Soapbox – what should a restructured 3millionlives do?

Times are tough for those who believe that technology can help improve the efficiency and effectiveness of healthcare delivery to improve patient outcomes. As pointed out by Richard Vize in the Guardian recently, telehealth has become the weapon of choice in the battle between GPs and the NHS, with publications such as Pulse and, most recently the HSJ, continuing to remind readers of the historic, and wholly-unrepresentative-of-telehealth cost effectiveness comparisons for the Whole System Demonstrator (WSD).

At the same time, the national Telehealth Forum’s survey of potential users indicated a lack of awareness of the technology and Invicta Telecare’s survey, a lack of preparedness to remain independent in old age. There is no single name that is used to describe the technology in a way that, say, people see statins as the answer to high blood pressure – and ask their GP for them – or Skype is short for easy-to-install-&-use videotelephony.

There can be little doubt that the previous incarnation of 3millionlives, or any other national organisation, did not focus adequately on either of the above, so the announcement that the programme is to be relaunched with a different constitution is good news if it is going to happen (or was the apparently outrageously misleading HSJ headline more accurate than the text?).

Ever keen to be supportive and helpful, here are Telehealth & Telecare Aware’s three positive suggestions for the new 3millionlives to improve the take-up of telemonitoring technology:

Firstly, if it’s not possible to bid farewell to the WSD, the most urgent action must be to deprive the opposition of any more ammunition. So academics should only be allowed further access to historic WSD data to produce more headline-grabbing negative press if they overprint each page with the words “Historic enquiry – does not represent current practice & costs”. And we need to see the full story, so if an RCT adversely affected the cost of providing telehealth, reduced the effectiveness of the technology by treating it as a simple intervention when it wasn’t, and used kit ordered seven years ago, the cost/QALY should not be compared unfavourably with the current NICE guidelines.  And don’t say for example that there was no evidence of improved self-care when that was not one of the primary end-points of the study and the RCT conditions expressly prevented that from being encouraged.

Secondly we need a charm offensive to the main professional stakeholders opposed to telehealth, to point out that the ‘evidence’ they keep digging up is well past its sell-by date. If for example they look at the Department of Veterans Affairs (VA) in the US there is incontrovertible evidence of huge benefits from telemonitoring when commissioned as outcomes…which will be essential if the UK is simultaneously to cut healthcare costs and improve patient outcomes as average age increases.  A further point is that a revised approach to commissioning technology will greatly improve its impact: by commissioning outcomes from providers who may or may not incorporate technology into the delivery of outcomes. That puts technology in its place, as no more than an enabler to improving people’s lives.

That all six CCGs in Surrey have bought into telehealth is a clear indication of how patient diplomacy can work. Perhaps it’s instructive to look at the history of the adoption of the stethoscope invented by the French clinician René Laennec in 1816 but only accepted by the medical profession in 1866 following the endorsement of Austin Flint, an outspoken American clinician of the time. Is Adam Darkins of the VA telehealth’s Austin Flint?

Thirdly we need an innovative public marketing campaign to get patients asking for it. That begins with agreeing a single name that hopefully patients will start demanding. I’m no PR expert, however I have watched with wonder at how strategic placement in a radio or TV soap (eg the Archers) of an issue can raise national awareness very effectively.  I’ve also been impressed by the radio and TV ads for bowel cancer awareness – if you can make the first signs of that palatable, you can certainly sell telehealth, whatever it is called. TTA is hugely supportive of the newly-national UK Telehealthcare, which we see as potentially a great partner to 3millionlives in increasing national awareness (however we do suggest they move on from pictures of older people lying semi-conscious clutching pendants, in vacant bus shelter poster slots).

Readers’ comments are always welcomed – especially to this post.

Categories: Latest News and Soapbox.

Comments

  1. Doug Miles and I are great fans of TTA, and appreciate the support we receive, both from you and from our membership, now around 100 organisations – and set to increase nationally with our re-branding as UK Telehealthcare. We are excited at the prospect of offering membership across the country, and yes, your third point about creating public awareness of telecare and telehealth services is something we have tried to implement for several years. However without some serious funding, we are very limited in the scope and impact of any campaign.

    Creative concepts must build on what little awareness the public already has of telecare devices, which is why, after consultation with our members, our poster campaigns often featured the alarm button in use, typically helping someone who had fallen. By the way, young people don’t fall so much, except after excessive alcohol consumption.

    We have used several ad concepts over the years, as you can see at http://www.uktelehealthcare.com/posters.asp – but the push button pendant is still the ‘entry level’ telecare device, just as a remote blood pressure monitor may well be the equivalent telehealth device.

    Having spent many years working in advertising, I know a little bit about what works, and the £2m worth of free poster space from ClearChannel has been a huge bonus for us in London, but sadly a drop in the ocean compared to what’s needed to make a real impact on TV – and real savings.

    We need the government to recognise that 3 million lives connected to telecare or telehealth will save the NHS money. All of our experience tells us so. If we only saved £300 per head, that equates to a saving of around £1 billion. For a fraction of that, UK Telehealthcare could create massive public awareness of the new services available – and start this process of educating those families with elderly relatives living alone, or struggling with long term conditions.

    Let’s engage with the decision makers, the commissioners and our elected politicians and make it happen. We hear so much about a ‘Can Do’ mentality – so let’s get on and ‘Just Do It’!

    John Chambers
    Managing Director

  2. Mark Baker

    As a member of the UK Telehealthcare Executive, I can confirm that we are all determined to do what we can to raise awareness, and will happily work with others with similar aims, whether they are from the supplier or provider side. At the end of the day, with all the technology that is out there we can all be winners, especially the people at the focus of it all – the patients or clients. We don’t represent any single supplier but welcome all as members alongside our ever-growing band of service providers. We are about raising awareness in partnership for mutual benefit.

  3. Kevin Doughty

    One of the problems of the 3ML campaign was that it was associated rather too much with the narrow remote vital signs monitoring agenda which some people have passed off as telehealth. In isolation, this form of telehealth/care definitely improves outcomes for people with CHF and COPD – at least as far as the NHS is concerned. However, it is other technologies and services that form part of a broader Digital Healthcare proposition that will transform our lives (and a lot more than 3 million of them!) by tackling the prediction and prevention agendas. We need a vision that will appeal not only to technologists and manufacturers, but also to service providers, commissioners and health, social care and housing professionals – and especially to the GPs and third sector volunteers who are probably the closest to the public who are the ones expected to use the Digital Healthcare technologies and services. In fact, unless the entire care sector repositions itself to be patient-centric then any attempt to modernise healthcare delivery will be doomed to failure.
    So I suggest that we all put ourselves into the shoes (or slippers) of a 75 year widow who is recovering from the stroke which she suffered 3 weeks after a mastectomy for breast cancer but who now has a confirmed diagnosis of diabetes, high blood pressure and asthma. She will probably need to take tamoxifen for 5 years, along with 3 or 4 other medications on a daily basis. She will know the possible side-effects and will need on-going support for depression in addition to the attention of her speech and language therapist, occupational therapist and physiotherapist if she is to remain independent – which is her hope. Unfortunately, she is concerned to hear that her local hospital, which has some severe quality issues, is to be closed down so that specialist services can be concentrated at another hospital several miles away from her home. Meanwhile, her GP surgery is only three miles away but requires a change of buses for her to get there.
    It would need little Digital Healthcare knowledge and a bit of imagination to work out a comprehensive package of Assisted Living Technologies and services that would be perfect for this lady. They might enable her to receive remote support from her entire primary care and allied professional team (perhaps through a set-top box) along with a telecare system that manages her risks and wearable devices (mhealthcare) that can support her to go out walking and to benefit from fresh air.
    But, like so many other people of her age, she has no home computer and will share her general concerns with the only person she really trusts – her GP. Is it his or her role to persuade her in an 8 minute consultation that technology is what she needs and that teleservices will improve her quality of life to such an extent that he/sh can recommend them to her?
    That’s the GP’s position today and a tremendous amount of evidence (and some pretty good local examples too) will be needed to change this stance – and that could be one of the reasons why GPs can be so negative about new ideas.
    On the other hand, if the lady came to the GP asking for the latest equipment that she can use to enable her to make the best possible recovery and to allow an early intervention if there are signs of things going wrong, along with access to a new group of friends and fellow sufferers for moral support – then I suggest that it would be a different story, and it would all be about the role of integrated care services in improving her well-being and quality of life. So while it’s important for GPs to be made aware of the collective benefits of these services (that could and should be prescribed), it is the public that needs to be excited about technology and its benefits.
    I believe that a new campaign needs to focus on this vision and to show how services can move away from pushing boxes at patients in favour of providing flexible services. Such a campaign must include all stakeholders (and those who can provide some funding) but it must not be led by the NHS and local authorities (because they may be seen as trying to save money), nor equipment providers (because they may be seen to be trying to sell boxes). Perhaps even service providers must also take a back seat as they too have a vested interest. It leaves charities, universities, the Royal College of General Practitioners and other independent organisations such as the Royal Society of Medicine. It might also leave new organisations such as UK Telehealthcare with a role to play because they carry no baggage. DH might like to consider some funding – but to make it a UK rather than English proposition, this should be supplemented by money from Scotland, Wales and Northern Ireland.

  4. supporting the comments above, in a way that is additive and constructive is not easy. the latest initiative http://news.sky.com/story/1138301/millions-should-not-be-in-a-and-e-exclusive shows that our government is trying to show some leadership in the care at home debate.
    1. In our hearts we know that we can’t continue to provide care in the same way as we have done for the last 50 years. This is not to decry the thousands of advances that have been made in clinical care in my lifetime. We can’t forget that people are living longer than ever, which is the most positive testament to all the advances over the years. It’s the way in which care is delivered that for the same years has been in need of a similar degree of enthusiasm and effort that has been put into the development of the clinical advances themselves. The need for change is long overdue.
    2. There is a lot of care provided to people in their homes that will not be easily improved. This relates to all those occasions when someone has to physically do something to assist the person at home. The role of carers cannot be underestimated in improving the life and well being of their clients or relatives. However, care at home assisted by some technology can play an important part in the patient’s care plan.
    3. Care at home, assisted by technology is but one strand of a number of changes that are needed. We have in effect made going to A&E the easiest way for a patient to get quick access to care when they have concerns over their health. We need to make the alternatives much more attractive. For example, if the GP surgeries were able to provide improved coverage in terms of hours open, this would be a tremendous step in reducing the number of acute beds occupied by patients with Long Term Conditions. (some 70,000 of the 107,000 acute beds in England are not occupied by patients with acute needs.)
    4. Kevin Doughty talks about what is it like for a patient. Well, this is what it should be like for a patient in a well-run telehealth supported care program. Each patient has a series of questions, which may include vital signs information, that they complete on an agreed periodic basis. For most poorly patients this will be daily, but for stable patients would be less frequent. There is no bar to a patient responding whenever they are feeling themselves going off a bit. The first question will always ask the patient how they are feeling compared to the last time. I have come to realise that it takes about a week on the telehealth service for the patient to realise that they have only to say that they are not feeling too good, and within a few hours this will result in a personal response from a nurse experienced in their particular illness. This degree of certainty provides massive confidence in the patient that someone is looking out for them.
    To provide this service in a cost effective way needs the nurses to be grouped together, so the coverage is always there, seven days a week, illness, holidays, changes in job role notwithstanding. This service is a proper full time job and is highly rewarding to the staff carrying it out.
    5. NHSE has to assign some meaningful budget to get this service underway. The ridiculous thing is that £500m has just been assigned to prop up the existing arrangements. We need to act on the root causes of the log-jam in A&E, and it is by no means only the problem (if at all) of the staff in A&E who are picking up the problem.
    6. In our new world, it has become a commonplace that clinicians need to be incentivised if they are needed to undertake anything different from current practice. How we got to this situation is not an edifying comment on the NHS. However, we now need a commission scheme to encourage clinicians to consider ordering increased care in the patients homes. This is urgent.
    7. The 111 service needs to be split into 2 parts. Those who are rare users of the service, for whom 111 can be appropriate; and those who are regular users of the service, who should be flagged and referred directly to appropriately qualified clinical staff (the existing Out Of Hours service who can provide local resources for example). This will reduce the numbers being referred into A&E.
    8. Charles Lowe talks about the WSD results. He is right, they have become irrelevant to the need to provide better care at less cost. They have become a backwater for statisticians to debate sterile issues. We need to move on and I believe that point has been well accepted within NHSE.

    NHSE, lets have some leadership and build on what we know……

  5. John Dyson September 8, 2013 As the comments above are complex and varied, my contribution, whilst supportive is also additive. It is also rather lengthy, but is intended to be wholly constructive. The latest initiative, http://news.sky.com/story/1138301/millions-should-not-be-in-a-and-e-exclusive shows that our government is trying to show some leadership in the care at home debate.
    1. In our hearts we know that we can’t continue to provide care in the same way as we have done for the last 50 years. This is not to decry the thousands of advances that have been made in clinical care in my lifetime. We can’t forget that people are living longer than ever, which is the most positive testament to all the advances over the years. It’s the way in which care is delivered that for the same years has been in need of a similar degree of enthusiasm and effort that has been put into the development of the clinical advances themselves. The need for change is long overdue.
    2. There is a lot of care provided to people in their homes that will not be easily improved. This relates to all those occasions when someone has to physically do something to assist the person at home. The role of carers cannot be underestimated in improving the life and well being of their clients or relatives. However, care at home assisted by some technology can play an important part in the patient’s care plan.
    3. Care at home, assisted by technology is but one strand of a number of changes that are needed. We have in effect made going to A&E the easiest way for a patient to get quick access to care when they have concerns over their health. We need to make the alternatives much more attractive. For example, if the GP surgeries were able to provide improved coverage in terms of hours open, this would be a tremendous step in reducing the number of acute beds occupied by patients with Long Term Conditions. (some 70,000 of the 107,000 acute beds in England are not occupied by patients with acute needs.)
    4. Kevin Doughty talks about what is it like for a patient. Well, this is what it should be like for a patient in a well-run telehealth supported care program. Each patient has a series of questions, which may include vital signs information, that they complete on an agreed periodic basis. For most poorly patients this will be daily, but for stable patients would be less frequent. There is no bar to a patient responding whenever they are feeling themselves going off a bit. The first question will always ask the patient how they are feeling compared to the last time. I have come to realise that it takes about a week on the telehealth service for the patient to realise that they have only to say that they are not feeling too good, and within a few hours this will result in a personal response from a nurse experienced in their particular illness. This degree of certainty provides massive confidence in the patient that someone is looking out for them. To provide this service in a cost effective way needs the nurses to be grouped together, so the coverage is always there, seven days a week, illness, holidays, changes in job role notwithstanding. This service is a proper full time job and is highly rewarding to the staff carrying it out.
    5. NHSE has to assign some meaningful budget to get this service underway. The ridiculous thing is that £500m has just been assigned to prop up the existing arrangements. We need to act on the root causes of the log-jam in A&E, and it is by no means only the problem (if at all) of the staff in A&E who are picking up the problem.
    6. In our new world, it has become a commonplace that clinicians seem to need to be incentivised if they are needed to undertake anything different from current practice. How we got to this situation is not an edifying comment on the NHS. However, we now need a scheme to encourage clinicians to consider ordering increased care in the patients homes. This is urgent.
    7. The 111 service needs to be split into 2 parts. Those who are rare users of the service, for whom 111 can be appropriate; and those who are regular users of the service, who should be flagged and referred directly to appropriately qualified clinical staff (the existing Out Of Hours service who can provide local resources for example). This will reduce the numbers being referred into A&E.
    8. Charles Lowe talks about the WSD results. He is right, they have become irrelevant to the need to provide better care at less cost. They have become a backwater for statisticians to debate sterile issues. We need to move on and I believe that the point has been well accepted within NHSE.

    NHSE, lets have some leadership and build on what we know…… – See more at: http://telecareaware.com/soapbox-what-should-a-restructured-3millionlives-do/#comment-6375

  6. Chris Wright

    Point 6 of John’s observation is key. Encourage/educate commissioners (both clinical and social care) to commission holistic solutions that better serve the needs of people. NHS England should show the lead on that, and must, as John points out, put some resource behind it. Get a team of good people together and run workshops on integrated commissioning across England. That’s what the next year of 3millionlives could have looked like, building on the momentum that was starting, despite the transition. Putting it in Domain 2 is the right thing to do, as long as Martin McShane gets behind it with real resources. However, I fear that bit will never happen because NHSE ‘leaders’ don’t really understand that educating commissioners to commission outcomes rather than technology is the way forward. That’s why the Pathfinder approach was doomed from the start.

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