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The Telecare 2007 exhibition with supporting keynote and case-history presentations took place on 27 September at the Lakeside Conference Centre, Birmingham. The following short report on its proceedings encapsulates the present status of telecare in the UK. Speakers came from across the spectrum of organisations that have been involved in exploring and developing telecare in the home countries: from central government to NHS community trusts and local authority housing departments. Most stressed that success in telecare depends crucially on getting the right mix of joint funding and partnership working, and the 'perfect recipe for that cake' still remains to be found. The challenges of shifting telecare from small-size projects to nation-wide adoption emerged as a dominant theme. Telecare in England Experimental home-based telecare schemes are beginning to show promise, having benefited from two years of government 'pump-priming' funding. But there could be significant difficulties next year when these micro-scale trials have to be translated into mainstream care, participants at the Telecare 2007 event were told. "Partners should be thinking about innovative ways of using existing and new funding streams — not just from central government but from sources like Supporting People, Partnerships for Older People Projects (POPPs) as well as Extra Care and other housing developments", said Mike Clark of the Care Services Improvement Partnership (CSIP), which is providing implementation support for England's Department of Health. The Department has allocated £80m worth of funding through the Preventative Technology Grant to get England's socialcare authorities and their partners ready for telecare and to support an additional 160,000 users. Local authorities and their partners should be looking to launch some form of mainstream, sustainable, local telecare service during 2008. They should already be phasing them in now, despite any present local difficulties in co-ordinating healthcare, housing and socialcare services, Mr Clark added. The money given to England's local authorities to seed telecare services has not been ring-fenced, and some leakage had occurred, Mike Clark said. To provide additional flexibility, the Department of Health has allowed any unallocated grant from 2007/8 to be carried over into the following year as long as it is spent within that year and subject to any local requirements. He also reminded the audience that socialcare users were eligible for direct payments and could request money from local authorities for telecare options — in future, individualised budgets may also be available to users to purchase services to meet their needs. But he also warned delegates to be aware of the problems that had emerged so far in programmes and pilots across the 150 socialcare authorities. An example of a potential 'show stopper' is charging: "If you haven't sorted out the charging arrangements for service users you are going to have real difficulties in March 2008", said Mr Clark. Take-up Another common experience in the current pilots and programmes has been poor take-up of telecare services, with low rates of referral and even some rejected referrals. The Department of Health is looking for 160,000 new users of telecare services from the £80m investment. Although significant progress has been made towards the additional user target during 2006/7, it has often proved difficult to convince commissioners and NHS trusts' finance directors that telecare can pay its way, even if they are aware of it at all. As a result, some of the original "too aspirational" local estimates of service-user numbers have been scaled back by local authorities for 2007/8, Clark advised. He said improved commissioning of telecare would emerge in the future from joint strategic needs assessments involving all local service-providers (NHS, housing, socialcare and the relevant independent and voluntary organisations) to identify who would benefit most from the technology. In England, as elsewhere, the focus of telecare is closely linked with preventing hospital admissions, especially those that are unplanned. But, "it's not always clear who needs these services", George Mac Ginnis, NHS Connecting for Health's Assistive Technologies Programme Manager, told delegates. "Effective case finding", therefore, "is a key component of a telehealth service, especially when designing preventative services that target less-acute cases." He said that the King's Fund's Combined Predictive Model uses data from both hospital and GP medical records to identify people who have not yet been hospitalised but whose histories suggest they may be moving towards admission. "This tool, though, only works when the supporting infrastructure enables effective sharing of health information", he added. Mr Mac Ginnis listed the people likely to benefit most from telecare as the frail elderly and those of any age with chronic heart disease, COPD or diabetes. National demonstrator projects The three national demonstrator projects identified in May 2007 by the Department of Health — in Cornwall, Kent and the London Borough of Newham — are mainly aiming at these groups. Charles Lowe of London Borough of Newham told the conference that the Newham project is focused on demonstrating a reduction in hospital admissions, lengths of stay when people are admitted and enhanced independence and wellbeing of patients. The demonstrators are to run over the next couple of years and will be evaluated. "Somewhere in the basement of the Treasury", Mr Mac Ginnis said, "there is probably a man with a spreadsheet trying to work out in which year he can switch the money out of building hospitals and into setting up telecare systems". As the saying goes, there's many a true word spoken in jest. The real significance of the demonstrators is their scale. The three sites serve a resident population of about a million in which several thousand potential users of telecare facilities and services will be included in the evaluation. To date, there are still many local authority programmes (apart from pendant alarm services) that are individually supporting only a few hundred users with sensor-based solutions. But although the evidence for telecare shows benefits for individual recipients of services, Mr Mac Ginnis said the scalability of the present technology presents challenges. Shift to crisis prevention Some valuable information is already emerging from the demonstrators. The first is that telecare, currently dominated by basic technology such as help-call pendants, should and could move more towards crisis prevention. One example is the use of physiological telemonitoring for early detection of increased risk of a crisis occurring, so that treatment or 'coaching' could be applied to avert it. Investments and returns Secondly, the economics are nowhere near cut-and-dried. To deliver new services, significant new capacity will need to be created within the community care sector, according to Mr Mac Ginnis. And payback is likely to take several years: in fact, some speakers at Telecare 2007 — including the eminent scientist and TV personality Professor Heinz Wolff — rejected the idea of payback, claiming that telecare would not reduce costs, only improve quality of life for its users. One longstanding problem of telecare — that those who fund and provide the service don't always see the returns — was summed up by Newham's Charles Lowe. "The benefits are: the Treasury gets more income tax; all carer-related and low-income supplemental payments are avoided; a bigger pension for users avoids future support; the community benefits from the person's spending; and fewer bed days are used. But", he added, "the council, as the original provider, sees almost none of this!" Fear of physiological telemonitoring Some care providers see adverse consequences from using physiological telemonitoring technology more widely. GPs, for example, dread the possibility of their patients checking their vital signs and phoning them every morning; many doctors are worried that the huge amounts of data collected by telemonitoring systems could be used against them in medical negligence claims; and hospitals are concerned that their systems will be flooded with false alarms and actually increase emergency admissions. "It will take time to create new capacity", said Mr Mac Ginnis. "We have to seek a balance that doesn't overstretch existing services." Telecare in Wales Wales, like Scotland, has many more small and isolated rural communities to cater for than in England. The Welsh telecare development strategy, launched in October 2005, is now backed by two funding streams worth a total of £37.6m for 2006–08, together with a capital fund of nearly £9m. Grants go to the country's myriad of small local authorities, rather than to the NHS. Lee Davis, Telecare Policy Adviser to the Welsh Assembly Government, told the conference that he expects to see 45,000 telecare users — 1.5% of the Welsh population — recruited by the time the grant period finishes in March 2009. But Wales's ambition is more than just reducing hospital admissions (though that's a big part of it). It extends to reform of the whole healthcare, housing and socialcare system. Community alarm services are to be merged and developed into large-scale platforms for service delivery, called contact and co-ordination centres. They will be staffed by skilled workers in close communication with service users and with links to the emergency services, such as police and fire, as well as gas and electricity services. "Care technology will become an integral part of users' everyday lives", said Davis. "We aim to develop new care models, not just give people gizmos." The future agenda, he said, is to mainstream telecare services and use them to remodel socialcare entirely. Telecare in Scotland Much the same applies to Scotland, though the reform plan here was triggered by the election of a minority Scottish Nationalist administration in May 2007. The Scottish Executive's Telecare Programme Manager, Moira Mackenzie, told Telecare 2007 that the new government is keen to reform healthcare, but can't get legislative changes through because of its minority position. So it is looking for change through administrative reform instead. It has already announced a phasing-out of prescription charges (already done in Wales) and an 18-week guaranteed referral time. There will also be a "much more relaxed" view about local government spending, with direct central control being displaced by local decision-making where outcomes justify it. Local partnerships have been invited to bid for £8.35m of telecare start-up funding made available by the Scottish Executive. Each bid must cite the specific health outcome that it hopes to achieve. In the first stage of the Programme, projected outcomes amount to 3,800 more people being able to live at home, 1,574 fewer unplanned hospital admissions and 430 fewer delayed hospital discharges — the latter is a big issue in Scotland, Ms Mackenzie said. She hopes that by 2010 telecare services (not counting community alarms) will be available to 75,000 people across Scotland, and an extra 19,000 people will be able to continue living at home. Net savings are estimated at £40m — more than five times the cost of the programme. The big picture Despite the optimism, the future of telecare still seems uncertain. One limiting factor is that the 'care infrastructure' needed for deploying telecare effectively does not yet exist. Echoing the DH's own view, market analyst Murray Bywater told conference participants that there were questions whether 'small-town' telecare systems serving a few dozen users could be successfully migrated to the national level. "The cost is not in the monitoring devices themselves, but in deploying them in people's homes and in the subsequent capture, transmission, interpretation and storage of data", he said. "Then you need an IT-enabled service provision to make use of the data for healthcare." He added: "I believe there is a big issue here of scalability, of whether large-scale integration of telecare can be made to work." The key to success will be big strategic alliances between suppliers, accompanied by investment in infrastructure by healthcare providers. In the meantime, he said, telecare projects will have to aim at limited scale and scope, restricted to "specific contexts where process priorities are well understood". Adrian Flowerday, Chairman of the Telehealth Group of the software industry association Intellect, agreed: "For the moment, telecare needs to be designed on a highly local basis to meet the needs and desires of local communities." But in the end, Mr Bywater said, the driving force to use telecare will come from the public. "There is a major shift taking place in society: people who have grown up with the Internet will have far higher expectations of technology and less fear of it." Organisational structures that resist the move to telecare will have to change to meet the demands placed on them by society, he predicted. Professor Heinz Wolff in his presentation expressed the same view: "The demarcations have to be removed. We need a new model for funding and a change in culture, and for telecare to be administered by a homogeneous body instead of by people who defend their own little silo." Pete Mitchell Freelance writer specialising in healthcare ICT in the UK. Email: peterm@snowstorm.demon.co.uk)
Last updated 5 November 2007
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