COMMENT
Julia Manning, chief executive of independent think tank 2020health, discusses the lessons in long-term condition management emerging from the USA.
A
t present, the NHS spends 70% of its budget on the 15 million individuals
who have one or more long-term condition. This number is expected to increase by 23% within the next 20 years due to our ageing population.
The current NHS delivery of care for pa- tients with long-term conditions is widely accepted as unsustainable in regards to cost and quality of care.
Awareness of these alarming figures dem- onstrates how important it is to review cur- rent procedures and to consider alternative methods that could be adopted to create a system that is more effective for its users, and more cost-effective for its payers.
In 2010, 2020health published the report ‘Healthcare without walls: a framework for delivering telehealth at scale’, which outlined how telehealth services could im- prove the cost and quality of care within the NHS. The report highlighted numerous proposals on how to implement these ideas at scale. On January 19 2012, on the day that the government launched its ‘3 million lives’ telehealth programme, 2020health produced a follow-up white paper, ‘Tel- ehealth – what can the NHS learn from ex- perience at the US Veterans Health Admin- istration?’ This built on the 2010 report, with more detail from the evidence and experiences of the Veterans Health Admin- istration (VHA).
Telehealth at scale
The white paper was based on interviews that took place with VHA chief executives and clinical leaders as well as research that had been previously published on or- ganisations’ use of telehealth at scale. Once again, 2020health’s paper sought to make key recommendations on telehealth imple- mentation that could inform NHS leaders, policy makers and commissioners.
The VHA is a major part of the Department of Veterans Affairs, which delivers federal benefits and patient care to veterans of the armed forces. Its mission is “to keep pa- tients healthy”, and to that end, it employs 225,000 staff in 153 hospitals and a num-
20 | national health executive Jan/Feb 12
ber of other centres, delivering healthcare services to 23 million veterans (2009 fig- ures). In 2010, the VHA’s annual budget for medical care was £30bn, which is ap- proximately a quarter of the NHS’s budget.
The VHA was failing as a healthcare sys- tem in the 1990s. President Bill Clinton ap- pointed an experienced physician, Dr Ken Kizer, as the VHA’s new Under Secretary for Health and he immediately began to reorient the system away from hospital- based care. Central to this was the install- ing of the Care Coordination / Home Tel- ehealth programme to improve nationwide healthcare, providing “the right care in the right place at the right time”.
The initial purpose of the programme was the vigorous control of long-term condi- tions and post-traumatic stress disorder (PTSD), but has now been expanded to pri- mary prevention of the above conditions along with, for example, an obesity man- agement programme and for additional conditions such as programme for those requiring palliative care, acute heart dis- ease and dementia.
The VHA has 21 areas for regional service delivery and these were all allotted $1m for the equipment needed to launch their telehealth programme. These areas were asked to supply telehealth for five condi- tions which included chronic heart failure, chronic obstructive pulmonary disease, hypertension, diabetes mellitus and PSTD. These conditions were targeted because they consume the majority share of health- care resources. Patients who had enlisted for this programme were provided with ‘care coordinators’ who assessed patients during the enrolment process, selected the appropriate technology, trained the car- egiver and the patient, assessed telehealth monitoring data when it is updated and provided active care management.
The results were stunning: a 20-56% re- duction in patient utilisation of services depending on the disease group.
In 2004, when the national Home Tel- ehealth programme was inaugurated, its purpose was to provide care for non-insti- tutional patients (patients who had deficits in three or more activities of their daily
© Keturah Stickann
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