Image: picture of a hand holding a cane.

Rewiring Long Term Care

Those of us who look forward to a healthcare system supported by fully-integrated technology were excited by last month’s announcement by the Department of Health (DH). It intends to fund up to three whole system long term condition demonstrators with a “powerful commitment to new, electronic assistive technologies”. But others are concerned that the demonstrators and associated framework contract may inhibit innovation and encourage an inappropriate focus.

About 17m adults in the UK live with a long-term conditions (LTCs) such as asthma, diabetes or heart disease. Many are elderly and need support to live independently. LTC management consumes a large part of NHS resources—about 80% of GP consultations and 60% of hospital bed days are related to it. As the UK’s population ages the number suffering from LTCs is likely to increase and the cost to the NHS of treating the increased caseload could be unaffordable.

To manage costs and provide better care, a new approach to healthcare delivery is needed. In particular, the DH wants the NHS and local authorities to co-operate in the demonstrators. This in itself may be difficult as these organisations have different cultures, assessment criteria and funding. This factor that may be further complicated if the benefits of any change—for example, reduced acute admissions—accrue to organisations that are not also bearing the costs.

Challenge of Long Term Care

“This is quite a complex and subtle area that needs insights from a whole variety of people, such as social services, nurses and other clinicians,” says John Harries, BT’s director of global health practice. BT has participated in pilot studies with the NHS and social care in the UK, including a telecare research study with Liverpool City Council called Liverpool Direct. Using the lessons it learned it has developed Vital Life, a system that is capable of monitoring multiple diseases and of integrating with the social care monitoring of local authorities.

Though it plans to work more closely with the local authority, NHS Direct is at the moment piloting assertive care management in Birmingham with the SHA, PCTs and UK Pfizer Health Solutions. Nurse care managers—some multi-lingual—offer 24 hour outbound telephone support to about 1000 enrolled patients with heart disease and diabetes, helping them to help themselves. “There have been some early changes in health behaviour and in clinical parameters, but we are waiting to see if they are sustained long term,” Mike Sadler, chief operating officer said.

Long Term Care: telemedicine or telecare?

NHS Direct selected its target patients, something the demonstrators may also need to do. The DH has represented its policy aims as a triangle resting on its base, divided into three levels of customer. At the apex, representing the smallest number, are those whose complex needs require the greatest care. In the middle are those with early problems and single conditions, and at the base, representing the largest number, is the general population. Each level has different healthcare needs, which include intensive disease management and support for self-carers.

With this in mind, some suppliers are anxious that the demonstrators, when combined with the commercial offerings in the pre-competed framework contract, may encourage a focus on a restricted target group. Dr Paul Johnson of Xenetec, developers of a remote and non-invasive physiological telemonitoring service, suggests telecare—helping the elderly and vulnerable to remain independent at home—may be over emphasised. “Though this is worthy, it will not deal with the chronic disease triangle and it is completely unsuited to three-quarters of the people in the trial,” he said.

Professor Lionel Tarassenko of t+ Medical, which develops user friendly technology to aid LTC management, has similar concerns. “I would agree there is some confusion between telecare and telemedicine,” he told me. “They seem to be concentrating on the highest level, the most acute patients, with a view to keeping them out of hospital through a combination of telecare and social care.”

Technology Means Transformation

Even with focused aims and organisations, providers of care for patients with LTCs have a wide choice of technical support, ranging from the landline and mobile phone to exciting new monitoring and diagnostic devices.

Toumaz Technology is carrying out clinical trials with one such device that transmits wirelessly to a PDA or laptop. Toumaz is working with Oracle Corporation to embed the device with intelligence so it transmits by exception, which will reduce transmissions and the demand for battery power. A new plaster-sized device is also under development that will exploit a tiny microprocessor and monitor up to 24 vital signs. Keith Errey, chief operating officer, said: “No-one really knows how to use it yet. It would need to be in a joined up healthcare structure, and we’re not quite there yet.”

This comment highlights the important dynamics at play in creating the demonstrators—and ultimately a healthcare system to manage LTCs effectively and economically. It is common to discuss organisations in terms of people, processes and technology. But these are not three pieces of a static jigsaw—they relate dynamically. Change one and the others will also be pressured to change.

The demonstrators offer an opportunity to look at those dynamics and learn important lessons from them. But we must be wary of allowing models of care to cement our thinking and our openness to new ideas and developments. What’s more, given the uncertainty of demographics and epidemiology, our approach must stay flexible. As BT’s John Harries put it: “You need something that supports the extremely unwell at the top of the triangle that can also be scaled economically to the bulk of the population with long term conditions.”

This article was published on E-Health-Insider in December 2006

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