By John Woolham
When the Department of Health (DH) published its Building telecare in England guidance in 2005, there was some concern about the strength of evidence behind this policy. To settle the issue, it commissioned a major study – the Whole System Demonstrator Project (WSD).
The research team working on this study randomly allocated 2,600 people from over 200 GP practices in three local authority areas into two groups: one which received telecare as well as ‘traditional’ care, and one that received care but not telecare. The study recruited people receiving a minimum level of social care service (or those considered as needing it) including people with mobility problems, a history of falls or at high risk of falling, or who had impaired capacity with a live-in or nearby carer or a carer who was deemed to face difficulties.
They followed up these two groups after 12 months to find out if telecare produced better outcomes for those who received it. At the time, evidence from earlier project evaluations of telecare preceding the DH guidance had all suggested that telecare could play a major role in supporting continuing independence, helping to avoid unnecessary hospitalisation or permanent admission into care. There was, perhaps, a general expectation that the WSD research would ‘seal the deal’ by validating the policy.
Outcomes no better
This didn’t happen. The WSD concluded, in 2013, that telecare didn’t produce better outcomes for people who used it. It found no statistically significant differences between the two groups in terms of mortality, proportions admitted to permanent residential or nursing care, number of weeks over which domiciliary social care was provided, and numbers of inpatient admissions – either elective or emergency. It also found no differences in respect of length of in-patient hospital stays, or the number of contacts with GPs. Finally, no difference was found between costs of hospital, social care and general practice.
These findings were published when adult social care departments faced unprecedented budget cuts. Many had already set up telecare services and invested heavily in telecare based on the premise that it offered better and more cost-effective outcomes. To-date, there’s little evidence they are scaling back on telecare due to WSD findings, and some evidence for significant investment. For example, in 2014, Hampshire council agreed to invest £20.7m in telecare over the following five years.
Findings ignored
Indeed, the WSD findings largely seem to have been ignored. All of this is rather troubling to anyone supporting evidence based, or informed practice or policy development. If telecare doesn’t work, then why are council adult care departments still using it?
A research team led from the Social Care Workforce Research Unit at King’s College London are currently exploring this issue in the UTOPIA study, funded by the School for Social Care Research. This study is trying to find out what local authorities want to achieve from using telecare, the things that promote and hold it back and how it’s actually used.
The research team has already interviewed telecare managers in a sample of 25 local authorities and gone back to four of these to interview other people involved in assessing, installing and responding to telecare. The final stage of the study is an online survey to all telecare lead managers in England. This survey is currently ‘live’ and all English local authorities are invited to take part. The link is here.
If you’re reading this and you’re a local authority telecare lead manager, or you know someone who is, and your local authority hasn’t yet completed this survey the research team would really like you to do so! The findings from this research will be made available to local authorities and it is hoped that they will contribute to the more effective use of assistive technology and telecare.
Find out more about the UTOPIA study.
John Woolham is senior research fellow at the Social Care Workforce Research Unit, King’s College London. His email is john.woolham@kcl.ac.uk
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I am writing this as a TEC (telecare/telehealth/telemedicine) lead in a Northern local authority and CCG. I enjoyed a very interesting presentation about the WSD earlier this year and it is important to share here something that two individuals involved in this study made very clear – there was substantial ‘interference’ (my words, not theirs) by ministers and senior civil servants before and during the study, significantly impacting on methodology, sampling and focus. Therefore the report about the WSD falls way short of clarify it was supposed to provide. There is ample ‘evidence’ around that states that where telecare/telehealth/telemedicine is introduced and used as part of a carefully designed pathway it makes significant differences to a person’s independence, enabling them to remain in their own home (at least for longer than without) and can save councils significant amounts of money (see e.g. published paper by Care Performance Partners http://www.capp-ltd.co.uk/resources/TelecareOutcomesEfficiency20150423.pdf). What is correct though is that there is not enough statistical evidence based on longitudinal studies in both the UK and elsewhere. My suspicion is that once councils and CCGs have gone past the ‘let’s try it’ stage they no longer publish the impact assessments both financially and in terms of quality of life and therefore the body of evidence is limited.
My take is … with all the statistical and anecdotal evidence around, can Councils and CCGs/Foundation Trust afford NOT to use TEC? And finally – a proper Cost Benefit Analysis will look at upfront investment with repaying true costs over a period of time. Therefore the ‘investment’ in TEC is not ongoing at a high level, but should produce savings over time.
Having worked in extra care supported housing I have seen some advantages and some disadvantages to the use of telecare/assistive technology. One advantage is that where a falls detector was fitted and alerted staff immediately when a service user fell and wasn’t able to summon help otherwise she would have been on the floor over night. Another example is a property exit was fitted and safeguarded one service user who has a tendency of going AWOL. The major disadvantage is that some service user abuse the system by pressing the pendant for staff to pick up their remote from the floor or to make a cup of tea. The over use at times can have a negative impact on service delivery in that staff gets bogged down with responding to the calls and sometimes the over use redirects the calls to the response service and I have experienced the mother board burning out due to overuse.
It would seem some social workers themselves does not have a full understanding of the use and have told service users to just “press your button”. This gives false hope to service users as their expectations are not being met. Where someone with dementia is given a pendant and told to call in an emergency this is futile as that individual is unable at the time to determine if there is an emergency. I do agree that the benefits of telecare/assitive technology requires serious consideration before being used.
They invest in it because they delude themselves that it will save money. Telecare is a misnomer. Most forms of care cannot be delivered remotely. What is called telecare is mostly about monitoring the need for care or timing its delivery more accurately. That doesn’t mean that telecare isn’t useful in some cases or can’t improve independence but the coalition of over-claiming manufacturers and purchasers desperate to have an “efficiency plan” leads to unrealistic expectations that will inevitably be disappointed.
Agree completely. SW staff in my workplace almost have a target of telecare referrals and are questioned if they don’t make many! It’s a horrendous waste of money when care budgets are being reduced – most of the stuff doesn’t get recycled when not needed anymore as there is no facility to collect, refurb, store and reissue it – which is a nice little earner for the (private) provider. It just seems to be thrown at people without any tangible demonstration of effectiveness in reducing need for care visits. It gives peace of mind to families particularly in an urgent situation but it can’t wash and dress someone or make them a drink or meal. A lot of the money ring- fenced for telecare (assume it is as seems a bottomless pit) could be used more effectively elsewhere. The costs of the equipment ‘written off’ are eye-watering!
I did find one thing to agree with in this item, which is that the care technology sector has been woeful at ensuring it gathers the evidence needed to demonstrate that it can deliver great outcomes and lower costs in social care. I fear that virtually none of the telecare managers and others who the research team has spoken to would have been be able to provide evidence of worthwhile, sustainable outcomes at scale.
However, the rest of the item was frankly disappointing and unhelpful. As the comment above points out, the WSD is now discredited as a failure of science that has set the sector back. The idea that you can get a meaningful impact by randomly throwing some equipment at people and hoping for the best is, with benefit of hindsight, laughable. PA Consulting has extensive experience of designing and delivering care technology services and the key challenges are to do with wide-scale behaviour change and intelligent process and pathway redesign focused around the service user. Typically, telecare services in councils are not equipped to drive change of this nature, or to collect robust evidence of the impact of their service.
The implied criticism of Hampshire County Council for recognising that technology could play a greater part in helping people with their care needs is misplaced. In fact, every single one of the 7,000 people in Hampshire with a care technology service receives a risk-based assessment of need. The outcome sought from the use of care technology is specified at the point of referral by a care professional. The financial benefit of using care technology “instead of” rather than “as well as” other more old-fashioned and costly care elements is stated at the outset and tracked at the individual user level for the duration of the provision. The result? A BANKED NET saving to Hampshire of £4.7m in the first three years of the contract. Qualitative benefits are also tracked carefully. More than 9 out of 10 care practitioners making a referral report that care technology is “good” or “very good” at achieving the desired user outcome. 93% of service users report they feel “safer and more secure at home” with their care tech in place.
John; I would be happy to welcome you to Winchester for a few hours to see how this is done before writing off technology in such an offhand manner. The last thing we need is more attention grabbing headlines that enable care practitioners who are resistant to change to claim that ‘technology doesn’t work’. Let’s take their smartphones, laptops, apps, tablet PCs, GPS devices and digital TVs off them and see how they fare without technology for a while.
It needs to be borne in mind that this study was conducted over 12 months which, whilst represented a longer period than any other similar research hitherto carried out, is still probably not a sufficiently long period upon which to make a definitive judgement about ceasing investment completely. The findings also probably need to be read in conjunction with associated findings published by the same team the following year, namely:
‘The effect of telecare on the quality of life and psychological well-being of elderly recipients of social care over a 12-month period: the Whole Systems Demonstrator cluster randomised trial’ in Age and Ageing, 2014; 43: 334-341. This study tentatively found, amongst other things, that ‘Telecare, relative to usual care, may limit or ameliorate declines in mental health as measured by the 12-Item Short Form Health Survey (SF-12).
The second publication was ‘Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial’ in Age and Ageing, 2014; 43: 794-800. Whilst this study cautioned against telecare being characterised as a ‘magic bullet’, it did propose that ‘Benefits may accrue primarily to families and carers of telecare users rather than telecare users themselves’.
So whilst the whole project failed to find any significant positive outcomes in the areas as described by John Woolham, other aspects of the study suggested there might be some psychological benefits to service users and also to families and carers which cannot be discounted completely. That, together with the fact that it is just one (albeit large) study, would make me think that further research needed to be carried out over a longer period before telecare was scrapped.
Like any service, it needs to be tailored to individual need and the purpose clearly identified rather than simply adding it onto a package of care because it is there!
In my direct experience, I have recently found a residential placement for someone who was able to live at home for almost a year longer with a package of care including telecare. Without the telecare, the placement would have been required much sooner. Telecare can work very well but as I said, it must have a fully thought out role as part of the package.
Telecare has a valuable place, but salesmen have overstated the case leading managers and councillors to the misguided view that it can be used to save money. It is of course useful when making cuts to point to the shiny new technology which is failing to replace the reduced care…..
I worked in a Telecare Team for around 5 years and unfortunately the Manager invested thousands of NHS money on equipment without knowing if it was fit for purpose or even if it would be beneficial. Some people did benefit and it kept them safe at home for longer before their needs meant they required a placement. Unfortunately other professionals did not have a good understanding of the equipment, particularly some workers with dementia services. We would constantly be asked to provide calendar clocks for people when actually they were of no help whatsoever.
I believe their is a place for telecare but it very much depends on the knowledge of the person referring to the service and if they are looking for a quick fix or if it will actually benefit the person or their carer.