Jumping the gun in the telehealth steeplechase?

If the adoption of telehealth were an Olympic sport, it would probably represent the steeplechase – an endurance event with obstacles that do not fall over when hit and with a 3.5-metre wide pit of water to jump across on almost every lap. Whilst many have been brave enough to try out for the event, most have decided not to enter at all as the barriers to success seem insurmountably steep.

By far the largest hurdle to the acceptance of telehealth has been the lack of robust evidence on outcomes to justify the investment. Earlier in the year, the Department of Health controversially published headline results from the Whole System Demonstrator trial ahead of the peer-reviewed evidence. These results turned heads since they claimed telehealth led to significant reductions in hospital admissions and mortality.

With the evidence barrier seemingly ‘removed’, the government used the results as justification for its Three Million Lives campaign, that established a commitment to work with industry, NHS and social care to roll out telehealth as a mainstream service. Though professionals and academics alike cautioned that full judgment should be withheld until the full evidence became available, the telehealth steeplechase began to look like a more promising prospect.

However, following the first peer-reviewed results of the Whole System Demonstrator trial published in the British Medical Journal in June, the accompanying editorials and commentaries concluded that the government had ‘jumped the gun’. They argued that the trial had not, in fact, provided enough of a convincing case to support a national rollout and that ‘the evidence base is essentially unchanged and uncertainties remain’. So, despite the fact that about 59 lives appeared to have been ‘saved’ in the trial through telehealth (a 3.7 per cent absolute reduction), the impact on utilisation and costs suggested little room for cost savings.

The upshot of the story, as exposed in the recent telehealth debate on Radio 4’s Inside Health, is that the evidence for the appropriateness and effectiveness of telehealth – and hence its rollout as a government priority – polarises opinion. The Whole System Demonstrator trial has not provided the ‘proof of concept’ on cost-effectiveness that it set out to demonstrate. Evidence, therefore, remains a significant hurdle to wider deployment, since even those who truly believe in the potential of new technologies will find it difficult to build the business case.

If telehealth is to be taken forward at all, then it must be part of a wider and long-term commitment to service redesign that seeks to support self-care and to better co-ordinate care and treatment to people with long term conditions in the home environment.

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#1301 Mike Stone

Evidence in general, seems 'interesting' for NHS behaviour/beliefs.

After that Panorama programme, the number of whistleblowers/abuse reports to the CQC increased enormously: but I'm sure that the figures previous to that Panorama programme, would have been quoted as 'evidence' - clearly, the earlier figures were unreliable.

#1302 Mike Stone

Although not necessarily applicable to telehealth, and a little off-topic, I do have a comment about ‘evidence’ and the NHS. My previous post was cut short by running out of online time.

It strikes me that the NHS likes simple evidence/feedback, of a type that can be easily analysed by statistical methods: things with yes/no or ‘tick a box’ answers.

But for many NHS issues, I think more complex narrative ‘this happened to me, and it is wrong because …’ feedback, is more useful in identifying problems/solutions.

However, politicians in particular, tend to only quote the evidence that supports their pre-existing position/intentions. So simply providing evidence, isn't enough.

And even scientists are not immune – I would be very reluctant to accept any evidence, however apparently well-proven, that homeopathic ‘pure water’ possessed physical properties that were different from other samples of ‘pure water’ !

#1303 John Worth
Know Your Own Health

Good article. Why is it when I see WSD I think WMD? Weird that.

It's time to put telehealth in a proper context. It is only one component from a mix of self-care and support interventions; inextricably linked to many of the other components outlined in policy (shared decision making, support for self-management, care planning, personal health records, support for independent living etc etc) which can/must work together as interdependent parts; they are equally important, we know that if one of the parts is missing then 'self-care' really won't flourish.

Sadly, we have the 3 Million Lives campaign, which although it can be seen to be a part of the process to systematise self-care, there is little in the way of meaningful linkage either through language or publicity. The campaign rhetoric is staggering because there seems to be a blind implication that self-care is a problem solved by technology alone (telehealth), with no part played by the mix of skills development, education, information and the significance of achieving behaviour change and in the way patients and health and social care professionals work together and the social context this is occurring in.

The Government has made self-care and long-term conditions a central pillar of QIPP, but we cannot expect GP’s and health and social care professionals to positively engage with self-care (or telehealth) if we shroud its purpose with the idea that its all about technology. Self-care is not all about the Internet or expensive kit festering on dusty shelves, nor is it about providing medical advice or any form of time-consuming didactic service delivery. Self-care is a living, breathing organism of multiple interventions that together can formulate successful outcomes for individuals, as has been evidenced by the NHS Year of Care work.

Telehealth can work and will probably be mainstream quite soon but it's not rocket science and it doesn't need to be complicated. There are thousands of mobile apps that could be used as telehealth applications - in fact many of the best telehealth applications are now being delivered through mobile phone devices with clinicians dashboards and all the other necessary red-flag/vital signs components. They are relatively cheap but the barriers to use are simply behavioural and cultural across both patients and clinicians.

We don't need an industry-led campaign, we just need high level leadership in the NHS to 'get it'; recognise that the transformation process is dependent on people understanding how the component parts fit together and making it simple for commissioners and health professionals to implement. It's really not rocket science, but I get the feeling that some of the big industry players desperately want us to believe that it is and it looks like the Government fell for it.

#1304 Mike Stone

'we just need high level leadership in the NHS to 'get it'; recognise that the transformation process is dependent on people understanding how the component parts fit together and making it simple for commissioners and health professionals to implement.'

John, my own interest involves the 'behaviour set' across different professions for end-of-life patients who are at home, and wish to die at home - it is not simple to get 'concepts' from something like the DH to grass roots level without them being corrupted along the way, and it is hugely difficult to get component parts to fit together properly, especially when the parts are different people (and even different professions) and not 'things'.

#1305 John Worth

Yes it's not simple, it's complex and challenging and requires many layers of skills development, capacity building and human support to achieve changes in practice and attitude across the professions as well as patients. But there are good examples emerging of visionary and brave commissioners and clinicians who are managing to piece the component parts together properly, who do 'get' the fact that telehealth is only one intervention amongst many that could support individuals and enable them to make genuine informed choices, such as dying at home with dignity. That's real progress. The 3 Million Lives campaign and WSD findings just seems to be 'noise' at the moment. It would be great if the 3 Million Lives narrative could include a wider range of concepts and approaches and demonstrate how the component parts work together.

#1306 John Worth

Qualifying my last point: achieving institutional and cultural change is not simple - but giving people the language and tools to put the component parts together need not be complicated.

#1307 Vickie Ferns

Mike we have exchanged comments in previous posts. It's interesting that your work is in the end of life patients. It was announced this week (finally after they have known for 25 years) that the elderly will not get cancer treatment in the future because aging health workers will mean not enough staff. 80% of graduates in medicine go overseas within two years. The public are advised to watch their diet, the only preventive to cancer. I've researched this and it seems between a third and up to 60% of cancers are due to diet depending on who you read.New Zealand and Australia seem to be relieing on investing in preventive medicine to prevent future health costs. I read an Australian report sent to businesses impressing on them the high cost of ill health from chronic condtions in lost work days and suggesting building good working relationships for happy workers. (The potential for increasing prejudice here is high,) Someone I know who has a bad back and fibromyalgia has a dietian and physio come to her house weekly, presumably in the hope she doesn't get heart disease,cancer or diabetes yet I could not go to hospital for ten years with severe pain due to an undiagnosed complication of roux-en -y surgery, I had narcotics of course but I had at least two days a week where Icould barely walk and sometimes spells of up to two months in that state 24/7 yet if I challenged my G.P I would get a shrug of the shoulders. At one stage he told me he was surprised I had not been referred back to him. Yet since I was born with a combined choledochal cyst/biliary atresia condition with 7 surgeries and frequent cholangitis, I have always had a specialist and I hope I always will even in this age where chronic patients are a huge cost that countries cannot afford. Ethically doctors will have to look at whether they should be saving babies if they than subject them to this type of poor treatment in the future because the country can't afford them. I think morally it is not right. I haven't caused my condition because of poor diet or bad life choices, the current complication of 15 years is due to surgery. Since I moved back to NZ from the Uk 9 months ago which I regret , I have had it constantly drummed in to me that NZ cannot afford chronic patients.I have suggested I need an electric wheelchair because I get caught out quite often when I go down to get my medication/groceries--I can feel well at home sitting on the couch all day but the movement ups my pain and it can be hard to walk. I can't have one as they cost $15,000. The same with an air mattress which would make it so much easier to sleep. I can't have one if I go into hospital because I am not subject to bedsores and at home they cost $7000. I should have had those things 15 years ago but have only just asked for them--I'm at the end of coping with the pain I am in. Suppling expensive at home care for people who are not even seriously ill yet leaving someone who is ill with poor care is not what medicine is meant to be about.
This week I have sent a letter to the editor of a popular middle class magazine, in reply to a nieve writer who felt the retirement age should be lowered rather than increased to 67.I hope it is printed as people deserve to know what was put in place 10 years ago and what they face in the future. In Singapore the aged can have an operation put against the value of their house so despite the increase in the aged they will still care for their citizens. They have a public health system but at all points of care the patient pay a small charge. They are also promoting positive birth replacement in population control.
The only people in NZ who know about community health care are health care workers and polticians, no one I speak to knows it exists. Last time they tried to change the health care system they had a $30 charge for outpatient appointments, a large group refused to pay, I suspect this is why the current social engineering is taking place. A man has just died of water on the brain, he had a headache which I assume would have been severe but the G.P did not send him to hospital and he died. The G.p would have been under huge pressure not to send patients to hospital--I'm assuming in past years it may have been wise to err on the side of caution and send someone to A&E, who would appear quite ill but now doctors are taking the risk.
I told my G.P what I have been finding out about community care and the 1st world aged care problem and that no lay people seem to know in NZ and he would not look me in the eye. As I was about to leave he said it was very interesting and he wondered what would happen especially with Greece etc.
I do understand the massive problem 1st world countries have and perhaps until the baby boomers die off things won't improve again.

#1308 Mike Stone

Hello Vickie,

The NHS is also very keen on 'nudging' people into life-style choices that lead to better health, and I agree with you about a lot of what you wrote above. But much of the problem you describe, is about resources.

My problem, is specifically that the DH wishes to allow about twice as many EoL patients to die at home, as the figures suggest many end up in hospital when they don't want to: so the behaviour/beliefs of various professionals, need to be acceptable from the position of a live-with relative. There are various issues around 'trust' - in particular, the system seemingly cannot cope with the complications of the communication-chain for home dying - and others around the interpretation of the Mental Capacity Act.

But my argument, is strongly grounded in the meaning of a law, and is therefore in principle fairly simple compared to your wider problem, about the payment for healthcare.

Even with my issues, far too many clinicians seem unable to interpret the law in a sensible way (some of the guidance is getting closer to the law, but other crucial bits of guidance are getting worse) - based on that, I think your problem(s) are, sadly, near to impossible.

Best wishes, Mike

#1309 Mike Stone

Vickie, just as an aside. You can register with the Nursing Times website for nothing (nursingtimes.net) and that lets you post comments in the discussions (except for subscription-only pieces).

You don't need to be a nurse to register, but I will warn you that some nurses dislike non-clinicians (or even non-nurses) from adding their comments - however, that is not the official policy of the site.

Thought you might be interested, Mike

#1310 Vickie Ferns

Thank you for replying Mike and explaining what you do as I had wondered. I think NZ might be ahead of the Uk on those issues but it would be more to do with keeping people out of hospital due to cost than observance of their wishes. I don't know a lot about this issue but from the little I have observed people usely die at home if they want to here or at a hospis, it would rarely be in hospital but we have a smaller population so perhaps it's easier to take into account patient views.
I have been following this site because I have lived in the Uk twice and plan to return in the next year or two but hope by talking about what has occured here over the last ten years of rolling out community health care with the public unaware of what has occured and the mistakes which have happened from my point of view someone might listen and avoid them in the Uk. I don't agree with treating the public like children. If the country/ first world countries cannot afford hospital health care anymore they need to be honest and tell the public , than explain what is being put in place to minimise distress. They also need to say it is a world wide problem and that other countries are following suite. Even my G.P seems to think it is a NZ problem only which it is not. I am researching for a novel looking 30 years into the future and back on this year. The story has a back drop of an aging population and the effect on health care. So I have read very widely over the last few months including the WHO site, Japan, Australia, USA etc to find out what has been going on.
I have probably said all I had to say now but thought you might be interested that they the Cancer Society have made that annoucement, though I was told 25 years ago that the elderly would not get medical care in the future. I hope that the Uk won't have to go that far.
Best Wishes
Vickie Ferns

#1311 Mike Stone

'they need to be honest and tell the public'

Yes, quite !

Politicians often have a problem with the 'honest' bit.

Good luck with the novel,


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