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Insight: telehealth
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Telehealth reduces hospital admissions and frees up GP time by allowing doctors to manage a small section of patients via technology, while the patient remains at home. These are very good reasons for family doctors to get involved with telehealth technology.
 
But while a succession of health secretaries have pointed to telehealth as part of the key to making the NHS more efficient and patient focused, it has not achieved mainstream status and is even viewed with suspicion in some quarters.
 
As commissioning responsibilities move to clinical commissioning groups there is massive potential to improve outcomes and achieve cash savings based on an appropriate payments model. The user base and evidence for wide-scale implementation of telehealth solutions are growing rapidly.
Intellect, the trade association for the technology industry in the UK, supports the definition used by the think tank 2020Health: "Telehealth is not a single, uniform type of technology; rather it is a targeted approach appropriate to the individual's needs, combining process, organisational and responsibility changes supported by monitoring and collaboration technologies."
 
This approach can be used to remotely monitor and regularly record clinical information from patients, particularly those with long-term conditions (LTCs) such as heart conditions, diabetes and chronic obstructive pulmonary disease (COPD).
 
The aim of telehealth is to enable a shift in the provision of care from the hospital to the community; ensuring care remains clinically effective while helping to reduce costs. Patients using telehealth frequently develop a deeper awareness of their situation, are better able to manage their conditions and ultimately benefit from a higher quality of life.
 
Scotland, Wales and several NHS trusts in England have been pioneering early investment in telehealth. And later this year the Department of Health (DH) is due to publish the results of the Whole System Demonstrator (WSD) programme, the largest evaluation of telehealth and telecare ever undertaken, covering three key sites – Newham, Cornwall and Kent – and involving a mix of roughly 6,000 patients.
 
The objective is to "provide an evidence base for more cost effective and clinically effective ways of managing long-term conditions." The DH plans to use the results to push for wider uptake of telehealth in England, where there are currently around 10,000 telehealth installations, with a few trusts looking at major implementations of 2,000 or more.
 
International experience also points to the scale of the opportunity that telehealth presents. The
Veterans Health Administration in the US uses a telehealth service to meet the needs of a vast population across a wide geographical area and is used to manage conditions such as diabetes, chronic heart failure, stroke, depression and post-traumatic stress disorder. Across the US there are approximately 200,000 telehealth users in total.
 
GPs will play a crucial part in mainstreaming telehealth both as providers and commissioners. But there is still work to be done to make sure the health and financial outcomes associated with these implementations are fully understood and accepted by the GP community.
 
Where implemented, telehealth has been shown to reduce hospital admissions and GP consultations and visits. Under the current system this may not be cash-releasing but can enable GPs to manage practice time and increase appointment capacity.
 
Earlier this year, Intellect published a short paper highlighting the benefits of telehealth and how it is being used across the NHS today. The paper highlighted the work of Dr Richard Berkley, a GP and clinical lead for The Orchard Medical Centre, who has observed measurable reductions in hospital admissions (46%), A&E visits (67%) and visits to the GP surgery (16%) by using telehealth solutions to manage heart-failure patients in their homes.
 
Other case studies showed that in NHS South East Essex a telehealth installation involving 65 COPD patients delivered similar reductions: 75% in A&E visits, 83% in hospital admissions, and 56% in GP visits. In Sheffield, the primary care trust implemented a localised telehealth solution for 45 high-risk COPD patients and is now saving £1.2m a year.
 
However, scaling isolated implementations is not quite as straightforward as buying more kit for more patients. Seeing telehealth in action across the NHS will require care process change, clinical buy-in from primary and secondary care providers, and a better commissioning and payments model.
 
From his own experience Dr Berkley noted that there is a "steep learning curve to understand the equipment, establish robust processes for deploying it and capturing the information received… [and] integrating the project into our daily routines. Once this was under control – using robust clinical governance procedures – the telehealth system became a very useful clinical tool."
 
Adrian Flowerday, Managing Director of Docobo, 
a healthcare solutions provider, argues that: "For GP consortia facing the challenge of managing patients with LTCs, telehealth offers a tool in the armoury of solutions 
to support patients.
 
"In addition, for episodic and diagnostic purposes, telehealth offers consortia an electronic patient diary allowing short-term daily collection of data to aid with diagnosis and titration of medication.
Where properly implemented, telehealth will provide in one year a return on investment for commissioning groups with the added value of improved quality of life and quality of care delivered."
 
Telehealth at scale requires significant commitment and a joined-up approach, which should start at the commissioning stage. This is where GPs should take the lead.
 
Angela Single, Health and Wellness Innovation Lead at BT Health, says: "As GPs become commissioners of healthcare, engagement of GPs in the telehealth agenda is a fundamental area to address, as any historical knowledge of how to commission integrated pathways, which include telehealth, may in fact be lost due to the major commissioning changes currently affecting the NHS."
 
The NHS also needs to redesign its payments model to allow telehealth to flourish. The current 'payments by results' scheme incentivises hospitals to increase activity while discouraging preventative and community care. This is plainly unsustainable for a NHS that is facing an unprecedented financial challenge. Hopefully the Health and Social Care Bill will remove barriers to integrated care by aligning payments to outcomes. This would give GPs real potential for ensuring that commissioning is aligned with optimised long-term health management.
 
Intellect advocates other important principles to keep in mind when commissioning integrated pathways that include telehealth. Savings made from telehealth should be made available for reinvestment at the frontline, for example, through more productive urgent care, and cheaper and automated services that complement the overall service.
 
Second, telehealth should not be seen as an 'add-on' service; real savings and productivity gains will only come if the services it replaces are scaled down or decommissioned over time. This requires a complete care pathway redesign in managing LTCs.
 
We are all familiar with the demographic time bomb that threatens to bankrupt the NHS. The healthcare model that we have inherited, with its focus on physical locations that demand patients travel to their doctors and where people aren't empowered to take responsibility for their own health and wellbeing, is fundamentally outdated.
 
Successfully modernising the NHS will depend on as many health professionals as possible understanding the true potential of telehealth and who will take responsibility for driving clinical buy-in.
 
The right incentives and support for this need to be in place for GPs to start making use of telehealth, from both provider and commissioner perspectives.
Work is currently underway on developing a toolkit to help commissioners incorporate telehealth, and the royal colleges have begun programmes to educate their members.
 
In the technology industry, companies are gearing up to deliver telehealth solutions at scale, working together with other health technology suppliers to ensure the digital equipment in people's homes can communicate and join 
up seamlessly with electronic patient records in a range of care settings.
In every other area of our lives, technology has changed the way we live. Technology has a big part to play in changing the way we deliver healthcare and telehealth presents a convincing opportunity to save money and improve care.
 
Jon Lindberg

Healthcare Programme Manager, Intellect
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