We interview a man running a chronic disease management programme in England which in the first two years suggests that hospital admissions in the group receiving the service have reduced by 52% and visits to family doctors by 33% - Andrew Donald, chief operating officer at NHS Birmingham East and North.

At a time when many English NHS projects are likely to be savaged, Donald has no plans to reduce expenditure on the Birmingham OwnHealth telehealth chronic disease management programme. “Yes, we are committed to spending £10m by March 2012, but estimates are that we will get a return far greater than that. Work completed in 2006 suggested anything up to £32m.”

That is a startling claim. In the USA, many chronic disease management programmes have shown little or no difference in clinical or financial outcomes. So why is Donald so confident?

Looking at the results from the two years of the programme he can point to initial statistics from patient surveys showing a substantial reduction in visits to hospitals and doctors. The survey also found very high levels of satisfaction with the service from clients who are essentially coached over the phone by a group of nurses in a telehealth centre. Some 42.9% said that the programme has reduced their need to go to hospital, 65.9% said it had improved their access to healthcare services, 97% said their case manager understood their condition and 85.1% would recommend the service to others.

In any case, Donald would dispute the claim that such programmes have not worked elsewhere. “In 2008 the US based Veterans Administration organisation published a paper setting out they had seen reductions in hospital utilisation in a cohort of enrolees totalling 31,000 patients and there have been a number of small scale projects in the USA which have produced good results, many of them within Randomised Controlled Trials.”

Donald accepts that these initial findings are preliminary but there are now 3,000-4,000 members in the programme with conditions varying from COPD, diabetes, heart failure, CHD and Chronic Kidney Disease. The University of Birmingham is analysing the clinical outcomes and will report shortly.
So why do such programmes sometimes fail? And what is the secret to getting them right?

Donald says: “There are many ways to fail. You can fail to get buy in from clinicians, you can fail to measure the results - which means you have failed before you start, you can fail to get the clinical criteria right. Above all, you will fail when the people who are tasked with implementing it, don’t get it.”

Avoiding these pitfalls calls for serious training and a great deal of thinking. Donald says: “Visitors come and see our telephone based care system and they say ‘Oh, I see! It’s a nurse with a phone!’ It is so much more than that.”

OwnHealth has won buy in from clinicians by getting the GPs involved in setting out the clinical criteria. And the nurses behind the phones have been through a bespoke training programme. Donald says: “The skills that are taught during the programme include cognitive behavioural skills, motivational interviewing and particular learning about the key diseases covered within the programme. The nurses become skilled in facilitating behaviour changed by not telling people what to do, but rather helping them to decide what they want to do.”

He says this is a very different approach from that followed in the USA, where telehealth programmes tend to be much more assertive. “There, cost is a significant driver both for insurance companies and employers. In the UK, the focus of the programme is about supporting people to look after themselves better”

So far, the Birmingham Ownhealth project has been based purely on telephone based care. Yet Donald is aware of the revolution taking place in IT and telephony - the development of a whole new wave of monitoring devices, of videoconferencing and even of devices that can predict when a patient may hit a crisis.

One of the next steps then is to develop the use of assistive technology in a member’s home and to take their own readings and send through to the care manager at the call centre. The issue says Donald is not the technology but getting the medical profession to trust the new devices and understand the technology helps them do their jobs better and more efficiently. “It is like flying on an aeroplane. We get on planes because we trust they will get us from A to B. Clinicians have to trust the benefits of the equipment and that it helps people to look after themselves with remote support.” But he sees this as an inevitable development and is the PCT is piloting the use of home monitoring for members with certain diseases.