james barlow - unanswered questions in telehealth 121002
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Unanswered questions in telehealth. The lessons to be learnt from the WSD trial
James Barlow
Evaluating the impact of telehealth: where next for research beyond the Whole System Demonstrator trial? 2 October 2012 Nuffield Trust, London
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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
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Lesson 1 Taking stock. What progress has been made in deploying remote care in the UK?
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Practice by Telephone The Yankees are rapidly finding out the benefits of the telephone. A newly made 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 do with it?" Grandmamma replied she would call the family doctor, and would be there in a minute. Grandmamma woke the doctor, and told him the terrible news. He in turn asked to be put in telephonic communication with the anxious mamma. "Lift the child to the telephone, and let me hear it cough," he commands. The child is lifted, and it coughs. "That's not the croup," he declares, and declines to leave his house on such small matters. He advises grandmamma also to stay in bed: and, all anxiety quieted, the trio settle down happy for the night The Lancet 29 Nov 1879, Page 819
The idea has been around a long time
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There is political support Successive UK governments have bought into 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)
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There are many industry case studies and other reports
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There have been many trials ... Diffusion of telecare in Surrey 1998-2005
7
Columba
Brockhurst Dementia unit
NEECH videophone pilot
Mid Surrey Falls Project Guildford Falls Project
Dray Court Telecare flat
COPD at Home Project
Dormers SMART House
LAA: Safe At Home
MEWS Hospital Discharge project
Mid Surrey Wristcare pilot Tandridge Telecare Flat
Community Alarm Teams, Elmbridge, Guildford, Mole Valley
& Runnymede
Thames Ward, Molesey Hospital
Leatherhead Hospital
COPD Project
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Even before WSD there was a large evidence base
Source: Barlow et al (2007)
• 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 evidence is limited
Bulk of studies are targeted at diabetes and heart disease
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Remote care is entering the public awareness
Which? (Feb. 2009)
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And yet …
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Adoption Spread Mainstreaming
Time
Level of uptake
The remote care adoption pattern in the UK
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So how much remote care is there in the UK?
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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
With Scotland & Wales
0
50000
100000
150000
200000
250000
300000
350000
Assumes 15,000 remote care users (2005) and 5000 users (2000)
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Lesson 2 How big is the potential UK market for remote care?
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Potential remote care market 2010
1,400,000
Actual remote care market 2010
350,000
Potential telehealth
market 2010 450,000
Actual telehealth market 2010
22,500
Source: based on CQC returns, JIT (Scotland) data, and authors’ research for WAG. Telehealth figures from Minutes of the Strategic Intelligence Monitor on Personal Health Systems [SIMPHS] meeting, Brussels, 17-18 November 2009.
Assumptions: • UK population aged 75+ is
c4.9m (2010) • c85% of older people wish
to remain at home as long as possible
• 1/3 needs remote care at any given time
Half a million, one million … or three million?
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We don’t know: How many people could benefit at a given snapshot in time or over a year (what is the rate of ‘churn’?) Which population groups can benefit most? (top of the ‘pyramid’, next tier, which conditions?)
“The Department of Health believes that at least three million people with long term conditions and/or social care needs could benefit from the use of telehealth and telecare services.” http://3millionlives.co.uk/about-3ml#background
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Lesson 3 Crossing the brick wall – mainstreaming remote care
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All those pilot projects have told us something about the organisational and economic factors which influence implementation of remote care
Columba
Brockhurst Dementia unit
NEECH videophone pilot
Mid Surrey Falls Project Guildford Falls Project
Dray Court Telecare flat
COPD at Home Project
Dormers SMART House
LAA: Safe At Home
MEWS Hospital Discharge project
Mid Surrey Wristcare pilot Tandridge Telecare Flat
Community Alarm Teams, Elmbridge, Guildford, Mole Valley & Runnymede
Thames Ward, Molesey Hospital
Leatherhead Hospital
COPD Project
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The challenge is not the technology!
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Adoption Spread Mainstreaming
Time
Level of uptake
Enthusiasts
Grants
Financial support has helped stimulate activity at a local level
Pump priming
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Adoption Spread Mainstreaming
Time
Level of uptake
Enthusiasts
Grants
We understand much about the organisational factors that influence implementation
Pump priming
Champions
Leadership
Project management
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Adoption Spread Mainstreaming
Time
Level of uptake
Enthusiasts
Grants
Pump priming
WSD has highlighted questions about the need for evidence and a business case
Evaluation Evidence
Business case
Champions
Leadership
Project management
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Lesson 4 Evaluation, evidence, policy and scaling up
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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
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So evaluating the impact of telehealth (and especially telecare) is very hard and leads to ambiguous, context-specific findings
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Yet there is a perceived need for very ‘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’
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Is an obsession with evidence beginning to stifle experimentation and innovation, and slow scaling-up?
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The future landscape is apparently 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
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But what about the business models for remote care?
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Suppliers have been searching for business models 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
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Finally, the questions we now need to address (apart from continuing to work on the WSD data)
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• How to engage with the part of the health system that has the bulk of the budget – CCGs
• What is the role of the supply side?
• What financial and contractual models for remote care are the most effective?
Do they have the capacity / expertise / inclination to plan and coordinate the implementation of remote care?
Many would like to move from a ‘box provider’ to ‘service provider’ role … but how to do this?
What PPP arrangements work and what do they embrace? • infrastructure only • infrastructure + monitoring • infrastructure + monitoring +
clinical care
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WSD research team: James Barlow, Jane Hendy and Theti Chrysanthaki Based on several projects funded by EPSRC and Dept of Health
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