11 June 2007 Jane Hendy, James Barlow

1. 11 June 2007 Jane Hendy, James Barlow Telecare in the UK. Translating national policy into sustainable local servicesTromsø Telemedicine and eHealth Conference. Elderly - Who cares?

2. Overview • Background • Theoretical framework • Research questions and method • Progress and early findings

3. Focus of presentation • Mainstream adoption of UK telecare services by local authorities, following recent government funding

4. 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

5. Government and other official reports mentioning telecare published annually Building Telecare in England National strategic programme for IT in the NHS Royal Commission on Long Term Care

6. 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

7. Overview • Background • Theoretical framework • Research questions and method • Progress and early findings

8. Few Stakeholders Simple Innovations • Single drug prescription • Laparoscopy • Minimally invasive cardiac surgery Few innovation elements Many innovation elements Complex innovations • Mammography screening • TB treatment Telecare • Immunization • HIV programme • Polio eradication programme Many Stakeholders An unbounded organisationally complex care service innovation - telecare Source: Atun, Barlow, Bayer, Kyratsis (forthcoming)

9. It’s not the technology!

10. 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

11. 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)?

12. 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 Adopting and sustaining complex health service innovations

13. Overview • Background • Theoretical framework • Research questions and method • Progress and early findings

14. Our research questions • How do contextual factors and current policy initiatives hinder or facilitate adoption? • How do social and cognitive differences in knowledgedetermine 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?

15. 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

16. Overview • Background • Theoretical framework • Research approach and questions • Progress and early findings

17. 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)

18. The existing evidence base for telecare Barlow et al: (JTT 2007 13: 172-9)

19. 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

20. 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

21. 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

22. Thank you & questions … Funded by EPSRC Contact: • Jane Hendy – j.hendy@imperial.ac.uk