Telehealth faces its moment of truth over the next few years. Championed by the English government, but questioned by critics over a perceived lack of evidence, it has become a divisive issue at a time of strangled budgets and pressured services.
As CCGs across England begin rolling out telehealth services, will the national drive be remembered as an essential innovation for a modern health service, or a flop like the National Programme for IT?
In January 2012, ministers launched the 3millionlives campaign with the aim of achieving the widespread adoption of telehealth and telecare in just a few years. This followed positive initial findings from a state-funded trial of the remote monitoring devices.
However, subsequent academic papers on the trial found the benefits to patient health came at a financial cost higher than the NHS would normally be prepared to pay (see box below).
|TELEHEALTH: THE STORY SO FAR|
Momentum behind telehealth has been building since the DH first reported findings from its Whole System Demonstrator (WSD) trial in December 2011.
This trial of 3,230 patients with COPD, diabetes or heart failure tested whether devices monitoring patients' health in the home are a clinically effective and cost-efficient intervention.
Initial results showed these services reduced A&E visits by 15%, emergency admissions by 20% and mortality by 45%.
Before the full findings were published, the DH said telehealth and telecare would be rolled out to three million patients over the next five years via the '3millionlives' programme, a joint campaign between the NHS and the telehealth industry.
But full findings published in BMJ papers found the service cost about £92,000 per year of good quality life gained - three times the NICE cost-effectiveness threshold.
Researchers from the London School of Economics said telehealth was unlikely to be good value for money unless equipment prices fell considerably. Since then, another analysis of the WSD data found that telehealth was unable to curb GP workload.
Undeterred, health secretary Jeremy Hunt pledged in November 2012 that 100,000 people in seven pathfinder areas would benefit from telehealth in 2013 under the 3millionlives campaign.
But in April, control of the programme passed to NHS England and its future is under review.
Undeterred, ministers threw their weight behind the push and added a new directed enhanced service (DES) for remote care monitoring to the imposed GP contract in April 2013. This brought GPs and practices directly into contact with local telehealth arrangements.
But how well is the roll-out proceeding and how convinced are CCGs about the telehealth drive?
Progress so far
To investigate progress so far, GP sent Freedom of Information (FOI) requests to all CCGs in England.
The responses revealed a patchy, often problematic attempt to roll out telehealth services, and shows that CCGs are divided over the part these technologies should play in local healthcare.
In all, 108 (61%) of the 176 CCGs which responded are commissioning telehealth services in 2013/14. In these areas, more than a quarter (28%) reported continuing problems. These ranged from fewer patients using the devices than expected, to delays caused by late delivery of equipment and, in one case, contractual problems with a provider.
While some CCGs have invested heavily - up to £1.7m a year - others are shunning telehealth altogether, cancelling contracts or freezing planned expansions.
In November 2012, health secretary Jeremy Hunt announced that seven pathfinder areas, including CCGs and councils, would spearhead the 3millionlives campaign by providing telehealth services to 100,000 patients in 2013.
GP's investigation found that progress towards this goal has been slow. Just 2,368 patients are actively using telehealth services across the pioneer CCGs. Of 26 pioneer CCGs, six decided not to commission telehealth services after all.
GP found these problems were not confined to pioneer areas. By September, just 26 patients out of an anticipated 120 were accessing telehealth services in North Lincolnshire CCG. Its FOI response said a number of factors had affected uptake, 'including acceptability by patients and clinical engagement in light of the evidence from the WSD report'.
But when GP asked for more information, Jane Ellerton, assistant senior officer for commissioning support and service change at the CCG, denied that local GPs had not supported the programme.
However, she added that feedback via community matrons was 'mixed', with 'some patients describing how the equipment has helped them learn to self-manage, (and) some patients finding it obtrusive and of no benefit'. Most had no strong view either way. The CCG is currently reviewing the service.
GP found 30 CCGs across England experiencing problems of this kind. But other areas reported a very different picture.
Wiltshire, Birmingham CrossCity and Kernow CCGs each now have at least 1,000 patients using telehealth services. The latter has budgeted £1m for the services in 2013/14.
Somerset CCG said that despite 'negative press' about telehealth, 'good local evidence' means it has seen an increase in uptake, with up to 300 users.
Professor Ruth Chambers, clinical lead for telehealth at Stoke-on-Trent CCG and a local GP, says it is vital GPs and CCGs learn from each other as telehealth becomes commonplace. 'What we need to find in the NHS is the cheapest, easiest option that has good quality and safety.
Everyone has to learn from everyone in that respect.
'GPs are so busy with everything. You've got to see the benefit to integrate it into our work. But we've got to do it.'
|CASE STUDY - FLORENCE: CARE BY TEXT MESSAGE|
Florence is an NHS-developed service that helps patients to manage their chronic illness by text message.
The service was developed at NHS Stoke-on-Trent PCT and is now run by the local CCG. After patients sign up, an automated website sends advice and reminders, helping them manage conditions such as asthma and hypertension. The service can be tailored to meet the care needs of a particular disease.
Patients with COPD undergo spirometry using a device in their home, then text back readings to the website, which logs the data and alerts clinicians to patterns.
The service hosts a forum where practices and CCGs can share ways in which they have used and adapted the service for different medical conditions.
Florence is also helping practices in some CCGs meet the requirements of the remote care monitoring DES. About 4,000 patients use the service. By March 2014, it is hoped 10,000 patients will be signed up across England.
Her CCG has developed and now runs a simple, low-tech and cheap service, called Florence, that could be a robust model for how to make telehealth work across the NHS. It uses a device already in almost every patient's home: the mobile phone (see box, above).
Professor Chambers believes it is inevitable that remote care will be widespread in years to come. She says general practice must learn to work more flexibly and be prepared to offer services such as remote consultations and interactive messaging.
But this can only be achieved if GPs and other senior CCG figures are prepared to champion different ways of working among their colleagues and encourage them to adopt the new technology, she says. 'We all need to be thinking: how can we modernise, but retain quality and safety?'
But how convinced are GPs overall that telehealth can improve care? Questions over the evidence for telehealth do not seem to have affected uptake of the remote care monitoring DES this year.
Responses from 71 CCGs suggest 85% of practices will take part this year. Whether this shows support for telehealth, or merely a desire to earn back money stripped from the QOF, remains to be seen.
Nevertheless, many CCGs are combining the DES specification with their existing local telehealth services.
This means GP practices will soon find themselves deeply involved in the telehealth roll-out. They will have the chance to scrutinise whether local schemes can deliver the promised benefits and if savings are likely to be made.
Budget pressures are forcing CCGs to get tough on schemes that do not deliver. The hope is that those schemes which do work can be shared more widely, and the Florence model shows this is possible.
But three million users seems a long way off yet.