Feature / On the way

Recent studies have cast doubt on the cost-effectiveness of telehealth – but advocates say its value can only be seen on the large scale. Seamus Ward asks whether it really can help the NHS

In an age where the videophone is becoming prevalent, videoconferencing is a widely used business tool and you can submit your gas meter reading online, it would seem bizarre if the NHS was not examining the benefits of web-enabled medical technology. All four UK administrations have backed telehealth, as they seek to offer patients a personalised service that avoids unnecessary hospital admissions and makes savings. But doubts, especially about cost, remain.

The logic of telehealth is simple. By monitoring vital signs (telecare) or allowing a patient to speak with a clinician via a video link (teleconsulting), patients can be supported to live independently in their own homes or a care home. Patients are happier and, with reduced admissions, providers are able to take out staff and beds.

The Department of Health carried out a telehealth pilot across three sites between 2008 and 2011, involving more than 6,000 patients. Known as the whole-system demonstrator (WSD), the teleconsulting element focused on long-term conditions – chronic obstructive pulmonary disease, coronary heart disease and diabetes. KPMG partner Roberta Carter, who worked closely with the WSD project, says the NHS is slowly seeking to adopt telehealth, with various pilots, trials and local developments.

Although the Department of Health In England is developing telehealth nationally through its 3 Million Lives campaign – through which up to 100,000 more people will be given access to telehealth services across seven pathfinder sites in 2013 – there is no large-scale national push or funding. However, the Department has given a direction that telehealth can be a key enabler for integrated care, particularly for people with long-term conditions.

Ms Carter acknowledges there are dissenting voices. ‘There is still a good deal of debate about the benefits and the case seems to need to be proved on a specific, local level for the population being considered,’ she says. ‘The 3 Million Lives campaign is an attempt to corral the strengths of interested parties, including industry, to encourage implementation for patient benefit. The WSD results are still trickling out, with a number of papers published to date, and each one generating new debate in the press. So I think trusts and clinicians are still deciding, but I am not sure that patients on any wider scale have been involved in the debate. They are involved at a local level and I have heard lots of anecdotal support from patients about the benefits but generally we seem to expect GPs to reflect views and needs of patients.’

The Department said the WSD showed, if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in A&E.

Incremental benefit

However, the final report on the WSD said savings were not significant and a study published in March covering the first year of the project was more critical, saying it was not cost-effective. The recent research measured cost effectiveness as incremental cost per quality adjusted life year (QALY) gained. It found that the cost per QALY, when added to usual care, was £92,000 – three times the National Institute for Health and Care Excellence-recommended ‘willingness to pay’ threshold.

Even when it was assumed that equipment prices fell by 80% or telehealth services operated at maximum capacity, telehealth remained slightly more costly than traditional care. But if equipment prices fell and services operated at full capacity, telehealth would be more cost-effective, costing £12,000 per QALY.

The study concluded: ‘The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost-effective addition to standard support and treatment.’

Reacting to the report when it was published, British Heart Foundation associate medical director Mike Knapton said telehealth had the potential to improve the quality of life for patients living with long-term conditions such as heart failure.

But he added: ‘This large study found self-reported total health and social care costs were far greater using new telehealth technology. In the current financial climate it is difficult to see how healthcare commissioners could justify investment in telehealth on the basis of this research.’

The 3 Million Lives campaign says the WSD showed positive outcomes, but acknowledges the cost per QALY is an obstacle that must be overcome to ensure patients can receive the benefits of telehealth services. Angela Single, chair of the 3 Million Lives working group, says: ‘Industry is working with three million stakeholders to produce revenue-based, lower cost models to enable uptake of these services at scale to help the millions who can benefit.’

This is the thrust of the Department’s approach to telehealth, which has signed a concordat with the industry and aims to reduce upfront capital costs in favour of giving manufacturers a usage-based revenue stream.

Airedale NHS Foundation Trust consultant physician in telehealth Richard Pope says there is no doubt deployment of telemedicine has to reach a minimum level before it begins to make economic sense. The trust, which was not involved in the WSD, has recently signed up its 1,000th patient to its telehealth hub. Albert Joyner, aged 101, who lives in a nursing home in Keighley (pictured overleaf), can now contact clinicians 24/7 via videoconferencing.

There are three arms to telehealth – or more accurately, teleconsultation – at Airedale. Via its hub, a telemedicine call centre staffed by clinicians, the trust offers the service to 20 prisons, as well as patients’ homes and care homes. Not only can patients signed up to the system reach a clinician for an on-screen consultation at the push of a button, but patients and clinicians can also hold e-outpatient appointments.

An independent evaluation of the Airedale scheme found it would have to avert 28 admissions a month to reach a break-even point. On the basis that 33% of unplanned calls appeared to avoid an admission, it would require an activity level of around 85 calls a month to reach break-even.

‘We are receiving more than 100 calls a month now. We are just kicking off our audit of the last year and will know more in a few weeks time, but on call volumes we are over the threshold now,’ Dr Pope says.

Funding doubts

The Airedale analysis also highlights a number of obstacles that need to be overcome. These include uncertainty over funding. The Department moved to support telehealth development in its 2013/14 payment by results guidance. It said a workstream will develop currency models for telehealth services and would be aligned to the 3 Million Lives pathfinder schemes.

The Airedale evaluation says a year-of-care tariff may help, but in the meantime uncertainty over funding streams is slowing down telehealth development.

Airedale’s telehealth provision is expanding rapidly (up from 30 patients in November 2011), particularly in care homes. It offers the service in 30 care homes and expects to double this by the end of the calendar year. The expansion into care homes is beneficial for the patients as they can remain in familiar surroundings and are only admitted to hospital where appropriate. Studies have shown that many elderly people living in care homes have a healthcare-acquired infection before they are admitted to hospital, unwittingly putting other patients at risk.

‘I think this is one of the reasons why care homes have taken off so quickly,’ Dr Pope says. ‘There are benefits for all involved – the avoidance of admissions is a major plus, as is the reduction in the risk of bringing community infections onto the ward. It works the other way as well, cutting the risk of bringing infections into the care homes.’

The care homes are coming onto the Airedale telehealth scheme in tranches of 10 to 15 as the trust wins contracts from local commissioners. Dr Pope is confident about the implementation process, both from the technical point of view – deploying the kit – and from a clinical perspective. ‘We are now quite slick and are bringing people on fairly quickly,’ he adds.

GP advantages

GPs could benefit from the scheme – perhaps through fewer calls to care homes – though it could lead to more calls as patients are able to seek help more easily. Airedale is assessing this by comparing GP call-outs to care homes with and without telehealth. Anecdotally, Dr Pope says there does not appear to be an increase in calls where telemedicine is in place.

‘The engagement before you start is really important so that everybody understands what it is there for and its capability, to ensure they are supportive of the programme,’ he adds.

The Airedale team have found new uses for telehealth – for example, they have worked with speech therapists to deliver a service to a woman with Parkinson’s disease. ‘She was unable to come to the hospital for daily speech therapy so we deployed the kit to her home while she received the therapy, and she showed huge improvement,’ Dr Pope says.

Despite the advantages, KPMG’s Roberta Carter insists the NHS must be cautious about the scale of the impact telehealth could have. ‘Telehealth is not a magic bullet or a miracle cure – it must be part of a wider set of local changes to deliver integrated care and help people have greater participation in managing their own healthcare,’ she says.

The question mark over value for money is partly driven by the fragmented, local nature of decision-making and implementation, she adds. ‘It is almost impossible for smaller businesses to create a strong going concern on the basis of scattered pilots, which are small in number, spread across the country and have a high cost of sale. So scale does still play a role, although the larger players such as BT and Bosch are probably better able to cope with the cost of sales and fragmentation issues.’

Dr Pope agrees that telehealth must be part of wider system redesign and not seen in isolation. ‘Telehealth is in a difficult place. Clearly it has a role to play, but not deployed in isolation. It must be as part of a complete system redesign. Then we will see its potential and, as it gets used more widely, the economics will start to look better,’ he says.

He expresses frustration over the impact of recent telehealth studies. ‘I have real concern over people’s perception of what is meant by telehealth. When some people talk about telemonitoring, they call it telehealth and tar the whole of telehealth with the same brush.

‘We need to be much clearer about which form of telehealth we are talking about. Remote teleconsultation – which is what we do – will, in the right clinical context, be very effective. Telemonitoring will be effective but its unit cost will be too high because at the moment the volumes are too low.

‘People are starting to say you cannot do research in this field in the traditional way, using a randomised control trial,’ continues Dr Pope. ‘By the time you get the results, the kit used in the study will be obsolete. We are two generations on from the kit deployed in most of the WSD sites. It is difficult to extrapolate the outcomes to a world where the unit cost of the kit can be an order of magnitude less.’

Telehealth could clearly play a role in improving patient experience and outcomes, but concerns over cost remain. Sceptics will not have been impressed by the WSD results, but telehealth advocates argue that it will only show its worth clinically and economically as part of a wider system reorganisation and at larger scale. With no definitive answers yet, the debate is set to rage.