- Smart Healthcare, Wednesday 3 June 2009 09.00 BST
Careful examination: a telecare pilot in Scotland
In July last year, health minister Ivan Lewis launched the Department of Health's Whole Systems Demonstrator (WSD) programme. The aim was to evaluate the business case for telehealth and telecare, techniques on which governments are set to place increasing reliance.
The programme established three pilot sites, which are expected to begin formal evidence gathering in the next couple of months. Although the recruitment of participants in the two-year trials to be undertaken in the London borough of Newham, Kent and Cornwall has been slower than anticipated, patient numbers have now hit 2,000 out of a target of 6,000.
The scheme is believed to be the largest randomised control test bed in the world, with similar projects in the US comprising no more than 300 people.
The aim, according to Nick Goodwin, who heads the WSD Action Network, is to establish whether telehealth and telecare can provide value for money in helping to support the needs of an ageing population suffering from increasing numbers of chronic health conditions.
Because public expenditure on healthcare is on track to double over the next 15 years, the ultimate goal is to shift the balance of care away from institutions and into the home, with telecare and telehealth potentially acting as tools to support that move.
"But the big stumbling block so far has been the evidence chasm. We believe that telehealth and telecare can make a difference, but we have to establish whether investing in it is cost-effective," says Goodwin.
Although limited amounts of evidence is available in the telecare world due to the government's £80m Preventative Technology grant, which was announced in 2004 to enable about 150 social care bodies to invest in such offerings, the same is not true of telehealth.
Prior to the release of £31m to fund the WSD scheme in May 2008, there were precious few financing options. It was also difficult for stakeholders, ranging from local authorities to primary care trusts (PCTs), ambulance services, police and mental health bodies, to share information due to data protection issues as there was no established way of doing so.
Under the WSD scheme, each participating public authority is required to recruit 1,000 telehealth candidates and 1,000 telecare ones. Telehealth is administrated through the NHS and participants are provided with equipment to measure vital signs such as blood pressure or blood sugar levels. The aim is to monitor changes to long-term health conditions such as diabetes, heart disease or chronic restrictive pulmonary disease to establish remotely whether an intervention is necessary.
Telecare, meanwhile, is an emergency service provided by local authorities' social services departments. Standard equipment includes a two-way communications 'lifeline' device, push button alarm, smoke detector and flood sensors.
So far there has been little overlap between the two groups, although the majority of participants in both are over 65 years in age. As the trial is a controlled one, half of the participants in each group will receive the equipment, while the other half will not. Comparable statistical evidence around, for example, the frequency of hospital admissions and how much nursing time is required will then be collected on a quarterly basis and anecdotal evidence will be garnered from interviews with patients, carers and care professionals.
News from Newham
But despite the difficulties involved in recruiting potential candidates, Martin Scarfe, WSD programme director at Newham, indicates that the process is now "coming to completion." "It's already big enough for a national trial and we could start evidence gathering now, but we want to get nearer to the 6,000, which we still believe is an achievable number. So the formal evaluation stage will kick off in the next few months," he says.
One of the single barriers to recruitment has been that many people are reluctant to be reminded of their illness by participating in a trial. "Technology is not so much the barrier – it's more people. No single piece of technology has failed to be installed due to technical problems. It's been more about the patient not wanting it, the GP not wanting it or whatever," says Scarfe.
This reluctance is particularly marked among those with diabetes, but the intention is to interview refuseniks during the trial in order to try to understand their reasoning and address it more effectively in future.
Other common challenges include the fact that potential participants do not always respond to the necessary formal letters requesting consent to join the scheme, or that they spend long periods visiting family elsewhere, which makes them ineligible on absence grounds.
But a key lesson learned so far is that clinicians must be involved in the recruitment process as both a "courtesy to them so they know what's happening with their patients," says Scarfe, but also because the patients themselves can become uncomfortable if their GPs are unaware of the situation.
To address the stakeholder information sharing issue, Newham has introduced formal agreements between the relevant organisations. The council and PCT have also jointly appointed an individual to take responsibility for integrated care across the borough.
But Scarfe would also like to see a statutory body set up to co-ordinate care in its broadest sense. "Rather than councils and PCTs having separate budgets, it would be about shared financing. The Department of Health now has health and social care under one body and I'd like to see that extended across the country. So we'd have regional or local bodies with statutory and financial responsibility for integrated care."
The first year of the trial will focus on generating evidence, while the second will concentrate on generating improvements based on lessons learned across the three localities and improving levels of service integration to enhance care.
Information will be shared through the WSD Action Network, a web site that is hosted by the King's Fund and DH Care Networks and as of 11 June will provide a searchable database of published evidence. This evidence will include case studies and structured information on barriers and facilitating factors to adoption.
But the database will also include input from 12 network member organisations from areas including Nottingham, Sheffield and Barnsley. They were unsuccessful in their bids to become WSD pilot sites, but are conducting smaller, unfunded trials of their own. The WSD Action Network's funding is guaranteed until June 2010, although financing may be continued for another year.
