Andrew Corbett-Nolan, Chief Executive of the Good Governance Institute discusses how the MOST (Model for Optimising Scalable Telehealthcare) project can offer guidance for implementing telehealthcare services at scale
The last 12 months have seen the largest ever reorganisation in the NHS, resulting in substantial reforms that impact on the way telehealthcare is commissioned. For GPs and commissioning managers, concerns are being voiced over the future of patient care and its delivery in the community. Specifically, how can they ensure that older patients, and those with long term conditions, receive the support that they require?
Commissioning changes in community care
GPs are now at the heart of deciding which needs and services are of most importance and relevance in local communities, but it is a difficult balancing act. CCGs, by design, are smaller and more numerous than PCTs, operating with reduced resources over localised areas. Consequently, their capacity for commissioning and implementing telehealthcare is likely to be diminished.
There are also concerns that the transfer of community health services to NHS Foundation Trusts may result in the de-prioritisation of community care, and telehealthcare, as Trusts receive more funding for delivering acute services. The need for technology-based solutions such as telehealthcare remains, but with resources stretched thin the appetite for commissioning may be significantly reduced.
In supporting older, more vulnerable patients, GPs and commissioning managers are currently challenged by three key factors: isolation in the aged / society as a whole; patients struggling to maintain their independence as a result of a lack of services or awareness and understanding of their condition; and the escalating demands on local health services.
Many GPs report how loneliness and isolation, heavily linked to heightened anxiety and depression, regularly leads to repeat and unnecessary appointments which take up valuable time. For some patients, seeing their GP is among the only social contact they have; GPs feel under pressure to maintain this, so as not to risk destabilising the patient.
Patients’ inability to maintain their independence, often as a result of a lack of services or understanding about their condition, is a particularly challenging issue. Many patients are of the mindset that if they have a health problem it is the responsibility of the ‘system’ to make it go away. Overcoming this obstacle is about education and changing behaviours. In the future, as a result of shifting population demographics, GPs will have less time or inclination to see the so-called ‘worried well’, and accordingly there will need to be a transfer to a more ‘informed’ patient.
Many GPs report a lack of community service support for older and frail individuals, which may be the result of a shortage of appropriate staff. This lack of service capacity is juxtaposed with increasing and unrealistic expectations of relatives, in turn putting a greater strain on resources.
Perhaps the most pressing issue affecting GPs is the increasing workload and the pressure this brings to a practice. It has been suggested that a gap exists in making sure routine assessments are not always practice-based. A lack of joined-up data also compounds the issue as GPs often see patients who have, unbeknownst to them, been directed their way for a diagnosis or medication change.
Solid foundations for better patient support
To help GPs and commissioning managers overcome the service issues outlined above, improvements are clearly needed in two fundamental areas: the ability to evaluate the care options available and match them to individual patient needs, and the approach to integrated care.
Special thought needs to be given to how telehealthcare can best be matched to the needs of an aging and increasingly isolated population. Since 2010 older people are having to wait on average a whole day longer in hospital before they are able to be relocated to a residential care home, amounting to almost 2 million bed days over the last four years. Older people need to be treated with understanding and compassion, and telehealthcare needs to find its role within this.
In tackling the care challenges of social isolation, frailty and patients’ inability to manage long term conditions, much inspiration can be drawn from Tunstall Healthcare, whose series of telehealthcare solutions clearly demonstrate how technology can be mapped to meet the various needs of the NHS.
Meeting the challenges
Older people who experience feelings of isolation may benefit from the provision of tablet computers, pre-loaded with customised software containing a range of simple, easy to navigate tools. These would provide easy access to the ‘outside world’, allowing the user to keep in contact with family and friends and importantly their GP, and maintain a more active social life.
Telecare, in the form of fall detectors and sensors in the home, can also help individuals who struggle due to frailty. Sensors mean that the right people are notified in the event of a fall. Relatives, carers and clinicians all have access to an individual’s records via an online portal, relieving the stress attached to having a frail and isolated relative, improving the accuracy and level of care delivered.
For people with long term conditions, the use of telehealth monitoring devices would enable the recording of vital signs information which, if needs be, can be escalated as an alert to a responding clinician. If an individual flagged up a problem, such as experiencing acute shortness of breath, a member of the community team would get in contact. GPs would also have access to records and be able to carry out consultations remotely through the device. By monitoring their own vital signs and symptoms in their own homes, users can reduce their number of hospital and GP visits, take ownership of their conditions and offer reassurance to family members.
Improving patient care with MOST
Having identified the problems facing GPs and areas for improvement, the challenge now lies in determining how this can be actioned. Insights from the Model for Optimising Scalable Telehealthcare (MOST) project, originally developed to demonstrate the deployment of new product solutions that would enable the up scaling of telehealth services, can go some way towards addressing this issue. Key action points can be used by GPs and commissioners to help them develop telehealth projects, offering guidance on service design and implementation.
The use of technology in the treatment of older people, as highlighted earlier, has the potential to improve efficiencies in a number of areas. It is crucial then that GPs who wish to implement telehealth care are given the chance to do so, despite the barriers that have emerged from changes in the health landscape. Drawing on the experience gained through previous large-scale telehealth programmes, key teachings highlighted by the MOST project can help commissioners and GPs to design care services that will successfully incorporate telehealthcare.
MOST identified the key areas to consider before designing a telehealth programme, such as identifying clear objectives and potential benefits and the estimated costs, efforts and timescales associated with the project. Service providers are encouraged to determine precisely what staff and patient training is needed, how the telehealth system is to be installed and how can data be best monitored.
Action points from the MOST project can help with patient selection, pinpointing those patient groups that will most benefit from telehealth. This will be important when prioritising locality rollout, and as a valuable tool with which to begin discussions with primary / community care and other clinicians. The report also identifies the key phases and actions for implementation, from set-up to full deployment.
Securing the future of care
For GPs and commissioners faced with caring for an aging population in an environment that is impeded by a variety of service issues, the lack of capacity coupled with the need for better-integrated services is affecting their ability to provide the best possible levels of patient care. The changes in the health landscape mean that the viability of telehealthcare inevitably comes into question, with restricted resources likely to channel prioritisation elsewhere. The fact remains though, that in cases where technology has been utilised effectively between services, it has yielded extremely positive results.
It is crucial that decision-makers don’t lose sight of the potential benefits that telehealthcare can bring, not only in helping to alleviate the pressures placed on GPs, but also in the provision of a better quality of care. By following the learning points raised by the MOST project, GPs and commissioners can ensure that telehealthcare plays a prominent role the reformed NHS.
Key learnings from the MOST project are available: http://uk.tunstall.com/about/partners
To read the full report, visit: http://www.good-governance.org.uk/publications/