designing scalable assistive technologies and services for independent healthy living and...

Technology Strategy Board

Assisted Living Innovation Platform (ALIP 3&4)

Economic & Business Models and Social & Behavioural Studies

‘SALT’

Designing Scalable Assistive Technologies and Services for Independent Healthy Living and Sustainable Market

Development in the Mixed Digital Economy

Key Findings

Project Leader & Principal Investigator

Professor Feng Li

Cass Business School, London

[email protected]

Date: August 2014 Ref: 2377-25137

mailto:[email protected]

SALT Final Report – Sustainable Business Models for Assisted Living Technologies and Services

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Contributing Researchers Institution

Professor Feng Li (PI) Cass Business School, City University London

Dr Ali Ziaee Bigdeli Cass Business School, City University London

Dr Festus Oderanti Business School Plymouth University

Dr Xiaohui Shi Cass Business School, City University London

Dr Rob Wilson Business School, Newcastle University

Professor Mike Martin Business School, Newcastle University

Prof John Wildman Business School, Newcastle University

Dr Peter McMeekin Institute of Health & Society, Newcastle University

Dr Katie Brittain Institute of Health & Society, Newcastle University

Dr Gary Pritchard Institute of Health & Society, Newcastle University

Dr Tracy Finch Institute of Health & Society, Newcastle University

Professor Louise Robinson Institute of Health & Society, Newcastle University

Professor Peter Wright School of Computing Science, Newcastle University

Professor Patrick Olivier School of Computing Science, Newcastle University

Dr John Vines School of Computing Science, Newcastle University

Graham Armitage Institute of Ageing & Health, Newcastle University

Dr Lynne Corner Institute of Ageing & Health, Newcastle University

The Funders This Project is funded by the Technology Strategy Board (TSB), with contributions

from the NHS National Institute for Health Research (NIHR), the UK Economic and

Social Research Council (ESRC) and our business partners, under the Assisted Living

Innovation Platform Programme (ALIP3 & 4): Economic & Business Models and

Social & Behavioural Studies.

Project Manager

Mr Daniel Martin – Newcastle University


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Contributing Partners Representatives

Fran O’Brien

Christopher Curry, David Rimmer

Daniel Heery, Kevin Wood

Stephen Hope, Sylvain Laxade

Greg Moorhouse, Glenn Carroll, Ryan Smith

Rutger Zietsma

Carl Brown, Alan Sanderson, Catherine Smith

Prof Peter Gore, Prof Garth Johnson

David Silver


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Steering Committee Institution

Pamela Denham (Chair) Chair of Project North East, Board Member of

Newcastle Primary Care Trust, Age Concern,

Years Ahead and the Institute for Ageing and

Health

Professor Tom Kirkwood Newcastle University

Professor Paul Watson Director of Digital Economy Hub, and Director of

Digital Institute, Newcastle University

Professor John Bond Prof of Social Gerontology and Health Services

Research, Institute of Health and Society

Professor Gail Mountain Professor of Assistive Technology, Sheffield

University

Professor Cam Donaldson Director of Yunus Centre for Social Business and

Health, Glasgow Caledonian University

Professor Carl May Professor of Healthcare Innovation, University of

Southampton

Gary Mouton Product Manager (Ageing Products), Accessibility

Business Unit, Microsoft Corporation

Phil Isherwood Chairman of the British Healthcare Trades

Association and Chief Executive of Nottingham

Rehab Supplies

Penny Hill The NHS Information Centre, Member of the

National Information Governance Board

Tommy Lovell Public Governor of Northumbria Healthcare NHS

Foundation Trust, Managing Director of Kablefree

Ltd

John Eaglesham Chief Executive, Advanced Digital Institute. West

Yorkshire

Gerald Wistow Government Advisor on social care policy; Visiting

Professor of Social Care, Durham University

Jim Greer Project Manager. North East improvement and

Efficiency Partnership (NEIEP)

Claire Horton Project Manager, Adult & Culture Services

Directorate, Newcastle City Council

Graeme Woodcock Director, Motorola Healthcare, UK


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Background of the SALT Project

This research investigates Sustainable business models for Assisted Living

Technologies and services (SALT) in the ageing society, in the context of the digital

economy. The current health and social care systems in the UK are not sustainable

duo to rapidly growing demand from the ageing population. There is insufficient

capacity and resources to simply maintain the current level of service provision, let

alone improving them. Indeed, in the current economic climate of austerity and

spending cut, the resource base is shrinking while demands continue to increase

rapidly. The radical changes to the NHS in England outlined in the government

whitepaper may further exacerbate the problem. Meanwhile, the heavy burden on

individual informal carers is likely to grow much further very rapidly. All these are

taking place against a background of growing demands for improving the mental and

emotional wellbeing of older people and enabling their independent healthy living in

communities.

Rapid developments of Assisted Living Technologies and Services (ALTS) offer

significant opportunities for addressing the challenges in the ageing society, both by

reforming existing provisions and by facilitating new market developments. These

technologies and services have mostly been designed and developed as a way of

supporting older people to remain independent for longer and to 'age in place'. The

uptake and use of ALTS, however, is complex and under-utilised, moreover the role

that informal carers have in using and implementing ALTS for their spouses or older

members of their family is often not acknowledged. The vision of the UK government

is to liberate the NHS by putting power into the hands of patients and clinicians,

removing layers of management. One way in which this may be achieved is by

general practice forming GP consortia. It is hoped that this shift in power will bring

decision-making closer to patients.

Traditionally, technological systems have often been developed almost entirely from a

commercial perspective, and therefore are often detached from a deep understanding

or consideration of the environment or users of the technology. Concerns over high

rates of abandonment of assistive devices have led to attempts to match individuals

more closely to the assistive devices that are being developed. Integrating

technologies into everyday life is complex and often involves hidden problems for


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users, in modifying the design and way in which these technologies are used. There

are a range of important human, social and organisational factors that either promote

or inhibit the successful adoption or use of technologies in people’s lives.

Understanding and highlighting these factors is vital in design processes for ALTS,

and it opens up new avenues for sustainable market development. It calls for the

development of sustainable and scalable new business models to align social

objectives of caring for the old with robust business principles to ensure these

products and services are affordable and usable.

SALT project has therefore adopted an integrated, multi-perspective approach to

address this significant societal challenge in the ageing society by focusing on three

key elements.

More radical reform in current health and social service provision is urgently

needed, by developing innovative solutions that are viable, scalable and

sustainable to improve their efficiency and effectiveness. The enormous

complexity and practical difficulties involved necessitates a co-construction

approach by creating the context in which different stakeholders can explore,

discuss and make sense of the complex relationships and conflicting demands,

and negotiate and co-develop consensus and plausible and workable solutions.

This will facilitate significant reforms within the current health and social care

provision to improve efficiency and effectiveness and reduce costs. Such an

approach can also be extended to address senstitive issues of private-public mix

where public services work with private busineses in health and social care

services. In particular, it enables the effective exploration of community

initiatives and ethical businesses which are likely to play a key role in future

healh and social care.

The growing demand for health and social care from the rapidly ageing

population also calls for new market development for assisted living products and

services in a mixed digital economy. Market development for ALTS has been

both slow and fragmented. In fact, even for many pilot projects that have been

deemed successful often fail to scale up or become financially sustainable once

the initial funding has run out. Important lessons can be learnt from other sectors

that have successfully deployed new business models to promote sustainable new

market development. This project has identified new business models to support


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sustainable and scalable new market development in assisted living products and

services. This will generate new resources and new capacity to support

independent healthy living by older people in communities, and improve the

wellbeing and welfare of older people and their relatives and carers.

To develop scalable business solutions for personalised services, we need to

understand the preferences and uses of ALTS by both current and future users,

and the contexts in which they are used and integrated into people's lives and

everyday routines. This will ensure inform the design processes for ALTS. In

particular, questions need to be answered concerning how ‘need’ is

conceptualised in the provision of ALTS and how this impacts on the

acceptability and use of ALTS in the home context, as well as the role of ‘choice’

in developing economic and business solutions that connect with the perspectives

of users.

Aims and Objectives

The overarching objectives of the SALT project are twofolds:

(1) Design scalable assistive technologies and services and new business models to

promote sustainable market development for independent healthy living in a mixed

digital economy;

(2) Understand and examine the factors that promote or inhibit the uptake, use and

integration of assistive technologies for older people living in the community from a

user-centred perspective.

This prjects addresses both themes of the ALIP 3&4 programmes by bringing

together a multi-disciplinary team of senior academics with practitioners from

business, health and social care services, government agencies, third sector

organisations and user groups to develop innovative, workable solutions. It leveraged

the extensive resources, expertise and relationships of the RCUK funded £12.6

million Digital Economy Hub on Social Inclusion through the Digital Economy

(SiDE), previous research projects in the Institute of Health and Society (IHS) on

Telecare and on Patient-Centred Care, and the extensive business engagement

programmes at Institute of Aeging and Health (IAH), Cass Business School and

Newcastle University Business School. The close involvement of businesses, health


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and social care organisations and users helped identify routes to market. It also makes

a significant contribution to capacity building in the UK, by developing and testing

innovative solutions within existing health and social care structures through co-

production; exploring new business models for sustainable new market development

through case studies and experiments; and informing and validating new workable

solutions from a user-centred perspective.

The SALT Approach

SALT has adopted a multiple-perspective approach through seven closely intertwined

Work Packages (WPs) to address key issues in economic and business models (WP1-

3) and social and behaviourial studies (WP4-5) in the mixed digital economy, with

two further packages (WP6-7) for synthesis and dissemination:

WP1: New Business Models and New Market Development (Led by Prof Feng Li)

Identify emerging business models for sustainable and scalable market development

in different sectors and domains through case studies and global best practice, and

explore their adaptation and implementation in assisted living technologies and

services for sustainable new market development.

WP2: Co-Construction of Shared Visions and Solutions (Led by Dr Rob Wilson and

Prof Mike Martin)

Providing contexts for different stakeholders to explore, discuss and make sense of

the complex relationships and conflicting demands and negotiate and co-develop

plausible solutions; co-production of product and service brokerage environment for

scalable services through federation.

WP3: Economic modelling (Led by Prof John Wildman)

Drawing on input from all other WPs to define plausible scenarios and then using

economic modelling to simulate and explore the costs and benefits involved and the

scale of the opportunities and challenges under different scenarios.

WP4: User Uptake (Led by Dr Katie Brittain; Dr Tracy Finch; Prof Louise

Robinson)


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Using interview, observation and focus groups to understand factors that promote or

inhibit the uptake, use and integration of ALTS for current and future generations of

older people living in the community and to develop solutions to promote the

effective integration of these technologies into users everyday lives.

WP5 User-centred design (Led by Prof Peter Wright, Prof Patrick Olivier)

Using a range of cutting edge experience-centred design techniques to design

experience prototypes of a range of innovative ALTS services, and by so doing, to

evaluate which user engagement methods are most suited for ALTS service design.

WP6: Synthesis and Theory Development (Led by Prof Feng Li)

Triangulating the data, results and learning from all strands of research through a

series of facilitated review workshops amongst the project team, together with an

invited audience where appropriate, to develop consensus and identify conditions and

circumstances under which the results can be effectively applied.

WP7: Dissemination and Public Engagement (Led by Graham Armitage, Dr Lynne

Corner)

Ensuring that the project is shaped by the needs of a broad range of stakeholders and

that project outputs are useful and widely disseminated to businesses, practitioners

and the public in the assisted living market.


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Table of Contents

Chapter One New Business Models & New Market Development ..................... 11

1.1 Introduction ................................................................................................... 12

1.2 Key Findings ................................................................................................. 12

1.3 Conclusion ..................................................................................................... 17

Chapter Two Co-Construction of Shared Visions and Solutions .......................... 21

2.1 Introduction ................................................................................................... 22

2.2 Key Findings ................................................................................................. 22

2.3 Conclusion ..................................................................................................... 24

Chapter Three Economic Modelling .................................................................... 26

3.1 Introduction ................................................................................................... 27

3.2 Key Findings ................................................................................................. 28

3.3 Conclusion ..................................................................................................... 29

Chapter Four User Uptake ................................................................................ 31

4.1 Introduction ................................................................................................... 32

4.2 Key Findings ................................................................................................. 33

4.3 Conclusion ..................................................................................................... 35

Chapter Five User-Centred Design.................................................................... 39

5.1 Introduction ................................................................................................... 40

5.2 Key Findings ................................................................................................. 42

5.3 Conclusion ..................................................................................................... 45

Chapter Six Synthesis, Dissemination and Engagement .................................. 47

6.1 Introduction ................................................................................................... 48

6.2 Key Findings ................................................................................................. 48


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Chapter One

New Business Models & New Market Development

Work Package Leader:

Professor Feng Li, Cass Business School

Contributing Researchers:

Dr Ali Z. Bigdeli

Dr Festus Oderanti

Dr Xiaohui Shi


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1.1 Introduction

Despite heavy investment in health and social care in recent years, large scale

deployment of Assisted Living Technologies and Services (ALTS) remains rare, and

the lack of sustainable business models is often regarded as one of the greatest

barriers. The main aim of this work package is to investigate new business models for

sustainable and scalable market development of ALTS through empirical research.

The key objectives of this this work package are:

To develop a systematic mapping of new business models for mainstreaming new

digital services and technologies.

To classify the assisted living technology and service market from the perspective

of business model development.

To articulate lessons for assisted living from international best practice in

sustainable market development of new digital technologies and services.

To explore barriers and facilitators for sustainable market development of assistive

technologies and services.

To develop case studies to illustrate the success and failure of business models and

market development in assisted living technologies and services for dissemination.

To inform research and debates in other WPs and to inform business practice and

policy.

1.2 Key Findings

The main objective of WP1 is to investigate new business models for sustainable and

scalable market development of Assisted Living Technologies and Services (ALTS).

Our findings are derived from a comprehensive review of previous research and

publications, our own empirical research comprising 31 case studies (18 from the UK

and 13 international), and interviews with experts. The initial results were refined and

validated through four facilitated workshops with key stakeholders, and a range of

dissemination events (e.g. conferences, workshops, discussions). We focus

particularly on digitally enabled ALTS.


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The Current State of the ALTS Market: small, fragmented and heterogonous.

The ALTS market is surprisingly small and highly fragmented, and actual market

growth has been significantly slower than previously projected. Large scale

deployment remains rare either in the UK or internationally.

In the UK, the ALTS market is dominated by the state (health and social care). In

comparison the insurance funded market and the self-purchase market are very

small.

Despite the significant long term potential, most ALTS providers are yet to achieve

sustainability and scalability in the conventional business sense, and few

companies are generating sufficient financial returns from their mainstream ALTS

products and services.

The self-purchase market is particularly underdeveloped. Few ALTS providers

have managed to reach significant number of consumers through self-purchase.

The lack of product maturity and common standard and the low levels of

interoperability discouraged investment and prevented people from purchasing

products and services.

Despite strategic interests from some traditional ALTS providers and large

multinationals from other sectors, the ALTS market is primarily served by a large

number of SMEs, many of them new start-ups, with immature products and

business models. Many rely on side activities to sustain their activities, such as

R&D income from different funding bodies, government grants and subsidies, cash

injection from owners or investors, or income from traditional ALTS products and

services.

The ALTS market is highly heterogeneous, which entails significant costs and

risks in developing and supporting new products and services for different market

niches. Most providers lacked the resources, capabilities and large scale

infrastructure required to provide higher value, longer term, contract-based,

supported services, which limited their business model options to providing stand-

alone, single or limited function equipment that are difficult to install, maintain and

use.

The heterogeneous nature of the ALTS market also means that individual market

niches are small. Many ALTS providers find that conventional retail or wholesale

models are insufficient to generate the level of returns required to sustain and scale


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up operations. New business model innovations are required (such as servitization)

to achieve sustainability and scalability.

While effective ALTS innovations do exist, they are generally run by local

champions and are mostly state funded. Most ALTS applications are yet to reach

large scale adoption. Our research has identified a wide range of barriers.

The UK has often been regarded as a world leader in ALTS innovations, although

concrete evidence to support such an assertion is patchy and the lead is being

eroded rapidly in recent years. Some innovative ALTS firms from other countries

are actively exploring different routes to the UK market, and the competition is

intensifying rapidly.

The Notion of ALTS: Lack of conceptual clarity and consistency

The lack of conceptual clarity and consistency in ALTS, although largely

unproblematic in everyday conversations, continues to cause significant problems

when setting boundaries, measuring sizes and impacts, and developing and

implementing business strategies and policies. It leads to inconsistent measures of

user uptake and market potential, and makes it very difficult for businesses to

describe coherent value propositions, customers and market segments, and pricing

and revenue strategies.

The conceptual inconsistency also led to many narratives for assisted living

technologies and services. When making business cases for policy and practice,

people often mix up different perspectives, shifting between reality and rhetoric,

necessity, affordability and desirability, and future aspiration and everyday

practice. This often adds to the confusion and undermines rational debate.

Since many health and social care issues are often emotionally charged, involving

diverse considerations ranging from ethics, obligations and entitlement, equality

and fairness, personal dignity and quality of life, wellbeing and welfare, to cost and

benefit. This has often made rational discussions very difficult when multiple

stakeholders are involved, and it calls for more rigorous theoretical and

methodological guidance in future research and analysis.


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Barriers to Market Development and Possible Solutions

The size of the ALTS market is difficult to estimate, partly due to the high level of

informal care that cannot be easily measured. The large number of research and

pilot projects has so far failed to generate concrete, consistent evidence on the

benefits from large scale deployment of ALTS; and the fragmentation of health

and social care and the limited development of the self-purchase market will

continue to hamper the development of sustainable and scalable business models in

this domain.

Due to the rapidly ageing population, the increasing demand for social and health

care cannot be fully met by the state alone. The insurance funded market and the

self-purchase market will need grow significantly which will provide new

opportunities for ALTS providers. However, there are significant cultural barriers

to overcome which call for policy interventions and public debates.

The culture of universal free health care in the UK negatively influences

sustainable ALTS market development when elderly people and/or their relatives

may have to pay for the products and services. However, our empirical

observations reveal that these challenges can be overcome if new products and

services can effectively address user needs and improve the quality of their lives.

We found the Diffusion of Innovation Theory to be a useful framework for

understanding the challenges involved in taking ALTS innovations into the

mainstream market. In particular, product innovations need to address all five

qualities that determine the success of an innovation: (a) relative advantage (b)

compatibility (c) trialability (d) observability, and (e) complexity.

A sustainable business model can be achieved through servitization, a strategic

reorientation allowing firms to broaden their position in the value chain by

generating revenues from services as well as products. The empirical analysis

suggests that users often prefer to be charged for services rather that for the

product or equipment itself. In telecare and telehealth initiatives, revenues can be

generated from the analysis of the data gathered through the use of the products

(e.g. data gathered through tele-rehabilitation processes), or the license fees of the

software they use, as well as directly from selling products and services.

Personalisation of products and services, particularly through user-centred design,

can increase user uptake and ensure business sustainability. For example, devices


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that are easy to use and that users are familiar with for data analysis will make the

products more users friendly. These devices may include general purpose devices

such as mobile phones and TVs. The value propositions need to articulate clearly

the values and benefits that their products have to offer.

To be more sustainable, manufacturers of ALTS products may need to design

products that are extendable to other user groups rather than products that are

exclusively designed for older people. This will help to reduce the barrier posed by

small market size of ALTS products and increase user uptakes and therefore

increase business sustainability.

Recommendations by trusted professionals such as GPs can significantly increase

user acceptability of products and services. For example, a physician may advise a

user that rather than coming to the hospital once per week, the user’s conditions

can be remotely monitored and hospital visit can be reduced to once a month.

Different stakeholders need to work more effectively together to determine where

cost savings are realised and who should pay for some services. The focus should

be on achieving savings at the whole system level, not simply reducing costs in, for

example, social care at the expense of increased health care.

ALTS require close collaboration between different industries, from health and

social care, computing and telecommunications, to manufacturing, home

electronics, transportation and construction. What needs to be developed is not

only a common standard for interoperability, but also a cross-industry eco-system.

This raises significant new challenges that go beyond current mainstream

management practice.

ALTS can play an important part in the management of long term conditions (or

chronic diseases) by delivering effective health and social care services to enable

independent living for older people. However, this can only be achieved by

deploying sustainable and scalable business models and generating healthy

financial returns for the providers. Even though the ultimate objectives are social,

ethical and political, the means to achieve them are financial and economic.

The research also identified significant cultural differences between different

regions and countries which will significantly affect uptake and use. What works

in one country may not translate into success in another. Different business

models may be required when entering international markets.


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Other Emerging Challenges

Looking after the older population adequately is a highly desirable social - and

policy - objective, and indeed, a basic condition of a civilised society, but financial

sustainability and affordability of any interventions cannot be overlooked. In other

words, the objectives are social but the means to achieve them are economic. This

call for the development of not only new business models, but also new forms of

organisations that can adequately address challenges.

Different from many other services, the quality of health and social care often

depends not only on professionalism but also genuine compassion and care on a

personal level. You can buy love and care but it would cost a lot of money. So

other incentives and rewards are required. Paying carers low wages while

expecting genuine compassion and consistent high quality services is a tall order.

For old people themselves and their relatives, the focus on cost and profit could

make customers highly sensitive to price. This call for the development of not

only new business models, but new forms of organisations (such as social business)

where success is not only measured in financial terms but also in terms of

contribution to human dignity and to civilization.

1.3 Conclusion

Through a comprehensive review of existing studies on Assisted Living Technologies

and Services (ALTS), we have identified the current trends in digital economy as they

relate to ALTS. We made a clear boundary in the definitions involved in the ALTS

initiative, and investigated and categorised various segments of assisted living market.

Also, various factors that hinder the ALTS commercialisation were presented. The

analysis of the evidence from previous studies reveals that that ALTS market is quite

fragmented and a successful commercialisation into the market requires sustainable

and flexible business models. Furthermore, it can be argued that there have been very

few studies that focus specifically on the business model aspects of assisted living

technologies or its potential segments in the United Kingdom compared to United

States or Scandinavian countries. We discuss that since the country has a traditional

health and social care systems with funding model that is entirely different from those

of other countries such as USA, it is highly necessary to look into business models


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that are sustainable, scalable for the UK context and possibly extendable to other

countries.

Also, the review shows that scholars do not agree on the terms and definitions of

various technologies and services of ALTS and their segments and thus on what their

business models ought to be. This lack of harmony raises doubts concerning the

usefulness of their empirical research and on the quality of research outcomes of these

previous studies which include the data they collected and analysed, and also in terms

of data evaluation approaches. Therefore, we provide a comprehensive up-to-date

literature review on ALTS and their commercialisation attempts and we have

carefully documented the discrepancies and dissonances in those literatures.

Furthermore, the critical review of literature reveals some perceived barriers or

factors that have made ALTS market difficult to develop. However researchers and

academicians agreed that these barriers and factors vary from one segment of ALTS

to another. Hence, we expect that if solutions to these barriers are taken into

consideration as suggested in this section it will have positive impact on sustainability

of ALTS market.

Assisted living technologies might have important roles as part of a strategy for the

management of long term conditions (or chronic diseases) and delivery of effective

health and social care services to enable independent living for older people, however,

the services will only become meaningful to the general public when the business

models are sustainable such that they will provide mutual benefits for providers as

well as the users. In this section, therefore, we focused on two essential approaches to

explain the ways that business models in the context of ALTS in the UK would be

sustainable and scalable. First, we argued that the successful business models will

depend on the capacity to provide very quality (qualities identified in DOI theory)

products and services to the customers at the least cost, high credibility to

stakeholders and generate sustainable revenue streams to the service providers. The

ALTS innovations will spread and business becomes sustainable when they evolve to

meet the needs of successive segments of the population in accordance with the

diffusions of innovation theory. Secondly, we discuss on a workable management

strategies for sustainable business models for e-health innovations which could help

to reduce the pressure on already stretched state funded health and social care services

in the UK and other economies. Our approach suggested the need to move from


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product oriented into product-service business models in order to achieve business

sustainability. Our systematic review offers further avenues for further research on

how servitized-oriented business models would lead to a sustainable market

development within the ALTS industry.

Our analysis from the perspective of diffusion of innovation (DOI) theory showed

that while there have been heavy investments in ALTS, adoption process is still in its

early stages. While effective ALTS innovations certainly exist, they are generally run

by local champions and are mostly state funded. Presently, almost no ALTS

applications (innovations) have been successful in reaching enterprise-wide and large

scale adoption. Various barriers to adoption of ALTS were investigated in this paper

and suggested solutions were prescribed. Through DOI theory, strategic framework

for sustainable business models that could make commercialisation of assisted living

products and services more effective are then presented in an organised manner. Our

case studies analysis gives various insights into commercialisation of ALTS and

strategies for driving ALTS innovations through the ‘Diffusion Chasm’ into the

mainstream markets by segmenting users into different populations based on

individual innovativeness. We provided various characteristics of individuals in each

segment of potential ALTS users as well as suggested strategies to reach them. Our

approach suggests that business model and diffusion of innovation theory are

complements, not substitutes.

There are significant differences between the assisted living technologies and services

markets in the UK and internationally. Based on 13 international case studies and

several interviews with experts from health and social care, we looked at these

differences through a socio-technical lens and categorised our findings/analyses into

four major categories. First we explored and presented the similarities and differences

of the UK and international markets in the regulatory and policy environment. We

found that the notion of ALTS in international markets is less fragmented; and many

international firms, compared to the one from the UK, are financially more

sustainable. This can be attributed to the fact that international firms we studied have

not relied as heavily on the state-funded market. Moreover, many of them are

positively embracing industrial partnerships, as they have learnt that they should be

part of the ALTS eco-system in order to be successful.


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We presented three categories of business models for the delivery of telehealth and

telecare services across the world, namely state reimbursement/purchasing model,

insurance-fund reimbursement, and self-purchased market. While we argued that the

self-purchased market is relatively small in the international markets, several

European governments have encouraged the insurance companies to subsidise parts of

the expenses of tele-health services. Relating to the technological (product and

services) issues, we found that the small market size have forced international

companies to diversify their products and services to cover more potential customers

and consumers. However, this has led to a complex maintenance of the heterogeneous

platforms. Subsequently it was discussed that, due to family values and cultural

differences, we should not expect that successful adoption of ALTS in one country

would have similar results in other countries.


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Chapter Two

Co-Construction of Shared Visions and Solutions


Dr Rob Wilson, KITE Research Centre/Business School, Newcastle University


Professor Mike Martin

Antonia Moran


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2.1 Introduction

The contribution of the co-production work package was to capture and analyse the

conversations of the different sorts of actors in sectors that are concerned with

assistive living technologies. We set out to achieve this by taking a co-production

approach to explore the range of concepts, issues and values which are represented

and are of concern. The working definition of co-production was joint production of

public services between citizen and state, with any one of the elements of the

production process being shared” (Mitlin, 2008). Our work was informed by our

knowledge of a simplistic purchaser – provider split is not appropriate in complex

areas of AL/AT in social care. Our starting assumption is that work was required at

the relationships between state agencies and between suppliers and the state (issues of

co-governance in local multi-agency service environments.

To inform this process, we convened a series of meetings and workshops with the

purpose of generating discussion, promoting mutual sense making and capturing the

often subtle and contended positions of actors from public administration, social and

clinical services and practice, the voluntary and third sectors and from commercial

operators. We ran a series of such workshops in collaboration with our WP partners

(Better Living Trust, Age UK Newcastle and NHS Innovations North with input from

other WP partners Docobo and Intrahealth) to co-produce a “big picture”, or, more

precisely, a coherent set of multiple views of a complex environment, within which

the wide range of stances and interests that are represented can be recognised,

positioned, interrelated and evaluated. Our underlying assumption is the range and

complexity of products and services in this market mean that a simplistic top down or

bottom up engagement activity would not address the complexity of the issues. We

turn first to some of the working definitions for this paper and background of the state

of the market followed by a view of the policy context.

2.2 Key Findings

The mixed economy in ALTS remains problematic. A mixed economy relies on

mixing being possible. The current point of mixing at the moment is very much at

the individual and their immediate network/carer level.


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This puts the responsibility on the part of the overall system which is probably the

most vulnerable and initially at least unable to cope.

Local authorities responsible for the delivery of personalisation and the not-for-

profit provider sector are struggling to deal with the challenges of providing the

scale required in the creation and support for personal budgets and the information

economy required to produce catalogues of services.

OTs and Nurses (District and Community) have key brokerage roles which lead to

recommendations being made for various ALT products and services to be

provided/recommended.

OTs expressed concerns about issues of status, the amount of discretion they could

exercise and their ability to keep informed about ALT developments and

availability.

District Nurses and Community Nursing were often charged with treating long

term conditions. This cohort of Nurses emphasised that they have to be both

generalists and specialists in different settings and circumstances across the

primary, community and secondary care contexts. ALT is potentially a fantastic

resource in helping them co-produce the best care with patients

Commercial and retail organisations providing products and services into this

fragmented marketplace struggle to move away from providing closed

platforms/integrated solutions to specific conditions and or assistive living

problems. This fragmentation stifles innovation, limits inter-operability and fails to

achieve the potential benefits of network externalities. It also leads to limited

joining up between the commercial and public sector to personalise the

client/patient/customer experience.

On the current trajectory the future development path of the current market is likely to

be threefold:

1. Firstly targeted services being ‘commissioned’ by CCGs and FTs to significant

scale to large non-NHS providers with a focus on Disease (e.g. CHD, CPD) and or

Older People (e.g. Reducing admissions).

2. Secondly any meaningful ‘personalised’ ALT offers a likely be largely self-funded

and separate from public sector provision and governance.


Page | 24

3. Thirdly individuals with complex needs will supported by charities/local

authorities/CCGs as part of a joint support/care package

However it does not necessarily have to unfold in this direction. Strategic and

focussed work at the community level around the challenge of joining-up the joining

up to develop and improve the resources for service co-ordination would provide

significant opportunities for the creation of a brokerage and intermediation

environment populated by those best placed to deliver: primarily those with existing

care and support relationships with those in need of assistance for living.

2.3 Conclusion

The mixed economy in ALT remains problematic. A mixed economy relies on mixing

being possible. The current point of mixing at the moment is very much at the

individual and their immediate network/carer level. This puts the responsibility on the

part of the overall system which is probably the most vulnerable and initially at least

unable to cope.

Local authorities responsible for the delivery of personalisation and the not-for-profit

provider sector are struggling to deal with the challenges of providing the scale

required in the creation and support for personal budgets and the information

economy required to produce catalogues of services. Work with OTs and Nurses

(District and Community) revealed their brokerage role in the assessment processes

(for people in a range of contexts supported and self-funded) which lead to

recommendations being made for various ALT products and services to be

provided/recommended. OTs expressed concerns about issues of status, the amount of

discretion they could exercise and their ability to keep informed about ALT

developments and availability. District Nurses and Community Nursing were often

charged with treating long term conditions. This cohort of Nurses emphasised that

they have to be both generalists and specialists in different settings and circumstances

across the primary, community and secondary care contexts. ALT is potentially a

fantastic resource in helping them produce the best care for their patients


Page | 25

Commercial and retail organisations providing products and services into this

fragmented marketplace struggle to move away from providing closed

platforms/integrated solutions to specific conditions and or assistive living problems.

This fragmentation stifles innovation, limits inter-operatability and fails to achieve the

potential benefits of network externalities. It also leads to limited joining up between

the commercial and public sector to personalise the client/patient/customer

experience. The routes of the diverse economy paths to the ALT is demonstrated in

the Figure below:

On current trajectories the future development path of the current market is likely to

be threefold. Firstly targeted services being ‘commissioned’ by CCGs and FTs to

significant scale to large non-NHS providers with a focus on Disease (e.g. CHD,

CPD) and or Older People (e.g. Reducing admissions). Secondly any meaningful

‘personalised’ ALT offers a likely be largely self-funded and separate from public

sector provision and governance. Thirdly individuals with complex needs will

supported by charities/local authorities/CCGs as part of a joint support/care package.

Primary and

Community

Care

Acute CareTertiary

Care

Domestic Care

Assistive Technology Products and Services

GenericTargetedSpecialised

Clinical “Push”

Client “Pull”

32

4

The recognition of a need and the

possibility of a solution

1

Self or family directed

initiatives to find solutions

to needs.

1

Care planning on a

discharge back into

primary from Acute Care.

2

Responding to changing

patient needs in

Community Care.

4

3

Highly Qualified

Unqualified

Hig

hly

Specia

lised

Genera

list

Care planning for

rehabilitation after complex

specialist treatment.


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Chapter Three

Economic Modelling


Professor John Wildman, Business School (Economics), Newcastle University

Contributing Researcher:

Dr Peter McMeekin


Page | 27

3.1 Introduction

The aim of this work package was to investigate the economics issues surrounding

ALTs. Using economic theory and econometric methods this work package

considered four main areas: the cost-effectiveness of ALTs, the market for social care,

the relationship between health and social care and the impact of ALTs on the health

of a cohort of 85 plus individuals.

The objectives of this project were to:

Investigate economic models in the area of social care (Deliverable 1 and

deliverable 5)

Identify costs of an ageing population (Deliverable 1, deliverable 3 and

deliverable 4)

Identify benefits of ALTs (Deliverable 3, deliverable 4, deliverable 5,

deliverable 6)

Consider costs and benefits alongside work package 1 (Deliverable 1 and

deliverable 3)

Evaluate approaches and make a recommendation (Deliverable 3, deliverable

4 deliverable 5, deliverable 6)

The objectives were chosen in order to cover a range of ageing and social care issues.

Also they provided a way to investigate the key economic issues associated with

ageing and ALTs.

There were four main approaches used as part of WP3. The first was the use of a

systematic review. These methods allow researchers to identify and evaluate the key

papers in an area of research. The methods are robust and replicable allowing others

to reproduce the search outcomes and to give insight into the quality of papers

considered. Key words and key terms for the review have been available and

references for all of the quality assurance measures clearly referenced.

The second method was the application of economics models to the ageing and ALT

market. Economics provides an insight into the working of markets and how

economic agents interact. This provides two key insights, firstly it is possible to

describe observed behaviour. Secondly, it is possible to investigate what will happen

when there are changes in the market.


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The third method was the use of economic theory to model individual behaviour.

Economics has provided many approaches for considering the way individuals act and

we apply two that are particularly pertinent for the areas of health and social care, and

for ALTs. These are the Grossman (1972) model – a model of household production

as applied to health. And the Lancaster (1966) model – a model of household

production focused on attributes with a particular focus on the ability to model new

products (which is especially pertinent for ALTs).

Finally econometric methods were applied to secondary data to investigate the role of

benefits, and potential cost savings. As SALT did not involve the creation of data – it

was not part of an evaluation of ALTs – it was not possible to use primary data

sources. Data with ALTs was identified and panel data models were applied to these

data to investigate how the ownership and use of ALTs affected two health outcomes.

The data are a longitudinal cohort of individuals who were first interviewed at the age

of 85.

3.2 Key Findings

Market failure is a problem for social care. Similar to the health sector, and partly

because of the link to the health sector, social care exhibits many elements of

market failure leading to efficiency and equity problems.

Problems in the insurance market mean that there are problems identifying who

should pay for social care. Failure in the insurance market requires government

intervention. Intervention means that individuals do not insure (privately) to

protect against old age. This leads to individuals not engaging in the market.

The lack of engagement in markets means that individuals may be unfamiliar with

purchasing devices and services that make up the ALT sector.

Evidence supporting the use of ALTs is limited, especially in terms of cost-

effectiveness.

Evaluation methods need to be developed and extended that can analyse the

impacts of ALTs.

A systematic review of the literature demonstrated a dearth of publication in this

area. Without robust evidence of cost-effectiveness the opportunities for growth in

the market may be limited.


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The presence of a very large health sector may crowd out possibilities in the social

care. The problem of crowding out is potentially the largest issue facing the ALT

market. Whether because of the size of the health sector, the potential problems of

supplier induced demand, or because of user expectations it is difficult for ALT

markets to grow

There are incentives in the funding mechanism that mean that individuals are more

likely to use health care services, when social care services and ALTs are more

appropriate.

Health and social care provide attributes that individuals value. There may be

considerable overlap in the attributes provided meaning that health and social care

become viewed as substitutes rather than complements.

Obtaining values for the attributes offered by ALTs would help the development

and marking of ALTs. It would offer insights into the important characteristics that

ALTs offer.

The use of ALTs (traditional types) is associated with individuals of lower health.

The use of ALTs delays deterioration in disability and depression among the oldest

age groups (85 plus).

3.3 Conclusion

Most markets have some element of market failure, and in the presence of market

failures, markets are often inefficient. In many cases the presence of market failure

leads to some form of government intervention, either directly, with the government

providing the service, or more indirectly through regulation and monitoring. The

health sector is widely considered to be unique because of the number of types of

market failure that are present. A similar analysis of the social care market has been

conducted as part of the SALT project and it can be shown that social care shares

many of the characteristics of the health market.

Insurance is one of the key mechanisms for dealing with uncertainty in outcomes, and

the ageing process clearly demonstrates many areas of uncertainty. However, the

market in this area is not well developed - and this is partly due to issues of adverse

selection and moral hazard, but also due to the presence of a large, public, compulsory

health insurance scheme in the form of the NHS. This latter issue is further developed


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in tasks three and five. Without private spending on social care there may be few

incentives to invest in ALTs, especially if there is a sense that many of the benefits of

ALTs should be provided by the health service.

In terms of service provision it is possible to view health and social care through the

lens of supplier induced demand, and the incentives inherent in the funding and

expenditure mechanisms for health and social care that may lead to sub-optimal

outcomes. It is interesting to note that the government has made increasing steps to

ingegrate health and social care during the life time of this project.

(https://www.gov.uk/government/policies/making-sure-health-and-social-care-

services-work-together). Further complecations arise if there are supplier induced

demand issues from actors within the health service. It is often suggested in health

economics that doctors induce supply in order to maximise their own utility. It may be

that many older individuals are encouraged to use the health service by doctors as part

of supplier induced demand.

There are also key issues of equity that are present in the area of social care. If social

care in increasingly left to the market, or if there are more areas of social care where

there are market forces then it may be possible for inequities to arise. Should there be

a concern for access, and should there be some notion of need? If the answer to these

is 'yes' then should there be some element of 'equal access for equal need'. And from

this should there be adjustments for vertical equity.

Finally, as part of the work on benefits, we have used a secondary data set that

contains information on the ownership and use of ALTs, as well as comprehensive

data on disability and depression. The data set provides information the ownship and

use of a range of traditional ALTs, and while this does not provide direct information

on high technology ALTS going forward, it does provide an insight into the general

use of ALTs. The data are taken from a cohort of 85 plus individuals living in the

Newcastle upon Tyne area.


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Chapter Four

User Uptake


Dr Katie Brittain, Institute of Health and Society (IHS)/Medical School, Newcastle

University


Dr Gary Pritchard

Dr Tracy Finch

Professor Louise Robinson


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4.1 Introduction

Older people are a heterogeneous group with a range of social and health care needs.

It is generally recognized that, to an extent at least, the care and support of older

people can be enhanced through technology. In recent years the UK government and a

range of other agencies have advocated Assistive Technology (AT) as a key tool in

addressing the plethora of care-related costs associated with more and more people

living in their homes who will have limitations in mobility, dexterity and mental

capacity.

WP4 addressed the problem of uptake, use and integration of AT, acknowledging that

a deeper understanding is needed of the personal and social meanings that people

attach to technologies and how the use of them are embedded within their social

context and everyday lives. Despite the perceived benefits of AT, evidence suggests

that uptake and use among older people has been low with a large survey conducted

by Phillips and Zhao (1993) finding that almost a third of all devices are completely

abandoned. There is a need therefore to understand how AT is embedded into the

lives of older people so that when emerging AT is developed the social environment

in which they are to be used is taken into account. Otherwise these technologies could

be developed out of context and run the risk of being abandoned or not used. A

further aim is to develop solutions to promote more effective integration of AT into

users’ everyday lives.

The background of this research is the growing awareness of the ways AT can support

older people to remain independent and also make the care of older people sustainable

while the population ages at an unprecedented rate. This WP used qualitative research

methods in order to look at older people’s current use of AT, they attitudes towards it

and critically examine how these influence the uptake, usage and abandonment of AT.

In this, we adopt a social science approach that draws upon a number of theoretical

perspectives from sociology, psychology and technology studies. Our work not only

explored people’s perceptions towards AT but also looked at the best way to connect

people to telecare and other ATs. The focus of the work within this WP was to

understand the factors that promote or inhibit the uptake and how ATs are used and

integrated into the lives of older people.


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This chapter is divided into 4 substantive sections that are based on the original

research questions contained in the second level plan. The first section explores

current perspectives on the role of AT; the second looks at uptake, use and integration

of AT by current users; the third discusses the role of the informal carer in supporting

‘ageing in place’ and the final section examines the needs and preferences of future

AT users.

The overall aim of WP4 was to gain an understanding of older people’s use of AT.

This is further broken down into 7 discreet project objectives:

1. To understand the context for maximising the potential of AT by exploring

people’s current attitudes and future expectations of AT and care in the

community

2. To describe how AT is currently accepted (or not) and integrated (or not) into

the everyday lives of older people

3. To understand how ‘need’ is conceptualised by individuals in the provision of

AT, and how this impacts on the acceptability and use of AT in the home

context

4. To explore the attitudes and future needs of the next generation of older people

with regard to AT

5. To explore the role of ‘choice’ in developing economic and business solutions

6. To understand the caring activities undertaken to support older people living

in the community.

7. To identify key concerns of current and future AT users and inform other WPs

on an on-going basis

4.2 Key Findings

WP4 adopted a sociological perspective in order to explore issues surrounding

older people’s use of AT. The specific focus was to look at social factors that could

encourage or discourage older people’s AT use. This was then separated into 4

broad areas of study: 1) current perspectives on AT; 2) uptake, use and integration

by current users; 3) AT and informal care and 4) understanding future AT users.


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The findings highlight a consensus on a range of issues and are derived from a

comprehensive review of previous research and publications and this WP’s in-

depth qualitative research. The methods used consisted of interviews, focus groups,

workshops and observational fieldwork.

Current perspectives on AT. We found that older people’s perceptions towards AT

varied greatly depending on the category of AT and level of disability and health

of our participants. Perspectives on AT depended in large to factors external to the

individual, for example awareness, cost, method of provision (i.e. private or public)

and also the type of assessment and consultation provided by ‘experts’. The

concepts of ‘independence’ and ‘stigma’ were shown to be important personal

influences that affected how older people view AT.

Uptake, use and integration of AT by current users. AT has the potential to shape

social relations surrounding the care of older people. Our analysis highlighted

some of the unanticipated social consequences of the deployment of the alarm

pendent, thus again showing how the social environment impacts on the use and

function of AT. Negative effects of alarm pendants are not the result of malevolent

intention on the part of those who design or operate these systems but rather, they

are a by-product of the practices and functional requirements of the device, as it is

currently conceived. Specifically, on occasion, these devices are not effective or

efficient; they can shift extra work onto older people and their carers; they can

work to dehumanize an older person by causing stigma and changing the

relationship of care. However, older people can subvert the intended function of

alarm pendants and resist these dehumanization effects by using the device

selectively, or not at all.

AT and informal care. Informal care involves a life change for both the carer and

the care recipient. Informal carers are often the primary user of an AT. Carers can

use AT to leverage a range of caring activities, making them less intensive and

demanding. Decisions on buying AT are mainly made jointly and based on


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practical circumstances and perceived usefulness. AT has the potential to change

the meaning of the home, in a negative way.

Understanding future AT users. Awareness and information about AT among the

general public is currently very low. Future users are capable of imagining how

technology could be integrated into their lives as they age. This group are generally

positive about the potential of digital technologies to help them in a variety of

ways (including providing aid in sensitive activities like toileting and bathing;

lifestyle advice; tracking medical information and as an emergency backup).

Participants generally didn’t like the concept of devices that are aimed specifically

at older people. A key factor in the acceptability of AT for future users was

whether or not the equipment would be provided by the state. Participants were

concerned with the ways AT might adversely affect sociability, human contact and

privacy. However some of these concerns can be eased through design.

4.3 Conclusion

As stated at the onset, the aim of this section is not to criticize alarm pendants or

telecare as a whole but rather to unpick some of the negative and unanticipated

consequences of use. However, it should be understood that there are positive effects

and is used by lots of people for many different reasons. In our research we witnessed

it’s perceived usefulness for people who are vulnerable to falling and those who enjoy

the reassurance of knowing a friendly voice is available at the touch of a button. The

device can be especially helpful for peoplewith long-term conditions, as it can give

them and their relatives a peace of mind that they’re safe in their own home. They can

also facilitate people living more independently in their own home for

longer, avoiding a hospital stay or delaying the move into a residential care facility.

We should also be careful not to compare current practices, which integrate the use of

pendant alarms with an unrealistic and overly romantic perception of traditional care.

Overall, this section has illustrated that just as a technology can mediate and shape a

social environment and relationships, they in turn can shape the function and uses of a

technology. The technology we have scrutinized is the alarm pendent, a device

deployed to streamline the care of older people. Alarm pendants are based on


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relatively unsophisticated technology and developments in this sector are expanding

rapidly and future assistive living technologies are likely to move away from first

generation device we have described in this paper. The potential for alarm pendants to

dehumanize and produce irrational social outcomes will depend therefore, in part, on

the development of the industry. For instance, if they adopt more digital participation

services – designed to stimulate social interaction – then potentially they can increase

a sense of community and counteract processes of dehumanization. Other

developments could allow users more agency and choice in the device they are

provided with, by having for instance, more flexibility that permit the choice to

activate multiple buttons to better communicate the urgency of help needed.

Providing older people with simple reminders of their agency is highly important

because it has been shown to significantly prolong life while the removal of agency

has been illustrated to lead others to treat them as uncivilized and irrational. Future

assistive technologies could also be more flexible and ensure choice and be

configured in a way to allow the user to choose who gets alerted when an alarm is

activated.

A further negative social effect of alarm pendent use we identified in our research was

its potential to cause deindividualization. Presently, older people who have a pendent

alarm are anonymous. There is a possibility of counteracting this by ensuring that

teleoperators have more information about the person they are remotely caring for. As

well as their name and other basic information, they could be provided with an outline

of their personal history, including their previous occupations, hobbies and family

life. The use of video would be a positive move to counteract the deindividualization

processes implicit in alarm pendant use.

Our argument here is that technological change in the field of gerontology is

something which older people and other users of assistive technology need to actively

shape, rather than respond to. These users should be consulted about the kind of

relationship they want from their caregiver and broader society should also reflect on

the type of relationship it want with its older citizens. We also argue that there is a

need for on-going engagement with older people and the users of such devices in the

design, development of technologies that are embedded within decisions of care.


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Currently, very little empirical research exists on how the social environment affects

alarm pendant use. A productive development in the study of gerontology and

technology would assess the impact of telecare on different social environments of

care and also how different social and cultural environments of care affect the use and

function of technological devices.

Following much of STS research, this section argues against the theory of

technological determinism – that is, the belief that technology develops in isolation

from society but in turn impacts upon it. The very development and promotion of the

alarm pendent as part of the solution to reduce care-related costs incurred by the

government shows that innovation doesn’t occur immune from the concerns of

society. Despite the designed intention of this device, the evidence of its effectiveness

is scare and the largest study conducted to date has shown no significant cost-

reductions. We argue that this is perhaps because adequate attention was not afforded

to the broader social environment in which they are deployed. In short, it seems the

advocates of alarm pendants subscribe to an understanding of the discredited (in STS

at least) model of technological determinism.

Our work with future users of AT identified important concerns people have about

future AT provision. In this section we first explores the acceptability of different

forms of AT in supporting our participants complete a variety of tasks. In this,

explored people’s perspectives towards technology specifically designed for older

people and viewpoints over who should fund future AT provision. Our second

substantive section analysed perceptions towards the potential of different forms of

AT to impact (both positively, and negatively) sociability and human contact. We

then looked at issues surrounding privacy and trust.

What inferences can be made from data from future users? Our conversations with

future users of AT was, by necessity, speculative. How expectations about futures

corresponds to what happens in reality is contested. From within the history of

technology there are important accounts of how expectations change over time, and

particularly longer time spans, in relation to various ‘real time’ factors. This shows,

for example, that expectations tend to reflect current conceptions of technological

utility or, as Marvin puts it, ‘the tendency of every age to read the future as a fancier

version of the present’. This characteristic is also clearly visible in the genre of


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science-fiction and the tendency to reflect present day concerns and hopes. We used

these visions as a starting point because users were familiar with robots etc. through

popular science fiction representations.


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Chapter Five

User-Centred Design


Professor Peter Wright, School of Computing Science, Newcastle University


Dr John Vines

Professor Patrick Olivier


Page | 40

5.1 Introduction

To make electronic and digital ALTS acceptable to those who may purchase, use and

live with them, technology designers and ALTS companies and organisations need to

develop a richer understanding of who ‘the user’ is that is being designed for. This

richer conception requires us to reframe the problem and design space of ALTS, and

to explore and develop new methods for organisations to richly engage with the lived

experience of those that might benefit from technologies to support their daily living.

We no longer simply use technology, rather we live it, and that in order to design

technologies and services that are aesthetically pleasing, flexible, support changing

needs, increase users' independence and empower them, we need to develop design

methods that yield a deep understanding of the experience of both living with

technology, and living with chronic illness and chronic conditions.

In recent years, there have been a number of developments in the field of human-

computer interaction (HCI) and broader design disciplines where researchers have

developed a myriad of new methods for exploring people’s experiences in depth.

Many of these new methods provide techniques and tools that support researchers and

designers in undertaking structured activities and engagements with users that elicit

discussions around peoples’ current experiences of technology and the implications

future technologies may have on their lives both as they exist now and how they may

exist in the future. This has included using speculative films as a way of capturing the

experiences of users (Raijmakers et al. 2006) or as a way of provoking responses from

users in design workshops (Briggs et al. 2012). Others have used interactive forms of

theatrical performances (Newell et al. 2006) or carefully crafted objects that are

‘completed’ by users in their homes to highlight what is meaningful and important to

them in their lives (Wallace et al. 2013). Many of these new approaches draw upon

developments in the arts, design and social sciences which argue for a more

interpretive and reflexive approach to social and experiential enquiry, which are

increasingly used in experience-centred design of new forms of communication

technology (Wright et al. 2008), the co-design of health services, and the co-design of

technology for the older old in residential homes (Blythe et al. 2010), and working

with people with dementia and their carers (Lindsay et al. 2012).


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The main objective of SALT WP5 was to explore how these emerging experience-

centred design methods might be used in the context of ALTS. In order to explore

these, we worked with three of SALTs industrial partners to define and conduct three

separate case studies. These case studies responded primarily to the immediate

ambitions of each organisation, which provided a context within which we were able

to define a design brief. Importantly, each of the industry partners wished to explore

issues that were quite radically different from each other (e.g. platforms for ratings

and reviews of consumer ALTS, schemes and services to support new forms of

voluntary community care, and app-based wearable and mobile healthcare) but issues

that are still of central concern to the future sustainability of older adult health and

care.

Having defined each case study, the WP5 team developed an experience-centred

methodology for each that provided a means to explore the potential of new design

methods to support the exploration of these contexts with potential users. The

methods chosen responded to the issues and ambitions of each of the case study

partners and allow users to have a voice in the design of future ALTS that may impact

upon their lives.

Through the completion of these case studies, we aimed to make three overall

contributions to the domain of ALTS. First, through the conduct of each case study

with project partners we aimed to make the findings immediately relevant and useable

to these companies, and as such support them in introducing new types of ALTS that

will be meaningful and used by the intended user groups. Second, we wished to

provide rich qualitative insights about these emerging areas of importance in ALTS

that would be of relevance to academics and industrial stakeholders working in the

domain. Third, we aimed to develop a deeper understanding of the efficacy of the

design methods, establishing how they support the revealing of rich insights about the

lives of potential ALTS users, and in what ways they promoted the generation of new

ideas or insights into how future technologies and services may support the lives of

these individuals.


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5.2 Key Findings

The main objective of WP5 is to investigate user-centered design methods that allow

researchers, companies and organisations working in the domain of Assisted Living

Technologies and Services (ALTS) to involve potential customers and users in the

design, research and development of new products and services. Our findings are

derived from three design case studies that were conducted over the course of WP5’s

2-year period of activity on SALT. These case studies were developed in close

collaboration with three of the project’s industrial partners. Our case studies were

focused around studying 3 main types of design method that responded to the specific

case study context driven by our partners, but also involved the use and development

of a total of 23 different design tools and techniques. Our findings come in two forms.

First, we provide rich insights about potential users and consumers of ALTS based on

our three case studies, each of which tackled challenges that are becoming

increasingly important for ALTS companies and organisations to be aware of and to

respond to. The key findings in relation to our case studies are:

Our first case study focused on using Film as a tool to provoke discussions and

generate ideas surrounding peer-to-peer and user-generated approaches to

developing information, advice and recommendation schemes for ALTS. We

highlight how the first step for enhancing the lived experience of ALTS for

consumers and users is to raise public awareness of what is available. Our central

message here is that the future of the ALTS market is dependent upon providing

tools and platforms for the public to create their own knowledge resources that can

be shared with and by peers. We highlight a range of barriers to trusting online

content surrounding ALTS use, many of which come down to issues related to the

provenance of information and the need to get ‘hands on experiences’ of aids and

equipment. Therefore, rather than just focusing on recommendations and review,

these platforms and tools need to provide ways for people to be directed towards

locally accessible resources, facilities and members of their local community that

can provide experiences of ALTS and share advice face-to-face. This requires

support by key trusted representatives, advocacy groups and stakeholders in the

ALTS domain in order to generate wide participation and support accessing hard to

reach groups and individuals.


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Our second case study focused on using Theatre to explore the potential

implications and aspirations surrounding future intergenerational community care

schemes and services. Our case study highlighted how there are huge significant

challenges facing the introduction of reward schemes in the context of community

care. We should avoid designing technologies that add simplistic reward systems

for volunteering based on how much time they spend with people or the ‘depth’ of

the activity and duties they perform. The primary value of voluntary care was seen

to be in its personalised qualities, where carers respond to the fluctuating needs of

the person they visit. Instead, we should look at forms of rewards that support the

exchange of appreciation and ‘gifts’ between those who receive care and those that

give it, rewarding those that are more responsive to the individuals they visit.

Furthermore, technology can play a role here in improving the experience of care.

This includes information sharing services, enhanced timetabling and co-

ordination activities, and systems that give greater awareness to care recipients

about who to expect a visit from and when.

Our third case study focused on using the new Google Glass technology as a

provocative prototype to engage people with Parkinson’s in exploring the potential

of wearable technologies to monitor their health and wellness. We noted how

mobile and wearable technologies provide opportunities for individuals with

conditions and ailments to self-track, monitor and enhance their personal

understanding of their condition and provide increased confidence and sense of

independence. The rising popularity and lower barriers of access to consumer

mobile and wearable technologies provides new opportunities for ALTS

companies to create resources, tools and applications for individuals to track and

monitor their health. Engaging with people living with specific conditions and

diseases at an early stage of developing such applications can reveal new design

opportunities that differ from those that might be prioritised by health service

providers and medical experts. As such, designing from the ‘bottom-up’ and

creating applications that are driven by end-user aspirations and sensemaking

around their condition rather than ‘top-down’ from the needs of service providers

provides a rich space to explore new business models around emerging

technologies.


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Second, we provide insights about the specific qualities of the design methods we

used, how they might be used by companies and other researchers, when in the

design, development and research process to use them, and the types of insights that

may emerge from their use. The key findings in relation to our design methods work

are:

Throughout our case studies with partners, we noted how there is great enthusiasm

for greater user and consumer consultation in the design and development of ALTS

but significant barriers to companies actually conducting these types of design

activities. The primary limitation is time. One challenge that all organisations in

this domain face is committing time and effort to undertaking design work that

involves potential users from an early stage of development. We noted how there is

sometimes a preference from some organisations to have insights provided to them,

preferring to be informed about user insights and not directly engage with them.

We responded to this during the project by going beyond our main 3 design

methods and developing an array of different methods that are more lightweight,

quicker and simpler to make, and involve less resource investment. These methods

require different degrees of effort and time, can be used at different stages of a

project, involve different levels of user and consumer involvement, and can result

in different types of insight. These may be used by a company to undertake design

activities directly with prospective users or customers, or to reflect on insights

provided by others who have been commissioned to undertake these activities.

We have developed an outline for a participatory innovation toolkit (PIT) for

ALTS that packages up the various methods we have used for organisations

operating within the ALTS domain to undertake their own user-centered design

activities with potential users in the future. In developing the toolkit we aimed to

synthesise insights gained from across the three main design case studies. In

particular, we looked to identify what are the core stages of undertaking design

consultation processes with end-users. Through our use of 23 different tools during

the SALT project, we have developed 5 different stages of participatory innovation

for ALTS. We have categorised and documented our various different methods in

terms of which of these different stages they support, and at the end of this report


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provide detail about when to use specific methods and how they may be used in

practice.

5.3 Conclusion

We have undertaken three detailed design case studies where people that are existing

users ALTS or potential future users, consumers or beneficiaries of such products and

services have been involved in envisioning the future of ALTS delivery in the UK.

Although each of our case studies were rather diverse, they each represented the great

value of collaborating with a wide range of stakeholders and user groups right from

the very start of a design process. The aim of each of the case studies was to explore

what is often termed the ‘messy front end’ of design —i.e., the space at the beginning

of a design process where the opportunities for what the eventual product or service

may be are diverse and ill-defined. Through our design activities and workshops with

participants at this stage of design, opportunities were presented for these potential

users of ALTS to have a voice in the decisions made around their development. As

highlighted in both case study 1 and case study 2, these engagements alerted us and

our case study partners to the dangers inherent in making poor decisions at this early

stage of design. Furthermore, in the context of case study 3, we have highlighted how

engaging with users at this early stage reveals a different set of issues to design

around when compared to designing for a specific group through a clinical

collaboration. Indeed, through our early engagement with our volunteers with

Parkinson’s we have formed a group of ‘lead users’ who are highly motivated and

willing to continue working with us and our partner in the development of new Apps

on the Google Glass device.

Although each of our case studies highlighted diverse issues related to the design and

delivery of future ALTS, there are a number of areas that need to be further examined

in future work. This is especially important given that our case studies have not led to

the creation of finalised technologies, products and services—the aim of each was to

undertake early scoping activities with users and derive requirements and implications

for future ALTS. Each of our individual case studies highlight a diverse range of

opportunities for the future development of these ideas, which are detailed at length

within each of the case study reports.


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There is also much more work to be done in the context of studying how the types of

design methods used during our project may influence future ALTS innovation. Our

case studies were designed so that the research team led the research and design

process and conducted the vast majority of user engagement activities. While our case

study partners had a significant involvement in providing us with a context to conduct

our work and contributed to the development of the methodological approaches, we

failed to achieve a situation where our partners were able to lead sessions and the

analysis of insights. Therefore there is still much work to be done around how these

design methods may be made less resource intensive but still meaningful to such

organisations in the future. While it was not possible to finalise an online toolkit in

the time-span of WP5, we envision that an important focus point of future work will

be to refine the methods described here and make them openly available online for

organisations to use. However, it is not just important to make the materials of these

methods available to use, but also to provide detailed instructions of how they can be

used, providing ways for templates to be modified to fit specific contexts, and

developing ways for ALTS companies and organisations to document their use and

feed their knowledge back to the wider ALTS community. Furthermore, while we had

a great amount of success with our lightweight paper-based resources, the most

innovative methods that used film, theatre and prototype are those that also come with

the most resource intensity to develop and deliver. Future work will have to examine

in more detail how these approaches can be made simpler to use or easier to

commission.


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Chapter Six Synthesis, Dissemination and Engagement


Graham Armitage, Institute of Ageing and Health/Medical School, Newcastle

University

Contributing Researcher:

Dr Lynne Corner


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6.1 Introduction

It is assumed that there is a substantial and growing global market for assisted living

technologies. It is also assumed that these will be ICT type technologies, which are

known from experience to have high growth potential. Businesses from the UK have

been amongst the first movers in the field, so Assisted Living should represent a huge

opportunity for UK Plc.

The opportunity has been well tended, with significant sums of UK Government and

European money provided for research and development and for pilot deployments of

these technologies. So what we really wanted to understand was why there isn't a

thriving assisted living industry, why ALT businesses seem to be highly dependent on

research and development funding, why ALT has not yet become embedded at scale,

and what needs to be done to change that.

6.2 Key Findings

What are Assisted Living Technologies?

This was a challenge for the project. Whilst Assisted Living Technologies is a

description which is becoming more commonly used, it encompasses a wide range of

equipment, which has previously often been described in other ways.

Telecare has been used generally to describe tools that mitigate risk or

apparent risk for vulnerable people. These have mostly been products such as

fall alarms or personal alarms but also encompass sensors and automation

which reduces risk. More recently, remote communication devices intended

for use between vulnerable adults and their carers have also been included.

Some of these take the form of complex tool sets intended to facilitate

communication between multiple carers and the cared for person.

Telehealth has been used to describe tools aimed at supporting optimum

management of long term conditions. This includes remote monitoring of

various measures by clinical teams and electronic information or prompts for

patients.


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Telemedicine probably doesn't fall within the scope of Assisted Living since it

is generally defined as the electronic transfer of patient information between

clinicians. However, it utilises the same technologies and encounters the same

challenges of data security and provenance as telehealth and is therefore likely

to be have a substantial overlap in commissioning organisations, clinical users,

and providers. Moreover, the term is also sometimes used interchangeably

with telehealth, whilst e-health covers both, plus electronic health self-

management for prevention.

Then of course there are a range of devices which are used to support

independent living, from walking sticks to complex automated wheelchairs,

toilets and the like. It is not clear how 'electronic' these would need to be to

qualify as ALT.

Nevertheless, skills for care include telecare, telehealth and assistive technology

equipment in ALT for the purposes of their guidance and recommend their use

together as part of an effective strategy. So perhaps part of the problem is that we tend

to think about them very separately, and procure them differently within traditional

but potentially ambiguous silos. Others have suggested that the separate

identification of these forms of equipment as a ‘special’ market is part of the problem,

suggesting that neither telehealth nor telecare will thrive until they are understood as

just elements of the delivery of good quality care.

Business Models

Key to successful business models is an analysis of the benefit provided, the

customers to whom it will be provided, the market through which it will be delivered

and which is of sufficient size to sustain the offer at an acceptable unit cost, and the

ability and willingness of customers to pay more than the cost of the intervention.

The Market

Well there is certainly a substantial care market, £17 billion per year is spent by

Government on adult social care in the UK alone. There is also a substantial but less

well understood level of informal care, provided by friends and families. These costs


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are driven primarily by long term conditions, which are accumulating in the

population because people live longer with them and because the population is ageing

and age is the single biggest risk factor for most of these conditions. 15 milliom

people in the UK have a long term condition, and their care accounts for 70% of the

health and social care budget. So there is a large and growing market for care. But

how this translates to a demand for technology is far less clear and will inevitably be

dependent on the value which can be offered.

Value

All of these tools produce different benefits for different people, which suggests the

need for different business models. Providing value is a matter of cost / quality trade

off. Since quality is often subjective this may include perceptions of quality which

differ between individuals. Providing technology as an addition may improve quality

but almost certainly at increased cost. Technology that substitutes for more expensive

personal attention may save money but be perceived as reducing quality. Assisted

living technology has traditionally been strongly technology driven and arguably the

failure to clearly identify the benefit to be delivered by these technologies is a key

element in the failure of the market to develop.

Telecare - Business Models

It seems likely that the majority of care will continue to be provided face to face.

ALT is not going to help disabled or frail older people to wash, dress and feed

themselves, at least not yet. And while communications technology is a good

supplement for a personal presence, people are very concerned about it becoming a

replacement.

'You can't hold someone's hand through a computer'

Telecare, in the form of alarms does relatively little for the cared for person, it does

not prevent adverse events, although some newer technologies can potentially predict

them or at least demonstrate a trend for increasing concern and vigilance. However

they have added value for local authorities. By mitigating the potentially


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unacceptable impact of someone, for example falling in their own home and not being

found for a long time, they reduce public and family concern at older people

remaining in their own home rather than institutional care. Institutional care

provision can be reduced and replaced with domicilary care. This has supported huge

(albeit virtual, given the growth in numbers) savings in social care, and local

authorities have been content to pay for that benefit.

This has to some extent served to focus the telecare market on a small segment of the

market, defined by those people entitled to Local Authority care. Whilst the number

of people needing this level of support continues to grow, government funding is

static, shrinking in real terms, essentially limiting the further growth in the market.

So rather than a growing market in this space we have a stagnant one, arguably

adequately provided for by the early entrant businesses. Improvements to the

technology to analyse trends and anticipate crises are expensive and provide little or

no additional advantage to the local authority funder.

So how do we expand the market. Similar benefits could be made available to

informal family carers, which would greatly expand the potential market. New

technologies could be offered to family carers and cared for people directly, since

both are actively seeking to avoid crisis events, and some businesses are starting to

move in this direction. But this would require a very differently shaped business, and

begs the question of how members of the general public would learn about the use of

assisted living technology and obtain advice on which devices to purchase. What is

clear is that this is an area that is poorly provided for.

Telehealth – Business Models

Telehealth has proved itself a hard market to enter. Clinical pathways are strongly

controlled by healthcare professionals, particularly clinicians. Where they are

motivated to use technology, they are inclined to seek solutions which operate without

adaptation to their normal ways of working. These therefore need to be low cost,

since there are few savings from which they could be funded. Technologies which

use ubiquitous technology -such as text messaging on mobile phones to prompt


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actions - are easily deployed, cheap and improve compliance and therefore outcomes.

These are showing some success.

On the other hand, solutions which have been developed through access to research

and development funding tend to be more specialist, complex and expensive,

particularly in small numbers. Potentially more effective at introducing efficiencies,

they would do so by impacting on existing pathways and are often highly constrained

by data management requirements. Where clinicians have shown interest, they often

require bespoke solutions which fit their way of working. As a result, the market,

whilst large and growing, is fragmented into tiny packages by clinical condition,

pathway variations and commissioning priorities.

So much for the large market: in fact the market is rather small and highly

fragmented, requiring small numbers of therefore premium solutions, which is fine if

you can get paid for them. But there are other problems.

Getting Paid

Importantly, health and social care budgets have tended to act as substitutes for each

other. Inadequate care results in hospital admissions picked up by the health budget

whilst inadequate or incomplete treatment or rehabilitation results in a higher need for

social care. This can drive inappropriate behaviours or more probably inadequate

awareness. It also confuses us about who pays and tends to emphasise the large

monopoly procurement status of the NHS.

In aiming at the public sector market, our options for payment are limited. Budgets

are controlled by government and tend to be somewhat arbitrary. There is little scope

for quality improvement or Rolls Royce solutions.

In practice, the health budget is larger and malleable and has attracted most attention.

Even technologies which seek primarily to support better management of care have

been aimed at the health budget, based on their potential to reduce crisis admissions to

hospital. However, the health budget is not an easy target. It has very high evidential

requirements which are hard for businesses to meet, particularly with new

technologies, potentially requiring years of costly trials. Where these trials have been


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facilitated by large scale implementation projects their outcome has not been clear.

What benefits are we measuring?

Even where theoretical cost savings can be demonstrated, there are challenges in the

public sector funded model.

Many of the savings cannot be implemented because of irreducable spare

capacity, therefore the technology is not affordable.

Where Savings can be realised it is likely that priming funding will be

required before the savings occur, therefore the technology is not affordable

unless accompanied by innovative financing.

Technology is often disruptive. Whilst it may make savings or add value, they

may not always match those to which the purchasing organisation is tethered,

for example reducing the number of times a doctor needs to see a patient

through remote monitoring is not particularly attractive if you are paid per

visit. Tariffs mechanisms may often create challenges to even the most

sensible solutions.

Finally, despite 20 odd years of 'business like' financial management and

recognition of spend to save measures, for the public sector an annual budget

is a far stronger driver than through life cost. Which is probably why,

internationally, better progress appears to be being made by those nations who

have at least partially insurance based health and care mechanisms. Insurance

companies recognise the through life cost of a condition, across the whole

pathway, without artificial organisational or temporal constraints.

Expanding the Market

So we have a small segmented market which struggles to implement and pay for

innovative solutions, now we are beginning to understand the problem. Add to this

the fact that the reputation for strong economic growth attributed to ICT is rooted in

its relevance to large numbers of users, its low cost and high value added and with the

benefit of hindsight it all sounds so obvious. Business computers are used throughout


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the world and are basically similar, making them relatively cheap. However, they

have large numbers of features and are highly user customisable making them flexible

so that all of these users can define their own ways of achieving benefits. None of

this seems to be true of assisted living technologies.

So that's all very well with hindsight, what should we do about it. If the current

market isn't big enough how can we grow it? If public funding doesn't suffice, how

do we reposition. One way is to address different values:

Care providers are under great pressure to do more with less, are there

solutions through which technology could help them prioritise, manage and

deliver more efficiently the same or better outcomes? It makes less and less

sense to separately fund the technology and the support response. This also

provides opportunities to address the problems that are really critical to care

providers such as electronic door locks, which allow authorised access for

carers as needed without the trouble of handling keys.

To address private funding we need to provide value of immediate interest to

individuals. Whilst there will be some interest in saving costs to informal

carers, these will mostly relate to quality of support. Delaying decline,

supporting re-ablement or pre-empting care needs preventatively might all be

valuable to self-funders, as might technology which addresses the many non-

clinical challenges of living with chronic disease.

Addressing needs that are common across multiple conditions would address

some of the challenges of multiple pathology associated with an ageing

society. It would also reduce the fragmentation of the market.

Housing associations and other businesses / agencies with frequent encounters

with vulnerable people are beginning to understand that they have a role in

identifying and intervening in declining health of their clients. By capturing

and monitoring interactions between staff and clients, and using the emerging

data effectively, they have a strong role in early assessment, particularly

amongst the harder to reach.


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Addressing the Private Market

Private funding is a potentially huge source of additional funding. Regardless of the

approach, working in a private market is likely to involve providing a service rather

than simply technologies. Some technology businesses are exploring these markets

but for the most part prefer to remain b2b, interacting with a range of integrators and

intermediaries who will deliver outcomes.

Accessing private funding also requires the development of a new market and of

market places. How will people access advice, guidance, selection support? How

will they become aware of the benefits of technology, which requires the technology

to be visible in society, which will benefit from reduced stigmatisation and more

attractive devices?

Who will be the target of marketing for these tools? Our work indicates that those

with few care needs like the idea of technology which will delay loss of independence

and that those who could afford it would be willing to pay. However, it is equally

clear that as care needs increase many individuals would rather reduce activity than

employ even technological assistance and those with care needs are often concerned

that technology will replace rather than enhance existing human support. A careful

balance of marketing to those with a need for support, their informal carers, industry

care providers and commissioners further emphasises the need to improve

understanding of the value provided by technologies and who they are provided to.

This cannot be achieved through a 'village' of specialist SME equipment providers. It

requires a new understanding of the industry to include integrators who will take

financial risk and deliver outcomes, and infrastructure and service providers who will

support and maintain capabilities. There will be new roles and new skills needed.

Technologists will need a better understanding of care and care workers of

technology.

Above all, there is a need to understand that these are not separate and independent

markets. Private funders may initially engage with the market as consumers but will

transition towards greater needs of physical and clinical support. Even those who age

healthily will eventually lose capability and require help with activities of daily living.

Those who self-fund care initially may eventually transition to public support.

Different marketing approaches are needed for solutions along this spectrum but


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ultimately they need to be understood as a continuum of care support if their value is

to be understood.

The Value of Change

A big Problem for the project has been to understand a health and care system

undergoing massive change. If it is a problem for an academic project well linked to

health, care and the industry, little surprise that businesses struggle to find their way

in, and many of those that do, even well-known brands quickly leave again.

The Care Act will introduce yet more change. However it enshrines in law

requirements for health and social care to work together and for local authorities to

provide support for all citizens to maximise their health and independence regardless

of whether it provides them with statutory care. These new requirements must surely

provide new opportunities for more aligned solutions and a mixed public private

market.

designing scalable assistive technologies and services for independent healthy living and...

Health & Medicine

social business

business partners

economic business models

health services research

director of digital

health research nihr

assisted living technologies

nhs national institute