Flexible Homes, Flexible Care, InflexibleOrganisations? The Role of Telecarein Supporting Independence

JAMES BARLOW, STEFFEN BAYER & RICHARD CURRYInnovation Studies Centre, Tanaka Business School, Imperial College, London, UK

(Received July 2003; revised March 2004)

ABSTRACT ‘Telecare’ involves the use of information and communications technologies to providesupport for vulnerable individuals living in the community. The UK government wishes to maketelecare available in all homes that need it by 2010. This expansion is seen as central to theimprovement of older people’s independence and quality of life by enabling them to live at homewhenever possible. The paper discusses the range of initiatives now in place to facilitate theintroduction of telecare in the UK. It argues that while there is now experience of telecare throughpilot and demonstration schemes, moving to mainstream service delivery is far from straightforward.Using a case study of a telecare scheme, along with supplementary data from other schemes, thepaper explores the reasons why it may be hard to meet government objectives. These include theorganisational and cultural characteristics of local care institutions and the complexity of schemeobjectives. It draws conclusions on the challenges in meeting aspirations for mass telecare over thenext decade and on the future role of the housing stock in care provision.

KEY WORDS: Community care, telecare, smart housing, innovation

Introduction

Enabling elderly people to remain independent by living in the circumstances they choose,

participating in their community and exercising choice over their care pathway is a key

principle of a forward looking health and social care policy. To help overcome the barriers

to achieving these aspirations that result from inadequate housing, policies to improve the

physical quality of the home and provide appropriate support services have been

introduced over the years. These include measures to facilitate the physical adaptation of

dwellings, promote the construction of purpose-built housing (Bull, 1998) and introduce

greater flexibility of use into housing design, based on the concept of ‘lifetime homes’

ISSN 0267-3037 Print/1466-1810 Online/05/030441–16 q 2005 Taylor & Francis Group Ltd

DOI: 10.1080/02673030500062467

Correspondence Address: James Barlow, Innovation Studies Centre, Tanaka Business School, Imperial College

London, South Kensington Campus, London SW7 2AZ, UK. Email: j.barlow@imperial.ac.uk. Tel: þ44 (0)20

7594 5928. Fax: þ44(0)20 7823 7685.

Housing Studies,

Vol. 20, No. 3, 441–456, May 2005

(DTI, 2000; Imrie, 2003). Parallel to these housing-focused measures, various home

support services have been developed (Quilgars, 2000).

This paper focuses on a third measure to supporting independent living, the use of

information and communications technology (ICT) to support care in the wider

community. This is now seen as a relatively inexpensive way of helping people to remain

in their own homes for longer or avoid moving into residential care altogether. Care

provision in ‘smart homes’—where occupants are afforded increased control over the

functionality of the home—and the use of ‘telecare’ to manage the risk of housing people

outside traditional caring settings are forming an increasingly important element of plans

for future community care models. This is partly the result of a desire to offer choice over

the location of care and partly the growing concern over the expense of residential care and

‘bed blocking’, delayed discharges from hospital as a result of inadequate home support

(Audit Commission, 1997; DoH, 2001a, b, c; Woolham& Frisby, 2002). A policy vision is

emerging of a technology-supported care system which is able to deliver care where it is

most appropriate, and potentially anywhere in normal physical environments, thereby

increasing the flexibility of the care package and improving people’s quality of life.

The aim of this paper is to explore the extent to which the mainstream deployment of

telecare is likely to be realised in the near term. As is argued below, there is almost no

research on the processes underlying the introduction of telecare, unlike the related field of

telemedicine, where there is a growing body of work on the factors underlying the success

and failure of schemes. Many of the problems in telemedicine relate to the organisational

and structural conditions within which the technologies are being implemented, and this

work is used to inform the analysis here of telecare deployment. There are also interesting

parallels with the findings noted by researchers investigating schemes that seek to

integrate housing with community care services (Cameron et al., 2001). The research

methodology is outlined in the Appendix.

The next section describes the key telecare technologies and the functions they support, and

the following section discusses the policy background that is driving the current interest in

telecare. Next, there is a look at what progress has been made towards the introduction of

telecare and an outline of some of the potential barriers to its mainstream deployment. A case

study is then presented of a telecare scheme to illustrate the importance of institutional and

structural factors in the adoption of technologically-based service innovation. The final

section draws conclusions on the challenges inmeeting aspirations for mass telecare over the

next decade and on the future role of the housing stock in care provision.

Flexible Homes and Flexible Care

ICT-enabled Home Care Delivery

ICT is used in a variety of ways to improve the home environment to make it more suitable

for those with disabilities and frailty. The use of ‘assistive technology’, stand-alone

equipment for helping people carry out everyday activities (e.g. wheelchairs) is already

widespread (Audit Commission, 2000, 2002). ‘Electronically enhanced’ assistive

technology (EAT) is increasingly available for use in the home by people who have

such severe physical disabilities that their needs cannot be met by conventional equipment

and adaptations to the home. Typically EAT provides greater control over such functions

as visitor access, door opening and closing, furniture and beds, the ambient environment,

and home entertainment and communications equipment. Because it affords increased

442 J. Barlow et al.

functionality within the home, EAT blurs with the notion of ‘smart homes’ (Fisk, 2001;

Gann et al., 1999; Tang & Venables, 2000).

Recent developments in ICT have, however, opened up the prospect of creating a far

more customised and integrated approach to care provision, where telecare is used to

monitor people at risk within the wider, non-institutional built environment. Two main

types of telecare that are currently emerging are systems designed for ‘information

provision’ and those designed for ‘risk management’ (Barlow et al., 2003a). The former

aims to provide information about health and social care issues more effectively to

individuals who need it. However, the focus here is on telecare for risk management. This

uses sensors to take measurements from an individual’s body or surrounding environment

such as the home (Table 1). The measurements are transmitted to a control centre which

will then act appropriately—process and transmit the data to a care professional, provide

support remotely, trigger an emergency response or alert a relative or neighbour. Future

developments in mobile communications mean that there is a growing capability to

provide some telecare services outside the home. There is also interest in the use of

telecare as a tool for preventive rather than emergency care and for self-management of

conditions. This is because of its ability to allow ‘lifestyle monitoring’, the continuous or

intermittent gathering and interpretation of data relating to the movement, activity and

behaviour of people so that changes in a pattern can be detected and an appropriate

response triggered.

An appropriately designed and good quality built environment remains fundamental for

supporting independent living. However, the combination of telecare, assistive technology

and EAT/smart housing offers the prospect of greater flexibility in the housing choices for

older and disabled people. In effect telecare could form part of the risk management that

every care professional undertakes, by transforming a previously unsuitable environment

into one that is sufficiently safe for a patient to be discharged to. The future care package

designed for an individual will therefore include conventional forms of support—

domiciliary visiting, medication, therapy, assistive technology and home adaptations—

and suitable telecare services.

Policy Background

Since the late 1990s a range of health and social care initiatives arguing for the

introduction of telecare and related technologies has emerged (Table 2). Housing-led

policy statements have also addressed the issue of telecare, notably the joint report by the

government departments responsible for housing and health, Quality and Choice for Older

Table 1. Examples of risk management telecare

Service Examples

Making the home environmentsuitable: in-home safety and securityalarms, personal alarm

Bath overflowing, gas left on, door unlocked,environmental control

Supporting activities of daily living Detecting falls, room occupancy, person identification& location, bed-usage, memory jogger, medicationcompliance

Physiological monitoring of vital signs Pulse rate, ECG, blood pressure, blood oxygen content,respiration

The Role of Telecare in Supporting Independence 443

People’s Housing—A Strategic Framework (DETR, 2001a). This emphasised the need for

housing, care and support policies to enable older people to live in their own homes “in

comfort and safety and in the best possible health, for as long as they wish to do so” (p. 16).

While it recognised that some will want to move to housing earmarked for older people, it

also endorsed the use of telecare and smart homes technologies to widen the housing

options available to them. The report recognised the benefits of the existing community

alarm service (see below) and the potential to graft other passive alarms and movement

sensors onto these services. Policy guidance for the Supporting People initiative (DETR,

2001b), which provides housing-related support for vulnerable people, develops this

vision further, stating that it needs to take account of the opportunities presented by remote

communication and support services for cost effective and high quality support.

Finally, ambitious targets for home telecare to be available in 20 per cent of homes

Table 2. Key policy statements and initiatives on telecare in approximate date order

Initiative Key telecare objectives

Information for Health(NHS Executive, 1998)

Recognised the role of telecare in providing reliablebut unobtrusive supervision of vulnerable peoplewho want to sustain an independent life in theirown home

The Royal Commission onLong Term Care (1999)

Highlighted the importance of disability equipmentand housing adaptations and the potential contributionof future developments in assistive technology

Fully Equipped andFully Equipped 2002(Audit Commission, 2000, 2002)

Recommended that equipment services be givena higher priority

Valuing People: A New Strategyfor Learning Disability for the21st Century (DoH, 2001d)

Noted how assistive technology can increase control,choice and independence for people with learningdisabilities

Integrating Community EquipmentServices (ICES) (DoH, 2001e, f)

Aims to modernise and expand local communityequipment services providing assistive technology.Also an initiative by the Scottish Executive (2001).Further investment in community equipment servicesannounced in July 2002 (DoH, 2002b)

National Service Framework forOlder People (DoH, 2001b)

Stated that identifying the need for equipment shouldbe an integral part of any assessment, treatment or careplan. Also endorsed the wider application of newtechnologies to support the safety and security ofolder and disabled people and reaffirmed the needfor an integrated approach by the NHS and localauthorities towards older people’s services

The House of CommonsHealth Committee (2002)

Stressed the ‘vital role of equipment services incontributing to the wider strategies to promoteindependence’ and highlighted the potential contributionof telemedicine and telecare in achieving cost savingsand providing people with the choice of remaining intheir own homes for longer

National Strategic Programme forIT in the NHS (DoH, 2002a)

States that government wishes to see what is describedas ‘home telemonitoring’ available in 20% of homesrequiring it by December 2007 and 100% of homesrequiring it by December 2010

Source: Curry et al. (2003) and authors’ research.

444 J. Barlow et al.

requiring it by December 2007 and 100 per cent of homes requiring it by December 2010

have been outlined in the national strategic programme for IT in the NHS (DoH, 2002a).

Progress Towards the Vision

There is now growing experience of telecare through pilot and demonstration schemes

around the world and the technology supporting telecare is developing rapidly. However,

there is only one telecare scheme in the UK that can be described as a mainstream service,

with approximately 1200 users in West Lothian, Scotland. The deployment of smart

homes technology is even more limited. There are a few demonstration projects, some of

which are focused on the care needs of older people (Curry et al., 2003). While these have

stimulated interest, they do not provide a realistic model that could be deployed widely.

However, there has been progress in two related areas. First, there are now over 4000

users of NHS-provided EAT in England, with approximately 400 systems being installed

each year (Curry et al., 2003) customised around individual users’ needs. Second, the UK

has a well-developed community alarm service. This provides a basic monitoring and

response system for vulnerable individuals and currently serves about 1.5 million people.

Some community alarm providers are now beginning to develop more proactive forms of

telecare by incorporating passive alarms and smart sensors that can alert the call centre

automatically when hazards arise. A range of devices, including fall, smoke, gas and flood

detectors, temperature sensors, pressure pads and door switches, is now being deployed or

tested. Economic modelling suggests that low cost investment in the service could provide

major cost savings across the care system (Brownsell et al., 2001).

What are the barriers to the expansion and development of telecare services?

At the operational level, two possible inhibiting factors identified by commentators are

(1) the lack of an infrastructure and adequate guidance for those responsible for making

client assessment and technology procurement decisions (Woolham & Frisby, 2002); and

(2) the general lack of awareness and knowledge about telecare amongst health and social

care professionals (Curry et al., 2003). With regard to the former, in a study of a pilot

telecare project for people with dementia, Woolham & Frisby argue that there is a need for

agreed operational protocols and structures for wider diffusion to occur. These include

suitable assessment procedures that recognise the ‘technology’ needs of individuals and

new local arrangements for securing community aids and equipment (cf. Audit

Commission, 2000). Curry et al. (2003) have highlighted the telecare knowledge gap,

arguing that the slow progress may result from a lack of appreciation by local senior

management of its potential system-wide benefits. However, Woolham & Frisby (2002)

note that while it is an essential pre-condition, simply providing knowledge about the

technology is unlikely to be enough to ensure it is used.

There may be more fundamental problems to the development of telecare services.

Research on innovation in manufacturing and service industries highlights a number of

other factors that influence an innovation’s deployment. Of particular importance are:

. The role of lead users, rather than technology suppliers or developers, in shaping

the demand for an innovation. It is not always clear who the lead users are and

how articulated they are into design and implementation processes (Wyatt, 2000).

Moreover, a lead user’s role tends to be highly dependent on their competencies

(Foxall, 1988; Shaw, 1985; von Hippel, 1979; Voss, 1984).

The Role of Telecare in Supporting Independence 445

. Organisational and cultural resistance, an innovation’s compatibility with the

values and cultural norms of an organisation and the degree to which its results are

visible to the potential adopter (Rogers, 1962). It may be necessary for users

to abandon old organisational routines, behaviours and mental models

(Leonard-Barton, 1995).

. ‘Triability’, the degree to which an innovation can be trialled on a limited basis in

order to reduce the risk of failure for potential adopters (Rogers, 1962).

. Attention to user needs. A lack of this has been shown to be a major inhibitor in

successful diffusion (Rothwell, 1986, 1992), including medical technology

(Shaw, 1998).

The importance of these factors has been recognised in research on the deployment of

telemedicine, which involves the use of ICT to support the exchange of information

between health care professionals. Telemedicine is inherently easier to implement than

telecare because it focuses on single conditions (e.g. teledermatology, telepsychiatry) and

involves simpler interactions with fewer stakeholders. Telecare, in contrast, involves

services targeted at individuals with a wide variety of conditions and brings together a

number of different stakeholders from across the care and housing systems. Recent

summative work has begun to identify common themes in the telemedicine literature,

which point to organisational and cultural barriers to its diffusion (Hailey & Crowe,

2003). These include the involvement of stakeholders, the stability of management

structures and co-operation between stakeholders. Jennett et al. (2003) suggest that

organisational ‘readiness’ for telemedicine is related to (1) planning readiness (the

development of strategic and business plans, needs assessment and analysis, the

identification of clinical, care provider and senior administrative champions); and (2)

workplace readiness (preparing staff, introducing change management processes). In a

comprehensive survey of the evidence, Gask et al. (2002) conclude that most

telemedicine schemes assume a naıve development model whereby high quality research

readily leads to its acceptance and integration into practice in a linear, rational way. This

is not generally the case because of the influence of political, organisational and project

‘ownership’ issues. To overcome these barriers there need to be positive links with local

or national policy sponsors, appropriate organisational structures, enrolment of actors into

relatively cohesive, co-operative groups, and integration at the level of professional

knowledge and practice.

Inadequate understanding of user needs has been shown to be a major barrier in the

implementation of smart homes technologies. Barlow & Venables (2003) and Gann et al.

(1999) argue that this is partly due to suppliers pursuing a technology-push, rather than

demand-pull approach, resulting in a gap between consumer requirements for systems

which are useful for managing everyday tasks and the available products. In the case of

telecare applications, ‘user needs’ are especially complex because of the variety of

stakeholders, and include their compatibility with service delivery organisation and the

capability for integration with existing systems that support service delivery (Barlow et al.,

2003b; Sixsmith & Sixsmith, 2000).

As well as these problems relating to organisational context, the lack of evaluation and

evidence has also been identified as an issue (Gask et al., 2002). While summative data

about individual telemedicine interventions tend to present a picture of clinical and cost

effectiveness, as well as high levels of patient satisfaction, systematic reviews demonstrate

446 J. Barlow et al.

that many study designs are in fact methodologically inadequate (Hakansson & Gavelin,

2000; Hersh et al., 2001; Mair & Whitten, 2000; Whitten et al., 2002; Williams et al.,

2002). This is especially problematic given the culture within which these innovations are

being introduced, which places great emphasis on high standards of proof of efficacy

before new products and innovations are adopted. Therefore, there is a tension within

health and social care policy between the desire for modernisation, including the

introduction of telecare, and the requirement for an evidence-base for innovation.

Inflexible Organisations? Case Study

It has been argued that the introduction of telecare is potentially slowed by a number of

factors. The paper will now explore the relative significance of these in a case study of a

telecare scheme. Data are also presented from additional schemes that have been

evaluated, to situate the case study in its wider context. The focus is on the extent to which

barriers to telecare result from ‘soft’ issues such as organisational behaviours, cultures and

attitudes rather than the complexity of the technology itself.

The case study is a telecare and intermediate care scheme developed jointly by the local

social services department and health authority in southern England. Its overall aim is to

provide an alternative to residential care for frail older people being discharged from

hospital by allowing them to remain in their own homes, following a period of short-term

intensive residential rehabilitation. A key objective is to ensure that patients return home

from hospital faster and are not re-admitted unduly soon. The service is based around a

residential care home, which contains a four-bed rehabilitation unit accommodating frail

older patients for up to six weeks following discharge from the local acute hospital. The

unit is designed to replicate home conditions to ensure that its users are as independent as

possible. It contains the same telecare systems to be installed in clients’ own homes and

therefore allows clients and their carers to familiarise themselves with the technology.

The scheme developed from the emerging demands for more community-based care

services and the national priorities emphasising intermediate care provision. It was partly

motivated by the county social services’ objective of reducing the number of residential

care beds in the area by 25 per cent. Initial estimates suggested that of the 100 frail elderly

patients discharged locally from hospital to social services funded residential care each

year, about a quarter would be suitable for discharge to their own homes, provided an

appropriate care package, including telecare, was available.

The planning and development history of the scheme illustrates how a combination of

objectives, local care service complexity and organisational and behavioural factors has

influenced its outcomes. In addition, it demonstrates how the different influences on the

adoption of innovations, described above, can be observed in telecare implementation.

In December 1999 a group of senior clinical and social service staff met to discuss the

development of older people’s services in the locality. Several of these had knowledge of

telecare and formed a small project team to consider how it might be used locally.

In October 2000 a project proposal was developed with funds the local health authority

had available for stimulating the development of telemedicine and telecare in the area. The

proposal envisaged that the first patients would be recruited by April 2001, following a

three-month set up, staff training and testing period. In fact, the scheme only began to

accept its first patients in early 2003. Enrolment of additional stakeholders from the care

services continued during early 2001. According to the project manager, who had been

The Role of Telecare in Supporting Independence 447

appointed in February 2001, ‘reluctant consent’ had been achieved by the summer. There

was concern about the perceived additional workload and the definition of the target

group, and an unwillingness to commit any money to the project. By October 2001,

a revised project plan was ready. This proposed that the Intensive Rehabilitation Unit

would be fitted out by January 2002 and the first patients recruited by September 2002.

The last stakeholder to be brought into the project was the local community alarm service,

in early 2002. Expenditure from the local housing service for upgrading the system to

accommodate the telecare sensors was not granted until mid-2002. Table 3 lists the key

events and the points at which different stakeholders became involved in the project.

The project finally opened in January 2003 but the accommodation in the Intensive

Rehabilitation Unit was immediately occupied by local people displaced from their poorly

heated homes by the bad weather that winter. Initially, there were severe problems in

recruiting appropriate patients, despite the nomination of a dedicated discharge co-

ordinator, and the unit was not used fully until March 2003. These problems were the

result of two factors: changes to local social services’ eligibility criteria which led to

several inappropriate admissions (where the care requirements were too high) and a lack of

familiarity with the scheme’s objectives. However, by the beginning of October 2003, 17

people had been through the scheme, all having been assessed as needing a residential

home placement. It is too early to evaluate the outcome of the scheme in terms of its

impact on patients and care process. However, of the 17 residents at the time of writing, 8

were able to return to their own homes, 5 had entered sheltered housing, 1 went to a

residential home and 3 returned to hospital following their stay in the intermediate care

facility. Those moving to sheltered housing did so partly because of factors such as family

situation and the state of repair of their home. In general, care staff felt that rehabilitation

had helped to rebuild patients’ confidence to live independently. The potential availability

of telecare as a risk management tool, even though it was not needed in the sheltered

housing cases, widened the options for accommodation and contributed towards the

process of confidence building.

Discussion

In common with other telecare schemes, the aim of the case study scheme is to reduce the

risk of people staying at home. However, it is dealing with a particularly vulnerable

population, meaning that it involves a larger number of stakeholders andmore complex care

pathways than other existing examples of telecare which are either focused on older people

in general (e.g. West Lothian) or those with a specific condition (e.g. Northampton County

Council’s scheme for people with dementia). The intended target population appears to

have increased the risk, and actuality, of implementation problems. To what extent can the

development and implementation of the scheme be explained by the organisational and

institutional factors discussed above? The key points are summarised in Table 4.

Two major problems that can be observed in the scheme’s planning and implementation

process were the absence of a clear lead user or ‘local policy sponsor’ and the restricted

understanding of care processes at a systemic level. The fact that there was no evident

champion led to considerable confusion over funding responsibilities. As one interviewee

said, “There had been an early verbal commitment by social care . . . but there was no

discussion with senior managers to pin this down”. The replacement of the hospital trust

by a primary care trust (PCT) and the restructuring of social services compounded the

448 J. Barlow et al.

Table 3. Key events and involvement of stakeholders

Date Key events First involvement of stakeholders

December 1999 Medical Director, local hospital trustDirector of Nursing, local hospital trustDirector of Information, local hospital trustStrategic Commissioning Manager(Older People), county council social servicesSenior Commissioning Manager(Older People), county councilsocial servicesService Development Advisor (Older People),local hospital trust

September 2000 Manager, Rapid Response TeamOctober 2000 Submission of business

case and project plan tolocal health authority

Manager, Intermediate Care Team

January 2001 Care Manager, local hospitalCare Manager, Adults and Community Care(county council)

Early 2001 Director of Therapy Services, local PCTFebruary 2001 Project manager appointedMay 2001 Meeting organised by

project manager for care teams(commissioning, local careservices, adult services[residential care homes]) andhuman resources

July 2001 Occupational Therapy Manager, local PCTOctober 2001 Publication of revised

project planDeputy Manager, local residentialhome/intermediate care facility

Early 2002 Local authority community alarm serviceFebruary 2002 County council Adult Services Manager

(Older People)March 2002 Education and training unit (ETU)

completedApril 2002 ETU telecare awareness days Attended by 45 staff from health,

social services and housingJuly 2002 Project manager leavesJuly 2002 Green light from community

alarm service for expenditureon upgrading

September 2002 Four half-day workshops forstaff involved with the scheme

January 2003 Scheme goes ‘live’March 2003 Scheme’s steering group

revived and metSlightly changed membership to reflectpersonnel and role changes in social servicessince the project was now moving intoits operational phase. Approval to appointa co-ordinator reporting to manager ofRapid Response Team

March 2003 Further staff awarenessworkshop

Source: Interviews and documentary material from the case study (see Appendix for details).

The Role of Telecare in Supporting Independence 449

ownership problems surrounding the scheme, and led to further confusion over funding

responsibilities. This also led to considerable turnover of personnel, which meant that it

was necessary to “. . . keep selling it and pushing it up the political agenda”, according to

another interviewee. Finally, the role of the project manager was ill defined and she was

not provided with sufficient authority to make, and follow through, planning and

implementation decisions.

The second fundamental problem, a lack of clarity over the care delivery process for the

target group, was reflected in the time taken to enrol all the necessary care providers and to

develop a process map for discharge, rehabilitation and return home. Because of its focus

on post-hospital rehabilitation, the existing care pathway was complex. A large number of

pre-existing teams from health, social services and the voluntary and private sectors were

involved in the scheme. All met similar, but slightly different, needs and only interacted

with each other peripherally. No one group had an overview of the entire process. This

meant that it was extremely difficult to identify and enrol all the necessary stakeholders.

Enrolment continued incrementally throughout the planning period as information about

the project was diffused locally and operational procedures began to be developed.

Eventually there were six distinct groups involved in the scheme at an operational level

drawn from the hospital, housing and social services. Briefing meetings had to be held with

over 60 staff. Mapping and agreeing operational procedures and structures was therefore

extremely complex. This task was originally planned to take about four months but was

not completed until 10–11 months after the scheduled date.

Table 4. Possible influences on telecare planning and implementation in general and in the casestudy scheme

Influence Experience in case study scheme

Infrastructure/guidance for client assessment& technology procurement decisions

None at commencement of scheme planning

Awareness and knowledge of telecare Recognition of the importance of educationand training: as well as workshops and a trainingprogramme for care staff at the rehabilitationunit, a separate education and training unit wasestablished at the local community hospital todemonstrate what telecare could do

Strong lead users and local policy sponsors Lack of clarity over lead users and projectmanagers, confusion about roles andresponsibilities, other stakeholders unclear

Organisational and cultural barriers Large number of stakeholders and interfacesbetween them, lack of understanding of roles,continuous revision of processes, importance ofclinicians in discharge process leading to somerisk aversion

Understanding of user needs Individual needs and potential role of telecareunderstood, but knowledge of system-widedemand for the service limited

‘Triability’ Scheme is being piloted prior to possiblemainstream deployment

Evidence base Scheme was sanctioned despite lack of evidencefrom other schemes for the potential careoutcome or system-wide benefits

450 J. Barlow et al.

Problems also arose initially fromdifferingorganisational cultures andbehaviours.Moving

from an institutional to a housing-based care model appears to have exposed differences in

care cultures. This was partly manifest in varying approaches to client risk management,

especially between health and social services, and problems in agreeing operational

procedures because of differing approaches to discharge assessment. In particular, clinicians

tended to view the hospital and other institutional settings as an environment where patients

could be ‘looked after’ and their safety ensured. Social service personnel weighed the risk

associated with discharge options differently, tending towards a perspective that emphasises

rehabilitation, ‘re-enablement’ and the promotion of independence.

Other issues raised by researchers on the deployment of innovation (see above) could

also be observed. There was, for example, no pre-existing infrastructure within which

procurement decisions on telecare equipment could be taken. While individual user needs

were understood, problems arose because the potential demand for a service that

discharges patients to the community via a rehabilitation facility was not understood.

Several interviewees argued there was an intrinsic lack of demand for the service because

people returning from hospital with highly complex care packages preferred to be

rehabilitated within their own homes, rather than spending time in an intermediate care

facility. It was suggested that the scheme’s focus should be reoriented to provide care

within people’s homes directly from the point of discharge.

It is noteworthy that the scheme was sanctioned despite the lack of evidence for its

possible benefits. As noted, there were no other schemes that had the same mix of

objectives—intensive rehabilitation followed by telecare—and in any case, evidence for

the system-wide benefits of telecare has yet to be gathered. In this instance, therefore, the

tension between the drive for innovation and requirement for evidence of its efficacy,

emphasised by Gask et al. (2002), does not appear to have been an issue.

Thecase study scheme is not unique in its experienceofplanningand implementation. It has

already been indicated that there is now a considerable volume of research which highlights

the success factors underlying the adoption of telemedicine. The authors of this paper have

also been involved in the evaluation of the introduction of telecare in a further 15 trials in the

UK,most ofwhich have demonstrated similar implementation problems, despite the fact they

were less ambitious in their scope. For example, another scheme, in the same case study area,

involved the management of patients with COPD (chronic obstructive pulmonary disease)

within their own homes. This type of telecare has been shown to be useful in reducing

unnecessary hospital admissions, preventing exacerbations and providing care in a more

suitable home setting. The context for the project was therefore favourable, yet it was

cancelled after the trial phase ended. This partly stemmed from initial problems in designing a

scheme that was sustainable beyond the trial and, in particular, bringing together all potential

stakeholders sufficiently early in the planning phase, making it hard to define a suitable

business and service model that was acceptable to all parties.

Conclusions

Conclusions can be drawn on two important questions for the future delivery of community-

based health and social care in the UK: the challenges in meeting government aspirations for

the introduction of telecare and the future role of the housing stock in care provision.

The first point relates to the need to reconfigure existing organisational boundaries

to allow telecare services to be integrated effectively into the existing care system.

The Role of Telecare in Supporting Independence 451

Curry et al. (2003) note that common to strategic documents and pilot telecare projects

is an understanding that supporting independent living requires multi-disciplinary and

multi-agency working and the integration of different approaches to care. These

include appropriate combinations of nursing care, domiciliary care, assistive

technology and telecare. The case study described in this paper suggests that success

partly depends on the quality of the interaction between stakeholders, typically local

authority social services and housing departments, the NHS, community alarm

services, housing associations and the technology suppliers.

Studies of community care show that even without the added complication of telecare

efforts to integrate the various elements of community care have not been wholly

successful. This is partly because of continued problems associated with joint working

(Cameron et al., 2001; Harrison & Heywood, 2000), partly because of the complexity of

the hospital discharge process (Sawyer, 1998) and partly because of a general lack of

awareness of housing issues in community care plans (Harrison & Heywood, 2000). It is,

of course, possible that the introduction of PCTs may in the longer term stimulate a ‘whole

systems’ approach since PCTs are locality-based, carry a ‘duty of partnership’ with local

service providers, have much more flexible shared financial arrangements, and possess the

authority to implement service and administrative infrastructures for patient-centric care

pathways. Moreover, telecare could become a focus for better integration of services and

teams, forcing stakeholders to question existing approaches and processes. However, as

the case study shows, its introduction may require significant changes to organisational

structures, working practices, planning, evaluation and monitoring, and training and

support.

The second concluding point relates to the changing way in which housing is used

as a result of technology and policy innovation. The Chronically Sick and Disabled

Persons Act 1970 made it a statutory duty for local authority housing policy to have

regard to the ‘special needs’ of chronically sick and disabled persons. The CSDP and

related legislation provided a framework for improving the housing circumstances of

older and disabled people, including the construction of specially designed housing.

Over 30 years later, new government policies and aspirations, changing public

expectations, and technology innovation are modifying people’s housing requirements.

Arguably, the notion of the home is becoming more broadly defined to include

appropriate access to services and neighbourhood facilities as well as good quality

secure accommodation. This is beginning to challenge notions of what type of

housing provision is appropriate for people’s varying needs. The sheltered housing

and residential care sectors in particular may need to change in response to the

successful deployment of telecare into the mainstream housing stock. Already

sheltered housing is increasingly asked to perform multiple roles as a location for

different levels of care, including ‘extra care’ with 24-hour nursing cover. The

introduction of telecare has implications for the construction of extra care facilities,

given that it is able to cover widely dispersed properties and therefore move the focus

away from single site facilities.

Moving from an institutional to an own-home setting changes the concept of person-

centred care. This has been recognised by community care workers but is thrown into

sharper focus by the use of telecare. Telecare potentially facilitates the delivery of far more

customer focused care packages to people in their preferred environment. However, it may

actually increase the need for measures to improve the physical quality of the housing

452 J. Barlow et al.

stock. There is no point providing telecare unless an effort is made to ensure recipients live

in suitable housing.

Acknowledgements

Part of this work was funded by the Engineering and Physical Science Research Council’s Integrated Healthcare

Technologies programme. The authors thank their project partners and the project advisory group for their help

and advice. The paper also draws on a Department of Health funded report prepared by one of the authors and

Mariana Trejo Tinoco and Dave Wardle. The authors are grateful for their input. The paper has also benefited

from the valuable comments of three anonymous referees.

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Appendix. Research Background and Methods

The paper is based on research for a project on the mainstream implementation of telecare.

Part of the research involved a case study of a telecare scheme in southern England from its

pre-development to operational phases. The project also involved the development of a

systemdynamics simulationmodel of the local care economy, in order to explore the potential

whole system impact of telecare (Bayer et al., 2003). In addition to an examination of

background documentary material, research methods included the following:

Workshops

A series of workshops was organised, involving stakeholders from the local social and

health care services and the project’s industrial partners. The workshops were directed at

specific topics: four were held on healthcare specific issues (e.g. improving the efficiency

and effectiveness of care delivery, managing risk, identifying patient and other stakeholder

requirements); and three were held on telecare technology issues (to identify possible

supply chains and relationships between industry partners). The findings from all the

workshops were consolidated and helped to inform a further, independently facilitated

workshop for a different set of representatives from health and social care services and

different industrial partners.

Semi-structured Interviews

Fourteen semi-structured interviews were carried out with those responsible for planning,

implementing and operating the scheme, as well as the scheme’s project manager.

Interviewees included the local medical director for older people’s services, the scheme’s

consultant geriatrician, the director of therapy services, manager of the intermediate care

team, occupational therapy manager (all from the PCT), commissioning manager for older

people’s services, adult services manager, care managers, residential home manager (all

social services), and three managers from the community alarm service. The interviews

covered eight main topic areas:

. Background on the interviewee’s role and responsibilities, and the origins of their

involvement in the scheme

. Perceptions of the scheme’s objectives

. The planning process

. Barriers to change during the planning and implementation phases

. The impact of the wider policy environment

. The impact of joint working with health and social care colleagues on the

planning and implementation

. Effects of the scheme on interviewee’s job and activities

. Lessons for care pathways of elderly people

Staff Workshops

The researchers attended four half-day workshops prior to the start of the scheme’s

operational phase. These were attended by a total of 45 people from health, social and

housing services, a local housing association and other voluntary sector organisations

involved in local care delivery. The workshops were designed to provide information on

The Role of Telecare in Supporting Independence 455

the operating processes and data collection for the evaluation phase. A questionnaire

designed by the researchers was completed by 40 workshop attendees. This provided

information on their views on their prior knowledge of telecare and how it might assist

their own clients.

Operational Phase Questionnaires

At the time of writing, front-line care staff were using a questionnaire, developed by the

researchers, to capture operational experiences week-by-week and data on the care and

housing outcomes. Questions include previous living arrangements, client’s medical

problems and reason for referral, current care package before referral to the scheme, likely

care package if not accepted onto the scheme, actual care package received and how this

changes over time, and whether the client was discharged to their own home, residential

care home or a nursing care home.

456 J. Barlow et al.