On the face of it in these tight financial times it’s an odd move for Cambridge Community Services NHS Trust to plan to spend up to £50,000 on an evaluation of its telecare and telehealth service, especially when it is considered to be a competent one that, in 2011, generated cost savings for social care of £595,049 to £661,165 and £15,089 to £16,765 per patient in NHS costs. But the documents announcing the tender (here and here (PDFs)) makes clear the reason for the study: despite their efforts over the years there is resistance amongst local practitioners to make greater use of it and the service perceives that only LOCAL cost-effectiveness data will bring about a change of attitudes.
They have looked at the shortcomings of the Whole System Demonstrator (WSD) programme structure as revealed by its subsequent analysis and are aiming to improve on that. TA’s favourite statistician gives the thumbs up that the proposed analytical methods are appropriate and – notwithstanding the decision to refer to telecare provision as telehealth – we think it is a good and brave move to invest in this evaluation…and a nice chunk of consultancy work for someone, even if the available funding is going to be tight to do it well.
The closing date for expressions of interest is Friday next week, 22nd February. As we are as keen to see the results as they are, let’s hope the 20-month timetable holds.
It’s great to see that a well thought out evaluation is being commissioned for a telehealth programme and I hope this will go some way towards convincing my fellow clinicians of adopting this technology. However, I have major concerns over the primary outcome measure of ‘out-of-hour (OOH) contacts’. The imminent roll-out of the NHS 111 service over the coming months will be the most significant change to OOH provision since 2004, and it is believed this alone will produce highly variable changes to OOH patient contacts. This could potentially skew the impact attributed to the telehealth intervention occurring over the same time period, and at worst, could show adverse results simply down to the 111 implementation timing. My background is not in statistics but I can recommend this MRC paper which provides guidance on development, evaluation and implementation of complex interventions to improve health:
http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC004871
Given the nature of most telehealth programmes in the UK, I would consider using the ‘Stepped wedge design’ (case study 6- page 22). This takes in to account the resource constraints in making telehealth available to a large population at once, without delaying the implementation of the intervention. I would also consider another primary outcome objective to be a reduction of all cause hospitalisation, with reduced pre-mortality and increased Quality of Life (QOL) as secondary objectives. Any impact attributed to telehealth on these measures will surely provide commissioners with compelling evidence to scale up; although I fear most will still feel the need for a proof-of-concept pilot in their patch before gaining the confidence to do so!