1. Mainstreaming telecare in the UK. Overcoming the barriers James Barlow Innovation Studies Centre Imperial College London Southern Institute for Health Informatics Conference University of Portsmouth 12 June 2003

2. Agenda  Background  Telecare services  Mainstreaming telecare  Conclusions

3. Agenda  Background  Telecare services  Mainstreaming telecare  Conclusions

4. Demands on care provision  Demographic and social change  Rising cost of care delivery  Demand for better quality services and improved access  Staff shortages

5. Government aspirations  The government wishes to see ‘home telemonitoring’ available in 20% of homes requiring it by December 2007 and 100% of homes requiring it by December 2010

6. Policy context  Information for Health (NHS Executive, 1998)  The Royal Commission on Long Term Care (1999)  Fully Equipped and Fully Equipped 2002 (Audit Commission, 2000, 2002)  Valuing People: A New Strategy for Learning Disability for the 21st Century (DOH, 2001)  Integrating Community Equipment Services (ICES) (DOH, 2001)  National Service Framework for Older People (DOH, 2001)  Quality and Choice for Older People’s Housing – A Strategic Framework (DETR/DoH, 2001)  The House of Commons Health Committee (2002)  National strategic programme for IT in the NHS (DOH, 2002)

7. Industry context  Telecoms – search for new services  Smart homes – emerging interest from some housing providers, consumer electronics and white goods companies  Digitalisation allows sensors/devices to be separated from transmission media so ‘technology silos’ can be broken  Sensors – developments in size, battery life, radio frequency

8.  Within this context new telecare services are beginning to emerge …

9. Agenda  Background  Telecare services  Mainstreaming telecare  Conclusions

10. ICT enabled health care innovation  Innovation in administration and management (e.g. EPR)  Innovation in the delivery of care –Telecare is a ‘B2C’ service – between the patient / client and the care system –Telemedicine is a ‘B2B’ service – between health professionals

11. Telecare service category Non-customised information – either ‘pushed’ by service provider or ‘pulled’ by customer Information Customised information – either ‘pushed’ by service provider or ‘pulled’ by customer Making the home environment suitable – in- home safety and security alarms, personal alarm Risk management Monitoring activities of daily living Physiological monitoring – vital signs Examples of telecare Telecare applications - summary

12. Potential information services PushPull Customised Support and advice, customised to an individual’s specific needs Professionally directed but not self-navigated, e.g. quit smoking programme Customised advice in direct response to question from an individual, triage, access to self-help groups Professionally directed, e.g. NHS Direct Non- customised General information and advice provided on an ad hoc basis Not professionally directed, e.g. pollen count warnings + reminders to take anti-histamine General information on health matters and lifestyle May be professionally directed, e.g. websites for specific conditions or general health/lifestyle advice

13. Progress towards info. services  40% of respondents (2001 MORI survey) identified the Internet as their preferred source of health information:  500,000+ hits per day on NHS Direct website; multiple delivery channels  2%+ of the 1bn+ www documents are health related (information on specific conditions and for informal carers)

14. Telecare service category Non-customised information – either ‘pushed’ by service provider or ‘pulled’ by customer Information Customised information – either ‘pushed’ by service provider or ‘pulled’ by customer Making the home environment suitable – in- home safety and security alarms, personal alarm Risk management Monitoring activities of daily living Physiological monitoring – vital signs Examples of telecare Telecare applications - summary

15. ServiceExamples Making the home environment suitable – in-home safety and security alarms, personal alarm Bath overflowing, gas left on, door unlocked, environmental control Monitoring activities of daily living Detecting falls, room occupancy, person identification & location, bed-usage, memory jogger, medication compliance Periodic physiological monitoring of vital signs Pulse rate and variability, ECG, blood pressure, basal temperature, blood velocity, profile, blood oxygen content, respiration, sweating, pallor, throat inflammation, heart and breathing sounds Continuous physiological monitoring of vital signs Not realistic because of response time? Examples of risk mgt. telecare

16. Response protocol Contact centre Events record EPR Response: home visit, emergency services, remote change Alarm ! Sensors: in home, on body Check status: VDI Record event Response service provider : HCA, neighbour, relative, ambulance, GP practice nurse, fire, police Telecare: schematic model

17. Telecare in the home

18. ‘Thanks to the smarter home, a home help is required only once a year, to adjust the clock’

19. Progress towards RM services  c.300 community alarms services serving 1.5m people  Several telecare demonstration projects, some intended to develop into mainstream services, but … –these amount to <500 users in total excluding ODOP (West Lothian, 1200 users) –few seem to be built upon lessons from projects in other locations

20. Agenda  Background  Telecare services  Mainstreaming telecare  Conclusions

21. Influences on implementation  Structural and operational complexity  Distribution of costs and benefits within the system  UK health system: policy innovation is faster than technology innovation, unlike many other sectors  Policy tension between modernisation (telecare) and evidence-based innovation (RCT as the ‘gold standard’)

22. Structural & operational complexity  Large number of stakeholders, incomplete understanding of care process by staff  Need to accommodate differing perceptions of risk and different value systems in different parts of the care system  Evolving policy priorities  (Generally much higher for telecare than telemedicine)

23. 100 referred patients (2/week) Assessment: 30 patients (0.6/week) 70 patients (1.4/week) 4 bed Rehab Unit >6 week stay Own home: care package + telecare Residential homes 76 people 24 people 80% 6 people 20% Columba – simplified pathways

24. Actual pathway process

25. It’s not the technology!

26. Implications for mainstreaming  Integration with existing care services  Project design  Procurement  Supply chain  Business models

27. Examples of telecare Telecare integration implications CategoryService descriptionIntegration implicationsNeed for integration Information provision Non-customised information – either ‘pushed’ by service provider or ‘pulled’ by customer Likely to be stand alone, commercial service No integration implications Lower Customised information – either ‘pushed’ by service provider or ‘pulled’ by customer May be stand alone, commercial service, Some services (e.g. medication reminders) may be part of mainstream care delivery & need integration Risk management Making the home environment suitable – assistive technology, in- home safety and security alarms, personal alarmEmergency response service requires close integration with existing care services Higher Monitoring activities – ADL, medication compliance, wandering Physiological monitoring – vital signs

28. Project design implications  Design must take into account requirements for future mainstream service delivery  Need for early involvement of all stakeholders in development phase, especially where integration needs are high  Need for clear ownership and leadership of the project  Telecare should become a focus for better integration of existing services and teams

29. Procurement implications  Start at the day to day operational level and then consider technology requirements  Mix and match approach – using beneficial technologies and systems to avoid technology silos  Care providers don’t have skills base for systems integration  Need for local single point responsibility for telecare procurement, working with systems integrators and within national framework

30. Supply chain implications  There are several possible ways of “cutting the stakeholders’ cake” – different supply chain models …

31. Response protocol Contact centre Response service provider : HCA, neighbour, relative, ambulance, GP practice nurse, fire, police Events record EPR Response: home visit, emergency services, remote change Alarm ! Sensors: in home, on body Check status: VDI Record event

32. Response protocol Contact centre Response service provider : HCA, neighbour, relative, ambulance, GP practice nurse, fire, police Events record EPR Response: home visit, emergency services, remote change Alarm ! Sensors: in home, on body Check status: VDI Record event

33. Actors in telecare supply chain Data Providers Patient Data & Protocols GP Hospital Records Community Nurse Potential Provider Service Providers Management Response Contact Centre Telecoms Operator Healthcare Provider NHS/Social Services Potential Provider Access Providers Network Service Provision PSTN Mobile Broadband Potential Provider Device Suppliers Hardware Medical Equipment Manufacturer Community Alarm Manufacturer Electronics Companies Potential Provider

34. Business model implications  Telecare business models remain unclear: –System procurement, financing and revenue arrangements (incl. leasing & licensing, subsidies) –Responsibility for maintenance, continuing support & upgrading technologies / infrastructure –Relationships between payers, technology providers, service providers (care agencies, telecoms, utilities, media) and customers –What are the billing arrangements?

35. Agenda  Background  Telecare services  Implications for mainstreaming telecare  Conclusions

36. Conclusions  The future evolution of the care system needs to start from existing service delivery and a recognition of what telecare can achieve  The purpose and fit of telecare services in the wider care system should drive its introduction – not the technology  This will require a better understanding of telecare’s impact at the system-wide level and new approaches to evaluation

37. Thank you for listening! For further information: T 020-7594 5936 F 020-7823 7685 E j.barlow@imperial.ac.uk