Feature / Virtual reality

Telemedicine and telehealth show real potential to make significant contributions to the QIPP agenda if they can be realised at scale. Steve Brown reports

Saving £20bn over the next four years in the NHS in England will require a transformation of services. An average requirement of 4% to 5% annual efficiency savings – even higher for some organisations – is unprecedented in a service that is more accustomed to achieving 2%. To meet the challenge, completely new ways of working will be needed.

Truly transformed services, where quality has been maintained or improved while costs have been reduced, are hard to find.  But perhaps the one area that could really make a difference – delivering the level  of efficiencies required while maintaining and improving quality – is greater use of telehealth and telemedicine.

There are issues to overcome. The acceptance of digital channels of healthcare delivery by practitioners and patients is perhaps the key one. But the potential is huge. And, albeit largely anecdotal, feedback from technology pioneers is encouraging, even if changes would be needed to current funding mechanisms to facilitate greater adoption.

Airedale’s telemedicine hub

Airedale NHS Foundation Trust is one of the organisations pursuing greater use of technology both to improve service and to contribute to a major savings drive (8.5% in 2011/12, 5% in both the subsequent years).

In September it opened a telemedicine hub, using regional innovation funding for the whole of Yorkshire and Humber. The hub is open round the clock to support patients in their own homes or nursing homes. It is being targeted at patients with long-term conditions such as diabetes, heart failure and chronic obstructive pulmonary disease. Patients are given set-top boxes that enable them to access clinical support through their televisions.

Early experience suggests savings for the health economy could emerge. Even within the first few weeks, with a very small population base as yet, potentially costly admissions have been avoided.

The service builds on a contract the trust has had in place to deliver initial emergency support and virtual outpatient consultations to the prison service. Currently the trust serves 20 prisons in this way, providing a secure two-way video link that enables outpatients resulting from referrals from prison medical centres to be undertaken without the time and cost of transporting prisoners.

Building on this, the trust has also used the technology to support local service delivery.  A virtual diabetes clinic, held by video conference with a health centre in a more distant part of its catchment area, saved patients significant travel time. And in stroke care, the technology was used as part of a pilot for the West Yorkshire Stroke Network to support the use of thrombolytic drugs. The basic aim was to increase thrombolysis rates by giving local hospitals virtual access to stroke experts in a specialist centre.

But the latest development in Airedale’s push on telemedicine comes with the installation of set-top boxes in individual patients’ homes . Initially targeted at long-term conditions patients, the kit uses a broadband connection to provide a videoconferencing link with a

24/7 clinical hub, manned by nurses and supported by consultants.

Patients ‘calls’ are answered within two minutes and a consultant opinion is offered within 20 minutes. Dr Richard Pope, the trust’s director of innovation and lead for the telemedicine initiative, says the unit is only managing 30 patients at the moment but even in the first few weeks of operation it had helped avoid an average of one admission a week.

He cites the case of one diabetes patient, who was back at home following surgery the week before. She had an infection at the site of her surgery. The telemedicine kit meant the trust and patient were in regular contact and, when she developed an abscess that burst , the trust was able to advise on medication and arrange for a district nurse to visit to change dressings.

‘We almost certainly avoided an admission as well as providing much better care for the patient,’ says Dr Pope.

In another case, a COPD patient who had previously seen their GP, took a turn for the worse in the middle of the night. The telemedicine nurse realised the patient needed antibiotics and arranged for these to be delivered to the patient. Again without the service, an admission would have been likely.

Better interaction

Dr Pope adds the system can enhance doctor-patient interaction. A consultant can timetable a follow-up call to check on development a few hours after a patient has called in. He rejects comparisons to NHS Direct. ‘This is different. This is about patients referred to us,’ he says. ‘We know their history and we have access to all their carers via our systems.’ 

Sheenagh Powell, the trust’s finance director, says the potential savings make it attractive given the economic climate and outlook. Reduced admissions are the major benefit.

Logic would suggest that it is admissions with zero to one day’s length of stay that will principally be avoided. But Ms Powell thinks it will penetrate beyond this. ‘There is a huge peak in COPD admission in the three- to five- day length of stay. There is evidence that once patients are in the system, they can stay in for several days.’  And in addition to reduced admissions, the system should enable earlier discharge of patients already fitted with the home kit or by installing it temporarily.

While the initiative is driven by quality, Ms Powell says a review by York Health Economics Consortium suggests that up to £3,000 a year can be saved per patient using the virtual support system. ‘We’ve done bed utilisation surveys that show 40%-50% of patients shouldn’t be here,’ she says. ‘For those patients these are expensive facilities.’

The trust sees keeping patients out of hospital where appropriate as fundamental to getting the right patient pathway. It has already shed 50 beds (out of 400) in the last six months as a result of various initiatives, including getting consultant opinion on patients earlier in the pathway. ‘Telemedicine is just one part of this system redesign,’ says Ms Powell.

The system perhaps has particular value for nursing homes, where a single telemedicine unit can be used to support a broader group of patients – and help avoid unnecessary admissions or journeys to hospital from one of the major sources of hospital admissions.

But the trust believes telemedicine can expand into providing regular appointments as well as on-call support. ‘The model works really well for repeat outpatient appointments,’ says Ms Powell. ‘For example diabetic children – they wouldn’t have to come to hospital. Instead they could dial in after school and then get straight on with their homework.’

In time, this would enable the trust to free up outpatient space – although the cost savings perhaps aren’t as significant as losing inpatient beds. And if telemedicine (virtual consultations) were married up with telehealth (virtual monitoring of vital signs – see right), the benefits could be multiplied.

Dr Pope acknowledges that the approach is not right for everything. ‘I think it lends itself to COPD, diabetes, heart failure, combinations of these, palliative care, some paediatric, nursing homes and mental health care,’ he says. This last area he thinks could be a huge beneficiary from the technology with the system able to support links with social care too.

There are challenges in rolling the system out, both within Airedale and more broadly across the NHS. Current funding flows appear to work against wider adoption. Under current payment mechanisms, if the trust spends money to put telemedicine kit into patients’ homes, it will incur the expense of the kit and the hub, while losing income from reduced admissions.  Analysis of the potential for just one pathway suggested that the service might save commissioners a minimum of £100,000 from relatively small numbers of admissions, while only releasing £21,000 of costs for the trust (which would also have to spread its fixed costs across a smaller overall income).

But, if deployed at scale, trusts will be able to close beds and take out costs. ‘The reduction in income and costs, especially the release of stepped fixed costs, will need to be managed across a health economy in a planned way to smooth potential financial volatilities,’ says Ms Powell. Two things are needed, she says. Commissioners need to fund the roll-out in some form and the whole system needs to be operated at scale.

While regional innovation funding is supporting the first year of the hub, from next April, the project needs to stand on its own feet. It has contracts for 40 boxes with its main commissioner as well as deals for a number of care homes and discussions under way with a local hospice. It needs funding for 500 boxes at £2,400 a box to make the scheme break-even. There’s a different financial model for nursing homes, with an installation fee supplemented by per use payments broadly similar to the basic accident and emergency attendance.

The trust has ideas it believes could improve the levers for telemedicine. Commissioners could be required to use ringfenced funds from the 70% non-elective tariff held back for over-activity or readmission penalties. They could be required to set up telemedicine links in nursing homes, where most unnecessary hospital admissions come from.

Alternatively, the tariff could be used to incentivise technology adoption. A premium or best practice tariff could be offered for patient spell pathways that use telemedicine. A year of care tariff for patients supported at home via telemedicine would also provide a payment mechanism for long-term condition patients.

The trust is enthusiastic about telemedicine but concerned that the funding arrangements may not allow enough time for it to take hold.

‘The history of telemedicine has been that the technology is ready, but people aren’t,’ says Dr Pope. ‘But the evidence is growing and the patient’s view is positive. And the drivers for primary and secondary care are taking us to the tipping point.’

Hospital admissions have fallen by up to 50% among nearly 400 COPD and heart failure patients from seven practices in North Yorkshire and York PCT as a result of a PCT-led telehealth programme.

Under the programme, patients referred for the service have a telehealth unit installed in their homes. They take their vital signs each day or at agreed intervals – blood pressure, oxygen saturation, weight, temperature and, for patients with diabetes as a comorbidity, glucose concentration – and these are transmitted via telephone line or mobile network to a monitoring unit run by telehealth units supplier Tunstall Healthcare.

Clinicians can check on their own patients by logging into the system but the primary daily monitoring is done by this centre. Any readings that cause concern will result in an initial call to the patient requesting a further set of readings. If the readings still suggest an issue, the patient is contacted again and, if required, they are put in touch with the referring clinician.

Patient satisfaction is extremely high – nearly 100% – and the quality aspects for patients are obvious. Fewer admissions, earlier capture of worsening conditions and greater peace of mind. There are peripheral benefits too. Clinicians using telehealth have reported fewer face-to-face visits with referred patients. But it is perhaps the additional financial benefits that should seal the deal.

After a small trial involving 120 telehealth systems from two different suppliers, the PCT decided to go for scale and procured a further 2,000 systems (this time from a single supplier, Tunstall). The initial capital outlay was £3.2m, giving a unit cost of £1,500 per system. There are ongoing annual revenue costs of about £894 per patient, covering installation, patient training and communication charges.  

The PCT has been monitoring patients who have been on the system for more than six months and comparing their admissions and other activity with comparable periods before the systems were deployed. Monthly monitoring reports show consistently higher than 35% admissions avoidance, up to 50% for some months. The PCT estimates net savings per patient of £371.

But perhaps the real savings will come at scale. In 2008/09, just over 3,400 patients from the PCT’s population were admitted as emergencies with respiratory conditions at an estimated cost of £7.3m. A further 3,313 emergency cardiac admissions cost a further £5.2m. Reducing these admissions by between 35% and 50% starts to deliver significant savings to commissioning budgets.

Crucially, once run at scale, acute providers should be able to reduce beds previously occupied with long-term condition emergency admissions, turning savings for the PCT into real savings for the whole health economy.

The PCT has just 385 of its 2,120 boxes deployed. Roll-out has not been straightforward despite the advantages for patients, GPs and budgets. Just seven out of a possible 98 practices have started to refer, but community services (now hosted by local secondary care providers) also refer to the service.

There are concerns among GPs despite positive feedback from colleagues in active practices. ‘We need to engage the GPs as chronic disease management should be delivered closer to home,’ says Kerry Wheeler, assistant director of strategy at the PCT. ‘Many believe telehealth will create additional work within the practice, but none of the evidence to date suggests that is the case. By recognising the importance that general practice has to play in deployment, the PCT is working closely with local GPs on incentives to deploy telehealth and manage patients in the community.’

As with the local telemedicine scheme in Airedale, the full potential of the system currently remains untapped. However if North Yorkshire and York succeeds in deploying its full 2,120 boxes, this would make them the single largest scale telehealth project in the UK.

Many people in PCTs and providers with significant QIPP targets will be keeping a close eye on progress.