Aims of the symposium and recent policy contexts

Andrew Eccles

University of Strathclyde

The aims of the eventThe symposium format:

(1) conference or meeting to discuss a particular subject

(2) a drinking party or convivial discussion

•The aims: an exchange of knowledge and ideas across research, policy and practice

•The outcomes: to make links across research and practice and form the basis to discuss future research

•Future developments: a two day event on October 17th 2013: (1) further research (2) pulling together a research proposal

10.00 -10.25 Aims of the symposium and recent policy contexts

  Andrew Eccles, University of Strathclyde

10.25 –

11.15

Assistive technologies: where are we and where are we headed?

  Dr. James Irvine & Dr. Jamie Banford, University of Strathclyde

11.15 Tea/Coffee

11.45 - 12.15 Response: where do social sciences need to engage?

  Professor Jennifer Harris, University of Dundee

12.15 - 1.00 Break out into small groups: discussion on previous papers

1.00 - 2.00 Lunch

2.00 - 3.00

 

Delivering the care in telecare: The case for practice-based

evaluation methods and the involvement of users

  Prof. Flis Henwood & Dr. Mary Darking, University of Brighton

3.00 - 3.30 Assistive technologies: ethical issues and ethical research

  Andrew Eccles, University of Strathclyde

3.30 - 4.00

 

Tea/Coffee

4.00 - 5.00 Break out into small groups: discussion on previous papers

10 - 10.15 Introduction to Day 2

  Andrew Eccles, University of Strathclyde

10.30 - 11.15 Assistive technologies and disability: research findings

  Prof. Jennifer Harris, University of Dundee

11.15 Tea/Coffee

11.45 - 12.30 Experiences from the Netherlands (1) Research and policy

agendas

  Prof. A. J. Pols, University of Amsterdam

12.30 - 1.00 Experiences from the Netherlands (2) Observation of technology

users using technologies

  Dr. Ike Kamphof, University of Maastricht

1.00 - 2.00 Lunch

2.00 - 3.20 Break out into small groups: discussion on previous papers

3.20 - 3.50 Tea/Coffee

3.50 - 4.20 Operational issues and pressures of responding to the policy

agenda

  Fiona Taylor, Local Government

4.20 - 4.50 Break out into small groups: discussion on the previous paper

4.50 - 5.00 Where next? Maintaining links, looking towards further research

  Andrew Eccles, University of Strathclyde

Assistive technologies

‘any device or system that allows an individual to perform a task that they would otherwise be unable to do, or increases the ease and safety with which the task can be performed (Cowan and Turner Smith, 1999, cited in McCreadie and Tinker, 2005: 91)

From the Scottish universities insight institute programme

‘The proposal focuses in particular on the technologies associated with Telecare’

Under the broad rubric of Telecare there will be papers and discussion around social care, health care and rehabilitation

Background

The Audit Commission (2004: 13) on benefits/cost savings: a ‘tantalising opportunity’. ‘[It makes] economic sense wherever possible to substitute Assistive Technologies for human effort’  Telecare in the UK and the (devolved) Telecare programme in Scotland: some background: how do we stand comparatively? Existing local Telecare practices across areas of the UK

Scottish Government explicitly argues that ‘Telecare services [should] grow as quickly as possible’ (Scottish Government, 2008:6).

DALLAS – Delivering Assisted Living Lifestyles at Scale

‘Over the next 20 years all industrialised and developing countries will experience a demographic shift from predominantly younger populations to older ones. As a result, current care models are unsustainable and

inadequate in terms of efficiency and effectiveness’.

 

The ‘Dependency Ratio’

Numbers likely to need some form of care or attention to long term conditions

A (relatively) smaller labour supply

Dependency Ratio between those in the labour market and those not

Care worker labour supply

Demographic change

So what’s the issue here?

Mort, Roberts and Milligan (2009: 85)

“ [there is an] ethical and democratic deficit in this field which has arisen due to a proliferation in research and development of advanced care technologies that has not been accompanied by sufficient consideration of their social context”.

The broader context

Agendas running in parallel

personalisation

integration of health and social care

The shape of Scottish governance: we would not necessarily start from here….

Current policy frameworksIn England the 3millionlives programme is set to extend telehealth and telecare to at least 3 million more people over five years from December 2011

David Cameron at the Financial Times Global Pharmaceutical and Biotechnology conference:

‘We've trialled it, it's been a huge success and now we're on a drive to roll this out nationwide…. And this is not just a good healthcare story. It’s going to put us miles ahead of other countries commercially too’

FT Global Pharmaceutical and Biotechnology conference: ‘discussion between leading industry executives, government decision makers, investors, analysts and other specialist providers’

WSD

The Whole Systems Demonstrator (WSD) program was set up by the UK Department of Health in 2007 ‘to provide the most robust evidence possible on which to base policy and investment decisions’ about future implementation of telecare and telehealth.

The evaluation included what is believed to be the world’s largest randomised controlled trials of remote care technologies to date, focusing on telecare (n=2600) and telehealth (n=3230). Participants were followed for 12 months. It cost £31m.

Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial

BMJ 2012;344:e3874 doi: 10.1136/bmj.e3874

What is already known on this topic

‘The known effect of telehealth on secondary healthcare use for patients with chronic diseases has been based on assimilating findings from several small trials often with conflicting results’

What this study adds:

‘Among people with chronic obstructive pulmonary disease, heart failure, or diabetes, a broad class of telehealth technologies could be associated with reduced rates of mortality and emergency hospital admission. This effect, however, could be linked to short term increases in hospital use observed in the control group that may have been affected by recruitment processes during the trial. The estimated scale of hospital cost savings for commissioners of care is modest, and the cost of the telehealth intervention should also be taken into account’

Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trialBMJ 2013;346:f653 doi: 10.1136/bmj.f653 (Published 26 February 2013)

What is already known on this topic

For long term conditions, telehealth has been promoted to reduce healthcare costs while improving health related quality of life (HRQoL), by facilitating self monitoring with remote surveillance by healthcare professionals. Evidence for the benefits of telehealth is ambivalent, with little empirical evidence on benefits on psychological outcomes. Methodologically rigorous trials of telehealth in relation to health related quality of life and psychological outcomes are required

What this study adds

Compared with usual care, second generation telehealth had no effect on HRQoL, anxiety, or depressive symptoms for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months.

The findings suggest that claims for potentially salutary or deleterious effects of telehealth are unfounded for most patients.

Telehealth should not be introduced with the aim of improving quality of life or psychological outcomes.

Telecare evaluation in Scotland

‘The evaluation relied on Project Managers or other staff working with the telecare users (e.g. those undertaking telecare assessments) to identify what they thought would otherwise have happened to the client at and subsequent to the time of issue of their telecare equipment. This information was then used to estimate the resources that would have been used if the telecare equipment had not been provided’.

(Scottish Government, 2009)

Telecare evaluation in Scotland

Cost analysis based on non-telecare care

Estimates of what would have happened had Telecare not been available

The research notes that, of three possible methods that could have been used to evaluate the cost effectiveness of the policy, the least robust was used, given the complexities and uncertain variables inherent in the data under evaluation (Beale: 2012)

WSD project lead Prof Stan Newman responds• John Linkous CEO American Telemedicine Association• Moira McKenzie National Telecare Programme

Manager, Scottish Government

• http://www.kingsfund.tv/telehealth

International Congress on Telehealth and Telecare - The King's Fund.mht

A view from abroad….

Pols, J & Willems, D. 2011(Sociology of Health & Illness 33. 3)

‘The dubious status of promises and the unpredictable processes of domestication [of technologies] that are so hard to trap with standard research methods, make implementing telecare technologies on a large scale and on a top-down basis, as is done in the UK, a hazardous investment’ (p.496)

Is there adequate review of these technologies (for example in areas of ‘dynamic diversity’)?

Different discourses

Greenhalgh, T. et al (2012) The Organising Vision for Telehealth and Telecare: discourse analysis BMJopen2012:2

•Modernist•Humanist •Change Management

Modernist Change M’ment Humanist

Value *Efficiency *Adoption *Experiences

*Cost effectiveness *Assimilation into *Relationships

*Rational solutions existing programmes *Reciprocities

*Technological progress *Sustainability

Research *Randomised

Control Trials *Case studies *Ethnography

Design *Generalisability *Explaining barriers *Interviews

to change *Understanding the individual’s

perspective

Research *Effect size *Accounts of change * the experience

Evidence *Admission rates (or lack of change) of using

technologies

Assumed *Smart * Practicalities *inoperability

characteristics *Reliable * Utility *potential

of technologies *Seamless constraints

CarnegieUK trust: Across the Divide (2013)

W hO iS Offl iN E iN Gl ASGO W ? 7 Figure 1: % households taking up fixed broadband, by age g ro u p 15

100

80

60

87 86 88 70 68

58

79

G reat Britain

40 35 43 Glasgow

20

0 15-24 25-34

12 35-44 45-64 65+

Base: 62,669 GB, 594 Glasgow

CarnegieUK trust: Across the Divide (2013)

Figure 2: % households taking up fixed broadband, by socio-economic g ro u p 16

100 89

80 81

60

40

20

83

72 G reat B ritain

71 56

47 36 G lasgow

0 AB C1

C2 DE

Base: 62,669 GB, 594 Glasgow

Whose discourse?Scottish Government (2008a: 6): ‘telehealth will

be widely recognised by service users and their carers as the route to greater independence and quality of life’

The ‘world leading telecare technologies corporation Tunstall: ‘the demographic timebomb’(2009:3)

Tunstall is officially a ‘partner’ of the Scottish government

• In Investing to Save: Assessing the Cost Effectiveness of Telecare (Clifford et al, 2012: 6-10) the authors conclude :

• ‘Councils should actively promote the provision of telecare as a ‘mainstream’ activity’ in local authority care services’

• and that

• ‘Councils should include standard methods of assessment and training in the applicability of telecare within their re-ablement and personalisation processes’.

• These conclusions are based on research in which ‘Tunstall assessors suggested appropriate telecare solutions’ (p5) and ‘costs of Telecare were calculated for each client using economic calculations provided by Tunstall’.

The space for debate

• As Callen et al (2009) note, public space for debate about the desirability of these technologies, their implications for care relationships and aspects of privacy, largely sits - such as it exists at all - outside the realm of parameters set by ‘experts’.

• The conflicts tend to be muted by a mutually reinforcing discourse amongst technology companies, government and some research in which these wider social tensions are often not openly addressed.

Areas for discussion

The policy discourse underpinning the use of assistive technologies

The interlinking of technology companies and government

The WSD research on telecare and telehealth and the claims made for these in public policy circles

‘…. many academics involved in the evaluation were affronted by the baldness of the claims and by what they saw as a dash to make policy on the scantiest of evidence’.

http://www.guardian.co.uk/society/2013/mar/05/telecare-could-be-future-elderly-care#ixzz2UhfErr9f