Nationally and locally, health and care systems need to manage the inevitable challenges of increased demand, expectations and reducing finances.
Across the UK, there are baseline objectives which underpin reform to achieve this:
- a whole population approach to improving health, regardless of health status, eligibility or service-user category and
- Greater emphasis on prevention at every level of need, including a focus on improving community and personal resilience.
The health and care systems in Cornwall, Brent, Havering, Surrey and Croydon have many characteristics in common with the national picture. In recent years, pressure on urgent/emergency care services has increased. The acute sector hospital trust/s are at the frontline of this pressure while community-based service activity is under-resourced and fragmented.
For example, Cornwall:
- Has one of the oldest demographics in England, with 1 in 4 of the population over the age of 65 and this is predicted rise to 1 in 3 by 2036.
- Cornwall’s population is expected to rise by a further 18% by 2040.
- Average life expectancy is higher in Cornwall than the national average.
- 9% of residents provide unpaid care to a family member, friend or neighbour.
- 1 in 10 residents (53,166 people) say their day to day activities are ‘limited a lot’ due to a long-term health problem or being disabled.
Demand pressures can be loosely prioritised and themed around:
- Falls and reduced/deteriorated mobility
- Frailty and cognitive issues including dementia related condition management;
- Social isolation, loneliness and mental health issues;
- Safeguarding around risk management and ‘safety’ of more vulnerable people who may be vulnerable as a result of a disability and/or situation/circumstance
- Those who have ongoing eligible needs transitioning from Children’s to Adults’ services.
(Whilst a thematic and generalised perspective, it is acknowledged that there is local variation in the order and exact composition of the demand pressure themes.)
Demographic changes, technological advances and the changing pattern of disease are pushing up the numbers of patients with complex conditions who require treatment in the community. There has also been a rise in the number of conditions and families presenting to services with complex and overlapping problems with alcohol, drugs, homelessness, mental health conditions and/or offending history. For example, the most complex patients in Cornwall – approx 2% of the population account for 16% of NHS spend in the County.
Increasing complexity of conditions and/or circumstances requires a coordinated response.
People’s expectations are changing
People’s expectations of public services are changing and their technological awareness is growing. Cornwall X and X and other authority areas are working towards transforming the way they use Technology Enabled Care (TEC) Services. These services must adapt and respond to meet this expectation to help people to lead their lives in the way that they wish to.
TEC can be used effectively to:
- Measure and manage risk more effectively
- Achieve and maintain independence using creative solutions
- Maintain choice and control
- Achieve outcomes that matter to them
Digital exclusion is not an excuse
Whilst acknowledging that digital inclusion remains an issue across the UK with 10% (5.3Mill) of the Adult population considered to be digitally excluded. Source: Office for National Statistics – Internet Users, Labour Force Survey (LFS)
The extent of the exclusion measured by the Basic Digital Skills Framework (The Tech Partnership) means that of that 10% in 2018 – 8% of those are considered to have no (zero) digital skills – i.e. they are unable to do any of the activities described in the five basic digital skills.
Digital Inclusion Strategies and Programmes are working to delete or at least significantly reduce the ‘digital divide’ and accessibility and equality is inherent with each Public Authorities area’s approach as driven by central government.
However, those who have some digital capability – 92% – they are rapidly becoming more technology savvy:
Doing it differently
TEC is becoming more predictive, learning from its environment and a variety of data sources. With the right combinations of technology, health/wellbeing crises can be prevented or detected much earlier. Careful monitoring and more timely interventions are possible and could even be administered by the person themselves. This discovery phase project aims to focus on the area of internet of things technology which is present in people’s lives, yet is not widely mainstreamed into the health and social care arena – yet.
Dependencies and stakeholders
- Service user – the person themselves – how we are capturing and learning from their perspective
- Carers – paid and unpaid perspective
- Workforce staff/other professionals’ appetite and understanding for the different approach using TEC – and matching innovative technology to support them doing their jobs well
- Current/future ambition of Care and Health commissioning models and opportunities
- Commercial availability and accessibility of the different types of IOT device/capabilities
- Interoperability and ambition of the individual manufacturers to have an ethical/wider community and ‘greater good’ perspective for their products/capability
- Care and Health System operational and system leadership commitment to the invest to save mentality that is required.
The discovery work will help us identify more opportunities for IoT use cases and start to calculate the potential benefits and savings, these finds would of use to not only Councils but NHS services throughout the UK.
TEC is becoming more predictive, learning from its environment and a variety of data sources. This discovery phase project aims to focus on the area of technology which is present in people’s lives – yet not widely mainstreamed into the health and social care arena – yet. The Internet of Things.
That by looking at a person’s outcomes which are able to be supported by technology enabled care – we can invest in appropriate and relevant IoT and Artificial Intelligence (AI) technologies – to measurably improve a person’s quality of life whist reducing the cost and demand trajectory on the Adult Care and Health System.
We will do this by focussing on possible TEC interventions which will impact the top 5 general demand pressures experiences by the Partners and the majority across the national system.
- Lifestyle monitoring via IOT devices can support informed decision making which is around positive risk taking backed by data.
- The qualitative case reviews which will be an integral part of this bid, will show a significant number with gaps in their outcomes being achieved via traditional care and support provision. Those gaps will have some kind of type of Technology Enabled Care intervention which, had it been deployed, may have further supported that person towards their stated outcomes.
- These themes and different types of technology which may have been deployed will start to inform a control perspective for the building of the evidence base.
- The findings themselves will be considered to be hypothetical until they can be litmus tested with a service user/end user person reference group which depending on the nature of the findings, may be best supported by physical show and tell, rather than talking about a type of intervention they may not be aware of when they come into the process. These reference groups around TEC are not necessarily in full existence within each Partner’s area.
Some of this information can obtained through existing systems and data sets via desktop review.
Some of this information can obtained through existing systems and data sets via desktop review for summary data.
A Qualitative Case Review is planned which is looking to achieve a rich qualitative viewpoint on the situations around the current care planning. Thematic profiles and personas are anticipated to be created to illustrate and appropriately share this information moving forward. These personas also allow the power of the findings and discoveries to be shared for others to learn from or augment their experiences with in the broadest sense.
It is looking to discover more fully what the parameters and opportunities could be with TEC potentially being utilised to support gaps in provision; or looking at the situation differently to manage risks; and/or achieve the person’s outcome aspirations in a creative TEC related way
With the desktop information distilled, we envisage to be able to use some early hypothesis findings to review with peer groups including service users whether by survey or focus group/s to further understand their views.
Secondly, we want to start understanding what the cost variables of potential solutions would be, specifically:
- Identity what types of IoT sensors could support the thematic outcomes and their costs
- IoT platform costs (e.g. Azure IoT services or other capabilities APIed in.)
- Skills required to progress to a proof of concept
Finally we want to do desktop research and network review glean a better understanding what has been achieved already in other organisations, not limited to government organisations or the UK, but investigate best practice from around the world in both private, public and non-profit organisations. In addition as well as a look at the ‘art of the possible’ and looking at what may not have been done anywhere else.
We also want to determine what appetite there may be from global technology leaders (e.g. Microsoft) in these areas for supporting and partnering in terms of skills and services for both the discovery phase and the delivery of a proof of concept in this area.
Not just financial benefits
93% of Directors of Social Care who responded to the ADASS 2018 Budget Survey said that “Technology Enabled Care was quite or very important in making financial savings”. There is no doubt it is a critical development area across the UK Care and Health System.
We are keen to explore and further quantify that TEC interventions have a broader positive effect than just financial benefit to the systems. Based on smaller qualitative pieces of work and ongoing reviews (by Cornwall, Brent, Havering and Surrey) we want to test the hypothesis that overarching wellbeing is being maintained and even improved as well as cost avoidance and improved cost profile trajectories. We talk about trajectories in terms of a person who has ongoing eligible needs but with TEC interventions the cost of meeting those eligible needs are either not increased, or on a flat or even decreasing scale as a percentage of total spend if the TEC intervention had not occurred. We are looking to investigate this further and understand how we could baseline wellbeing measures around TEC interventions as well as cost avoidance and cashable savings evidence/learnings.
These broader social benefits (person, family, carers and their community) are not clearly measured across the partners and we would hypothesise these are not clearly measured across the UK health and social care system also.
The planned focussed Qualitative Case Review is hoping to bring a more solid evidential base to this hypothesis. The 3D qualitative perspective will also hopefully result in further articulation of possible thematic variables which may interplay on a persons situation. How to accurately and realistically review what kind of alternative interventions may or may not have been palatable/possible for the person with these types of profiles is to be investigated further in the discovery phase. The hypothesis is that a summary of themes of variables could be created to then take to a person (service user) reference group for them to give feedback on the situations presented and their thoughts on the types of technology which may support those situations as a starter.
We are also grappling with how to engage and understand more from those people who are not currently service users in the Care and Health System, but may within the high risk population profile.
Challenge the traditional ‘package of care’ approach
For a person in receipt of social care in UK – the default option is still a traditional packages of care delivered at home or within a care home environment. There isn’t the workforce available nor the money available to continue to support this traditional and historical approach.
Cornwall Council and NHS Kernow CCG currently commission around 40,000 hours of Home Care per week. This amount has increased significantly in the last three years, most recently with the addition of two ‘blocks’ of 100 hours, one ‘block’ of 300 hours and one ‘block’ of 250 hours (total 750 hours / c.60 additional packages of care) which are available to the market to meet the seasonal challenge of winter (2018/19).
Brent Council estimate that for each service user they are able to discharge home from hospital with a suitable AT package, instead of placing them in residential care, could save an estimated £27k per year (based on £1500 for an AT package vs the monthly cost of a residential care home).
How could creative uses of IOT support a person to either reduce costs or spend support money differently in the top 5 demand pressure areas where traditional packages of domicillary care or care delivered in a care home environment are the ‘default’ option for that person currently?
How will we collaborate?
We need to consider our team, our working environment(s), the technology and tools we’ll be using, and how we’re delivering our findings at the end of discovery.
- Our team will be split across a number of Local Authorities from across the UK. The lead authority is Cornwall Council whilst our partner organisations are London Borough of Brent, London borough of Havering and Surrey County Council.
We propose structuring the team into 3 communities of practice, focused on the outcomes we’re looking to achieve. Our 3 communities of practice will be:
- User Needs & Resident Analysis
- Service Design
- Technology Architecture
Partner Authorities will contribute team members, and the associated skills, to 1 or more of the communities of practice.
- A collaboration tool – Microsoft Teams – to help engender cross organisation communication. If partner organisations do not have access to Microsoft Teams we would propose using Slack as an alternative
Teams or Slack will also help give us a virtual “wall space” around which ideas can be discussed, hypothecated, developed and progressed.
- Documentation – it will be really important to be able to collaborate across organisations when creating the findings report. MS Teams gives us the ability co-edit documents, which makes it a natural choice. If MS Teams is not available the plan is to use we would use Google Documents.
Governance and structure
Governance and structure are important to consider, especially when a team is made up of authorities from a variety of geographic locations.
If MS Teams is adopted as the collaboration tool, we would suggest adopting a daily SCRUM, run by the Delivery Manager from Cornwall Council, progressing your backlog. The Regular stand up would focus on moving backlog tasks through delivery, whilst a weekly or bi-weekly stakeholder stand up would importantly keep the Service or Directorate stakeholders up to date with progress in our 3 communities of practice.
We would like to be able to benefit from:
- Use of MHCLG offices for any London-based face to face meetings during the project, given the geographically spread out nature of the partners,
- Option to access to GDS user research labs (to help us bring down the project cost for user research sessions)
- Badging our research as MHCLG endorsed, which will strengthen the profile of our work and encourage participation
- Introductions at the appropriate level to government agencies such as NHS Digital (eg Directory of Services, 111 online) and CQC etc
- Ability to send comms, surveys etc via MHCLG channels (blogs, newsletter, twitter, etc.) to help us ‘work out loud’, and to help with sharing the outputs with the local gov sector
Whilst training is not fundamentally required in order for us to deliver this discovery work, GDS or LDCU training would be appreciated if there were opportunities to upskill. We also have Gartner support available for SME advice, peer review and content/paper review.
CC and Partners may need to cross-skill, which can be arranged as needed. User design skills will be key to this project.