WSDAN Progress: Telecare and Telehealth in Nottingham
David Miles, Sally Parker, Malcolm Clarke
This article was prepared by Mike Clark, co-project lead for WSDAN, and is based on the presentation made to the WSDAN regional event on the 11 June 2009 at the Leeds Marriott Hotel. The presentation can be accessed on our past events archive.
One of the aims of the WSDAN regional events is to showcase the important work carried out around the country in developing telecare and telehealth services. In this example we feature recent developments in Nottingham reported by David Miles (Nottingham City Council), Sally Parker (NHS Nottingham) and Malcolm Clarke (Brunel University).
Typical of a large city, Nottingham has areas of deprivation. Life expectancy differs across the city and there are a lot of hospital admissions for long-term conditions.
Telecare
Telecare in Nottingham has been funded through the Preventative Technology Grant and also by the PCT. There are 883 telecare users to date and the service may in fact run short of funding as it has really taken off in recent months. There are bespoke arrangements of telecare equipment to meet individual user needs with referrals from adult social care, health professionals together with housing requests and self-funders. There is new money in Nottingham for a standalone assistive technology project.
Nottingham has a number of recent case studies that provide examples of how telecare has been used in practice to improve quality of life for individuals and carers. Some initial evaluation work suggests that there may be a saving on average of around £960 per user.
Nottingham is looking at providing telecare into residential care settings, however, there are some challenges to address in terms of the equipment configuration, responsibility for monitoring and whether any user charges apply. In addition, the provision of telecare for people with learning disabilities is being explored together with objective 10 of the national dementia strategy.
Telehealth
For telehealth, there were ten units in the original pilot. This has now been mainstreamed with the purchase of 300 units. Telehealth is very much part of the service delivery approach and not a ‘bolt on’. The aim is to deliver services more effectively. Since the pilot, 50 units have been put into general circulation. From the 300 units purchased, 250 have been held back for the randomised controlled trial (RCT), which has recently commenced after passing through ethics approval.
Deployment of telehealth is across case management in the provider services part of NHS Nottingham. This includes community matrons, the COPD specialist team (includes physiotherapists and occupational therapists) and the heart failure team. The PARR combined model is being used to enable the targeting of patients. This means case managing the right patients, the patients that are most at risk. Proactive management of the patient’s condition with telehealth is important as well as the early identification of any deterioration.
It includes a top-to-toe examination and a constant overview of the patient’s condition including the management of medication. Promotion of self-care and patient education is important in moving from a paternalistic model to a more enabling and empowering approach of self management.
Telehealth is also being looked at in conjunction with the early stroke discharge team. This could support patients returning home more quickly. Monitoring can be carried out in the short term using telehealth to provide better assurance. The telehealth approach for stroke discharge would be different as it would be short term.
NHS Nottingham is also looking at providing telehealth within a sheltered housing scheme. This could use a control centre to pick up the initial patient reports and then alerting a clinician where vital signs are exceeding parameters.
Evaluation
In looking at the evaluation of telehealth, earlier work carried out by Malcolm Clarke and colleagues at Brunel University has identified various approaches that involve primary care, secondary care and community services in supporting remote patient monitoring. The optimum approach can depend on the long-term condition being monitored, the resources available, data sharing arrangements, the organisation structure and urban/rural settings. There was no one way of monitoring that would apply to all circumstances.
With any trial or remote patient monitoring, it is always difficult to define ‘usual care’. There is no placebo equivalent for the technology as with trials of new drugs. How do you evaluate improved service? What is the study size? How do you collect the data? How do you define outcomes? How do you make it generalisable and transferable?
NHS Nottingham is well placed in that it has an established community matron service with good GP and nursing information systems. It should therefore be possible to study the impact of adding the technology to the existing well developed service. There is a good system for identification of the patients – they are already in the service. Patients would already have been assessed and be on case management programmes. Baseline information is more readily available. This allows the study to look at the psychological impact of having the technology in the mid-term and final survey along with the data from the home monitoring devices. A number of tools would be used to measure impact on quality of life as well as specialist questionnaires covering heart failure and COPD. It should be possible to obtain good outcome data on patient benefits (eg, reduced anxiety, reduced depression/stress), changes in hospital visits/admissions, impact on length of stay as well as impact on the health system such as caseloads and service costs.
One of the most important lessons already learnt in preparing to recruit people into the trial is that telehealth is not a treatment but an important diagnostic tool to manage the patient better and for them to manage their own conditions.