Background
Research objectives
Methods
Case study sites
Data collected
Study timetable | Interviews conducted | Observations (on site and strategic meetings) | Document review |
---|---|---|---|
Pre-trial phase: Planning and early implementation July – Oct. 2008 | 5 LA managers | 11 x 3 hr local site management meetings | 14 meeting notes |
1 NHS manager | 2 x 3 hr strategic WSD team board meetings | 1 WSD evaluation proposal | |
8 other associated staff | 1 ministerial document | ||
1 x 4 hr national remote care expert network meeting | 3 presentations regarding remote care progress and initiatives in the UK | ||
Total:
|
14
|
43 hours
|
19 documents
|
Phase I: Participant recruitment and clinical engagement | 14 LA managers | 10 x 3 hr local site management meetings | 17 meeting notes |
14 NHS managers | 5 x 3 hr strategic WSD team board meetings | 3 site project management documents, 1 Newham telecare care model overview, 1 Newham telecare procedures and 1 Newham telehealth response interim care pathway documents | |
Nov. 2008 – Mar. 2008 | 3 joint LA & NHS managers | 4 x 4 hr national remote care expert network meetings | |
12 presentations about remote care progress and initiatives in the UK | |||
Total:
|
31
|
57 hours
|
35 documents
|
Phase II: Delayed delivery group joins the trial and the focus shifts to evaluation Sept. 2009 - Oct. 2010 | 14 LA managers | 10 x 3 hr local site management meetings | 20 meeting notes |
14 NHS managers | 3 x 3 hr strategic WSD board meetings | 1 telehealth pilot report | |
15 presentations about remote care progress and initiatives in the UK | |||
1 joint LA & NHS manager | 5 x 4 hr national remote care expert network meetings, 1 x 6 hr conference and 1 x 3hr launch of Kent telehealth pilot event | ||
Total:
|
29
|
68 hours
|
36 documents
|
Phase III: Business continuity plans and early mainstreaming days April – July 2011 | 10 LA managers | 2 x 3hr local site management meetings | 2 meeting notes |
14 NHS managers | |||
17 other associated staff | |||
Total:
|
41
|
6 hours
|
2 documents
|
Overall total:
|
115 interviews
|
174 hours of observations
|
92 documents
|
Data analysis
Sites | Cornwall | Kent | Newham | Overall Total |
---|---|---|---|---|
WSD Organisational lead
| Cornwall Primary Care Trust | Kent County Council | London Borough of Newham | |
Telecare users pre-trial
| <1000 | c.2000 | c.2500 | 5500 |
Telehealth users pre-trial
| 0 | c.200 | 0 | 200 |
Trial telecare users
| ||||
Intervention group | 545 | 427 | 304 | 1276 |
Control group | 492 | 462 | 370 | 1324 |
Total
|
1037
|
889
|
674
|
2600
|
Trial telehealth users
| ||||
Intervention group | 566 | 583 | 456 | 1605 |
Control group | 625 | 595 | 405 | 1625 |
Total
|
1191
|
1178
|
861
|
3230
|
Overall numbers (telehealth/telecare)
|
2228
|
2067
|
1535
|
5830
|
Results
Whole system redesign
" I would describe it actually not as being a whole system…because of the segregation between telehealth and telecare. I think we’ve called it whole system and it’s not. I think it is two separate systems that have the potential of being the whole but… as part of the trial there was no group which had both telehealth and telecare equipment installed… It wasn’t a proper evaluation strand…it should have been (senior manager). "
" A person in the NHS cannot create a care package in social services even though they’ve been talking about how to do it for the last five years and I can see why, because the NHS doesn’t want… well the council doesn’t want the NHS spending its budget. While you can talk about philosophy as much as you like, until there’s an integrated budget system, it’s never going to work (healthcare professional). "
Implementation challenges in the context of an RCT
" (We were) all about how you use telehealth and telecare to improve health and social care for your population, which had nothing to do with randomised control trials. It caused massive damage in terms of what we would have been doing, because we had to stop doing what was obvious, which was helping those people that benefit most, and alter the direction of travel… Encouraging social services to refer their clients that could benefit from this was destroyed by the randomised control trial… So, it was very destructive in a sense (senior manager). "
" We’re very restricted in relation to WSD and, in fact, some of the people we referred to be included as part of WSD never got the kit … which leaves a bad taste because they did fit the criteria (social care professional) ."
" We had already stripped out of Newham all of those people who could most benefit from telecare so they are outside of the trial… Anybody that really thought about where to actually do this would not choose somebody that had already done telecare (middle manager). "
" Telehealth had a far greater exposure and it’s definite that the focus of the WSD was on the health service. Social care was always seen as an aside… It was very, very health focused, looking at mainly clinical and medical outcomes. So, no, I think it was really biased towards the NHS (social care professional). "
" I think having clinical champions as well as senior clinical managers out there saying ‘I have had really good success with this’ - I wouldn't want to lose that…When you hear that positive feedback, and we've made sure that’s all fed through to the PCT Board, then it’s hard for the PCT to say no, we’re not doing this (healthcare professional) ."
Organisational learning
" There was certainly a period where we were rather locked into WSD being a discrete add-on service, as opposed to being an integrated whole system approach. That was influenced quite strongly by the need to not distort the evaluation process. So, we carried on doing some things that we knew were either expensive or just under par (middle manager). "
" I think it has … made me realise about the limitations of RCTs. That whilst they are the gold standard in evidence, to some extent they don’t allow flexibility in terms of what you’d offer. Some of these sites have been working for two or three years, and I think … if left alone… they would be offering something different now than they were when they started, but we’ve restricted them from doing that (policy advisor). "
" You have to unpick all the processes and procedures we put in place to deliver the RCT because they’re not good business processes. They’re too constrained so we’ve had to take everybody in that mind-set out of the programme environment (senior manager). "
Moving forward
" The problem with the WSD programme was that … it required us by virtue of the numbers game to install telehealth in all sorts of people's homes. I think we now need to focus its use in the right places. Now that will mean taking some of the triallists off, and it will mean adding new patients on, where we are in control of the use of telehealth, rather than it being driven by the needs of the evaluation process (senior manager). "
" I am one hundred and fifty percent committed and believe that telehealth is the way forward and I will be looking to work in a way that I can drive it forward and make it happen… So, absolutely it has changed me (healthcare professional). "
" But I think we've also learnt that quite a component of telehealth has been picking up previously unmet need. My guess is that a lot of the activity on WSD has … made it better for people if they've been in touch with health services. But quite honestly, some of that need would not have been being met before (senior manager). "