Select Committee on Health Minutes of Evidence

Memorandum by the Tunstall Group Ltd (DD 24)

  1     Executive summary.

  2     The Tunstall Group—an introduction.

  3     Issues relevant to the inquiry:

  3.1  Delayed discharges—hospital issues and external factors.

  3.2  Inter-agency co-operation.

  3.3  Communications including Telemedicine and Telecare.

  3.4  The management of appropriate alternatives to hospital admission.

  3.5  The impact on patients, staff and carers of delayed discharges.

  4     Recommendations.

  5     Conclusions.

  6     Addendum.

         Terminology/definitions and The Case for Telehealth.


  1.1  Whilst delayed discharges are the focus of the committee's enquiry they are only symptomatic of other challenges in the NHS. Too many people are needing too few beds in acute hospitals and staying too long in those beds. Telehealth care can safely divert demand from hospitals to provision in the community, and speed up discharges.

  1.2  We believe that Telehealth care solutions, which are available immediately, could play a greater role in helping to alleviate the problem of blocked beds significantly.

  1.3  Research shows that people prefer to be in their own home environment providing they feel secure and that their care is being regularly monitored by health or social care professionals.

  1.4  Tunstall supports the Grant for Building Care Capacity scheme recently announced by the Government (also known as the Cash for Change Programme), which is designed to reduce delayed discharges, but believes that the scheme's success depends on closer partnership working within health, housing and social care. The pooling of budgets should be encouraged in order to enable supportive Telehealth care services to be used. This will enable people to move to maximum independence in the community more quickly but will require "joined up" management by the agencies involved. Tunstall believes that the absence of this integrated approach is one of the reasons why progress has been slow on this front.

  1.5  If additional money is to achieve the Government's objectives care professionals must monitor the health and well being of their clients on a continuous basis and ensure that home care services are being delivered effectively and efficiently.

  1.6  An existing well-established infrastructure of monitoring centres (offering community alarm services) exists to support the delivery of new technology based services without the need for new and expensive monitoring centres to be established.


  2.1  Our particular interest is in the role of Telehealth (Community Telemedicine and Telecare) in providing the systems to enable early intervention and so avoid patients requiring admission to an acute care setting.

  2.2  Tunstall established itself as a British manufacturer in 1957 with a simple warden paging system. Today, it is the UK and European market leader in the development of personal and home reassurance solutions and operates throughout the world.

  2.3  Tunstall currently provides its technology and services to local authorities, health trusts, housing associations, charities, NHS Direct and other care providers.

  2.4  Technology is constantly evolving and Tunstall devotes significant resources to research and development.

  2.5  There are community solutions that are available now and are being used by an increasing, but still a minority of authorities throughout the country.


3.1  Delayed discharges—hospital issues and external factors

  3.1.1  Delayed discharge can occur for a number of reasons such as the lack of residential and nursing home accommodation, delays in local authorities carrying out care assessments, the provision of providing specialist home equipment or organising a reliable care programme in the patient's home. Often the department with the responsibility for the service does not have the budget—hence the need for a joint approach.

  3.1.2  Practical experience has shown that by avoiding admission to hospital and speeding up discharges, very expensive acute services in hospitals can be used more appropriately, efficiently and cost effectively. This change in the delivery of the service should increase the overall capacity of the NHS to treat the most acutely ill patients.

  3.1.3  Giving evidence to the Health Select Committee the Minister of State, Jacqui Smith MP, said of the new money: "it should be contributing precisely to the sort of intensive home care packages, to the measures to promote independence that are going to be important if we are going to reconfigure the system." And she continued: "it is not about beds, it is about how the system is able to change, be managed more effectively so that it delivers the right sort of care for people in the right place at the right time." (17 October 2001).

  3.1.4  If this policy is to work successfully, care professionals will need to manage risk effectively and identify early potential problems.

  3.1.5  Telehealth provides the means to support people living in their homes. Early intervention using this technology can register detection and deterioration of certain medical conditions and in some cases prevents hospital admission or readmission.

3.2  Inter-agency co-operation

  3.2.1  An infrastructure of monitoring centres (offering community alarm services and often provided by district councils), already exists and is well established to support the delivery of home care services to people in their home environment. Due to much of the newer technology being software based, it is possible to extend the use of these monitoring centres to include Telehealth services. There is no need for new and expensive call centres to be established—but the adoption of Telehealth solutions does require new partnerships and new ways of working.

  3.2.2  The development of care services using Telehealth solutions has already encouraged cross boundary working between agencies. We can point to a number of existing schemes where health, housing and social care professionals are working together to provide more effective services. This reflects current government policies, but it does require people to think differently and sometimes work in a different way.

  3.2.3  Telehealth creates opportunities for the effective joint funding of services including contributions from private contributors. Providing integrated services involves a number of agencies or budget holders and this is one of the reasons we believe why progress has been slow. The full potential for joint working with the private sector has not been fully explored, and the impact of charging for some services not properly assessed. By extending the use of existing monitoring centres it would be possible to improve the cost effectiveness of existing services. We welcome the proposals in the recent White Paper on local government in this respect.

3.3  Communication including telemedicine and telecare

  3.3.1  As new ideas and new technologies emerge, existing community alarm services can be reprogrammed and updated. The technology platform is future proof—even in a rapidly changing technological world. The solutions are so flexible that the extent of the monitoring systems used can vary according to the needs of the user. The monitoring centre acts as the "nerve centre" of these solutions and processes.

  3.3.2  Using this technology has the power to reduce dependency on increasingly scarce nursing resources and residential home places for people discharged from hospital after an acute episode. Given the reduction in the number of residential and nursing homes in the UK and the likelihood that numbers will continue to fall due to current local authority rates and new registration regulations, finding ways of enabling people to remain at home safely, and without undue risk is of greater importance than ever.

  3.3.3  Greater use of information technology is key to improved communication. Simply improving communication can mean linking individual's homes via a personal and home reassurance system to a monitoring centre and local carers. This ensures that round-the-clock access to help is available and emergency treatment can be administered quickly and early. In this way a safer home environment to which people can be discharged from hospital is created and the incidence of re-admission is reduced. In the longer term, this environment delays the need for individuals to enter institutional care.

3.4  The management of appropriate alternatives to hospital admission

  3.4.1  Hospital professionals are reluctant to discharge patients without a risk assessment—and quite rightly so. Patients must not be left as the responsibility of their GP when they still need specialist oversight and healthcare management. By using technology, risk can be reduced, patient data (and progress) shared, and the need for further interventions by health personnel identified—all without the need for the patient to remain in hospital, or be visited so frequently by primary health care personnel.

  3.4.2  Current technology facilitates the direct recording of data on individual clients and services provided, from initial assessment stage right through to monitoring of actual service delivery. Because all information regarding the delivery of services is downloaded via software, care records can be updated instantly without the need for time-consuming and error-prone manual inputting of data; also, data integrity is maintained.

  3.4.3  This technology can provide enhanced patient data for clinical management as well as for planning and research. Good care requires regular or constant monitoring of a patient's health and well being. As the incidence of Chronic Diseases within the elderly population in hospital increases, any therapy management programme will require a monitoring capability before the patient is discharged. The data created using Telehealth solutions helps build up a picture of the patient's health. It can also create a comprehensive database for the future planning of services and for research into treatment methodologies.

3.5  The impact on patients, staff and carers of delayed discharges

  3.5.1  Our research shows that people prefer to be in their own home environment, providing they feel secure and that their care is being monitored by a health or social care professional with appropriate training.

  3.5.2  Telehealth system users say they feel more secure than they did without the system. By making it simple for them to communicate with a monitoring centre, it reassures them that they are not alone, and that help can and will come if they are unwell. This should also help to reduce social isolation.

  3.5.3  By taking the service to the patient rather than the current pattern of the patient going to the service, the quality of the patient's and carer's life is improved and the likely rate of recovery enhanced. It can also avoid the need for additional expensive and often inflexible "bricks and mortar" solutions.

  3.5.4  Telehealth solutions have the ability to impact on staff in several ways:- they become better informed of their patient's condition, so enabling earlier diagnosis, treatment and closer management of chronic diseases if necessary.

4.  Recommendations

  4.1  Unlike Scotland (Scottish Telemedicine Action Forum) and Wales (All Wales Telemedicine Development programme), England and Northern Ireland appear not to have "ring fenced" or "earmarked" funding streams for the implementation of Telehealth solutions. What is now needed is a UK-wide policy for Telehealth solutions, which should be established with funds earmarked in the short term to encourage the development of services within all agencies concerned.

  4.2  There is a lack of definition in government statements in respect of Telehealth. The first step would be for the Government to adopt the definitions appended to this evidence.

  4.3  There is concern that the healthcare sector does not recognise that supporting people moving from an acute care setting to their own home environment is the healthcare provider's responsibility. Government policy should encourage a more robust approach of recommending alternative solutions to hospitalisation, with the funding streams to match.

  4.4  The implementation and restructuring of the Primary healthcare sector is delaying any possibilities of partnerships within health and social care. Solutions are available now. However, the Government needs to take affirmative action to encourage health, social care and all local authorities including District Councils to form joint working practices and pool budgets, thus enabling greater investments into the implementation of strategies for reducing delayed discharges.

  4.5  There is a lack of commitment to public/private partnerships leading to delays in developing services. We welcome the Secretary of State's recent commitment to "Changing (the NHS) from a monolithic, centrally run, monopoly provider of services to a values-based system where different care providers—in the public, private and voluntary sectors—provide comprehensive services to NHS patients within a common ethos . . . Who provides the service becomes less important than the service provided." (Speech, 15 January 2002). Telehealth solutions and the associated monitoring services are ideal candidates for this approach.

  4.6  Despite growing evidence and benefits of the effectiveness of Telehealth Solutions there remains a lack of awareness in many parts of the public sector. The Government should consider carrying out an educational campaign designed to promote the benefits of dependent people being cared for in their own homes. This would encourage the public and the healthcare professional to appreciate that this is a safe and reliable alternative to institutional care.

  4.7  There is continuing concern that budgets tend to be in boxes and rarely transferred and that this delays the development of packages of care. Without pooled budgets, the holistic approach of caring for patients will not be achieved. A good working example of pooling budgets and resources is the Government initiative to integrate Community Equipment Services. Local councils are being encouraged to integrate the delivery of equipment services. The aim is to combine health and social care provision in a single integrated community equipment service, whilst improving the quality and range of equipment on offer to people of all ages. Whenever joint initiatives and strategies are put in place, budgets should therefore be pooled.

5.  Conclusions

  5.1  The Government's recent focus on promoting independent living as an integral element of its strategy to alleviate the problems of delayed discharges is welcome. However, to be effective, it requires continuous monitoring of patients' health and well being as part of the home care package. We strongly believe that Telehealth solutions have a vital role to play in implementing this strategy.

  5.2  A network of existing monitoring centres is available to provide continuous and comprehensive cover nationwide. What is lacking is the commitment of the Health service professionals to this technology as an alternative to hospitalisation, and appropriate funding to promote and implement the solution.

  5.3  Using technology enables primary care staff time to be more effectively managed and of course MRSA is far less prevalent at home than in hospital. Taking all considerations in to account, we believe that Telehealth care makes sense both for the patient and for the provider of services.

  5.4  Tunstall would very much welcome the opportunity to assist the Committee further by providing oral evidence in support of this submission. If the Committee so wish, we will gladly arrange for them to see a Telehealth project in operation in the community.

6  Addendum


  Within this document we use the generic term Telehealth to describe two core services—Telecare and Community Telemedicine. Our definitions of these terms are as follows:


  Use of sensors and communications technology to provide remote support to people who are vulnerable at home.

  Community Telemedicine:

  Application of information and communication systems to enable a clinical process to be conducted in a community setting and involving remote healthcare professionals.



  The term Telehealth encompasses both Community Telemedicine and Telecare. The Government has recently announced a change of policy away from the provision of extra care beds and towards more home care services. If this fundamental change in policy is to work successfully, health providers will need to be able to monitor the health and well being of their clients on a continuous basis. This is the essence of Telehealth. The term encompasses both Telecare (use of sensors and communications technology to provide remote support to people to people who are vulnerable at home) and Community Telemedicine (application of information and communication systems to enable a clinical process to be conducted in a community setting and involving remote healthcare professionals). Between them, they provide the key to independent living for older and vulnerable people.

  Telehealth solutions already exist as do the monitoring centres needed for monitoring people in their own homes. There could not therefore be a better time to hold a Select Committee Inquiry into whether Telehealth has a role to pay in implementing the Government's strategy in respect of acute healthcare.


  In their evidence to the Health Select Committee on October 17, both Jacqui Smith MP (Health Minister) and Alan Milburn MP (Health Secretary) signalled a change of strategy from the funding of increased numbers of care beds towards greater home care provision. Jacqui Smith said:

    "We do not need to maintain necessarily exactly the level of capacity we have previously because older people have said to us as a Government, and they will undoubtedly have said to us as individual MPs, that what they increasingly want are the sorts of services that enable them to stay in their homes that prevent them from having to go into hospital in the first place but help to promote their independence and rehabilitate them if they have been in hospital and they come out. So there is a challenge in the system which is about managing the capacity whilst we also reconfigure and develop new services."

    —  On October 9, "Building Capacity and Partnership in Care" announced a £300 million "cash for change" initiative designed to tackle the problem of "bed-blocking" over this year and next. £100 million is available for the remainder of this financial year with £200 million available in 2002-03.

  Last year's money was allocated to local authorities. The 50 councils with the most severe problems were targeted for extra help. £45 million went to them with another £45 million allocated to the other 100 councils. The remaining £10 million was to be used by a team of health and social care change agents to implement changes where there are specific service problems. In addition, advance funding for 15 new Care Trusts was expected to be met with money from this initiative.

  Jacqui Smith described what she thought this money should and should not fund:

    "The money would fund, for example, 7,000 extra nursing home beds, however I do not think that is what it should be funding . . . I think it should be contributing precisely to the sort of intensive care home packages to the measures to promote independence that are going to be important if we are going to reconfigure the system."


  The missing link, which can enable home care packages to be effective in keeping people out of hospital, is Telehealth

    —  Home care packages would enable more people to be treated, more cost-effectively because Telehealth solutions allow patients to be treated out of hospital and live more independently. At the same time an existing) network of monitoring centres has the potential to substantially reduce the monitoring and response burden on the NHS nationwide.

    —  For patients, the benefits are clear. In the right circumstances, care at home is probably the preferred option for most people. With Telehealth, they get the 24-hour monitoring and reassurance they need whilst maintaining their independence and avoiding the stress and associated risks of in-patient stay.

    —  If Telehealth solutions were adopted by health providers nationally it would be possible to treat far more people remotely, allowing them to achieve greater independence which is what they want. This is evidenced in its groundbreaking partnership with the West Yorkshire Metropolitan Ambulance Service (WYMAS) and Pontefract Emergency Respiratory Team (PERT).

    —  This 24-hour monitoring service is provided by WYMAS NHS Trust, which operates NHS Direct in West Yorkshire from purpose-built facilities on the outskirts of Wakefield. It already uses advanced technology to provide nurse-led consultation, health information, GP co-operative services and a social services community alarm system. Hence the necessary infrastructure and expertise to operate Telehealth already exists.

    —  Telehealth does not break the traditional doctor-patient relationship. It strengthens it by providing essential information on vital health signs to support clinical judgements.


(a)  "Cash for Change"—9 October 2001

  £300 million Government money was announced, to be spent over this year and next for bed blocking in addition to the agreement; "Building Capacity and Partnership in Care" between local government, the NHS and private and voluntary sector partnerships.

    —  Community Telemedicine provides the technology for patient's health to be monitored from their own homes when their treatment has finished.

    —  Telecare provides the technology to allow older people to be discharged from hospital and continue living in their own home with equipment to ensure their safety.

    —  The monitoring centre infrastructure allows people throughout the country to be monitored more cost-effectively while living in their own homes. This will have the added bonus of considerably reducing the burden on the NHS if rolled out nationally.

(b)  New Star Performance Ratings for Social Services—19 October 2001

  Each council will now be given star performance ratings based on an assessment of their overall performance. One of the indicators used in the new ranking system is the number of delayed discharges from hospital.

    —  Social Services are suffering from severe budget pressures. Closure of sheltered housing schemes is leading to an increase in delayed discharges. Telehealth can enable people to be discharged to their own homes.

(c)  Reforming emergency care—25 October 2001

  The reform programme identifies delayed discharge as one of the problems in emergency care and proposes two solutions. One is using the "cash for change" money as set out by Jacqui Smith MP (see above) and the second is delivering the standards set out in the National Services Framework for Older People through organisational change. Thus, for the latter, it is envisaged that there will be improvements in preventative and domiciliary care, avoiding admissions to acute hospitals.

    —  The Government is looking to address the length of waiting times in all departments within the NHS, in particular A&E. The Government has identified delayed discharges as being at the heart of the problem in both A&E and paramedic unit turn-around times.

    —  Therefore delayed discharges directly contributes to problems faced throughout the hospital system.

    —  Telehealth has the potential to help alleviate this problem.

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