The UK Whole System Demonstrators For Health Care
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The UK Whole System Demonstrators

 For Health Care

Background

For some time there has been increasing interest in England in finding new, more efficient ways to provide care services that address the growing needs of people with long-term medical conditions and ongoing social care needs.  The need to find new ways of delivering health and social care is all the more acute because of limitations on resources available in the coming years compared with previous years.  By 2019, the percentage of gross domestic product (GDP) devoted to health care in England is predicted to fall from 8.2 per cent (its historic high) to 6.7 per cent.  With the Government also currently spending £14.5 billion per year on adult social care in England (just over half of this on services for older people), but with future cuts in funding already announced, the current funding system has been described as unsustainable.

Even if health and social care budgets were to increase over time, there has been a longstanding recognition that money alone cannot address the gap between resources and increasing demand. Many policy analysts thus agree that the increasing demand for health and social care services can best be met by more efficient and effective management and deployment of resources, along with integrated governance in support of client-centred care.

Telehealth and telecare have the potential to play an important role in delivering more cost-effective care.  Through enabling a client-centred, integrated and home-based system, it is hoped that it will be possible to support more people to live independently for longer, and so reduce the need for institutional care in a nursing home or hospital. 

Prior to planning the WSDs, several reviews of the effectiveness of telecare and telehealth had been published, both within specific disease areas and across different disease areas.  Much of the literature that was then available referred to pilot projects and the assessment of the impact of these devices on short-term outcomes and the majority of studies did not meet robust evaluation standards.  Very few of the studies reviewed had assessed the longer-term or routine use of such technologies.  

A systematic review of 24 trials of interactive health communication applications had recently been published (Murray E, Burns J, Tai S, Lai R, Nazareth I: Interactive Health Communication Applications for people with chronic disease. Cochrane Database of Systematic Reviews 2005, , 4: CD004274).  In that review,  telehealth had been found to have a significant positive effect on knowledge, social support, behavioural outcomes (e.g. calorific intake, exercise and medication taking) and clinical outcomes (e.g. asthma symptoms, HbA1c levels and body mass index).  It had not been possible though to determine whether they had an effect on emotional outcomes or overall healthcare resource use.  A later systematic review of telecare and telehealth interventions reported an emerging evidence base for the clinical effectiveness of telehealth technologies aimed at vital signs monitoring but insufficient high quality evidence for the effectiveness of telecare applications such as safety and security monitoring (Barlow J, Singh D, Bayer S, Curry R: A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. Journal of Telemedicine and Telecare 2007, 13:172-179). 

There was thus a clear pointer towards the potential that telehealth and telecare technologies could   improve care and reduce costs but there was a lack of rigorous evidence of actual impact.  This reinforced the case that a more rigorous scientific evaluation was required and allowed myself and colleagues in the Department of Health to make the case to Ministers to provide significant funding for a major implementation and evaluation to be put in place. 

In 2006, we commissioned the Whole System Demonstrator (WSD) programme and selected three sites (Kent, Cornwall and Newham) to be part of a cluster randomised controlled trial (RCT).   This ‘whole systems redesign’ was designed to create multidisciplinary teams in health and social services and the development of integrated care plans to deliver care more effectively to these patient populations.  An important part of the ‘whole systems redesign’ was the introduction of telemonitoring technology in the home to support the provision of these new services and serve as an ‘effect multiplier’ for changes in service delivery.  The aim of the WSD trial was to evaluate whether telehealth for people with long-term conditions and telecare for people with social care needs could provide cost-effective care to improve outcomes, maintain independence, achieve significant gains in quality of life and reduce unnecessary acute hospital use and costs.

Trial Design

General practices were randomised so that eligible patients within their populations would receive access to one technology (i.e. either telehealth or telecare). Each practice would thus provide intervention participants for one technology (e.g. telehealth) and control participants for the other technology (e.g. telecare) or vice versa. This ensured that equity of access existed at the level of the practice population, and that no practice was asked to risk randomisation to a no-treatment control where all patients would be denied access. 

The key research questions in the study were as follows:

• Theme 1: Service utilisation. Does the introduction of telehealth or telecare result in reduction of service utilisation and costs of care?

• Theme 2: Clinical effectiveness. Does the introduction of telehealth or telecare result in improvements in quality of life, well being, self care, and carer burden?

• Theme 3: Cost-effectiveness. What are the economic consequences of introducing telehealth and telecare?

• Theme 4: Patient and professional experience. What is the experience of service users, carers and health and social care professionals during the introduction

of telehealth and telecare?

• Theme 5: Service delivery and organisation. What organisational factors facilitate or impede the sustainable adoption and integration of telehealth and telecare?

Initial results from the evaluations were published by the Department of Health in December 2011 and two papers have subsequently been published during 2012.  In summary nearly 6000 people have been included in either the intervention or control arms and included in the analysis – and this is thought to be the world’s largest randomised controlled trial of telecare and telehealth to date.  In the workshop, more details will be provided on the various sub-studies carried out, and the results obtained.

Professor William Maton-Howarth – Brief biography

William (Bill) Maton-Howarth studied for his BSc and subsequently for a PhD in Solid State Physics at Imperial College, London after which he worked as a research fellow at Cambridge University. He then joined Thorn-EMI, working in their Central Research Laboratory on the magnetic and superconducting properties of materials.

Bill then joined the Department of Health (DH) in England, working in the diagnostic imaging group for several years before obtaining a two-year secondment (from 1988-1990) to the Cabinet Office to work on science policy. During this period Bill worked for the Government’s Chief Scientific Advisor specifically supporting a high level Advisory Council for Science and Technology (ACOST).  Bill established an Emerging Technologies Committee and supported a wide range of work linking with a number of Government Departments, with senior academics including University Vice Chancellors, and with captains of industry.  Bill was responsible for the publication of a number of influential reports during this secondment, including ones on biotechnology, advanced materials, expert systems, biosensors and advanced manufacturing technologies. Of particular note was the work on the biotechnology report where Bill worked with Sir Keith Peters, Lewis Wolpert, Sidney Brenner and others in highlighting a range of important opportunities from developments in genetics, and also the importance of consultation with the public. 

On returning to DH, Bill took up a post in the R&D Directorate. Initially this involved leading on the establishment of the Health Technology Assessment (HTA) programme which now forms a major plank in the programme of the English National Institute for Health Research (NIHR). Bill then took a lead role in managing policy focused research in various clinical areas including cancer, diabetes and heart disease, as part of the DH Policy Research Programme.

Bill was appointed as Chief Research Officer for Public Health in 2003, where he was responsible for overseeing policy research in areas including antimicrobial resistance, eHealth, risk, vCJD, health protection, health care associated infection, new and emerging infections, hepatitis, and Less Invasive Autopsy. All of this research has been closely informed by working directly in partnership with DH policy teams so as to identify their needs for research and so as to manage the delivery of the research in the most effective way to inform and influence the development of policy.

In 2006 Bill was also asked to take a lead in establishing the Invention for Innovation (i4i) Programme as part of the NIHR R&D strategy, a dual role he continued for a period of three and a half years.  Whilst building the i4i programme, Bill became very involved in thinking about the most appropriate R&D funding mechanisms that best assisted the flow of ideas through the innovation pipeline, with a particular emphasis on support for SMEs.  During this time, Bill worked closely in collaboration with the Technology Strategy Board in establishing the Assisted Living Innovation Platform (ALIP), the Detection and Identification of Infectious agents (DIIA) Innovation Platform, and took a lead role in piloting and developing the renewed cross Government Small Business Research Initiative (SBRI) Programme.

In 2010, Bill was awarded an honorary Professorship in health sciences by the University of West London in particular for his work over the past ten years on antimicrobial resistance and healthcare associated infections.

Since the end of March 2012, when he left the Department of Health,  Bill has been acting as an independent consultant working with clinicians, universities, funding agencies and business to assist in the identification of effective and cost-effective innovative products and services, and to identify ways to accelerate their translation into the healthcare sector.