Telecare in the UK. Translating national policy into sustainable local services

Tromsø Telemedicine and eHealth Conference. Elderly - Who cares?

11 June 2007

Jane Hendy, James Barlow

Overview

• Background• Theoretical framework • Research questions and method• Progress and early findings

Focus of presentation

• Mainstream adoption of UK telecare services by local authorities, following recent government funding

Telecare: care remotely delivered to the user’s home

• Telecare a hybrid technological / service delivery innovation spanning both public / private sector

•Information & advice

•Safety & security monitoring

•Vital signs monitoring

•Lifestyle monitoring

012

3456

789

1998 1999 2000 2001 2002 2003 2004 2005

Government and other official reports mentioning telecare published annually

Royal Commission on Long Term Care

National strategic programme for IT in the NHS

Building Telecare in England

Why telecare …the time has come

• Over 20 government reports since 1998 have called for telecare, including the 2006 White Paper: Our Health, Our care, Our Say

• National objective to implement telecare for all older people by 2010

• New finance (c£150m) via Preventative Technology Grant and other initiatives

• Wider policy agenda: long term conditions, prevention and self care

• Capacity limits within health and social care system, and decrease in informal carer numbers

Overview

• Background• Theoretical framework • Research questions and method• Progress and early findings

An unbounded organisationally complex care service innovation - telecare

Few Stakeholders

Many Stakeholders

Few innovation elements Many innovation elements

Simple Innovations

Complex innovations

• HIV programme

• TB treatment

• Single drug prescription

• Immunization

• Laparoscopy

• Minimally invasive cardiac surgery

Polio eradication programme•

•Mammography screening

Telecare

Source: Atun, Barlow, Bayer, Kyratsis (forthcoming)

It’s not the technology!

Telecare pilot projects

• Despite thousands of pilot projects and trials there is still limited knowledge on – adoption processes – economic effects and how to measure them– how to re-design service models

• Most pilot projects are not sustained

• Over-optimism and over-simplification of mainstreaming challenges

Big questions

• How are complex technological and organisational innovations – such as mainstream telecare services – adopted?

• How are innovations adopted across multiple organisational levels (policy directive, strategic, operational)?

Adopting and sustaining complex health service innovations

• Systematic reviews of studies of factors influencing health service innovation adoption & diffusion (Greenhalgh et al. 2004; Fleuren et al. 2004; Rye & Kimberly in press):

– abundant research on organisational characteristics and on inter-organisational networks

– significant gaps: role of evidence, impact of power and authority structures, political dynamics

• Ferlie et al (2005) has highlighted the links between health service innovation and

– evidence

– policy

– context

– professional boundaries

– power relations

• However, focus was on simple, bounded innovations

Overview

• Background• Theoretical framework • Research questions and method• Progress and early findings

Our research questions

• How do contextual factors and current policy initiatives hinder or facilitate adoption?

• How do social and cognitive differences in knowledge determine what constitutes benefits and evidence?

• How can benefits be measured and translated across multi-disciplinary boundaries?

• How does the relative power of different stakeholders influence the decision-making process?

• How do inter/intra-professional boundaries (created by well-developed professional roles, values, identities, traditional work-practices, organisational policies and politics) impact on adoption and diffusion?

Methods

• 5 case studies (local social services rolling out ‘mainstream’ telecare services)

• Different organisational characteristics (size, structure, finance, staffing, experience)

• Matched semi-structured interviews across 3 organisation levels (national experts, strategic managers, local project managers)

• Multiple stakeholders (social services, health, private)

• Longitudinal process research (18 months)

• Analysis of adoption processes - grounded theory

Overview

• Background• Theoretical framework • Research approach and questions• Progress and early findings

Work so far

• Systematic review of evidence base for home telecare services (8666 papers)

• Developed interview schedule and sampling framework

• Identified case study sites and project leads (from a UK sample of telecare projects)

• 44 one-to-one taped, transcribed interviews with range of telecare project managers

• 37 contextual interviews (embed the findings in national context)

Focus of telecare scheme included in systematic review

Evidence on:

Individual outcomes, i.e. clinical or QOL improvement

Systemic outcomes, i.e. economic impact or impact on

processes

Specific application, e.g. telecare aimed at patients with diabetes

Relatively good, growing – numerous individual studies on which to build systematic reviews

Limited, problematic – poor specification of assumptions, lack of robust data

General application, e.g. aimed at a heterogeneous population (‘frail older people’)

Largely anecdotal, growing – not yet peer reviewed

Virtually unresearched – based on simulation modelling with limited data

The existing evidence base for telecareBarlow et al: (JTT 2007 13: 172-9)

Some early findings from the case studies

• Lack of awareness of need for a process: difficulties with assessment of telecare clients (staff training and re-defining of roles) – stockpiling equipment

• ‘Pockets’ of innovation versus integration and whole system change

• Lack of GP buy-in

• Ambivalent health / social care relationships

• Distortion of progress (performance indicators)

• Little awareness of research ‘evidence’ but focus on local cost/benefit evaluation – primary aim

A lack of evidence hasn’t been a barrier to government policy initiatives …

… but local decision makers are concerned about providing evidence for future long-term investment

Next steps

• Expansion of case study sites

• Expanded time frame to take into account further government investment in 2 of the current case study sites

• Expansion of stakeholders through the inclusion of vital signs monitoring and health services

Thank you & questions …

Funded by EPSRC

Contact:

• Jane Hendy – j.hendy@imperial.ac.uk