Memorandum by the Tunstall Group Ltd (DD
1 Executive summary.
2 The Tunstall Groupan introduction.
3 Issues relevant to the inquiry:
3.1 Delayed dischargeshospital issues
and external factors.
3.2 Inter-agency co-operation.
3.3 Communications including Telemedicine
3.4 The management of appropriate alternatives
to hospital admission.
3.5 The impact on patients, staff and carers
of delayed discharges.
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
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. THE TUNSTALL
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
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. ISSUES RELEVANT
3.1 Delayed dischargeshospital 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 budgethence 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 establishedbut 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
3.3.1 As new ideas and new technologies
emerge, existing community alarm services can be reprogrammed
and updated. The technology platform is future proofeven
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
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
3.4 The management of appropriate alternatives
to hospital admission
3.4.1 Hospital professionals are reluctant
to discharge patients without a risk assessmentand 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 identifiedall 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
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.
4.1 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 providersin
the public, private and voluntary sectorsprovide 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.
5.1 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
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.
Within this document we use the generic term
Telehealth to describe two core servicesTelecare 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.
Application of information and communication
systems to enable a clinical process to be conducted in a community
setting and involving remote healthcare professionals.
THE CASE FOR TELEHEALTH
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.
2. FROM CARE
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
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
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.
4. HOW TELEHEALTH
(a) "Cash for Change"9 October
£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
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
Services19 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 care25 October
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.