaucratic and cash-strapped, making any significant investment risky. To encourage companies to invest in new technologies, we will need to reassure them that they will not lose their shirt in the process. Nevertheless, now that telehealth has a stronger evidence base and the support of the Department of Health, we have created the most receptive environment for it yet, which could fundamentally change the way service users and patients experience care.

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Comments

#638 Gavin Colthart
GP

The inclusion of remote monitoring and support into the integrated care of patients at home clearly holds the potential to deliver real benefits to patients and their carers and, potentially, to reduce costs. However, the preliminary reporting of the results of what is described as a randomised controlled trial, and some of the rhetoric surrounding the announcement, should ring alarm bells.
A few points:
1. Pre-publication announcement of trial results smacks of PR and immediately makes debate of the results themselves (which do not yet appear to fully peer-reviewed or available) seem reactive and defensive.
2. The trial-related literature is odd for a supposedly scientific study as it repeatedly stresses its intent to show a positive benefit rather than evaluate what benefit there might be - it could appear as though the trial was established to prove a point, although this may of course not be the case.
3. Whether or not the trial was intent on proving a positive benefit of the technology, it would be important to be able to assess any confounding in either design or execution before taking the results at face value. For example, patient-professional contact time (such as with GPs or telephone services) in the study group may have been greater than in the control group, a variable independendently associated with better outcomes, or there may have been issues around blinding of data assessments or collection. Perhaps not, but this can't be evaluated despite the very public announcement calims of a 45% reduction in mortality.
4. The figures presented to date appear so dramatic as to render any cost-benefit analysis moot. Despite this, the analysis needs to be done.
5. Implementing this technological boost to integrated care is being marketed as part of a wealth-creating technology drive. But the only sure winners in this will be the technology suppliers if the funding is centralised and the procurement agenda influenced by those same suppliers. Previous NHS experience with IT might temper our naivety here.
6. The various monitors used in the trial are mostly simple and well-established, the main innovation being in their use as part of a system of care. However, the temptation for suppliers will be to goldplate the hardware, make it as proprietary as possible, and sell it as part of a package of services, thereby (quite sensibly for them) increasing profits and reducing competition. My impression (based admittedly on the limited trial details I have found in the public domain) is that some off-the-shelf components were used in the trial. It seems likely that existing products and communication systems could deliver the bulk of the required functionality without diverting unnecessary amounts of public money towards specialised medical equipment suppliers.
So, probably a Very Good Thing but let's not allow the benefits of remote monitoring and support to be lost in a blaze of hype and special interests.

#642 Younus Saleem
Consultant Forensic Psychiatrist
Nottinghamshire Healthcare NHS Trust

In your post above you state. "UK telehealth market (particularly in England) a tough nut to crack". I totally agree with this. I have been using telepsychiatry for nearly seven years providing direct clinical care/ activity (gate keeping assessments, follow up appointments, risk assessments, court reports, attending case conferences etc) and both published and promoted this type of work in UK and further afield (as far as US and Autralia). The biggest obstacle to making this easily available to a variety of service users is not technological but one of 'attitude'. Medical and nursing collegues are extremely reluctant to embrace innovation. There is a plethora of evidence base to show that telepsychiatry is safe, user friendly, efficeint, cost effective etc. But the emphasis on face to face contact is still so sacrosanct to mental health professionals that they are unwilling to maximally benefit from telepsychaitry where appropriate. For example there are a number of prisons where mental health services are difficult to access. Telepsychiatry could pave the way to bring inaccessible care within the reach of those who most need it. Even where in-reach mental health services are available, the use of telepsychiatry could cut costs and improve efficiencies. I hope the governement pushes the healthcare providers in the direction of telepsychiatry and telehealth to cut costs. This of course should be done without compromising patient safety. I beleive it is possible to do so without putting patients at risk.

#646 Ashley
Public and Mental Health Researcher

Dear Mr. Newman,

Hello. My name is Ashley Karr. I am a public and mental health researcher focusing on telehealth. My PI recently found out about the Whole Systems Demonstrator (WSD) study, and we are interested in learning more about the findings and reports generated from the Whole WSD study. So far, we have found the following:

- the WSD Programme Headlines Findings (Publish December 2011) dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131689.pdf
- the Study Protocol titled A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial biomedcentral.com/1472-6963/11/184
- the WSD Overview of Telecare and Telehealth dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_100947.pdf
- This blog posting
- the WSD Programme overview found on the Department of Health website dh.gov.uk/en/healthcare/longtermconditions/wholesystemdemonstrators

Do you know where we can find more information on the study, results, findings, and or publications?

Thank you for your time. Happy Holidays.

Best,

Ashley

#647 Ashley
Public and Mental Health Researcher

Dear Mr. GOODWIN,

Sorry about confusing your name is the first posting. Newman and Goodwin are not at all alike! I am not sure why I got it in my head that your last name was Newman. I apologize for any defense, and I think this is a sign that I should stop and take my lunch as soon as my blood sugar starts dropping, rather than continuing to read articles and write emails and blog comments!

Happy Holidays to you.

Warm Regards,

Ashley

#655 Nick Goodwin
Senior Fellow
The King's Fund

Dear Ashley
Further results should be available in the New Year, though don't know exactly when. Many of the results will feature at our international telehealth and telecare congress in March

#1037 vince doherty
Great Western Hospital

Hi Nick
I'm doing some high level strategic analysis work for the Trust on implementing community integration, including telehealth/telecare.
I have not been able to access any further evaluation work from the WSD sites. So I would be very grateful if you could confirm the headline findings. Is the reduction in bed days at 14% on top of the elective and emergency admissions reductions at 14% and 20%. As I'm sure you are aware it makes a very significant difference in modelling any impact assessment.

#1038 Nick Goodwin
Senior Fellow
The King's Fund

Vince

Thanks for your post

The full results of the WSD trial have yet to be made public, but are imminent and planned to be presented out our conference on 6-8 March.

What is important to recognise is that the results/impact will look different to what the DH has announced. This is because the DH has extrapolated impact on the basis of 'when delivered properly' and we'll need to know how that was done. Moreover, there is no indication to the cost-effectiveness results from the trial as yet, and they will be important to answer whether the gains in measures of health outcomes have been 'worth' the investment. There is also no detailed explanation that would answer your questions.

So whilst the evidence looks as though its going to be promising, its very important not to plan or benchmark a possible impact (even in a ballpark manner) on the basis of the DH figures as currently reported.

#1039 vince doherty
Great Western Hospital

Thanks Nick for the response and the big "health warning" on the findings.
The more I have reseached into the topic, the more confident I feel that telehealth/telecare should form part of a Trust's long term strategy in re-shaping acute service delivery. One major barrier however will be the current structure of PbR and unless the evaluation makes some recommendations on how tariffs should be restuctured to incentivise both providers and commissioners it will struggle to take off. There seem to be quite a few evaluations, albeit small scale, using very simplistic financial analyses to justify the cost benefit. These are generally done from the commissioners perspective and I would argue are misleading as they ignore the whole impact on the health economy.

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