1. Evaluation of the Scottish National Telecare Development Programme Findings and implications for future research Sophie Beale Senior Consultant, York Health Economics Consortium, University of York sjb29@york.ac.uk

2. Overview  What is Telecare?  Introduction to the Telecare Development Programme (TDP)  Overview of the evaluation of the TDP  Summary of the findings  Implications for the evaluation of telecare  Conclusions

3. Telecare Development Programme  Telecare Development Programme (TDP) launched in August 2006. ‘To help more people in Scotland live at home for longer, with safety and security, by promoting the use of telecare in Scotland, through the provision of a development fund and associated support’  Supported by c£8M in funding  Expected to provide a foundation for telecare to become an integral part of community care across Scotland.

4. Telecare/Telehealth/Telemedicine  There is considerable variation in the way in which telecare, telehealth and telemedicine are defined  All involve the delivery of services via telecommunications and computerised systems, usually to individuals in their own home

5. Telecare/Telehealth/Telemedicine Tele-interventionExamples Telecare Telecare is concerned with monitoring over time to manage the risks (which may be the concern of health and/or social care) associated with independent living.  Natural gas or bottled gas detector;  Wearable fall detector;  Passive Infra Red (PIR) movement detectors;  Nocturnal bed monitor;  Opening alerts for external doors. Telehealth Remote exchange of physiological data between a patient at home and medical staff to assist in diagnosis and monitoring  Blood pressure monitoring;  Blood glucose monitoring;  Cardiac arrhythmia monitoring; and  Medication reminder systems Telemedicine Use of medical information exchanged from one site to another via electronic communications  Remote consultations with specialists;

6. Telecare Development Programme: Specific objectives  Reduce the number of avoidable emergency admissions and readmissions to hospital;  Increase the speed of discharge from hospital once clinical need is met;  Reduce the use of care homes;  Improve the quality of life of users;  Reduce the pressure on informal carers;  Extend the range of people assisted by telecare;  Achieve efficiencies (cash releasing/time saving);  Support effective procurement. Majority of these have important economic implications for health and social care

7. Evaluation Overview  Joint Improvement Team commissioned an evaluation of the TDP  Assessment of the implementation and uptake;  Assessment of performance against the agreed objectives;  Provide an evidence base on the costs and benefits of the Programme;  Develop metrics that can become embedded in practice.

8. Evaluation Methods  Multiple methods explored at the outset of the project  Emphasise that the TDP was an investment programme, not a research exercise  Pragmatic approach  Work with existing routine data where possible;  Minimise burden of data collection on partnerships;  Fit-for-purpose study, acknowledging the limitations.

9. Evaluation Methods  Quarterly, self-reported monitoring from partnerships on progress and outcomes against pre-specified objectives  E.g. number of users, number of admissions avoided, number of delayed discharges avoided  Surveys of users and carers to understand their perceptions  Supplemented with case studies, including in-depth interviews with stakeholders, users and carers

10. Findings: Welcome financial headlines!  Partnerships estimated to have saved over £11.5M as a result of the TDP investment  Reduction in admissions to care homes, equating to over 60,000 care home days = c 31% of savings  Reduction in unplanned hospital admissions, equating to over 13,000 bed days = c 30% of savings  Improved speed of discharge, equating to over 5,000 bed days = 16% of savings  TDP produced savings against 6 efficiency targets identified at the outset of the study

11. Findings: Impact on Users and Carers  60% of users reported improvements in quality of life  Nearly 70% reported feeling more independent  Over 90% reported feeling safer  Less than 5% reported feeling lonelier as a result of telecare  Nearly 75% of informal carers felt that telecare had reduced pressure/stress  Facilitated greater independence for users

12. Findings: Organisational & Policy impact  Almost 8,000 new users of TDP funded telecare during 2007/08  Predominantly older people (85% aged >65)  New users with dementia, learning disabilities or physical disabilities  Predominantly female (62%)  Approximately half of partnerships used the National Framework Agreement to purchase telecare  Some partnerships found cheaper or better solutions outside of the National Framework Agreement

13. Limitations  Impact is self-reported  Reliant on partnerships to consider the impact relative to no TDP grant.  Not possible to include a control arm - difficult to know the counter-factual  Not possible to attribute any incremental effect to TDP - some of the programmes were already underway  Incentives for partnerships to overstate the benefits  In addition to this, caution should be taken in interpreting the financial outcomes  Some of the efficiency gains are unlikely to be ‘cash- releasing’

14. Limitations  Partnerships took time to implement telecare solutions  Not all partnerships were able to complete all quarterly returns over the course of the evaluation  Time-lag due to time involved in the purchase and implementation of telecare solutions  Additional time lag associated with the need for cultural change in users and professionals attitudes to care  E.g. referral triggers

15. Limitations  Impossible to quantify displacement or unintended consequences of telecare  Are additional resources required in communities as a result of less reliance on secondary care/care homes?

16. What can we interpret from the findings?  Pragmatic study of telecare in use assessed against a wide range of outcome measures  Beneficial impact on health and social care efficiencies  More importantly, beneficial impact on user outcomes, such as independent living and perceptions of safety  The study does not provide definitive evidence of the effectiveness of any specific intervention  Too many interventions included to assess effectiveness in any meaningful population

17. Implications for future research: RCTs  Randomised controlled trials are the most appropriate means of assessing the effectiveness of individual interventions  Allow for identification of an attributable effect by controlling other influences  However, RCTs may be of limited value in supporting the mainstreaming of telecare  Effectiveness is context specific  Heterogeneity in users and service environments  Heterogeneity in access to interventions  Practical difficulties in recruitment and randomisation  Hawthorne effect – observed in telehealth studies?

18. Implications for future research  A number of alternative approaches to evaluation were explored:  Before and after study  Monitor users before and after the introduction of telecare  Problematic in progressive conditions or where telecare has been provided after a sudden change in health state (e.g. stroke)  Use of predictive models  Predicts expected hospitalisations based on an individual’s characteristics  Methods not fully mature – problematic in progressive illnesses and focussed primarily on health care  Use of control groups  Difficulties in selecting control group – what should you control for?  Is it ethical to refuse to provide telecare to a member of the control group?

19. Implications for telecare adoption  Widespread adoption of promising technologies remains limited due to the limited availability of high-quality evidence  Studies tend to be commissioned by those with an interest in promoting telecare  Small populations and lack of follow-up lead to limited generalisability of findings  Therefore, adoption of promising technologies remains limited

20. A model for pragmatic, evidence-based uptake of telecare?  A ‘risk-sharing’ model may support appropriate adoption  Purchasers and suppliers define reasonable objectives for telecare and evaluation criteria  Promising results support further adoption  Failure to achieve objectives explored  Rebates in place for sub-optimal performance?

21. A model for pragmatic, evidence-based uptake of telecare?  Risk-sharing is suited to promising technologies characterised by uncertainty over their effectiveness  Addresses purchasers’ concerns about equivocal evidence base by providing some form of ‘guarantee’  Addresses manufacturers concerns about the need to continuously invest in context specific trials  Generates further evidence on the barriers and facilitators for implementation in practice settings  Increasingly applied to pharmaceuticals – possibly more relevant to interventions such as telecare  Hard endpoints available from routinely collected data

22. Summary & Recommendations The Scottish TDP programme appears to have been a cost effective use of resources Acknowledge the limitations of the pragmatic evaluation Acknowledge that many of the benefits of the programme have yet to materialise The TDP evaluation provides further evidence to support the mainstream use of telecare, although the findings are equivocal Are RCTs the most appropriate means of supporting mainstreaming of telecare? An evidence based approach to the staged widespread adoption of promising telecare technologies might address the concerns of all stakeholders involved.

23. Acknowledgements  Diana Sanderson Associate Senior Consultant  Jen Kruger Project Support Officer  Paul Trueman Director  Joint Improvement Team  TDP partnerships