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 a diametrically opposite result to that intended from the WSD: it is slowing the development of telemonitoring in the UK, and elsewhere. Perhaps the most recent example of this is the publication by the Royal College of GPs of their 2022 GP: a vision for General Practice in the future NHS, where the Compendium of Evidence dismisses telehealth (P36) on the basis of a WSD paper, leading it on the following page to quote remote delivery of test results as the most advanced medical development likely to affect GPs over the next nine years. At every conference too – including the recent excellent Kings Fund International Congress on Telehealth & Telecare – there are clinicians who after listening to a WSD paper appear to believe it to be the current state of the technology and begin sounding off about wasting money.
So what are the reasons? Let me begin with equipment specification and cost. In the autumn of 2006 we made what I still believe was, then, a great choice of telehealth equipment that we would use, were we to be successful with our WSD bid. In the intervening seven years however, equipment cost has fallen substantially and functionality has improved significantly.
A related issue is that the WSD was in a sense an oxymoron: as both control and intervention groups were in the same (Newham) system, we were unable to demonstrate the effect of whole system change. Worse was that we had to run two systems side by side – one for those in the trial, and one for the rest, which naturally increased operational costs. The result of this, combined with the WSD equipment costs, means that the historic costs, which were far higher than a well run programme now results in, are of value only to historians.
Looking next at flexibility and speed of response, perhaps most importantly the prospect of telehealth as an app downloadable onto a smartphone both significantly further reduces upfront cost and completes the move to a mobile, instantly available, service – compared with the month that our telecoms provider used to require to install a broadband line (and then only if the application form was completed perfectly first time). So, for example, equipping someone with telehealth to facilitate early discharge from hospital is now easy, whereas in 2007, when the trial was being designed and the types of interventions finalised, it was not even seriously contemplated.
Likewise, instantly installable telecare was often not available then either, to provide monitoring cover as soon as a user was assessed for it.
Those who have not endured a rigorous RCT will perhaps be unaware of how restrictive communications with patients can be, both in the patient selection phase, and in interactions once users have been allocated to the intervention or control groups. It was therefore especially galling when I chaired a session at the recent Kings Fund event to hear a paper showing no significant evidence of self-care behaviour in the intervention group when that was not one of the principal WSD objectives, and the RCT’s rules of conduct expressly forbad the sort of interaction that would have fully encouraged patients developing self-care behaviour.
Patient selection is also worth a mention. In Newham we unintentionally ended up removing many of the neediest people from possible involvement in the trial. This happened because, at the time of the award, we had already rolled out almost 3,000 telecare installations. Although this total, which represented a little over 1% of the Borough’s population, obviously couldn’t include all those with the highest need, it certainly contained many. When a decision was taken after we had won that a randomised control trial (RCT) methodology was to be used, of course all these higher need people were then excluded from the WSD trial because they already had technology.
It’s fair to say that the recruitment process for the initial 3,000 had added further bias too, because those already paying £2/week for our pendant-only community alarm who spotted that, by moving to full telecare, they got a better service, and one that at that time was free, did so in large numbers and so excluded themselves from the trial. Only those who continued to pay £2/week for the restrictive service were therefore eligible for the WSD trial. Also excluded from the trial were the two categories of telecare user who we considered at the time to deliver the greatest benefit to the Council – people with a learning disability, particularly those who required ‘waking night’ care, and people caring for those with dementia that were prone to wander.
Perhaps as a consequence of the above, the headline results were disappointing to those of us who have seen hugely impressive results from using technology as part of a genuinely whole system intervention, although of course using a much less rigorous evaluation method (typically before-and-after). Combined with the very high historic costs, that gives the WSD extremely unfavourable cost/QALY figures.
So what to do? I am told that now that WSD funding has ceased, academics are producing WSD papers in their own time so there will likely be a continuing stream of such unwelcome results for a little while yet. Of course it’s understandable that academics with access to a huge quantity of historic data may have different objectives to those of us keen to implement modern technology successfully. Perhaps the DH could though be encouraged to provide just a little extra funding for them to finish off their current WSD work quickly? This would draw a line under the whole affair so the world can move on, looking for ways of using technology best, rather than looking back to prove yet again that we were still at a much earlier stage in technology use six (shortly to be seven) years ago?
None of the above is a criticism of the WSD trial – it was a visionary approach to kick-starting the use of telecare and particularly telehealth to improve patient outcomes and reduce costs. Partly as a result of the trial, equipment cost and functionality have changed so much, and we have learned so much more about how best to deploy and prove the benefits of the technology. Indeed, in spite of published material, all three WSD sites decided subsequently to mainstream telehealth which is as good an indication as any of its value (all had already mainstreamed telecare) – in Newham the business case was primarily founded on improved efficiencies in the use of clinical staff rather than any of the results of the WSD Trial.