MALCOLM Assisted Living Capability Analysis Report January 2015
The MALCOLM project was selected under the European Cross-border Cooperation Programme INTERREG IV A France (Channel) – England, co-funded by the ERDF.
Part 2 – English Region Research Summaries (Hampshire, Surrey, East Sussex, West Sussex, Kent)
Medway
Surrey Kent
Hampshire
W Sussex
Southampton
E Sussex
Portsmouth Isle of Wight
Brighton and Hove
2
Contents 1 Regional Overview – English MALCOLM Region ......................................................................8 1.1 1.2 1.3 1.4 1.5 1.6 1.7
Geography ........................................................................................................................................ 8 Administration ................................................................................................................................. 9 Economy ......................................................................................................................................... 11 Policy .............................................................................................................................................. 12 Research Insights ........................................................................................................................... 13 Good Practice ................................................................................................................................. 13 Opportunities ................................................................................................................................. 13
2 Demographics ........................................................................................................................ 15 2.1 Population ...................................................................................................................................... 15 2.1.1 Population Density ................................................................................................................... 15 2.1.2 Population over 65 years .......................................................................................................... 16 2.1.3 Life Expectancy ......................................................................................................................... 17 2.1.4 Population Projection ............................................................................................................... 18 2.1.5 Old--Age Support Ratio ...................................................................................................................... 19 2.2 Policy .............................................................................................................................................. 19 2.3 Research Insights ........................................................................................................................... 20 2.4 Opportunities ................................................................................................................................. 20
3 Housing in England ................................................................................................................. 22 3.1 Introduction ................................................................................................................................... 22 3.1.1 Housing Options........................................................................................................................ 22 3.1.2 Rented Accommodation............................................................................................................ 22 3.1.3 Social housing ........................................................................................................................... 23 3.1.4 Owner--Occupied Accommodation ................................................................................................... 24 3.1.5 Benefits ..................................................................................................................................... 24 3.2 Housing and Health ....................................................................................................................... 25 3.2.1 Decent Homes Standard ........................................................................................................... 25 3.3 Policy .............................................................................................................................................. 26 3.4 Research Insights ........................................................................................................................... 26 3.5 Opportunities ................................................................................................................................. 26
4 English Regional Infrastructure ............................................................................................. 29 4.1.1 Transport .................................................................................................................................. 30 4.1.2 Digital Communications ........................................................................................................... 32 4.1.3 Energy ....................................................................................................................................... 34 4.1.4 Intellectual Capital ................................................................................................................... 35 4.2 Policy .............................................................................................................................................. 35 4.3 Research Insights ........................................................................................................................... 35 4.4 Opportunities ................................................................................................................................. 36
5 Health and Social Care System in England ............................................................................ 37 5.1 Overview of the Health and Care System in England .................................................................. 37 5.2 Research Insights ........................................................................................................................... 41 5.3 Good Practice ................................................................................................................................. 42
3
5.4 Opportunities ................................................................................................................................. 42
6 Health Services in England ..................................................................................................... 44 6.1 Overview of the Health Services in England ................................................................................ 44 6.1.1 The National Health Service (NHS) .......................................................................................... 44 6.1.2 NHS Choices .............................................................................................................................. 44 6.1.3 Primary Care............................................................................................................................. 45 6.1.4 Secondary Care ......................................................................................................................... 45 6.1.5 Tertiary Care ............................................................................................................................ 45 6.1.6 Quaternary Care ....................................................................................................................... 46 6.1.7 General Practitioner ................................................................................................................. 46 6.1.8 Out--of--Hours Service ......................................................................................................................... 46 6.1.9 NHS telephone service .............................................................................................................. 47 6.1.10 NHS Accident and Emergency Departments (A&E) ............................................................... 47 6.1.11 NHS Walk--in Centres ...................................................................................................................... 47 6.1.12 NHS Minor Injuries Units ........................................................................................................ 47 6.1.13 NHS Funded Nursing Care ...................................................................................................... 47 6.1.14 NHS Continuing Healthcare ................................................................................................... 48 6.1.15 Hospice Care ........................................................................................................................... 48 6.1.16 Intermediate Care................................................................................................................... 48 6.1.17 Rapid response community teams.......................................................................................... 48 6.1.18 Virtual Wards ......................................................................................................................... 49 6.1.19 Reablement (including rehabilitation) .................................................................................. 49 6.2 Private (non--‐NHS) Healthcare .............................................................................................................. 49 6.3 Policy .............................................................................................................................................. 49 6.4 Research Insights ........................................................................................................................... 50 6.5 Good Practice ................................................................................................................................. 50 6.6 Opportunities ................................................................................................................................. 51
7 Social Care Services in England .............................................................................................. 53 7.1.1 Overview of the Social Care System in England ....................................................................... 53 7.2 Adult social care provision in England ......................................................................................... 53 7.3 Social Care Services ....................................................................................................................... 56 7.3.1 Care at Home ............................................................................................................................ 56 7.3.2 Housing with Care .................................................................................................................... 56 7.3.3 Care away from Home .............................................................................................................. 58 7.4 Social Care Service Commissioners and Providers ..................................................................... 59 7.4.1 Local Authorities....................................................................................................................... 59 7.5 Independent Providers.................................................................................................................. 60 7.6 Third Sector Organisations ........................................................................................................... 60 7.7 Individuals as Purchasers ............................................................................................................. 61 7.8 Policy .............................................................................................................................................. 61 7.9 Insights ........................................................................................................................................... 62 7.10 Opportunities ............................................................................................................................... 62
8 Health and Social Care Funding in England ........................................................................... 63 8.1 Overview of NHS Health Care Funding in England...................................................................... 63 8.2 Paying for Health Care................................................................................................................... 64 8.2.1 NHS Continuing Healthcare ..................................................................................................... 64 8.2.2 NHS--Funded Nursing Care ............................................................................................................... 64 8.2.3 Private Health Care .................................................................................................................. 64 8.3 Overview of Social Care Funding in England ............................................................................... 65 4
8.4 Access to Adult Social Care Services, Funding and Benefits ....................................................... 66 8.4.1 Local Authority Social Care Assessment Process ..................................................................... 66 8.4.2 Access to Dept of Work & Pensions Benefits & Entitlements ................................................... 67 8.5 Choosing Social Care Services ....................................................................................................... 68 8.6 Paying for Social Care Services ..................................................................................................... 68 8.6.1 Paying for Care at Home .......................................................................................................... 68 8.6.2 Paying for Residential Care ...................................................................................................... 69 8.6.3 Older People’s Income............................................................................................................... 70 8.7 Policy .............................................................................................................................................. 74 8.8 Research Insights ........................................................................................................................... 74 8.9 Opportunities ................................................................................................................................. 74
9 Health and Social Care Market Access in England ................................................................ 76 9.1 Commissioning v Procurement..................................................................................................... 76 9.2 Who Commissions Which Services ............................................................................................... 76 9.3 Market Access: Procurement, Facilitation, & Influencing ........................................................... 76 9.4 Market Access: Procurement of NHS Health Care Services ........................................................ 78 9.4.1 Tenders ..................................................................................................................................... 78 9.5 Framework Agreements................................................................................................................ 79 9.6 Market Access: Innovative Solutions for the NHS ....................................................................... 80 9.6.1 Small Business Research Initiative (SBRI) ............................................................................... 80 9.6.2 NHS Supply Chain – Innovation Scorecard .............................................................................. 80 9.6.3 NHS Shared Business Services .................................................................................................. 80 9.6.4 NIHR Healthcare Technology Cooperatives (HTCs) ................................................................ 81 9.6.5 NICE Medical Technologies Evaluation Programme (MTEP) ................................................. 81 9.6.6 Academic Health Science Networks (AHSNs) .......................................................................... 81 9.6.7 Medilink Network ..................................................................................................................... 81 9.7 Market Access: Procurement of Private Healthcare Services ..................................................... 82 9.8 Market Access: Procurement of Social Care Services .................................................................. 82 9.9 Research Insights ........................................................................................................................... 83 9.10 Good Practice ............................................................................................................................... 84 9.11 Opportunities ............................................................................................................................... 84
10 Older People and Technology ............................................................................................. 87 10.1 Older People and Communication Technologies ....................................................................... 87 10.1.1 Mobile Internet connections ................................................................................................... 87 10.1.2 Internet activities ................................................................................................................... 88 10.2 Skills of Older People to use Technology ................................................................................... 89 10.3 Attitudes of Older People towards Technology ......................................................................... 89 10.3.1 Enablers of Assisted Living technologies................................................................................ 90 10.3.2 Barriers to Assisted Living technologies ................................................................................ 90 10.4 Policy ............................................................................................................................................ 90 10.5 Research Insights ........................................................................................................................ 91 10.6 Good Practice ............................................................................................................................... 91 10.7 Opportunities ............................................................................................................................... 92
11 Regional Assisted Living Activity ......................................................................................... 94 11.1 Suppliers of Products and Services ............................................................................................ 94 11.2 National AL Projects and Initiatives ........................................................................................... 95 11.2.1 The Preventative Technology Grant....................................................................................... 95 11.2.2 Whole Systems Demonstrator ................................................................................................ 95 11.2.3 Delivery Assisted Living Lifestyles at Scale (dallas) ............................................................... 96 5
11.2.4 3 Million Lives ......................................................................................................................... 98 11.2.5 Academic Health Science Networks ....................................................................................... 99 11.3 Regional AL Projects/Initiatives in Health and Social Care ....................................................100 11.3.1 East Sussex ............................................................................................................................ 100 11.3.2 Brighton and Hove................................................................................................................ 100 11.3.3 Medway ................................................................................................................................. 100 11.3.4 Kent ....................................................................................................................................... 101 11.3.5 Hampshire ............................................................................................................................ 102 11.3.6 Surrey.................................................................................................................................... 104 11.3.7 West Sussex ........................................................................................................................... 105 11.3.8 Local Councils and NHS Trusts............................................................................................. 105 11.4 Policy ..........................................................................................................................................106 11.5 Research Insights ......................................................................................................................106 11.6 Opportunities .............................................................................................................................106
12 Regional Centres of Expertise ........................................................................................... 107 12.1 National Centres of Assisted Living Expertise .........................................................................107 12.1.1 The Technology Strategy Board ........................................................................................... 107 12.1.2 The Telecare Learning and Improvement Network ............................................................ 107 12.1.3 Foundation for Assistive Technology (FAST) ....................................................................... 107 12.1.4 The Kings Fund ..................................................................................................................... 108 12.1.5 The Telecare Services Association ........................................................................................ 108 12.1.6 UK Telehealthcare ................................................................................................................ 108 12.2 Regional Centres of Assisted Living Expertise ........................................................................108 12.2.1 Kent Whole System Demonstrator ....................................................................................... 108 12.2.2 Surrey Telecare..................................................................................................................... 109 12.2.3 South East Health Technologies Alliance (SEHTA) .............................................................. 109 12.2.4 University of Portsmouth...................................................................................................... 109 12.2.5 University of Surrey .............................................................................................................. 109 12.2.6 University of Kent, PSSRU ..................................................................................................... 109 12.2.7 Wessex Health Innovation and Education Cluster (HIEC) ................................................... 110 12.2.8 Telehealthcare Network ....................................................................................................... 110 12.2.9 Healthcare over Internet Protocol CIC ................................................................................. 110 12.3 Policy ..........................................................................................................................................110
MALCOLM Project Assisted Living Glossary .............................................................................. 111 Tables and Figures Table 1 Local Authority Responsibility for Services ....................................................................... 10 Table 2 MALCOLM counties and Unitary Authorities ...................................................................... 10 Table 3 Summary of Health Care Services in England ................................................................... 44 Table 4 Social Care Services in England ...................................................................................... 54 Table 5 Social Care Settings in England ...................................................................................... 55 Table 6 UK Government Tenders ................................................................................................ 78 Figure 1 The MALCOLM region within the United Kingdom ............................................................... 8 Figure 2 Local Authority Responsibility for Services ........................................................................ 9 Figure 3 Counties and Unitary Authorities in the MALCOLM region .................................................. 10 Figure 4 Second-tier Local Authorities in the MALCOLM region ....................................................... 11 Figure 5 Percentage of population in most deprived national quartile, by second-tier local authority .. 11 6
Figure 6 Median earnings per residence, by second-tier local authority ........................................... 12 Figure 7 UK Regional Population – mid-201210 ............................................................................. 15 Figure 8 Population density across the MALCOLM region11 ............................................................. 16 Figure 9 Percentage of population aged 65 and over across the MALCOLM region ............................ 16 Figure 10 Age profile of Men and women over 65 yrs in the MALCOLM region .................................. 17 Figure 11 Age expectancy of men and women living in the MALCOLM region at age 65..................... 18 Figure 12 Discrepancy between number of healthy years lived by men and women aged 65 and their life expectancies ..................................................................................................... 18 Figure 13 Population Projection: People aged 65+ across the UK (2012 – 2037) .............................. 18 Figure 14 Old Age Support Ratios across the MALCOLM region....................................................... 19 Figure 15 Housing Options in England ......................................................................................... 22 Figure 16 Regional Infrastructure Interrelationships and Interdependencies .................................... 30 Figure 17 Main Transport Links .................................................................................................. 31 Figure 18 MALCOLM English Region Broadband availability by SE Local Authority (Ofcom 2013) ........ 32 Figure 19 UK MALCOLM region average modem speed (Mbit/s) by Local Authority (Ofcom) .............. 33 Figure 20 UK MALCOLM region overall broadband performance (Ofcom) ......................................... 34 Figure 21 Simplified Overview of the Health and Care System in England ....................................... 37 Figure 22 Overview of Adult Social Care in England ...................................................................... 54 Figure Figure Figure Figure
23 24 25 26
NHS Health Care Funding in England ............................................................................ 63 Social Care Funding in England .................................................................................... 65 Assessment Process for Social Care Funding in England .................................................. 66 Who Commissions Which Health and Social Care Services for the Elderly in England .......... 77
Figure 27 Market Access: Procurement, Facilitation and Influencing ............................................... 77 Figure 28 Mobile phone Internet connections by age group ........................................................... 87 Figure 29 Percentage of over 55s making purchases online ........................................................... 88 Figure 30 Internet purchase by type by over 65s ......................................................................... 88 Figure 31 Digital Confidence Scores by age and sex ..................................................................... 89 Figure 32 Suppliers of AL products and services by region (Source: Medilink UK)............................. 94
7
Regional Context The following research summaries provide an overview of the English regional context: ▪ ▪ ▪ ▪
1
Regional Overview – Geography, administration, economy, Demographics Housing Regional Infrastructure.
Regional Overview – English MALCOLM
Region
This section provides an overview of the geography, economy and administration of the English region covered by the MALCOLM project. The English MALCOLM region comprises 5 of the 8 counties of South East of England, highlighted in pink in Figure 1: ▪ ▪ ▪ ▪ ▪
Kent East Sussex West Sussex Surrey Hampshire
Figure 1 The MALCOLM region within the United Kingdom
1.1
Geography
South East England is the third largest region in England, covering more than 19,000 square kilometres (sq km) and constituting almost 8% of the total area of the UK. It comprises three distinct zones: 8
1. 2. 3.
an urban north-west area surrounding London, a coastal area bordering the English Channel, a predominantly rural band between the previous two areas.
Being located so close to London, the region does not have very large cities of its own. Nevertheless, its proximity to London and other capital cities (via its excellent international air, high-speed rail and water transport links - see Chapter 7 for more details) provides a wide variety of business, cultural and leisure opportunities and also encourages national and international tourism to the region.1
1.2
Administration
National policy is set by central government and its implementation is the responsibility of various government departments and their agencies, such as the Department of Health. Government departments are funded by parliament and work with local authorities, non-departmental public bodies, and other government-sponsored organisations. Although England is divided into 9 regions, there is no longer any regional administration in England. The Regional Development Agencies were abolished in 2012. Administration at a local (sub-regional) level is the responsibility of Local Authorities. Local government (councils and unitary authorities) is funded by government grants, council tax and business rates, and is responsible for all day-to-day services and local matters. Local Authorities vary throughout England and can comprise one or two organisational levels (tiers) with each tier responsible for providing different services. Figure 2 provides an overview of the administrative structure in England.
Figure 2 Local Authority Responsibility for Services
1
ONS, “Regional Profiles - Population and Migration - South East England, March 2013”, http://www.ons.gov.uk/ons/dcp171780_301561.pdf
9
In areas where there is only one tier of local government, this tier is responsible for provides all local services. This single administrative tier includes unitary authorities, London boroughs, and metropolitan boroughs. Areas with 2 tiers of local government comprise: ▪ ▪
Tier 1 - county councils Tier 2 - district, borough or city councils
Table 1 shows which tiers are responsible for specific local services. Table 1 Local Authority Responsibility for Services Tier 1 Services -
Tier 2 Services
Health Services Social Services Education Waste management Roads, highways and transportation Environmental Health Approving planning applications Enforcing health, safety, environment and trading standards requirements
-
Parish-level services
Council tax Leisure services Rubbish collection Recycling Housing
-
allotments public clocks bus shelters community centres play areas & equipment grants to local organisations consultation on neighbourhood planning
The MALCOLM region within South East England comprises the 5 counties and 5 Unitary Authorities listed in Table 2. Table 2 MALCOLM counties and Unitary Authorities Counties Kent Surrey East Sussex West Sussex Hampshire
Unitary Authorities Medway Brighton and Hove Portsmouth Southampton Isle of Wight
These counties and Unitary Authorities are mapped in Figure 3. The 46 second-tier local authorities that comprise the counties are mapped in Figure 4.
Figure 3 Counties and Unitary Authorities in the MALCOLM region
10
Figure 4 Second-tier Local Authorities in the MALCOLM region
1.3
Economy
South East England is economically very prosperous. The economy of the South East as measured by gross value added (GVA) was worth £202.6 billion in 2012, which was the second highest of any region (after London) and constituted 14.7% of the UK total. It was the only English region to increase its share of UK GVA between 2006 and 2011. However, the South East does have pockets of severe deprivation, in particular along the coastal fringe of the region, as shown in Figure 52.
Figure 5 Percentage of population in most deprived national quartile, by second-tier local authority
2
"Deprivation", http://www.aphp.org.uk/resource/view/aspx?RID=126453
11
The gross disposable household income (GDHI) per head in the South East was £19,126 in 2012, 13.9% above the national average of £16,791.3 The range across the region is notable, however, with GDHI lowest in Portsmouth at £12,290 per head, compared with £22,070 per head in Surrey.4 Figure 6 maps the median earnings by residence in the MALCOLM region (the median earnings across England is £518.10).5 The highest earnings are generally made by people living in Surrey, followed by people living in North and central Hampshire.
Figure 6 Median earnings per residence, by second-tier local authority
1.4
Policy
The top ten clusters of technology jobs in the UK are all close to the M4, M3 or M25 motorways located in the South East and London areas of England.6 However, in order for the Government's vision for the UK to be the technology centre of Europe to be realised, new jobs and prosperity must be created across the country. Progress to achieve this vision is slow, hindered by slow transport links between the cities in north England and the reluctance of investors to venture beyond the capital (22% of the venture capital invested in England went to the 14% of companies located in South East England). Today, 3% of GVA is spent on R&D in South East England, compared to only 1.3% in North East England. 7 Nevertheless, the investment in new high-speed rail links, the funding of Enterprise Zones and the benefits of up to 30% lower salaries 8 and up to 50% lower office space costs mean that businesses may be attracted away from South East England in the coming years.
3
ONS, “Regional Economic Indicators” 8th July 2014, http://www.ons.gov.uk/ons/dcp171776_369754.pdf
4
ONS, “Regional Profile of South East - Economy, June 2013”, http://www.ons.gov.uk/ons/dcp171780_314461.pdf
5
Department of Work and Pensions tabulation-tool-dmp.creditgov.uk, August 2013
6
KPMG, "TechMonitor UK: Understanding tech clusters and tracking the UK tech sector's outlook for employment and growth", 2013 7 8
BVCA, "Private Equity and Venture Capital Report on Investment Activity 2012", May 2013 ONS "Patterns of Pay: Estimates from the Annual Survey of Hours and Earnings, UK, 1997 to 2013", Feb 2014
12
1.5
Research Insights
The MALCOLM region is an excellent test-bed for assistive living technologies as it covers urban and rural areas, areas with particularly young and particularly old populations, and relatively affluent as well as relatively deprived areas.
The proximity of the MALCOLM region to London and other European capital cities makes it an attractive place to be located and/or do business with.
The conditions in South East England are favourable for an AL service marketeddirectly at the individuals with early onset long-term conditions (referred to as elective services) as the mean weekly household income of its pensioners is relatively high (£780 for a couple,compared to the national average of £660).9
1.6
Good Practice
This section contains examples of Good Practices, i.e. initiatives and projects of relevance to the geography, economy and administration of the MALCOLM region that create opportunities for AL. More detailed information about each Good Practice is available in the MALCOLM projectCatalogue of Good Practices. ▪
International Centre of Excellence in Telecare (ICE-T, part of South East Health Technologies Alliance) ran a £1million collaborative grant-funding programme to accelerate innovative nearmarket product and service development in telecare in South East England. Funded by the (now discontinued) South East England Development Agency (SEEDA), this programme addressed some of the demographic challenges to health and social care services that arise from the peculiarities in the region's geography and economy by investing in ten regional assistive living projects.
1.7
Opportunities
Policy Makers/government
The MALCOLM region is an excellent place for the national government to test the clinical and economic benefits of assistive living technologies as it covers urban and rural areas, areas with particularly young and particularly old populations, and relatively affluent as well as relatively deprived areas.
Patients /service users
The attractiveness of South East England as a place for technology companies to be based and/or do business with means that there is more opportunity for the local population to become involved in trials of new technologies that can support them with their health and social wellbeing.
The overall prosperity of the South East of England means that a disproportionately large proportion of the local population can afford to purchase new technologies to help them lead happier, more productive lives.
Care providers
9
The overall prosperity of the South East of England means that a disproportionately smaller proportion of the local population are dependent on statutory services to support their health and social wellbeing. By encouraging the population to purchase AL technologies DWP "The Pensioner's Incomes Series, UK 2012/13", July 2014
13
themselves, the statutory services can focus their resources on the relatively fewer people who cannot afford to purchase them privately and/or support those with the greatest need more fully.
AL technologies can help to overcome the challenges that face health and social care delivery to the rural band between the urban north and coastal south of the MALCOLM region.
Solutions providers, including third sector
The coastal area of the MALCOLM region is not only home to a disproportionately large proportion of elderly people, but also pockets of deprivation. Both of these factors translate into heightened need for more effective and efficient methods of health and social care delivery, creating a market for AL technologies.
South East England already boasts a number of technology clusters, and new solutions providers can benefit from the established networks and infrastructures that this provides.
Heathrow airport, located just north-west of the MALCOLM region in South East England has submitted a revised plan to the Airports Commission to build a third runway. This would enable the airport to provide up to 740,000 flights a year, allowing the region to remain competitive with Paris, Frankfurt and Amsterdam as a hub for international trade.
14
2
Demographics
2.1
Population
The South East is the largest region in England in terms of population with 16.3% of the total English population (see Figure 7). In mid-2012, the population of the South East was approximately 8.72 million, which is a 0.8% increase from 2011. This is a higher increase than that experienced across the rest of England (0.7%), but it is a significantly smaller increase than that experienced by London (1.3%).11
Population by Region 10,000 9,000
Thousands
8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 South East (16.3%)
London (15.5%)
North West (13.2%)
East West South Yorkshire East (11.0%) Midlands West and The Midlands (8.5%) (10.5%) (10.0%) Humber (9.9%)
North East (4.9%)
Figure 7 UK Regional Population – mid-201210
2.1.1
Population Density
The South East has a population density of 458 people per sq km, which is third highest in England (after London with 5,285 and North West England with 502).10 In 2011, the South East’s population density was 4.5 people per hectare, which is higher than the population density for England and Wales (4.1 people per hectare).11 Figure 8 shows how the population density varies across the MALCOLM region, with population density being highest near the outskirts of Greater London and by the coast. Portsmouth Unitary Authority has the highest population density in the region, with 50.7 people living in each hectare. In contrast, Chichester District Council has the lowest population density in the region, with only 1.4 people living in each hectare. Taken together, a disproportionately high percentage the South East's population lives in a rural area (20.4%, compared to 17.6% across England in mid-2011).12
10
ONS, "Region and Country Profiles - Key Statistics Tables, October 2013"
11
ONS, "Table P04UK, 2011 Census: Population density, local authorities in the United Kingdom"
12
www.ons.gov.uk/ons/rel/regional-trends/region-and-A fifth (20.4%) of the region’s population lived in rural areas, compared with 17.6% for England in mid-2011.country-profiles/region-and-country-profiles---key-statisticsand-profiles--october-2013/key-statistics-and-profiles---south-east--october-2013.html
15
Figure 8 Population density across the MALCOLM region11
2.1.2
Population over 65 years
In 2011, people aged 65 and over made up 17.9% of the South East population, compared with 19.1% for the under-16s. This compares with averages for the UK of 16.9% and 18.9% respectively. Of all the regions in England, the South East has the greatest subregional variation in the proportion of older people. Figure 9 highlights where in the MALCOLM region the proportion of people aged 65 and over is particularly high and low.13 Generally, the coastal districts have higher proportions of older residents than the rest of the MALCOLM region, with Rother District County in East Sussex and Arun in West Sussex being home to the highest proportions of elderly people.
Figure 9 Percentage of population aged 65 and over across the MALCOLM region
13
http://www.neighbourhood.statistics.gov.uk/dissemination/Info.do?m=0&s=1397677904884&enc=1&page=analy sisandguidance/analysisarticles/local-authority-profiles.htm&nsjs=true&nsck=false&nssvg=false&nswid=1366
16
Figure 10 shows the numbers of males and females aged 65 and over in the MALCOLM region, and as a percentage of the total MALCOLM region population 14. The age profile diagram for the MALCOLM region shown in Figure 12 shows that women live longer than men, with more than twice as many women living past the age of 85.15
Age profile 180 160
2.6% 2.5% 2.2% 1.9%
140
Thousands
120
1.9% 1.6%
100
1.8% 1.6% 1.1%
80
0.9%
60 40 20 0
65 - 69
70 - 74
75 - 79
80 - 84
85+
Male
157,841
123,437
99,359
71,168
55,852
Female
168,395
137,803
119,743
100,544
116,179
Figure 10 Age profile of Men and women over 65 yrs in the MALCOLM region
2.1.3
Life Expectancy
The average life expectancy at age 65 across England is 18.8 years for men and 21.1 years for women. The average number of healthy years at age 65 across England is 9.2 years for men and 9.7 years for women. Figures 11 and 1216 show the life expectancies and number of healthy years at age 65 years for men and women living in the MALCOLM region. There are small gender differences in which CCGs have particularly high and low life expectancies and also how long people with poor health live for. Moreover, significant inequalities in life expectancy have been found between social classes across England and Wales:there is a gap of over three years in life expectancy at age 65 between the highest and lowest classes in the National Statistics Socio-economic Classification.17
Figure 11 Age expectancy of men and women living in the MALCOLM region at age 65
14
ONS, "Table DC1117EW, 2011 Census: Sex by single year of age"
15
ONS, "Table DC1117EW, 2011 Census: Sex by single year of age"
16
ONS, "Healthy Life Expectancy at birth and at age 65: Clinical Commissioning Groups (2010-12)"
17
http://www.ons.gov.uk/ons/rel/mro/news-release/average-age-of-retirement-rises-as-people-worklonger/pension-trends.html
17
Figure 12 Discrepancy between number of healthy years lived by men and women aged 65 and their life expectancies
2.1.4
Population Projection
The number of people of state pension age (SPA) in the UK is projected to increase by more than 30% in 25 years, from 12.3 million in 2012 to 16.1 million by 2037. The sharpest increase is projected to occur between 2022 and 2032 as shown in Figure 1318. Across all age groups, the South East is projected to see a 7.8% increase in population from 2012 to 2022. This is the third highest increase of all the English regions (London and the East Midlands are expected to see population increases of 13.0% and 8.6%, respectively). However, the South East region is projected to experience a disproportionately high increase in the percentage of people aged 65 and over, at 24.3%, which is second only to the East Midlands region.19
Projected UK population of Pensionable Age 17
Millions
16 15 14 13 12 11 10
Series1
2012
2017
2022
2027
2032
2037
12.3
12.4
12.5
13.9
15.6
16.1
Figure 13 Population Projection: People aged 65+ across the UK (2012 – 2037)
19
18
ONS, "Chapter 2: Part of National Population Projections, 2012-based Reference Volume: Series PP2 Release" http://www.ons.gov.uk/ons/dcp171776_355182.pdf 19
ONS, "2012-based Subnational Population Projections for England" http://www.ons.gov.uk/ons/dcp171778_363912.pdf
18
2.1.5
Old-Age Support Ratio
The old-age support ratio is a measurement of how many people of working age (16-64) there are relative to the number of people of retirement age (65+). The lower the ratio, the fewer younger people there are to support the over 65s. Figure 14 shows the support ratio across the MALCOLM region for 2011. The average support ratio across the South East region is 28.4, which is higher than the national average of 26.4. Rother District Council in East Sussex has the highest old-age support ratio in the MALCOLM region, at 54%.
Figure 14 Old Age Support Ratios across the MALCOLM region
2.2
Policy
The overwhelming influence on public health and social care need is the age structure of the population. The UK's ageing population, brought on by the 'baby boom' years that followed World War II, presents a demographic timebomb for the NHS and its social care services - services with finite national budgets that are shared amongst regions and sub-regions according to an age-weighted capitation formula. The inevitable consequence of this situation is that the level of need required to receive these services must increase. Health and social services are not the only public services that will struggle more and more to meet demand in the coming decades. A common strategy, named adoption of the Conservative-Liberal Democrat's 'Big Society', is seen as an all-encompassing way to shift some burden away from all of the stretched public services. The 'Big Society' ambition promotes empowerment of individual citizens and communities to "come together, solve the problems they face and build the Britain they want", and it is being achieved by giving neighbourhoods more power to shape their localities and encouraging people to take an active role in their communities.
19
Nevertheless, the Government's pledge to spend 84% of its £30 billion National Infrastructure Plan budget in London and South East England20 is a clear indicator that it realises that it must prioritise this area of the UK during any available resource allocation in order for the UK to remain economically competitive on a global scale in the future.
2.3
Research Insights
Widespread adoption of AL technologies to enable health and social care to bedelivered in innovative and more efficient ways could be particularly attractive to the MALCOLM region because: demand on its health and social care services will increase as its already very high elderly population grows at one of the highest rates in England. there will be less human resource to provide these health and social care services as its old age support ratio grows at one of the highest rates in England. its large swathes of rural areas make it difficult to deliver standard health and social care efficiently. its concentrations of elderly populations, especially its popular coastal retirement destinations, should attract suppliers of assistive living technologies to bring employment opportunities to the region.
There are significant discrepancies between English people's life expectancies and the number of healthy years that they live. These discrepancies are, on average, more than nine years for men and more than eleven years for women. AL technologies have the potential to allowpeople to enjoy a higher quality of life during their final years, boosting their economic and social contributions to the region in which they live.
2.4
Opportunities
Policy Makers/government
If supported and empowered adequately, elderly people have great potential to contribute to the economic and social betterment of the UK.
Clustering of elderly people in specific areas, such as along the coast, should allow public services in those areas to benefit from economies of scale.
Patients /service users
Recognition that elderly people can contribute to the economic and social betterment of the UK means that these people stand to benefit from strategies to support and empower them to enjoy a better quality of life.
Clustering of elderly people in specific areas, such as along the coast, should allow these people to enjoy more services tailored to their needs, increasing their quality of life.
Care providers
The attractiveness of the UK to immigrants is bolstering the UK's health and social care workforce.
20
"Population Growth and Housing Expansion in the UK", Population Matters 2012, https://www.populationmatters.org/documents/population_housing.pdf
20
Strategies to increase healthy life years will reduce the period of time that elderly people are intensively dependent on health and social care services, freeing up resource so that these services can be delivered more effectively when they are eventually needed by an individual.
Solutions providers, including third sector
The declining support ratio is increasing the need for innovative methods of delivering health and social care to be explored and implemented across the UK.
The MALCOLM region is home to areas where the proportions of elderly people are extremely high, such as in many of its coastal towns, as well as rural areas, where health and social care delivery can be inefficient. Suppliers should target their marketing at these areas.
21
3
Housing in England
3.1
Introduction
This section provides an overview of issues related to housing in England. Housing is an important factor to consider not only because it is a key determinant of the health and social wellbeing, but it is also an important enabler and barrier to uptake of Assistive Living solutions.
3.1.1
Housing Options
There are more than 22 million households in England, 5.7 million of which are headed by someone who is 65 years or older.21 All of these households live in either social or private housing. The benefits of social housing over private housing usually are:
greater security (longer contracts) cheaper.
The benefits of private housing over social housing usually are: greater choice of housing, including location faster acquisition (no waiting lists). There are three sources of social housing and two options for people wishing to live in private housing, as shown in Figure 15.
Figure 15 Housing Options in England
3.1.2
Rented Accommodation
A 'tenant' is the name given to someone renting accommodation. In the case of social housing, the owner is usually a second-tier local authority or a Housing Association and these bodies are collectively called Registered Providers. A small number of commercial organisations who are beginning to offer social housing too. Privately rented accommodation is owned by a private landlord, which can range from a single individual to a large-scale commercial organisation.
21
Table KS105EW, 2011 Census: Household composition, local authorities in England and Wales
22
The responsibilities of a tenant include:
General day-to-day upkeep of the property Paying rent according to the terms in the tenancy agreement Paying the bills agreed in the tenancy agreement.
The responsibilities of a Registered Provider / landlord include:
3.1.3
Maintaining the property in a habitable state Upkeep of heating equipment Servicing the gas supply and gas appliances.
Social housing
Council-owned social housing is owned and managed by second-tier local authorities. These local authorities must adhere to Government guidance when allocating their available housing, however the powers endowed to them by the Localism Act 2011 give their Rent Officers the freedom to tailor the specific details of their allocation criteria to the needs of their Broad Rental Market Areas (geographical areas, which may or may not align with local authority boundaries, with relatively homogenous access to facilities and services for health, education, recreation, banking and shopping). Rent Officers may adjust rental rates every April. Housing Associations are independent and not-for-profit providers of social housing. They provide 54% of social housing22. The only formal functional difference between council-owned social housing and Housing Association housing is that tenants have a 'right to buy' council-owned housing that they have lived in for a certain length of time (usually five years), but tenants of Housing Association housing only have a 'right to acquire', which is a less generous offer (the discount is smaller). Housing Association housing also tends to be more expensive to rent than council-owned housing, but it is usually higher quality accommodation. The demand for social housing is high but in short supply. Prospective tenants are encouraged to apply both to the central council waiting list as well as Housing Association waiting lists as this increases the chance that they are successful in being allocated a place. To apply for either of these types of social housing, a prospective tenant must complete a form describing their level of need. Factors that increase level of need considerably include:
life-threatening illness or sudden disability health hazards in their existing accommodation if they require regular medical attention at a location that is difficult for them to access from their existing accommodation.
Registered Providers rank the applicants by combining their needs with how they have been on the waiting list. There are five grades of social housing available, ranging from level A, which is shared housing, to E, which is a four-bedroom house. All of these houses should meet 'Decent Housing Standards', i.e. they should:
be free from health and safety hazards be in a reasonable state of repair have reasonably modern kitchens, bathrooms and boilers be reasonably insulated.
22
"English Housing Survey: Headline Report 2012-13", https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284648/English_Housing_Survey_ Headline_Report_2012-13.pdf
23
3.1.4
Owner-Occupied Accommodation
The average price for a house in South East England is £297,000, which is considerably higher than the average for England of £256,000.23 Retirement housing is often more expensive than the equivalent housing not attached to a retirement facility because the costs of the extra facilities and services need to be covered whether they are used or not. Additional costs such as Council tax may also be higher.24 The typical price of a retirement home in South East England is £110,000.
Less than 6% of retired UK owner-occupiers have less than £75,000 of equity and therefore cannot afford retirement housing. 17% of retired UK owner-occupiers have between £75,000 and £125,000 and so are restricted in the choice of retirement housing available to them. 20% of retired UK owner-occupiers have between £125,000 and £175,000 and so have a good choice of retirement housing available to them. 57% of retired UK owner-occupiers have more than £175,000 and therefore more than enough to buy a retirement property outright.
In England there are approximately 533,201.24 Retirement Houses (Sheltered houses, Extra-care houses, Close Care houses and houses in a Retirement Village) in England. This is equivalent to only 60 properties per 1,000 pensioners. Fewer than 20,000 of these properties are part of a Retirement Village25. Only 20% of Retirement Housing is owned, compared to 80% ownership across all housing inhabited by pensioners, reflecting the reluctance of the elderly to commit themselves to long-term high costs. It is common for elderly people to be forced to sell property to pay for their residential care because property value is taken into account in financial assessments for this care.
3.1.5
Benefits
Benefits and entitlements for the elderly are available from the Department of Work and Pensions to help with housing costs. Housing Benefit Housing Benefit is a state benefit available to people struggling to pay for the housing that they are renting (social or private). Generally, Housing Benefit covers most, if not all, rental costs for people renting social housing, but only a proportion of rental costs for people renting private housing because the costs are a lot higher. The maximum Housing Benefit that can be claimed by someone renting privately is called Local Housing Allowance and it is calculated based on household composition. Council Tax Reductions Council Tax Reduction (formerly called Council Tax Benefit) is a state benefit available to those living alone (25% reduction), on low incomes or in receipt of certain benefits that will pay some or all council tax depending on individual circumstances. Winter Fuel Payment Winter Fuel Payment is a tax-free amount paid once per year to people in receipt of a State Pension to help pay for heating bills. It is paid at two different rates: 1) £200 for single people under 80 years living alone and £100 for couples, or 2) £300 for single people 80 years and over living alone and £200 for couples.26
23
Table 47a: Average regional house prices, 2012, www.ukhousingreview.org.uk
24
"Affordability of retirement housing in the UK", Aldridge et al. (2012), New Policy Institute
25
www.bbc.co.uk/news/health-17923976
26
Gov, Winter Fuel Payment, https://www.gov.uk/winter-fuel-payment/what-youll-get
24
3.2
Housing and Health
It is difficult to establish links between poor housing and ill health because of the inability to prove causation: does poor housing cause poor health, or does poor health relegate people to poor housing? In favour of the poor housing causing poor health hypothesis is the fact that poor housing can contain a number of health hazards. These hazards include the cold (because of the poor energy efficiencies of the UK's housing stock in general), damp and mould (which can cause respiratory infections and disorders such as asthma), overcrowding (which can also cause respiratory problems because of poor air quality as well as high spread of infectious diseases and mental stress) and more obvious hazards such as stairs (1,500 fatalities in the UK population aged over 65 result from a fall in the home) 27. The elderly are most susceptible to these hazards because they spend the greatest amount of time at home. On the other hand, people with poor health and negative wellbeing are more likely to live in poor housing because it compromises regular employment and the ability to buy life insurances, both of which are need to be proved to be considered for a mortgage today28. Reduced employment also has the problem of lower income, meaning that only the cheapest properties are affordable, leaving little in reserve to renovate them.
3.2.1
Decent Homes Standard
Britain's housing stock is one of the oldest in Europe.29 This has significant consequences for the standards of housing available to the English population (and the subsequent consequences for their health). Local authorities are responsible for ensuring that all of their social housing and at least 70% of privately rented housing for vulnerable people in their locality meet Decent Homes Standard. The aim was to achieve this by 2010/11, however only 92% of social rented housing in England met this standard by that time. The Government therefore dedicated £1.6 billion for 2011-15 to improve these properties,30 but this funding appears to be insufficient as 15% of social housing in England failed to meet the Decent Homes Standard in 2012-13. This is still an improvement over owner-occupied and privately rented homes, of which 20% and 33% did not meet the Decent Homes Standard in 201213.22 Three-quarters of the lowest income band living in the country's worst housing are elderly owner-occupiers.27 Although not all privately rented housing must meet Decent Homes Standard, they must meet "Housing Health and Safety Rating System" assessment standards 31, which help to avoid or, at the very least, minimise potential hazards.
27
"Housing and Health: The relationship", Islington Local Involvement Network (Housing & Health Working Group), 2012 28
"Housing and Health: Building for the Future", British Medical Association, 2003
29
"Laying the Foundations: A Housing Strategy for England", HM Government, 2011, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/7532/2033676.pdf 30
http://www.homesandcommunities.co.uk/ourwork/existing-stock
31
"Housing Health and Safety Rating System Guidance for Landlords and Property Related Professionals", https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/9425/150940.pdf
25
3.3
Policy
The Government has guaranteed £10 billion for their Housing Strategy to build new houses, motivated in part by the fact that every £1 spent on housing construction puts almost £3 back into the economy.32 There are calls for 'Help to Move' tax incentives, such as removal of Stamp Duty, for people who are downsizing. This should encourage elderly people to downsize into more appropriate housing, although this is dependent on more retirement housing being built because current supply is very low. The Care Act 2014 Government bill received Royal Assent on the 14th May 2014.33 This Act overhauls the social care system in England, opening up more opportunities for housing to engage with the health and care sectors. It also introduces a cap on care costs an individual will pay over their lifetime of £72,000. This cap should see fewer people having to sell their home to pay for their care.34
3.4
Research Insights
2014 saw private renting overtake social renting for the first time, with the percentage of people living in privately rented accommodation increasing to 18% but the percentage of people living in social housing dropping to 17%. This trend is likely to continue because: only 6% of private renters are single occupants aged over 60 but they are the most prevalent group of social renters, accounting for 24% of all social renters fewer and fewer young people are able to afford to purchase their own home (the percentage of people who are owner occupiers has been decreasing every year since 2003).22
Regardless of the extent to which poor housing causes poor health and/or poor health relegates people to poor housing, the Building Research Establishment estimates that poor housing contributes £600 million a year to NHS costs.35 There is greater acknowledgement of this fact from central and local governments than ever before.
The Government's priority to realise integration of its health and social care structure should help to address housing-related health inequalities considerably. The creation of Health and Wellbeing Boards is one step towards achieving this.
Housing has the potential to provide a very attractive route to market for providers of assistive living solutions. For this to happen on a large scale, it will require commitment and strong leadership from central Government.
3.5
Opportunities
Policy Makers/government
The typical lifespan of a building is 50 to 100 years and it is estimated that 80% of current housing will still be in use in 205037. Government therefore has a critical opportunity to 'futureproof' the housing that will support the ageing society by introducing legislation to ensure that new houses are designed to be a core infrastructure into which readily interchangeable (modular, affordable and accessible) applications (AL or otherwise) can be plugged.
The UK Government's Housing Strategy provides strong leadership on issues such as Zero-Carbon housing but this policy currently makes no explicit mention to provisions for AL technologies.38 This is a wasted opportunity.
26
Patients /service users
People who require AL technologies are often reluctant to receive/purchase them or to embrace them once they are installed because they feel that they are a badge of inability/disability. Smart Homes may help in this instance, by allowing any AL technologies to be concealed within a larger system that does not have any stigma attached.
By analysing the activity of a vulnerable person about their home, real-time Building Information Modelling can be useful for inferring which assistive solutions they would benefit most from and where they ought to be located in the house to be most effective at keeping them safe and healthy.
Patients stand to benefit from more efficient and competent decision making about their health and social care if healthcare professionals are able to access comprehensive data about health and wellbeing using AL technologies. For example, changes in activity patterns in the bathroom could indicate diabetes.
Care providers
More and more housing associations are beginning to recognise new business opportunities in working with health commissioners and providers to develop integrated models of health, care and support, either positioning themselves are healthcare providers or entering into joint ventures with NHS Trusts.
AL technologies have the potential to provide healthcare professionals with acomprehensive view of a patient's health and wellbeing from which they can make more efficient and competent decisions. For example, changes in activity patterns in the bathroom could indicate diabetes, which can be better managed (and even prevented in the case of pre-diabetes) whendiagnosed early, reducing costs to the healthcare system in the future.
In 2011 it became mandated that energy suppliers must install smart meters in all homes and buildings that they supply energy to by 2019. Government and energy suppliers are working together to set up an infrastructure to set up centralised energy data and communications infrastructures, called The National Smart Utility Network. This Network will provide a platform that health and social care providers can access to provide innovative services.
Solutions providers, including third sector
The infrastructure and funding of health commissioning and delivery is undergoing great change, meaning that "business as usual" is not an option. It is therefore an opportune time for solutions providers to implement new ways for designing services that incorporate settled, supported and fit-for-purpose housing fitted with AL technologies.
Building companies can differentiate their housing by making it "future-proof", i.e. able to support modular, affordable and accessible technologies.
More and more Housing Associations are beginning to recognise new business opportunities in working with health commissioners and providers to develop integrated models of health, care and support, either positioning themselves are healthcare providers or entering into joint ventures with NHS Trusts.
Solutions to integrate data from AL and other Smart Home technologies with electronic patient records systems that healthcare professionals can easily access are still in their infancy.One challenge for this high potential industry is converting the continuous sensor-network datastreams ('Big Data') into manageable and reliable discrete entries in healthcare records.39
Solutions to support real-time Building Information Modelling, which can be useful for inferring 27
which assistive solutions residents would benefit most from and where they ought to be located in the house to be most effective at keeping them safe and healthy, are very much in their infancy.
In 2011 it became mandated that energy suppliers must install smart meters in all homes and buildings that they supply energy to by 2019. Government and energy suppliers are working together to set up an infrastructure to set up centralised energy data and communications infrastructures, called The National Smart Utility Network. This Network will provide a platform that solutions providers can integrate into to provide innovative services.
36
Housing LIN, www.housinglin.org.uk
37
"Home Truths", Boardman et al., Environmental Change Institute, Oxford, 2007
38
"Laying the Foundations: A Housing Strategy for England", www.gov.uk
39
"Using data from ambient assisted living and smart homes in Electronic Patient Records", Knaup & Schöpe, 2014
28
4
English Regional Infrastructure
The South East region is one of the most economically prosperous regions in the UK. Only London is more prosperous. The South East has the highest employment rate at 75%, and an unemployment rate of 6.4% in Q4 201240. The average Gross Disposable Household Income (GDHI) per head is £18,100, which is 12.8% above the average for the UK, although there are variations within the MALCOLM region where Portsmouth has the lowest GDHI at £12,290 per head, and Surrey the highest at £22,070 per head. However, although prosperous, the South East region does have pockets of severe deprivation, in particular along the areas that border the channel. A region’s economic infrastructure can have a significant impact upon the ease with which technology innovations can be deployed to meet social objectives such as healthcare. The infrastructure of a region is an important factor for organisations considering developing, deploying or using AL solutions and services. The sectors and networks that are of most relevance to AL are: ▪ ▪ ▪ ▪ ▪
digital communications energy transport housing intellectual capital
This section highlights the following infrastructure information: ▪ ▪
The main transport links and hubs Broadband availability, speeds and uptake
In 2010, the UK Government developed a National Infrastructure Strategy41 as a first step towards providing a more integrated approach to infrastructure development across the five sectors and networks that directly contribute to economic growth (energy, transport, water, waste and communications). This strategy was distilled into a National Infrastructure Plan, first issued in 201042, revised to include more regional detail in 201143, and updated in 201344 to report progress against the plan. An interactive map45 is available that shows the status of UK infrastructure projects. Based on the framework in the National Infrastructure Plan 46, Figure 16 shows the interrelationships and inter-dependencies between the care network and the regional economic infrastructure. For example, a poor transport infrastructure can offer opportunities for AL services, whereas a poor digital communications network would be a constraint.
40
ONS, “Regional Profile of South East - Economy, June 2013
41
HM Treasury, “Strategy for National Infrastructure,” 2010 1-March, www.direct.gov.uk/prod_consum_dg/groups/dg_digitalassets/@dg/@en/documents/digitalasset/dg_186451.pdf 42
HM Treasury, “National Infrastructure Plan 2010”, 2010 1-March, www.hmtreasury.gov.uk/ppp_national_infrastructure_plan.htm, 43
HM Treasury, “National Infrastructure Plan 2011” 2011 1-November, http://cdn.hmtreasury.gov.uk/national_infrastructure_plan291111.pdf, 44
HM Treasury, “National Infrastructure Plan 2013” December 2013, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/263159/national_infrastructure_pl an_2013.pdf 45
HM Treasury, National Infrastructure Pipeline 2014, http://www.building.co.uk/infrastructure-pipelinemicrosite/map/ 46
HM Treasury, “National Infrastructure Plan 2010” “www.direct.gov.uk/prod_consum_dg/groups/dg_digitalassets/@dg/@en/documents/digitalasset/dg_186451.pdf,” 1 March 2010
29
All the elements within this infrastructure depend on utilizing the Intellectual Capital within a region, and it in turn depends on these networks to facilitate the take-up of science and technology innovations. The 2011 Infrastructure Plan recognizes the importance of good transport and digital communication links in facilitating the development of innovation hubs, science parks and clusters, which will all benefit from investment in world-class research facilities. The co-location of these innovation clusters with universities will also foster knowledge transfer and expertise exchange.
Figure 16 Regional Infrastructure Interrelationships and Interdependencies
4.1.1
Transport
Access to health care provision and social care services can depend upon the ease with which people can move around the region. If roads are congested, people may find it difficult to reach care services, and once there, they may find parking is either not available, full, or presents a costly challenge. Remote delivery of care via AL services, could be a potential solution to transport and travel issues. The English Channel regions have excellent connectivity with the rest of the South East of England, London and France. There are major ports at Dover, Southampton and Portsmouth. The high-speed Eurostar train runs from London, through Ashford and Ebbsfleet in Kent to several destinations in France and Belgium. The region has the second largest airport in the UK, Gatwick in West Sussex, as well as 3 smaller airports: ▪ ▪
Southampton Shoreham (Brighton) in West Sussex
The region has easy access to the Heathrow, the largest international airport in the UK. More than a fifth (22%) of England’s motorway network is located in the South East. These gateways are vital for attracting foreign investments and for exporting goods and services produced throughout the UK.
30
High-speed rail links between the Channel Tunnel and London have increased the volume of traffic to the continent in recent years and provided a wealth of opportunities within the region47. In 2008, the South East region had the largest share of traffic on all roads in Great Britain. The vehicle flow is the highest in Great Britain (5,000 vehicles per day compared with a Great Britain average of 3,500). Road traffic in the South East is expected to increase by more than a third over the next 20 years48. The Communications Infrastructure 2012 update reports49 the following progress on infrastructure delivery programmes and Autumn Statement 2012 capital announcements relevant to the South East region: ▪ ▪
Starting soon: Bexhill-Hastings Link Road – 2013 New funding announced: M3 J2 to 4A accelerated delivery pilot (part of £95 million scheme)
Rail commuters in the South East account for one third of all rail journeys in the UK. The Government is funding South East Flexible Ticketing, a £45 million programme that will enable operators to provide rail passengers in the South East of England with smart tickets that offer more flexibility to users, and facilitate the purchase of tickets. Season tickets and existing ticket types will be the first products to be made smart, in 2013, with new products launched in 2014.
Figure 17 Main Transport Links
47
ONS, “Regional Trends, No. 43, 2011 Edition,” 2011 8-June, www.ons.gov.uk/ons/rel/regional-trends/regionaltrends/no--43--2011-edition/index.html 48
SEEDA, The South East of England Profile (1 February 2010).
49
Ofcom, “Communications-infrastructure-report 2012 update,” 20 December 2012, www.ofcom.org.uk http://stakeholders.ofcom.org.uk/binaries/research/telecoms-research/infrastructure-report/Infrastructurereport2012.pdf
31
4.1.2
Digital Communications
Ofcom, the independent regulator and competition authority for the UK communications industries. has reported50 that during the last 10 years, the UK’s communications market has been totally transformed. Digital technology has developed extremely quickly, and has changed the way that communications services work for consumers. It has also had a major impact on businesses and networks. For AL to take advantage of these rapid developments, a region must have an adequate digital communications infrastructure. Ofcom is now tasked with reporting on broadband take-up, speeds and availability, using data provided by communications providers. The connectivity of a region has a direct impact upon the implementation and take-up of AL products and services. The UK Government aims to have the best superfast broadband network in Europe by 2015 by providing all homes and businesses in the UK with access to at least 2Mbit/s broadband and that superfast broadband should be available to 90 per cent of people in each local authority area. There will be a particular focus on making sure that people in remote, as well as urban areas, get good online access. The most recent information on broadband in the UK has been compiled by Ofcom. The Digital Economy Act 2010 requires Ofcom to report on the state of the UK’s communications infrastructure every three years. Ofcom has also produced the UK's first interactive map 51 showing accurate information on broadband take-up, speeds and availability, using data provided by communications providers. Figure 18 shows the availability of broadband across the South East region based on: ▪ ▪ ▪ ▪ ▪
the percentage of homes with broadband currently not achieving 2Mbit/s speeds the percentage of addresses which are within the coverage area of superfast (over 24Mbit/s) broadband networks the number of existing broadband connections as a proportion of premises (including superfast broadband connections) the percentage take-up of superfast broadband The individual scores have been combined to provide an overall view of broadband in each area.
Figure 18 MALCOLM English Region Broadband availability by SE Local Authority (Ofcom 2013)
50
Ofcom, The Communications Market 2011, 4 August 2011, www.ofcom.org.uk http://stakeholders.ofcom.org.uk/market-data-research/market-data/communications-market-reports/cmr11/?a=0 51
Ofcom, Broadband Speeds Map, http://maps.ofcom.org.uk/broadband/
32
Ofcom has also collected data on the average maximum speeds of existing broadband connections, although notes that speeds achieved in the home will be slower. Figure 19 shows the average modem speed (Mbit/s) by Administrative Authority.
Figure 19 UK MALCOLM region average modem speed (Mbit/s) by Local Authority (Ofcom)
Ofcom52 has ranked each area on a scale of 1 to 5, with 1 the highest or fastest, and 5 the lowest or slowest on how they score on four broadband metrics: • • • •
Average modem sync speed (Mbit/s): The average maximum speeds of existing broadband connections. Speeds achieved in the home will be slower. Percentage receiving less than 2Mbit/s: The percentage of homes with broadband currently not achieving 2Mbit/s speeds. Superfast availability: The percentage of addresses, which are within the coverage area of superfast (over 24Mbit/s) broadband networks. Average take-up: The number of existing broadband connections as a proportion of premises, excluding superfast broadband connections.
Figure 20 shows the ranking (1 = highest /fastest, 5 = lowest/slowest) within the MALCOLM region by administrative authority. Figure X shows the ranking (1 = highest /fastest, 5 = lowest/slowest) within the region by administrative authority. All areas perform well with a performance ranking of either 1 or 2. The Communications Infrastructure 2012 update reports53 that the Government has ‘established a framework agreement for Local Authorities to use to deliver rural broadband projects and secured state aid clearance to enable investment to proceed.’ Surrey is one of these rural areas that is through procurement and into delivery. Brighton & Hove, and Portsmouth in the MALCOLM region are three of the first ten ‘super-connected’ cities that have been successful in their bid for funding to deliver ultrafast broadband and public wireless connectivity.
52
Ofcom, “Communications-infrastructure-report 2011,” 6 July 2011, www.ofcom.org.uk
53
Ofcom, “Communications-infrastructure-report 2012 update,” 20 December 2012, www.ofcom.org.uk http://stakeholders.ofcom.org.uk/binaries/research/telecoms-research/infrastructure-report/Infrastructurereport2012.pdf
33
Figure 20 UK MALCOLM region overall broadband performance (Ofcom)
4.1.3
Energy
The UK Government aims to make every home and every business an intelligent part of an electricity network, to help moderate demand at peak times and to preserve supply and demand balance despite increased amounts of intermittent, renewable electricity generation. The aim is also to ensure greater energy interconnection with continental Europe and Ireland. Smart meters are part of the Government’s plan for upgrading the UK’s energy system. The aim is for all homes and small businesses to have smart meters by 2020. Between now and 2020 energy suppliers will be responsible for replacing over 53 million gas and electricity meters54. With smart meters being considered as a potential important opportunity for the delivery of AL, the roll-out of smart meters represents a significant milestone. As part of its National Infrastructure plan, the UK Government’s Smart Meters programme will see Smart Meters deployed in ‘all GB households and several million small non-domestic sites by 2020’. Smart meters provide the consumer with a real-time, accurate, record of the gas and electricity used, and how much it costs. Smart meters also enable information to be exchanged between the consumer and their energy company. In the future, smart meters could link up with other household appliances
54
UK Gov, Smart Meters: https://www.gov.uk/government/policies/helping-households-to-cut-their-energybills/supporting-pages/smart-meters
34
- for example freezers, washing machines, kettles, and other sensors. Smart Meters will also enable industry efficiencies, provide energy networks with better information, and become ‘a critical part of the platform for smart grids which support sustainable energy supply.’55
4.1.4
Intellectual Capital
Intellectual capital is vital for attracting inward investment, stimulating innovation and allowing the UK and its regions to be competitive in the global knowledge economy. In its Infrastructure Plan 2010, the Government recognized the important role that Intellectual Capital plays in the UK’s economic infrastructure and is committed to providing funding to develop the UK’s Intellectual Capital, for example: ▪ ▪ ▪ ▪
enabling investment in science, research and innovation through provision of research facilities and equipment in universities. supporting (including by way of capital investment) the work of the Research Councils and investing in innovative technologies in and for infrastructure. supporting the Technology Strategy Board to incentivise business led technology innovation; establishing a network of Technology and Innovation Centres.
See Section 12 for information about regional Centres of Expertise and Innovation.
4.2
Policy
The UK Government’s infrastructure policy is set out in its annual National Infrastructure Plan 56. The plan sets out the challenges facing UK infrastructure and the government’s strategy for meeting the infrastructure needs of the UK economy.
4.3
Research Insights
One effect of Government’s National Infrastructure Strategy, published in 2010, was to highlight the interconnectedness of the different sectors that impact upon the potential for the development of AL solutions: energy, transport, and digital communications, and intellectual capital.
A region’s economic infrastructure can have a significant impact upon the ease with which technology innovations can be deployed to meet social objectives such as healthcare. The sectors and networks that are of most relevance to AL are energy, transport, and digital communications and surrounding them all is the region’s ability to generate intellectual capital. The research carried out by the MALCOLM project has revealed that the care network has its own interdependency within the infrastructure, and to develop a holistic AL service information is needed from all these connected sectors.
An understanding of the significance of a region’s infrastructure to health and social care can help identify where AL products and services could be deployed to best advantage.
The UK Government is committed to ensuring that high-speed broadband networks are available across the UK. The implication is that no home should therefore be unable to access AL services and that new services utilising higher speeds or greater bandwidth than the current services can be implemented.
55
UK Gov National Infrastructure Plan Dec 2013
56
HM Treasury, National Infrastructure Plans, https://www.gov.uk/government/collections/national-infrastructureplan
35
4.4
Opportunities
On the whole, the infrastructure available in the South East region is favourable for the deployment of AL and the predicted overcrowding on the region’s roads could further stimulate the uptake of AL. However, some parts of the MALCOLM region within the South East are more sparsely populated and have poorer infrastructure. The implementation of AL would improve equity of access forpeople in regions with large rural populations or other difficulties in accessing care.
57
Ofcom, Broadband Speeds Map, http://maps.ofcom.org.uk/broadband/
58
BEAMA, 22 April 2013 http://www.beama.org.uk/en/news/index.cfm/Seizing-the-smart-grid-opportunity-Astrong-Investment-Case-for-Smart-Grids-Today.
36
Health and Social Care in England The following research summaries provide an overview of the health and social care in England: ▪ ▪ ▪ ▪ ▪
5
Health and Social Care System in England: Health Services in England Social Care Services in England Funding of Health and Social Care Health and Social Care Market access.
Health and Social Care System in England
This section provides an overview of the health and care system in England. For the purposes of this study, we will describe health and social care separately, however, in practice, health and social care services are delivered in combination, and it is the policy of the UK Government to integrate health and social care to provide seamless care.
5.1
Overview of the Health and Care System in England
The health and care system in England is extremely large, and complex, but it is helpful to understand how the component services relate to each other, and which services are commissioned and delivered nationally or locally. Figure 21 provides a simplified overview of the system.
Figure 21 Simplified Overview of the Health and Care System in England 37
The Secretary of State for Health The Secretary of State for Health has ultimate responsibility for the provision of a comprehensive health service in England and for ensuring that the whole system works together to respond to the priorities of communities and meet the needs of patients. The Department of Health The Department of Health, lead by the Secretary of State for Health, is responsible for creating national policy and legislation on health and social care, funding and ensuring the continuity of services, and encouraging innovation and continuous improvement. In conjunction with other Departments, the Department of Health focuses on the following 4 areas: ▪ ▪ ▪ ▪
Public health National Health Service (NHS) Social Care Public safety and emergencies
Public Health England (PHE) Public Health England is a new national body and is an executive agency of the Department of Health. Its role is to protect the nation’s health and address health inequalities. The National Health Service (NHS) The main provider of healthcare in England is the National Health Service (NHS). NHS services are funded through taxation, and most are available free of charge to those with a health need. Several different organizations come together to form the NHS and include both NHS and non-NHS organizations. The NHS budget is £95.6 billion59. Monitor Monitor is a non-executive body of the Department of Health and is the sector regulator for health services in England. It is accountable to the Secretary of State for Health. Monitor ensures that health care services are provided effectively, efficiently and economically, and ultimately work better for patients. Monitor’s role is to: ▪ ▪ ▪ ▪ ▪
License providers of NHS-funded care Ensure procurement, choice, and competition work in the best interests of patients Set a national tariff for services to ensure fair pricing Ensure continuity of services, and manage provider failure Authorize foundation trusts, and ensure that they are well led.
Monitor works closely with other organizations that provide regulation and oversight: • the Care Quality Commission (CQC) • NHS England • the NHS Trust Development Authority • HealthWatch England • the National Institute for Health and Clinical Excellence (NICE) • the National Quality Board NHS Trust Development Authority The NHS Trust Development Authority (TDA) provides support, oversight and governance to NHS trusts (geographical and functional divisions of the NHS); it helps them to improve performance and the quality of services to patients and for NHS hospital trusts to achieve foundation trust status. It is accountable to the Secretary of State for Health.
59
https://www.england.nhs.uk/allocations-2013-14/
38
NHS England Prior to 1 April 2013, NHS England was known as the NHS Commissioning Board. NHS England is an executive non-departmental public body of the Department of Health. Although it operates nationally, it is supported by 27 Area Teams across England. The main aim of NHS England is to improve the health outcomes for people in England, specifically to improve against all 5 domains in the NHS Outcomes Framework60: 1. 2. 3. 4. 5.
Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm
NHS England funds, oversees and supports the commissioning system for NHS-funded services at a national level. It commissions those services which are more appropriate to commission at a national level, including: ▪ ▪ ▪ ▪
primary care, including GP services specialised services (such as those for rare diseases), offender healthcare some services for members of the armed forces
NHS England is also responsible for ensuring that the system of commissioning NHS funded services works well. It supports and monitors CCGs and is their accountable body. This involves working on plans to improve commissioning for specific conditions (e.g. dementia) or patient groups (e.g. children’s services). Care Quality Commission The Care Quality Commission (CQC), is the independent regulator of health and adult social care services in England. Its role is to ensure that hospitals, care homes, home-care agencies, ambulances, dental surgeries, GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care that comply with governments standards of quality and safety, and encourage them to make improvements. The CQC does this by inspecting services and publishing the results. The CQC is accountable to the Secretary of State for Health and works closely with other NHS organizations and partners: ▪ ▪ ▪ ▪ ▪
NHS England Monitor HealthWatch NHS Trust Development Authority Social Care Institute for Excellence (SCIE)
Clinical Commissioning Groups Clinical Commissioning Groups (CCGs) are groups of GP practices that include other healthcare professionals such as nurses and hospital doctors, as well as members of the public. 211 CCGs are responsible for commissioning - choosing and buying - services for their local population, and have a budget of £63.4 billion. Each CCG will commission health services for emergency care, elective hospital care, maternity services, and community and mental health services. CCGs can obtain support from Commissioning Support Units (CSUs) and Clinical Senates, but are also free to choose another provider. Commissioning Support Units Commissioning Support Units (CSUs) are governed by NHS England and provide commissioning support services to NHS commissioners, including local Clinical Commissioning Groups (CCGs), NHS
60
https://www.gov.uk/government/publications/nhs-outcomes-framework-2013-to-2014
39
England, acute trusts and local government. Eighteen CSUs provide business intelligence, undertake contract negotiations and provide contract management. Clinical Senates Twelve Clinical Senates across England, comprised of clinicians, patients and other partners, give advice to commissioners and providers in their area on topics where CCGs do not already have that expertise, for example, on particular patient groups or conditions. Local Authorities A Local Authority is an organization responsible for the administration of a local area. There are two tiers of Local Authorities in England: county councils and unitary authorities are top-tier local authorities and made up of district or borough councils, which are second-tier local authorities. Local authorities are responsible for a range of services for both individuals and business. Top-tier local authorities are responsible for: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Health Services Social Services Education Waste management Roads, highways and transportation Environmental Health Approving planning applications Enforcing health, safety, environment and trading standards requirements etc
Second-tier local authorities are responsible for:
Council tax Leisure services Rubbish collection and recycling Housing
Each Local Authority: •
in partnership with Clinical Commissioning Groups, is responsible for commissioning the majority of NHS Services for patients within their local communities
•
has a Health and Wellbeing Board
•
funds a HealthWatch Local
•
is responsible for protecting and improving health and wellbeing61.
Health Care Providers An NHS Health care provider is an organization acting as a direct provider of health care services. provides direct health care, such as: ▪ ▪ ▪ ▪ ▪ ▪
GP practices NHS trust Registered non-NHS Provider (e.g. Independent provider, Independent sector healthcare provider) Care trust Councils with social care responsibilities Other agencies
An Independent provider is a private-sector Health Care Provider that is contracted by the NHS in the provision of healthcare or in the support of the provision of healthcare. 62 Independent providers are
61
http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/l/local_authority_de.asp?shownav=1 62
http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/
40
typically the smaller providers of healthcare, such as hypnotherapists, medical consultants working privately outside of the NHS, nursing homes, private practices and clinics, etc. Social care providers Social care services help people who need support because of illness, disability, old age or poverty. Local authorities are responsible for providing social care services, either directly or through an independent provider. Social care services include: ▪ ▪ ▪
help at home, e.g. with shopping, laundry, cleaning or preparing a meal personal care such as washing and dressing 24-hour care in a care home or a housing with care scheme (also known as sheltered accommodation)
HealthWatch and HealthWatch Local HealthWatch is the new consumer champion for both health and social care. It ensures that the voice of the consumer is strengthened and heard by those who commission, deliver and regulate health and care services. HealthWatch operates at the national level as HealthWatch England and at the local level as HealthWatch Local. HealthWatch England is a national body that enables the collective views of the people who use NHS and social care services to influence national policy, advice and guidance. HealthWatch England is a committee of the CQC, but it operates independently of the CQC and can escalate concerns about health and social care services raised by local HealthWatch, users of services and members of the public to the CQC. A Local HealthWatch is funded by its Local Authority – there are 152 Local HealthWatch organisations. The aim of local HealthWatch is to give individuals and communities a stronger voice to influence and challenge how health and social care services are provided within their local area. Local HealthWatch organizations can help and support Clinical Commissioning Groups to ensure that services are designed to meet the needs of their local population. Health and Wellbeing Boards Health and Wellbeing boards are established and hosted by local authorities. Their aim is to ensure better integrated commissioning across health, social care and wider council services. Due to their diverse membership, that includes the NHS, public health, adult social care and children's services, elected representatives and Local HealthWatch, Health and Wellbeing Boards are uniquely placed to ensure closer working between commissioners of health and social care services, and wider council departments, such as housing.
5.2
Research Insights
A major priority for the UK government today is integration of its health and social care services. Discrepancies between the geographical areas responsible for social care (County Councils and Unitary Authorities) and health care (CCGs) makes this challenging to achieve.
There are inconsistencies and incompatibilities between the health and social care systems because, until recently, the focus has been to optimise health and social care independently (often described as "in silos") rather than to optimise wellbeing in general.
One step that the government has already taken to shift efforts towards general wellbeing is to form Health and Wellbeing Boards across the country. It has also chosen fourteen "Integration Pioneers" to test ways to implement and deliver integration of health and social care in their regions.
The Integration Pioneers are deliberately wide-ranging so that the combined learning from their five years of experimentation can be used to inform national guidance that is applicable across the country. By allowing the mechanisms for achieving integration of health and social care to vary 41
across the country, every locality is given the opportunity to implement an optimal system for its population and context.
Allowing flexibility in how health and social care are integrated could come at the cost of creating geographical silos.
5.3
Good Practice
This section contains examples of Good Practices, i.e. initiatives and projects of relevance to the health and social care system that create opportunities for AL. More detailed information about each Good Practice is available in the MALCOLM project Catalogue of Good Practices.
Kent is one of the fourteen Pioneer sites expected to invest Better Care Fund monies (redirected healthcare budget) to test methods for bringing about integrated care. Of relevance to AL technologies, Kent plans to create electronic patient-held care records, pilot the "PatientsKnow Best" internet networking solution (allowing patients to see and share their health and social care plan) and implement an Advanced Assistive Technology Partnership to roll telecare and telehealth across the county (as part of the national 3millionlives initiative). As part of their Pioneer status, Kent will share their learning, meaning that these efforts should influenceGovernment's understanding of the role of assistive technology for achieving integrated health and social care.
The Ostrich Group is an independent, unbiased and free to use service provider. They aim to support all aspects of daily living for people who need care or are supporting people who do, from guidance on how to access and fund care, to selling of AL technologies and providing games for carers.
5.4
Opportunities
Policy Makers/government
Stakeholders of AL products and services believe that there has not been any widespread implementation of assistive living to date because there has been a lack of support at policy, government and leadership level.
Decision makers can improve the likelihood that more assistive living solutions emerge by: -
having a longer term focus, as it can take longer than the current financial year to recoup return on investment better aligning incentives and funding between payer and provider organisations being less risk averse (less reliant on research data) and more open to business transformation continuing to build bridges between previously separate organisations, as innovation is likely to occur where different ideas come together enforcing greater collaboration between disparate decision makers, as transformation change requires the co-working of many different regions, departments, organisations, etc. publicising greater governmental support for technology in care and enforcing its adoption by regional decision makers.
42
Patients /service users
Integrated care can take advantage of the synergies between health and social care in order to improve efficiencies in care management and delivery. This ought to enhance the quality of life for service users directly.
It is in the public's interest to proactively endorse integration of health and social care because it is a major step towards creating a culture change focussed on general wellness, which involves wider determinants such as employment and housing, rather than only on specific aspects of health that are a consequence of the wider determinants.
Devolvement of care decision making allows service users to influence their local care systems, i.e. they can sit as lay members of CCGs, HealthWatch and Health and Wellbeing Boards, championing the rights and interests of the local public.
Care providers
Devolvement of care decision making gives care providers the power and opportunities to shape their local care systems, i.e. they can sit on the governing body of CCGs, HealthWatch and Health and Wellbeing Boards. This provides a way for ambitious and innovative care providers to action innovative activities within their local population, which, if successful, could be seen as a best practice for national dissemination.
Integrated care provision will require closer working of currently separate care providers as well as create exciting new opportunities for care providers to work at the interface.
Solutions providers, including third sector
Integration of the currently inconsistent and incompatible health and social care services will create a plethora of new challenges that innovative solutions providers can help to address/solve.
Innovative solutions with common basic platforms that individual regions can build on top of to deliver their regional plans could help to overcome any geographical silos that arise as a consequence of flexible integration of health and social care.
Devolvement of care decision making allows solutions providers to influence their local care systems, i.e. they can sit as lay members of CCGs, HealthWatch and Health and Wellbeing Boards, championing the rights and interests of their industry.
Devolvement of care decision making gives solutions providers a much larger number of channels to explore to find clinical champions and/or to market their solutions.
43
6
Health Services in England
This section provides an overview of the health services in England. For the purposes of this study, we will describe health and social care separately, however, in practice, health and social care services are delivered in combination, and it is the policy of the UK Government to integrate health and social care to provide seamless care.
6.1
Overview of the Health Services in England
6.1.1
The National Health Service (NHS)
The main provider of healthcare in England is the National Health Service (NHS). NHS services are funded through taxation, and most are available free of charge to those with a health need. Several different organizations come together to form the NHS and include both NHS and non-NHS organizations. The NHS budget is £95.6 billion. The NHS was created in 1948 on the basis that good healthcare should be available to everyone, and based on need, not on ability to pay. This principle still underpins the NHS in England today – NHS health care services are free for UK residents, although charges may apply for dental, eye-care and pharmacy services. In England, health care is delivered in a variety of ways and locations, depending on the health need.
6.1.2
NHS Choices
NHS Choices is a National Health Service website that provides comprehensive information about access to NHS health care, conditions, treatments, local services and healthy living63. Table 3 provides a summary of the health care services in England.
Table 3 Summary of Health Care Services in England
63
Primary care
Local non-urgent health services provided by GPs, nurses, health visitors, midwives, dentists, pharmacists and opticians
Secondary care
Specialised medical services provided in hospital, including outpatient and inpatient services to local area
Tertiary care
Specialised medical services for complex medical conditions provided nationally or regionally
Quaternary care
Ultra-specialised medical services for complex medical conditions provided nationally or regionally
Health Services information
NHS Choices
General Practitioner
Located in GP surgeries / health centres
Out-of-hours service
Provided by GP, locums or other health care centres, and may be located in GP surgeries/walk in centres/hospitals
Walk-in Centre
Walk in Centre (WiC)
NHS Choices, http://www.nhs.uk/
44
Home nursing visit
District nurses Community nurses GP Home visits Domiciliary visits
Out Patient Health Care Centres
May be located in hospitals or Primary Care Centres
Intermediate care
Services may include:
Care at Home
Care provided in a person’s home by Local Authority or private providers:
Care Home
Home care agencies Domiciliary care agencies
24-hour residential care provided by:
6.1.3
Rehabilitation Reablement Virtual Ward Hospital at Home
Care home without nursing Residential care home
Care Home with Nursing
24-hour residential care provided by a Care home with nursing/Nursing home
Hospital – inpatient
Hospital services provided to patients staying in hospital
Hospital – outpatient
Hospital services provided to patients without requiring an overnight stay in hospital
Urgent care
NHS Accident and Emergency Departments (A&E)
Minor Injuries Units
NHS Minor Injuries Units (MIUs)
Telephone health advice service
NHS 111
Hospice
Hospice
NHS Continuing Healthcare
Funding for nursing care (in any setting)
NHS Further Nursing care
Funding for nursing care (in nursing home setting)
Primary Care
Primary care comprises the range of services provided by GPs, nurses, health visitors, midwives and other healthcare professionals and allied health professionals such as dentists, pharmacists and opticians. Care is provided to a local population and is usually located in local GP practices, health centres, or at their own premises, depending on the services provided.
6.1.4
Secondary Care
Secondary care is usually provided in hospitals and refers to specialised medical services and commonplace hospital care, including outpatient and inpatient services. Access is often via referral from primary care services.
6.1.5
Tertiary Care
Tertiary care services specialise in the more complex areas of healthcare, such as cancer management, cardiac surgery, neurosurgery and treatment for severe burns amongst many others. 45
Tertiary care services are provided on a national or regional level and cover a number of geographical areas, as opposed to the primary and secondary care services, which are provided for the local population.
6.1.6
Quaternary Care
Quaternary care services are similar to tertiary care services but they are even more specialised, often offering the most cutting-edge care available worldwide.
6.1.7
General Practitioner
A General Practitioner (GP) is a doctor who is the main point of contact for general healthcare issues. GPs usually work in practices as part of a team, which includes nurses, healthcare assistants, practice managers, receptionists and other staff. Practices also work closely with other healthcare professionals, such as health visitors, midwives, and social services. All UK residents are entitled to the services of an NHS GP free of charge, however, GPs may charge for some services, e.g. travel vaccinations. GPs provide the link to other health professionals, primary heath care services and secondary care services. They refer patients to hospital, to specialists (consultants) and to social care services. GPs also record important information about the care and treatment provided to an individual, via the Patient Record. In order to access GP services, UK residents must first register with a GP practice. People may choose their GP providing that they live within the catchment area of the practice and that the practice has space for new patients. GP services are usually available during weekdays only. When GPs are not available, they will provide access to an out-of-hours service, provided by themselves, or other services.64,65
6.1.8
Out-of-Hours Service
The out-of-hours period is 18.30-08.00 on weekdays, and all weekends and bank holidays. The organizations that provide an Out-of-Hours service varies in different areas. Out-of-hours services can be accessed by calling the local GP telephone number, which will provide the telephone number for their out-of-hours service. Alternatively, the telephone advice service NHS 111 will either be able to give immediate healthcare advice or direct the caller to the best local service that can help. Some GP practices may deal with out-of-hours services themselves. Other GP practices may work together so that the GPs from more than one surgery can take it turns to provide care. Other surgeries pay private companies to provide care on their behalf. Other options for out-of-hours cover may include some or all of the following: •
GPs working in Accident and Emergency (A&E) departments, walk-in centres or minor injury units
•
Teams of healthcare professionals working in places such as primary care centres, A&E, minor injury units, or NHS walk-in centres
•
Health care professionals other than doctors giving home visits, after a detailed clinical assessment
64
NHS Choices. RCGP Guide to Practitioner services ‘It’s Your Practice’ http://www.nhs.uk/choiceintheNHS/Yourchoices/GPchoice/Documents/rcgp_iyp_full_booklet_web_version.pdf 65
NHS England, Guide to the NHS in England, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/194002/9421-2900878-TSONHS_Guide_to_Healthcare_WEB.PDF
46
•
6.1.9
Ambulance services moving patients to places where they can be seen by a doctor or by a nurse, to reduce the need for home visits.66,67
NHS telephone service
NHS 111 is a telephone service that enables people to access local NHS healthcare services in England. The service is available 24 hours a day, 365 days a year and calls are free from landlines and mobile phones. The NHS 111 service should be used when urgent medical help or advice is needed, but when it is not a life-threatening situation. For example, NHS 111 should be called if: •
medical help is required but it is not a 999 emergency
•
A&E or other NHS urgent care services may be required
•
the caller does not know who to call or does not have a GP to call
•
the caller needs health information or reassurance about what to do next.
The NHS 111 service is staffed by a team of fully trained advisers, supported by experienced nurses and paramedics, who will ask questions to assess symptoms and then either give immediate healthcare advice or direct the caller to the best local service that can help.
6.1.10 NHS Accident and Emergency Departments (A&E) A&E are hospital departments that assess and treat patients with serious injuries or illnesses. Major A&E departments are open 24 hours a day, 365 days a year, although not all hospitals have an A&E department. Urgent transport to the nearest A&E department can be requested by calling 999. Once in A&E, a doctor or nurse will assess the patient's condition and decide on further action.
6.1.11 NHS Walk-in Centres NHS walk-in centres (WICs) offer convenient access to a range of treatments for minor illnesses and injuries; a complementary service to those provided by GPs and A&E. WICs are usually managed by a nurse but some offer access to doctors as well as nurses. Nevertheless, they are not designed for treating long-term conditions or immediately life-threatening problems. WICs can be accessed by everyone and patients do not need an appointment.
6.1.12 NHS Minor Injuries Units NHS Minor Injuries Units (MIUs) provide treatment for minor injuries such as minor burns, insect and animal bites and broken bones. MIUs are usually managed by a nurse and are available to everyone. Patients do not need an appointment.
6.1.13 NHS Funded Nursing Care NHS-funded nursing care is care provided by a registered nurse for people who live in a nursing home that is funded by the NHS. People must be assessed to determine if they are eligible to receive NHSfunded nursing care. To be eligible, the individual: ▪
must live in a care home registered to provide nursing care,
66
NHS Choices, Out-of-hours, http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/out-of-hoursservices.aspx 67
NHS web archive, Out-of-hours services, http://webarchive.nationalarchives.gov.uk/20060919094917/nhsdirect.nhs.uk/articles/article.aspx?articleId=630& sectionId=3419
47
▪
does not qualify for NHS Continuing Healthcare but has been assessed as needing care from a registered nurse. The NHS makes a payment directly to the care home to fund care from registered nurses who are usually employed by the care home.68
6.1.14 NHS Continuing Healthcare The NHS continuing healthcare care package is arranged and funded solely by the NHS for individuals who are not in hospital but have complex ongoing healthcare needs. People must be assessed to determine if they are eligible to receive NHS continuing healthcare. Eligibility for NHS continuing healthcare does not depend on: •
a specific health condition, illness or diagnosis
•
who provides the care
•
where the care is provided.
If eligible, care can be provided in any setting, for example: •
in own home – the NHS will pay for healthcare, such as services from a community nurse or specialist therapist, as well as personal care, such as help with bathing, dressing and laundry
•
in a care home – as well as healthcare and personal care, the NHS will pay for care home fees, including board and accommodation.
6.1.15 Hospice Care Hospices provide residential, respite and care at home for people who have been diagnosed with a terminal illness. Hospice care places a high value on dignity, respect and the wishes of the patient. It aims to look after the medical, emotional, social, practical, psychological, and spiritual needs of the patient and their family and carers, which extends into the bereavement period after the patient has died. Hospice care is free of charge. Patients can be referred to a hospice by their GP or nurse, or they can contact a hospice directly.69
6.1.16 Intermediate Care Intermediate care is an umbrella term for a number of care services aimed at helping people stay out of hospital or to live as independently as possible after a hospital stay. It includes:
Rapid response community teams Virtual Wards Reablement (including rehabilitation)
6.1.17 Rapid response community teams Rapid response is a relatively new care concept that involves multidisciplinary teams delivering clinical care to people in the community experiencing a non-emergency health crisis, avoiding the need for these patients to be admitted into hospital. There is regional variation in the organisation and operation of rapid response community teams, but most aim to make contact and/or assess a patient that has been referred to them by local hospitals, ambulance services, GPs, community nurses, social services or other healthcare professionals within two hours (during extended working hours). They may provide nursing care at the patient's home/care home for up to 72 hours before referring the patient to other community services if required.
68
NHS Choices, July 2014, http://www.nhs.uk/chq/pages/what-is-nhs-funded-nursing-care.aspx
69
NHS Choices, July 2014, http://www.nhs.uk/planners/end-of-life-care/pages/hospice-care.aspx
48
6.1.18 Virtual Wards Virtual wards are a new care concept that combines the predictive powers of patient risk stratification with the innovative Hospital at Home care delivery model in order to reduce patient exacerbations and avoid hospital admissions. Specifically, Hospital at Home is an integrated care service that involves a team of nurses, allied health professionals, healthcare support workers, social care staff, GPs and consultants delivering the same systems and daily routines for care in a patient's home/care home that they would if the patient were based in hospital.
6.1.19 Reablement (including rehabilitation) Reablement aims to equip people who have lost skills as a consequence of poor health, disability, impairment or accident with the tools to continue living as independently as possible, either at home or in a care home. Tools for reablement include:
sessions with physiotherapists, to direct physical rehabilitation sessions with occupational therapists, to be trained in how to use adaptations social support to put systems in place that promote social, psychological and vocational wellbeing.
Reablement services are currently available to people leaving hospital or requesting social care support for the first time. In most cases, these services are delivered at regular times in the home, however some patients may instead reside in a care home or specialist intermediate care facility to receive intensive support for all or part of the duration of the service. The maximum duration of reablement care is usually six weeks, after which time either a standard package of long-term home care services is organised for those patients who are still eligible for it, or it is necessary to move the patient into a more intensive setting, such as a care home.
6.2
Private (non-NHS) Healthcare
There are a number of reasons why people may choose private healthcare over NHS care:
to avoid NHS waiting lists if they are not satisfied with the NHS to get a second opinion because certain treatments are not available on the NHS because they wish to choose their consultant.
Many people can access private healthcare for free because their employer offers it as a perk. Alternatively, people can pay for private healthcare directly, including by taking out a loan. Although the private healthcare sector and NHS are separate, they work together closely. Some GPs have contracts with private hospitals, meaning that they refer their patients to these hospitals for certain investigations and treatments rather than to an NHS hospital.70
6.3
Policy
The English healthcare structures described in this guide have been operating since April 2013. These structures are considerably different from the structures that were in place prior to this date. The rationale behind the changes was to devolve decisions on the operation of the NHS away from the
70
www.privatehealth.co.uk
49
Department of Health and Ministers to a local level where they can be better aligned with local patient needs. Better alignment with individual patient wishes is a second priority for healthcare in England today. As many people wish to remain in settings that are most familiar and convenient for them and their friends and family, decision-makers are exploring new models of care that allow them to receive healthcare at home or in the community rather than in hospital, such as virtual wards. These innovative schemes are being funded by the money that Government is withholding from secondary care providers who do not meet Government targets. For example, hospitals now do not receive payment for emergency readmissions made within 30 days of discharge following an elective admission. Penalties are also in place to encourage secondary healthcare providers to reduce emergency admissions and ambulance clinical handover times. Unfortunately, because this system of penalising secondary healthcare providers in order to fund primary healthcare providers to deliver results is perverse, bed-blocking, i.e. keeping patients in hospital for longer than necessary in order to reduce the chance that they are readmitted, has become a pressing problem that is receiving media attention.
6.4
Research Insights
Despite the demands being placed on the NHS changing dramatically since its inception in 1946, its central business model of being free at the point of use remains the same.
In the past, the NHS has gone through many individual peripheral changes to meet the challenges of changing demographics, health profile and expectation. All of these peripheral changes have resulted in a system that end users find difficult to navigate, that is motivated by perverse rewards and penalties systems for providers, and that consists of legacy structures suboptimal for current purpose.
In 2013, the NHS underwent its most radical restructuring since its inception. With all hospitals being expected to achieve Foundation Trust status in 2014, and with infrastructural and management change likely to accompany integration of health and social care over the coming years, change is still ongoing.
The Nuffield Trust's 2014 "Into the Red: The state of the NHS's finances" analysis warns of an impending financial crisis for the NHS that about half of key Government and NHS leaders believe will result in the NHS no longer being free at the point of use within ten years.
In order for the NHS to continue to be free at the point of use, savings will need to be made through individuals and patients taking far greater responsibility for their own care, placing a greater care burden on informal and family carers, and by shifting considerably more healthcare delivery to the community.
6.5
Good Practice
This section contains examples of Good Practices, i.e. initiatives and projects of relevance to health services that create opportunities for AL. More detailed information about each Good Practice is available in the MALCOLM project Catalogue of Good Practices.
From 2010 until 2014, Surrey County Council ran its Community Alarm Telecare (CAT) Hospital Discharge scheme, which equipped its residents with a free community alarm for up to three months after discharge from hospital. The aim of this scheme was to help prevent people from being readmitted to hospital and so can be seen as the first step towards rolling out the Hospital at Home concept across Surrey. 50
The success of two telecare pilot projects run in West Sussex lead to the County Council to contract assistive technology supplier WELbeing to provide free alarms to residents who had been discharge from hospital for up to 13 weeks. As with the CAT scheme in Surrey, this scheme can be seen as the first step towards rolling out the Hospital at Home concept across West Sussex.
6.6
Opportunities
Policy Makers/government
Influential organisations and leaders ought to take advantage of general awareness that public services are seeing cuts to their budgets in order to promote patients to take greater responsibility for their health, informal care and the services of the third sector.
The imminent financial pressures facing the NHS justify it pursuing more radical and potentially risky change, including advocating the use of technology for health care and enforcing its adoption by local care providers. It is important that these changes are well communicated to the public as there is already a great deal of confusion about how the NHS operates.
To encourage the emergence of assistive healthcare technologies, the NHS should have a longer term focus, as it can take longer than the current financial year to recoup return on investment, and it should better align incentives and funding between payer and provider organisations.
Patients/Service Users
There is more support than ever for the general public to take greater responsibility for their own health and a more proactive role as a member of others' Circles of Care.
The recent increase in provision for community and intermediate care, including the emergence of the Virtual Wards concept, should allow more service users to access healthcare in the location of their choice.
Care providers
As patients take greater responsibility for their own health and a more proactive role as a member of others' Circles of Care, the role of care providers should shift from being solely care deliverers to something more akin to care facilitators, providing advice, guidance and signposting to their patients.
Increasing investment in community and intermediate care provides new, exciting and potentially lucrative avenues for care providers to become involved in.
Solutions providers, including third sector
Whether the NHS can continue to be free at the point of use or not, the opportunities for manufacturers and suppliers of new products and services to maintain wellness and enable selfcare are very appealing.
51
For the NHS to continue being free at the point of use, innovative ways to encourage and assist patients to take greater responsibility for their health and for informal care to be provided will need to emerge.
If it becomes financially unviable for the NHS to continue being free at the point of use, meaning that it must become privatised, the subsequent shake-up should stimulate significant innovation activities.
52
7
Social Care Services in England
This section provides an overview of the social care system in England. For the purposes of this study, we are describing health and social care separately, however, in practice, health and social care services are delivered in combination, and it is the policy of the UK Government to integrate health and social care to provide seamless care.
7.1.1
Overview of the Social Care System in England
Social care is defined by the Department of Health as: ‘The wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships.’ (Department of Health 2006) A more informative definition that illustrates the breadth of services provided, is: ‘Adult social care includes preventive services, assessment and care management, nursing and residential homes, community services (home care, day care, meals), reablement to prevent hospital admission or enable continued independence, intermediate care (after a spell in hospital), supported and other accommodation, individual budgets and direct payments to service users, safeguarding, and the provision of equipment. Service users may include older people, adults with learning disabilities, or mental health issues, and with physical or sensory impairments.’71 Social care services essentially help people who need support because of illness, disability, old age or poverty. In England, top-tier Local authorities are responsible for providing social care services, either directly or through an independent provider. Over the past few years, the adult social care sector has been evolving in response to the development of new types of provision aimed at helping more people to live at home for longer. The 2011 CQC report into adult social care provision noted that extended stays in hospital are being replaced by new or expanded models of provision, such as Extra Care Housing/Housing with Care, and short-term nursing care in homes. CQC registration data shows that there are 564 such Extra Care housing locations across England72.
7.2
Adult social care provision in England
Care services can be provided in a variety of settings: ▪ ▪ ▪
Care in own home, usually referred to as domiciliary care or home care Care homes, including residential homes and nursing homes Community venues, such as day care centres and drop-in centres.
There are also different types of social care available: ▪ ▪ ▪
Personal care, such as help with washing, toileting, dressing, and eating, etc Practical help, such as help with shopping, cleaning, etc Nursing care, which is any service provided by a registered nurse in any setting
71
Think Local Act Personal http://www.thinklocalactpersonal.org.uk/_library/Resources/SouthEast/Legacy/Other_Improvement/A_Short_guide _to_Adult_Social_Care_Commissioning_for_GP_consortia_members_Other_Report.pdf 72
CQC, “The state of health care and adult social care in England,” 15 September 2011, www.cqc.org.uk/sites/default/files/media/documents/state_of_care_2010_11.pdf
53
Figure 22 provides an overview of the adult social care in England.
Figure 22 Overview of Adult Social Care in England
Table 4 lists the different types of care services available in England, and Table 5 lists the different settings in which care can be delivered. Note that the different types of social care services are not necessarily dependent on the care setting (i.e. the location in which care is delivered), for example, practical help and personal care can be provided by domiciliary care in a person’s own home, and by carers in a residential care home. Table 4 Social Care Services in England Care Service
England
Personal care
Personal Care tasks ▪ ▪ ▪ ▪ ▪
Practical help
Eating (feeding and preparing meals) Bathing and washing (personal hygiene and grooming) Dressing Toileting (including continence-related tasks) Walking and transferring (such as moving from bed to wheelchair)
Practical tasks: ▪ ▪ ▪ ▪ ▪ ▪
Managing finances Travel (driving or using public transit) Shopping Using the telephone and other communication devices Managing medication Housework and basic home maintenance
54
Equipment aids for daily living (excluding technology)
Personal care and hygiene products: ▪ ▪ ▪ ▪ ▪
Bath boards Raised toilet seats Toilet frames Comodes Grab rails
Food preparation products: ▪ ▪ ▪
Lever taps Adapted kitchen utensils Kettle tippers
Mobility and movement products: ▪ ▪ ▪ ▪ ▪ ▪ Equipment: home adaptations (excluding technology)
Bed raisers Bed rails Rising/reclining chairs Walking frames Wheelchairs Grabbers
Hand rails Ramps Smoke alarms (stand-alone) Key safe Falls detector
Equipment aids for daily living (technology)
Pendant alarm Bed chair occupancy sensor Pill dispensers Smoke alarms (telecare linked) Door contact alarms Enuresis alert Flood detector Gas detector Passive infrared detector (PIR) Bogus caller alarm Temperature extremes alarm Carer alert system Remote controlled mains switch
Information & advice
Health and care services (provided by GP clinics and Councils with Adult Social Services Responsibilities) Financial services (provided by local district or borough councils and the national Citizens Advice Bureau)
Table 5 Social Care Settings in England Care Type
Setting
Care at Home (domcilliary care):
In own home
Care at Home - sheltered housing
Sheltered housing Retirement housing
Care at Home - shared lives
Shared lives
Care at Home - extra care housing
Extra care housing Very sheltered housing
55
Housing with care Assisted Living Care at Home - close care housing
Close care housing
Care at Home - retirement village
Retirement village Retirement complex Retirement community Retirement scheme
Care Home:
Care home Care home without nursing Residential care home
Care Home with Nursing
Care home with nursing Nursing home
Care information & advice
7.3
May be provided by Community Venues, such as day centres, drop-in centres, Citizen’s Advice Bureau, Local Authority, Charities
Social Care Services
Social care services can be broadly categorized by those services that are provided to an individual in their own home and those services that are provided away from home, e.g. in a residential setting or day care centre. Social care services include: ▪ ▪ ▪
help at home, e.g. with shopping, laundry, cleaning or preparing a meal personal care such as washing, dressing 24-hour care in a care home or a housing with care scheme (also known as sheltered accommodation)
7.3.1
Care at Home
Personal care and practical help can be provided in a variety of home settings. It is government policy to enable the elderly to remain living at home for as long as possible with assistance from social care services as needed.
7.3.1.1
Domiciliary Care (Home Care)
Domiciliary care, also known as Home Care, is care delivered in a person’s own home. It can be either personal care, such as help with washing, toileting, dressing, and eating, etc., practical help, such as help with shopping, washing and ironing, cleaning, etc., or a combination of both. Domiciliary care services can be provided by either the local authority or an independent care agency. An additional service provided by local authorities, the private sector and third sector is meal delivery. The standard price is £3 per hot meal, plus delivery costs.
7.3.2
Housing with Care
The charity the Elderly Accommodation Council (EAC) defines Housing with Care as: ‘all forms of specialist housing for older people where care services are provided or facilitated. This includes extra care housing, assisted living, very sheltered housing, close care and continuing care environments, and care villages’73.
73
EAC, Extra Care Housing.org.uk, 1 March 2010, www.extracarehousing.org.uk/
56
7.3.2.1
Sheltered housing
Sheltered housing (or retirement housing) offers independent living with access to extra facilities to people over 60 years old (although some schemes are available for the over 55s). Many schemes have their own 'manager' or 'warden', either living on-site or nearby, whose job is to manage the scheme and help arrange any services residents need. The level of support will vary depending on the individual scheme. Properties are usually also linked to a care-line service (also called emergency alarm or community alarm service) so that residents can call for help. These schemes usually consist of 20 to 50 self-contained houses, flats or bungalows with their own front doors, kitchens and bathrooms, and a number of extra resources. Communal facilities such as laundry, lounge or garden, guest suite, and social activities and events, may also be available. Residents are free to come and go as they please. Sheltered housing may be provided by a local authority or it can be bought or rented from a private retirement housing complex.74
7.3.2.2
Extra Care Housing
Extra care housing (also called very sheltered housing or housing with care) is social or private housing that has been modified to suit the elderly or people with long-term conditions or disabilities that make living in their own home difficult, but who do not wish to move into a residential care home. Residents live in self-contained properties, but meals, practical care and personal care could also be provided if required. Extra care housing includes converted properties and purpose-built accommodation such as retirement villages, apartments and bungalows. Properties are available to buy, rent or a mixture of both through shared ownership schemes. Developments vary in size and can include large-scale villages with up to 300 properties. Extra care housing may be run by housing associations and charities, Local Authorities or private sector providers.75
7.3.2.3
Close care housing
Close Care developments are a relatively new concept and consist of independent flats or bungalows built on the same site as a care home. Residents often have some services (such as cleaning) included in their service charge and other services can be purchased from the care home. The care home provides personal care services to the residents and often allows a move to the care home if needed. This form of housing can be a good option for couples who have different needs. Close care schemes can either be rented or purchased. Purchasers may receive a guarantee that the management will buy back the property if they enter the care home.76
7.3.2.4
Retirement villages
Retirement villages have no specific definition – they vary in the type of homes provided and scale (although a general rule is that they consist of a minimum of 100 residences), but they are all intended to cater for the needs of older people. In addition to self-contained homes, many of these schemes provide communal facilities and services including, on-site laundries, lounges, cafes and gyms. Some may also include a care home.77
74
NHS Choices, July 2014, http://www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/shelteredaccommodation.aspx 75
NHS Choices, July 2014 http://www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/extra-care.aspx
76
EAC July 2014.http://www.firststopcareadvice.org.uk/jargon-close-care-housing.aspx
77
EAC July 2014. http://www.firststopcareadvice.org.uk/jargon-retirement-village.aspx
57
7.3.2.5
Shared Lives
Shared lives is a little-known arrangement in which a vulnerable person spends a substantial amount of family and community life with a volunteer carer, possibly even moving into their home. The carers are paid a modest fee to cover their time and expenses. There are only 4,500 of these arrangements in England today, but 12,000 people have been trained in one of 150 local schemes to be shared lives carers.78
7.3.2.6
Community Venues
Day Centres / Drop-in Centres are services managed by the local council social services, NHS or voluntary or private bodies, which people who are socially isolated can attend during the day. These centres give people the opportunity to meet other people, have meals, receive low-level personal care such as nail clipping, learn new skills and participate in activities such as bingo, tea dances, and arts and crafts. In many places, transport to and from the day centre is provided.
7.3.3
Care away from Home
Care in a non-home setting is usually provided by care homes. Care homes fall into two categories, those that provide nursing care and those that do not. Some care homes may be registered as both ‘with nursing’ and ‘without nursing’. Care homes are usually registered to care for more than one type of person.
7.3.3.1
Residential Care Home
A Residential Care home is a care home that provides accommodation and 24-hour care for people who are no longer able to live independently in their own home. CQC reports that the most common type of provision is for older people and/or people with a learning disability or autistic spectrum disorder. Residential care homes are registered to provide personal care and practical help, but not nursing care. Example tasks that residential care homes will help residents with include: ▪ ▪
▪ ▪ ▪ ▪ ▪
Eating (feeding) Personal hygiene: bathing, washing, dressing and toileting (including continence-related tasks) Mobility: walking and transferring (such as moving from bed to wheelchair) Managing medication Travel (driving or using public transit) Shopping if required Using the telephone and other communication devices
Residential care homes can provide long-term or short-term accommodation. Short-term accommodation may be provided either as respite care for people who normally receive care at home (for example while their carer is away), or intermediate care while adaptations are being made to their own home. Residents usually have their own room and access to communal facilities, such as a TV lounge, dining room, gardens, etc. Care homes will also provide residents with activities and arrange outings. Care homes can be owned and run by the Local Authority or a private company (either for-profit or not-for-profit).
78
www.sharedlives.org.uk
58
7.3.3.2
Care Homes with Nursing
A care home with nursing (nursing home) is a care home that provides 24-hour accommodation and nursing care in addition to the personal care and practical help provided by a residential care home. According to the CQC for care homes with nursing, the most common type of provision is for older people and those with dementia. Nursing homes can also be owned and run by the Local Authority or a private company (either forprofit or not-for-profit). They may also provide long-term or short-term accommodation and residents usually have their own room and access to communal facilities. However, unlike residential care homes, nursing homes must employ at least one registered nurse in addition to care workers.
7.4
Social Care Service Commissioners and Providers
As a result of state-funded social care being both needs- and financially-assessed in England, there are a number of social care commissioners and providers. Social care services can be commissioned or purchased by: ▪ ▪
Local authorities Individuals
Social care services can be provided by: ▪ ▪ ▪ ▪
Local authorities directly Local authorities indirectly through contracted independent providers Private companies Third sector organisations, e.g charities, community and voluntary organisations
7.4.1
Local Authorities
A local authority is an organization responsible for the administration of a local area. There are two tiers of local authorities in England: county councils and unitary authorities are top-tier local authorities and made up of district or borough councils, which are second-tier local authorities. Adult Social Services departments of top-tier local authorities are responsible for commissioning and providing social care services to adults and the elderly. In order to receive these services, an assessment of need must be carried out. This assessment is called a Community Care Assessment and it is used in combination with a financial assessment to decide whether the local authority will fund the services. If an individual is eligible for state-funded social care, the Local Authority may provide the services directly or indirectly, via an independent provider. Each local authority has Adult Social Services department with responsibility for social care services for the elderly. Local authorities can provide a wide variety of services, including: ▪ ▪
▪
Care at Home - help from care workers with personal care and daily living tasks, provision of aids and equipment (including telecare), etc. Care away from home - temporary or permanent accommodation in a residential care home or nursing home for respite care, day centre care or intermediate care (for rehabilitation or while home adaptations are being made) Structural improvements, for example, home adaptations, minor works in the community and disabled parking bays.
In order to receive social care services or funding for these services from the Local Authority, an assessment of need must be carried out. This assessment is called a Community Care Assessment and is used to decide whether a person needs a community care service and, whether it can be provided by the local authority.
59
As the number of frail elderly and younger people with disabilities continues to outstrip funding, Local Authorities are using stricter needs and financial criteria about who in their locality they can give financial support to for the different services79. The result of this is that resources are directed towards people with the greatest need and lowest means, who therefore require expensive services, rather than to the larger number of people with less acute (and therefore less expensive) needs. If an individual does not meet the criteria to receive state-funded care, the Adult Social Services must provide information and advice about how they can access these services privately, either from from independent providers or third-sector organisations.
7.5
Independent Providers
Individuals may commission social care from independent providers at any time. These services can either be searched and accessed independently, or with the advice and guidance of the Adult Social Services department at their local top-tier local authority. Independent providers may also be commissioned to provide social care by local authorities who do not have the resources to deliver the services themselves (perhaps at the required volume). In fact, 60% of the non-residential social care managed by local authorities is contracted to independent providers,80 including: ▪ ▪
▪
Care at Home - help from care workers with personal care and daily living tasks, provision of aids and equipment (including telecare), etc. Care away from home - temporary or permanent accommodation in a residential care home or nursing home for respite care, day centre care or intermediate care (for rehabilitation or while home adaptations are being made) Housing adaptations.
7.6
Third Sector Organisations
Third Sector Organisations (TSOs), otherwise known as Voluntary, Community and Social Enterprise (VCSE) sector organisations, are a growing body of social care providers. They include small local community and voluntary groups, large and small registered charities, foundations, trusts, social enterprises and co-operatives. The services that their volunteers may provide either for free or at a low cost include: ▪ ▪ ▪
Care at Home - help with personal care and daily living tasks via companionship services Care away from home - day centre care Minor housing adaptations.
Generally, these services are less intensive than the equivalent provided by the public and independent sectors, reflecting the fact that users normally have a lower level of need. 81 Individuals may approach TSOs for social care at any time, or they may be referred by local authorities if they are inelgible for state-funded care, although each TSO will have its own needs-based criteria for deciding whether they will be able to provide a service to an individual.
79
People who are not eligible for financial support can still receive local information and advice about independent services from their CASSR. 80
https://www.langbuisson.co.uk "Care of Elderly People, UK Market Survey 2012-13"
81
"The third sector and welfare state modernisation: Inputs, activities and comparative performance", Kendall (2000)
60
TSOs are a growing source of social care because the Community Care Assessment criteria for people to receive state-funded social care are continually being raised and also because the profile of TSOs as providers of personalised, flexible and trusted care is increasing. This sector not only plays a critical and integral role in the provision of services, but it also serves as an advocate and represents the voice of service users, patients and carers. The sector makes a substantial contribution to the delivery of high quality health and social care services. The UK government recognizes this contribution and also acknowledges that these organisations have a strong track-record of designing services based on insight into clients’ needs, and are often well placed to respond flexibly to those needs. Third-sector organisations may also provide home care services, i.e. by volunteers from, for example, Age UK or Crossroads Care. Third-sector home care often differs from commercial or statutory home care by being less likely to provide live-in or night-sitting services. Users normally have a lower level of need too82. A common service provided by the third sector is companionship services, which means that the volunteer regularly checks up on the vulnerable person either in person or by phone, assists them with collecting prescriptions, filling in paperwork, etc.83 In addition to providing social care services, many TSOs are also actively engaged in promoting the voice of social service users and carers in public policy making.
7.7
Individuals as Purchasers
Until recently, the only individuals who could commission social care were people who had the capital to fund these services from independent providers privately. Today, however, individuals who have been assessed as eligible for social care services by their Local Authority can choose how those services are provided: ▪ ▪
The Local Authority can arrange the delivery of social care services (as previously) The individual can use their personal budget or direct payment to select social care services and providers.
A personal budget is funding from the Local Authority that the user can choose how to spend on their social care. Once this choice has been approved by social services, either the local authority can pay for them directly or the individual can receive the money and pay for them instead. Direct payments are similar to personal budgets but they remove the need for users to seek approval from social services on their choices. This added flexibility requires the user to assume all of the responsibilities of an employer. Individuals who are not eligible for Local Authority-funded social services or who have not chosen to have an assessment can purchase social care services from independent providers or charities.
7.8
Policy
The Department of Health's "A Vision for Adult Social Care: Capable Communities and Active Citizens"84 describes the first value for future social care services in England as 'Freedom', i.e. a shift of power away from the state and towards the people and communities. Embodied by the "Think
82
"The third sector and welfare state modernisation: Inputs, activities and comparative performance", Kendall (2000) 83
www.findmegoodcare.co.uk
84
http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf
61
Local, Act Personal"85 national partnership of more than 30 organisations committed to transforming health and care through personalisation and community-based support, this 'Freedom' is being achieved through personal social care budgets and direct payments to individuals (see Chapter XX: 'Funding Models for Care'), as well as public promotion of the third-sector as care providers (thirdsector care providers are generally seen as a trusted providers, which, combined with their relative autonomy, means they are well placed to respond flexibly to the needs of their clients). A second priority for the Department of Health is to integrate health and social care86. There are currently 14 Integration Pioneer sites across England (Kent being one of them) that have been chosen to test new systems for joining up their health and social care services 87. Most Pioneers are testing systems for combining the (recently introduced) personal healthcare budgets to their (more established) personal social care budgets. The learning made by these Integration Pioneers will inform how the £3.8bn "Better Care Fund" (previously known as the "Integration and Transformation Fund") used to integrate health and social care across England from April 2015 will be spent. This Fund is money from the existing NHS budget that must be redirected to systems for integrating health and social care, i.e. it is to be shared with the local authorities responsible for delivering social care.
7.9 ▪
▪
▪
Insights
Budgetary constraints, personalisation, choice, and the desire by both policy makers and individuals to remain in their own home for as long as possible are key drivers for social care services. Care in a home setting requires a range of services to enable people to live as independently as possible: practical help, personal care and nursing care, and both services and the way they are delivered are evolving in response to this requirement. This is a potential market opportunity for AL solutions. Personalisation and the freedom to choose services are intended to give individuals more control over the care they receive. In practice, the ability by an individual to make informed choices is very much dependent upon the information provided to them about the options for care and how well they understand the choices presented.
7.10 Opportunities Opportunities for the Third Sector The introduction of personalisation, where people are given more choice and control over the services they access through personal budgets and direct payments, provides opportunities for the voluntary sector to support people through the delivery of flexible, innovative services which people can purchased individually after a social care assessment. The requirement for Adult Social Services to provide information about how social care needs can be met means there is an opportunity for charities already providing these services to explore with Local Authorities how they can fulfill this requirement.
85
http://www.thinklocalactpersonal.org.uk
86
This priority was exposed by the 'Law Commission 2011' Review, which identified that "the separation of health and social care established in the post-war period was increasingly hampering the delivery of seamless services as patients move between different settings and as their needs change" 87
http://www.england.nhs.uk/2013/11/01/interg-care-pioneers/
62
8
Health and Social Care Funding in England
This section provides an overview of how the health care and social care systems are funded in England. In practice, health and social care services are delivered in combination, but their funding models differ. The funding landscape in England is very complex, and our aim is to provide a sufficient level of detail to enable those unfamiliar with health and social care in England to understand the context in which these services are delivered, and the main organisations that commission and fund them.
8.1
Overview of NHS Health Care Funding in England
Funding for the National Health Service (NHS) in England comes from the UK Treasury through money raised by taxation. The budget for health is approximately £107 billion per year and is allocated to the Department of Health (DH). The DH retains a proportion of the budget for its running costs and the funding of bodies such as Public Health England. NHS England currently receives around £96 billion a year from the Department of Health (2012/13). Approximately £30 billion is retained by NHS England to pay for its running costs and the services it commissions directly: primary care (including GP services), specialised services, and offender and military healthcare. The remainder is passed on to Clinical Commissioning Groups (CCGs) to enable them to commission services for their populations. Nearly half (47%) of the NHS budget is spent on acute and emergency care. General practice, community care, mental health and prescribing each account for around 10% of the total spend. Figure 23 gives an overview of the funding model for health care in England.
Figure 23 NHS Health Care Funding in England 63
8.2
Paying for Health Care
UK residents do not have to pay for their health care and treatment by the NHS, unless they choose to pay for private health care. In addition, every person over 60 years receives free prescriptions (usual cost £8.05, 1 April 2014) and free eye tests, and if on a low income, they could also receive a voucher towards the cost of glasses/contact lenses, free dental treatment, and help with travel costs to receive NHS treatment.
8.2.1
NHS Continuing Healthcare
The NHS continuing healthcare is a care package arranged and funded solely by the NHS for individuals who are not in hospital but have complex ongoing healthcare needs. People must be assessed to determine if they are eligible to receive NHS continuing healthcare. Eligibility for NHS continuing healthcare does not depend on: •
a specific health condition, illness or diagnosis
•
who provides the care
•
where the care is provided.
If eligible, care can be provided in any setting, for example: •
in own home – the NHS will pay for healthcare, such as services from a community nurse or specialist therapist, as well as personal care, such as help with bathing, dressing and laundry
•
in a care home – as well as healthcare and personal care, the NHS will pay for care home fees, including board and accommodation.
8.2.2
NHS-Funded Nursing Care
NHS-funded nursing care is the financial contribution paid by the local CCG towards the cost of meeting your nursing care needs if you live in a nursing home. It is paid directly to the care home. From April 2014, the contribution is £110.89 per week.
8.2.3
Private Health Care
Standard health care insurance policies usually cover tests, treatments, and surgery for common acute conditions that develop after a policy has been taken out. More expensive policies may also cover private GP consultations, costs associated with pre-existing conditions, treatment for less common conditions, and even indirect costs, such as hospital accommodation. Depending on the policy agreement, there may be an excess charge payable to receive the private care in addition to the regular fee for the insurance. What is more, if a claim is made, it is likely that these rates will increase above what they would otherwise in the future. Many companies offer their employees free private healthcare insurance as part of an attractive package of benefits. Alternatively, private health care can be paid for directly by the individual receiving the care, perhaps by taking out a loan. In either case, the first step to receiving private health care is for an individual to receive a referral from their local GP and then liaising with the insurance provider. Rather than paying for a full health insurance policy, individuals can opt for a more affordable health cash plan. This "NHS top-up" scheme costs a few pounds every month, and can be used to reimburse routine dental and optical treatments, specialist second opinions, physiotherapy, hospital stays and up to £300 of car parking at NHS facilities. It may also be available to fund advanced drugs that are not available on the NHS. 64
8.3
Overview of Social Care Funding in England
Unlike health care in England, social care services are not generally free. It is the responsibility of Local Authorities (unitary authorities and county councils) with social services responsibilities to commission social care services for the local community. Social care services provided by a Local Authority are means tested, which means that if an individual has an income or substantial savings, they may be required to pay for or contribute towards the cost of these services. In contrast to the way NHS health services are funded, social care is funded in a much more localized way, with much of the spending being controlled by Local Authorities. Consequently, there are wide geographical variations in the way social care is funded. In England, social care is funded through: ▪ ▪ ▪ ▪ ▪
central government funds allocated to the Local Authority council tax revenues individuals’ contributions to their council care package, and/or individuals’ contributions to services arranged independently88. The voluntary or third sector also provides and subsidises a range of care services.
Figure 24 gives an overview of the funding model for social care in England.
Figure 24 Social Care Funding in England
88
The King's Fund, 1 March 2009, www.kingsfund.org.uk/publications/briefings/funding_adult_social.html
65
8.4
Access to Adult Social Care Services, Funding and Benefits
Social Care services and funding contributions for the elderly are accessed via the Local Authority Adult Social Services Department, and are subject to an assessment being carried out. Some additional benefits and entitlements for the elderly are accessed via the Department of Work and Pensions (DWP), and are also subject to assessment or eligibility requirements. Figure 25 gives a high-level overview of the assessment process for accessing social care services, funding, benefits and entitlements for the elderly.
Figure 25 Assessment Process for Social Care Funding in England
8.4.1
Local Authority Social Care Assessment Process
Once a referral has been made to the Local Authority, it has a legal duty to carry out an assessment of anyone living in its area who may need community care services and then make a decision as to whether to provide a service. Care Needs Assessment The first stage of this assessment is a Care Needs Assessment. Local Authorities with responsibilities for adult social care have a responsibility to carry out a care needs assessment for anyone requesting social care and they must use national criteria89 to categorize the level of need. 89
Department of Health, “Fair Access to Care Services: Guidance on eligibility criteria for adult social care,” 25 February 2010, www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113155.pdf.
66
Eligibility Criteria The Local Authority uses the national criteria90 to categorize an individual’s level of need as low, moderate, substantial or critical. Each Local Authority has its own budget for adult social care and decides which of these four needs bands it will fund (some councils fund moderate needs, others cover only the substantial and critical bands). Anyone below their council’s needs eligibility threshold must pay for their own care. In England, an adult who is eligible to receive social care is means-tested to determine what their contribution to the cost of their care will be. Over time, Local Authorities have been increasing the eligibility thresholds for social care, which has resulted in an increasing number of people moving out of state-funded social care and into self-funded care. This change created a growing market for AL services. In order to make access to care more consistent, to end the regional disparity between care services provided by Local Authorities, and to stem the reduction in eligibility by Local Authorities, in 2013, the government issued draft legislation regarding new national eligibility criteria to be introduced in 2015, which will set a minimum national threshold beyond which Local Authorities will not be able to reduce their eligibility. This new national threshold would be equivalent to “substantial” in the current system, which is the level currently operated by the vast majority of Local Authorities. Financial Assessment If a Local Authority determines that an individual is eligible to receive state-funded social care then it will carry out a Financial Assessment to determine how much an individual must contribute towards the cost of their care. Self-funder Anyone who falls below their Local Authority's needs and financial eligibility thresholds (i.e. is not eligible to receive state-funded social care) must pay for their own care. Individuals who are not eligible for Local Authority-funded social services or who have not chosen to have an assessment must pay for their own care. They can choose to purchase social care services from independent providers or charities.
8.4.2
Access to Dept of Work & Pensions Benefits & Entitlements
Elderly people may be entitled to a range of state-funded benefits or entitlements, including: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Attendance Allowance Housing Benefit Council Tax reductions Cold Weather payments Winter fuel payment Free TV licence Free prescriptions Free eye tests Free bus passes & travel concessions
Pension Credit, Housing Benefit, Council Tax Support, winter fuel payments and free prescriptions are dependent upon attaining the minimum state pension age, whereas others can only be claimed from the set age of 65 (or 75 in the case of free TV licences). The state pension age is the earliest age that a person can claim their state pension.
90
Department of Health, “Fair Access to Care Services: Guidance on eligibility criteria for adult social care,” 25 February 2010, www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113155.pdf
67
8.5
Choosing Social Care Services
If a Local Authority determines that an individual is eligible to receive state-funded non-residential social care, the individual can have a choice over how those services are provided: ▪
If the Local Authority arranges the delivery of social care services and pays for the services directly, the individual cannot choose who provides the services.
▪
If the Local Authority allocates a Personal Budget, the person receiving care can decide how it is spent. The recipient can use their personal budget to select social care services and providers (not residential care). Once social services approve this plan, either they can pay for it on behalf of the person receiving the care, or the person receiving the care can receive the money and pay for the services directly
▪
If the Local Authority makes a Direct Payment to the person who has been assessed as needing services, in lieu of social service provisions, the recipient will arrange and pay for their social care services. Direct payments are similar to personal budgets, but offer the greatest flexibility in how care is organised, however, the recipient must keep appropriate records and accounts as they take on all of the legal responsibilities of an employer91.
Where a Local Authority is funding residential care, it must allow the person to choose which care home they would prefer. Social services must first agree that the home is suitable for the person’s needs and that it would not cost more than they would normally pay for a home that would meet those needs. If the person chooses to go into a more expensive home, a relative or friend may be able to "top up" the difference in cost.
8.6
Paying for Social Care Services
Unless they are on a very low income, most older people will find that they have to pay for some or all of their social care services. Older people’s income, savings and property, can be taken into account when determining eligibility for Local Authority funded social care services and some DWP benefits.
8.6.1
Paying for Care at Home
If an older person has been assessed as eligible for social care services at home, they will also undergo a financial assessment to determine how much they will contribute to that care. This assessment will take into account the person’s income and savings but not property (capital). If an individual has less than £14,250 savings, not including the value of their home, the Local Authority will pay all care at home fees. If an individual has between £14,250 - £23,250 savings, not including the value of their home, the Local Authority will pay towards care at home fees (sliding scale of £1 per week for every £250 over £14,250). If an individual has more than £23,250 savings, the individual will pay all care at home fees. The Draft Care and Support Bill, which will come into effect in 2016 if government passes it, proposes that:
Social care costs exceeding £72,000 over an individual's lifetime are met by government The means-tested threshold will be raised from £23,250 to £118,000.
The purpose of introducing this Bill is that fewer people will have to sell their home to pay for their care.92
91
www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/Directpayments.aspx
92
www.nhs.uk/CarersDirect/social-care/Pages/what-is-social-care.aspx
68
8.6.1.1
Personal Budgets
If a person’s financial assessment has determined that a Local Authority will contribute to the cost of their care at home, they can choose to receive this contribution as a Personal Budget. A personal budget is funding from the Local Authority allocated to an individual to pay for social care services of their choice, although these choices need to be approved by the local authority before they can receive them. The recipient can choose how their chosen services are provided: ▪ ▪
they can ask the Local Authority to arrange and pay for them on their behalf they can take their personal budget as a direct payment, and pay for them themselves. A
personal budget can only be used for social care services provided in a person’s own home.
8.6.1.2
Direct Payments
If a person’s financial assessment has determined that a Local Authority will contribute to the cost of their care at home, they can choose to receive this contribution as a Direct Payment. Direct payments are cash payments paid into a separate bank account that eligible individuals can spend on services to meet their eligible needs without needing to seek prior approval from their local authority. In this way, recipients are fully responsible for managing the money, organising and paying for their chosen services.93 Depending on the service, individuals may take on the responsibilities of an employer. Direct payments must be sufficient to enable the recipient to purchase services to meet their eligible needs, and must be spent on services that meet eligible needs. For example, Direct Payments may be used by a recipient to: ▪ ▪ ▪ ▪ ▪
employ their own care workers buy services from a voluntary or private agency buy equipment or pay for home adaptations purchase other types of support to meet their assessed needs pay for a short stay of up to four consecutive weeks within any 12-month period in a residential care home.
Direct Payments cannot be used to: ▪
▪ ▪ ▪ ▪
pay a spouse, civil partner, live-in partner, or a close relative who lives in the same household as the recipient to care for them (except in certain circumstances that have been agreed with the local authority) buy services from the local council pay for permanent care in a care home. However,they can be used to pay for a short stay of up to four consecutive weeks within any 12-month period pay for services that the NHS has a duty to provide pay for services provided by housing authorities94,95
8.6.2
Paying for Residential Care
If an older person has been assessed as eligible for social care services in a residential care home, they will also undergo a financial assessment to determine how much they will contribute to that care. This assessment will take into account the person’s income, savings and property (assets).
93
http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS24_Self-directed_supportdirect_payments_and_personal_budgets_fcs.pdf?dtrk=true 94
Age UK, Personal Budgets in Social Care, Sept 2012 http://www.ageuk.org.uk/documents/en-gb/informationguides/ageukig26_personal_budgets_inf.pdf?dtrk=true 95
Age Uk, Self-directed support: Direct Payments and Personal Budgets, Jan 2014 http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS24_Self-directed_supportdirect_payments_and_personal_budgets_fcs.pdf?dtrk=true
69
If an individual has more than £23,250 in savings and assets, the individual will pay all care home fees. If an individual has less than £23,250 in savings and assets, the Local Authority will pay some or all care home fees, but the individual's pension must also contribute towards the fees. The value of an individual’s home is not included in the financial assessment for temporary stays in a care home, and for permanent stays if the home is occupied by: ▪ ▪ ▪ ▪
their partner (husband, wife, civil partner or someone they live with) a relative who is 60 years old or over, or a younger relative who is ‘incapacitated’ a former partner who is divorced /estranged but who is a lone parent a child under 18 years who the individual is liable to maintain.
8.6.2.1
Self-funding social care services
People who pay the full cost of their social care are known as ‘self-funders’. Self-funders are people who: ▪ ▪ ▪
have chosen not to request help from adult social services have been assessed but are not currently eligible for services are eligible for services, but have savings and assets that are above £23,250.
The CQC reports that ‘an estimated 45% of care home places in England are occupied by people who are self-funding, meaning their costs are met privately rather than by the state. In addition, some people funded by local authorities have their care home fees ‘topped up’ by relatives or other third parties, to bridge the gap between what their council will pay and what the care home charges. Across England, around a quarter of local authority care home placements may be co-funded in this way. It is estimated that 168,700 older people pay privately for care in their own homes, and this increases to over 271,500 if widened to include those who pay for support with things like housework and shopping’.
8.6.2.2
Unpaid social care services
The social care system in England relies heavily on the informal (unpaid) care provided by close family and friends. The ONS analysis of the 2011 Census data shows that the amount of unpaid care in England is increasing, and the expectation is that the demand for informal care will also increase. There were approximately 5.8 million people providing unpaid care in England and Wales in 2011, representing just over one tenth of the population. The largest growth was in the highest unpaid care category of fifty or more hours per week. Unpaid care has increased at a faster pace than population growth between 2001 and 2011 in England and Wales; the same is true in Wales and across all English regions other than London, where it decreased. Authorities with higher percentages of their population who are ‘limited a lot’ in daily activities also have higher levels of unpaid care provided.96
8.6.3
Older People’s Income
Older people’s income may be made up of: ▪ ▪ ▪
Earnings State pension Private pension
96
ONS, 2011 Census Analysis: Unpaid care in England and Wales, 2011, http://www.ons.gov.uk/ons/rel/census/2011-census-analysis/provision-of-unpaid-care-in-england-and-wales-2011/art-provision-of-unpaid-care.html#tab-Key-Points
70
▪ ▪
Pension credit State benefits and entitlements
8.6.3.1
Earnings
On 1 October 2011, the Government abolished the Default Retirement Age (DRA) 97, which meant that employers could force their employees to retire at the age of 65. Employees can now remain employed beyond the age of 65 years if they are willing and able to do so, but do not have to. In February, 2012 statistics published by the Office for National Statistics (ONS) showed that that people are working longer than they used to. ‘The average age at which people left the labour market rose from 63.8 years to 64.6 years for men and from 61.2 years to 62.3 years for women between 2004 and 2010. Retirement peaked around State Pension Age (SPA) for both sexes; but many people retired before SPA, and others worked beyond SPA.’98
8.6.3.2
Pensions
Older people may have income from a state pension, workplace pension, private personal pension or some combination of these three types of pension. The State Pension provides a regular income once someone has reached State Pension Age. The state pension age is the earliest age that a person can claim their state pension. From 6 April 2014 the state pension age for women is 62 and 65 for men. The amount of State Pension an individual receives is based on the amount of National Insurance contributions they have paid. The full Basic State Pension, which can be claimed by anyone over the state pension age who has paid at least 30 years of National Insurance contributions, is currently £113.10 a week. This amount can still be claimed if the individual has chosen to continue working past state pension age. However, pensioners who have made contributions for less than 30 years may receive means-tested (non-taxable) pension credit. From April 2016 the State Pension will become a single-tier and flat rate, i.e. all pensioners will receive the same amount. It is also government policy to increase the state pension age. By 2018, the state pension age for both men and women will be 65 years. It will then increase every few months, to 66 years by 2020. The next planned increase, towards age 67, will start in 2026 and end in 2028. This policy is significant because some DWP benefits are dependent upon attaining the minimum state pension age. Government has also recently passed an "Auto enrolment" law, making it compulsory for every employer to automatically enrol their employees into a workplace pension scheme by 2018. This means that during working-age employment, employers must automatically transfer a small percentage of their employees' income into a workplace pension scheme if they earn more than £10,000 a year. This contribution is supplemented by the employer and the government (via tax relief on Income Tax). Unlike workplace pensions, private personal pensions remain voluntary schemes that individuals can set up and pay into in order to create an additional source of pension upon retirement.
97
Gov, The Employment Equality (Repeal of Retirement Age Provisions) Regulations 2011, http://www.legislation.gov.uk/uksi/2011/1069/contents/made 98
ONS, News Release, http://www.ons.gov.uk/ons/rel/mro/news-release/average-age-of-retirement-rises-aspeople-work-longer/pension-trends.html
71
Both private personal and workplace pensions can currently be taken from as early as 55 years of age, depending on factors such as the type of work the individual has been involved in. This will rise to age 57 from 2028. It is usually possible to initially take out a tax-free lump sum of private personal and workplace pensions up to a maximum of 25%, however the remaining amount is paid out regularly in taxable small amounts (the exact amount is decided by the insurance company based on their prediction of life expectancy). These payments may either be money purchases, i.e. depend on how much was paid into the pension scheme, or defined benefits, i.e. fixed amounts based on factors such as final salary. According to the ONS, pensions provide modest levels of annual income for many pensioner households. In 2010/11, 45 per cent of single pensioners had total pension income (state benefit income and private personal and/or workplace pension income) of less than £10,000, while 27 per cent of pensioner couples had less than £15,000.99 Pension Credit Pension Credit is an income-related state benefit and is made up of two parts: Guarantee Credit (available to people aged 62 years and above) and Savings Credit (available to people aged 65 years and above). Guarantee Credit tops up weekly income to £148.35 for single people or £226.50 for couples, although any single top up cannot exceed £67.80. Savings Credit is an extra payment for people who saved some money towards their retirement, providing up to £16.80 extra per week for single people and £20.70 for couples. People in receipt of Pension Credit are also eligible to claim other state benefits such as housing benefit or council tax reductions.
8.6.3.3
State Benefits & Entitlements
People aged 60 or over could be entitled to state benefits to help them remain independent and improve their standard of living by helping with housing costs, care needs or general day-to-day living expenses. Attendance Allowance The main care-related benefit is Attendance Allowance. Attendance Allowance is a state benefit paid by the DWP to UK residents aged 65 years and over who have personal care or supervision needs. Attendance Allowance is not taxable, is not based on national insurance contributions, and is not means-tested. A person must apply to the DWP to receive Attendance Allowance. Attendance Allowance is paid weekly at a rate defined by the level of help required: ▪ ▪
Lower rate: £54.45 if help is needed during the day or at night Higher rate: £81.30 if help is needed during the day and at night
Housing Benefit Housing benefit is a state benefit available to those in rented property, which can be used to help pay for some or all rent. Council Tax Reductions Council Tax Reduction (formerly called Council Tax Benefit) is a state benefit available to those living alone (25% reduction), on low incomes or in receipt of certain benefits that will pay some or all council tax depending on individual circumstances.
99
ONS, Pension Trends, Ch 12, http://www.ons.gov.uk/ons/rel/pensions/pension-trends/chapter-12--householdpension-resources--2012-edition-/art-pension-trends-chapter-12.html#tab-Key-points
72
Winter Fuel Payment Winter Fuel Payment is a tax-free amount paid once per year to people in receipt of a State Pension to help pay for heating bills. It is paid at two different rates: 1) £200 for single people under 80 years living alone and £100 for couples, or 2) £300 for single people 80 years and over living aloneand £200 for couples.100 Cold Weather Payment Older people in receipt of Pension Credit are eligible to receive a Cold Weather Payment. Payments are made when the local temperature is either recorded as, or forecast to be, an average of zero degrees Celsius or below over seven consecutive days. Payments of £25 are made for each 7-day period of very cold weather occuring between 1 November and 31 March. Free TV licence (over 75 years) Those aged 75 years and over are eligible to apply for a free TV licence. Older people under 75 years who are in residential care are eligible to apply for a discounted licence of £7.50. The usual licence fee is £145.50 per year. Health Entitlements Everyone aged 60 or over in England is eligible for free NHS prescriptions and free NHS sight tests. Older people who receive the Guarantee part of Pension Credit, and others who are on a low income, may receive help towards NHS health costs for: free NHS dental treatment an NHS eye test every two years (or as recommended by the optician) a voucher towards the cost of glasses or contact lenses help with necessary travel costs to receive NHS treatment referred by a doctor or dentist or to see a consultant free NHS wigs and fabric supports. Free bus passes & travel concessions Free Bus Pass: Older people are entitled to free off-peak travel on local buses anywhere in England once they reach State Pension Age. Discounted Coach Travel: National Express offers a Senior Coach card for those aged 60 years and over. It costs £10 and offers 1/3 off coach fares throughout the year. Discounted Rail Travel: Purchasing a Senior Railcard entitles anyone 60 years or over to save 1/3 on Standard and First Class rail fares throughout Great Britain for 12 months. A one-year Senior Railcard costs £30. Community Transport: Local community transport schemes such as social cars, dial-a-ride, or taxicard schemes are available to those who are disabled and unable to use public transport. Shopmobility schemes based in shopping centres and town centres help people shop in town centres by lending wheelchairs and scooters. Blue Badge Scheme: Blue badges allow people with severe mobility problems to park close to where they need to go. The scheme is run by local councils and operates throughout the UK.
100
Gov, Winter Fuel Payment, https://www.gov.uk/winter-fuel-payment/what-youll-get
73
8.7
Policy
Personalisation: The UK Governments personalisation policy aims to give individuals more choice and control over their care through personal budgets & direct payments. State Pension Age It is government policy to increase the state pension age. As of 6 April 2014 the state pension age for women is 62 and 65 for men. By 2018, the state pension age for both men and women will be 65 years. It will then increase every few months, reaching 66 by 2020. The next planned increase, towards age 67, will start in 2026 and end in 2028. This policy is significant because some DWP benefits are dependent upon attaining the minimum state pension age. Care Act 2014 A Bill to reform the law relating to care and support for adults and the law relating to support for carers, to make provision about safeguarding adults from abuse or neglect, to make provision about care standards, to establish and make provision about Health Education England, to establish and make provision about the Health Research Authority, and for connected purposes.101
8.8
Research Insights
How funds are allocated to the various organisations responsible for the delivery of health and social care is complex. This complexity reflects the fact that the conditions that health and social care have to cater for are changing. The increase in the number of elderly, the move to localise services and the focus on prevention all contribute to this complexity. All this is happening in a period when central government is cutting health and social care spending as well. Whilst most of healthcare provision is free at the point of demand, social care is subject to assessment and means testing. How and what funds trickle down to provide individual social care can depend on professionals, carers and patients knowing what services are available in the local area. To ensure people are getting the care that they need and are entitled to, requires professionals, carers and patients alike to understand a complex system with possibly some local rules.
8.9
Opportunities
Information and communication technology (ICT) can help those responsible for delivering care and those receiving care to know what should be available for them and how to access it. There are examples (see later in the report) of such services and they all meet a very real need. Many more such services are required and a knowledge that they exist and how to use them ought to be common knowledge especially for care professionals who can signpost individuals to them. These services need to incorporate the services of a “navigator” or “broker” who would be perceived as providing an honest assessment of the options. Voluntary sector organisations backed by industry are well placed to provide such services. The information that is required comes from undertaking a holistic assessment of need. Only then can the correct products and services be recommended. Once again, this assessment ought to be standardised across England and the products and services selected from a standard set. In this way, the quantity and quality of services that people receive can be assured across England. Here again, voluntary sector organisations backed by industry are well placed to provide such services.
74
Market Opportunities: The market for AL services Over time, Local Authorities have been increasing the eligibility thresholds for social care, which has resulted in an increasing number of people moving out of state-funded social care and into self-funded care. This change created a growing market for AL services. Opportunities for companies and third sector: ▪ ▪
101
As providers of information to social services and to individuals As independent brokers to navigate the range of social care services and products
http://services.parliament.uk/bills/2013-14/care.html
75
9
Health and Social Care Market Access in England
This section provides an overview of how health care and social care services are procured (purchased) in England and aims to provide a high-level overview of the essential information to enable suppliers/providers to understand the various procurement systems. It is also important to understand the difference between two key terms suppliers will come across when selling health and social care services: ‘commissioning’, and ‘procurement’.
9.1
Commissioning v Procurement
Commissioning is the process through which NHS health care services and some social care services are ‘purchased’ on behalf of service users. It is a continuous cycle made up of: ▪ ▪ ▪ ▪ ▪
assessing population needs prioritisation specifying requirements procuring services from providers monitoring the performance of providers
Procurement is the process of purchasing or procuring identified services. Services are purchased from the most appropriate providers through contracts and service agreements. Procurers of AL technology (telecare, e-health) will mainly be from the Social Services sector, but since the it is thepolicy of the UK government to integrate health and social services, including the commissioning ofthese integrated services, it is important to understand how procurement works in both sectors.
9.2
Who Commissions Which Services
Health and social care service commissioning and procurement in England is quite complex as there is no central purchasing system for both health and care services. Some services are commissioned nationally, others locally. Figure 26 provides a simple overview of the different organisations that commission health and social care services for the elderly on either a national or local basis.
9.3
Market Access: Procurement, Facilitation, & Influencing
It can be very difficult for a business to understand how to access the health and social care market, and which organisation to approach when they have solutions to sell. Some organisations commission products and services directly, others can influence commissioning decisions, whilst others exist to facilitate the entry of new and innovative solutions. Figure 27 provides an overview of the key organisations that comprise the health and social care ‘market’ in England and their market access roles. The Summary of the Health and Care System in England provides more information about these organisations.
76
Figure 26 Who Commissions Which Health and Social Care Services for the Elderly in England
Figure 27 Market Access: Procurement, Facilitation and Influencing 77
9.4
Market Access: Procurement of NHS Health Care Services
NHS health care services can be procured in 3 ways: 1. 2. 3.
Nationally, via NHS Supply Chain102 Regionally, via Collaborative Procurement Hubs Locally, via case-by-case engagement with individual healthcare organisations
NHS organisations can procure new or replacement health care services in one of two ways: 1. 2.
By requesting tenders (bids) for a large-scale contract that prospective providers can compete for (either individually or as part of a collaborative group) By securing small-scale contracts for individual patients to receive the services of their choice (from Any Qualified Provider, i.e. any provider who has been assessed as meeting rigorous quality requirements and able to deliver under NHS prices).
9.4.1 Tenders All Public Sector organisations have to abide by The Public Procurement Regulations 2006 which is the law that relates to Procurement and is common to all European member states following the European Procurement Directive 2004/18/EC. Under the current Procurement Regulations, services are categorised as Part A or Part B services. Health and social care services are categorised as Part B services, which means that more flexible procedures can be used when procuring these services, however, they must still adhere to the general principles of non-discrimination, equal treatment and transparency. CCGs may contract decision-making related to procurement and commissioning (implementation of new or replacement services) to other bodies, however they retain overall responsibility and accountability for these decisions. Commissioners are advised to select the Most Economically Advantageous Tender from those that they receive bids from, i.e. they should take risk and quality into account as well as face value. Table 6 UK Government Tenders Contract Value
Where advertised
Link
Under £10,000
UK Government's Contracts Finder (optional)
https://online.contractsfinder.businesslink.gov.uk/
£10,000 to £100,000
UK Government's Contracts Finder
https://online.contractsfinder.businesslink.gov.uk/
Over £100,000
UK Government's Contracts Finder
https://online.contractsfinder.businesslink.gov.uk/
Over €200,000 or of international interest
UK Government's Contracts Finder
https://online.contractsfinder.businesslink.gov.uk/
Official Journal of EU
http://www.ojeu.eu
Tenders Electronic Daily (Supplement to the Official Journal of the European Union)
http://ted.europa.eu/TED/main/HomePage.do
102
http://www.supplychain.nhs.uk
78
9.5
Framework Agreements
Different types of contractual arrangement exist, including Framework Agreements. If a public sector organisation knows they are likely to need particular products or services, but are not sure what will be needed or when, they can to set up a group of approved suppliers that they can use when necessary. This is called a ‘framework agreement’. The organisation will invite potential suppliers to put themselves forward for the framework and select the most suitable potential suppliers. Once the framework is set up, individual contracts are made throughout the period of the agreement. If there’s more than one possible supplier on the framework, a ‘mini-competition’ may be held to decide who gets the contract.103 Framework agreements can be national such as those produced by NHS Supply Chain, regional, or local, and usually last for a period of 4 years.
National National and regional framework contracts simplify the procurement process. These contracts also build credibility, meaning that commissioners are more likely to place orders with these providers/suppliers. However, national and regional framework contracts do not guarantee that many, or even any, orders will be placed. To make these contracts attractive to a large number of commissioners, they are usually relatively general and mainstream. NHS Supply Chain manages the purchasing and delivery of more than 620,000 products to more than 600 healthcare organisations across England. Providers can tender for inclusion in their online catalogue, NHS Cat, once every four years. This catalogue can be viewed at https://my.supplychain.nhs.uk/catalogue. An additional benefit of selling through NHS Supply Chain is that it can also help suppliers reduce costs by providing warehousing, freight and customer service for their products.
Regional Regional contracts can be drawn up for individual organisations, a specific group of organisations, or all organisations within a geographic region. Within the MALCOLM region, there are two Collaborative Procurement Hubs that specialise in managing these types of contracts: NHS Commercial Solutions for Kent, Surrey, Sussex and Medway, and PRO-CURE Collaborative Procurement Hub for Hampshire and Isle of Wight.
Local Most NHS procurement is made at the local level. It is necessary to procure locally if implementation of a new or replacement service requires redesign of a clinical pathway. Although local hospitals and GP surgeries are all under the NHS brand, they have considerably different needs and procurement processes. Nevertheless, the first point of contact within hospitals for prospective providers/suppliers is usually always the Procurement Department. This department will signpost the prospective provider/supplier to in-house clinicians in order to develop product champions and a business case to present to hospital directors. It is usually necessary for providers to have clinical champions in order to be procured through any of these access points. In order to gain the support of clinicians in this way, providers will need to have evidence of the benefits of their services, perhaps from a clinical trial.
NHS Contracts & Payment Mechanism The NHS Standard Contract can be used to procure services that meet baseline requirements. The NHS Tariff is a list of national prices that may be paid for these services, although there is some flexibility for commissioners to negotiate on these prices because of regional variations in demand and supply of different services. For 2014/15, existing providers have a 4% efficiency gain requirement to allow NHS commissioners to meet rising demand for the services that they offer their populations.
103 UK Gov, Tendering for public sector contracts, https://www.gov.uk/tendering-for-public-sector-contracts/theprocurement-process
79
To improve standards of care within the NHS, not only has the Standard Contract for 2014/15 been made more flexible, enabling a wider range of contracts to be secured, but all NHS providers must now develop an action plan for innovation. One formal way that the NHS is incentivising innovation beyond this baseline level is via the Commissioning for Quality and Innovation (CQUIN) framework and Quality and Outcomes Framework (QOF). NHS Commissioners may secure additional CQUIN monies totalling as much as 2.5% of their NHS Standard Contract spend for providers to deliver services above the baseline quality and innovation levels. Up to 0.5% of this money is set aside for innovations addressing national goals, which change each year. QOF provides an alternative source of additional funding for industry, as GPs who meet achievement thresholds in specific clinical areas, including chronic disease management (achievement thresholds are defined for each of the most common chronic diseases) are financially rewarded once a year.
9.6
Market Access: Innovative Solutions for the NHS
It can be very difficult for businesses developing innovative health care solutions to get these solutions adopted by the NHS. Organisations now exist to help businesses engage with the NHS and understand the potential of their innovations to respond to the unmet needs of the NHS. Whilst these organisations and funding opportunities facilitate innovation, they do not guarantee that the solutions will be adopted by the NHS.
9.6.1
Small Business Research Initiative (SBRI)
The Small Business Research Initiative (SBRI) 104 facilitates the development of innovative solutions to challenges faced by the health and other public sectors. This competitive funding programme generates new business opportunities for companies, provides SMEs with a route to market for their ideas and bridges the seed funding gap experienced by many early stage companies.
9.6.2
NHS Supply Chain – Innovation Scorecard
NHS Supply Chain105 provides healthcare products and supply chain services to the NHS. In addition their innovation programme is a service to business whereby market-ready innovations can be assessed as to their suitability for the NHS. Suitable solutions are then fast-tracked market and included in the Online and National Catalogues for the NHS in England, usually within a six months. and if appropriate, offered a quicker route to the NHS market. NHS Supply Chain uses an Innovation Scorecard106 to assess innovations and is designed for products beyond prototype stage which already have CE Marking, and evidence of clinical trials and health economics.
9.6.3
NHS Shared Business Services
The NHS Shared Business Services107 provides business support services, including procurement to the NHS. They can provide a route to market for suppliers in the following categories: purchased healthcare, clinical, business services; office and IT; estates & facilities; capital and pharmaceuticals. They also enable potential suppliers to submit innovative solutions for expert review108.
104
SBRI, https://sbri.innovateuk.org
105
NHS Supply Chain, http://www.supplychain.nhs.uk
106
NHS Supply Chain Innovation Scorecard, http://scorecard.nic.nhs.uk/SSCLogin.aspx#
107
NHS Shared Business Services, https://www.sbs.nhs.uk/procurement/information-for-suppliers
108
NHS Shared Business Services, Innovation review, https://www.sbs.nhs.uk/procurement/information-forsuppliers/innovation
80
9.6.4
NIHR Healthcare Technology Cooperatives (HTCs)
In January 2013, the National Institute for Health Research (NIHR) launched 8 Healthcare Technology Co-operatives (HTCs) which focus on key areas of unmet clinical needs. The ‘aims of the NIHR HTCs are to: •
Act as a catalyst for NHS “pull” for the development of new medical devices, healthcare technologies and technology-dependent interventions
•
Focus on clinical areas and/or themes of high morbidity, which have high potential for improving quality of life of NHS patients and improving the effectiveness of healthcare services that support them
•
Work collaboratively with patients and patient groups, charities, industry and academics.’109
9.6.5
NICE Medical Technologies Evaluation Programme (MTEP)
The Medical Technologies Evaluation Programme (MTEC) 110 run by the National Institute for Health and Care Excellence (NICE) enables businesses to submit innovative medical devices or diagnostic technologies for evaluation. This can result in a NICE recommendation for the product to be adopted by the NHS. However, these new medical technologies must provide equivalent or enhanced clinical outcomes for equivalent or reduced cost. Evaluation does not guarantee adoption by the NHS.
9.6.6
Academic Health Science Networks (AHSNs)
Fifteen Academic Health Science Networks (AHSNs) 111 have been established throughout England to create a step-change in the way the NHS identifies, develops and adopts new technologies through collaboration between industry, healthcare providers, universities, and local government. Each AHSN has a remit to engage with industry to identify, facilitate and encourage the adoption of technological solutions to healthcare needs within their region. There are two AHSNs in the MALCOLM Region: the Kent, Surrey Sussex AHSN, and the Wessex AHSN112.
9.6.7
Medilink Network
The Medilink UK Network113 comprises 8 independent regional Medilink organsations established to: ▪ ▪ ▪ ▪ ▪
support businesses in the health technologies sector – pharmaceuticals, biotechnology, medical devices, diagnostics, telehealth and telecare identify local, national and international market opportunities for business facilitate collaborations between academics, clinicians and industry engage with key players in the supply chain provide access to information and business support programmes
The South East Health Technologies Alliance (SEHTA) 114 is the Medilink for the South East region, and works closely with regional AHSNs to identify commercial opportunities for businesses.
109
NIHR HTCs, http://www.nihr.ac.uk/about/healthcare-technology-co-operatives.htm
110
NICE MTEP, http://www.nice.org.uk/About/What-we-do/Our-Programmes/NICE-guidance/NICE-medicaltechnologies-guidance 111
AHSNs, http://www.england.nhs.uk/ourwork/part-rel/ahsn/
112
AHSN map, http://www.emahsn.ac.uk/emahsn/national-map.aspx
113
Medilink UK, http://www.medilinkuk.com
114
SEHTA, http://www.sehta.co.uk
81
9.7
Market Access: Procurement of Private Healthcare Services
Private healthcare providers are responsible for almost 20% of the UK healthcare expenditure. It is an attractive option for industry to sell to private healthcare providers because 1) private hospitals are typically smaller than NHS hospitals, and 2) they do not have the same level of bureaucratic requirements to fulfil, meaning that procurement can usually be completed more quickly. Most private healthcare providers will adopt best practice with regard to procurement, advertising official tenders on their company websites and following similar evaluation processes to the NHS. Private healthcare providers sometimes contract their procurement out to specialist consultancies that can reduce the price of the services that they commission on behalf of all of their members through economies of scale.
9.8
Market Access: Procurement of Social Care Services
Social care services (personal and practical help) are procured by: ▪ ▪ ▪
Local Authorities Individuals Companies providing social care
Local Authorities are responsible for commissioning public health services and social care services for their local population, however, Local Authorities are moving away from providing social care services themselves to outsourcing these services. In addition, personal budgets and direct payments have moved responsibility for purchasing services to the individual assessed by the Local Authority as needing social care. Changes in eligibility to receive social care through the Local Authority means that an increasing number of people are purchasing care for themselves.
9.8.1.1
Personal Budgets (incorporated into Procurement Summary)
If a Local Authority contributes to the cost of an individual’s care at home, they can choose to receive this contribution as a Personal Budget. A personal budget is funding from the Local Authority allocated to an individual to pay for social care services of their choice, although these choices need to be approved by the local authority before they can receive them. A personal budget can only be used for social care services provided in a person’s own home (domiciliary care). The recipient can choose how their chosen services are provided: ▪ ▪
they can ask the Local Authority to arrange and pay for them on their behalf they can take their personal budget as a direct payment, and pay for them themselves.
9.8.1.2
Direct Payments
If a Local Authority contributes to the cost of an individual’s care at home, they can choose to receive this contribution as a Direct Payment. Direct payments are cash payments paid into a separate bank account that eligible individuals can spend on services to meet their eligible needs without needing to seek prior approval from their local authority. In this way, recipients are fully responsible for managing the money, organising and paying for their chosen services.115 Depending on the service, individuals may take on the responsibilities of an employer. Direct payments must be sufficient to enable the recipient to purchase services to meet their eligible needs, and must be spent on services that meet eligible needs. 115
http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS24_Self-directed_supportdirect_payments_and_personal_budgets_fcs.pdf?dtrk=true
82
For example, Direct Payments may be used by a recipient to: ▪ ▪ ▪ ▪ ▪
employ their own care workers buy services from a voluntary or private agency buy equipment or pay for home adaptations purchase other types of support to meet their assessed needs pay for a short stay of up to four consecutive weeks within any 12-month period in a residential care home.
Direct Payments cannot be used to: ▪
▪ ▪ ▪ ▪
pay a spouse, civil partner, live-in partner, or a close relative who lives in the same household as the recipient to care for them (except in certain circumstances that have been agreed with the local authority) buy services from the local council pay for permanent care in a care home. However,they can be used to pay for a short stay of up to four consecutive weeks within any 12-month period pay for services that the NHS has a duty to provide pay for services provided by housing authorities116,117.
9.9
Research Insights
▪
The UK’s health and care system could be much more ‘business friendly’. For organisations wanting to sell health and social care products and services, the routes into this market are complex and require an understanding of the roles that various organisations play in procurement and commissioning.
▪
The recent changes to the health and social care systems add a further layer of complexity, and challenges to understanding, and this complexity is likely to increase with the planned integration of health and social care.
▪
There is no readily available information from these care delivery organisations to help solutions providers to understand how to access this market.
▪
There is no single point of entry, with some services being commissioned nationally and others locally.
▪
Procurement of established, standardised, low technology health care products is more easily understood, and market access for these products is facilitated by organisations such as NHS Supply Chain.
▪
Market access for innovative and early stage solutions, including telehealth, telecare and AL, is much less straightforward. Organisations (such as those listed in this summary) do exist to help those with innovations and assessment of such solutions, but this is not a guarantee of market access. The future role of NICE in this area is still not clear.
▪
The process of getting innovations adopted, particularly within the NHS and by social care commissioners, can be very slow, making this market much less appealing for smaller SMEs.
▪
The social care market is perhaps a more attractive for AL solutions providers because the UK social care market is more privatised than the health care market, and it can be faster to access as the requirements for approvals/trials, etc. are often less involved. However, the routesinto this market are not always clear.
▪
It is recognised that for the NHS and social care system in the UK to rise to future challenges, especially that of saving money, it must be open to innovative solutions and embrace collaboration with industry as a means of co-developing solutions.
116
Age UK, Personal Budgets in Social Care, Sept 2012 http://www.ageuk.org.uk/documents/en-gb/informationguides/ageukig26_personal_budgets_inf.pdf?dtrk=true 117
Age Uk, Self-directed support: Direct Payments and Personal Budgets, Jan 2014 http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS24_Self-directed_support-
83
9.10 Good Practice This section contains examples of Good Practices, i.e. initiatives and projects with relevance to market access. More detailed information about each Good Practice is available in the MALCOLM project Catalogue of Good Practices.
The HealthTech and Medicines Knowledge Transfer Network funded a collaborative study 121 between SEHTA and Medilink West Midlands to provide an overview of where the opportunities lie within the UK for the development of the AL sector. The analysis of the data provides an initial guide for public sector organizations who are tasked with introducing AL services in their region, and for organisations in the voluntary and private sectors who are developing AL products and services.
9.11 Opportunities Policy Makers/government ▪
118 119
Market access is very difficult for innovating businesses. Although there are organisations and services aimed at innovation, the gap between introduction/evaluation and adoption needs to be bridged and speeded up.
Telecare LIN website: http://www.telecarelin.org.uk ALIP website: https://connect.innovateuk.org/web/assisted-living-innovation-platform-alip/overview
120
COMODAL project website: http://www.coventry.ac.uk/research/research-directory/allied-health/health-designtechnology-institute/health-design-technology-institute-research-projects/comodal/ 121
UK Assisted Living Capability Map, http://www.healthktn.org/capabilitymap/
84
▪
The slow uptake of innovative solutions means that there is a danger that innovating businesses will look to other markets, to the detriment of the UK’s health and care system.
▪
Whilst it has always been accepted that social care is not wholly funded, the change towards fewer and fewer people being eligible for Local Authority funded care means that policy makers have a role in managing expectations of the public, service users, care providers and industry.
Patients/Service Users ▪
The introduction of personal budgets and direct payments for social care has resulted in people requiring social care having more control and choice of service provider; individuals can be more creative about the solutions they choose to meet their care needs, and select those that compliment their lifestyle and support their current ‘circles of care’.
▪
The take up of personal budgets and direct payments is patchy as some Local Authorities do not have confidence in this approach.
Care providers ▪
The move towards outsourcing social care by Local Authorities means greater opportunities for independent providers.
▪
The introduction of personal budgets and direct payments for social care opens up a new market for care providers: the individual. This means that care providers could begin to deal directly with the end-user and will need to adjust their business model accordingly.
▪
Social care providers could explore the use of technology in the delivery of care to help them meet the challenge of having fewer resources to provide services to a greater number of people.
▪
As people increasingly incorporate technology into their daily lives, social care providers should anticipate and make provisions for an inevitable increase in expectation from the public to receive packages of care enhanced by technology.
Solutions providers, including third sector ▪
With the requirement for Local Authorities to provide information about social care options, there is an opportunity for organisations to provide information aimed at two potential markets: Local Authorities and individuals and their families.
▪
Obtaining an assessment prior to getting a statement of need is a “rate limiting step” in the provision of care. There is a need for the provision of rapid holistic assessment services that can inform the client of the products and services that could meet their needs, not only the ones provided by the statutory services.
▪
Understanding the range of social care solutions available in the market provides an opportunity for businesses to become ‘honest brokers’ or ‘navigators’ and provide these services to social care professionals, commissioners, and users.
▪
As more people become ineligible for Local Authority funded social care, the market of individual purchasers will grow. Consequently, solutions providers may need to consider a change of business model from B2B to B2C that is directed more towards end users.
85
Regional AL Competencies The following research summaries provide an overview of the regional competencies and capabilities in AL: ▪ ▪ ▪
Older People and Technology Current Assisted Living Activity Centres of Expertise.
86
10
Older People and Technology
This section provides an overview of older people’s attitudes to technology, what they use it for, and how acceptable would it be for delivering AL services to them.
10.1 Older People and Communication Technologies Since emerging over 15 years ago, digital communication technologies have been adopted by an increasing number of people in England. New innovative communications devices and services continue to be adopted by consumers across all age groups, albeit to a lesser extent by older people and those in lower socio-economic groups. Nevertheless, take-up for older people is increasing, and currently 67% of 65-74s and 32% of over-75s have home Internet access (up from 56% and 31% in 2013, respectively).
10.1.1
Mobile Internet connections
There has been particularly noteworthy growth in the adoption of mobile Internet technology over the past few years, with the number of people using a mobile phone to access the internet increasing from 122
24% in 2010 to 53% in 2013 . Although this growth is fastest among those aged 16-24, with Internet use over a mobile phone increasing from 43% to 89% over this period, there have been significant increases across all age groups, including from 2% to 9% of all people aged over 65 (see Figure 28).
Mobile phone Internet connections by age group, 2010-2013 100
Percent
90 80 70 60 50 40 30 20 10 0
16-24
25-34
35-44
45-54
55-64
65+
2010
43
44
30
21
9
2
2013
89
83
70
51
29
9
Figure 28 Mobile phone Internet connections by age group
122
ONS, Internet Access - Households and Individuals 2013, 8 August 2013, http://www.ons.gov.uk/ons/dcp171778_322713.pdf
87
10.1.2
Internet activities
In 2013, a quarter of all Internet users made telephone or video calls online, however only 9% of people aged 65 and over used the Internet for this purpose compared to 40% of people under 24 years old123. Figure 29 shows that the numbers of older people using the Internet to make purchases is continuing to increase. In recent years, this increase has been proportionately more significant for people aged 65 and over than for people in the younger age bracket, evidencing the tendency for the oldest members of society to be late adopters of new behaviours. The rate of people aged 55-64 using the Internet to make purchases (70%) is close to the national average across all adults of 74%.
People aged 65 and over making online purchases
Percent
80 60 40 20 0
2008 2009 2010 2011 2012 2013 2014
55-64 years
45
52
58
59
61
67
70
65+ years
16
20
22
27
32
36
40
Figure 29 Percentage of over 55s making purchases online Figure 30 shows the type of goods and services purchased online by those aged 65 and over. The most popular purchases were household goods (purchased by 18% of people aged over 65), books, magazines and newspapers (18%), holiday accommodation (15%), and clothing and sports goods (14%).
Internet purchases by type made by over 65s Other computer software and upgrades 4%
Video grames software and upgrades 2%
Computer hardware 3%
E-learning material Medicine 1% 3%
Clothes and sports goods 12%
Telecommunication services 4% Share purchase and insurance poicies 6%
Household goods 13%
Food/groceries 4% Travel arrangements 10% Electronic equipment 5%
Films and music (including downloads) 4%
Books, magazines and newspapers 11%
Tickets for events 7%
Holiday accommodation 10%
Figure 30 Internet purchase by type by over 65s 123
ONS, Internet Access - Households and Individuals 2014, 7 August 2014, http://www.ons.gov.uk/ons/dcp171778_373584.pdf
88
10.2 Skills of Older People to use Technology In 2013, Ofcom, the independent regulator and competition authority for the UK communications industries, developed its Digital Confidence Score, with 100 equaling the aptitude of the average adult in the UK to use communications products and services. As can be seen in Figure 31124, women of all ages have a lower Digital Confidence Score than men of a comparable age, and 61% of people aged over 55 register a below-average score. With regard to the Internet specifically, 53% of people aged 65+ in the UK report that they do not have basic skills. This percentage is expected to fall rapidly in the next decade as the equivalent percentage for the 55-64 years age bracket is only 16%125.
Digital Confidence Scores, by age and sex 120 115 110
Score
105 100 95 90 85 80 75 70 Male Female
6-7
8-9
10-11
12-13
14-15
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
100
104
108
110
114
112
110
108
108
107
107
100
100
97
92
92
87
82
97
102
104
109
112
111
106
104
100
101
96
92
89
92
90
87
82
79
Figure 31 Digital Confidence Scores by age and sex
10.3 Attitudes of Older People towards Technology Other than lack of digital skills and the associated anxieties towards technology, a common finding in studies aiming to understand behaviours towards technology is that lack of interest / awareness is a major barrier for the elderly to adopt technology. This is evidenced by the fact that 41% of people over 55 years old have never heard of 4G mobile technology, and 28% have never heard of smartphone / tablet applications124.
124
Ofcom, The Communications Market 2014, 7 August 2014, http://stakeholders.ofcom.org.uk/market-dataresearch/market-data/communications-market-reports/cmr14/ 125
BBC Media Literacy study, September 2013, http://www.bbc.co.uk/learning/overview/assets/bbcmedialiteracy_20130930.pdf
89
10.3.1
Enablers of Assisted Living technologies
Three main sets of circumstances tend to precede installation of assistive living technologies: 1. 2. 3.
change in health (fall, hospitalisation, progression in dementia, etc.) change in living arrangements (including bereavement) inheriting telecare (e.g. when moving into supported housing).126
Important enablers for people to accept these technologies include:
10.3.2
being able to trial the technologies money-back guarantees, extended warranties, etc. product aesthetics and positive, life-affirming marketing reliability good maintenance and servicing.127
Barriers to Assisted Living technologies
Because assistive living products are most often installed in response to an acute event rather than out of premeditated desire, end-users can feel a low sense of ownership and even intrusion towards these technologies. A number of potential barriers can make this acceptance more difficult. The top barrier for private purchasing of AL technologies is cost, although industry typically overestimates the significance of the initial cost barrier but underestimates the barrier attributed to long-term ongoing adoption. Other important barriers include:
lack of awareness of AL technologies and their benefits, including fear that they will replace human interaction lack of information / knowledge about where to purchase these technologies lack of national standards to enable comparison between competing products / services inappropriate design and marketing, either aimed at young people, promoting gimmicky features that do not interest the elderly, or aimed at the frail elderly, which most of the elderly do not identify with either anxieties associated with setting off causing inconvenience / setting off false alarms equipment complexity limited functionality, such as only being operational in the home insufficient training in its usage.127
10.4 Policy In April 2014, the UK Government launched its Digital Inclusion Strategy with the aim to boost the UK economy and strengthen its communities by getting 2.7million additional people online by 2016 and a further 25% every two years thereafter. 40 public, private and voluntary sector organisations have signed a Charter to commit themselves to achieving these goals. With the Digital Inclusion Strategy working to overcome the Grey Digital Divide, i.e. the low levels of internet connectivity in elderly people's homes, the next political challenge to overcome in order to encourage the elderly to be more accepting of assistive living technologies is for national standards to be established and enforced. This is important because it reassures prospective end users that the technology or service that they are looking to purchase / subscribe to meets basic safety and effectiveness criteria. UK-based Telecare Services Association is an established provider of quality assurance for its international portfolio of telecare service providers. However, the need for consistent standards to be
126
"Researching Telecare Use using Everyday Life Analysis: introducing the AKTIVE Working Papers", 2014
127
COMODAL project "Understanding consumer needs in a changing assisted Living market", 2014, http://www.comodal.co.uk/comodal/Comodal-Insight-to-industry.pdf
90
developed for a wider range of assistive living technologies across Europe has led to the recent development of the European Code of Practice for Telehealth Services by DNV-GL certification and assessment body (http://www.telehealthcode.eu/). Because the European Commission recognises the benefits that electronic and mobile Health (eHealth and mHealth, respectively) technologies could have for its member states, in 2012 it launched its eHealth Action Plan 2012-2020128 and in April 2014 it published its EU mHealth Green paper129. This Plan and Green paper provide guidance on data protection and security, safety and performance requirements, transparency of information, equal access to technologies and interoperability, all of which are potential barriers to adoption of AL technologies in general if not managed correctly.
10.5 Research Insights
People aged 65 and over are still significantly lagging behind other age groups in terms of interest and confidence in using technologies. This is reflected in their much lower uptake of technologies, including Internet access at home.
The Grey Digital Divide will almost certainly reduce to a fraction of what it currently is in the next decade because: people in the 55-64 age bracket, who have significantly higher digital confidence and Internet habits (such as online purchasing) much more in line with the national average, will age into the older age bracket the Digital Inclusion Strategy should equip the majority of people with Internet by 2020, providing the elderly with greater opportunity to improve their Digital Confidence Score and become more accepting of its usage.
A number of research projects have identified enablers and barriers to uptake of AL technologies by the elderly. It is in the interest of all stakeholders (public bodies concerned with health and social care, suppliers of AL technologies, and end users) that the enablers are supported and promoted and that the barriers are broken down or at least reduced. The European Commission is currently developing directives to achieve this.
10.6 Good Practice This section contains examples of Good Practices, i.e. initiatives and projects with relevance to older people and technology. More detailed information about each Good Practice is available in the Catalogue of Good Practices.
Activities that educate and train elderly people to use information and communication technologies in their everyday lives should help to allay their anxieties towards technologies and normalise their usage, increasing acceptance of AL solutions. An initiative being run within the MALCOLM region of relevance to this idea is "Dropby" is a small charity based in Surrey that offers a social networking platform for the over 60s to keep in touch.
128
http://ec.europa.eu/information_society/newsroom/cf/newsletter-item-detail.cfm?item_id=9156
129
http://ec.europa.eu/digital-agenda/en/news/green-paper-mobile-health-mhealth
130
http://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Report-Computers_and_the_internet.pdf
91
A number of MALCOLM regions have provided ways for their residents to trial assistive living products and services before choosing to pay for them: Since 2009, Community Alarm Telecare (CAT) scheme has provided around 8,000 of Surrey's residents with free telecare for up to 12 weeks after discharge from hospital. About 70% of end users purchased their telecare once the free period had expired. The findings from pilot studies motivated West Sussex County Council to contract AL technologies provider WELbeing to provide alarms to its residents upon discharge from hospital for free for up to 13 weeks since 2010.
10.7 Opportunities Policy Makers/government
Ofcom (the independent regulator and competition authority for the UK communications industries) produces an annual Communications Market report 124, which provides national data and analysis on broadcast television and radio, fixed and mobile telephony and broadband and mobile Internet. However, policy makers would find these data considerably more useful for targeting their efforts in reducing Digital Divides if they were available at a regional, if not county, level.
By engaging people with technology, such as through the Digital Inclusion Strategy, the efficiencies of local and national government services, including the NHS and Social Care departments, can improve significantly as it allows them to replace time-consuming paper-based systems with digital ones.
Equipping people with the tools (infrastructure, products and services and skills) to embraceAL technologies should help to improve patient responsibility, reducing the burden on national health and social care budgets.
Patients/Service Users
The benefits of information and communication technology to combating loneliness, providing education and information and assisting with daily living are well recognised. For this reason, training courses are available to all adults through further education colleges, community learning providers and websites, some of which are free and some of which have to be paid for. There is also publicly available content, such as on the BBC's Webwise webpages.
A large proportion of the people who could benefit most from using AL technologies are the same people who stand to directly benefit from the Digital Inclusion Strategy.
A number of public services, such as ordering repeat prescriptions, can now often be accessed and managed online. This repeated exposure to technology in daily living is helping people with low digital confidence to improve their skills and become more accepting of its usage.
Care providers
131
Equipping people with the tools (infrastructure, products and services and skills) to embrace AL technologies should help to improve patient responsibilisation, reducing the
http://www.uktelehealthcare.com/
92
financial burden on individual NHS and social care departments at a time when their budgets are being continually stretched.
The COMODAL project discovered that the most prospective consumers of AL technologies currently seek advice / information from healthcare professionals / specialists.127 Care providers are therefore well placed to direct the future of AL technologies in the UK, which they could use their advantage.
Solutions providers, including third sector
Ofcom (the independent regulator and competition authority for the UK communications industries) produces an annual Communications Market report 124, which provides national data and analysis on broadcast television and radio, fixed and mobile telephony and broadband and mobile Internet. This report may help solutions providers to define their strategies so that they give themselves the best opportunity to see return on investment.
It is in the interest of solutions providers to take the enablers and barriers of assistive living technologies identified in various research studies into account when developing and selling their products and/or services.
The COMODAL project discovered that the biggest discrepancy between industry and consumer perspectives concerned where prospective consumers of AL technologies currently seek advice / information: industry greatly overestimated the percentage that would search the internet, as the vast majority relied only on signposting by healthcare professionals / specialists.127 This finding should motivate solutions providers to target their efforts at educating and supporting healthcare professionals / specialists to promote their technologies.
The pre-disposition of the population aged 55-64 to purchase goods and services online suggests that AL technologies will be purchased online to a greater extent in the future.
Television has proved a resilient audio-visual broadcast medium, and has evolved to encompass digital technology, with smart TVs starting to provide Internet access. Consumption of TV increases with age - the over 65s spend on average 5.7 hours a day watching television compared to an average of 3.9 hours for the typical viewer in 2013. With access to the Internet via TV becoming more widely available, this may be relevant to the delivery of AL services for the older demographic in the near future.
93
11
Regional Assisted Living Activity
11.1 Suppliers of Products and Services Figure 32 below illustrates private companies selling products and services into the AL market. The chart includes companies whose primary area of business is manufacturing and / orselling the following products and services:
Telecare: Telecare products and services only, includes devices and managed services Telehealth: Telehealth products and services only, includes devices and managed services Telecare & Telehealth: Combined Telecare & Telehealth products and services, includes devices and managed services Environmental Control: Home automation and Environmental Control solutions Communication aids: Including Video Conferencing solutions and products and services for people with Dementia, Learning Disabilities and Sensory loss. Care Technology: Devices and services to support care workers delivering AL services in the community
Statutory Telecare and Telehealth providers are excluded from these figures unless they provide a privately managed service option.
Figure 32 Suppliers of AL products and services by region (Source: Medilink UK)
94
The South East has 42 organisations involved in AL. The Technology Strategy Board’s Assisted Living Innovation Platform (ALIP) has a directory132 of technology suppliers ranging from traditional Telecare and Telemedicine through to Environmental control and Memory support and Prompting devices, that can be searched on by region. There also several national and multi-national large companies which have some interest in AL, including: Johnson and Johnson, O2, Vodafone, Fujitsu, Siemens, Hitachi, Microsoft, GE Healthcare, Serco, Nokia, Panasonic, Novartis, Pfizer, Siemens, Research in Motion (Blackberry), Orange, Honeywell.
11.2 National AL Projects and Initiatives National initiatives designed to support and underpin the mainstreaming of Telecare and Telehealth have been included because of their relevance to the MALCOLM project and potential impact upon the adoption of AL in other regions and at scale.
11.2.1
The Preventative Technology Grant
The Preventative Technology Grant was a centrally-funded grant to kick-start mainstream telecare services that funded a number of the trials occurring in 2006-8 below. £80 million was made available by national government to local authorities: £30 million in 2006-7 and £50 million in 2007-8 (shared between the local authorities based on their need profiles).133
11.2.2
Whole Systems Demonstrator
In 2006, the Department of Health announced the establishment of three pilots, known as the ‘Whole System Demonstrators’, to test the benefits of integrated health and social care supported by AL technologies like telecare and telehealth. WSD was set up to look at cost effectiveness, clinical effectiveness, organisational issues, effect on carers and workforce issues. The programme aimed to provide clear evidence to support important investment decisions and show how technology can support people to live independently, take control and be responsible for their own health and care. The randomized trial (the largest of its kind) was launched in May 2008 (ended 2010) and involved 6,191 patients and 238 GP practices from three areas of England: Cornwall, Kent (in the MALCOLM region) and Newham. Patients either received telehealth or acted as controls by receiving usual care. Three thousand and thirty people with one of three conditions (diabetes, heart failure and COPD) were included in the telehealth trial. For the telecare element of the trial people were selected using the Fair Access to Care Services criteria. The trial lasted 12 months for each participant and reported 15% fewer A&E admissions, 20% fewer emergency admissions, 14% elective admissions, 14% fewer bed days, 8% lower tariff costs and 45% lower mortality rates for the intervention group compared to the control group.134 The first set of initial findings from this programme was made available in December 2011. They show that, if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in A&E.
132
Technology Strategy Board Assisted Living Directory, https://connect.innovateuk.org/web/assisted-livinginnovation-platform-alip/assisted-living-directory 133
www.ice-ageing.eu/?page_id=1617
134
"Whole System Demonstrator programme: Headline findings - December 2011" https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215264/dh_131689.pdf
95
The programme was one of the most complex trials ever undertaken by the Department of Health and will continue to provide useful information as the analysis continues, in particular as the industry awaits the final results for telecare.
11.2.3 Delivery Assisted Living Lifestyles at Scale (dallas) The Technology-Strategy Board funded Delivery Assisted Living Lifestyles at Scale (dallas)135 programme is thinking beyond traditional health and social care to consider how new technology can be used to improve the way people live. The dallas programme, developed by the UK’s innovation agency, the Technology Strategy Board, and joint funded by the National Institute for Health Research and the Scottish Government, tasks four consortia with running this huge scale innovation programme and testing it with communities throughout the UK. The consortia have been awarded £25 million of government money, to which they’ve added their own financial contributions. The total investment in dallas, improving health, wellness and quality of life for UK older adults, is £37.3 million. By the summer of 2015, the dallas programme aims to involve nearly 170,000 people across the UK in the dallas programme, benefitting from new and innovative products, systems and transforming their choices as they age. The four dallas consortia consist of: ▪ ▪ ▪ ▪
Living It Up (Scotland) Mi – Liverpool (North West England) iFocus (National) year Zero
11.2.3.1
Living It Up
A digitally, enabled, thriving community of opportunities to support better health, wellbeing and active lifestyles in Scotland. Highlights to date ▪ ▪
▪ ▪ ▪ ▪ ▪
LiU soft launch 3 Key LiU service prototypes delivered; Hidden talents Exchange Keeping connected Community support roles created to aid the project managers in adding content and guides for digital channels. Community engagement developed further to reach out to the first group of people to get involved in the pilot Recruitment and Marketing campaign deployed to engage the first group of people in the project Digital channels open – TV, Web and mobile Target popn +1500 individual people were recruited to test and feedback on the LIU service
More information at http://livingitup.org.uk
11.2.3.2
Mi – More Independent (Liverpool)
Enabling people to take control of their own health, wellbeing and lifestyle through the use of technology. Mi (More Independent) is a Government-funded initiative that is being piloted across four UK regions. Liverpool has been chosen as one of the pilot areas. The Mi partnership is funded by the Technology Strategy Board, which finds ways to boost the UK economy through technological innovations. Mi has been designed to: ▪ ▪
135
enable you to take charge of your health, wellbeing and lifestyle use technology to allow you to feel safer and live more independently in your own home
Technology Strategy Board Dallas project, https://connect.innovateuk.org/web/dallas
96
▪ ▪
give peace of mind to yourself and your family reduce the amount of time you have to spend on appointments, by supporting you to manage better at home
Mi offers a wide range of ways to increase independence, some of which are aimed at those with health needs. But it is also suitable for people who are looking ahead, and planning the next stage of their lives. The gadgets offered – Life Enhancing Technologies – can help you live more independently, monitor your health, make everyday life simpler, and help you stay in touch with your family or carers. They offer security, and the chance to take control. One of the key focuses of Mi Liverpool was to develop a Smart House in Liverpool. You can also see a version of it on the Mi website136. The Smart house shows you a selection of the different tools that are available, and the ways they can change your life. More information at http://www.moreindependent.co.uk
11.2.3.3
i-focus
The dallas programme is made up of four communities, with the i-focus project supporting all four, and includes two main themes of interoperability and Warm Neighbourhoods®. The aim of the i-focus partnership is to improve how AL technology is used and deployed at pace and scale across all dallas communities. i-focus aims to help the dallas communities develop their system architectures to support interoperation between all the multiple services and multiple suppliers, across the programme. i3i is a concept developed under dallas aimed at bringing industry, commissioners, consumer interests and other stakeholders together to collaborate on agreed standards, interoperability and common approach. The vision is to create a framework where innovation can happen more easily, and solutions can be adopted with more confidence and with more choice. It is conceived in line with similar initiatives in digital television and mobile communications, where pre-competitive collaboration has created world standards and opened up opportunities that would not have happened if competitive forces alone had operated. The intention is that i3i continues the interoperability work begun under i-focus in dallas, but that it extends beyond dallas scope and timescale to address the entire market interests of UK industry. The first areas of interest for i3i are mHealth Apps and Digital Telecare, but there will be others, perhaps including Accessibility for Disabilities. 2.
Undertake the Pilot for Warm Neighbourhoods
Following the positive response to last winters' small scale pilot of the prototype Warm Neighbourhoods informal reassurance service for people at an early stage of their vulnerability to be supported by their families, friends and neighbours, i-focus will now be developing detailed plans to further explore the potential of offering such a service commercially by undertaking a large scale prototype deployment. The intention is to support a deployment to around 200 - 250 vulnerable people who, together with their families, friends and neighbours in their 'neighbourhood', will represent a total of around 750 1000 service users. ADI, who have led this development through their i-focus project, will continue to work with the Health Design and Technology Institute and Carers UK working closely with its potential channel partner over the coming months to help them develop and deploy this prototype service. More information: http://ifocus-dallas.com
136
More Independent website, http://www.moreindependent.co.uk/life-enhancements/smarthouse/
97
11.2.3.4
Year Zero
Year Zero is a three year programme that brings together expertise in healthcare, design, media and technology to develop user-centred tools that will deliver new digital healthcare services and enable citizens to take greater control of their own health and wellbeing. The program is a partnership between five leading NHS providers and five innovative companies, including Illumina Digital, a Digital Life Sciences company. Year Zero will create a suite of innovative digital services and apps each of which will be supported by, or interact with, an individual’s Personal Health Record (PHR) – an online record owned by the patient, allowing them to add and organise personal health information, as well as to integrate health records from different providers, and share this with other individuals and institutions at will. ▪ ▪
Alpha Version of a Better Plan has been rolled out with NHS partners Currently rolling out the parental version of the E-Redbook
More information: https://connect.innovateuk.org/web/dallas/year-zero
11.2.4 3 Million Lives The 3 million lives (3ML) campaign was motivated by the results from Whole Systems Demonstrator in support of the Department of Health's belief that at least 3 million people would benefit from telecare/telehealth in this country. Launched in December 2011 3 million lives (3ML) is underpinned by the idea of service integration to improve patient care and outcomes. When different services and sectors work together towards shared goals, patients get far more flexible, better, and more appropriate care. To achieve true service integration, NHS England recognise that 3millionlives needs to be delivered through a genuine partnership across NHS England – facilitating collaboration between clinicians, and empowering patients to better self manage their conditions, with the use of technology. They also recognise this cannot be achieved through technology alone – the key will be to deliver service transformation through realising the potential of that technology to support clinicians, patients and carers. Under the overall leadership of NHS England Medical Directorate, 3 million lives will be delivered by combining clinical advocacy, service improvement and technology strategy – making it a true partnership and synergy within NHS England. NHS England is committed to the delivery and success of 3millionlives, and they are confident that this approach will put 3millionlives right at the heart of their ambition to deliver High Quality Care for All.
11.2.4.1
3 Million Lives Pathfinder Sites 137
3Million Lives aims to help at least three million people with long term conditions and/or social care to benefit from the use of telehealth and telecare services. The seven pathfinder sites have agreed contracts with industry to ensure that 100,000 people benefit from technology in 2013. The pathfinder sites are: ▪ ▪ ▪ ▪ ▪ ▪ ▪
Worcestershire (3 CCGs and Worcestershire County Council) NHS Merseyside North Yorkshire & York and Humber PCT Cluster (will involve the CCGs as they develop) NHS South Yorkshire & Bassetlaw (Sheffield, Barnsley Rotherham, Doncaster and Bassetlaw PCTs but will include CCGs as they develop) Kernow CCG and Cornwall & Isles of Scilly PCT NHS Kent & Medway (8 Kent CCGs, Kent Community Health Trust and Medway Unitary Authority) Camden CCG (with UCL Partners)
Seven Pathfinders, one of which is Kent and Medway in the MALCOLM region, were set the target for 2012 to equip 100,00 people with telecare, as the first step towards meeting the 3 million target by
137
http://3millionlives.co.uk
98
2017. These Pathfinders awarded contracts to industry suppliers so that the telecare technologies could be provided at no upfront cost138. However, none of the Pathfinders came close to reaching their targets, meaning that the 100,000 target was far from achieved (by September 2013 only 2,368 of the 10,000 target had been achieved - in Medway they only achieved 19 of their 250 target, despite inheriting equipment from Whole Systems Demonstrator)139 The 3 ML initiative has come time at a bad time for the NHS and Local Authorities as they (particularly CCGs) have a huge agenda of other changes to implement besides adopting telehealth. The ambition is still there but as the report from E-Health Insider140 makes it clear it will take a lot longer to achieve the goal. The most oft cited explanation for this is that improving the quality of life for 3 million people with chronic conditions is about change management and care pathway re-design not merely about technology. For more information see: http://www.3millionlives.co.uk Both initiatives support the development of the elective market, which aims to put the patient and carer at the centre of procurement. The elective market includes healthcare services and products that can be procured or purchased directly by the individual or carer. Many Telecare and Telehealth products and services can be purchased directly from providers outside of statutory provision. The elective market is essential to the growth of the AL sector as it encourages the development of a competitive market, which in turn drives down cost. The elective market alsoencourages the self-care agenda, which places greater responsibility on the individual to manage their own health. Encouraging greater own health responsibility is one of the most important objectives of the reforms going forward. This will significantly reduce the burden on services but can only succeed if theAL sector is allowed to grow, enabling it to provide a full range of cost effective products and services to meet the growing demands. Innovation is recognised as an essential part of the future of the NHS. The development of Academic Health Science Networks (AHSNs) across England resulted from the 2011 report Innovation Health and Wealth: accelerating adoption and diffusion in the NHS.
11.2.5 Academic Health Science Networks NHS England has confirmed the designation of 15 new Academic Health Science Networks (AHSNs). AHSNs have the potential to transform health and healthcare by putting innovation at the heart of the NHS. This will improve patient outcomes as well as contributing to economic growth. AHSNs present a unique opportunity to pull together the adoption and innovation with clinical research and trials, informatics, education and healthcare delivery. They will develop solutions to healthcare problems and get existing solutions spread more quickly by building strong relationships with their regional scientific and academic communities and industry. The AHSNs provide an important mechanism for achieving step-change in the way the NHS translates research, innovation and best practice in to effective and cost-effective treatments and services for patients. They will help to develop better technology and make better use of the skills of NHS staff. The designated AHSNs are: ▪ ▪ ▪ ▪ ▪ 138
East Midlands Eastern Greater Manchester North East and North Cumbria North West Coastal www.ice-ageing.eu/?page_id=1617
139
Whole System Demonstrator programme: Headline findings - December 2011" https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215264/dh_131689.pdf 140
E-Health Insider, Lis Evenstad, http://www.ehi.co.uk/news/EHI/8375/pathfinders-losing-their-way) 11 February 2013
99
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Imperial College Health Partners Oxford South London South West Peninsula Kent, Surrey and Sussex UCL Partners Wessex West Midlands West of England Yorkshire and Humber
11.3 Regional AL Projects/Initiatives in Health and Social Care 11.3.1
East Sussex
Eastbourne was one of three control sites (the others being Isle of Wight and Medway) for Department of Health's Telecare South East Region Project in 2004 with the aim to raise the profile of telecare and create evidence for its benefits (supervised centrally by DH's Health and Social Care Change Agent Team). All sites already had established alarm services but Eastbourne was awarded £45,000 by the commissioning body for the government's Supporting People programme (part of adult social care in East Sussex) to demonstrate the use of telecare in four pilots: 1. 2. 3. 4.
Intermediate care Extra Care Hospital discharge Older people with mental health needs
The hospital discharge trial was run for 5-6 people in the Eastbourne Downs area under the partnership of Eastbourne Borough Council, Lewes District Council, Wealden District Council, Tunstall, Vivatec, Occupational Therapy Services in Health and Social Services, East Sussex Social Services and East Sussex Healthcare Trust. The participants were issued with the Tunstall Lifeline System and the Vivatec wristcare system (worn like a watch, it detects user condition from skin conductivity measurements).
11.3.2
Brighton and Hove
Extended Primary Integrated Care Project (2014-2015) In April 2014 20 GP collaborations in Brighton were awarded £1.8million of the Prime Minister's £50million Challenge Fund to implement "Extended Primary Integrated Care", including through the use of telecare, for one year141.
11.3.3
Medway
Medway Telecare South East Region Project (2004-5) Medway was one of three control sites (the others being Isle of Wight and Eastbourne in East Sussex) for Department of Health's Telecare South East Region Project in 2004 with the aim to raise the profile of telecare and create evidence for its benefits (supervised centrally by DH's Health and Social Care Change Agent Team). All sites already had established alarm services but £70,000 was raised for Medway's project by their IT steering group, £40,000 of which was spent on IT systems and £30,000 of which was spent on occupational therapy services to demonstrate the use of telecare to support vulnerable people in home (independent living, fewer health and social services interactions and faster discharge from hospital back home) and avoid hospital admissions in partnership with social services. This activity was part of Medway's e-government plan. The 30 participants were issued with Tunstall
141
http://www.england.nhs.uk/south/2014/04/16/bright-pmfund/
100
Lifeline base units and a variety of different monitors and sensors (fall, smoke, bogus caller, motion, flood, heat). These participants came from five different groups: falls, dementia, hospital discharge, socially isolated and geographically located. The project was run by Medway Council, Tunstall Health Promotion, Medway PCT and Medway's Lifeline Service for one year153.
11.3.4 11.3.4.1
Kent Biz4Age (2013- )
Biz4Age is the combination of two INTERREG 2 Seas projects: CURA-B & 2 Seas Trade, and lead by Anglia Ruskin Higher Education Corporation in partnership with Kent County Council amongst others, with the remit to provide assistance to SMEs to bring products that contribute to healthy ageing to market, thereby improving the quality of life & reducing public expenditure142. Kent's aim for April 2013-14 was to increase the use of telecare and telehealth in the county to 10,000 as part of the 3 million lives scheme143. 2,103 of the Whole Systems Demonstrator participants were from Kent.
11.3.4.2
Whole Systems Demonstrator (2008 -)
Whole Systems Demonstrator was one of the most complex and comprehensive Department of Health studies. This randomised control trial was launched in May 2008 and one of the three trial sites was Kent.134 2,103 of WSD's participants were from Kent. Kent is one of the Department of Health's 14 Integration Pioneers tasked with testing methods for bringing about integrated care in order to understand best practices. There is £3.8 billion available for this project, but the money is only available to the project partners so that they can provide support and advice to the Pioneers. The Pioneers are expected to set aside 2% of their budget for this program. They will receive support for up to five years. During this time they will be monitored centrally to check their progress against their plans and they will be stripped of their status if they lose their way. Kent is one of the largest Pioneers in terms of population. Kent's Integration Pioneers involves collaboration with Kent County Council, Kent CCGs, East Kent Hospitals Trust, Kent and Medway Commissioning Support Unit, Kent Community Trust, Kent and Medway Commissioning Support Unit and Social Care Commissioning Trust and Swale Borough Council. The overarching aims of Kent's Pioneer team are: 1. 2. 3. 4. 5.
achieve greater patient independence, reduce acute care and care home admissions, create new workforce for delivering integrated care, create 24/7 community-based care models, create (electronic) patient-held care records, and 6) extend fully integrated personal budget for health and social care.
Contact Jo Toscano,
[email protected], 01622 694931144,145
11.3.4.3
KCC Telehealth Development Pilot
Kent Telehealth Development pilot (2005 - 2007) Kent County Council funded Kent's Telehealth Development Pilot, which had 250 participants with COPD, CHD and/or diabetes, and ran from March 2005 until December 2007. 179 participants continued to use the equipment once the trial had finished.146
142
http://www.interreg4a-2mers.eu/clusters/approved-clusters/applied-research-innovation-and-businessSupport/biz4age/en 143
www.elmi.co.uk/insight/analysis/1076/two-thousand-lives
144
http://www.icase.org.uk/pg/cv_blog/content/view/89070/network?cview=87280&cindex=13
145
"Kent submission for the Department of Health’s Integration Pioneer Programme", 28 June 2013
101
11.3.4.4
KCC Telecare Pilot (2004)
Kent County Council ran a Telecare Pilot in 2004, which saw 1,000 homes in Kent fitted with telecare products. 750 of these homes chose to continue using the equipment once the pilot had ended 146. The percentages of participants that had the following sensors/detectors installed were147: Passive infra-red motion sensor, 33% Bogus caller alarm, 41% Pull cord, 28% Smoke detector, 66% Fall detector, 41% Bed/chair occupancy sensor, 1% Property exit sensor, 1% Lifeline alarm unit, 93% Pendant alarm, 86% Extreme temperature sensor, 19% CO2 detector, 3% Flood detector, 23%
11.3.5 11.3.5.1
Hampshire Portsmouth
Portsdown Group practice (five GP practices covering Portsmouth and the surrounding area) are building on the findings from Whole Systems Demonstrator to trial OBS Medical's touch-screen tablets and peripheral devices for physiological monitoring and daily questions that are monitored by a Specialist Nurse in Medvivo. 100 COPD patients are involved in the trial (run in partnership with Solent NHS Trust), and after 6 months GP home visits were reduced by 85%, unplanned hospital admissions were reduced by 57%, GP appointments were reduced by 67% and A&E attendances were reduced by 52%. They are currently extending this trial to chronic heart failure and diabetes 148. Funding for this trial came from a Strategic Health Authority innovation grant. Dr. Neal of Portsdown Group Practice is a local and national pioneer for telehealth.
11.3.5.2
Telehealth pilot
Southern NHS Trust currently working with Tunstall on a one-year telehealth pilot involving 300 machines. 80 patients have been recruited so far. An assistive Technology Project Manager has been appointed to develop the business case. Portsmouth County Council's website includes a virtual tour of a smart home they have built.
11.3.5.3
Telecare Infrastructure Pilots
Portsmouth received £106,684 for 2006-7 and £177,099 for 2007-8 from the Preventative Technology Grant to set up robust telecare infrastructure (on top of the existing Community Alarm Service) and test them through pilot schemes (evaluated by the Centre for Healthcare Modeling and Information at
146
"Promoting and sustaining independence in a community setting: Kent Telehealth Evaluative Development Pilot"
147
"Piloting telecare in Kent County Council: The key lessons", Alzaszewski (2004)
148
"the link" quarterly magazine of Telecare Services Association, Summer 2013 edition
102
University of Portsmouth). 20 people at risk of falls took part in the falls pilot, and 20 people with dementia took part in the medication pilot (alert was raised if they had not taken their medication by a set time). Telecare Coordinator for these pilots was Rosanne Brown,
[email protected],023 9268 8394149. Docobo provided the telehealth equipment (doc@HOME) for Solent (Southampton and Portsmouth) NHS's COPD Interreg III trials PEACE (Personal care environments delivering support for vulnerable people) from September 2008 until November 2011, and PEACE anywhere (Personal care environments anywhere at any time) from October 2009 until December 2012. These trials were awarded £1.74 million and £2.429 million respectively and involved Southampton PCT, Age UK, HW Communications and Chubb Electronic Security Systems. More than 100 COPD patients trialled Docobo's Healthhub across Southampton and Portsmouth, resulting in 242 fewer admissions to acute services between 2009 and 2011150. In their "Directed Enhanced Services" announcement, Government encouraged GPs to offer telehealth to their patients. Portsmouth CCG is citing this to conduct a 12-month trial for text messaging for their stroke patients - "Florence" project, financed by NHS Stoke. They are keen to roll it out to hypertension, diabetes and kidney failure patients too. The texts request that vital signs, medication compliance, etc. information are returned. Portsmouth County Council Project Manager for Assistive Technologies is Katie Cheesman.
11.3.5.4
Southampton
Docobo provided the telehealth equipment (doc@HOME) for Solent (Southampton and Portsmouth) NHS's COPD Interreg III trials PEACE (Personal care environments delivering support for vulnerable people) from September 2008 until November 2011, and PEACE anywhere (Personal care environments anywhere at any time) from October 2009 until December 2012. These trials were awarded £1.74 million and £2.429 million respectively and involved Southampton PCT, Age UK, HW Communications and Chubb Electronic Security Systems. More than 100 COPD patients trialled Docobo's Healthhub across Southampton and Portsmouth, resulting in 242 fewer admissions to acute services between 2009 and 2011151. Southampton was one of twelve sites to run projects in 2008-11 alongside Whole Systems Demonstrator to test telecare and telehealth innovations. These projects formed the WSD Action Network, made up from regions that were unsuccessful in being a main WSD site and tasked with performing action research. NHS Southampton focused on telehealth for COPD and CHD, interoperability between telehealth and telecare systems and its out-of-hours community alarm.152
11.3.5.5
Isle of Wight - DH Telecare South East Region Project
Isle of Wight was one of three control sites (the others being Medway and Eastbourne in East Sussex) for Department of Health's Telecare South East Region Project in 2004 with the aim to raise the profile of telecare and create evidence for its benefits (supervised centrally by DH's Health and Social Care Change Agent Team). All sites already had established alarm services but IoW received funding to demonstrate the use of telecare for people who have fallen/are at risk of falling. This involved spending £55,000 to upgrade WightCare's Lifeline system to support the Tunstall Lifeline and falls monitors that participants were issued with. Partners in this project include Social Services, IOW Housing Association, Community Equipment Service, IOW Social Services Commission, District Nurses, Falls Coordinator at St Mary's Hospital, Tunstall and Wightcare153.
149
"Telecare in Portsmouth", Telecare Knowledge Network, University of Portsmouth, 2007
150
"doc@HOME digital care platform: An EU Success Story - From an RTD Project to a delivered service"
151
"doc@HOME digital care platform: An EU Success Story - From an RTD Project to a delivered service"
152 153
Perspectives on telehealth and telecare ", Giordano et al., King's Fund. Department of Health's "Getting started with telecare South East Region Project", Belinda Thorpe (2004)
103
11.3.6 11.3.6.1
Surrey COMODAL (Consumer Models for Assisted Living) (2011-2014)
The 3-year COMODAL (COnsumer MOdels for Assisted Living) project, funded by the Technology Strategy Board, aims to support the development of a consumer market for electronic AL technologies (eALT). It focuses on those people aged 50-70 who are approaching retirement and older age to gain an in-depth understanding of the barriers to market development and create consumer led business models developed through collaboration with consumers, industry and the third sector. Innovations include a direct and unique focus on the consumer (rather than statutory) retail market, social innovation techniques (co-creation, active consumers, user led design) and a multi sector partnership between the Health Design & Technology Institute (Coventry), Age UK (National), Grandparents Plus, Years Ahead and South East Health Technology Alliance (SEHTA) (Surrey). As a result of the COMODAL project there is an improved understanding of the issues around consumer potential and eALT market growth. The project findings have been presented to the eALT industry and others interested in ‘breaking in’ to the market. Interest in the findings and consumer insights has ignited debate around adapting their business model approaches to this market. As a result of the findings from the COMODAL project, four consumer-led business models were developed to enable companies to see how they could work differently in this new market. The value proposition, new partnerships and new service proposals are key to these business models and they encourage companies to think differently and approach the eALT market using consumer insights. The Columba project was a telecare and rehabilitation scheme run in NW Surrey between March 2003 and March 2004 by established teams and individuals (Surrey Social Services, North Surrey PCT, Runnymede Borough Council, Careline and Tunstall). 25 participants received short-term residential rehabilitation in Brockhurst Dementia Unit, followed by telecare. This resulted in two-thirds being diverted from residential care and no hospital readmissions in that time period.154 A 3-month telehealth pilot for COPD patients (55 participants) was run in 2003. Participants measured their O2 SATs, pulse and weight and also received a call from a nurse every day. This led to a drop of about 50% in hospital admissions. Surrey's 24 hour "Telecare Visiting Response Project" was trialled in Elmbridge in collaboration with their Reablement Team and Surrey Fire and Rescue for six months, starting in September 2013. This project allows people without two named friends/family members available for contact in an emergency (or who do not wish to nominate two people because they do not wish to be a burden on family/friends) to also receive telecare services, naming fire and rescue as their first responders instead155. The project is currently being coordinated and managed by Mole Valley District Council telecare call centre, but it is anticipated that it will be rolled out across the county. Surrey County Council has made the delivery and mainstreaming of telecare a core ambition of its Adult Social Care Directorate Service Plan for 2011/12 - 2014/15156. Waverley and Guildford councils were awarded £151,205 from the Preventative Technologies Grant to run "Safe at Home", which began after September 2007. "Safe at Home" consisted of six pilot telecare projects157: 1. Hospital discharge (50 participants) 2. Monitored smoke detectors 3. Passive falls monitoring (20 participants) 4. Prescription compliance and dementia support scheme 5. Dementia monitoring in enhanced extra care schemes 154
"The design of pilot telecare projects and their integration into mainstream service delivery", Barlow (2003)
155
http://www.surreycc.gov.uk/ data/assets/pdf_file/0008/721682/Q2-2013-14-Directorate-Priorities-Report.pdf
156 157
www.surreycc.gov.uk/-data/assets/pdf_file/0016/721501/ASC-24-Hours-Visting-Response-EIA.pdf "South West Surrey Safe at Home Project Evaluation Report", Horton and Anderson (2007)
104
6. Monitoring for Chronic Obstructive Pulmonary Disease (Tunstall Safe 21 Telemedicine monitoring units) Guildford Borough Council’s Central Emergency Communications Service (CECS) played a key role in liaising with the project teams and the service users and referrers in these projects. Medvivo is currently working closely with Surrey County Council to engage their CCGs, GPs, care providers, hospital trusts and patients to design and deliver telehealth services 158. This partnership was announced August 2013. The Medvivo dedicated Senior Project Manager is Julie Shuter.
11.3.7
West Sussex
West Sussex County Council won £439,787 for 2006/7 and £733,094 for 2007/8 from the Preventative Technology Grant to run four telecare/telehealth pilots with 150 participants in 2007: 1.
2. 3. 4.
Long-term conditions telehealth packages (HomMed Genesis and Doc@Home, approx £2,000 each) linked to Community Matrons and a Heart Failure Specialist Nurse in Horsham and Chanctonbury area. 3-month hospital discharge telecare packages in the western part of the county Dementia resource centre in Worthing Intermediate care and admission avoidance in Worthing
These findings from these pilots led to another project, this time focused on telecare for hospital discharge and intermediate care and admission avoidance only 159. As a result of this second project, WELbeing has been contracted since 2010 to provide alarms and other necessary telecare products to vulnerable people discharged from hospital, free at the point of use for up to 13 weeks. The contract is for approximately 200 connections per month160.
11.3.8 Local Councils and NHS Trusts There are approximately 22 projects in telehealth and 48 projects in telecare being undertaken in the South East. Further details of these telecare and telehealth projects and services in the South East and the rest of England can be found at the following Google map links (last updated spring 2011): Telecare Services Map: http://maps.google.co.uk/maps/ms?hl=en&ie=UTF8&msa=0&msid=100406857045032193451.0004540c223f16f2 d1c 9d&ll=52.842595,-1.867676&spn=8.339986,18.676758&z=6 Telehealth in England Map: http://maps.google.co.uk/maps/ms?hl=en&ie=UTF8&msa=0&msid=100406857045032193451.00047bfad6341183c8 523&ll=54.329338,-1.604004&spn=8.052625,18.676758&z=6 Several organisations and groups are currently planning further projects e.g. Kent County Council, Surrey County Council, collaborators in Buckinghamshire, and the Wessex HIEC (see Section 7). Some are also bidding into the Technology Strategy Board funding programme DALLAS (Delivering Assisted Living Lifestyles At Scale).
158
www.medvivo.com
159
"West Sussex Preventative Technology Grant: Preventative Technology Strategy - Part 2, Long-Term Strategy Document v2.0 June 2008" 160
"Lifeline Service: Overview and Scrutiny Commission", June 2013
105
11.3.8.1
Southern Health NHS Foundation Trust
Based in Southampton, Southern Health provides an extensive range of physical and mental health services across Hampshire and has just completed an initial trial of telehealth.161
11.4 Policy In the Department of Health's "The Mandate: A mandate from the government to NHS England: April 2014 - March 2015162 one of the objectives is "enhancing quality of life for people with long-term conditions", particularly by "embracing opportunities created by technology". NHS England are legally required to pursue these objectives, and their progress is measured using the NHS Outcomes Framework. The Department of Health recommends that new telecare/telehealth trials be run in collaboration with existing local authority bodies (which may already have telecare/telehealth within their remit). These bodies include Integrated Community Equipment Services (responsible for buying, delivering, collecting, maintaining and decontaminating community loan equipment to keep people independent and safe in their homes), Local Strategic Partnerships (non-statutory, non-executive organisation of representatives from the public, private, business, community and voluntary sectors that make strategic decisions about the community) and Supporting People arrangements (housing related support services)163. 41.7% of polled local authorities in the country offer telecare as part of their Integrated Community Equipment Service package164.
11.5 Research Insights Ever larger scale AL development and implementation projects are being undertaken. Theneed for a new method of delivering health and social is not in doubt, nor is the UK technical capability to do it. The technical and regulatory infrastructure that allows both the statutory sector and the private sector to provide AL services is being put in place. The remaining hurdle is toconvince care providers to use AL products and services routinely, and to convince thepublic that AL is the way of the (near) future.
11.6 Opportunities Following the Whole System Demonstrator (WSD) the government has announced that 3 million lives could be improved through the use of AL products and services. This gives an enormousboost to industry to introduce the products and services currently in development and to engage with clinicians and future users to develop those of the future.
161
http://www.buildingbetterhealthcare.co.uk/news/article_page/Southern_Health_secures_CQUIN_funding_following _successful_telehealth_programme/91568/cn45810?dm_i=8EU,1UFH7,84PHSC,6LT9I,1 162
UK Gov, http://webarchive.nationalarchives.gov.uk/20130922140506/https://www.gov.uk/government/publications/the- nhsmandate 163
webarchive.nationalarchives.gov.uk/+1www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic yAndGuidance/Browsable/DH_5464318 164
http://www.gloucestershire.gov.uk/extra/CHttpHandler.ashx?id=54711
106
12
Regional Centres of Expertise
This section provides an overview of the national and regional centre of expertise in e-health, telehealth, telecare and AL.
12.1 National Centres of Assisted Living Expertise 12.1.1 The Technology Strategy Board The Technology Strategy Board (TSB)165 is the UK's innovation agency, offering support and funding to help businesses develop new products and services and bring them closer to market. Established by government they are a business-led executive non-departmental public body sponsored and financed by the Department for Business and Innovation and Skills. In 2007 the TSB launched the Assisted Living Innovation Platform, which ran until 2012. The aim of this platform was to fund impactful projects that addressed the challenge of AL for the ageing population and also for people with long-term conditions so that they can live with greater independence166. The platform was lead by the HealthTech and Medicines Knowledge Transfer Network, which is one of 15 national networks (of networks) tasked with supporting a technologyspecific sector (here the health technology and medicines sector) by connecting individual innovative communities within the sector via events, meetings, workshops, special interest groups, newsletters, access to reports and advice on TSB calls as well as providing help with aspects of innovation167. The Transfer Network also leads the Telecare Learning and Improvement Network.
12.1.2 The Telecare Learning and Improvement Network The Telecare Learning and Improvement Network (LIN) 168 is the national network supporting local service redesign through the application of telecare and telehealth to aid the delivery of housing, health, social care and support services for older and vulnerable people.
12.1.3 Foundation for Assistive Technology (FAST) The Foundation for Assistive Technology169 is a national charity focused on tackling the inadequate design of products and services for disabled and older people. They work at the national and strategic level to: ▪ ▪ ▪ ▪ ▪
165
raise awareness document all UK activity into research and design work on national level projects provide expert analysis of research and development trends and challenges promote good practice.
www.innovateuk.org
166
https://connect.innovateuk.org/web/assisted-living-innovation-platform-alip/about-us
167
https://connect.innovateuk.org/web/healthktn
168
http://www.telecarelin.org.uk
169
www.fastuk.org
107
12.1.4 The Kings Fund The King’s Fund170 is a charity that aims to understand how the health care system in England can be improved with the intention of helping to shape policy, transform services and bring about behavioural change. Telecare and Telehealth is one of the topic areas that the Fund covers in detail. In particular, the Telehealth Evidence Database is a free resource for anyone looking for information on telecare, telehealth and the management of long-term conditions. The database is updated weekly and holds 1,000 records of publications, journal articles and web resources.
12.1.5 The Telecare Services Association The Telecare Services Association (TSA) 171 is the industry body for telecare and telehealth. They are not-for-profit and membership-based, with more than 370 members, including Local Authorities, social landlords, health providers and the private sector (services, technology, infrastructure, etc.)
12.1.6 UK Telehealthcare UK Telehealthcare is a membership-based organisation for all telecare and telehealth professionals, service providers, CCGs, registered social landlords and suppliers in the UK. Their aim is to raise the profile of telecare/health services and their members. They organise events and workshops.172
12.2 Regional Centres of AL Expertise 12.2.1 Kent Whole System Demonstrator The Kent Whole System Demonstrator (WSD) project is one of 3 projects that aim to support individuals with longer-term and complex health and social care needs through the creation of multidisciplinary teams at PCT and local authority level. The teams will develop integrated care plans, and where appropriate, advanced assistive technology will be deployed in the home to support the provision of care. The aim of the demonstrators will be to show that we can help people with more complex needs maintain their independence, achieve significant gains in quality of life and reduce unnecessary acute hospital and care home use. In December 2011, headline findings from the three WSD projects across England were published. The early indications show that if used correctly telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly they also demonstrate a 45% reduction in mortality rates.173, 174
170 The Kings Fund, http://www.kingsfund.org.uk/topics/technology_and_telecare/index.html 171 172
http://www.telecare.org.uk www.uktelehealthcare.com
173
The Kings Fund, WSD Results, http://www.kingsfund.org.uk/applications/site_search/?term=Kent+whole+system+demonstrator&searchreferer_i d=20177&submit.x=28&submit.y=13 174
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131684
108
12.2.2 Surrey Telecare Surrey Telecare175 is a Local Council Partnership Initiative to promote the benefits of a Community Alarm or Telecare system in your home, or the home of a close relative or friend, and peace of mind it brings.
12.2.3 South East Health Technologies Alliance (SEHTA) The South East Health Technologies Alliance (SEHTA)176 is part of the national Medilink network and has a considerable background in AL through its membership (which includes companies active in AL, statutory sector bodies and universities) and through its funding initiative, International Centre of Excellence in Telecare (ICE-T), which stimulated the development of 10 new innovative AL products and services.
12.2.4 University of Portsmouth University of Portsmouth has active telecare/telehealth researchers in its Centre for Healthcare Modelling and Informatics (part of Computing department): 9 academic staff, 2 associate academic staff, 4 research and administration staff and research students.177
12.2.5 University of Surrey University of Surrey has active telecare/telehealth researchers in its Centre for Research in Nursing and Midwifery Education178, Department of Healthcare Management and Policy 179 and Faculty of Health and Medical Sciences180. It is pioneering the development of 5G telecommunications at its 5G Innovation Centre, which has been awarded £32million of public and private (mobile operators and infrastructure providers) funding.
12.2.6 University of Kent, PSSRU University of Kent are partnered with the London School of Economics to form the Personal Social Services Research Unit (PSSRU) 181. PSSRU have been conducting independent research into social and healthcare since 1974. They undertake policy analysis, research and consultancy in the UK and abroad. The Personal Social Services Research Unit was established in 1974 and now has branches at three UK universities: the University of Kent, the London School of Economics and Political Science, and the University of Manchester. Its mission is to conduct high quality research on social and health care to inform and influence policy, practice and theory. The University of Kent's Centre of Health Service Studies also has active telecare/telehealth researchers182.
175
Surrey Telecare, http://www.surreytelecare.com/
176
South East Health Technologies a/lliance, www.sehta.co.uk
177
University of Portsmouth, www.port.ac.uk/site-search/?q=telecare
178
www2.surrey.ac.uk/healthandsocialcare/people/khim_horton
179
www.surrey.ac.uk/hcmp/people/jane_hendy
180
www.surrey.ac.uk/fhms/research/healthcarepractice/people/wendy_knibb.htm
181
PSSRU, http://www.PSSRU.ac.uk/
182
www.kent.ac.uk/chss/staff/associates/alaszewski-a.html
109
12.2.7 Wessex Health Innovation and Education Cluster (HIEC) The Wessex HIEC183 hosted by the University of Southampton was one of 17 funded following a competitive bidding process, leading to broad coverage across England. The Wessex HIEC, which covers Hampshire, IoW, Southampton and Portsmouth, was founded in 2010 using Department of Health funding, and since 2012 they have been self-sufficient. The Wessex HIEC has telehealth and telecare as one of its three core themes. Docobo is their partner for pilot work on telehealth and telecare services in the region. Their aim is to improve understanding, facilitate knowledge transfer and bring about positive change in telecare and telehealth services. They organise free workshops, seminars and events, facilitate networking and meetings and provide information about funding. They have more than 40 health and care organisations as members. University of Southampton also has active telecare/health researchers in their School of Health Services184.
12.2.8 Telehealthcare Network The Telehealthcare Network185 was established in 2009 by the Department of Health South East Adult Social Care and Local Partnerships team to share knowledge and good practice in telehealthcare in recognition of the increasing importance of assistive technology in the fields of health and adult social care. Network meetings are held quarterly. All members have a primary interest in telehealthcare and work in the health service, an independent organisation or one of the 19 local authorities in the South East region.
12.2.9 Healthcare over Internet Protocol CIC Healthcare over Internet Protocol Community Interest Company, based in Hampshire, works to develop a body of knowledge around, and encourage the uptake of, personal healthcare and wellness services delivered via internet/web technologies. It provides consultancy, research, innovation broking, collaboration and project management services. It is involved in a number of regional, national and European research collaborations, typically as lead partner, working with industry (from global infrastructure providers to local SMEs), the third sector, local authorities, academia and trade associations186.
12.3 Policy Through its own direct funding and through the Technology Strategy Board, the government has been investing in the development of new AL products and services, and consequently, thecreation of expertise in this sector. Many of these new products will have the opportunity to be tested at scale in the SBRI-funded DALLAS187 initiative, and other AL initiatives.
183 184
Wesex Hiec, http://www.wessexhiecpartnership.org.uk/ https://search.sharepoint.soton.ac.uk/Pages/results.aspx?k=telecare&submit=&s=Health+Science
185
Telehealthcare Network, http://www.hscpartnership.org.uk/networks/telehealthcare/index.aspx
186
http://www.hoip.eu/about-us
187
DALLAS, Technology Strategy Board Dallas project, https://connect.innovateuk.org/web/dallas
110
MALCOLM Project Assisted Living Glossary Abbreviation/Term
Explanation/Definition
Activities of daily living
Activities of daily living are basic personal care tasks: • Eating (feeding and preparing meals) •
Bathing and washing (personal hygiene and grooming)
•
Dressing
•
Toileting (including continence-related tasks)
•
Walking and transferring (such as moving from bed to wheelchair)
Other tasks that enable people to live as independently as possible include: • Managing finances •
Travel (driving or using public transit)
•
Shopping
•
Using the telephone and other communication devices
•
Managing medication
•
Housework and basic home maintenance
Acute care
Medical and surgical treatment usually provided by a hospital. Usually care for diseases or illnesses that progress quickly, feature severe symptoms or have a brief duration.
Adult Social Care
There is no single definition of adult social care. It covers a wide range of services provided by local authorities and the independent sector to adults either in their own homes or in a care home, e.g. help with washing, dressing, feeding or assistance in going to the toilet, meals-on-wheels and home help for people with disabilities. It also includes services provided by day centres.
Adult Social Care
Adult social care services include the commissioning and provision of home care, meals, equipment and adaptations, day services, residential and nursing home care. It also includes the mechanisms for delivering these services, such as individual and carer assessments, personal budgets and direct payments, and adult protection procedures (Law Commission 2011) http://www.scie.org.uk/publications/ataglance/ataglance45.asp
Adult Social Care
Adult social care includes preventive services, assessment and care management, nursing and residential homes, community services (home care, day care, meals), reablement to prevent hospital admission or enable continued independence, intermediate care (after a spell in hospital), supported and other accommodation, individual budgets and direct payments to service users, safeguarding, and the provision of equipment. Service users may include older people, adults with learning disabilities, or mental health issues, and with physical or sensory impairments. Source: http://www.thinklocalactpersonal.org.uk/_library/Resources/SouthEast/Legacy/Ot her_Improvement/A_Short_guide_to_Adult_Social_Care_Commissioning_for_GP_c onsortia_members_Other_Report.pdf
Adult Social Services (UK)
Support services provided by a Local Authority following an assessment of need
AL
Assisted Living
Assisted Living
Assisted Living is the development and use of sensor and information and communication technologies (ICT) to facilitate the remote delivery of care and support to people to improve their quality of life and allow them to live as independently as possible in the lowest intensity care setting, consistent with their needs and wishes.
Assistive Technology
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 Any equipment or system that assists people who have difficulties owing to age or disability in carrying out every day activities, e.g. walking stick or helping hand*
Attendance Allowance
Attendance Allowance is a state benefit paid by the Department of Work &
111
Pensions to UK residents aged 65 yrs who have personal care or supervision needs. Attendance Allowance is not taxable, is not based on national insurance contributions, and is not means-tested. Autonomie (Fr)
UK equivalent = Independence
Care Package
Following an assessment, a care package is agreed to enable a patient to receive care appropriate to their needs. Where necessary this covers both NHS and social care.
Care Plan
Care plans are written agreements setting out how care will be provided within the resources available for people with complex needs.
Care Network
A network of health and social care professionals from different organisations working together across institutional and local boundaries to provide care.
Carer
A person who provides a substantial amount of care on a regular basis, who is not employed to do so by an agency or organisation. Carers are usually friends or relatives looking after someone at home who is elderly, ill or disabled.
Commissioning
Commissioning is the process through which NHS health care services and some social care services are ‘purchased’ on behalf of service users. It is a continuous cycle made up of: ▪ assessing population needs ▪ prioritisation ▪ specifying requirements ▪ procuring services from providers ▪ monitoring the performance of providers
Community Care
Network of services provided by local authority social service departments, the NHS and volunteers, designed to keep people independent and able to live in the community rather than in institutional care; for example, older people, people with physical disabilities, learning disabilities or mental health problems. Services are often provided in the home.
Community Care Assessment
A community care assessment is a social care needs assessment carried out by a Local Authority and used to decide whether a person needs a community care service and whether it can be provided by the local authority.
Community Care Services
Community care services are provided or arranged by the local authority. They are defined in section 46 of the NHS and Community Care Act 1990, and include: ▪ Assistance in the home -home help/care or a personal assistant ▪
respite in various forms
▪
day care
▪
night-sitting services
▪
care in a care home
▪
provision of aids and equipment to help with daily living tasks and for home safety
▪
provision of home adaptations and disability equipment
▪
pre-prepared meals delivered to an individual
▪
advice and information about services and welfare benefits
▪
preventive and rehabilitation services
▪
services to meet psychological, social and cultural needs
▪
assisting in placement in various types of supported housing
▪
community transport
▪
services in conjunction with health and other services where needs overlap
▪
services to help you work or access education.
Clinical Commissioning Groups (CCGs)
Clinical Commissioning Groups (CCGs) are groups of GP practices & other health professionals that are responsible for commissioning - choosing and buying services for their local population.
Clinical Senates
Clinical Senates are comprised of clinicians, patients and other partners, and give advice to commissioners and providers of health and social care services
Conseil Général
An elected council responsible for the administration of a French administrative
112
‘Department’. It is broadly equivalent to a County Council in the UK. Community care
This is care enables people to maintain their independence within their own homes wherever possible.
Data security
The measures taken to ensure that, once collected, personal data is kept safe and secure from potential abuse, theft, or loss. We need to ensure definitions comply with the EU Directive 95/46/EC - The Data Protection Directive – and other national standards
Deprived Area
Geographic regions or areas that have significantly higher levels of unemployment and lower rates of income per head than the national average.
Direct Payments
Direct payments are cash payments made to individuals who have been assessed as needing services, in lieu of social service provisions. (Dept of Health)
Domiciliary Care
Personal and practical care provided to support an individual living in their own home, either alone or with a relative or other carer. Also known as ‘Home Care’
Economic Infrastructure
The networks and systems in energy, transport, digital communication, flood protection, water and waste management. These are all critical to support economic growth. Infrastructure networks enable people, goods, energy, information, ideas, water and waste to move efficiently around a country and, in some cases, across its borders.
e-health
An umbrella term for a combination of telehealth and telemedicine
e-health company
An organization developing or supplying products/services as part of the care pathway supply chain: diagnose/prescribe – monitor – response.
Elective services
AL products or services that are available to users, carers and other members of the general public
Extra Care Housing
All forms of specialist housing for older people where care services are provided or facilitated. This includes extra care housing, assisted living, very sheltered housing, close care and continuing care environments, and care villages. EAC Definition.
Framework Agreement (for public procurement)
A framework agreement is a general term for agreements with providers that set out terms and conditions under which specific purchases (call-offs) can be made throughout the term of the agreement. In most cases a framework agreement itself is not a contract, but the procurement to establish a framework agreement is subject to the EU procurement rules.188
Good practice
A good practice is an innovation: a new way of doing a new thing, a new way of doing an old thing, or an old way of doing a new thing; in a new context
Home Care
Personal and practical care provided to support an individual living in their own home, either alone or with a relative or other carer. Also known as ‘Domiciliary Care’
Hospices
Hospices provide residential, respite and care at home for people who have a terminal illness. Hospice care includes medical, emotional, social, practical, psychological, and spiritual needs, as well as the needs of the person’s family and carers.
Help for Independence (FR) what is the French term?
In France, this is a grant provided by the Conseil Generale (broadly equivalent to a County Council) to cover part of the expenditure to enable older people & those who are unwell to pay for support to stay at home, e.g. personal care, shopping,
Local Authority
A Local Authority is an organization responsible for the administration of a local area. Local Authorities vary throughout England and could be for example, a county council, district council, London Borough or Unity Authority.
Mutuelle or Police (?) complémentaire
Complementary to the state healthcare provision, a Mutuelle is a compulsory, contributory, health insurance policy paid for by an individual that makes up the difference between what the state contributes and most of the cost of treatment. It is compulsory for those in work to contribute. If unemployed, contributions to the Mutuelle are paid for by the state to a state-nominated Mutuelle.
188
OGC Guidance on Framework Agreements in the Procurement Regulations https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/62063/ogc-guidance-frameworkagreements-sept08.pdf
113
NHS
National Health Service is a publicly-funded organization in England responsible for the delivery of health care that is free to all residents at the point of delivery.
NHS-funded nursing care
NHS-funded nursing care is care provided by a registered nurse, paid for by the NHS, for people who live in a care home.
NHS Health care provider
An NHS Health care provider is an organization acting as a direct provider of health care services
Locum
A locum or sessional doctor is a fully qualified GP who works at the practice on a temporary basis to cover the regular doctors when they are away from the practice, for example on holiday or on maternity leave.
Old-age dependency ratio
The number of people of pension age and over for every 1,000 people of working age. (Kings Fund)
Old age support ratio
A measurement of how many people of working age (20-64) relative to the number of retirement age (65+). The lower the ratio, the fewer younger people there are to support the over 65s.
Pension Credit
Pension Credit is an income-related benefit made up of 2 parts - Guarantee Credit and Savings Credit. Guarantee Credit tops up weekly income to £148.35 (for single people) or £226.50 (for couples). Savings Credit is an extra payment for people who saved some money towards their retirement, e.g. a pension. (Gov.uk)
Personalisation
Personalisation means that every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings. (Dept of Health)
Personalised budgets
An amount of funding allocated to a user after a social services assessment of their needs that allows them to control, which services that funding, is used to purchase. Users can either take their personal budget as a direct payment, or while still choosing how their care needs are met and by whom - leave councils with the responsibility to commission the services. Or they can have a combination of the two.
Procurement
Procurement is the process of purchasing or procuring identified services. Services are purchased from the most appropriate providers through contracts and service agreements.
Primary care
Healthcare delivered outside hospitals. It includes a range of services provided by GPs, nurses, health visitors, midwives and other healthcare professionals and allied health professionals such as dentists, pharmacists and opticians.
Reablement
This is specialised help for people to regain the skills and confidence they need to continue living independently at home. Reablement services are currently available to people leaving hospital and people requesting social care support for the first time.
Rehabilitation
Any treatment, therapy or process that helps return a person to health. It aims to support people to achieve the highest possible quality of health and life within their circumstances and within the resources available.
Secondary care
Care provided in hospitals: Specialised medical services and commonplace hospital care, including outpatient and inpatient services. Access is often via referral from primary care services
Social Care
Social Care is the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships. (Department of Health 2006)
Social Services
These are local authority departments that provide direct services in the community to clients.
Smart-home (domotics)
A smart home is a dwelling incorporating a telecommunications network that connects electrical appliances and environmental sensors such that the home conditions can be automatically adjusted or remotely monitored
State Pension Age
The state pension age is the earliest age that a person can claim their state pension.
Statutory Services
Services that must be provided by law, e.g. NHS hospital treatment, social services and the provision of schools.
114
Telecare
The delivery of social care services to an individual using a combination of information and communication technologies and sensor technologies. This term is used in the UK, but not in France, where telecare is included under telemedicine.
Telehealth
The exchange of physiological data between a patient in one location (usually at home) and medical practitioners in another location (usually in a hospital)l to assist in health management and care planning
Telemedicine (FR)
The legal definition (telemedicine decree of 2010): Medical procedure, performed remotely by a device using ICT: Teleconsultation Telexpertise Telemonitoring Remote medical support
Telemedicine (UK)
The UK uses the World Health Organisation’s definition: “The practice of medical care using interactive audiovisual and data communications, this includes the delivery of medical care, diagnosis, consultation and treatment, as well as health education and the transfer of medical data.” (WHO) Telemedicine is the practice of medical care using interactive audiovisual and data communications to enable remote diagnosis
Telemonitoring
The act of remote monitoring but emphasizing the role of telecommunications
Tertiary care
Tertiary care is specialised consultative health care in a facility that has personnel and equipment for advanced investigation and treatment. Patients are referred from secondary care organisations.
Third party monitoring
A third party monitoring organisation is an organization or service that responds to information or activity initiated by another party, e.g. a doctor or a patient 1st party = initiator, e.g. doctor, 2nd party = recipient, e.g. patient, 3rd party = responder, e.g. call centre.
Third Sector
Non-governmental organisations which are run on a not-for-profit basis and which are not part of the public sector. Third Sector Organisations include small local community and voluntary groups, large and small registered charities, foundations, trusts, social enterprises and co-operatives. They are also referred to as Voluntary, Community and Social Enterprise (VCSE) sector organisations
Third Sector organisations
The third sector organizations include: ▪ community associations, self help groups, voluntary ▪
organisations, charities, faith-based organisations, social enterprises, cooperatives
▪
and mutual organisations. They display a range of institutional forms, including
▪
registered charities, companies limited by guarantee (which may also be registered
▪
charities), community interest companies, industrial and provident societies
▪
unincorporated associations.
115
