WSDAN Progress: An integrated approach to the delivery of telecare and telehealth in Norfolk

Mike Clark reports on a presentation by Wendy Hardicker

On 11 February 2010, at the WSDAN Roadshow event at Stansted, Wendy Hardicker gave a presentation on the development of integrated telehealth and telecare services in Norfolk. The presentation can be viewed at WSDAN’s past events pages.

Background

Norfolk is a large rural county in the east of England, with a population of 720,000. There are two main urban centres: Norwich and King’s Lynn. The population is generally healthy but health inequalities are apparent. There is a rapidly ageing population, with 20 per cent of people aged 65 and over, and 10 per cent aged 75 and over. Its rurality and poor transport links represent key challenges to service delivery.

What is meant by integrated services in Norfolk?

About three to four years ago, when Norfolk County Council introduced telecare, they soon realised that it was important to look at telehealth too. Over the past couple of years, the primary care trust (PCT) and county council have worked together to provide these solutions. From an early stage, they considered that it was important to integrate telecare and telehealth for service users, but were not sure initially what that would entail.

The organisations had different timescales, objectives and team structures, and none of these were aligned. Norfolk concluded that an integrated delivery system should comprise a ‘network of organisations’ that provided or arranged a co-ordinated continuum of services, and was clinically and fiscally accountable for the health of the population.

Key features in the development of the network have included:

  • shared values and goals
  • alignment of incentives
  • clinical leadership
  • a culture of teamwork.

It was a challenge to change the culture within both the PCT and the county council, and each had to try and do that from the bottom up. They looked at various models of integration – horizontal, vertical and virtual – before deciding what would work best for them.

Norfolk is one of 16 integrated care organisation (ICO) pilot sites established by the Department of Health in England that are seeking to understand the value of different approaches to care integration. The ICO pilots were set up following recommendations from the NHS Next Stage Review that recognised the need to encourage primary, secondary and social care professionals to take more collective responsibility for designing, commissioning and delivering integrated services.

In Norfolk, the PCT and county council considered that an integrated model of telecare and telehealth should include the following:

  • the ability of the assistive technology (AT) spectrum of equipment to support the individual in their own home
  • a partnership working agreement
  • an agreed, shared documentation framework
  • a single point of referral
  • a single contact point
  • commitment.

The importance of pathways

Norfolk started to look at how telecare and telehealth linked into care pathways as they were developed. A key driver was to understand how quality of care could be improved and how each organisation’s systems could be made more efficient.

In particular, the two organisations have been looking closely at how to provide care closer to home for the frail and elderly populations in six GP practices, using telecare and telehealth as one of the solutions. In this project, they are looking at an ‘opt out’ policy rather than an ‘opt in’ arrangement. Service providers have to be accountable as to why somebody is not using telecare and telehealth. They have taken the view that users, patients and carers have to be involved from the outset, and that providers are delivering the outcomes that commissioners are asking for through a much more efficient system.

In the next five to ten years (especially with the advent of personal health budgets), people will want much more choice and flexibility over their care package. This was also an important message for suppliers, who need to change the way they make and model some of the equipment so that it is easier to use.

Commissioning telecare and telehealth services

From a commissioning perspective, Wendy Hardicker considered that it was important to look directly at this personalisation agenda, and to examine ways to enable people to make the best use of care services through more flexible arrangements that could tailor care to their individual needs.

Norfolk PCT is currently looking at developing joint commissioning strategies. This includes linking with practice-based commissioners and the county council in terms of pooling some budgets.

Telecare and telehealth support for people in the community has been established as a commissioning priority in the PCT – it is part of the five-year strategic plan – and has been an important part of world class commissioning. The approach aims to ensure that they are providing good-quality care and managing resources more efficiently.

In terms of developing the market and the workforce, the third sector is a key player, both as a strategic partner and a provider.

Norfolk is also developing the concept of a personal health coach or advocate – someone who can help people navigate their way through the system – as well as carrying out broader research to examine the role of the workforce in providing these services.

Achievements and outcomes to date

There have been a number of milestones and achievements to date.

  • 25,000 homes linked to Community Alarm systems.
  • In 2008, 4,000 homes were assessed and people were supported with standalone telecare solutions.
  • Development of an integrated model of assessment, installation and monitoring.
  • Integrated governance and standard documentation frameworks.
  • Increase in the number of telehealth monitors deployed to support chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD).
  • Engagement with practice-based commissioning consortia to develop business plans to reduce the impact of COPD and CHD using telehealth.
  • Support for practices to improve access to health care through technology installations in non-traditional environments.
  • Ongoing deployment of multi-user monitors into care homes.
  • Working as part of a county-wide, multi-agency falls group.
  • Involved with relocation of learning disability service users from NHS campuses to supported living in the community.
  • Providing support to residential and ‘Housing with Care’ schemes.
  • Working with acute trusts to reduce falls in hospital wards.
  • Forming the cornerstone of prevention services within Adult Social Services/NHS Norfolk.

These extensive activities have resulted in outcomes that have been captured in an independent evaluation of the original telehealth pilot projects (University of East Anglia and Cordis Bright 2008). These suggest some encouraging results, including:

  • a reduction in hospital admissions (source: UEA and Cordis Bright 2008)
  • a reduction in GP/primary care contact (source: UEA and Cordis Bright 2008)
  • improved patient experience (including quality of consultation with GP)
  • integrated pathway for the arrangement of telehealth installation
  • support for clinicians
  • regional winner of the 2008 Innovative Health and Social Care Technology Award
  • e-health insider award 2009, winner of category: ‘Best use of telecare and telehealth’.

Challenges to implementation and the keys to success

As with services around the country, Norfolk has faced a number of challenges in providing telehealth and telecare, including:

  • communication barriers
  • different systems of working
  • staff resistance
  • professional protectionism
  • ‘government policy’ vs ‘organisational policy’.

However, Norfolk have overcome these barriers and started to identify the keys to successful implementation of telecare and telehealth in an integrated health and social care setting. These include:

  • champions – assistive technology ‘evangelism’
  • ownership, commitment, buy-in
  • willingness of partners to participate and make it work
  • shared vision and goals
  • evaluation criteria and performance monitoring (eg, acute admissions, length of stay)
  • quality, including patient and clinician satisfaction
  • governance and safety, including equipment reliability, complaints and compliments.

The WSDAN team is currently capturing the lessons learned from across the 12 sites involved in the action network. Later this year, we will provide a range of papers looking at what progress has been made and how, how innovations have been sustained, and what impact this had had on care services in practice.

Mike Clark is co-project lead for WSDAN

Wendy Hardicker is Assistant Director, Out of Hospital Care, NHS Norfolk