TTA Contributing Editor Charles Lowe asks whether it is now time to stop looking back to the UK’s pioneering Whole Systems Demonstrator (WSD) programme.
As the person who led the bid for Whole System Demonstrator status for LB Newham back in 2006/7, this is my case that it’s time now to bid farewell to the programme, as soon as is possible.
Why? This was a great programme that came up with some encouraging results for telehealth, and taught us a huge amount about how best to implement telehealth and telecare. However the echoes from that long gone time are increasingly providing ammunition for the naysayers, when in reality the world is now a totally different place. The technology is unrecognisable from that that we considered when bidding for the WSD in 2006; it is far more efficacious and far cheaper; and it can be deployed much faster & for many more conditions, opening up many possibilities not available to us when we won in 2007. We now know much more about how to implement the technology too: in particular it delivers greatest benefit when a part of an overall programme for improving care and not, as the WSD randomised control trial (RCT) treated it, as a simple intervention, like most drugs. In retrospect therefore there were significant weaknesses in the way the trial was run.
The continuing drip-feed of WSD results is sadly resulting in (more…)
The seventh of 15 expected academic papers arising from the study of the Whole System Demonstrator (WSD) programme has just been published in the Journal of Health Services Research & Policy. The big takeaway is that local ‘ownership’ of new services DID lead to more collaborative practices across the care system BUT that the concept of whole system redesign around remote care is currently unrealistic. With headings such as ‘Misalignment between vision and enactment’, ‘Wider barriers’ and ‘Whole system working: Ambiguity and diversity’ one can see that the underlying analysis is more nuanced than the main conclusion might suggest. Stimulating whole system redesign: Lessons from an organizational analysis of the Whole System Demonstrator programme by Theopisti Chrysanthaki1, Jane Hendy and James Barlow, all of Imperial College, London is also available as a free 10-page PDF download.
A complete list of the WSD papers, updated as they are published, is being maintained here by Mike Clark, to whom thanks for the heads-up on this publication.
More often than not Professor Stanton Newman has been the bearer of bad tidings…the Whole Systems Demonstrator Program (WSD) hasn’t delivered the hoped-for, definitive, glowing results and he has had to see them used for telehealth-bashing by some doctors and the GP press. In an article in the GP online magazine Pulse Today, he gets the chance to bust a few myths and to reaffirm his belief that there are good reasons why GPs should consider telehealth positively. Telehealth gives patients the chance to take more control over their care. (Requires free sign up to view if you have not done previously. Worth doing.) His comments are apt in view of the remote care monitoring directed enhanced service (DES) conditions (PDF) recently published by the Department of Health. Heads-up thanks to Mike Clark.
Since one of the Whole Systems Demonstrator (WSD) let drop at the King’s Fund conference last March that the telehealth Quality Adjusted Life Years (QALY) cost calculation was coming out at £80,000 the actual paper has been ‘eagerly’ awaited, with speculation and concern that the calculation included management and other study-related costs that would not apply in a normal service setting. The paper is published by the BMJ today and a) such costs were excluded and b) the QALY figure is actually £92,000. Well, that’s the headline figure that is already being headlined by Pulse but, of course, the calculations are more nuanced. Foe example:
Whether telehealth is considered to be cost effective will depend on the willingness to pay for the outcomes generated. Figure 1 presents the probability that telehealth would be seen as cost effective as an addition to usual care, using an acceptability curve for different values of willingness to pay. At the £30,000 threshold (associated with NICE recommendations), the probability of cost effectiveness was 11%. Figure 1 also shows the probability of cost effectiveness if costs related to project management were excluded: at the £30,000 threshold, the probability of cost effectiveness was 17%. Indeed, this probability including management costs only exceeded 50% at threshold values of willingness to pay above £90,000. Excluding project management costs, the probability exceeded 50% only at values above about £79,000.
The discussion is also worth reading carefully, as is the final conclusion:
A community based, telehealth intervention is unlikely to be cost effective, based on health and social care costs and outcomes after 12 months and the willingness to pay threshold of £30,000 per QALY recommended by NICE. A reduced cost of telehealth per QALY may be possible by combining the effects of equipment price reductions and increased working capacity of services; On the assumption of reduced equipment costs and increased working capacity, the probability that telehealth is cost effective would be about 61%, assuming a willingness to pay threshold of £30,000 per QALY.
BMJ paper: Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial BMJ 2013;346:f1035
Mike Clark’s Updated list of WSD results papers.
Interview with Professor Martin Knapp As “telehealth” grows, experts question cost benefits Reuters.
David Brindle, in The Guardian anticipated these results last month and, in a follow up article commented “Fourteen months on from its launch, 3millionlives seems to be going nowhere. Intuitively, telecare/telehealth feels like a key pillar of the future care system. To be that, however, it does need a credible evidence base.”
3millionlives press release: 3millionlives – enabling change to benefit patients and carers. (PDF)
GP Online Telehealth ‘not good use of NHS money’, finds DH-backed study.
NHS Choices Are benefits of telehealth care worth the cost?
Ileana Welte, Head of Bosch Healthcare in the UK, helps to re-frame the ‘Does telehealth work?’ question for readers of The Guardian, helped by a pertinent comment by George Margelis (General Manager, Australia, at Care Innovations) about the Whole Systems Demonstrator (WSD) approach. Still time for more comments on How can we maximise the benefits of telehealth for patients across the UK?
At the end of this month NHS North Yorkshire and York (NYY) – a Primary Care Trust (PCT) – and the Yorkshire and the Humber Strategic Health Authority (YHSHA) that oversees it, will be no more. They will be replaced by four Care Commissioning Groups (CCGs).
NYY and YHSHA together spent £3.2million capital money on Tunstall telehealth equipment in 2010, with the PCT paying ongoing support fees and depreciation costs. The procurement was intended to provide 2,000 devices for a project to deliver telehealth to people in the area. It was a pre-cursor of the 3millionlives (3ML) campaign but the local GPs had to be persuaded to participate without the benefit of knowing the Whole System Demonstrator (WSD) results.
The NYY project has had the aspect of a slow motion car crash for everyone apart from (more…)
Given that GPs are so heavily reliant on technology these days – for medical records, for communications, for finding patients’ homes when undertaking visits, etc. it is somewhat surprising that the medical profession is represented as being so hostile to telehealth monitoring by one of their major publications, Pulse. One would assume from the benefits the doctors get from technology that their stance would be to encourage their patients and the patients’ carers to benefit from the technology now available. Perhaps its a doctor-patient power thing. Or perhaps they are insensitive to the disruption caused to the people who have struggled along to the waiting room for something that could be dealt with by phone, SMS or email. Or perhaps it is a symptom of the profession’s current displeasure with all things Government-endorsed. Whatever the reason, Pulse has now published an index of its articles on the subject of the Whole System Demonstrator (WSD) programme – Timeline: the evidence so far on telehealth, telecare and telemedicine. UPDATE: Friday 8 March – This article now seems to be accessible only if you register on the site.
Quick on the heels of the telecare study from the Whole Systems Demonstrator (WSD) Programme reported here today, comes another research report, this time from the BMJ: Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial.
Here are a few quotes from the abstract:
Objective: To assess the effect of second generation, home based telehealth on health related quality of life, anxiety, and depressive symptoms over 12 months in patients with long term conditions.
Conclusions: Second generation, home based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients.
So can we now not even say ‘Never mind the business case, that can be improved – it’s very good for patients’ sense of well being’? Heads-up thanks again to Mike Clark who is keeping an updated list of the reports as they are published.
UPDATE Thurs 28 Feb: Pulse does its usual thing with this study, but note the comment from the GP at the end: DH-commissioned report finds telehealth fails to improve quality of life.
The latest journal article containing results of the Whole System Demonstrator (WSD) programme has just been published and the conclusion is “Telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.” We note the “as implemented” caveat. Article, from where it can also be downloaded as a PDF: Effect of telecare on use of health and social care services. Age and Ageing. Heads up thanks to Mike Clark.
UPDATE: 6 March 2013. The GP paper Pulse’s take on the study: No evidence telecare can cut costs, says DH-funded study.