News

The following are announcements and commentary from the institute regarding issues in the news and new developments at the institute. The commentary represents the opinions of individuals in the institute and this is identified in the by line.

Digital Change in Health and Social Care

Digital change in health and social care – a report by the King’s Fund

Reviewed By: Dr Adam Hoare

Digital change in health and social care King's Fund Bayswater Institute
Digital change in health and social care

This report by the King’s Fund, presented at the Digital Health and Care Congress 2018, usefully draws out some of the challenges in adopting and scaling digital health and care interventions through consideration of five significant case studies. It begins by recognising some of the unique challenges of digital change and goes on to identify some key themes. The report is a practical and timely contribution to the practical understanding of digital change and not only references some of the work that The Bayswater Institute (BI) members have been involved in for many years but raises many of the issues that the BI come into contact with on a daily basis.

The report recognises several challenges around large-scale digital change. The negative memories around the National Programme for IT (The Implications of e-health System Delivery Strategies for Integrated Healthcare) and the inability to undertake such change whilst under pressures of current demand on resources being key issues.

The Evidence About Managing Digital Change

The report references the Wachter review (Making IT Work) which identifies the need for change processes using digital technology to be ‘adaptive’ and ‘technical.’ That “Adaptive change is change that relies on human behaviour for its success.” At the heart of this challenge lies approaches that are central to the BI way – action research and sociotechnical systems. Action research involves iterating towards a solution and sociotechnical systems thinking recognises that the solution is a collaboration of people working with technology. This recognition represents a significant departure from the “big-bang” approach to system change where it is assumed everything is known up-front. It signifies a shift to more “test and learn” thinking that underpins so much successful innovation in other industries and endeavours.

The report goes on to recognise the productivity paradox identified by Brynjolfsson (Beyond the Productivity Paradox.) That efficiency gains accompanying widespread digitisation is often absent in the traditional indicators. Our work indicates that it is often necessary to expand the range of indicators and evidence to understand how new practice is being enabled and what that means. This means that the evaluation approach must evolve with the intervention.

The work of Prof. Eason (a member of the BI) is discussed with regard to the tensions between top-down and bottom-up approaches in digital innovation (Bottom-up & Middle-out Approaches to Electronic Patient Information Systems.) The benefits of a middle-out approach are recognised in trying to link front-line change to national standards and frameworks. The work of Eason goes on to recognise that large-scale digital change is challenging and frequently fails (Getting the Benefit from Electronic Patient Information that Crosses Organisational Boundaries – Final report NIHR service delivery organisation programme)

In considering the barriers to successful digital change the work of Greenhalgh is cited (Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies ) which distinguishes between complicated and complex interventions. Complexity in this sense arises from systems that are interconnected and dynamic and produce emergent behaviour. Too often solutions are assumed to be complicated and fail because they do not address the complexity. In discussing the use of telephone triage in primary care the report refers to the absence of clear evidence of benefits but that some practices improved their ability to cope with demand. The same intervention in a different sociotechnical implementation could yield completely different results. Further, the originally identified benefit may not always be the useful benefit found in practice. This complexity again goes back to the need for a “test and learn” approach. This situational complexity and lack of a one-size-fits all approach underlies the challenges of the Whole System Demonstrator which saw the intervention as fixed and tried to generate an economic value (or QALY) for the intervention. Although the value of telehealth in reducing emergency admissions and better managing patients is generally recognised (Reduced Cost and Mortality Using Home Telehealth to Promote Self-Management of Complex Chronic Conditions: A Retrospective Matched Cohort Study of 4,999 Veteran Patients) it is highly situationally dependent and cannot be implemented as a black box approach as it is a sociotechnical intervention. The report reiterates that digital change is adaptive and does not lead to static states for testing – it evolves.

The report goes on to explore five different digital interventions across very different sites and applications. It identifies five key themes that are highly correlated to themes we see recurring in our BI work.

Leadership and Management

A key theme here was that personalities count. Often, selecting the right person to lead on a particular aspect was central to success. This is reinforced by the observation in the report that technology implementations should not be seen as IT projects but as a cultural change that is highly dependent upon good leadership. This leadership is most effective when clinically driven. At the BI our experience shows that many digital projects are approached as linear implementations that do not seek to learn or understand what is working and what is not. The need to build collaborations, often across organisational boundaries, is underestimated. In our work we regularly see digital projects pigeonholed as IT and lacking in the attention to culture change and leadership identified in the report.

User Engagement

The report recognised that a common approach across the case study sites was to recognise user engagement not as a single event but as a continual collaborative process involving users of the technology. The work we did at the BI in the BOLD-TC (Better Outcomes for People with Learning Disabilities – Transforming Care) project was based on just such an ethos involving not just the front-line practitioners across health and social care but also people with learning disabilities and their families. The move to a more collaborative, ongoing engagement with users is essential if services are going to evolve.

Information Governance

The case study sites focused on cultural rather than the technical aspects of information governance. By creating the right environment for partners to come together and solve the problems of sharing data it was found that collaboration, in general, was increased. Leadership and approaching information governance as a framework rather than trying to solve each problem as it occurred led to sustainable approaches.

Partnerships

It was identified that the right supplier could act as a facilitator for change by coordinating actors and change processes. Our experience at the BI is very similar. The ability of a supplier to see all of the challenges being addressed by the organisations coming together in pursuit of a common digital solution puts them in a key coordinating role. By providing each of the stakeholders in the intervention with valuable reporting and evidence specific to their needs they can act as the glue that binds the intervention. However, this requires an open supplier that sees the long-term benefits in building trust and collaboration. As the report points out choosing suppliers is a significant contribution to the success of the approach.

Resourcing and Skills

For the project to succeed the resources and skills need to be there, over and above what is required to keep the engine of delivery going. For large-scale digital interventions this is challenging in the current environment. Recognition was given to starting small and evolving solutions in a phased way. This was particularly important when crossing organisational boundaries. Trying to do too much at once absorbed resources and slowed progress. Our experience reflects this. Developing solutions that can have an impact on day-one but evolve over time to cross boundaries is essential and, again, part of the ongoing “test and learn” approach.

Evaluation

Although not a separate heading the importance of evaluation was noted. Significantly, the importance of evaluating success and failure was recognised. One of the quotes equated randomised control trials with a lack of rigour recognising that iterating understanding and learning was essential. At the BI we are committed to evaluation that engages with complexity and evolves with the intervention to develop learning and understanding. This requires formative evaluation and an understanding of the challenges the collaboration partners are facing.

Conclusion

The report is a significant contribution to understanding the challenges of implementing digital change. The use of case studies that demonstrate both the barriers and how they were overcome is the most useful way to share learning and understanding. At the BI we hope to see more of this kind of sharing and a move to learning “what works for who and under what circumstances.”

In my work with Airedale NHS Foundation Trust we addressed the issues of one-size-fits-all, the black box view of technology and the need to embrace complexity. Beginning in 2008 as part of the Assisted Living Innovation Platform (ALIP) we worked with Airedale NHS Foundation Trust and partners to use video in the home to address a range of care scenarios. Over a period of eight years Red Embedded Systems Ltd. developed the v-connect service. We developed a communication platform that could facilitate a range of care scenarios including video calls through the TV and delivery of educational content. We implemented interventions for long-term conditions, social care interventions such as virtual visiting, support for people with renal failure and remote support for people with learning disabilities. We integrated ambient monitoring, remote physical measurements, evidence collection and reporting (A Socio-technical Approach to Evidence Generation in the use of Video-conferencing in Care Delivery and Factors Affecting the Move to an eSystems Approach to remote Care delivery.) Many of the challenges discussed here were addressed in working with a broad range of partners in care delivery. We overcame barriers in all of the key themes identified but failed to make the commissioning case in every situation. Digital interventions have the potential to prevent and reduce current activity in the care system. Better educated and managed patients are more independent, and this reduces the need for care. For people with learning disabilities, remote support enables them to live more independent and confident lives. Prevention reduces need for care, independence and confidence all reduce the amount that the current providers are paid. This raises significant issues for leaders and for culture change. Often the right thing to do for the patient or client is the wrong thing for the financial standing of the organisations involved. This requires leadership at the policy and Governmental level. The focus of this report is on how successful digital interventions can be against the resource and skills challenges in the current climate. Imagine how successful they could be if there was a strategy and funding to facilitate a market in solutions.

We can only hope that future initiatives such as the Industrial Strategy Challenge Fund on Healthy Ageing (Industrial Strategy Challenge Fund: for research and innovation) and the recently announced £487m Transformation Fund for Healthcare will begin by taking notice of what we know and not try to reinvent the wheel.

Transforming care and health through information and technology: Local Investment Programme – Interim Report

By Dr Adam Hoare

Local Government Association – Local Investment Programme

Local Government Association Local Investment Programme Interim Report

Local Investment Programme – Interim Evaluation Report

In 2017 the Local Government Association in collaboration with NHS Digital introduced the Local Investment Programme. The programme recognised that the imperative for local care services to transform has never been greater due to rising needs, citizen demands and expectations alongside sustained pressure on resources. Although technology will never be a replacement for the delivery of care it can, if used appropriately, support people to live at home for longer, enable professionals to work more effectively together and help commissioners target services where they have the greatest impact. The Local Investment Programme (LIP) supported transformation through one-off local investment funding of up to £50,000 for projects that seek to use information and technology to improve adult social care and health outcomes and deliver financial savings as well as supporting more resilient care services and in improving outcomes, including people’s experience of care.

The programme was underpinned by a number of key principles:

  • encouraging open and replicable approaches which enable other LAs to adopt digital ways of working
  • supporting innovation and new thinking within adult social care and health, assisting its digital maturity within a challenging financial environment
  • assisting cross-council or multi-agency use of information and technology
  • developing an evidence-base and tools to support ongoing local digital investment in adult social care and health.

It was expected that the outputs and learning from these projects would be reusable and replicable, enabling them to be shared and implemented widely across the sector.

Councils who were successful in their bids for funding received support from an external partner organisation to help evaluate benefits, capture learning and support dissemination to assist other local areas. Participating local authorities were required to actively support this work, over the course of the programme, including in the development of guidance and tools for the sector.

The Bayswater Institute and OPM Group (now Traverse) were successful in winning the opportunity to evaluate the 19 technology interventions funded by the programme. In April 2018 an interim report was produced capturing the learning on the ground as well as considering the programme itself.

The Future of Work: Automation and Continuous Change?

By Prof Ken Eason

Predictions for the future of Work

Christmas saw the publication of another forecast of the number of jobs that are at risk because of the march of robotics and artificial intelligence. This time it was the IPPR (Institute of Public Policy Research) forecasting that up to 44% of UK jobs are at risk across wide sectors of the economy.

IPPR Report on Managing Automation

There are now many forecasts of massive job losses and attention is being focused on a world where a small proportion of people (the highly skilled ones) will be employed and the rest will be out of work and poor.

But there is also another common theme in the debate about the future of work. It is that we exist in a complex, ever changing, interconnected, global economy and that to survive organisations have to be flexible, resilient and adaptive. The cry is that:

The Only Constant is Change

 Who will manage the change?

How do we reconcile these two different perspectives on the future of work?  Our clever technology may be very good at doing the operational work but it cannot help us make sense of the messy world of international trade, market forces, competitiveness, social change, government action and technical innovation. And it cannot determine what we should do to take advantage of new opportunities and defend against threats. AI may be smart but it is a narrow intelligence with a clever understanding of a specific work domain. Indeed, such narrow AI is also known as weak AI because it cannot replace the breadth of capabilities of a human. However imperfect they may be, human beings are currently the only general purpose intelligent resource we have that can make sense of a confusing, changing world – sentience is known as strong AI.

How is a work organisation to manage in a changing world with a small labour force and a large and sophisticated technological base that may be difficult and expensive to change? The small labour force may have a big agenda: to manage the technology and make sure nothing goes wrong, to monitor the outside world and spot opportunities and threats and to design and implement new ways of working to meet changing requirements. And to keep doing all of these things all of the time. There are many reasons to predict that this model of future work organisations will be ineffective and could be dangerous. One of the reasons for this prediction is what we know about how work actually gets done.

People as the adaptive, coping agents in work systems

 Every study of how work actually gets done shows that it is rarely done strictly according to the formal processes specified that may be embedded in the technology. The people in the work system embellish the formal processes with their own knowledge, often tacit and undeclared, in order to give work delivery the flexibility to meet varied and emergent requirements. They are the ‘oil in the system’ that ‘keeps the show on the road’. They recognize what is new and different, learn how to adapt, and add new, often unspecified, procedures to the repertoire of the organisation. In doing so they often have to ‘work around’ inflexibilities in the formal system to get work done and meet customer requirements.

As a result in any well-established work system there are people who have a deep but often implicit understanding of how the system actually works and a learning capability that means there is a bottom-up process of adaptation and evolution in place that responds to local changes.

The danger of the current narrative about robotics and artificial intelligence is that it implies the replacement of this human resource with technologies that will produce the work on their own. If that is the case not only will work systems become less resilient and adaptive but all the collective tacit knowledge will be lost. And as the saying goes ‘you don’t know what you have lost ‘til it has gone’.

There is always ‘Organisational Choice’:  changing the balance of task 1 and task 2

 To their credit, the IPPR recognize that it is only some of the tasks that can be automated and there are many other parts of jobs that are best done by people. So instead of just assuming technology will replace people we have to ask how the new technological capabilities and the very different capabilities of human resources can be harnessed together for the long-term resilience and adaptability of work organisations. The solution has to be sociotechnical change not just technical change. There will be significant organisational choices to be made to find the right solutions and we need some principles to guide this process. Here are a few to consider:

  1. Immediate cost-effectiveness may be a dangerous objective. The key argument for automation may be economic – you get greater and more reliable productivity from robots and they are cheaper than human resources. That may be so, but you also have to consider what you might lose….
  2. Knowledgeable and skillful human resources provide a sense making resource that can cope with the unforeseen. We need to keep a general sense making capability at all levels within the organisation; to keep a watchful eye on our technology and to provide flexibility and adaptability wherever it is needed. But to be effective people need to keep their knowledge and skills up-to-date and that means actually doing the operational tasks some of the time. So, enabling them to ‘keep their hand in’ is an important design criteria for future systems design.
  3. Having people who understand the task domain means there is a double-task resource to add significant knowledge to planning future developments. Task 1– getting today’s work done – has dominated.

People also have Task 2 abilities – to step back and reflect, to review their performance, to see what can be improved etc. The more they can do this, the better chance the organisation has of coping with the need for continuous change.

Helping people and organisations develop their Task 2 capabilities is an important part of the Bayswater Institute mission. It could be that one of the consequences of robotics and AI will be that people need to spend less time on Task 1 and they can spend more time on Task 2 – in particular thinking about how the work system may be changed to meet new challenges and opportunities. Exploring the potential impacts up-front would seem a good investment in that this is a global challenge and will generate new requirements of the work force that could benefit from planning rather than reacting.