Buckinghamshire Assistive Technology (AT)
Strategic Vision 2014-17
(Telecare and Telehealth)
Buckinghamshire County Council
Adults and Family Wellbeing & Children and Young People
Chiltern Clinical Commissioning Group
Aylesbury Vale Clinical Commissioning Group
Buckinghamshire Healthcare Trust
Bucks New University Centre of Excellence for Telehealth and Assisted
Living
Author:
Adam Willison,
Joint Commissioning Manager, Assistive Technology
Contributors:
Amy Moore,
Joint Commissioning Manager, Transitions
Dr. Tom Davis,
GP Clinical Advisor
Oliver Stykuc-Dean, Telecare Project Officer, Buckinghamshire County Council
Adrian Timon,
Telehealth Project Officer, Buckinghamshire County Council
Firas Sarhan,
Director of CETAL, Bucks New University
Jo Fairley,
Director, Healthwatch Bucks
Graham Softley,
Director of Information Technology and Digital Innovation,
Buckinghamshire Healthcare Trust
1. Strategic vision for Buckinghamshire
To deliver a broader, integrated and equitable AT offer for 10,000 social care,
health and private retail users by 2017.
There will be more emphasis placed on ensuring that the patient/service user
and carers are at the heart of AT development, breaking down barriers to
achieve greater equity of service. There will also be a greater drive to ensure
barriers such as age, condition specifics and inter-agency working do not limit the
ambition of achieving the desired co-creation, choice and relevance for the
residents of Buckinghamshire.
Despite ambitious aspirations, there is practical acceptance that provision will
need to be long term and sustainable, whilst maintaining Buckinghamshire as a
pioneer site for AT development.
2. Introduction
We know that technology has the potential to enable people to live independent
lives, by supporting them in managing their own care needs more effectively. We
also know that technology can provide health and social care professionals with
information that helps them understand changes in condition or welfare and
when an intervention may be required.
There is clear and well documented need to change the way social and
healthcare demand is managed and although technology alone does not provide
the answer, there is an opportunity now to embed it as part of whole system
redesign. The real challenge is how do we ensure that the key stakeholder, the
service user/patient, are at the heart of our AT commissioning decisions?
The UK Government has created several initiatives in recent years to stimulate
growth and required culture change in order to adopt AT e.g. Whole System
Demonstrator trials, 3 Million Lives campaign (now known as TECS –
Technology Enbaled Care Services), Digitalising the NHS, Telecare in England,
Delivering Assisted Living Lifestyles At Scale (DALLAS). However, as has been
discovered across several of these initiatives, no amount of money and targets
can resolve the issues facing health and social care in the 21 st century. Nor can
it detract from the repeated mistake of trying to make technology the focal point,
as opposed to the service user/patient.
The NHS and local government are large, complex organisations, where change
will not readily occur and AT needs to be seen as part of a long term
development plan to modernise services.
We already use technology in many aspects of our everyday lives, for example,
internet shopping or banking, so the next 3 years will be an important period for
AT as developments strive to become equally mainstream. This is particularly
challenging against a back drop of barriers in organisational culture, budgetary
restrictions, significant legislative change, increased public expectation and how
the demands of an ageing population with complex needs can be met.
At the same time health and social care providers are facing increasing
expectation to reduce costs, whilst maintaining or improving the quality of care.
This had led to an active search for different ways of delivering care that do not
compromise quality and dignity, but help to prevent ill health, promote healthy
lifestyle choices and can be financially sustainable.
The AT market continually develops and innovates at a rapid pace. This is seen
as one of the limiting factors of some academic research that has investigated
the efficacy of AT interventions. Whilst evidence based practice is important in
supporting commissioning decisions, by the time research papers are published,
the relevance of these results can be questionable due to time that has elapsed.
Strategy in Buckinghamshire will need to continue to focus on local area need,
innovating and trialing new AT as it comes to market. This will help to ensure
that the county remains at the cutting edge of technology development for the
benefit of its residents. The commissioning challenge with this approach is to
ensure that AT is trialed and developed, with adoption becoming ‘business as
usual’ in increasingly shorter periods of time and at reduced cost.
With a firm foundation now in place to significantly grow AT in Buckinghamshire,
this is our prime opportunity to ensure that it forms a core part of the continued
integration of health and social care and meets the requirements of major
legislative change, such as that laid out in the new Care Bill.
3. Background
AT (encompassing terms such as Telecare, Telehealth, Digital Innovation,
Telemedicine, Environmental Control Solutions and Stand Alone Technology) is
the overarching definition which is applied to the use of technologies that assist
people in their daily life. People are generally familiar with Telecare as pendant
alarms which social care have traditionally provided and Telehealth as vital signs
monitoring equipment which has traditionally been delivered by health.
AT has seen considerable growth in Buckinghamshire over the last 5 years. The
current, county wide programme, managed within Joint Commissioning, is
delivered via an integrated and diverse network of partnership and contract
arrangements that span public, private and voluntary sectors. The Telecare
element is a fully operational service within Buckinghamshire County Council
(BCC), with Telehealth a developing programme within Aylesbury Vale and
Chiltern Clinical Commissioning Group areas (AVCCG and CCCG).
The programme of work to date has involved close collaboration between
partners, with the new 3 year vision having been developed further to both BCC
and NHS Commissioning Board recommendations around AT Strategy: 



Should focus on the traditional spectrum of AT, but include greater
emphasis on high volume, low cost systems and mobile phone
technology.
With cross cutting themes, AT should link to relevant Programme Boards
and Operational Plans to ensure accountability with respective areas e.g.
Mental Health and Learning Disability.
Should have clear link into Information Management & Technology (IM&T)
and Service Re-design strategies.
Consider evaluation of pilot studies, with outcome measures inserted in
relevant contracts in order to give clear indication of the benefits (e.g.
reduction of admissions to A&E).
4. National and international drivers
People with health and social care needs are on the increase, with demographics
changing and people living longer. For example, patients with long term
conditions are high users of health services, accounting for 55% of all GP and
68% of all outpatient and A&E appointments in the UK.1
The current approach to the delivery of care to people with social and health care
need is widely recognised as unsustainable both in terms of cost and quality of
care. For example, the NHS already spends 70% of its budget on the 15 million
people who have one or more long term condition. With an ageing population,
patient numbers are expected to grow by 23% over the next 20 years. 2
A 2013 report from the House of Lords Public Service and Demographic Change
Committee identified increasing use of technology and eHealth as a potential
way of reducing pressure on the UK health and social care systems.
AT should be an important element of any strategic initiative to improve and
encourage the management and self-care of users and patients in their own
homes. Carefully and appropriately deployed, AT can support people with social
and health care needs, in order to improve their independence and quality of life;
1
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
2
enable self-management and targeted intervention by the appropriate
practitioner; reduce emergency hospital admissions and A&E attendances; and
focus on educating and empowering patients, reducing short, medium and longterm demands for care. 3
The aim of any AT programme should be “to embrace the use of informatics,
disease management/care co-ordination, and home ‘tele’ technologies to
enhance access to care and improve the health of designated individuals and
populations – with the specific intent of providing the right care, in the right place,
at the right time.” 4
With a population of just over 500,000, Buckinghamshire is similar in size to
Gloucestershire, where around 1% of the population have a long-term condition
such as heart failure, chronic obstructive pulmonary disease, diabetes or
coronary heart disease. Only 5% of the population account for half of all stays in
hospital and in 2010/11 the above four primary diagnoses generated 4,386
emergency admissions, a 4% increase on 2009/10. These admissions cost
approximately £13.7m in 2010/11, an increase from £12.8m in 2009/10. In
Gloucestershire the cost of emergency admissions for these individuals is around
35% more than it was for the same period last year.5
Patient/service user benefits of using AT include: Enhanced quality of life (for
users and their carers); empowerment to self-manage their condition with less
anxiety; and better clinical outcomes: mortality, symptom management and
medication titration. 6
Health and social care economy benefits include: Reduction in unplanned
hospital admissions; fewer A&E visits and ambulance call-outs; less outpatient
attendances; reduced need for traditional homecare, increased case
management potential; savings associated with a reduction in the use of services
in the acute sector and operational efficiencies in community care.7
AT in health must be clinically driven and in social care, practitioner driven.
Constructive clinical and practitioner engagement should not be underestimated,
in terms of spending time with professionals and patients to both design the
intervention and implement the service.
AT should, where possible, be
3
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
4
Telehealth- What can the NHS learn from the US Veterans Health Administration? John Cruickshank January 2012 –
2020Health.org
5
Managing long term conditions with telehealth – Patient survey results June 2012 – NHS Gloucestershire
6
The NHS Gloucestershire telehealth programme – the largest GP referring service in the UK – NHS Gloucestershire /
Tunstall
7
The NHS Gloucestershire telehealth programme – the largest GP referring service in the UK – NHS Gloucestershire /
Tunstall
embedded within existing care pathways and is not just about equipment in
isolation, but how AT augments into an integrated, long-term condition and case
management strategy. AT and its ‘wrap around’ services, bring the rest of the
health and social care system together for the patient, acting as a hub that can
enable swifter flow of communication and data, in order to aid effective decision
making.
The Veterans Healthcare Administration (VHA) in the United States can be
equated in particular to the NHS. To achieve the staffing and logistical
efficiencies seen in the VHA (between 20% – 56% reductions in patient
utilisation, depending on disease group), the NHS needs to find ways to deliver a
step-change increase in the scale of AT implementation.8
The VHA data can be extrapolated to demonstrate the potential decrease in
resource utilisation through the use of scalable AT, as demonstrated in the table
below:
VHA has demonstrated that those who manage the delivery of AT, need not be
local to the patient or user, but do need to interact closely with the responsible
community care professional.
As part of an overall redesign of care, AT represents a vital element in the shift
towards more preventive care, reducing the imbalance between hospital and
community care spend and making better use of scarce resources. 9
A technology-enabled care service needs considerable investment and time to
generate results. It also needs substantial change to the organisational
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
9
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
8
infrastructure, particularly around training and competencies and performance
management systems. To provide the confidence required for large scale
referrals into an AT service, clinical and practitioner engagement is essential,
based around clear evidence of benefit to specific patient and disease groups.10
5. Local achievements
Buckinghamshire is recognised nationally as one of the leading local government
and health authority areas for AT development and innovation, providing national
benchmarking advice to the Cabinet Office, NHS England, Local Government
Association and internationally, to organisations such as Veteran’s Healthcare
Administration in the USA.

First Telecare strategy (2008) and delivery plan (2009-13).

First Telehealth strategy and associated work programme (2011).

Over £4 million investment by BCC and NHS in AT development since
2008.

Over 4,000 users supported with AT across Buckinghamshire.

AT eco-system fully established (2011) linking assessment, installation
and maintenance, 24/7 monitoring and 24/7 community response with
technology enabled service providers and excellent links with partners and
key stakeholders.

Partnership Board (2008) and Overview and Advisory Group (2011)
established to inform and drive the strategic direction of AT and exploit
development and economic opportunities across a community of
academia, industry, third sector and health, housing and care.
National level evidence also confirms that the strategic commissioning approach
for AT taken by Buckinghamshire since 2008 has been sound. These can be
summarised as follows: 
Patient/service user age being a barrier to adoption of AT is a myth.
When supported by a robust assessment and ancillary services, people
can very quickly adapt to various AT interventions.

There are significant cultural barriers around acceptance of AT as a
means of clinical delivery. This has been highlighted through a lack of
delivery of appropriate training and change management.
Healthcare without walls – A framework for delivering healthcare at scale. John Cruickshank November 2010 –
2020Health.org
10

AT is moving rapidly towards cloud based data and mobile technology
solutions, with over 8 in 10 adults going online and 6 in 10 adults using a
smart phone.

Integration and interoperability of systems has highlighted limitations of AT
deployment across health and social care and the importance of having
open-protocols.
6. What is patient/service user engagement?
One key point that has never been fully addressed in AT commissioning is ‘who
is the primary customer? the healthcare professional? the patient? the service
user?’
Because the patient/service user has historically been seen as a passive
recipient, with decisions and budget resting elsewhere, commissioners and
industry have continued to evade this question. We have predominantly
delivered a technology driven, halfway house of initiatives. Take medication
concordance, where we trialed a system to remind patients to take their
medication. Not only did we not sufficiently engage with the patient, we did not
take the time to fully understand which AT intervention, if any, was required. For
example, what would be more appropriate for the recipient? A complicated
dispenser, or a simple text message reminder?
The drive for better engagement is one of the recent government initiatives
aimed at putting the patient at the centre of health and social care development.
But if industry has struggled to make this logical step, why do we expect the
public sector, charged with delivering against tough patient/service user
engagement targets to do any better?
There are 3 important questions that need to be addressed:
1. Do we understand what consumer/patient focus actually means?
2. What personal and organisational barriers are there to making this
change?
3. Even if we remove these barriers, what active steps do we then need to
take?
Rather than answering these questions in general terms, it would be preferable
to get straight to the role AT has in not only addressing the direct issues of
service delivery, but also in helping both social care and health become positively
patient focused, with subsequent gains in outcome and returns against effort and
spend.
The two main challenges are around how to re-focus what has already started
and how to start with a new focus. And all this with the baggage of our old
habits, no particular training and a system set up to deliver ‘to’ the patient, rather
than ‘with’.
Strategic recommendations:
1. Use AT as a reason to start understanding the complete patient pathway
and acknowledge that the current system is poor in delivering patient
centric actions.
2. AT provides an opportunity for entirely new ways of thinking, allowing us
to take a fresh approach and to challenge old habits.
3. AT goes well beyond purely service delivery, with the process being less
important than the objective, experience and result for patients e.g. how
can we motivate someone to take better care of themselves?
4. There needs to be a realisation that patients hugely impact on the value of
AT outcomes.
5. Ask the right question of patients and do not reinvent the wheel – work
closer with organisations established to support this. We should not ask
vague, open ended questions like ‘what do you need?’ or ‘how could this
be improved?’, but rather ‘what’s stopping your service from being
brilliant?’ and ‘what aspect is not working as well as it could?’ It is easier to
provide solutions to practical negatives, than futuristic positive. It is also
important to remember that patient groups are on catch up as well, with
their voices needing more training and support to give strategically
valuable insights.
6. Accept that although a small part of the Health and Wellbeing journey, our
input can have wide-ranging positive impacts. Promote this fact.
7. Sell the opportunity, but do not suggest AT can ‘replace’ face to face
contact with a professional, but rather that it can dramatically improve the
quality of partnership before the contact, during the contact and after. The
distinct possibility of no longer needing the contact is best seen as a
pleasant result, rather than a key objective.
If we focus on these recommendations, we will become great at asking the right
questions and from this, we can discover the right answers are there waiting to
be given by patients and also by ourselves.
7. Achieving the strategic vision for AT
A strategic delivery plan (see Appendix A) has been developed setting out the
objectives and actions to achieve the strategic vision for AT over the next 3
years. At the moment the plan focuses on 2014-2015 but it will continually be
updated as the AT work programme progresses.
8. Conclusion
This is an exciting time in the delivery of AT in Buckinghamshire; to have adapted
the service from infancy to a fully functional system has been a significant
achievement. However, the greatest test will now be to ensure that this service
continues to deliver the best outcomes for our residents and that they are
assured the support received from us is of an outstanding quality. If the goals set
out in this document can be driven by our service and gain support from our
organisation, there is no reason why we cannot create a financially selfsustaining AT service that continues to pioneer and innovate within the field of
care delivery.
Further reading
http://www.carersuk.org/news/press-releases/carers-missing-out-ontransformative-telecare
Carers UK overview of Telecare access for carers and service users
http://www.telecarelin.org.uk/_library/Resources/Telecare/Telecare_advice/Newsl
etter/Telecare_LIN_eNewsletter_April_2014_Supplement_BCF_Final.pdf
Assisted Living Innovation Platform overview of Telecare health and social care
integration through Better Care Fund (BCF)
http://www.scotland.gov.uk/Resource/0041/00411586.pdf
Scottish Government Telecare and Telehealth Vision 2012-15
http://www.england.nhs.uk/2013/11/15/new-tech-imprv-hlt-serv/
NHS England and Department for Communities and Local Government
Technology Enabled Care Services (TECS) forthcoming 3 year Vision.
http://www.insidecommissioning.co.uk/article/1286743/ccgs-commissionsuccessful-telehealth-services
Inside Commissioning, Tackling Telehealth – How CCG’s can commission
successful Telehealth Services
http://www.kingsfund.org.uk/topics/telecare-and-telehealth/what-impact-doestelehealth-have-long-term-conditions-management
Kings Fund – What impact does Telehealth have on long term conditions
management?
http://www.rsm.ac.uk/academ/downloads/telemedicine.pdf
Royal Society of Medicine eHealth and Telemedicine Section Overview
http://www.telecare.org.uk/standards/telecare-code-of-practice
Telecare Services Association (TSA) Integrated Code of Practice