Examination of Witnesses (Questions 40-54)
PROFESSOR CARL
MAY, MR
BALJIT DHEANSA,
MR JOHN
WILKINSON, PROFESSOR
SIR JAMES
UNDERWOOD AND
MR TONY
RICE
3 MARCH 2005
Q40 Dr Naysmith: Have you anything to
offer in this area on how it might be done because I know that
usually when I speak to clinicians about this sort of thing they
say they do not want bits of paper flying around the system and
charging each other. Although it is coming in in in some centres.
Mr Dheansa: I think it may well
be in the form of recognition. So, for instance, with payment
by results, where care at a particular facility is paid for, I
think when one is actually organising tariffs for patients one
ought to introduce a cost within that for telemedicine and telecare
because it is the simplest and most efficient way of doing things.
Dr Naysmith: Thank you.
Q41 John Austin: I think everybody can
point to the long-term potential benefits of various new technologies,
but it is quantifying the risks and balancing the risks and I
think that Professor May was talking about some of the problems
about lack of a central sponsorship or procurement, and I think
Professor Underwood was talking about the lack of compatibility
with other systems. We have also had some evidence that sometimes
there is a problem with patient compliance as well, even in some
of the well and heavily managed trials. How do you balance the
benefits of the risks, are they clearly understood and how they
are managed, particularly when we are talking about a proliferation
of potential commissioners and purchasers of these services?
Mr Rice: Just an observation,
which is that it is very easy to go for a number of high technology
solutions that are incompatible. It is really important, certainly
in the teletechnology field, that the solutions are relatively
simple, the clinician still has complete control of the process
and where more complex solutions are needed then they are delivered
in an institutional setting where the quality of the assessment,
for example, can be higher. I always have a concern about non-compatible
systems. One of the interesting things about telecare is that
we already have an installed base of telecare systems and monitoring
systems which can be used for simple monitoring. That really just
removes, if you like, the bread and butter workload from the clinicians
so that they are free to do the more higher quality work in an
institutional setting or, indeed, by using teletechnology if they
want. I do think that with the National Programme for IT and the
desktop applications that are overlaid on that in terms of teletechnologies
that it is very important that they are compatible, they are simple
and they work in a mass market, because the savings are immense
and the qualitative benefits are huge. To give you a very quick
example, the example we always use for telecare, which is similar
to my colleague at the end, is pregnant women in the outer isles.
We install vital signs monitors there because at present—or
until two years ago—they had to fly to Glasgow for assessment,
stay overnight after assessment and fly home, and arrange childcare
if they could not arrange childcare on North Uist, or whatever.
Now we have vital signs monitors where they can be assessed and
a nurse in Glasgow looks at it and says, in 99% of the cases,
"Fine, same time next month," and in 1% of the cases,
"You need to come over here." But actually that is not
the mass market, the mass market is Mrs Smith, aged 82, who has
a routine visit to her local hospital or her clinic, and for her
it is much more arduous to get from the south of Leeds to the
north of Leeds by public transport for a monthly assessment when
she could go to a local health centre or indeed the common room
of her sheltered housing development to have an assessment. So
I think there is a simple market and there is a complicated market;
the complicated market I am happy to leave to my clinical colleagues,
who know a lot more about it.
Q42 John Austin: I think Professor May
wants to come in.
Professor May: I was going to
echo that point, which is that it is very important to separate
the different kinds of service. Telemedicine is usually a very
specialised clinical service and telecare is a much more general
field. It is worth contrasting the failure of the NHS to invest
in telecare systems with the massive investment in teletriage
which you have with NHS Direct and NHS 24 in Scotland. Those have
been very successful; they were rigorously piloted; good quality
data was collected about successes and failures and, lo, we now
have the National Teletriage Service which will provide advice
and referral and will call you an ambulance if it transpires that
you need one. The failure of the NHS to engage with telecare systems
comes back to the problem where the benefit lies. The benefit
for telecare lies largely, as Mr Rice has said, in the field of
social services because it manages often elderly, often disadvantaged,
often very vulnerable people remotely. It has very clear parameters
for calling in specialised or expert help and that means it can
be very cost effective. The cost effectiveness of telemedicine
systems is sometimes in doubt and that cost effectiveness is in
doubt largely because of the poor quality of most of the economic
evaluations that have been done. The truth is that we do not know
whether these systems are cost effective—not that we say
that they are not cost effective—and that is because the
economics of the National Health Service are really some of the
most extraordinarily byzantine things in the history of humanity.
Q43 Chairman: Can I pick you up on that
point? What you are saying is that the kind of stuff that the
telecare aspects of this inquiry are more beneficial to financially
is social services. My recollection of the last time I visited
Tunstall Telecare, Mr Rice's company, was probably last year some
time—and I cannot remember whether you were actually there,
Mr Rice—and you gave somebody from the Treasury and myself
a presentation on the cost implications for the NHS of avoiding
elderly people falling in their own homes, and in particular fracturing
their hips which, as we all know, is a common problem that leads
to other difficulties and is hugely costly for the NHS, and we
had a presentation which enabled us to understand a series of
quite simple mechanisms that can be fitted into a person's home
that enables elderly people to be less susceptible to falls of
the kind that result in broken hips. Basic, simple straightforward
things like when you get out of bed to go to the loo during the
night, when your foot hits the mat the light goes on and you can
actually see where you are going. Simple, straightforward, commonsense
things like that. The figures that his company gave us showed
a direct impact upon NHS costs of saving the person having that
serious accident. So I think I would disagree with you—unless
I have misunderstood what you are saying—that I think there
can be huge cost savings for the NHS in telecare.
Professor May: I cannot comment
on that particular case but what I can say is that the published
evidence about cost effectiveness is often of methodologically
very poor quality. Individual companies can produce service specific
evaluations, as can individual NHS Trusts. To go back to what
you were saying, there are some even more simple ways of stopping
elderly people breaking their hips, using hip pads and using cushioned
underlay—Duralay make a cushioned underlay for carpets—that
will negate some of those problems.
Q44 Chairman: The point I was concerned
about was that the outcome of that meeting with Mr Rice's company,
with this Treasury person, who was involved by the way, and I
took to see, and what I thought was interesting stuff was that
in the budget statement last year we got some additional resourcing
for investing in telecare, which in a sense will save huge amounts
of money in the NHS, and it is commonsense, and it frustrates
all of us that we cannot see these connections more often. There
are all sorts of hands going up. Mr Wilkinson.
Mr Wilkinson: The point I was
going to make is actually telecare, investments in IT, investments
in all manner of technologies only work if they are integrated
into a system of care and you re-engineer, as my colleague said,
the whole way that you manage patients. I think most of these
technologies are enablers of significant changes. We have had
lengthy discussions about telemedicine. Implantable devices, a
lot of them are very active, produce information; pacemakers produce
information about the status of the patient. That, while the patient
is walking around, can be transmitted back to a computer which
can analyse what is going on and flag up problems. That is, one,
very good for the patient; but, two, it potentially eliminates
regular checkups because you can actually pick up the patient's
call when the need is there. This principle applies to most of
the technologies. They have to be applied across the system and
that is about evaluation methodologies, getting the value appreciated
across the system and re-engineering the patient pathway and the
way the patient is cared for. That is where the real value is.
Q45 John Austin: I wanted to go on to
the evidence that we had from the Medical Technology Group, and
I understand that Ms Lobban is stranded somewhere, but perhaps
Mr Wilkinson might be able to answer the point, because in their
submission they were talking about slippage between the national
guidelines being issued by NICE and the introduction of the new
medical technologies, and really saying that what happens on the
ground, particularly with PCTs, that if there was something within
the National Service Framework there was more likelihood of implementation,
whereas there was a real slippage if there was not.
Mr Wilkinson: It is a shame that
Trudie is not here because she could speak very clearly from a
patient's perspective, but I will attempt to cover the issues.
Q46 Chairman: We understand that she
is stuck in Oxford, so she has made every effort to get here.
Mr Wilkinson: The issue she is
talking about is very much about that there are centres in the
UK which take, adopt and use new technology as fast as anybody
in the world. The challenge we face is getting that translated
and being available for patients broadly across the country, particularly
in relation to NICE recommendations. We have seen some recent
work done on the implementation of NICE recommendations and concerns
that these technologies just do not get out and do not get propagated
and are not available to large portions of the population. So
this is real postcode, not prescribing but availability of technologies.
I think I have already alluded to that in the context of diabetic
pumps. You can look at many technologies; if you are in the right
place at the right time you can get access to these things and
if you are not then you cannot. Clearly there are a number of
mechanisms that drive towards that. NICE is one. Just creating
the atmosphere in the environment for innovation and encouraging
doctors and systems to become informed and pull innovation in
the ways that patients are treated would be an encouraging move
forward. The Department has just announced the establishment of
an Institute for Learning Skills and Innovation and if that works
well—and we hope it does—that will be crucial to supporting
this process of getting good practice, good ideas out, and that
means that patients get access to the good stuff that is available
in parts of the country.
Q47 John Austin: Much of the examples
that have been given have been about technologies which are used
outside of a clinical setting, possibly in the patient's home,
involving very much the patient or the carer of the patient. Does
this prevent new risks and what are the implications for patients,
and also what use is being made of user groups in terms of learning
about new technologies and designing them so that they are patient
friendly?
Mr Wilkinson: If you transfer
the focus of care from a highly controlled environment into a
less controlled environment, if you like into a domestic environment,
then you need to build new quality systems to manage that, particularly
if patients are involved, and then patients are intimately apprised
of the challenges of managing their situation and need to be full
stakeholders. Medicine is not being done to people the way it
was 25 years ago. People are increasingly being engaged in their
care and I think engaging patients, patient groups to help set
up the systems which effectively manage the use of these technologies
in these new environments is crucial to their success.
Q48 Dr Naysmith: If we can return to
the discussion that was going on about on about five minutes ago
about the economic benefits of some of these new technologies
and looking in a wider sense, not just about telemedicine, although
it is included here, there is a feeling—and it was in the
MTG memorandum and I am sure you have read it, Mr Wilkinson—it
talked about the traditional approaches to measuring the benefits
often fail to address quality of life and productivity dimensions
in the way new techniques are assessed. I suppose it draws to
mind the old joke about the surgeon—I apologise, Mr Dheansa—saying,
"The operation was a success but unfortunately the patient
died," and just evaluating things from the purely medical
and clinical may not reveal all the benefits to patients. Is there
something in that?
Mr Wilkinson: Perhaps I can give
you a couple of examples which might illustrate the situation.
Potentially fatal cardiac arrhythmias, ie random stopping of the
heart in young children, is sadly not as rare an event as many
of us might like to think. Can you imagine the situation where
you, as a parent, have a child who is susceptible to this complaint,
it has been identified and you have been present when your child
has dropped to the floor lifeless, you have administered CPR or
whatever and brought your child back to life. The stress of living
with that sort of tension for the child, for the family, for anybody
engaged with that child, the teachers, is enormous; it does not
bear thinking about. I have fortunately never had to experience
it. The technology is available to implant a device which monitors
the heartbeat and when it starts behaving badly it effectively
gives it a jolt and gets the thing going, so that the fear of
going to bed one night and kissing your child goodnight and waking
up the next morning and finding him a lifeless corpse is eliminated;
it is very profound. Another example, if I could quickly burden
you, I met a patient who had severe Parkinson's Disease, shuddering
severe Parkinson's Disease, of the sort in which the physical
manifestations are profound but the psychological effect is even
more profound and you become a social leper effectively and really
do not want to present yourself to the world. One of our member
companies has a technology which allows you to implant electrodes
in the brain and provide minute electrical stimuli, and you can
walk up to this chap who is standing at a bar with a pint in his
hand, rock solid, shake his hand and have a conversation and you
would not be able to distinguish him from any of us sitting in
this room. It has profound impact on that person's life; he has
a productive job, he is engaged in normal life. I think those
sort of criteria are often lost and they have, I suspect, profound
economic consequences as well as social consequences.
Q49 Dr Naysmith: Why do you think that
is? Is it—because I was suggesting that these things are
looked at in the purely medical and clinical effects—that
not enough attention is paid to what it allows patients to do?
Is that a factor in it?
Mr Wilkinson: I think often technologies
are looked at as very technical solutions by technical people
to specific problems and I think further engagement with patients
and understanding the real impacts of these technologies on their
lives can only be good.
Q50 Jim Dowd: I wanted to press that
a bit further with Mr Wilkinson. I accept the point he is making,
but what kind of formula, what kind of uniform calculation could
be made of such abstract notions about quality of life and impact?
Mr Wilkinson: There are many models
for life adjusted quality of life. It is all very esoteric and
rather complex, I am afraid, to most lay people including myself
in that context. I think there is scope to work on methodologies
to evaluate these impacts. Certainly the economic impacts are
profound. The difference between somebody getting work and earning
the average wage and paying taxes like the rest of us, rather
than being a burden on society, is a very simple number to calculate.
I think some of the quality of life issues are much more difficult,
but there is scope for methodological research in that area.
Q51 Jim Dowd: But you run up against
the practicality of public spending, which it is that it is better
under the system we operate to spend a pound from now until infinity
than to spend £5 now once off.
Mr Wilkinson: I think that is
where the evaluation methods need work and it needs to engage
patients, clinicians, economists who can capture some of those
things, so that we get a mechanism for making decisions with the
annual budgetary cycle or even the five-year political cycle because
some of these technologies have profound benefits long-term. We
have to find methodologies that achieve that and some of the stepping-stones
are in place to do that. The effectiveness of NICE is clearly
one, the HITF report alludes to the Device Evaluation Service,
a lighter on its feet mechanism for looking at the value that
various technologies can produce. I do not think there is a perfect
answer but I think there is scope for much more rounded input
from a variety of stakeholders in the process.
Q52 Dr Taylor: We have talked quite a
bit about cost effectiveness. You have just mentioned, Mr Wilkinson,
Payment by Results. I am very bothered when in your submission
you say that the present tariffs' arrangement is not clear "and
some procedure payments appear to be so inadequate they would
fail to cover the cost of the technology alone" and you have
given us a table of uncoded activity and the huge payment shortfalls.
Could you expand on this a little bit?
Mr Wilkinson: I think, broadly
speaking, the industry is supportive of Payment by Results. Because
if the quality agenda attached to Payment by Results and the flexibility
agenda which allows flexibility in the way that patients are cared
for and treated come to fruition, I think that would be very good
for all concerned—and, most importantly, patients. We do
have some concerns, however, in terms of implementation and the
capacity of the system at the moment to generate accurate, reliable
tariffs. There is also a concern that if this massive process
of generating large numbers of tariffs is slow then new technologies
will not be reflected in the tariffs, or they will be reflected
very late, so we have made some very specific proposals regarding
mechanisms to try to circumvent some of these less than ideal
outcomes in the process. As an industry, many of my members have
experienced payment-by-result type schemes coming in in other
countries, so we have seen a lot of the problems. I think we are
very heartened by the fact that the Department of Health is keen
to engage us in helping to resolve some of those problems.
Q53 Dr Taylor: Will it be possible to
have tariffs for virtually everything, including the implantable
defibrillators that you mentioned?
Mr Wilkinson: The view is that
tariffs are targeted to be aggregates of a number of procedures.
In some cases, there is no aggregating. There is a need for very
specific tariffs for technologies which do not fit comfortably
into the buckets which might have been created in the system.
The key thing is to have a system which is light on its feet,
which engages very much with clinicians, industry and other stakeholders,
and is not just an accounting exercise, because there are profound
impacts of getting this wrong. If we get that sort of engagement,
we may get the system to work rather more rapidly and effectively
than we have seen in other countries.
Q54 Jim Dowd: If I could go back to the
theme I was exploring earlier, triggered by Dr Taylor's mention
of the implantable defibrillator. In an earlier inquiry we were
told that this cost about £30,000 for unit and the procedure.
The difficulty we were faced with was evaluating the benefit of
that for one individual—for whom it is crucial: literally
a matter of life and death—when you can employ a nurse for
£30,000 a year. How do you evaluate the contribution he or
she could make to a number of people over the course of that year
compared to the benefits for one person?
Mr Wilkinson: If I were to use
an industry analogy: companies that do not invest in technology
and look at new ways of doing things, get drowned with trying
to do the same thing over and over again more effectively more
often. I think there is a balance between human resource needs
in delivering healthcare and using technology effectively to minimise
the increase in human resource. I wish I could give you a clear
answer, but clearly every individual treatment and situation has
a different set of dynamics to it.
Chairman: I am very conscious that this
has been an extremely short session and I think all of us would
like to have pursued the various avenues we have touched on at
much greater length. I apologise that it has been brief, but it
has been very valuable from our point of view. It may be that
you would wish to follow up with further written comment on issues
that we have touched on and we would be very pleased to hear from
you. Could I place on record our thanks to all of you for coming
along today.
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