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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.

 

 

Socio-Technical Theory and Work Systems in the Information Age

Book chapter entitled ‘Socio-technical theory and work systems in the information age’

This chapter of the book set the traditional focus of socio-technical systems theory on primary work systems in modern context where information and communication technology (ICT) has a major influence in the way work is undertaken. The chapter begins with a summary of the original work of the Tavistock Institute of Human Relations and critically reviews the major concepts to emerge from these studies. This is followed by a review of recent studies of the impact of ICT on work systems and how socio-technical systems are used to interpret these findings. Finally, concepts and methods of designing and implementing customisable and generic ICT systems in organisations. The authors call for a recognition and evaluation of socio-techcial systems as never completed but evolving over time; placing an emphasis on the emergent behaviour resulting from the use of new technical systems.

“Technology presumes there’s just one right way to do things and there never is.”

– Robert M. Pirsig

Socio-technical theory design networking systems

Google Books Link

EASON K. AND ABDELNOUR-NOCERA J. Socio-technical theory and work systems in the information age. In Whitworth B. and de Moor A. (eds) ‘Handbook of research on socio-technical design and social networking systems’ Information Science Reference, Hershey New York 65-77

Information Technology and Organisational Change

A book addressing the need to consider technical and organisational change as a system in the implementation of information technology

The Preface for this book published in 1988 was contemporary and on reflection, nearly thirty years later, still applicable in many ways today to implementation of information technology. It opens:

It is widely acknowledged that information technology will revolutionise organisational life. And yet if you look at most organisations you will find that the pace of change is slow and that there is not much sign of a revolution. In many organisations expensive equipment seems to be making very little contribution to the goals of the enterprise. It seems that suppliers are always in the midst of editing new technological breakthroughs whilst potential user organisations are still trying to assimilate yesterday’s technology. The pace of technological development poses the end user with the perpetual headache of trying to decide what is worth using and how to use it.

Ken wrote – of nearly twenty years as one of the founders of the HUSAT research centre, I have been working with my colleagues to understand the difficulties people encounter when trying to harness information technology and then to build tools and techniques which will help them in the process. As information has advanced the methodologies and tools for technical systems design have become progressively more sophisticated and efficient. By contrast the techniques by which uses can specify their needs, evaluate alternatives, implement systems, make complementary organisational changes etc. have hardly progressed at all. Most design methodologies pay scant attention to these issues. It is almost a truism to say that we need socio-technical systems design; the joint design of the technical and social sub-systems in the organisation. However, many forces keep the two processes apart. Technical design is the province of technologists who know little of social system design. Technical tools do not address this issue.Organisational change is the province of management but is seen as separate from technical change and ether are few tools to help the fusion of the two kinds of change.

Information Technology and Organisational Change Ken Eason

 

EASON, K.D. Information Technology and Organisational Change, (1988) Taylor & Francis, London.

Google Books Link

Amazon Link to Book

Other Publications in this Area:

Understanding Organisational Ramifications of Implementing Information Technology Systems

1966 and All That: Trends and Developments 1956-1974 within UK Ergonomics

Development of ergonomics in the UK between 1956 and 1974

Abstract:
The 1960s represents a key decade in the expansion of ergonomics within the UK. This paper reviews trends and developments that emerged out of the 1960s and compares these with ergonomics research and practice today. The focus in particular is on the expansion of ergonomics as a discipline within industry, as well as more specific topics, such as the emergence of areas of interest, for example, computers and technology, automation and systems ergonomics and consumer ergonomics. The account is illustrated with a detailed timeline of developments, a set of industrial case studies and the contents of important publications during the decade. A key aim of the paper is to provide the opportunity to reflect on the past and the implications this may have for future directions for ergonomics within the UK.

The paper provides practitioners with an insight into the development of ergonomics in the UK during one of the most important decades of its history. This is especially relevant given the fact that in 2009 the Ergonomics Society celebrates its 60th anniversary.

Introduction:

The quote from the Italian writer Italo Calvino was made during a debate held on ‘industry and literature’ at the beginning of the 1960s. Calvino sums up what were to become dominant themes in later accounts of the period, namely, the growth of automation and the increasing role played by technology within society. Both of these themes are important within ergonomics and continue today as sources of debate in research and practical applications of the subject. Similarly, many issues have declined in interest or relevance as compared to 40 years ago. Much has been written about the origins of ergonomics, alongside other discussions centred around pioneers within ergonomics and the future of the discipline (e.g. Frederic Bartlett). By comparison, little detailed information is available covering specific periods within the development of ergonomics. This paper focuses on the 1960s within UK ergonomics for a number of reasons. First, the 1960s can be seen as a mid-point between the immediate post-war roots and birth of ergonomics and its subsequent development into a fully fledged discipline. Second, during the 1960s, ergonomics became firmly established within industry and made firm steps towards closer engagement with civil, government and industrial users and practitioners. The late Brian Shackel (1927–2007), in a paper written to celebrate the 50th anniversary of ergonomics within EMI, viewed the period as a bridge between earlier work on military ergonomics and a later focus on consumer ergonomics in the 1970s.

In 2009 the UK Ergonomics Society celebrates its 60th anniversary. It seems timely and appropriate to stand back and review trends and developments over the period and compare these with present day ergonomics.

Taylor and Francis Ergonomics Ken Eason developments 1956 1974 within uk ergonomics

Taylor and Francis Publication Link

WATERSON P. AND EASON K.D. 1966 and All That: Trends and Developments 1956-1974 within UK Ergonomics. Ergonomics 52(11) 1323-1341

People and Computers: Emerging Work Practice in the Information Age

A chapter in the book ‘Psychology at Work’ reviewing the impact of information technology on work practice and the link between people and work

 

Psychology at work Ken Eason People and computers emerging work practice in the information age

Amazon Book Link

EASON K.D. People and Computers: Emerging Work Practice in the Information Age. In P.B.Warr (ed) ‘Psychology at Work’ Penguin, London, 5th Edition pp 77-99 ISBN 0-14-100010-4

Consumer Behaviour of Employees Using Information & Communications Technology Products in an Organizational Setting

Human Factors and Ergonomics in Consumer Product Design: Uses and Applications

Every day we interact with thousands of consumer products. We not only expect them to perform their functions safely, reliably, and efficiently, but also to do it so seamlessly that we don’t even think about it. However, with the many factors involved in consumer product design, from the application of human factors and ergonomics principles to reducing risks of malfunction and the total life cycle cost, well, the process just seems to get more complex. Edited by well-known and well-respected experts, the two-volumes of Handbook of Human Factors and Ergonomics in Consumer Product Design simplify this process.

The second volume, Human Factors and Ergonomics in Consumer Product Design: Uses and Applications, discusses challenges and opportunities in the design for product safety and focuses on the critical aspects of human-centered design for usability. The book contains 14 carefully selected case studies that demonstrate application of a variety of innovative approaches that incorporate Human Factor and Ergonomics (HF/E) principles, standards, and best practices of user-centered design, cognitive psychology, participatory macro-ergonomics, and mathematical modeling. These case studies also identify many unique aspects of new product development projects, which have adopted a user-centered design paradigm as a way to attend to user requirements.

The case studies illustrate how incorporating HF/E principles and knowledge in the design of consumer products can improve levels of user satisfaction, efficiency of use, increase comfort, and assure safety under normal use as well as foreseeable misuse of the product. The book provides a comprehensive source of information regarding new methods, techniques, and software applications for consumer product design.

Chapter: ‘Consumer Behaviour of Employees Using Information & Communications Technology Products in an Organisational Setting’ introduces the idea of seeing workers as consumers of IT

“Perhaps the most interesting chapter, though, is Ken Eason’s which makes a compelling case for regarding employees at work in an organisational setting as consumers of IT products.” – Gordon Baxter

Link to Review on Taylor and Francis Site

Human Factors Ergonomic Product Design Ken Eason Information & Communications Technology

Amazon Book Link

Google Books Link

EASON K. D. Consumer behaviour of employees using information and communications technology products in an organizational setting. In ‘Human Factors and Ergonomics in Consumer Product Design: Uses and Applications’ Eds. W. Karwowski, M. M. Soares and N. A. Stanton, CRC Press, Boca Raton p241- 253

Understanding the Organisational Ramifications of Implementing Information Technology Systems

Handbook of Human-Computer Interaction (Second Edition)

Publisher Summary:
Information technology is a major force for organizational change. Every organization that applies the technology experiences organizational ramifications. This chapter charts the development of different models of organizational effects over a 40-year period. During the 1960s and 1970s, many studies of organizational impact were undertaken that produced conflicting results. As a result, a contingency model of computer impact emerged that accounted for the different impacts by reference to different forms of technology and application. In the last decade, it has become clear that this is also an inadequate model because it does not allow for the active nature of organizations that act to shape the impact of the technology. The chapter examines nine case studies to explore the processes by which organizational impact takes place. The active manner in which these processes operate is summarized in model three. This is an organizational assimilation model in which the three sub-systems of an enterprise interact and create outcomes in each sub-system. The chapter ends with a review of the many methods now available to support this approach and outlines the need for organizational stakeholders to play significant roles in new system developments.

Human Computer Interaction User Centred Design Organisational Impact Information Technology

Google Books Link

Science Direct Link

Eason K. D. (1997) Understanding the organisational ramifications of implementing information technology systems. In ‘Handbook of Human-computer interaction’ M.G. Hollander, T.K. Landeaur and P.V. Prabhu (eds) , Amsterdam, Elsevier

DOI Link

Managing Computer Impact

Managing Computer Impact: An International Study of Management and Organizations

Managing Computer Impact describes research undertaken in eight organizations in five countries. The approach determines the impact of computer-based information systems on organizations and management. Results at several levels of analysis support the conclusion that few changes are determined by computer technology.

Managing Computer Impact: An International Study of Management and Organisations Ken Eason

Link to Google Books

BJORN-ANDERSON, N. EASON, K.D. & ROBEY, D. (1986) Managing Computer Impact, Ablex, Norwood NJ.

Productivity? – Don’t Just Fund the Technology Phil! A response to the budget of the 22nd November 2017.

By Dr. Adam Hoare

The Organisation for Economic Co-operation and Development has downgraded its 2017 growth forecast for the UK to 1.5% from a 1.6% estimate made in September, making Britain the weakest economy in the G7. The office for budget responsibility had taken the rosy view that after 2008 UK productivity growth would return to previous levels of around 2% It has now admitted, after years of getting it wrong, that it is likely to sit around 1.3-1.5% until 2020. Last week’s budget reverberated with the recurring issue of low productivity growth. The solution presented was an industrial strategy. Something that had fallen out of favour as Government interference.

The announcements based on borrowing came thick and fast:

  • Digital skills and startup funding to reinvigorate the UK’s waning productivity.
  • £3 billion to cushion the landing of a potential hard Brexit, the chancellor said: “This Budget is about much more than Brexit. For the first time in decades Britain is genuinely at the forefront of this technological revolution. Not just in our universities and research institutes, but this time in the commercial development labs of our great companies, and on factory floors and business parks across this land. But we must invest to secure that bright future for Britain.”
  • Last year’s £23 billion National Productivity Investment Fund was to provide £31 billion in funding over six years, compared to the originally planned five. R&D to receive another £2.3 billion investment, under the government’s Industrial Strategy aim to ramp up R&D spending to 2.4% of GDP.
  • To double the number of tech startups founded in Britain with the goal to see one created every half an hour.
  • A £10 million Regulators’ Pioneers Fund to help regulators find new ways to bring emerging tech – AI and 5G – to market.
  • Tech City UK, to be rebranded as Tech Nation, a body with a remit to spend £21 million on developing the UK’s various startup hubs.
  • In a bid to tackle the UK’s stark digital skills gap, the chancellor also outlined fresh cash to retrain people and provide a greater focus on maths and computing for children and teenagers.

The idea of a strategy and a long list of funding opportunities for new technology seems to overlook some very important evidence. Figures for various IT projects (some of the figures originating from the National Audit Office no less) demonstrate a persistent gap between the projected benefits and the reality:

  • Child Support Agency – £500m estimated loss;
  • DEFRA Rural Repayments Agency – £130m estimated loss;
  • Inland Revenue NIHS – £3-4 billion estimated loss;
  • Magistrates Court LIBRA – £232 million estimated loss;
  • HM Prison Service C-NOMIS – £690 million estimated loss;
  • Fire and Rescue FiReControl – £469 million estimated loss;
  • NHS NPfIT – £20 billion estimated loss.

As we borrow money to fuel a technological “hail Mary pass,” it would seem a good time to think about why we fail to convert so many such passes to a touchdown. The Bayswater Institute has been extensively involved in embedding and evaluating digital technologies in health and social care over several decades. Over the last decade alone there have been hundreds of initiatives to improve productivity in care provision by elevating the use of technology to 21st century standards. Although there has not been an overall assessment of the impact of these initiatives the experience of care provision points to low impact from these initiatives. From seeing these projects from the inside, we have developed a level of understanding of why they struggle – and it is not the technology. Two things work against the use of technology in many of these scenarios:

  1. The technology does not exist in isolation it is part of a system that involves the people using it and the people receiving services. If it does not work for them it is not productive.
  2. Where there is an increase in productivity it usually means a single person can handle more work or the workforce can be reduced. This inevitably generates resistance.

Both of these challenges are rooted in social science and the interface between people and technology. Understanding these sociotechnical systems is essential in successfully capturing the benefits the technology can bring. Looking back over the announcements we cannot see where this is mentioned. Throwing money at the technology and expecting social transformation is an interesting approach but the evidence is – it has been done before and it will fail.

A third issue that recurs in productivity considerations. To know a system is more productive than it was before it must be measured in a meaningful way. This links back to point 1 above. If it works for the professional but not the citizen – it does not work. Hence, the outcomes of productivity must include social value and social impact otherwise public money is spent on making the system happy and the service recipient unhappy.

We spend much of our time providing summative evaluations of where the barriers and challenges are in technology projects that are trying to embed into practice. We have a special interest in formative evaluations of interventions where we can draw on our experience and anticipate some of the problems ahead of the development and have the opportunity to have an impact on the NAO estimated loss. If the focus remains on the technology and not the combined scoiotechnical system the return on investment is likely to be negative. The last thing that Phil wants.

Factors Affecting the Move to an eSystems Approach to Remote Care Delivery

Abstract:
Optimization of care provision, in the future, requires a shift from the current paternal model of dispensing care, to a collaborative model of coaching, supporting and enabling self-care and promoting independence. This will not be appropriate for all people and for all care providers but if resource utility is to be maximized, an approach must be developed that facilitates as much independence and self-determination as each person can safely and capably engage in. This requires that care provision be personalized and include broader engagement, such as social and family connections, as part of a person’s care network.

In order to facilitate a transformation of care providers into care collaborators, communications technology can play a significant enabling role as it has in other eSystems. Ubiquity of such technology across care providers, care receivers and their support networks can underpin new models of care provision. Developing a platform approach for communication and having a menu of interfaces and devices, care services can be personalized such that the technology reflects a person’s specific needs. This novel approach to person-centered communication moves away from a “one-size-fits-all” model and can facilitate combinatorial interventions. However, the move to eSystem- mediated autonomy in remote care provision is confounded by many factors. This paper will discuss the development of just such a communication platform and more than ten year’s experience will be explored in developing combinatorial innovations reflecting personal needs in two care scenarios. Through working with care practitioners and patients the platform has addressed needs in primary, secondary and social care in the UK. The current challenges in scaling the approach will be examined from the point of view of the difficulties in mapping the use of eSystems on to the fragmented nature of current care delivery.

IEEE Link

Hoare A, Factors Affecting the Move to an eSystems Approach to Remote Care Delivery Conference:  2016 9th International Conference on Developments in eSystems Engineering (DeSE), Liverpool, 2016, pp. 7-12.
doi: 10.1109/DeSE.2016.3