hbs management challenge - telemedicine for prisons final

Henley Business School

University of Reading

An investigation into the provision of primary healthcare

services to HM Prisons using Cisco HealthPresence™ for

telemedicine applications.

Situl Shah

Management Challenge Report submitted in partial fulfilment of the

requirements for the degree of Master of Business Administration 2010

Henley Business School MBA Programme at the University of Reading.

Disclaimer: (This report is not intended to be overly critical of national Government policy on

provision of healthcare for UK citizens and residents, as this is outside the scope of this study.)

Acknowledgements

I would like to thank all staff of the UK Public Sector Healthcare and Justice

Organisations who participated in the interviews, and various teams from

Cisco, who has provided support and encouragement.

I would also like to thank my fellow Henley MBA programme members,

faculty staff and programme leader, Alison Llewellyn for providing the

support and motivation during the various challenges of the course.

Very special thanks go to my project supervisor, Dr David Paskins for this

guidance and support throughout this detailed study.

However, my greatest thanks go to my loving wife, Bina for all her ongoing

support, dedication, guidance and generosity throughout this journey.

Without this, the study could not be completed.

Situl Shah

Purpose: This report outlines a strategic ‘business case’ for an important Central

Government Department, the Ministry of Justice and its executive agencies,

the National Offender Management Service, NOMS, and HM Prisons

Service, HMPS.

The intention is to assist deployment of collaboration solutions including tools

to drive operational efficiencies and provide quality primary health treatment

to the Prison population.

Terms of Reference The issue of public sector budgets and finances has been widely reported in

general media over the past few months, especially since the recent bailout

of the Banking Industry last October 2008 resulting in the need for UK and

other major Western Governments to rebalance their National Finances over

the next 5 years.

The Author: Situl Shah is a strategic marketing professional from the technology &

communications industries for over 17 years holding a variety of Global roles

across Enterprise, Commercial & Government sectors.

The Client: Cisco Systems is the world leader of internet networking solutions. The

company is currently investigating key activities into the Public sector across

the European Union to address the needs of Governments in helping reduce

their national financial deficits through the use of technology solutions to

improve access to health care.

Table of Contents Acknowledgements ................................................................................................................. 2

Executive Summary: ................................................................................................................ 8

1.0 Introduction .................................................................................................................... 10

1.1 Background ................................................................................................................. 10

1.1.1 Prison Population Growth. -‐ Why the increase? ..................................................... 13

1.2 Operational Effectiveness ........................................................................................... 14

1.2.1 Strategy: ............................................................................................................... 14

1.2.2 Structure .............................................................................................................. 15

1.2.3 Systems ................................................................................................................ 15

1.2.4 Style ...................................................................................................................... 15

1.3 Key challenges: ............................................................................................................ 16

1.3.1-‐Managing the Increasing prison population: ....................................................... 16

1.3.2-‐ Improving overall efficiencies and effectiveness: ............................................... 16

1.3.3-‐ Other challenges. -‐ Improving the system: ......................................................... 16

1.4 IT is considered a low priority for healthcare providers. ............................................ 17

1.5 Funding restraints ....................................................................................................... 18

1.6 Achieving cost savings through Return on Investment ............................................... 18

1.7 The general marketplace for technology in prisons .................................................... 19

1.8 Summary of key challenges and marketplace for technology in prisons. ................... 21

1.9 Key technology trends for Healthcare in Prisons ........................................................ 22

1.9.1 Summary of key trends. ........................................................................................... 25

2.0 Literature Review ............................................................................................................ 27

2.1 Overview ..................................................................................................................... 27

2.2 Introduction ................................................................................................................ 27

2.3 Objectives of literature review .................................................................................... 27

2.4 Concepts: ..................................................................................................................... 28

2.5 Basic definitions used in literature review .................................................................. 30

2.6 Key findings from the literature review ...................................................................... 31

2.7 Organisational culture in the Public Sector. ................................................................ 32

2.8 Strategies for complex public sector organisations. ................................................... 33

2.9 Strategies for implementing technology based solutions into the Public sector ........ 34

3.0 Strategic Alliances & Partnerships ............................................................................... 35

3.1 International perspectives: ......................................................................................... 37

3.2 Financial implications for government. ....................................................................... 39

3.2 Using video conferencing & ‘Presence’ technology for telemedicine. ........................ 39

3.3 Relevance of current thinking. .................................................................................... 43

3.4 Examples of current thinking: ..................................................................................... 45

3.5 Summary of findings from the literature review. ........................................................ 47

4.0 Research: Gathering Information, interviews, key findings & analysis. .......................... 48

4.1 Overview ..................................................................................................................... 48

4.2 Key research objectives for this management challenge include; .............................. 49

4.3 Methodology ............................................................................................................... 49

4.3.1 Reasons for this approach include; .......................................................................... 50

4.3.2 Sampling. .................................................................................................................. 51

4.3.3 Cross Section ............................................................................................................ 51

4.3.4 Surveys ..................................................................................................................... 52

4.3.5 Deductive & Inductive processes ............................................................................. 52

4.3.6 Quality: ..................................................................................................................... 53

4.3.7 Reliability: ................................................................................................................. 53

4.3.8 Validity: .................................................................................................................... 53

4.3.9 Generalisability: ....................................................................................................... 53

4.4 Limitations of the Research Approach ........................................................................ 54

4.4.1 Interview Selection Process ..................................................................................... 55

5.0 The Research Question: .............................................................................................. 56

5.1 Key findings from primary research ............................................................................ 57

5.2 Varying costs of healthcare provision. .................................................................... 57

5.3 Using technologies for Telemedicine ...................................................................... 58

5.4 Cost effectiveness for the payer for primary health treatment. ............................. 60

5.4 Other findings .............................................................................................................. 61

5.5 User experiences with ICT vendors ......................................................................... 61

5.6 Increasing staff productivity .................................................................................... 62

5.7 Increasing accountability and transparency for Prison operations, e.g. Prisoner transfers between establishments ................................................................................ 62

5.8 Prisoner transportation between courts, hospitals & other facilities. .................... 63

5.9 Helping achieve specific initiatives for Prisoner Healthcare management, Education, & reduce wastage from ‘old’ working practices. ......................................... 63

5.9.1 Summary of findings: ............................................................................................... 64

6.0 Conclusions ................................................................................................................. 66

6.1 Key Recommendations ................................................................................................ 67

7.0 Reflections ....................................................................................................................... 70

7.1 An evaluation of my findings ....................................................................................... 70

7.2 Experience of the research process ............................................................................ 72

7.3 Personal development objectives ............................................................................... 75

8.0 References ....................................................................................................................... 76

Appendices ............................................................................................................................ 82

Key Definitions: ................................................................................................................. 82

Appendix 1-‐ Industry Five forces ....................................................................................... 84

Appendix 2 -‐ Market Opportunities .................................................................................. 85

Appendix 3 -‐ Market forecast ............................................................................................ 86

Appendix 4 – ICT Spending Overview: .............................................................................. 87

Appendix 5-‐ Return on Investment ................................................................................... 88

Appendix 6 -‐ Research Questions for HM Prisons Service Transcripts of interviews with Healthcare managers and Governors / Deputy Governors. .............................................. 89

Appendix -‐7 Value chain for NOMS & HM Prison Service. ................................................ 94

Appendix 8-‐Prison Population ........................................................................................... 95

Appendix 9 -‐ Healthcare Escorts & Bedwatches ............................................................... 98

National Tariff 2008-‐09 ..................................................................................................... 98

Escort Events ................................................................................................................. 98

Bedwatch Events ........................................................................................................... 98

One-‐off .............................................................................................................................. 98

Hourly Rate ........................................................................................................................... 98

One-‐off .............................................................................................................................. 98

Hourly Rate ........................................................................................................................... 98

AREA RATES ....................................................................................................................... 98

RATE 1 ............................................................................................................................... 98

RATE 4 ............................................................................................................................... 98

Aylesbury ........................................................................................................................... 98

Bullwood Hall ................................................................................................................ 98

Appendix 10 – Financial Accounts ................................................................................... 101

Appendix 11 – Stakeholder map of NHS contacts & departments for Prisoner Healthcare. ........................................................................................................................................ 102

Executive Summary:

Following several years of general increases in the prison population and

rising health care costs across major economies of the world, there is an

increased awareness of the need for a strategic approach to managing this

situation based on economics, rather than ideology alone.

The UK and other major countries in the developed economies have seen a

steady rise in the overall Prison population which had more than doubled

since 1993 to an imprisonment rate of 154 per 100,000 in England & Wales

and is now Western Europe’s biggest incarcerator. Further, between 1995

and 2009, the prison population in England & Wales grew by 32,500 or 66%,

despite an extra 20,000 prison places provided since 1997 an increase of

33%.

This is presents various challenges in the provision of key services to this

segment of the general population while managing risk and ensuring public

safety.

Transformative technology solutions including Cisco HealthPresence™ and

related collaboration tools such as Cisco WebEx™, & Unified Contact

Center™ offer an excellent alternative to the current status by enabling

operators to provide multiple services over a highly reliable network platform.

This ultimately reduces costs and drives efficiency savings throughout the

organisations and presents opportunities to government for new ways of

collaborating with the wider public and interested parties.

By combining medical devices with these collaboration tools, Cisco

HealthPresence™ offers exciting opportunities for healthcare provision

through enabling live and interactive face to face consultations across

geographical boundaries with medical experts.

Key benefits include:

• Expanding access to cost effective healthcare to the Prison population

• Optimising scarce resources and reducing travel costs for healthcare &

justice professionals

• Reducing risks to and from Prisoners and Offenders through the provision

of care in a secure custodial environment

• Increasing operational effectiveness through effective, team based

collaborations with related sectors. Health, Police, Probation, and

Rehabilitation services.

Users and operators benefit from faster responses to primary care issues

including mental health and basic medical procedures including dermatology

& cardiology with specialists who can be located around the world on a 24

hour, 7 day basis.

The impact of using such technologies in the application of Telemedicine can

also be served as a model for other countries internationally where budgets

for prisoner care from private and public sources are facing increased

pressure for greater efficiency.

1.0 Introduction The original scope of this management challenge report was deemed far too

broad and with the agreement of the supervisor, was narrowed down to

focus on using Cisco HealthPresence™ as a key enabler for healthcare

provision. This is an adapted version of commercially proven Telepresence 1

systems to deliver primary healthcare using Telemedicine 2 to the prison

population and act as an enabler for improving operational efficiencies.

1.1 Background Traditionally, the UK Government and related agencies such as the

Probation Service, Police Service and the Courts service operated in silos in

determining custodial sentencing and the provision of any rehabilitation

programmes required. This was considered by many experts as only partially

effective in reducing overall crime.

During 2005/6, a strategic review was conducted and from May 2007, the UK

Home Office was split in two which represented an important structural

change over the past few years in this sector. The former Department of

Constitutional Affairs, DCA, took responsibility for probation and the

prevention of reoffending and then renamed as the Ministry of Justice,

(MOJ), serving under the Lord Chancellor & Minister for Justice. Hence,

since 2007, the Ministry of Justice was created by an act of Parliament and

for the 1st time brought together overall responsibility for the Justice system,

1 Telepresence refers to a set of technologies which allow a person to feel as if they were present, to give the

appearance that they were present, or to have an effect, at a location other than their true location.

Telepresence videotelephony is a higher level of videoconferencing, deploying greater technical sophistication and

improved fidelity of both video and audio. 2 Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred

through the phone or the Internet and sometimes other networks for the purpose of consulting, and sometimes

remote medical procedures or examinations.

including HM Courts, Police, Prisons and Probation services to work in

partnership for greater public confidence and improved decision making.

From this strategic shift in Government policy, a new department, the

National Offender Management Service, (NOMS) was created in July 2008,

and now holds management responsibility for the overall Prisons Service in

the Public & Private Sectors.

This shift in moving responsibility for Prisons into the MOJ is in line with

recent trends in all 47 countries of the Council of Europe3, except Spain, and

is also the position in most of North & South America and some parts of

Africa & Asia. A notable exception is in the Middle East where the prisons

are managed by each respective Country’s Interior Ministry.

According to the International Centre for Prison Studies, January 2009, there

are currently 158 Prisons in the UK, of which 11 are currently managed by

private operators including Serco, G4S, & Kalyx. Since November 2009, a

new, category C prison, HMP Bure, in Norfolk opened resulting in a total of

140 Prisons in England & Wales. (This will be privately operated & managed

using a private finance initiative, PFI sourcing model). Source: NOMS

Five forces analysis summary Variable factor Rating Reasons

Supplier power High Significant penalties exist for NOMS to 'break out' of any existing contracts.

Buyer power Medium MOJ – The main government agency that holds judicial responsibility to Parliament

Medium NAO - National Audit Office – Independent body that monitors major government spending

New entrants High There is a growing threat from the private sector to the management of Prisons operations

Substitutes Medium Using disruptive technologies such as Telepresence, VC & RFID electronic tagging.

Low Financial penalties to family & friends if a prisoner fails to comply with sentencing terms.

Summary table of key factors affecting HM Prisons - Adapted from M Porter

(1995)

3 The Council of Europe is one of the oldest international organisations towards European integration. It has particular emphasis on legal standards, human rights & democratic development under the rule of law & co-operation. It has 47 member states with some 800 million citizens.

To put this into context and appreciate some of the wider macro factors

affecting this public sector organisation, figure 1 illustrates the total UK Public

sector borrowing as a % of gross domestic product (GDP) which is currently

at an all time high.

Figure 1

Current thinking and indications from UK Central Government suggests that

this trend will continue until 2011/12 before reducing. This is in agreement

with leading consultancies who predict higher than average public sector

deficits for the next few years. Source: IHS Global Insight (2009).

There is also a drive by all main political parties to reducing the estimated

national debt burden of £178bn which is translated to 12% of Gross

Domestic Product. (GDP) Source: HM Treasury. (2009).

It is widely expected that any incoming government from the 2010 general

elections will be considering alternative options to help reduce this over the

longer term and one significant method of doing so may be offering large

Public Sector outsourcing contracts and increasing efficiency savings.

1.1.1 Prison Population Growth. -‐ Why the increase?

Due to a variety of reasons, including higher conviction rates, the UK prison

population is predicted to rise to over 96,000 by 2012 and exceed 100,000

by 2014. (Office of National Statistics, July 2009). 4 To partly address this,

in 2007, the Ministry of Justice, via its agencies, NOMS & HMPS, has acted

on key recommendations from Lord Carter’s Review, and embarked on a

“Capacity Development Programme” to ensure an additional 10,500 prison

places are created and available by 2014.

One of the aims of this programme is to help reduce overcrowding rates

while providing more efficient care and prisoner management for increased

public confidence and safety.

Whether this is achievable is doubtful partly due to funding restrictions

imposed HM Treasury following the effective bailout of the Banking sector by

some £80bn during autumn 2008 and throughout 2009 by the Chancellor,

the Right Honourable Alistair Darling, MP. As a result, funding resources to

the Prison service has been significantly reduced.

This report aims to show that the provision and delivery of primary

healthcare services to the prison population can be done effectively using

Telemedicine applications.

Adaptations of market leading solutions including Cisco HealthPresence ™

will significantly reduce operational costs and provide additional benefits for

users and operators.

4 This figure also includes offenders who are attending prison on a temporary basis, as well

as those who have electronic tagging orders and are under house arrest.

1.2 Operational Effectiveness

To understand how NOMS & HPMS can benefit from a greater use of

strategic technology in its future operations, the diagram below helps assess

overall effectiveness through several interrelated elements for the use of

telemedicine.

Adapted from McKinsey’s ‘7 S’ Framework.

1.2.1 Strategy: For NOMS & HMPS, the effective strategy of the organisation may determine

the structure of its operations, and in turn, it’s systems. It should be noted

that in practice these dependencies are not linear or mechanistic. Long, T.

(2006).

ValuesGovernment led

Political &Vendor neutral.

Staff

SystemsEnsuring relevant procedures

are used for effectivecustody management.

StyleNon profit operations moving to PFI model

Closed culture & red tape

SkillsSome training required for using video systems for telemedicine applications

StrategyCost reduction & efficiency savings.

Partnering with industry for increasing capacity.

Ensuring sufficient leadership talent.Adapted from McKinsey

Structure140 in Public ownership

in England & Wales

Source McKinsey 2009

1.2.2 Structure The current structure of HM Prisons service is still hierarchical in nature with

many departments operating in silos with low levels of communications

between them. Partly due to changes in the wider economy, strategic

initiatives by government, and proposed spending cuts, NOMS & HMPS has

introduced a flatter organisational structure by removing several layers of

management. This can improve levels of empowerment for local

‘management’ teams in making decisions and helping increase overall

efficiency and raising productivity. Drucker (1984)

1.2.3 Systems Despite recent changes by NOMS, there are still too many decisions made

through bureaucratic ways. Examples include arranging visits by members of

the public. In many cases, Bureaucratic management is sometimes referred

to as ‘classical management’ and often characterised by Weberian

bureaucracy as dependant on rules and procedures that lead to a hierarchy

and clear division of labour. Weber, M (1864 -1920).

1.2.4 Style The management style at NOMS & HPMS is a ‘top down’ approach with top

management dictating business strategy. From Central Government policy

recommendations Gershon (2004), there is also a need for openness that

supports learning from change with a more open management style,

encouraging initiative. Changes made towards a flatter structure would lead

to best practice in the public sector and NOMS should also embrace a

bottom up approach to compliment this. This would enable ‘top’

management to provide improved leadership and coach teams and individual

contributors to facilitate necessary changes. To succeed in a global, 21st

century environment, managers will have to adopt a trust and empower style

and recognise that the role of work in people’s lives has shifted radically.

Peters, T (1992)

1.3 Key challenges:

There are a number of key challenges for NOMS including; 5

1.3.1-‐Managing the Increasing prison population: The UK prison population has been rising steadily since 1995, to 2009 by

32,500 or 66% presenting a significant challenge for Government

departments including the Criminal Justice System and Health services. The

huge increase in adult prisoners and young offenders has resulted in the use

of emergency measures such as using police & court cells as short term

facilities; resulting in expensive & tactical management of prisoners.

1.3.2-‐ Improving overall efficiencies and effectiveness: This includes delivering key reforms including driving efficiency in prison &

probation providers through improved contract management & benchmarking

to achieve savings of £200m in 2010/11.

1.3.3-‐ Other challenges. -‐ Improving the system: This includes the provision of healthcare and other related services in a cost

effective and efficient manner. E.g. Using Telemedicine/Telehealth

applications for primary health, education and rehabilitation services.

For vendors seeking to work extensively with Public sector departments and

agencies including HM Prisons and Healthcare, it is vital to offer solutions

that offer long term value for money through reduced operational

expenditures from the outset.

5 Ministry of Justice et al (2009) NOMS Strategic and Business Plans 2009-10 to 2010-11, p7

(Valdez, G) states that Technology is constantly evolving and provides

tangible benefits to users and providers (vendors) in many ways such as the

new opportunities in learning and self care.

To put this into context, most vendors agree that Healthcare is generally

defined as a large vertical market with many different players including

primary care trusts (payers), insurance providers, strategic health authorities

and government. The general public and healthcare professionals also have

some influence on the provision of key services at reasonable cost.

To help contain some of these overall costs, investments for Telehealth &

eHealth systems & services are gradually being increased to 5% of overall

health budgets from the current 1-2%. This will save time and money over

the longer term through increased efficiencies in diagnosis, treatments and

faster decision making. Source: Business Insights (2005)

To support this growth, leading vendors operating in the Justice and

Healthcare markets including GE, Philips, HP, Polycom and Cisco are

investing in new and innovative products to address market opportunities

and optimise scarce resources.

However, there are also many barriers faced by technology vendors

including funding constraints, a lack of internal and external markets,

priorities (and perceptions) given to IT by healthcare managers, and the

difficulty in proving a fast return on investment (ROI).

1.4 IT is considered a low priority for healthcare providers.

Although some IT solutions can have a direct impact on medical practices

including the speed and efficiency in the provision of care treatments, this is

mainly indirect with staff training usually required at additional expense.

However the main priority for healthcare providers remains the provision of

healthcare, not administration and it is the nature of decision making by

primary care trusts and strategic health authorities which makes it difficult to

justify IT spending when there are other valid uses of financial resources. For

example, if choices are to be made between IT systems and critical medical

equipment, then a medical professional will normally opt for the latter.

In addition, many healthcare professionals are still not very comfortable with

some types of modern technology including personal computers, and

handheld wireless devices, video IP telephones and are reluctant to use

newer technologies such as Telepresence systems, unless they are

customised for simplicity of operation.

1.5 Funding restraints

Although the current Department of Health’s NHS budget of £110 billion for

2010-11 appears to be secure by the current government administration,

some hospitals and clinics have difficulty in obtaining funding for substantial

technology projects. This is partly due to increased red tape from the

Government’s own reform agenda and increased scrutiny from key

stakeholder groups including the Taxpayers Alliance and other interested

parties. Given the political issues surrounding healthcare funding in the UK,

and with an upcoming general election to be held in 2010, these restraints

may increase over time.

1.6 Achieving cost savings through Return on Investment

A key reason for IT investments is achieving cost savings through increased

operational efficiencies with associated job cuts. In general, some public

sector organisations including Health Primary Care Trust’s and

NOMS/HMPS have found it very challenging to generate cost savings from

IT initiatives and also downsize non essential staff. Historically, it is the

nature of the public sector in general that employee’s trade in higher salaries

for relative job security, and therefore, until some administration workers

retire or leave, primary care trusts and related service providers (such as

prisoner health trusts) cannot achieve the expected savings required.

However, there is a movement towards using Telehealth & Telemedicine by

government and backed by the European Commission. Cost savings can be

achieved by no longer recruiting replacement staff, rather than reducing

staffing levels.

As a result, a key restraint for ICT investment into segments of the public

sector is expected to be reduced over the next few years.

A combination of factors including those already described, contribute to the

challenge for vendors & IT service providers to demonstrate a clear ROI and

especially in areas where it is difficult to quantify such as internal meetings

and learning activities.

One leading company, Cisco Systems, has developed a comprehensive ROI

tool that clearly demonstrates the Cisco HealthPresence™ system as a very

strong alternative to traditional delivery of care services with additional

applications for even greater utilisation and increased operational

efficiencies.

Therefore, a demonstrating clear and fast ROI measurement for any ICT

investment remains a key priority in the decision making process and is in

line with practices in the general commercial environment.

1.7 The general marketplace for technology in prisons

This section briefly describes the general technology marketplace in this

segment of the Public Sector, with major challenges, key trends and new

market opportunities etc.

As previously described in this report, as of December 2009, there are over

84,231 adults held in custody throughout the Prison establishments at an

estimated average cost to the taxpayer of £41,000, up from £37,500 in 2007,

and equating to £34,534,710 pa. Source: Prison Reform Trust (2009)

According to the MOJ & NOMS, there are a number of concerns for reducing

risks and related security concerns in prisoner transfers between offsite visits

to hospitals and other medical and judicial facilities. This is combined with a

need for increasing accountability and transparency in Prison operations

including e.g. Prisoner transfers, accurate records management, and health

services etc. By supporting the use of technology, for education and

management, there is an overall reduction in re-offending rates and

improvements in the provision of effective healthcare. Scharf (2008).

From this lens, and especially during the current economic climate, Her

Majesty’s Prison Service is ripe for the introduction of new technologies

including Cisco HealthPresence™ and associated services that provide

multiple benefits such as reduce operational costs, increase efficiency and

improve productivity in the provision of primary healthcare delivery which are

highly labour intensive activities.

Although market drivers are high, there are several barriers to overcome

including;

• Reductions in operational budget allocations by HM Treasury and a key

measure which should be considered by respective vendors.

• Lack of technology familiarity and use by staff activities. E.g. Using paper

based record keeping of prisoner movements & related treatments,

instead of an internet based online management system which can be

viewed and amended only by authorised persons. E.g. Medical Doctor,

Head of Health services etc. Therefore, any solutions should be simplified

for staff and visitors to increase adoption & use.

• Pressure by unions and other interested parties, (representative groups)

to use their staff instead of technology to avoid necessary reductions in

some job roles. E.g. The need for high levels of administration staff.

• Some psychological perceptions from a greater use of technology such

as lack of personal contact and face to face dealings.

• Political interference – both in the technology procurement and budgeting

processes by different Government agencies and opposition parties.

An underlying issue of organisational culture and resistance should not be

discounted for any business that wishes to work with NOMS & HMPS, and

offer new products & services while simultaneously improving their prisoner

care activities.

1.8 Summary of key challenges and marketplace for technology in prisons.

It can be seen that there are a number of very significant challenges faced

by government departs such as MOJ & NHS in funding and maintaining

health services cost effectively over the long term. Improved partnerships

with the private and third sector can help address these shortcomings by

working with leading companies such as Cisco to benefit from global

technology expertise and business leadership.

Using adapted technologies from field proven Telepresence™ systems can

provide excellent user experiences in the prison & health service

environments and yet demonstrate a fast return on investment (ROI),

through multiple applications including learning, learning and rehabilitation

programmes.

The implementation and management of such technologies can be complex,

and the use of third party outsourcing contracts is already commonplace with

organizations including HP, Steria, Cable & Wireless, Serco and others

holding proven track records. This is an area that is likely to continue but with

the added challenge of large scale Public Sector ICT contracts being

reduced due to commitments made by the main political parties.

1.9 Key technology trends for Healthcare in Prisons

This section highlights a few trends that are emerging in this solution and

how the use of strategic technology can aid operational efficiencies in the

Prison Service.

TECHNOLOGIES DESIGNED TO ACHIEVE COST SAVINGS

Institutional Systems Community

Mature

Technologies

Prison & Offender

Management

Prisoner Records

Management

Video Surveillance

CCTV

Emerging

Technologies

RFID & Biometric

Health

Management

Integrated Criminal

Records management

with Health &

Education

management.

GPS based tagging

Remote Dentistry

Remote Ophthalmology &

Optometry

Remote Dermatology

Disruptive

Technologies

Bio-Identification

Telepresence &

various

adaptations.

Risk Assessment Behaviour Management

Of key value to vendors and users for the general uptake of Telepresence, is

system interoperability. Put simply, this means where one vendor’s systems

will work with another vendors across open standards. By using such an

approach, it very is likely to increase usage of such solutions and vertical

market adaptations (i.e. Cisco HealthPresence™) over time and will further

drive use for real time collaborations, discussions, trainings, counselling &

other team based activities over a more integrated supply chain.

Therefore, the issue of greater interoperability as a basic requirement for

organisations is very important for increasing overall market adoption.

However, it should be noted some vendors are unwilling to share aspects of

their proprietary systems expertise with competitors for their own commercial

and technical reasons including patent applications.

Many organisations are also enabling workforces to engage with customers,

and the wider supply chain through different technologies including audio &

video conferencing, virtual private networks (VPN) access, contact centres &

unified communications. This may also act as a driver of Telepresence

systems to be fully open standards compliant and thereby help overall

adoption of such systems.

Another growing trend is for managed services. 6 This offers organisations

increased choice of services with improved flexibility and much lower risk of

hardware & software procurement from a variety of “service providers”

including BT, CW, Global Crossing, AT&T, Orange Business Services etc.

This also serves as an important channel for mainstream vendors such as

Cisco, (including Tandberg), HP, Polycom, Lifesize, Teliris etc and will also

form the start of the service providers’ own versions of Telepresence being

positioned to customers in different vertical markets.

Alternative “service providers” could also be established using existing

operational outsourcers including Serco and G4S which already hold

national prisoner transportation contracts with NOMS. However, to date,

these alternative providers do not possess the necessary in-house business

and technical expertise to offer this service as part of their portfolio.

Wider background research suggests there are two main segments for

Telepresence solutions. 6 The centralised and publicly consolidated nature of UK healthcare means that government policy has a more direct effect on IT spending than other countries.

1- Room based suites that consist of all physical hardware, & software as

technology and other elements including furniture, air conditioning,

heating, lighting, spatial sound acoustics & dedicated power.

2- “One off” builds for room design, planning, implementation,

commissioning, testing and training – This also may include additional

options for network provisioning, configurations, monitoring, maintenance

and support.

The main application for Telepresence based solutions are holding

organisational meetings by dispersed teams that help reduce travel costs

considerably.

In light of strategic and operational activities in the wider Public Sector, more

specific uses are emerging for tailored applications of this technology

including legal healthcare (including telemedicine), recruitment, training and

education.

This includes designing and building specific versions of Telepresence for

Healthcare and Learning, i.e. a “Service Presence” or “Health Presence”.

Another important trend is that of tagging using electronic devices such as

RFID – Radio Frequency Identification for monitoring low risk prisoners

during their offender management programmes.

Although RFID has been in existence for some time already, until now it has

not been a viable offering due to its unreliability from radio signal interference

in a contained environment such as prisons or jails.

Due to developments over recent years, this has changed with different radio

frequencies being available and improved supporting equipment and more

sophisticated, smaller tags that informs the authorities if the offender does

not report back to the prison or police station or within a set timeframe.

Storage – As information regarding prisoner health is moving to being

recorded electronically in accordance to general legislation, data records

management and security is a trend that is likely to continue in the future.

This raises important questions about the supporting infrastructure including

communications bandwidth and the reliability of the IP network which needs

to be robust and scalable enough to cope.

According to EMC, a leading information management company, information

held electronically is increasing at exponential rates and set to continue with

the growing acceptance of ‘cloud computing’ in Government departments.

Source: EMC (2008)

1.9.1 Summary of key trends.

As the wider technology market for Telepresence systems evolves, fuelled

by organisational initiatives to reduce travel expenses & environmental

impact to society, several trends including Telemedicine, Home Monitoring,

Long range Ethernet Connectivity, and Private Networks are emerging for

specific systems that offer vendors, business partners and third parties

profitable opportunities to expand their offerings; capture market share and

gain competitive advantages through being first to market with proven

solutions such as Cisco HealthPresence™.

Summary of ICT solutions for healthcare

Source: Business Insights (2005)

These trends are increasingly relevant for major vendors such as Cisco

which include the provision of robust and scalable networks that can be

utilised for multiple applications. E.g. Cisco HealthPresence™ and Unified

Communications. It can be argued that future versions can be adapted for

Learning and Legal services.

As a basis for EU directives on eHealth,7 it is necessary to have high speed,

and reliable networks due to the huge amount of confidential data being

processed and stored at any given time. Therefore, these networks must be

highly secure and robust. However, at the same time, budgets for

healthcare and operations are being constrained in many parts of the public

sector, including the Prisons Service which necessitates a strong case for

using alternatives to the provision of key services including primary

healthcare using Telemedicine. There are many advantages in doing this,

mostly cost advantages and increased operational efficiencies by using

shared networks with improved staff productivity and care as a result.

7 Commission communication “Telemedicine for the benefit of patients, healthcare systems and society”, COM(2008) 689 final, 4.11.2008. http://ec.europa.eu/information_society/activities/health/policy/telemedicine/index_en.htm

2.0 Literature Review

2.1 Overview This section highlights an under use of specific technologies by NOMS and

HMPS for the primary health treatment of prisoners as part of their

operational strategies. Also revealed are a number of questions linked to the

under use of high speed internet & video based technology with key benefits

including increased efficiencies, higher productivity gains & faster access to

primary and specialist healthcare.

2.2 Introduction The subjects of Internet based high definition video technology systems

(Telepresence), vertical market adaptations, (Cisco HealthPresence™),

Telemedicine and the Prisons Sector were chosen due to business

relevance by the sponsoring client and current thinking from Government

departments as possible conduits of efficiency measures to operate more

‘business like’.

The review shows possible avenues for government and the private sector to

work in partnership for achieving strategic objectives including improved

delivery of services, achieving efficiency gains and reductions in the cost of

delivering prisoner health services.

2.3 Objectives of literature review These include;

• Identifying costs in provision of primary healthcare to prisoners

• Investigating ways of increasing efficiency of key services including

healthcare

This aims to highlight areas of potential efficiency in providing primary

healthcare to prisoners and discover areas where improvements can be

made through the use of telemedicine applications using proven IT solutions.

However, before making a case for the use of Telemedicine, and indirectly,

Telepresence, it is important to briefly explore these concepts.

2.4 Concepts: Telehealth is typically referred to describe technology applications that are

used between different and often remote parts of a country for initial

consultations and assessments.

Telemedicine is widely known as the provision of healthcare, usually primary

over long distances using a range of digital technologies including video

conferencing, live internet web chat & IP telephony.

Telehealth is a generally accepted term for remote health and often used

interchangeably with Telemedicine, however a key difference is that with

minor surgical procedures including basic dentistry and dermatology can be

performed with Telemedicine.

Telepresence is widely referred to as a set of technologies including internet

broadband connectivity, IT hardware, (high definition video systems, spatial

sound, personal computers), software, firmware, call centre systems and 3rd

party peripherals that allows a person to feel as if they were present in real

time, in a location other than their true location, and with a greater technical

sophistication & improved fidelity. Leading IT vendors of Telepresence

systems include Cisco, HP, Polycom, Teliris and others have their own

versions of Telepresence systems. Cisco is the current market leader of such

systems with an estimated market share exceeding 31% excluding the

recent acquisition of Tandberg.*

Cisco HealthPresence™ is an adapted and ruggedized version of the Cisco

TelePresence™ solution with third party medical grade accessories for

primary health treatments.

Although the use of technologies by businesses, consumers and public

sector organisations has been around for some time, its use as a strategic

enabler is fairly recent.

Strategic technologies including Telepresence & Cisco HealthPresence™ is

hereby referred to as a key enabler for NOMS & HMPS to aid the

management of its activities more efficiently. In doing so, this can help

improve the delivery of key services including healthcare, learning, and

rehabilitation within a secure environment.

A review was undertaken comprising of a number of core subject areas;

telemedicine, organisational strategy, public sector culture, & leadership.

The main reason for studying these topics this review is that there is

increasing relevance of using Telepresence solutions as part of telemedicine

for efficient delivery of healthcare.

Key sources of this literature review information include:

Ministry of Justice departments (NOMS & HM Prisons Service)

HM Treasury

Office of National Statistics

National Audit Office

Various technology company reports, e.g. Cisco, HP, BT, Tandberg,

Polycom, Philips, Lifesize.

Journal of Telehealth and Telemedicine

Various Internet sites & articles: e.g. http://www.mwbex.com/industry-

news/index.php/2008/06/27/the-costs-of-telepresence-technology/

www.getintohealth.com

Social networks & special interest groups, e.g. www.linkedin.com

The Economist Newspaper

The Economist Intelligence Unit (EIU)

Harvard Business Review

2.5 Basic definitions used in literature review

1-The word technology itself originates from the Greek word “Technolgia”,

defined as the interaction between elements or artifacts and the practices

that can be realised through these artifacts. (Flores, et al 1988).

This term was first used by Leavitt and Whisler in 1958 to highlight the role of

computers in supporting decision making processes and information

management (Benunan –Fich, 2002). The focus on managerial abilities in

the use of technology and hence its strategic value to organisations and

individuals.

2- Strategic technology is of key interest and defined as a dynamic &

reflective process that organizations engage in for deriving maximum

potential of emerging and advanced technologies. This stresses the need

for technology to be integrated as part of an organisation’s strategic plans

and operational processes to ensure key objectives are met. This enables

key stakeholders to gain short and long term value for their respective

organization that gives its importance.

3-Flynn (2002), defines Public Sector Organisations, (PSO’s) as those who

receive funding wholly or partly by taxation and generally refers government

agencies, departments and other non- profit entities.

4- Key stakeholders (for this report) refer to those who provide services and

benefit from public sector organizations. These include NOMS, HMPS, NHS,

Strategic Health Authorities (StHA’s), PCT’s, Third sector charities,

commercial vendor companies, and the general public.

Therefore a focused approach is necessary to ensure relevant material from

a range of sources is considered and represented.

2.6 Key findings from the literature review

From this review, some main themes may be drawn upon including but not

limited to research showing a general inertia by public sector organizations

to the concept of using technology and related management tools, despite

proven efficiencies and best practices from other countries, notably Canada

and Australia. J.R Moehr et al (2005).

In general terms, there is a misalignment in using technology as part of

organisational strategy; partly due to perceptions by some key decision

makers that technology is mainly a support function, instead of a strategic

tool that can be used as a key differentiator in delivering vital public services.

(Gershon 2004) (From Sir Peter Gershon’s report on Public Sector

improvements as part of an e-government agenda.)

Although a clear strategic direction on the role of technology is provided by

HM Government, the largest key stakeholder, it is not effectively utilised by

NOMS & HMPS, and it seems unclear on how to use specific video based

systems & tools to pursue strategic its objectives including protecting the

general public from criminals, and providing custodial facilities with education

and health care opportunities for eventual resettlement.

This raises more questions about the political structure and culture of the

Prison service & NOMS, and how this is very relevant in overall change

initiatives.

2.7 Organisational culture in the Public Sector.

Practices

Knowledge creation, sharing &

use.Behaviours

Values

Norms

Adapted from Long, D & Fahey, L. (2000)

David W. De Long and Liam Fahey (2000) investigated and researched over

50 companies on how they share knowledge and discovered organisational

culture is the main barrier to creating and using knowledge based assets.

This suggests that culture is intangible & often determines what is

recognised as useful or important in a public sector organisation. In turn, this

directly and indirectly affects the use of technology by individuals for their

daily operational activities. This is especially apparent when management

tries to encourage individuals in using strategic technology to improve their

operations & become more effective.

Wang (2004) suggests that employees who refuse using modern technology

could be seen as fearful of change. Of possible, greater significance is that

this is also linked to organizational culture and behaviour traits. It seems an

organisations’ culture and interdependent relationships with its subcultures

play a significant role in the greater use and adoption of technology and how

it is distributed throughout.

2.8 Strategies for complex public sector organisations.

Drucker (1994) believes organisations must continuously create advantage

through leaderships in four main areas including;

Price & quality, knowledge & timing, creating strongholds and large resource

pockets.

Further, he believes this requires the destruction of old advantages to enable

the organisation to create multiple short term advantages on a constant

basis instead and is supported by examples where organisations &

commercial companies can find themselves stagnating in crisis situations.

As organisations become more successful, they tend to take existing

theories as normal practice or behavior, suggesting they need to be tested

regularly. An organisation must systematically monitor itself and test its own

“theory of the business” by building in the ability for it to change itself.

For complex and larger organisations, there is a need for early and regular

reviews so that it can be reorganised if required. This is in order to change

policies and practices in line with its operating environment, gain new

competencies and develop existing ones.

Porter (1996) argues that the heart of the problem of organisational change

often lies in the failure to distinguish between operational effectiveness and

long term organizational strategy.

Operational Effectiveness (OE) means performing key activities much better

than rivals however, an organization can only outperform competitors if it can

establish a clear difference which can be preserved and maintained by

developing a unique position.

The organisational strategy depends on some unique elements including

choosing a different set of activities to deliver unique value.

An alternative to Porter is by Ohmae (1982) for a generic strategy that

focuses on 3 ‘C’s, Customers, Competition and Corporations. He argues

that customers cannot be treated as masses and specific needs should be

identified and targeted. Many competitors will differentiate their key offerings

and by doing do, will incur additional costs. The way corporations are

structured and managed can have a significant impact on their products &

services offered.

However, Kotter (1996) believes that applying a simplified process for driving

change throughout the organization including;

• Having a strategy with Leadership support & ongoing sponsorship

• Helping individuals eliminate obstacles and encourage a degree of

risk taking

• Repeatedly communicating throughout the organisation and beyond

to reference successes, and to a lesser extent, any negative stories to

learn from.

2.9 Strategies for implementing technology based solutions into the Public sector

Given the nature of technology as a strategic enabler for organisations, there

are notable examples where telemedicine is being utilised successfully for

the application of medical services. Studies by the Centre for Rural Health,

University of Aberdeenshire (2009) and the Scottish Centre for Telehealth

(2008) show that up to 90% of patients reported a positive experience for

primary care treatments using Cisco HealthPresence™. This incorporates

rich media video, audio & contact centre technology with diagnostic medical

equipment over a high speed IP network platform. In addition, today’s more

advanced systems with media rich features including high definition displays,

advanced audio and efficient lighting & heating systems provide a more

engaging experience for users.

This is of major benefit to remote communities where the cost of time &

travel between facilities can be expensive with unnecessary environmental

impact through increased carbon emissions; as well as interpersonal

relationships between, medical practitioners, staff & prisoner patients.

Cost effective methods for deploying these solutions would be through

packaging the equipment, related software, internet services and required

medical devices into a single offering that can be paid for by the user

organisation, (Prisons service & PCT’s) and cost of capital can be recouped

using existing capital leasing arrangements from leading financial providers

or large vendors.

3.0 Strategic Alliances & Partnerships

As Cisco HealthPresence™ is an excellent offering for providing primary

healthcare services to the prison population, any strategic alliances &

partnerships can have a significant impact in overall adoption of this solution

into the wider criminal justice system.

A Strategic Alliance is defined as the joint of effort of two or more companies

or organisations that are linked together in the supply chain to reduce the

total cost of acquisition, possession and disposal of goods and services for

the benefit of all parties concerned. (Underhill, 1996). These alliances enable

organisations of all sizes to focus on their core competencies so that the

main benefits are derived from shared resources including people,

processes, systems, & information exchange. This enables organisations to

adapt and respond quickly to new threats and opportunities. (Thompson and

Martin, 2005)

However any alliances & partnerships between two or more organisations

may also need to deal with potential conflicts and the extent of activity

between them.

Strategic Alliance Topology

Pre Competitive Alliances

e.g. Cisco & AAP3Cisco & Philips

Competitive Alliances

e.g. Microsoft & HP

Pro Competitive Alliances

e.g. Cisco & Tribal UKCisco & Civica PlcCisco & Serco

Non Competitive Alliances

e.g. BT & CiscoCisco & Global Crossing

LOW

Conflict Potentia

lHIGH

LOW Extent of Organisational Interactions HIGH

Adapted from Yoshino & Rangan (1995)

Pro competitive alliances are by their very nature inter industry, vertical

market based relationships between manufacturers, suppliers or go to

market distributors/resellers. E.g. Cisco & Tribal UK etc

Pre Competitive alliances typically enable organisations with different

backgrounds to work together on well defined activities including technology

developments, sales & marketing programmes etc. E.g. Cisco & Philips

Non Competitive alliances tend to be those with intra industry links between

non competing firms, e.g. BT & Cisco, or Global Crossing & Cisco

Competitive alliances are similar to non competitive alliances for joint

activities, except in the partners are suited to be direct competitors in the

final product. E.g. HP & Microsoft

As the value chain acts as a source of competitive advantages, individual

organisations such as Cisco, can build interrelationships with others by

having distinctive value chains through using strategic alliances &

partnerships.

3.1 International perspectives:

Examples from other countries including Australia, Canada, USA, New

Zealand and parts of the Asia, are ensuring strategic technology is adopted

in playing a role in transforming operational activities with resulting greater

efficiencies.

Rowe et al (2008) suggests there are wide ranging benefits from the use of

video conferencing in the primary health treatment of remote communities

who cannot get access to medical facilities due to a variety of reasons.

Experience from other countries, notably Canada and Australia, supports the

view that costs and people resources are the main factors in the ability of

providing care to communities. The strategic use of technology for

telemedicine applications is central to successful heath service delivery.

This is supported by Reynolds et al (2008) who states videoconferencing has

been widely used to provide distant advice in many healthcare specialties

across the word. This has been extended to support distance learning and

has been evaluated through a number of educational projects.

To maximise the full impact of technology, strategic partnerships may need

to be developed further between the public, private and third sectors to help

achieve key objectives, targets in overall efficiency improvements.

Governments in countries including Canada, USA, India, Australia & parts of

the EU are using technology strategically to transform their internal and

external functions in order to reduce their public sector costs and implement

new internet based services for greater collaboration with the population.

An example of greater use of technology for healthcare is in India where

there is growing spending on private healthcare from $40 billion in 2008 to

over $323 billion by 2023, encouraged by government, and partly due to

rising demand from an increasing middle class. Source: Technopak

Healthcare (2009)

Source: Health care spending as a % of GDP. Economist 2009

From the World Bank Indicators, the UK currently spends up to 7% of its

GDP on public sector healthcare in comparison to emerging countries such

as China and India which spend less than 2% and 1 % in public healthcare.

As an example of greater investments in technology, the bar chart shows

there is a correlation to increased private healthcare spend of 2.1% for China

and 3.2% of GDP for India, mostly from private firms and charities which is a

higher share that any other country.

3.2 Financial implications for government.

Given the state of the public finances in the UK, one approach being

seriously considered is based on cost reduction through the use of

standardised infrastructure that can support multiple government offerings

with access to new and existing and services. Datamonitor (2008)

This approach is also likely to lead to significant cost reductions in other

areas of public sector spending and encourage the further adoption of

strategic partnerships to reduce risk, share key IT services and offer joint

solutions including comprehensive telemedicine.

Many successful companies such as Cisco, IBM, BT, HP & SAP etc are

already using Telepresence technology as enablers for organisational

change and operational improvements. It is the ability of key public sector

organisations including NOMS & HMPS to align this strategic technology with

their own organisational strategy for improved efficiencies that is in question.

It is also important to understand how these public sector organisations, i.e.

NOMS and PCT’s use strategic technologies for telemedicine to assess the

full impact this can have on their activities and overall improvements in their

operations.

3.2 Using video conferencing & ‘Presence’ technology for telemedicine.

Andrew (1980) and Borgeois (1988) state that effective business strategy

should reflect on decisions which align corporate resources and capabilities

to external threats and approaches, thereby enabling complex organizations

to increase efficiencies. Although this may seem simple, organisations may

find it difficult to implement new technologies as part of wider initiatives due

to many reasons, including inherent organisational culture, fear & resistance

to change, and possible staff training requirements.

This raises the question of why key public sector organisations are not using

these resources effectively and efficiently. – Could it be a lack of

management understanding to the value of strategic technologies to

organisational effectiveness or the inability of measuring financial returns on

investment?

Experience from the Correctional Facilities Program in Iowa, USA

demonstrate significant cost savings up to 87% can be achieved using video

conferencing as the primary method of telemedicine based healthcare.

These costs vary considerably depending on the distance between the

health care facility and the prison, number of inmates traveling to receive

care per trip and the number and salaries of custodial officers and drivers

involved. Zollo (1999)

The issue of personnel is briefly explored as two key roles in providing

telemedicine services are that of a coordinator and a video communications

expert. Telemedicine requires a different approach in consulting and the staff

providing the service must also be interested in the technology itself to

understand key differences. Depending on the size and complexity of the

telemedicine programme, allocation of existing personnel will be required.

Using modern systems such as Cisco HealthPresence™ and other tools

such as call centre applications and system integration management tools

can ensure simple and effective operations by regular staff including prison

officers and administrators. This would result in no ‘specialists’ being

required as long as sufficient training is given.

This implies a fast ROI that can be measured in months or even weeks,

rather than years.

However, there are less quantifiable benefits of telemedicine that need to be

considered such as having medical doctors present (from other locations)

during the consultation and less misunderstanding of a doctor’s advice from

clear and real time communications. Zollo (1999)

This is in line with findings from the Scottish Centre for Telehealth which

showed that up to 90% of patients reported a positive experience in their

treatments. This has the ability to transform access to services and improve

the effectiveness of delivery across a wider number of patients with greatly

reduced costs of provision.

Critics including Tapscott (2001) believe it is largely the inability to clearly

measure returns on investment that is hindering technology investment in the

Public Sector and widely reported IT project failures by the media is

hindering greater technology adoption. This is especially relevant at a time

when there are likely to be large scale public sector budget cuts imposed by

any Government affecting all Public Sector organisations to operate more

efficiently.

The term ‘disruptive technology’ or ‘disruptive innovation’ generally describes

any new technology or innovation that evolves to challenge and then replace

existing technology. Christensen (1995)

In doing so, it effectively changes people’s behaviour into new and different

ways of activity. Over time, there are many examples including the mobile

phone, personal computers, television, MP3 players and the modern car.

It can be argued that Telepresence & Cisco HealthPresence™ as a part of

wider collaborative technologies are forms of disruptive innovation that will

fundamentally shift the balance of power in whole industries and markets,

which can often spell the end of established vendors.

Recent examples of “Disruptive technologies” are highlighted below.

Technology Timeline Disruptive impact

PCs 1980s Personal computers and the client-server architecture model started the end of most

existing mainframes and minicomputers, hence creating new markets for mobile

computing.

Mobile

phones

1990s-

present

The mobile phone has significantly changed the entire telecommunications industry,

and has essentially become a must have technology. More recently, the rise of

smart phones including the Blackberry™ and iPhone™ is adding to further

disruption creating an additional new wave of modern communications.

VoIP 2000-

present

Initially voice over IP or VoIP, was limited and had well known quality issues.

Leading companies including Cisco™ and Skype™ were pioneers of this form

disruptive technology. Over time, greatly improved performance, free voice calls,

and simpler pricing models have impacted telecoms service provider revenues and

indirectly created a new generation of handsets.

Therefore, technologies over recent years from the private and military

sectors, combined with new approaches to measuring ROI for investments,

can aid public sector leaders on which solutions to invest into, e.g. video,

collaboration networks etc. There are many ‘hard’ & ‘soft’ benefits including

reductions in travel related expenses, time management and improved staff

productivity. These can also be combined with softer factors including

reduced disruption to medical facilities by unplanned hospital visits and

instant online interaction between medical staff and prisoners. Ultimately,

disruptive technologies such as Telemedicine applications become cost

effective as the volume of remote consultations increases. Zollo (1999)

However critics including De Mayer (1988), call for strategic approaches to

managing technology investments in organizations with the creation of

strong links between the business environment and developing and

maintaining its technological base. This is essential for building strong

synergies between public sector organisations and partnerships with the

private sector for access to wider expertise and resources.

3.3 Relevance of current thinking.

For the purpose of the study, it is assumed collaboration technologies

including Telepresence, Cisco HealthPresence™, video conferencing,

contact center, IP telephony etc should be widely used for improving

organisational activities operational efficiencies that ultimately represent

better value for money for taxpayers. The importance of the custodial

environment is respected in promoting multiple uses of technology for

healthcare services and other uses including, remote court appearances,

rehabilitation activities and internal staff meetings in a cost effective way.

These include, but are not limited to remote psychiatry, counseling, cognitive

behavioral therapy, remote learning, interactive training, mentoring & health

assessments. Many of these services have been successfully delivered on

countries including the USA, Canada and Australia. Mary Ann Liebert Inc.

(2009)

By adapting existing products from established vendors, new tailored

solutions can be offered through a choice of systems that have their

respective advantages and disadvantages. The main three vendors are

Cisco,8 HP, & Polycom with Cisco having a clear lead in terms of scale,

network reliability, existing commercial customer mindshare at senior

management level, especially after the recent acquisition of Tandberg, and

strong global partnerships with companies including BT, Cable & Wireless

and Global Crossing; who provide internet connectivity & managed services

offerings.

Another major advocate of Telepresence solutions is from HP, one of the

biggest technology companies with revenues exceeding $114 billion, and

8 As of 1st October 2009, Tandberg was in process of being acquired by Cisco for approximately $3.4 billion, subject to regulatory approvals.

No. 1 overall IT market share (Gartner 2009). HP has extensive experience

with a very large customer base, including complex government accounts,

large enterprise customers and small businesses combined with extensive

research and development resources. The HP HALO™ studio system is

generally more expensive than the Cisco TelePresence™ solution; however

it is regarded by customers as having a higher quality room solution with the

better performance of its HVEN™ network. The addition of the HP Meeting

Collaboration solution has further improved the overall flexibility of HP

solutions. Frost & Sullivan (2008).

The next major player in this market is Polycom™ who is traditionally known

as an advanced audio video conferencing company specialising in affordable

voice & video communications. It is the smallest of these three players with

net revenues of $699 million for year ended 30th September 2009. Polycom

has offered Telepresence systems since 2007 through its acquisition of

Destiny Conferencing and has established its position in the general

videoconferencing sector to gain an approximate 12% market share. It has

the ability to offer full interoperability across its product range which provides

its customers with an easy to use, open standards based, compelling value

proposition that will grow over time.

The company also has an extensive partner and distribution network that

enables it to deliver and support complex requirements of a Telepresence

solution with organisations including BT, Avaya, Cisco, IBM, Juniper,

Microsoft and Siemens.

However, due to the recent Cisco acquisition of Tandberg, another leading

competitor, the relationship is likely to deteriorate due to Cisco’s strength in

sales and marketing channels, customer & partner base, new product

development and strategic alliances with IBM, BT and others.

Another leading player is Teliris, and one of the most established vendors

and which has benefited from the recent focus by Cisco & HP in promoting

the wider benefits of high definition video conferencing by increasing its

market share to approximately 16.9%. It is set to grow further by developing

“gateway” systems to support interoperability with existing video

conferencing systems and also offers held devices including Smart phones.

Over recent years, Teliris has expanded in EMEA & Asia where it sees

strong growth potential due to higher travel costs and a greater

environmental awareness. As a result, of solid sales growth, it has built new

video network centre facilities to complement existing ones in London and

New York.

The company has invested in strategies to increase its market share by

developing new global partnerships and accelerate its marketing activities

through more specialist channels for education, healthcare, manufacturing

and defence.

3.4 Examples of current thinking:

From discussions and briefings held with Cisco, NOMS and Health service

representatives during August to December 2009, current thinking suggests

the following areas are being considered.

• Adopting Telehealth & Telemedicine as practical alternatives to

provide types of primary health care to the prison population.

• Experience of trials in other countries, notably the USA, Canada,

India, and Australia indicates there are tangible benefits including cost

savings & faster access to health specialists for treatments in a secure

environment.

• Innovation and practices from developing countries, notably, India &

Brazil suggests Telemedicine is far more likely to be adopted in

emerging markets where the costs of healthcare are generally paid for

by private insurers & individuals, rather than governments. How this

affects health treatments to the respective prison population remains

to be seen.

• Discussions with various Cisco and industry representatives indicate a

significant number of prisoners should be treated using an adapted

version of their successful HealthPresence™ so that the solution is

cost effective. At time of writing, this could be approximately 30

sessions per month or 360 per annum based on the existing offsite

visits conducted from the current data sample. Further, by increasing

system utilization rates for learning activities, internal staff & visitor

meetings, suggests even greater cost savings through reduced travel

expenses between multiple sites resulting in even lower running costs

and faster returns on investments.

“From my discussions with the Scottish Centre of Telehealth, it

appears the key application they see is ‘mental health/primary’ care in

prisons…” Corinne Marsolier, Cisco (2009)

• Industry sources including Business Insights (2009), suggest global

demand for collaboration solutions using suite based Telepresence

systems is growing at a compound annual growth rate of 4% (2008-

2013), due to a number of factors including: the need to improve

communications between remote teams & individuals, combined with

need to maintain business continuity, reduce travel costs &

environmental impact. By adapting Telepresence for telemedicine

applications with additional medical devices, specific hardware &

bespoke software, ‘new’ markets can be addressed by vendors.

However, the high cost of these systems is slowing its growth,

especially in the cost sensitive public sector.

3.5 Summary of findings from the literature review.

• There is some misalignment in part of the Government’s agenda for using

technology to improve services in this segment of the Public Sector.

• A general lack of understanding about the important role video and

internet based collaboration technologies can play in improving

operational efficiencies and delivering key services at lower costs into the

Prison Service.

• There is a lack of measureable benefit of using specific technology

investments. E.g. Cisco HealthPresence™ for Telemedicine.

• There is a secretive and suspicious organisational culture in HM Prisons

Service that is acting as a major barrier to accepting and improving

behavioural change.

• There are positive examples from Scotland, Canada, India, USA &

Australia of using Telemedicine to successfully provide primary health

services to remote communities, which can be applied into the Prison

environment.

These findings serve as a basis to assess the use of Telemedicine as part of

ICT collaboration systems in the Prison sector.

4.0 Research: Gathering Information, interviews, key findings & analysis.

This section focuses on analysing information gathered from interviews,

discussions and other meetings with key decision makers from parts of

NOMS & Healthcare sectors.

It shows some key findings and insights in areas where tangible operational

efficiencies can be improved & cost savings achieved using solutions

including Cisco HealthPresence™

4.1 Overview

Given the sensitive nature of this government agency and related

departments some information provided about Prisoners cannot be

disclosed. However, special attention was given to identifying and engaging

with Prison Governors and Healthcare managers for assistance.

In addition, there is a naturally secretive organisational culture present at

NOMS & HMPS which is very challenging for vendors, consultants & other

interested parties in gathering support from individual stakeholders to

engage with in an open and unbiased manner.

Key findings show an insight into a current segment of public sector’s

management thinking. Also highlighted are their perceptions of collaboration

technologies as an enabler for operational efficiencies in the provision of key

services to HM Prisons.

4.2 Key research objectives for this management challenge include;

• To identify the costs involved in providing primary health treatment to

prisoners

• To understand if Prisons are open to using telemedicine for primary

health treatments.

• Additional objectives include ways to increase efficiencies of prison

operations using Cisco HealthPresence™ and Telemedicine as enablers

for improving internal processes.

4.3 Methodology

By considering different research methods available, a qualitative research

based methodology was used by adopting the ‘research onion’ framework,

Saunders et al, (2005). An additional and extensive literature review was

conducted, supported by semi structured interviews and supplementary data

from industry professionals. Analysing findings from semi structured

interviews and making key assumptions were also deemed necessary.

Realism & InterpretivisReaSamplingCross section

Surveys & Case studies.

Deductive & Inductive

Realism & Interpretivism

Use of primary & secondary dataInterviews and Survey’sObservations

Timelines

Research strategiesData collection

Adapted from Saunders, (2005).

4.3.1 Reasons for this approach include;

• Identifying the needs of using disruptive technology including Cisco

HealthPresence™, to improve the provision of primary healthcare to

prisoners cost effectively.

• Exploring additional uses of this technology for other services that

provide value for money. E.g. education, learning, counseling, remote

visitation and discussions with supply chain stakeholders.

Where necessary, further meetings with relevant 3rd parties, e.g. Mental

Health Trusts & Prison Reform charities were conducted to help validate

some of the findings.

1- Summarising information gathered and presenting key

recommendations. (In line with scope of study). E.g. Using video

based systems and aspects of telemedicine to improve access for

prisoner healthcare (mental and dermatology).

2- Using a pilot case study in the UK, the Scottish Centre of Telehealth

and the Royal Aberdeen Infirmary model as a possible best practice

example for a HealthPresence technology based solution and

benefits.

4.3.2 Sampling.

From the current HM Prison estate of 140 establishments in England &

Wales, a sample of 16 were identified and chosen based on their inmate

profile, location and security category rating; A-D, where A is defined as a

maximum security closed prison and D, is an ‘open’ prison that allows

inmates to conduct community service and other activities as part of any

offender management programmes.

4.3.3 Cross Section

From the sample of 16 prisons, 8 were visited over a 100 day period

between August to November 2009 based on category and location.

Interviews were held with key decision makers including Governors, Deputy

Governors, Healthcare managers over a 120 day period. In addition,

meetings and follow ups discussions were held with 8 health managers from

local Primary Care Trusts up to December 2009. Due to logistical & time

constraints all Prisons in England & Wales could not be visited in person,

therefore qualitative methods were primarily used with direct meetings with

Prison & Health managers.

4.3.4 Surveys

From agreement with respective managers in NOMS, HMPS & local PCT’s,

a short questionnaire was sent to each decision maker, e.g. Healthcare

manager, Governors etc, before arranged meetings to ensure participants

were comfortable about the questions asked. In nearly all cases, several

follow ups by telephone & email were required to ensure the questionnaire

was received, understood and subsequent appointments scheduled. See

appendix 6.

4.3.5 Deductive & Inductive processes

During the meetings, it was very important to understand the nature of each

prison’s operations within the context of their respective inmate population.

This provided a valuable insight on their challenges for providing health and

related services with local budgets & plans in line with Government policies.

Although national guidelines & policies for healthcare are provided by the

Department of Health via the National Health Service, it is the delivery of

these health services that is dependent on the local primary care trusts for

each prison and their allocated resources.

Some establishments including HMP Pentonville have a relatively high

turnover of prisoners serving short term sentences of less than 30 days and

indicated that only basic care may be required & therefore a full Cisco

HealthPresence™ system may not be appropriate. In comparison, a “ low

turnover ”, high security prison such as HMP Belmarsh could benefit greatly

from telemedicine applications using Cisco HealthPresence™ offering due to

high risk prisoners, length of sentences served and the high levels of field

resources required in moving prisoners between various courts, police and

medical facilities.

This suggests a two tier approach may be required with high security

Category A&B prisons benefiting greatly from the immediate use of Cisco

HealthPresence™ systems and also Category C&D to a lesser extent.

4.3.6 Quality: To ensure collected data & other relevant information could withstand

validation; emphasis was given to the criteria used to assess the accuracy of

findings. These were discussed with members of NOMS & the Healthcare

profession, who agreed they were in line with their own internal data.

4.3.7 Reliability: To ensure consistent data collection & analysis were consistent, the

following was done;

For primary data collection the sample of Prison manager chosen for

interview was selected based on prisoner profiles and risk categories A-D. (A

= a high security facility and D = an open prison). Other factors that

influenced the decision on selecting which prisons interviewed included

geographical location with good public transport links and recommendations

from respective PCT’s.

Secondary data was also used from a few public sources including MOJ

accounts, NOM’s Strategic Plans, & wider technology market reports.

4.3.8 Validity: To minimise chances of producing any analyses that are biased, the

questions used in the field work were chosen and developed carefully from

the wider subject theme of Telemedicine readings, Healthcare & IT, and the

literature review.

4.3.9 Generalisability: Saunders et al (2005), states that a concern of the researcher when

designing the research in the context to which the findings may be equally

applied to other settings. It is accepted by the researcher, that in conducting

this research study, the level of generalisation is reduced significantly and

recognises its merit in doing so.

Of key interest is understanding the main costs of providing primary levels of

healthcare to HM prison population and identifying practical ways of

providing this more efficiently with additional longer term benefits. Although

the study is within the operational environment of NOMS and the respective

PCT’s, I can see the results and conclusions would be similar for other public

sector organisations that may be facing significant budget cuts.

4.4 Limitations of the Research Approach

As a result of some members of NOMS & HMPS, some resistance was

encountered during investigations, possibly as they may have felt the author

was “another management consultant looking to disrupt their activities”.

However, after a period of identifying key stakeholders & working with

supportive line managers, I was able to gain meetings with key decision

makers through their facilitation.

Nearly all primary research has certain limitations, and this is no exception

with the research data limited from experts in the Prison & Health Service

that have been interviewed.

Also, due to time constraints and the nature of the Prison Service &

Healthcare industries, this does not include the opinion of the entire custodial

& medical service professions.

4.4.1 Interview Selection Process

The chosen managers identified & selected for interview are professionals

within NOMS/HMPS & PCT’s who provided their perspectives on the

research question.

The first stage of this process was to gain an “Executive manager’s” support

within NOMS and act as an internal sponsor. Once achieved, the second

stage was to enlist the support of a line manager to work with on a regular

basis and help facilitate relevant meetings. For discussions with local PCT’s,

this was done independently as they were more receptive to engaging with

MBA students. The respondent names have not been disclosed due to

confidentiality; however their position & organisations are listed.

Summary table of interviews with NOMS, HMPS & key vendors.

Position / Role Organisation

Product Manager Cisco

Governor HMPS/NOMS

Deputy Governor HMPS/NOMS

Operations Manager NOMS

Health Services Manager NOMS

Operations Budget Manager NOMS

Project Lead, Offender Health Department of Heath

Contracts & Finance Manager BT

ICT Manager Birmingham East & North Primary Care Trust

Bid Pricing Manager Orange Business Services

Health Services Manager Wandsworth Teaching PCT

Pharmacy Manager West Herts NHS PCT

Health Services Manager Barnet, Enfield and Haringey Mental Health Trust

Interim Commissioner, Offender Health & LD Services

NHS Greenwich

Project manager, Offender Learning Services

Imperial College NHS Trust

Operations Manager Cambridge University Hospital NHS Foundation Trust

5.0 The Research Question:

Research is defined as the systematic collection and interpretation of

information for a clear purpose to find things out (Saunders et al 2005)

For the purpose of this study, primary research is to find out the following;

Q- “What are the key factors and costs for providing primary health to the prison population and can this be reduced by using technologies such as Cisco HealthPresence™ & Telemedicine as ways of helping improve overall efficiencies?”

Although the question is simple, there are a number of sub questions which

are detailed as:

• What are the costs of providing primary health services into the Prisons?

• Does the concept of using new technologies such as Cisco

HealthPresence™ and /or video conferencing as part of an overall push

towards Telemedicine seem acceptable?

• How would this be beneficial and cost effective in the current

environment?

This was further segmented into the following;

Q1a - “What are the key costs for providing primary health to the prisoners

Q1b – How can technologies such as HealthPresence for Telemedicine applications be acceptably used?

Q1c - Would this be cost effective to the payer? (NHS Primary Care Trusts?)

This highlights a case for using Cisco HealthPresence™ solutions providing

primary health services into the prison population. This segment of the Public

sector is ripe for the introduction of disruptive technologies that can change

an organisations behaviour and culture. Christensen (1995).

5.1 Key findings from primary research

This section addresses the main findings from the qualitative primary

research from the questions posed by the author for key factors & costs in

providing primary healthcare to prisoners. This also clarifies senior

managers’ understanding of MOJ & DH strategies and provides a valuable

insight into long term challenges faced for operational activities. Specifically,

I asked how much is the average cost of sending a prisoner to a local

hospital for primary medical treatments and if Telemedicine could be used as

a viable alternative to traditional methods.

5.2 Varying costs of healthcare provision.

The average cost of providing primary care to the prison population varies

between £695 to £2000 at each establishment for each offsite visit according

to need & type to treatment required.

This is based on a number of factors including, historical agreements with

regional Health Authorities. There are also national agreements in place for

higher risk prisoners by the Department of Health & NOMS for Category A

prisons that usually located near specialist hospitals. E.g. HMP Whitemoor &

Cambridge University Trust Hospital.

5.3 Using technologies for Telemedicine

From interviews with HM Prison Governors, Healthcare Managers and

Professionals 7 out of 8 respondents indicated they were open to the

concept of using new technologies for improving health services to prisoners.

One interviewee indicated he would avoid this as prisoners were only in

custody at his establishment for a short period of time anyway and would

receive healthcare treatments after release into society anyway. From all

respondents there was general concern that any technologies must be

simple to use and provide excellent value for money.

By using adapted technology based solutions such as Cisco

HealthPresence™, the varying costs of providing some healthcare to

prisoners can be substantially reduced while achieving similar “face to face”

experiences with medical professionals.

A notable example in the UK is the Scottish Centre for Telehealth, who

completed trials in 2008 for treating patients with ear, nose & throat

problems, minor cuts & burns, using telemedicine with positive experiences

by over 90% of respondents. This shows there is a real possibility that

primary healthcare can be provided to the prisoner population with no

detrimental effect in the quality of care.

Example of a pilot system used in early trials. Source: Cisco (2009)

Several types of primary care exist with some varying forms.

• Mental Health including Psychiatry, Psychology & Counseling

• Dermatology

• Dentistry

• Basic Ophthalmology and Optometry (Eye care)

• Cognitive Behavioural Therapy

• Basic Cardiology, e.g. Heart monitoring,

These conditions can be fully or partially treated using telemedicine with

proven examples in other countries including the USA, Canada, Australia

and New Zealand.

Example of remote dentistry using telemedicine equipment.

Source: Kings College, London (2009)

5.4 Cost effectiveness for the payer for primary health treatment.

Given the nature of each prisons operations and profile of each inmate held

in custody, the actual costs of providing primary care treatment varies greatly

by each establishment from £695 to £2000 for each offsite visit to a nearby

hospital. (The higher offsite visit costs are representative of limited category

‘A’ prisons holding high risk inmates such as HMP Belmarsh, Liverpool,

Whitemoor, etc.)

The table below summaries the average costs for each offsite visits per

month to a local hospital for primary health treatment.

HMPS VisitsPrison Establishment Ave cost of offsite prisoner healthcare costs, each time.Ave no of offsite visits per month.

£ (for Primary Health treatments).

Wormwood ScrubsB 695.00£ 50.00 34750Pentonville C 1,200.00£ 40.00 48000Brixton C 900.00£ 20.00 18000Whitemoor B 1,200.00£ 40.00 48000The Mount C 800.00£ 24.00 19200Grendon B 1,800.00£ 40.00 72000Belmarsh A 2,000.00£ 10.00 20000Leeds B 1,500.00£ 35.00 52500

10095.00 259.00 312,450.00£

1,261.87£ 32.371,261.00£ 32.00 41,184.00£

494,208.00£

Information from meetings held with Prisons August to November 2009.

5.4 Other findings

5.5 User experiences with ICT vendors

During meetings with decision makers, a series of questions were asked

about current experiences of IT from established vendors including, HP,

EDS, Orange, BT, C&W, Microsoft etc. EDS was frequently mentioned by

HMPS & Healthcare managers as especially challenging to work with in

resolving support issues & providing a consistent quality of service. This

suggests that for any vendors operating in this segment of the public sector

should consider simplifying their solutions in a way that is easy to use by non

technical and multi lingual staff. It was also suggested that vendors

5.6 Increasing staff productivity

All prisons interviewed are expected to meet increased staff productivity

targets by conducting a wider range of activities including joint training, basic

health, risk assessments etc. This is a challenging requirement under any

circumstances however the use of Cisco HealthPresence™ systems may

help achieve productivity targets through multiple applications including

remote training, staff meetings and faster decision making in a rich media

room environment.

5.7 Increasing accountability and transparency for Prison operations, e.g. Prisoner transfers between establishments

In the current fiscally challenging environment, virtually all areas of the Public

Sector are subject to increased scrutiny from various groups & political

parties ahead of a general election.

Given the estimated national deficit of £178 billion the public sector in

general is viewed by many as an area for cutbacks. The MOJ and its

executive departments are already facing budgetary reductions from 2010/11

and are likely to reduce their IT spending as a result.

Some media reports suggest some public sector organizations with have

their budgets cut between 10 to 15% from the 2010/11 fiscal year. Source:

BBC News9

9 http://news.bbc.co.uk/1/hi/uk/8400790.stm

5.8 Prisoner transportation between courts, hospitals & other facilities.

This is an area is outside the scope of this study however warrants further

investigation as Cisco HealthPresence™ & related tools can achieve cost

savings from reduced travel requirements & productivity gains.

Since late 2007, the emergence of ‘green IT’ as a key driver to reducing

business costs has also become more apparent. Successful leading

companies including Cisco, HP, Polycom, Teliris and others are actively

using their respective versions of Telepresence to effectively promote

greater global collaborations between stakeholders in their supply chain.

This also simultaneously reduces environmental impact through lower

carbon emissions from reduced travel.

Partly as a result, Telepresence systems are also used for multiple

applications including remote learning, mentoring, and other interactions at

far lower cost with the almost the same level of experience as traditional, in

person face to face interactions.

5.9 Helping achieve specific initiatives for Prisoner Healthcare management, Education, & reduce wastage from ‘old’ working practices. The Prisons sector is a relatively untapped market segment of the wider

justice system with strategic opportunities for wider engagements by vendors

in shaping government policies. Using adapted technologies including Cisco

HealthPresence™ for healthcare, can result in significant reductions in

operational expenditures with minimal impact to offenders and staff.

5.9.1 Summary of findings:

Given that Telepresence systems from a select number of vendors are

relatively new in the marketplace, adapted systems for Health & Education

from technology leaders including Cisco can provide a very valuable method

in treating prisoners and other offenders which allows for quality care in a

secure & contained environment.

During the course of investigations, it was also discovered there are similar

systems in existence from other established vendors including Polycom and

HP, however these have been partially successful due to a variety of

reasons including a lack of a rich media experience and interactive

engagement with healthcare professionals.

However, this demonstrates the basic technology is viable and given clear

direction and support from NOMS & HMPS management, could be used

more extensively in other applications such as telehealth and telemedicine

programmes.

The research findings also demonstrate there are mainly organisational

barriers to wider adoption of this strategic technology, rather than the

technology itself. One way to overcome potential resistance is to ensure

future improvements of the Cisco HealthPresence™ system is simple to

operate so that medical professionals and prison officers are very

comfortable in using it. This will also aid overall utilisation.

Due to the nature of funding streams of healthcare into HM Prison Service,

via NHS Trusts & local consortia, there are wide variations in the average

cost of providing treatments. The use of Cisco HealthPresence™ offers a

standardised, convenient & very cost effective way of providing telemedicine

to this segment of the population.

As the actual costs of healthcare provision are met by the NHS Trusts &

other bodies, such systems can also help increase overall accountability

through greater transparency in this area of the public sector.

Further, encouragement by the European Union in promoting overall

Telehealth & Telemedicine is also acting a key driver for government in

finding viable alternatives for healthcare provision to the general population

and the prison sector is one which can benefit greatly from this.

It was apparent there are multiple uses of the Cisco HealthPresence™

system across the parts of the justice sector including court appearances,

visitation by friends & families, probation meetings, rehabilitation & mentoring

programmes, legal discussions, and education services. Although outside

the main focus of this study, additional applications of this technology will

ultimately increase adoption and improve system utilisation rates which

further increase efficiencies.

6.0 Conclusions

This section highlights major conclusions from the research process and

subsequent findings.

HM Prison Service is a public sector market that is facing pressures of

change and ripe for the introduction of modern technologies to aid

operational efficiencies through multiple applications including, Healthcare

services.

1- Overall spending on the Prisons sectors has increased in real terms

since 1997, especially for capacity development measures in

response to rising prisoner numbers. However, the Government and

key policy makers are increasingly aware the prisoner population is

increasing faster than budgets or operational capacity allow.

2- Rising Prison costs are impacting other public sector budgets

allocated by HM Treasury which can affect areas such as welfare,

education & rehabilitation programmes.

3- The use of proven technologies including Video conferencing & Cisco

HealthPresence™ systems for prisoner care can help reduce overall

operational costs & increase efficiencies. Research from other

countries, notably, the USA, Canada, & Australia support the long

term cost saving impact of these technologies.

4- Barriers to adopting these proven technologies include political

pressures to use existing staff, a general lack of awareness of key

benefits, low priority for healthcare providers (PCT’s) and realising the

cost savings achieved. Other barriers such as lack of understanding

how to use systems can easily be overcome by comprehensive

training & support programmes.

5- Successful deployments should include a proof of concept over a set

period of time that requires vendor support including demonstration

equipment, licensed software, support personnel and a clear funding

route.

Therefore, using adapted video conferencing & related systems from leading

vendors including Cisco offer an excellent & proven alternative for providing

primary healthcare treatments to Prisoners as part of wider efforts. These

can also deliver multiple benefits including use for other related activities

including education, rehabilitation, mentoring, remote visitation by friends &

family and travel reductions between the courts, hospitals & other prisons as

part of operational efficiency improvements & cost reductions.

6.1 Key Recommendations

This section details some key recommendations based on the research

objectives, findings and discussions with NOMS, HMPS, PCT’s, Cisco teams

and independent stakeholders with an interest in Prisoner welfare

NOMS & other Public sector organisations including NHS Primary Care

Trusts should seriously consider implementing Cisco HealthPresence™

systems for provision and delivery of key services including primary

healthcare, education and rehabilitation programmes.

1- Leaders in the Justice system (e.g. NOMS, HMPS, Courts, Probation

& Police services) should seriously consider investment in Cisco

HealthPresence™ systems to aid operational activities. Each Prison,

Youth Offenders Institution and Detention centre should install a

minimum of 1 Cisco HealthPresence™ unit per site that is linked to

the nearest contracted PCT via a highly secure and reliable IP & video

communications network. The Criminal Justice System including HM

Prison service can greatly benefit from using these solutions for cost

effective access to primary health services prisoners including Mental

Health Services, (Psychology, Counselling, Dentistry & Dermatology

etc), and also for Learning, Rehabilitation and Remote visitation to

‘high risk’ inmates.

2- Varying costs of healthcare provision – NOMS & respective NHS

Primary Care Trusts should seriously consider using alternative

methods of treating prisoner patients for primary healthcare and some

limited forms of secondary care. As mentioned earlier in this report,

best practices from other countries, notably, USA, Canada, &

Australia proves Telemedicine is a highly reliable and very cost

effective way of providing key services including Healthcare to the

prison population with many benefits including lower overall costs of

provision, faster access to specialists, reduced environmental impact

through lower carbon emissions and improved prisoner acceptance.

3- Cisco should address the issue of systems interoperability which is a

major concern for HM Government as part of the wider IT agenda and

drive towards open source & industry standard solutions. (Gershon,

2004) Given this background Cisco should ensure their

HealthPresence system and related collaboration tools including

Cisco Webex™, Unified Contact Centre, Network Security & IP

Telephony systems should work easily on any major vendor platforms.

In doing so, a major concern of Government and the wider ICT

industry is addressed which enables a level playing field for industry

competitors. The potential vendor issue of investment protection is

duly noted by the author.

4- User Experiences: Cisco should address key concerns from members

of the Primary Care Trusts, NOMS & HM Prison Service for its

solutions to be simple to use, yet robust to withstand potential

damage in a custodial environment. This is a key driver to increased

user adoption for most new technology solutions (Christenson, 1996)

and can help also drive innovation from leading vendors (Tovstiga,

2009) By showing staff and managers real time productivity gains

from and cost savings using adapted solutions will result in a higher

success rate for implementations.

5- The use of Strategic Alliances and Outsourcing Partnerships is greatly

encouraged for Public Sector agencies including NOMS and various

NHS Trusts. There are many reasons for this including efforts to

convey greater transparency, increase operational efficiencies,

improve staff productivity and provide better value for money to the

taxpayer. By working closely with existing outsourcing partners

including Serco, G4S, Cable & Wireless & Steria will aid current

activities however, developing alliances with Cisco, BT, Civica, Capita,

CSC, Tribal UK, System One, and other specialist partners will create

an ecosystem that leverages the best capabilities of each in a level

playing field and enable longer term benefits from shared resources,

knowledge transfers, improved working practices and reduced risks.

6- To benefit from technology advances applied to the public sector, it is

advisable to better understand smaller partners and independent

software vendors (ISVs) that operate in this sector and form strategic

partnerships with those that offer innovative solutions. A proven

partner management programme is required to ensure these mutual

partnerships are managed effectively to help bring new and exciting

solutions to market.

7- Reducing risk through shared resources. By using a shared go to

market model can help wider allocation of key resources that can be

leveraged to respond to new opportunities. As thought leaders and

innovators in this field, Cisco can help drive new ways of interacting

and communicating with key government agencies such as the

criminal justice sector and the public. This generates increased

relevance with Central Government as technology partners of choice.

8- Investment in Prison Capacity. HM Government through the MOJ

should continue to build more Prison capacity with necessary high

speed communications infrastructure to enable telemedicine and

other remote services at lower cost. These newer facilities should be

privately managed and operated using existing partners including

Serco & G4S with the possibility of building them in remote areas for

increased public confidence using existing Public Finance Initiative

(PFI) models with financial incentives for achieving targets over the

contract duration. Capital costs would be recovered from overall

reductions in crime, reoffending and reduced healthcare expenditures.

9- Investment in dedicated resources. Any approach should consider

investment in people resources through Cisco funded personnel

based onsite at the MOJ on a full time basis. This helps create an

atmosphere of trust and openness designed to help with any project

related enquiries and provides valuable support to NOMS & HMPS

during a period of significant change.

7.0 Reflections

7.1 An evaluation of my findings

This management challenge was a major milestone and clearly the greatest

test of the entire Henley MBA programme. As the journey unfolded, the

individual challenges became more apparent and even greater than

previously envisaged especially within the timescales and subject theme.

The research has provided me with very valuable insights into how key

government organisations operate and their effect on modern UK society.

When I first started this management challenge, I aimed to achieve the

following objectives,

1- Becoming a subject matter expert for Telepresence and adapted

vertical market solutions for Telemedicine offered into complex public

sector organisations.

2- Gaining in depth experience and understanding of the Research

Process that can be applied in future situations.

My learning’s to become a subject matter expert in a relatively new

technology such as Telepresence and market adaptations including Cisco

HealthPresence™ has been very challenging; yet rewarding due to the

support received from the Cisco product teams and analysing reports from

leading consultancies. Prior to starting my Management Challenge, my

knowledge of Telepresence was superficial with perceptions that it was just

another version of existing, high definition video conferencing systems.

However, as the overall research process continued, my knowledge and

understanding of this valuable technology with great potential has developed

and increased substantially.

However, there were a few limitations in my research due to the subject

matter and the nature of the public sector such as gaining interview access

to more Prison decision makers and spending a great deal of time on pre

arranging meetings.

The topic of Telemedicine is one which I had no idea of previously and

although it has been in existence for several years, supporting technologies

for it to be a truly viable proposition are relatively new. This resulted in limited

UK information and resources available related to my research topic.

Therefore, during the investigation process, primary, qualitative research

methodology was used with direct interviews being the main source of

information.

Information and experiences of best practices from other countries was of

key interest and in line with my research findings. This has further advanced

my knowledge base of this very interesting topic and is directly related to

current thinking from technology leaders such as Cisco.

7.2 Experience of the research process

The decision to use a primary based qualitative research was mainly due to

the following reasons.

1- Lack of response from emails, letters, telephone calls and internet based

short surveys with target prospects. I.e. HMPS officials.

2- After discussion and agreement with the, primary based qualitative

research methods were deemed the best approach due to the nature,

size and complexity of the organisations involved; with the need for high

levels of engagement required.

3- Gaining key insights from these organisations was critical in the overall

process and was best achieved by spending a sufficient amount of time

with managers to understand their main issues & significant challenges.

As this in depth research process used mainly qualitative techniques, the

author followed a series of semi structured interviews & observations in an

open manner, supported by quantitative industry information from leading

business consultancies.

During the primary interviews and follow up discussion with representatives

from NOMS, HMPS & PCTs’ it became apparent that it was not the lack of

funding available for such technologies to be adopted, but rather it was

organisational barriers created by users and operators themselves, possibly

out of fear and misunderstanding of the general benefits presented.

To monitor progress on the study, the author used a research log which was

one of the best tools for this and any other complex research based project.

The log contained all the key activities and tasks from initial proposal to

report submission and helped me stay on track for the final submission.

Combining this research log into a diary & online calendar with assigned

target due dates for project steps, was especially useful for this project over

many months.

A summary table is shown below.

Research Log Summary

Key Item Date

Final reviews and editing prior to Submission April 2010

Write up & Review of Reflections March 2010

1st Draft of Management Challenge Report February 2010

Write up Key Recommendations & Conclusions February 2010

Write up of Conclusions February 2010

2nd Draft Key Findings and Current Thinking January 2010

1st Draft Key Findings November 2009

Research Methodology November 2009

Finalising Literature Review February 2010

1st Draft of Literature Review December 2010

Literature Review – Investigation & Analysis September –December 2009

Primary data collection & analysis November & December 2009

Arranging follow up discussions October – December 2009

Arranging key interviews & visits August – November 2009

2nd Draft of research questionnaire October 2009

Investigating Telemedicine September – November 2009

Drafting Research questionnaire design September 2009

Initial investigation into HMPS & PCT’s August 2009-October 2009

Identifying key themes, Public Sector, Organisational Culture, Prisoner Health, Strategic Technology, etc. September - October 2009

Initial project scoping with client August 2009

The key learning and benefits derived from this exhaustive study are

immense and very valuable to me in my future career as a professional

manager and consultant operating in the ICT & Healthcare industries. The

author has been exposed to new technology product developments for large

vertical markets & sectors in fast paced environments, rather than previously

from a manufacturing only perspective.

Given the time and resource challenges, the qualitative research approach of

using semi structured interviews and observations have worked well despite

the nature of the public sector organisations involved.

If I had to do the same again, the overall process would be done slightly

differently by directly engaging with senior leaders at NOMS earlier to gain

improved sponsorship first and then selecting target establishments based

on their initial recommendations. In addition, the literature review would have

been more targeted and perhaps not have read all the material in full detail.

By linking new & adapted technologies with real life organisational situations

in the Public sector, I have been able to greatly appreciate the benefits of my

recommendations being considered for adoption by relevant government

departments.

In today’s highly competitive environment, virtually all technology

investments face additional scrutiny and this experience has taught me how

to meet address these concerns with a thorough appreciation of research

processes for complex public sector organisations

7.3 Personal development objectives

The personal objectives I set at the start of this Management Challenge

included changing career from a business development manager working for

an IT vendor to a dual subject expert in a fast growing area of technology

and healthcare.

Due to the challenging nature of the project, various levels of interactions

were required with members of public sector bodies and this fully tested my

interpersonal and communication abilities in engaging with them at all levels.

This also required vast amounts of energy in identifying key decision makers

& influencers in the organisations as well as with the client and industry

competitors.

The extensive amount of time spent learning and understanding concepts,

research methods, data collection, interviewing techniques and critical

analysis of qualitative data has helped me understand and fully appreciate

the challenges faced in large, complex public sector organisations and

commercial companies driven by profit.

Upon reflection, the immense exposure to the knowledge and insights

gained throughout my research is very high and has taken me greatly

outside my comfort zone. From this study, it can be argued any

organisational challenge involving technology can be broken down, analysed

and considered thoughtfully with the aid of industry information that is

supported by relevant theories and concepts.

Overall, my experience of the management challenge process and wider

learning’s have been highly valuable both personally and professionally as

an investigative practitioner and manager. Needless to say this project has

been intellectually challenging and incredibly rewarding in terms of

knowledge gained and has provided me with the confidence to tackle

complex projects in a structured and time bound manner.

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implications for Health Promotion and Healthcare

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and sustainable use of custody in England & Wales.

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Review of Public sector efficiency' www.hm-treasury.gov.uk and

http://news.bbc.co.uk/1/hi/programmes/newsnight/3917423.stm

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The International Centre for Prison Studies, January (2009)

http://www.kcl.ac.uk/schools/law/research/icps

Published as a joint release by the Office of National Statistics and HM

Treasury on 19 November and available at http://www.hm-

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Experience in Penal Management Systems, A Report by the International

Centre for Prison Studies, Kings College London, University of London

Lord Carter’s review of prisons, ‘Securing the future, proposals for the

efficient and sustainable use of custody in England and Wales’, December

2007

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Prison Policy Group, ‘Building more prisons? Or is there a better way? A

discussion paper on the proposals put forward in Lord Cater of Coles’ review

of prisons: ‘Securing the Future”, June 2008; Annex 1.

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2009

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and e-Health

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Reports,

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Experience and Assessment of Program Costs

Appendices

Key Definitions:

Telemedicine is a rapidly developing application of clinical medicine where

medical information is transferred through the telephone, Internet and

sometimes other networks for the purpose of consulting, and remote medical

procedures or examinations.

This may be as simple as two health professionals discussing a case over

the telephone, or as complex as using satellite technology and video-

conferencing equipment to conduct a real-time consultation between medical

specialists in two different countries. Telemedicine generally refers to the use

of communications and information technologies for the delivery of clinical

care.

http://en.wikipedia.org/wiki/Telemedicine

• According to Wikipedia, “this is a term used by industry. It is a rapidly

developing application of clinical medicine where medical information

is transferred by telephone or internet and sometimes other networks

for the purpose of consulting and sometimes remote medical

procedures or examinations.” http://en.wikipedia.org/wiki/Telemedicine

• Telehealth is a general term used to describe an expansion of

telemedicine to cover wider areas of health treatment and is often used

interchangeably with Telemedicine. It encompasses preventive,

promotive and curative aspects. Originally used to describe administrative or

educational functions related to telemedicine, today telehealth stresses a

myriad of technology solutions. For example, physicians use email to

communicate with patients, order

• Collaboration software is generally defined as a concept that greatly

overlaps with computer supported cooperative work (CSCW).

• Video conferencing is commonly known as two or more video systems

between sites for the purpose of communicating in real time with little

or no time lag.

• Telepresence is a generic term for high definition video conferencing

systems and widely in the ICT industry and leading vendors including

Cisco, HP, Polycom, Tandberg, Teliris, Lifesize (Logitech) etc.

• Disruptive Technology - technology or technologies that significantly

improves an existing product or service – measured in terms of

performance, scalability, lower cost, greater convenience etc. – to the

point where it surpasses the established, or existing, technology.

Appendix 1-‐ Industry Five forces

Buyer PowerTraditional & New

Ministry of Justice,NOMS, CJB etc.

Key influencers, NAO, UK Taxpayer Alliance,

Prison Reform Trust etc.

Key suppliers;Dept of Health,NHS,

Strategic Health Authorities& PCT’s

Outsourcers: EDS(HP), CW Plc, G4S, Steria,Serco etc.

SubstitutesLower cost alternatives

& technologiese.g. Open prisons & jails with

Electronic tagging.Collaborative technologies.

New entrants &Greater ‘competition’

Kalyx, G4S, Geoprime, Serco.

HM Prisons UK

Adapted from M Porter, (1995)

The existing five forces framework was used for several reasons, summarised below.

• View market dynamics and ways to increase efficiencies through

partnerships with vendors including BT, Cisco, HP, Polycom, etc.

Five forces analysis summaryVariable factor Rating ReasonsSupplier power High Significant penalties exist for NOMS to 'break out' of any existing contracts.Buyer power Medium MOJ – The main government agency that holds judicial responsibility to Parliament

Medium NAO - National Audit Office – Independent body that monitors major government spendingNew entrants High There is a growing threat from the private sector to the management of Prisons operations Substitutes Medium Using disruptive technologies such as Telepresence, VC & RFID electronic tagging.

Low Financial penalties to family & friends if a prisoner fails to comply with sentencing terms.

Appendix 2 -‐ Market Opportunities

IT spending by healthcare payers in France, Germany and the UK, 2004-2010

Source: Business Insights

IT spending by healthcare payers in France, Germany and the UK in US$m, 2004-2010

2004 2005 2006 2007 2008 2009 2010 CAGR

France 248 270 295 320 348 371 394 8.0%

Germany 284 307 332 358 385 408 430 7.1%

UK 46 49 53 57 61 64 68 6.7%

Total 578 627 679 735 794 843 892 7.5%

Appendix 3 -‐ Market forecast

Information from Kable (2009) estimates the ICT spending opportunity in the

criminal justice sector is in current decline at a compound annual growth rate

(CAGR) of -7.4%.

The current ICT spending budget for the Ministry of Justice, (MOJ,) Police

Service, Courts Service, National Offender Management Service, NOMS,

Prisons & Probation Service, is valued at, £1.31bn for 2008/9, 1.2825bn for

2009/10 , £1.271 for 2010/11 and a predicted £1.273 for 2011/12 Source:

MOJ & Kable (2009)

Appendix 4 – ICT Spending Overview:

The table below highlights current and estimated technology spending for

HM Prisons in England & Wales. This excludes the cost of providing any

healthcare or education services as they are from a different funding route

(via the NHS) and are therefore omitted.

In comparison to other segments of the criminal just sector including the

Courts and Police services, IT spending in prisons is far lower. However, due

to the very nature of the Prison & custodial environment, and potential

security risks, IT has not generally been adopted quickly or in line with other

segments.

Therefore, partly due to rising prisoner numbers over the past few years, and

above inflation costs of providing healthcare services, this sector is ripe for

the introduction of disruptive technologies to aid overall efficiency and

provide excellent alternatives for primary care treatments, at far lower cost

than traditional methods.

Appendix 5-‐ Return on Investment

Example of basic ROI for Cisco HealthPresence™ in a Prison Environment.

This demonstrates that for an average of 20 ‘visits’ per week at 30 minutes

each time per week the HealthPresence system is utilized at 17%. However,

when the number of visits remains the same, yet the duration of each visit

increases to 60minutes, the utilisation only increases slightly to 20%. This

implies that to maximise usage of the system, each meeting or visit should

be no longer than 30 minutes.

According to Cisco, the average cost of providing a HealthPresence session

is only £65-00 based on connectivity and internet network costs, but

excluding actual medical treatment costs.

Appendix 6 -‐ Research Questions for HM Prisons Service Transcripts of interviews with Healthcare managers and Governors / Deputy Governors. NB. – Any Actual names & roles have been removed for confidential reasons.

Dear Sir/Madam,

Thank you or agreeing to take part in this short survey on Prisoner Healthcare. Your input and feedback is very valuable in my independent & unpaid research project on using key telemedicine applications & technologies for improving access healthcare. This should take no more than 45 -60 minutes to complete.

If you prefer, your responses can be anonymous and if you would like this, please kindly state this on the form.

My contact details are Situl Shah, Mobile: 07727 132 456 and email: [email protected].

Name & Role: Removed by author for confidentiality.

HMP. – Name: Removed by author for confidentiality.

Q- 1- “What are the key factors and costs for providing primary health to the prison population and can this be reduced by using technologies such as HealthPresence & Telemedicine as ways of helping improve overall efficiencies?”

1a -What is the average cost of sending a prisoner to outside hospital for primary health treatments? E.g. 1000, 3000,5000, 7500 GBP + etc.

Comments: Average costs vary considerably as XXXX holds a number of Cat A prisoners. Average for 08/09 was £2k.

DURING CONVERSATION, WAS TOLD THIS IS HIGHER IN 09/10 TO APPROX £ 2.5K.

• Q 1b - How can technologies such as HealthPresence for Telemedicine applications be acceptably used?

Comments: I believe we are open to using appropriate and established

technologies depending on necessary precautions in place.

• Q1c- - Would this be cost effective to the payer? (NHS Primary Care

Trusts?)

Comments: Yes, assuming a strong business case and funding from relevant

sources.

Q- 2- What are these ‘costs’ made up of? / What do they consist of? E.g. Transport, Security (what kind), Admin, Other? Ideally in % or actual figures.

Do these costs include additional staffing overtime & wage costs? If so, does their redeployment result is added costs within the prison?

Comment: Costs predominantly are escorting officer costs. Admin is probably @ 30 -60 mins each escort transport currently provided via HMPS and therefore inclusive of escorting costs for the PCT. No usually as prison profiles for 2 escorts per day and as a result should be covered by rotas within normal capacity.

Q- 2a-Who pays for this hospital treatment? E.g. The Prison Service, NHS PCT and/or other.

What other costs are included or need to be paid for? E.g. Transportation, Security?

Comments: The PCT generally pay either through acute allocation via other commissioning streams or through the additional allocations for elective surgery etc…. PCTs used to receive an additional funding allocation to give to acute hospitals for additional capacity for prisoners.

Q- 2b-Which PCT(s)

Comments: NHS Trusts have responsibility for all prisoners financially for physical health. Mental health can be different as if a hospital bed was needed then the originating PCT for the patient would pay.

Q- 2c- Why is this so? (Historical agreements with PCT?).

Comments: This is defined under the responsible commissioner guidance and further for prisoners and mental health.

Q- 3-In a typical month, what proportion of the population is likely to require outside medical treatment – on a daily, weekly or monthly basis?

Comment: there are 900 places with an average of 2 escorts per day. There are probably about 1 additional escorts required per month on top of this. Therefore 116 -120 escorts per year.

APPROX 9.5 VISITS PER MONTH X 2K = 19,300 GBP

Q -4- What types of treatment do they mainly require? E.g. Primary, Mental, Psychological?

Comment: – For mental health, psychology etc… people will visit the Prison. Escorts are mostly for minor surgery, secondary care assessments, cardiology, ENT and Dermatology.

Q-5 - Why is this? – E.g. Government policies, lack of housing availability, longer term health needs.

Comment: Due to consultants wanting to see patients and as a result of lack of expertise on site.

Q-6 - How overcrowded are your facilities & why?

Comment: Facilities are in the main not too overcrowded but rising quickly.

Q-7:- What is your operating budget for 2009/10/11?

Do you expect to see a reduction or increase in this? (Y/N)

Please state why?

Comments: total allocation is over 4m however this is split across physical, mental health and supplies etc.

We expect this to be reduced in regard to the PCT having to make savings for 10/11 and the prison budget will not be exempt.

PCT now has allocation within their main budget and no longer a ring fenced budget.

Q8 - In your view, what is your current staff morale like and why? - OPTIONAL

Comment: Morale is fair to middling due to a tender exercise currently being progressed. From a healthcare perspective staff are generally pretty rushed but appreciate the variety and challenge of the work.

Q9 - How much of your operating budget is used for offsite prisoner visits and medical treatment?

C Comment: @ 10% most of which is on security and escorting costs.

Q10 - What is the demographic breakdown of your prison population? E.g. How many men/women. Using the 16 plus one system

Comment: all male prison.

Q11 - Ethnicity & Age?

Comment: 58% White, 26% Black, 8% Asian, 3% Chinese.

3% under 21, 43% 21-29, 25% 30-39, 20% 40-49, 9% 50 or older.

On a scale of 1-5 (1 = lowest and 5 = highest), how would you rate the current areas below?

• Quality of healthcare services provided by the local PCT provider? (Delivery = ), (Staffing & Delivery = ) 3

• Ease of treating prisoners with current custody policies? 3

• Current staffing requirements? 4

• Staff morale? 3

• Amount of case loads 4

Now, thinking about the growing use of technology as an enabler, What (if any), are your experiences like with various technology companies?

Would you welcome the use of technology to help provide better services in prison for healthcare, learning, remote visitation etc?

Comments?

This Prison currently uses telehealth as a medium to link with outside specialisms. The issue is getting patients to the facility and co-ordinating someone at the other end!

If working with an existing technology partner, which companies first come to mind?

Blackberry (RIM)

BT

Cable & Wireless

Dell

Fujistu – Yes

Microsoft - Yes

IBM -

HP (including EDS). - Yes

Atos Origin-

Cisco- Yes

Raytheon –

Siemens –

Steria -Yes

Orange – Yes

O2 -

Why do these companies come to mind?

• Reputation (Good, Bad, Indifferent). -

• Quality (Product, Service, People, Support)-

• Brand Recognition -

• A responsible local employer / Previous engagements -

• All of above.

Any other comments: Most of these are companies we have previously engaged with. The others are not listed.

Would you prefer to be anonymous for the purpose of this questionnaire?

(Yes / No). Yes!

Thank you again for your input and please feel free to provide any comments & suggestions that may be useful in improving this survey.

Kindest regards,

Mr. Situl Shah

E: [email protected]

MBA Programme Member, Henley Business School.

Appendix -‐7 Value chain for NOMS & HM Prison Service.

Key Activity Core capabilities, key assets and resources, efficiency, & effectiveness.

Competitive position

Competitive Advantage

Firm infrastructure Top management, Key financial resources, Company ownership structure.

Government body part of National Offender Management Service (NOMS)

Major player- Government funded and backed.

Financial resources that enable strategic initiatives in targeted areas help keep company competitive.

Human Resources Training & development, rewards and incentive programs, Performance management etc.

National programme for workforce training is a valuable offering for improved skills and learning.

Medium High

Procurement Mainly use Central Government OCG procurement contracts & regional agreements with local ‘service’ providers. E.g. West Herts PCT for HMP Mount.

Centralised purchasing power is high with little regard for true value for money. Focus is on cheapest rather than best value.

Very high High

Operations Leveraging all related activities and processes.

Med to Low Low levels of effectiveness to be addressed by recruiting skilled, personnel from wider industry with business savvy.

Low

Outbound logistics

National level contracts for prisoner transportation between prisons and courts.

High – Only 2 main contractors, G4S and Serco.

Service Delivery

Medium

High High and reducing slowly.

Appendix 8-‐Prison Population

PRISON POPULATION & ACCOMMODATION BRIEFING - 18th Dec 2009 Population

Male 79,972

Female 4,259

No. of prisoners in police cells under Operation Safeguard and in court cells 0

TOTAL 84,231

Useable Operational Capacity 85,986

No places are currently activated under Operation Safeguard.

Number under Home Detention Curfew supervision 2,534

Definition:

1 - The operational capacity of a prison is the total number of prisoners that an establishment can hold taking into account control, security and the proper operation of the planned regime. It is determined by area managers on the basis of operational judgement and experience.

2 - Useable Operational Capacity of the estate is the sum of all establishments’ operational capacity less 2,000 places. This is known as the operating margin and reflects the constraints imposed by the need to provide separate accommodation for different classes of prisoner i.e. by sex, age, security category, conviction status, single cell risk assessment and also due to geographical distribution.

Population on corresponding Friday 12 months ago:

Male 78,534

Female 4,384

No. of prisoners in police cells under Operation Safeguard and in court cells 0

TOTAL 82,918

Useable Operational Capacity** 84,725

No places were activated under Operation Safeguard

Number under Home Detention Curfew supervision 2,559

** Useable Operational Capacity of the estate is the sum of all establishments’ operational capacity less 2,000 places.

Population figures have been drawn from administrative data systems. Although care is taken when processing and analysing population returns, the data collected is subject to the inaccuracies inherent in any large scale recording system.

Where data has not been received from an establishment, the population for that site from the last reliable, comparable day is rolled forward

Population in custody: by type of custody and sex 18th December 2009. Males Females Total All population in custody, of which 80,289 4,347 84,636 Prisons 79,972 4,259 84,231 Police cells 0 0 0 SCHs 131 26 157 STCs 186 62 248

All population in prison1, of which 79,972 4,259 84,231 Remand 11,849 774 12,623 Untried 7,887 506 8,393 Convicted unsentenced 3,962 268 4,230 Under sentence 66,934 3,410 70,344 Fine defaulter 99 20 119 Immediate custodial sentence 66,835 3,390 70,225 Non-criminal prisoners 1,189 75 1,264

All adult population in prison1, of which 68,980 3,801 72,781 Remand 9,586 675 10,261 Untried 6,382 448 6,830 Convicted unsentenced 3,204 227 3,431 Under sentence 58,300 3,056 61,356 Fine defaulter 96 20 116 Immediate custodial sentence 58,204 3,036 61,240 Non-criminal prisoners 1,094 70 1,164

All 15 -17 year olds in prison1, of which 1,818 55 1,873 Remand 407 13 420 Untried 292 10 302 Convicted unsentenced 115 3 118 Under sentence 1,411 42 1,453 Fine defaulter 0 0 0 Immediate custodial sentence 1,411 42 1,453 Non-criminal prisoners 0 0 0

All young adults2 in prison1, of which 9,174 403 9,577 Remand 1,856 86 1,942 Untried 1,213 48 1,261 Convicted unsentenced 643 38 681 Under sentence 7,223 312 7,535

Fine defaulter 3 0 3 Immediate custodial sentence 7,220 312 7,532 Non-criminal prisoners 95 5 100

1 Population in prison includes those held in prisons in England and Wales, including the three removal centres of Dover, Haslar and Lindholme.

2 Young adults are those aged 18 - 20 and those 21 year olds who were aged 20 or under at conviction who have not been reclassified as part of the adult population

Table A1: Tables of overall projected prison population

Projected prison population (at the end of June)

Year High Medium Low2010 85,700 84,900 83,9002011 88,600 86,900 84,9002012 90,200 87,700 84,9002013 91,100 87,600 84,0002014 92,400 88,000 83,5002015 93,900 88,700 83,300

Average projected prison population (financial year)

Year High Medium Low2010/11 86,400 85,300 84,0002011/12 88,800 86,900 84,6002012/13 90,200 87,400 84,3002013/14 91,100 87,400 83,5002014/15 92,500 87,900 83,100

Note: all numbers rounded to the nearest hundred.

Year2008

projection2009

projection Difference2008

projection2009

projection Difference2008

projection2009

projection Difference2009 85,100 83,454 -1.9% 84,300 83,454 -1.0% 83,300 83,454 0%2010 88,100 85,700 -2.7% 86,400 84,900 -1.7% 84,400 83,900 -1%2011 90,500 88,600 -2.1% 87,900 86,900 -1.1% 85,100 84,900 0%2012 92,100 90,200 -2.1% 88,700 87,700 -1.1% 85,000 84,900 0%2013 93,000 91,100 -2.0% 88,600 87,600 -1.1% 84,100 84,000 0%2014 94,200 92,400 -1.9% 89,000 88,000 -1.1% 83,600 83,500 0%2015 95,800 93,900 -2.0% 89,700 88,700 -1.1% 83,400 83,300 0%

Note: 2009 projection figures for 2009 are actual June population figures

Medium LowHigh

Source: Ministry of Justice (2009)

NB. Actual population figures quoted throughout this bulletin for months prior to July 2009 are taken from monthly published population in custody figures: www.justice.gov.uk/publications/populationincustody.htm. The July 2009 prison population figure is a provisional figure published on the 31 July 2009 by HM Prison Service: www.hmprisonservice.gov.uk/assets/documents/1000481131072009_web_report.doc

Appendix 9 -‐ Healthcare Escorts & Bedwatches

National Tariff 2008-‐09

Escort Events Bedwatch Events

One-off Hourly Rate

One-off Hourly Rate

All Rates at 2008/2009 values

Overhead charge per event

Time away from prison (Two-person

escort)

Overhead charge per event

Time away from prison (Two-

person escort)

Standard National Rate £55.76 £41.96 £182.02 £41.59

Locality Area

Area Rate 1 £65.66 £49.41 £214.34 £48.97

Area Rate 2 £65.08 £48.97 £212.44 £48.54

Area Rate 3 £62.98 £47.39 £205.60 £46.97

Area Rate 4 £61.82 £46.51 £201.80 £46.10

Area Rate 5 £58.32 £43.88 £190.39 £43.50

Area Rate 6 £56.34 £42.39 £183.92 £42.02

AREA RATES

RATE 1

RATE 4 Brixton

Aylesbury Holloway Bedford

Pentonville Bullingdon

Wandsworth Bullwood Hall

Wormwood Scrubs Chelmsford

Grendon/Springhill

Reading

Woodhill

RATE 2

RATE 5

Feltham Lewes

Huntercombe Winchester

Latchmere House

The Mount

RATE 3 RATE 6

Belmarsh Birmingham

Coldingley Bristol

Downview Littlehey

Highdown Long Lartin

Send Onley

NB Standard National Rate applies to all other English prisons not listed above.

Source: NOMS (2009)

Sample of Escorts & Bedwatch costs for Prisoner Healthcare Figures are real and kindly provided by NOMS for the purpose of this study.

Variable Fixed Total Healthcare Escorts & Bedwatches: Total Escort hours---> 40:51 £1,715.70 £1,176.00 £2,891.70Daily Activity Capture Record Total Bedwatch hours---> 782:40 £32,089.33 £546.00 £32,635.33

Calculated £35,527.03Date/Time inType Healthcare facility visitedOther data Other data Duration of prisoner's visit (h:m) Variable ChargeFixed Charge Total Charge# Escort Victoria 02:01 84.70 56.00 140.70# Escort Princess Royal 01:45 73.50 56.00 129.50# Escort RSCH 02:00 84.00 56.00 140.00# Escort RSCH 01:00 42.00 56.00 98.00# Escort RSCH 01:45 73.50 56.00 129.50# Bedwatch RSCH 124:30 5,104.50 182.00 5286.50# Escort RSCH 03:45 157.50 56.00 213.50# Escort Victoria 02:00 84.00 56.00 140.00# Escort RSCH 02:35 108.50 56.00 164.50# Escort Victoria 01:20 56.00 56.00 112.00# Escort RSCH 01:50 77.00 56.00 133.00# Escort Brighton General 01:35 66.50 56.00 122.50# Escort RSCH 01:55 80.50 56.00 136.50# Escort RSCH 01:20 56.00 56.00 112.00# Escort RSCH 01:30 63.00 56.00 119.00# Escort RSCH 02:10 91.00 56.00 147.00# Escort Princess Royal 02:00 84.00 56.00 140.00# Escort RSCH 01:40 70.00 56.00 126.00# Escort RSCH 03:10 133.00 56.00 189.00# Bedwatch RSCH 629:15 25,799.25 182.00 25981.25# Escort RSCH 02:00 84.00 56.00 140.00# Escort RSCH 01:30 63.00 56.00 119.00# Escort Princess Royal 02:00 84.00 56.00 140.00# Bedwatch Princess Royal 28:55 1,185.58 182.00 1367.58

NB. For confidentiality, any prisoner identifications have been removed by the author.

Appendix 10 – Financial Accounts MOJ summary accounts 2008/9, provided by NOMS.

Source: NOMS Accounts 2008-9

As detailed in the accounts, a significant portion of overall budgets are used

up by;

Travel & related expenses at £6,442,000 per annum

IT Services representing £2,140,000

Communications £2,634,000

The author suggests a significant portion of NOMS operational budgets can

be reduced by using Cisco HealthPresence solutions for treating prisoners

with Primary care needs and also for remote court appearances, education

and rehabilitation and visitation services.

Appendix 11 – Stakeholder map of NHS contacts & departments for Prisoner Healthcare.

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 2

NHS Service Contacts Map

Education Departments

Schools Higher /

Further Education

Research

Special Education

Needs

EducationPsycholog

y

Social Services

DomiciliaryCare

Older People

Services

Children's Services

AdultServices

MentalHealth&LD

Local AuthorityServices

Housing

Direct ServiceDelivery

Links

Charities

Non-Statutory

Organisations

Private Hospitals

Independent

ServiceProviders

Estates Management

External Support Services

Management Services

Logistics

NHSInc Primary care, Acute

Care, Mental Health &

Ambulance

DH Cf

H

Patients

Relatives & Carers

MOD

Other Government

Depts

DFES

Home Office

Audit Commissio

n

ForcesHealthcar

e

DCAf

Tribunals

Service

DeFRA

DWP

Prison Healthcare

Home Office Service

Contracts

Courts

Prison Service

Young Offenders

Team

PrisonHealthcare

Other NHS Organisation

NICE

NPSA

Information CentrePPA

Public Health

Healthcare Commission

Drug Companie

s

Prosthetics / Appliance Suppliers

Pharmacies

Other Health ServicesChiropodist

s

OpticiansPhysio-

therapists

Dentists

Edu Depts..

Source: Cisco UK Government & Public Sector Team (2009)

Word Count: 14,428

(Excluding Executive Summary, References, and Appendices)

hbs management challenge - telemedicine for prisons final

Documents

national finances

uk public sector healthcare

programme leader

situl shah

faculty staff

needs of governments

health care

special thanks