Much has been written about telecare, and the evidence regarding its use is the subject of debate. As well as looking at the existing evidence on telecare, this webinar will look at the findings from a new study looking at the use of telecare and put forward ideas for developing practice. Aimed at: Commissioners and practitioners in adult social care. View the recording of this webinar. Partners and subscribers have full access to recorded webinars. Please note: you will need to login to your RiPfA account.

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What does evidence-informed
telecare look like?
Hosted by Dr John Woolham

2. 2
What does evidence informed
telecare look like?
John Woolham
Senior Research Fellow,
Social Care Workforce Research Unit,
King’s College London.
3rd October 2017

3. Agenda
1. Introductions and welcome
2. Webinar learning objectives
3. Presentation 1. Definitions and an example
2. How we got here:
• Policy development
• Summary
• Discussion points
3. Research evidence:
• Early studies
• The Whole System Demonstrator
project
• Discussion points
4. The policy problem
5. The UTOPIA study:
• New findings
• What these findings tell us
3. Further reading
3

4. Webinar objectives
› Provide an overview of policy
development and evidence for telecare
› Encourage critical reflection on
relationships between evidence and
policy
› Encourage telecare stakeholders to
reflect on what ‘evidence based’ or
‘evidence informed’ approaches to
telecare service delivery look like
› Using current research evidence, put
forward ideas for developing practice.
4

5. 1. Telecare in practice: definitions and a
quick example
› The Problem:
o Mrs Smith forgets to light gas
cooker after turning it on.
o Risk of suffocation or explosion
o High level of concern from
neighbours and relatives
› The Solutions?
o Admission into care
o Substitute gas for electric or
microwave
o Disconnect cooker
o Use technology to manage
risks
Definitions
o Electronic assistive technology
o Telecare

6. 2. Policy development
Difficulties in implementation of telecare: formidable barriers and a
lack of local infrastructure to support widespread use:
o Didn’t ‘belong’ to any existing public sector agency – no one sector has
all the expertise
o Because early social alarm technology had to be user activated it was
widely believed that telecare per se was only useful for ‘cognitively
able’ people.
o Focus was on the people with CI who were unable to use the
technology rather than limitations of the technology itself.
o Local agencies don’t always work well together
o Telecare seen as ‘big brother’ - superficial thinking but resistance
• Big gaps in expertise
o who assesses for,
o who decides what telecare,
o who installs,
o who responds
o who pays
o who realises the savings that can be made
• Best practice: re-engineering services to exploit benefits of
telecare not trying to fit them in to existing services
6

7. 2. Policy development
1. 2005: the Preventive Technology Grant. 80m over 3 years
for all English local authorities.
 To pump prime and stimulate demand
 Good for industry - was seen as needing help
 Came with strings: Performance Indicators = to get
telecare and electronic assistive technologies into homes of
as many older people as possible.
2. Recognition of the need for better research:
commissioned the WSD.
7

8. 2. Policy development
Austerity
Telecare as prophylactic and panacea?
› ASCD budgets not protected
› Cuts of between 25-40% since 2009
› No end to austerity and reduced
public sector spending
› Telecare seen as a less expensive
way of meeting needs
o Signposting of non-eligible people
o Service of ‘first resort’ - before care or
as a substitute for care
o To keep people out of hospital
o To facilitate early discharge
o To prevent/delay admission into care

9. 2. Policy development summary
On-line poll:
Have national telecare policies helped the development of telecare in your Local
Authority? (Y/N)
› Governments have seen a key role for assistive technology for two decades
› Implementation has been difficult because of formidable barriers & lack of an
infrastructure at a local level to support the widespread use
› The Government willed the means as well as visioning the future for telecare
with the PTG and PIs.
› It also commissioned the WSD to fill the gap in evidence of impact and
effectiveness.
› Public sector austerity has led to a renewed interest in telecare as a cost
effective way of providing help to people needing adult social care.
Discussion point
Did anything hold back telecare use in your Local Authority?
9

10. 3. Research evidence: early projects and
studies
› Falkirk Mobile
Community Alarm
service
› Adre ‘n’ Saff (Anglesey)
› Croydon Aztec Project
› Kent
› Edinvar Housing
Association
› Gloucester Smart Home
› Northamptonshire
Safe at Home
Project
Comparisons of care packages provided to Safe at Home service users and the
Essex group at the start and end of the fieldwork period
0.6
1
0.5
6.6
3.6
5.5
1.4
2.1
5.8
11.6
9.7
18.1
0
2
4
6
8
10
12
14
16
18
20
Av. no.
services at
start
Av. no.
services at
end
Av. no. visits
p.w. at start
Av. no. visits
p.w. at end
Av. no. hrs.
p.w. at start
Av. no. hrs.
p.w. at end
Safe at Home
Essex comparator
Odds ratio of likelihood of moving into care
SAH Essex
Stayed 134 41 ((134*132)/(99*41)) = 4.35
Left 99 132
Rates at which participants left community settings

11. 3. Research evidence: WSD findings
Some, fairly limited
evidence of positive impact
of telehealth applications
WSD compared outcomes
for telecare users with a
controlled, randomised
group people who received
no telecare.
None of the measured
outcomes were statistically
significant
‘In this trial, telecare did not
significantly alter rates of health
or social care service use or
mortality over 12 months’
Steventon et al. (2013 p.6)
Control
(n=1, 236)
Intervention
(n=1,190)
Admission proportion (%)
Mortality (%)
Emergency hospital
admission per head
Elective hospital admission
per head
Outpatient attendance per
head
A&E visits per head
Falls admissions per head
Hospital bed days per head
GP contacts per head
Practice nurse contacts per
head
Proportion admitted into
permanent residential care
(%)
Domiciliary care weeks per
head
Hospital tariff costs per
head
GP surgery costs per head
Social care costs per head
49.2
8.9
0.57
0.41
3.80
0.70
0.11
8.48
6.63
3.21
3.2
15.36
2,604
315
4,287
46.8
8.7
0.65
0.38
3.92
0.72
0.14
8.65
6.72
2.80
3.1
15.41
2,846
305
4,210

12. 3. Research evidence: a closer look at the
WSD
› Strengths and limitations of the
WSD
› Strengths
− Largest telecare trial in the world
− RCT: rigorous design
− Robust findings
› Limitations
− Destroyed goodwill by ignoring pre-
existing good practice in the sites
− Unable to explain its findings (not what
RCTs are designed to do)
− Did not specify what technology was
installed
− Sample included people with a wide
range of needs and disabling conditions
− Follow-up was for 12 months only.
12

13. 4. Telecare: a new policy problem?
WSD findings = problems for:
› The Government: current
policies support the
development of service
provision seemingly offering no
advantages over traditional
care & support
› Local authorities, some of
which have invested v. large
sums at a time of unrelenting
budgets cuts
› Telecare manufacturers: ability
to offer shareholder dividends
jeopardised if care industry dis-
invests.
› Telecare ‘pioneers’ and early
evaluators whose results were
very positive
Investment case studies:
› Birmingham, (14m) North
Yorkshire, (3.5m?)
Hertfordshire, (5m?)
Manchester & Newcastle
› ADASS response to Better Care
technology Survey (2014)
‘This is an important survey
which…will support members to
generate further momentum in
realising the potential for assistive
technology….We hope our investment
in resources to support members
with their telecare service
development can now be focused in
the areas that make the most
difference’
(Dave Pearson, ADASS President 2014)

14. 5. The UTOPIA study:
objectives & methods
Objectives
To understand Adult Social
Care Departments
(ASCDs) perspectives
about:
› Strategic aims of telecare
for older people?
› Local evidence to enable
ASCDs to assess
achievement
› How aims are
operationalised and
delivered
Methods
› Online survey using ‘Survey Monkey’
software
› 114 valid responses (75% response rate)
› All types of council and regions represented
26 29
15
19
11
0
20
40
60
80
100
Shire
County
Unitary London
Metropolitan
Metropolitan Not known
Type of Council
20
17
15
12
10
10
8
7
3
0 20 40 60 80 100
South East
London
West Midlands
North West
South West
Yorkshire & Humberside
East
North East
East Midlands
Region

15. 5. UTOPIA findings
› Local Authority telecare manager
responses: views about the WSD.
› Reflective point
› how good is the evidence?
› what implications does this have?
As I understand, analysis of the data was
complicated with many factors to consider
and so it was difficult to isolate the impact
of telecare leading to fairly inconclusive
results
I feel that the findings are fairly old now, a
larger more in depth study is required
I feel that the findings did not take into
account the softer outcomes and the
health economics were not very robust
I felt the outcomes were disappointing and
missed an important opportunity to look at
the positive side of telecare provision
Its finding does not tally with what
customers and carers /friends tell us about
telecare
There are questions over the methodology
used and how scientifically robust the trials
were.
The sample size was limited, with mixed
results, which are probably out of date
now. Technology has moved on improving
the ran ge of options available especially in
the area of telehealth and mobile
solutions.
15
› ADASS: Alternative perspectives?
› The Better Care Technology Survey (2014)
› ‘The findings of the survey, based upon a response
rate of 49% of councils will be considered by the
ADASS policy networks and ADASS regions to inform
how to best support councils in taking forward the use
of technology.’
› Call for Evidence Report (2015)
› ‘to allow councils to share practice and case studies to
sustain and accelerate momentum in the use of
technology in meeting improved health and wellbeing
outcomes’
› Both offer useful insights into innovative
practice, but evidence to support
effectiveness was not strong. Neither
report mentions the WSD.

16. 5. UTOPIA findings
1. Strategic aims
› delay needs for support
› enhance quality of life
Operationally, the main
ways in which telecare was
intended to help:
› risk management and
safety,
› support for unpaid carers
Linkage between strategic &
operational goals =
Linkage to quality of life =
Telecare seems to be used
mostly to reduce future
anticipated costs
100
81
77
61
49
28
14
0 20 40 60 80 100
Manage risk/promote safety
Provision of support for unpaid carers
Remind and prompt people to do things/not…
Keep people oriented in time and place
Enable communication/social contact/prevent…
Enable people to engage in…
Some other kind of purpose
What are the main ways in which telecare is
intended to meet needs of older people?
97
90
85
84
66
33
0 20 40 60 80 100
Delaying and reducing the need for care and
support
Enhancing quality of life for people with care &
support needs
Safeguarding adults whose circumstances
make them vulnerable & protecting them…
To prevent carer breakdown/to support carers
Ensuring people have a positive experience of
care & support
Some other kind of need
What needs are telecare intended to meet
for older people in your Local Authority?

17. 5. UTOPIA findings
2. Level of financial
commitment
40% felt telecare would
save money. Not all
could evidence this claim
Some had done financial
modelling and developed
‘hypothecated’ savings
“I used to gather … what
services would have gone in,
if not for the telecare. But
because of the non-robust
nature of that evidence, I
couldn't ever prove it. So,
for me it's probably very
much a case of common
sense from knowing
individual cases, rather than
any systematic proof” (LA-A)
3. Assessing eligible older people for
telecare: what gets considered?
› High proportions answered affirmatively to
questions about the kinds of things
covered in assessments
54
63
72
75
80
83
88
89
89
92
92
92
92
0 20 40 60 80 100
The ability of the person to problem solve
The person's grip strength & dexterity
What activities are important for the person…
The person's insight into their abilities and…
What may be unsafe about the way they do…
What activities the person needs to do in…
The social support the person has inc.…
The person's physical environment inc.…
The mental & physical capacity of the person
The person's daily routines
The person's ability to communicate
The person's memory & whether this is…
The person's ability to mobilise & move…
What do you assess within your
telecare assessment?

18. 5. UTOPIA findings
4. Assessing older people for
telecare
› Formal assessments of need for
telecare not always done:
− For some devices
− Hospital discharge
− For self-funders or Direct Payment users
• Over 1/3 = older people could self-
assess
• Over 1/2 = can spend a Direct
Payment on telecare.
• Half also said advice was available to
support self-assessed/private
purchasing decisions
• Care Managers, specialist telecare
workers and OTs could all assess for
telecare
5. Assessing older people for
telecare: reviews
› Reviews were often done by
telephone: sometimes focused
on equipment not the person

19. 5. UTOPIA findings
6. Training
› Over 80% said training
was available to telecare
assessors
› This was usually on-the-
job or by telecare
manufacturers
› Almost no training was
formally accredited or led
to a formal qualification
› The length of the training
course or session was
usually short
› Focus of much training
may have been on how
devices worked
37
29
45
4
15
0
20
40
60
80
100
On-the-job
training on a
peer-to-peer
basis
Training by
Local
Authority
training team
or person
Training by
telecare
manufacturer
or supplier
Training by
college or
university
Some other
kind of
training
Who provides training for telecare
assessors?
44
3 3
26 23
0
20
40
60
80
100
1/2- 1
working day
2-3 working
days
4-5 working
days
More than 1
week
n/k
How long does it take someone who
assesses for technology to complete any
telecare training?

20. 5. UTOPIA findings
7. What telecare was available?
› Most ASCDs relied on a small
number of telecare suppliers – one
in particular
› The three most commonly used
devices were
− Pendant alarms
− Fall detectors
− Bed/chair occupancy sensors
• 29 types of device were
mentioned in total but some
were not telecare
32
75
17
8
0
20
40
60
80
100
1 to 2 3 to 5 6 to 10 10+
How many suppliers does your
ASCD obtain telecare
equipment from?
53
50
48
42
37
30
21
19
14
12
9
0 20 40 60 80 100
Lifeline & Pendant alarm
Falls detector
Bed / chairOccupancy Sensor or…
Smoke detector/ alarm
Door sensor/exit sensor
Med. Dispenser
GPS & tracking device inc. Buddi…
Env. Sensors inc. Just…
Carbon Monoxide sensors
Epilepsy sensors
Ambient temperature sensor
Most frequently used
AT/Telecare devices

21. 5. UTOPIA findings
8. Installation and
maintenance
› Telecare usually installed
and maintained by specialist
telecare workers, telecare
manufacturers/ suppliers
› Over ½ said maintenance
was based around devices
programmed to alert a call
centre when servicing was
needed. Some said users
and family carers were
responsible for basic
maintenance.
› Reasons for requesting
telecare to be removed were
changes in need, failure to
‘get on’ with devices and
concerns about costs and
charges
9. Responding to alarms generated
by telecare
› Just under ½ said the ‘first line
responder’ was an unpaid/family carer
› Shire counties did not provide a 24/7
paid response service.
› ¼ of those not offering a paid
response service said if no-one could
act as a responder no telecare is
provided
› Some thought about cutting back on
response services and involving
unpaid carers more often:
› “I think in some cases, it should be the
family. And if they don't want to take it or
they simply don't answer the phone they
know that that call is then going to be
forced to us. I think we need to move back
to having more family involvement with it”
(LA-L)

22. 5. UTOPIA issues &
implications
› Our study does not confirm the
views of many LAs and the
telecare industry that the WSD
researchers ‘got it wrong’
› We also disagree with any
suggestion that telecare can
never be a cost effective use of
public resources
› We think that effective use will
depend on a number of pre-
conditions, including
We speculate that the rejection
of the WSD and creation of
‘alternative facts’ may have
prevented LA ASCDs from a
critical examination of the
effectiveness of telecare
o Investment in accredited
training for telecare
assessors and installers
o Rigorous, person-centred
assessments
o The availability of a wide
range of technologies to
improve matching with need
o Accurate information to self-
funders or Direct Payment
users
o The development of
arrangements for social
response services in all
areas

23. 5. UTOPIA issues &
practice implications
› Should strategic focus be so much on
risk management and safety?
› Does the focus on saving money by
using telecare have ethical
implications?
› When is OK to use telecare without an
assessment and when is it essential?
What might be the consequences of
non-assessment?
› Who should assess for telecare? What
matters?
› When is it OK for assessments/reviews
to be done not in the user’s home?
› Are reviews of telecare sufficiently
rigorous?
› Is access to a limited range of telecare
sufficient?
› Does telecare support carers or add to
carer burden?
› Are person-centred approaches to
telecare be compromised: e.g. by
− focus on risk management and
safety
− austerity and cost-savings
− the withdrawal of other ways of
meeting needs
− remote assessment
− access to a limited range of
devices
− the absence of mobile response
service
› Is there a need to develop better
training for telecare staff?
› How to ensure people who self-
assess and use Direct Payments or
private funding make the right
decisions for them?
Discussion & comments if
time permits

24. Further reading
Association of Directors of Adult Social Services (ADASS) (2014) Better Care Technology Survey 2014 Report. London, ADASS
Association of Directors of Adult Social Services (ADASS) (2015) Better Care Technology: Results of Call for Evidence. London, ADASS
Audit Commission (2000) Fully Equipped: the provision of equipment to older or disabled people by the NHS and Social Services in
England and Wales. Abingdon, Audit Commission Publications.
Barlow, J., Singh, D., Bayer, S. & Curry, R. (2007) A systematic review of the benefits of home telecare for frail elderly people and
those with long term conditions. Journal of Telemedicine and Telecare 13 172-179.
Bjørneby, S., Topo, P. & Holthe, T. (1999) Technology, Ethics and Dementia. Oslo/Norway, Norwegian Centre for Dementia Research.
Department of Health (2001) The National Service Framework for Older People London, Department of Health .
Department of Health (2005) Building telecare in England. London Department of Health.
Fisk, M. (2003) Social alarms to telecare. Bristol, Policy Press.
House of Commons Select Committee on Health (2002) Delayed Discharges Third Report of Session 2001-02 Cm5645 London, The
Stationery Office
Knapp, M., Barlow, J., Comas Herrera, A., Damant, J., Freddolino, P., Hamblin, K., Hu, B., Lorenz, K., Perkins, M., Rehill, A.,
Wittenberg, R. & Woolham, J. (2015) The case for investment in technology to manage the global costs of dementia. PIRU, LSE,
PSSRU.
Marshall, M. (ed.) (2000) ASTRID: a Social and Technological Response to meeting the needs of Individuals with Dementia and their
Carers. London, Hawker Publications.
McColgan, G. & Bowes, A. (2009) Smart technology and community care for older people: innovation in West Lothian, Scotland.
Edinburgh, Age Concern Scotland.
Mitchell, R. (unpublished) (1996) Mobile Emergency Care Dementia Project An Evaluation. Falkirk Social Services
NHS (1998) An Information strategy for the modern NHS 1998-2005 London, Department of Health.
House of Commons Science and Technology Committee (2005) 1st report of session 2005-06. Ageing: Scientific Aspects HLP20
London, The Stationery Office.
Royal Commission on Long Term Care (1999) With Respect to Old Age: Long term care – rights and Responsibilities (Cm4192-1
London, the Stationery Office.
Secretary of State for Health (2000) The NHS plan: a plan for Investment, a plan for Reform CM 4818-1 London, HMSO.
Secretary of State for Health (2005) Independence Wellbeing and Choice: Our vision for the Future of Social Care for Adults in
England Cm6499, London, the Stationery Office.
Steventon , A., Bardsley, M., Billings, J., Dixon, J., Doll, H., Beynon, M., Hirani, S., Cartwright, M., Rixon, L., Knapp, M., Henderson, C.,
Rogers, A., Hendy, J., Fitzpatrick, R. & Newman, S. (2013) Effect of Telecare on use of health and social care services: findings from
the Whole Systems Demonstrator Cluster randomised Trial Age and Ageing 42 (4) 501-08.
Wey, S. (2005) One size does not fit all: person centred approaches to the use of assistive technology. In Marshall, M. (ed.)
Perspectives on Rehabilitation and Dementia pp 201-210 London, Jessica Kingsley.
Woolham, J. (2005) The Safe at Home Project London, Hawker Publications.
24

25. 25
The findings presented in this
webinar were made possible by
research funding from the National
Institute for Health Research (NIHR)
School for Social Care Research. The
views expressed in the webinar
presentation are those of the
presenter and not necessarily those
of the NIHR, School for Social Care
Research, Department of Health or
the UK National Health Service.