The challenges for commissioning telecare and telehealth

Nick Goodwin and Mike Clark¹

The Commissioning Context

Addressing the needs and demands of an ageing population and the increasing prevalence of chronic illness cost-effectively lies at the heart of current government policy towards commissioning. The emphasis has shifted from buying ‘episodes’ of care and treatment that promote productivity to actively using commissioning as a means to secure a positive impact on people’s health and well being – ‘adding life to years and years to life’ as the World Class Commissioning mantra goes.²

In order to achieve this, commissioners need to: change the balance of care settings, shifting activity undertaken in nursing homes and hospitals towards the home environment; invest in upstream interventions through enhanced primary and community care-based alternatives; and focus on supporting ‘self-care’.

The Commissioning Conundrum

Although there is a belief that telecare and telehealth have the potential to enable this shift in the balance of care settings, there is a lack of evidence, particularly on cost-effectiveness related to performance issues such as changes to utilisation rates, health gain, and contribution to savings targets.

As a result of this, commissioners cannot reassure themselves of the business case for investment and therefore seek to minimise risk through ‘pilots’ and/or the use of grant funding rather than core resources. While a few innovators and early adopters have utilised technology, most commissioners are playing a ‘waiting game’ until the data on clinical and cost-effectiveness provides reassurance that such investments are wise.

The current credit crunch, and the long-term cold economic climate that lies ahead, means that commissioners will no longer enjoy the benefits of the unprecedented funding boom of recent years. The investment histories of commissioners would suggest ‘non-core’ or speculative ventures in which outcomes and investment returns are uncertain are the ones most likely to be frozen or discarded as expenditure is cut; this may prove bad news for telecare and telehealth.

This creates a paradox: investment in home-based telehealth and telecare services may prove problematic in the face of financial realities, but those schemes have the most potential to develop the strategies of offering care at home.

Strategies for Commissioning Telehealth and Telecare

There are a number of possible approaches to commissioning telecare and telehealth, all of which have associated risks:

‘Go for it’ – initiate major programme

Risk: infrastructure not in place, overwhelmed with data, unexpected outcomes

Phased implementation

Risk: infrastructure not in place for large-scale programme, resistance to change, programme stalls

Stay with controlled pilots and projects

Risk: No organisational transformation to handle scale, inconclusive local evidence

Wait for the money

Risk: No identified external funding, difficult to build a local business case

Wait for the evidence

Risk: Some findings not conclusive, difficult to build a local business case, missed opportunities

Do nothing – ‘its not a priority’

Risk: Unable to meet known/unidentified demand with existing services, demographic time-bomb

For those wishing to promote commissioning, an examination of telecare and telehealth developments since 2004 shows the importance of advocates to stress the underlying strategic rationale for investment. Where such technologies have been included in joint strategic needs assessment, commissioning plans and local area agreements to show its meaningful contribution to meeting the needs of individual users and the local population, investments are more likely to be made. Focusing on sustainability is also important – commissioners are much more likely to sign up to the delivery of a service model over a number of years than to buying a one-off product with a potentially limited shelf-life.

While the evidence base is still developing, it is also difficult to ignore the work of health, housing and social care services that – together with the work of independent and supplier organisations – have used new technologies extensively and often successfully. Areas such as dementia, falls programmes, intermediate care and re-ablement have proven fertile ground for new innovations, while the growing use of telehealth and support for carers has been highlighted in a number of themed reports based on the Preventative Technology Grant. These reports provide useful supportive information for remote monitoring.

One area of growing importance for commissioners is handling the data from home monitoring devices and also potentially from self-purchased devices (eg, blood pressure monitors) that can generate alerts and data on trends. Making sense of the data and ensuring it is captured appropriately in a health record is an area that NHS Connecting for Health has been exploring at the recent WSDAN events. If you would like to be involved in some of the ongoing discussions about data handling then contact the .

Take-Home Messages for Successful Commissioning

With the developing local and national evidence base providing a recognition for the potential of telehealth and telecare applications, it is important that commissioners continue to explore innovative approaches to long-term care management such as remote monitoring and supported self-care. Key take-home messages to establishing projects include:

Review current effectiveness of long-term condition management
Identify people who could benefit from remote monitoring services
Agree commissioning approach – doing nothing is probably not an option
Engage stakeholders and build a realistic programme
Ensure infrastructure is in place – data handling, workforce etc
Use project management techniques, ensure there is accountability
Monitor performance and outcomes and make adjustments

Nick Goodwin and Mike Clark are co-project leads for WSDAN

Notes

[1] This article is based on presentations by the authors made at the conference Managing Long Term Conditions held in Harrogate on 7 April 2009:

Mike Clark LTC Conference presentation (6327 kb)
Nick Goodwin - LTC Conference presentation (2082 kb)