Health Service Focus

From science fiction to NHS services

NHE spoke to Jonathan Thorpe, telehealth project manager, and David Barrett, nurse lecturer in telehealth at the University of Hull, about the Centre for Telehealth and the Hull Telehealth Hub.

Telehealth is coming, whether the critics and the cautious are ready or not. The Centre for Telehealth has brought together the local and neighbouring NHS, Hull City Council and the University of Hull for over ten years to research telehealth and deliver a remote telemonitoring service.

The Centre was a key participant in the Hull Telehealth Hub, funded by the former SHA and led by the university. The Hub aims to join up “pockets of really good practice” in the region.

Project manager Jonathan Thorpe and nurse lecturer at the University of Hull David Barrett spoke to NHE about the challenges and opportunities around telehealth.

“The Centre for Telehealth is an interdisciplinary research group that covers a range of areas, including heart failure, disposable medical devices and service design,” Thorpe said.

The other participating areas are Barnsley and Airedale, which run a telecoaching service and video consultations respectively.

Pooling resources

All three areas applied for SHA funding, and a single pool of resources was provided to develop the services. Barrett explained: “The SHA decided wisely that it would pool the resources and those three partners should get together and look at ways to increase the scale and do it beyond traditional boundaries.

“The long-term aspiration was to see whether it was feasible to deliver those services outside your normal boundaries; to see whether it made sense and was useful to have one area providing those three different services.”

These goals were “broadly achieved”, and all three services have continued running.

Different elements of telehealth were also provided to patients in East Riding, Yorkshire, “demonstrating that it could be done”.

Separate services

The Hub’s long-term aim was to develop an independent entity to identify and provide an appropriate level of remote care, whether phone-based support, remote monitoring, video support, or a combination of the three.

Taking the project to the stage of a single service in this manner was very challenging, Barrett said. “It became three very effective, very efficient services, still doing their [work] but doing it quite separately.

“The principle of the Hub – you have different levels of remote care and you give the patient whatever’s best for them – that’s continuing.

“What isn’t happening and I don’t think will happen now is any kind of organisational merger.

“We learned so much from the Hub that it’s easier to take the lessons learnt and build our own services from that. In Hull this works; we can look at different levels of service delivery, increasing the scale, making it more streamlined, using it to integrate health and social care.

“The model of delivery is something we’re taking and growing. In the NHS, the way it is nowadays, getting three different organisations from three parts of one region and bringing them together is quite challenging.

“The project finished formally nearly a year ago, but we’ve continued to develop those services.”

Tackling resistance

The challenges when providing services at other sites included “general resistance to change”, which can be “made worse when you start introducing the idea of remote care”, Barrett said.

The case for telehealth often emphasises efficiencies, making staff anxious about their job security. Barrett said: “Of course it shouldn’t necessarily do that – it should enable people to keep up with the rising demand and to provide better care without having to spend a lot more money. But people do worry about it.

“The other factor is the technology; some people are quite resistant to using new technologies. That’s an element which can hinder adoption.”

Achieving wider acceptance of services being delivered within a new locality was also challenging. In East Riding, good existing relationships helped make this possible, but “getting somebody we didn’t know to suddenly commission services from Hull, even when they were offered at a very cheap rate as part of the Hub project, was much more difficult”.

He said: “People like to run their own services, which they’ve grown. People tend to be more open to building on [that], using people they know, based geographically.”

Averting admissions

There remains controversy and confusion around the evidence base for telehealth, particularly with the publication of some, but not all, of the Whole System Demonstrator (WSD) results. “A lot of clinicians particularly are wary of the evidence base of some of these interventions,” Barrett noted.

Outcomes from the Hub suggest some hospital admissions were averted, although more research is necessary to reach more solid conclusions.

He added: “We’re hoping to do some work around that and to get more data. We’re pretty confident we’re keeping people out of hospital by monitoring them remotely.”

The research in this instance was a service evaluation, rather than a randomised controlled trial, but “it showed the service is doing what we expected it to do”.

Barrett described other robust evidence that use of telemonitoring in certain groups, particularly patients with heart failure or COPD, does provide clinical benefits. “It seems to keep people out of hospital, and in the case of heart failure it seems to reduce mortality,” he said.

The Whole System Demonstrator

The WSD supports this view, with positive results for reduced mortality rates and admissions to hospital. But a bigger complication is the lack of evidence for quality of life benefits. “You can spin that any way you like,” Barrett said. “The people who are pro-telehealth were pleased with the fact that there’s no change in quality of life because therefore telehealth doesn’t cause social isolation.

“If you don’t like telehealth you can make an argument that this wasn’t empowering people, making them more reassured or confident. It’s a tricky one.”

The other headline-grabbing aspect of the WSD results so far is the cost of the technology; it looks to be around three times too expensive in terms of QUALY. But Barrett said costs have changed remarkably since 2007 when the equipment for the trials was bought, potentially nullifying this objective. He explained: “Costwise it’s really a different world. 3 Million Lives are quite right in saying that costs have come down an awful lot since the WSD.”

It means clinicians can only hypothesise as to what today’s prices for equipment could mean for the viability of telehealth on a large scale.

Barrett said: “The WSD has confused things a bit. Clinically there seems to be something positive, but it doesn’t seem to be necessarily having the quality of life impact we would expect it to have, and certainly at the time, it was an expensive service.

“That’s why there is controversy regarding the evidence.”

Consumer-led change There’s no doubt that telehealth would, and should, be rolled out across the health service, he said. “In terms of the specific applications, they will change and adapt and get better, but we’ll certainly do it.

“Over time, the idea that patients at home are having their vital signs monitored in the same way as patients in hospital will become normal. We trust people to take their own medication at home and we will start trusting them to monitor their own vital signs.

“The philosophy of needing to be able to care for people regardless of geography, regardless of distance, will undoubtedly grow and the way we do that will change. But it’s not going to go away; it’s just going to be done in a slightly different way.”

A new way to triage

When NHS Direct was in its early stages, Barrett noted, it was greeted with scepticism and criticism. “There was lots of ‘it’ll never work, you can’t do this, you can’t provide nursing care over the phone’. There were teething troubles, but it did start to work, and it got better and better and more effective.

“And then when they took away NHS Direct and replaced it with 111, there was uproar, because NHS Direct had become embedded in our culture. These things do happen, but they take time.”

Thorpe added: “At the moment [telehealth] does sound strange and quite alien, but it is going to simply become the next generation, the way things are done.

“It is going to become the way that a significant proportion of care is delivered. But it’s not ever going to be the only way, and nor should it be.”

In the people’s hands

Increasing numbers of people are monitoring their blood pressure, activity and weight, providing the motivation needed to introduce more technology to the NHS. Yet the public taking the steering wheel presents two challenges for the NHS, Barrett said.

The first is that patients are now more well-informed than ever, thanks to Google and the internet: “Suddenly you’re having people measuring stuff they never measured before. People have much more information about themselves and are doing things that used to be just in the domain of statutory healthcare.”

The pace of change in technology is also incredibly quick, with new, cheaper and more accessible equipment being provided far earlier than products and devices used in the healthcare system.

He called this “problematic but quite exciting as well” and said: “This stuff develops so quickly that the usual way that healthcare does stuff just can’t keep up. 

“Things that would have sounded like science fiction three years ago are now nearly on sale.”