Strategic intelligence monitor on personal health systems, phase 3 (SIMPHS3) : TDP (United Kingdom), case study report.
Date: 2015-06-15
Institutions: Institute for Prospective Technological Studies
Subjects: United Kingdom, care for the elderly, case study, data collection, elderly person, health care, health care system, health policy, new technology, organisation of health care, public health, research report, telemedicine

 Strategic Intelligence Monitor on 
Personal Health Systems Phase 3 
(SIMPHS3) 

TDP (United Kingdom) 
Case Study Report 

Authors:  
Francisco Lupiañez-Villanueva 
Alexandra Theben 

Editors: 
Fabienne Abadie  
Cristiano Codagnone 

2 0 1 5  

Report EUR 27273 EN 

 
 
 
European Commission 
Joint Research Centre 
Institute for Prospective Technological Studies  

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EUR 27273 EN 

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Abstract  
The  Telecare  Development  Programme  (TDP)  case  in  Scotland  (UK)  is  a  patient-centred  Integrated  Care  management 
process  targeting  the  65+  population  in  the  country.  It  particularly  addresses  vulnerable  subgroups  of  patients  and 
patients with complex illnesses within the 32 communities across Scotland. The TDP case is a funding initiative developed 
between 2006 and 2011 by the Scottish Government in order to  encourage the adoption of the telecare by health and 
social care services. It sought to demonstrate how telecare could contribute to support  the safety and quality of life of 
older  people  and  enable  them  to  live  at  home  longer,  while  significantly  reducing  the  cost  of  health  and  social  care 
services  provisioning.  During  the  period  of  2006-2011,  no  less  than  51  telecare  projects  were  operating  within  all  32 
Communities, covering the whole population of Scotland. The starting point of the TDP case was a change in the policy 
context that required a shift from a healthcare system oriented towards hospital-based treatment to a system based on 
preventive  care  to  manage  long-term  conditions.  TDP  enables  vertical  integration  within  the  Communities  of  Health 
Partnerships (CHPs), but should also promote full integration in a short to medium-term perspective, especially as the new 
legislative  framework  coming  into  force  in  March-April  2015  aims  to  integrate  health  and  social  care  units,  as  a 
consequence of a recent health care spending review.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preface 

The Strategic Intelligence Monitor on Personal Health Systems (SIMPHS) research started in 
2009 with the analysis of the market for Remote Patient Monitoring and Treatment (RMT) 
within Personal Health Systems (PHS). This approach was complemented in a second phase 
(SIMPHS2)  with  the  analysis  of  the  demand  side,  focusing  on  needs,  demands  and 
experiences  made  with  PHS  by  healthcare  producing  units  (e.g.  hospitals,  primary  care 
centres), healthcare professionals, healthcare authorities and patients amongst others.  

Building  on  the  lessons  learnt  from  SIMPHS2  as  well  as  on  the  European  Innovation 
Partnership  on  Active  and  Healthy  Ageing  initiative,  SIMPHS3  aims  to  explore  the  factors 
that  lead  to  successful deployment  of  integrated  care  and  independent  living,  and  define 
best operational practices and guidelines for further deployment in Europe. This case study 
report is one of a series of case studies developed to achieve these objectives. 

The outcomes of SIMPHS2 are presented in a series of public reports discussing the role of 
governance, innovation and impact assessment in enabling integrated care deployment. In 
addition,  through  the  qualitative  analysis  of  27  Telehealth,  Telecare  and  Integrated  Care 
projects  implemented  across  20  regions  in  eight  European  countries  investigated  in 
SIMPHS2,  eight  facilitators  have  been  identified,  based  on  Suter’s  ten  key  principles  for 
successful health systems integration.  

The eight main facilitators identified among these as necessary for successful deployment 
and adoption of telehealth, telecare and integrated care in European regions are:  

Interoperable information systems 

  Reorganisation of services 
  Patient focus 
  Governance mechanisms 
 
  Policy commitment, 
  Engaged professionals 
  National investments and funding programmes, and  
 

Incentives and financing.  

These  eight  facilitators  have  guided  the  analysis  of  the  cases  studied  in  SIMPHS3  and  a 
graphical  representation  with  arrows  whose  length  represents  the  relative  importance  of 
each facilitator is presented in each case study. 

In  addition  to  the  above  facilitators  analysed  in  each  case  report,  a  specific  section  is 
dedicated  to  the  analysis  of  care  integration.  It  should  be  noted  that  the  definition  of 
vertical  and  horizontal  integration  used  in  this  research  is  taken  from  the  scientific 
literature  in  the  field  of  integrated  care1 and  differs  from  the  one  mentioned  in  the 
European  Innovation  Partnership  on  Active  and  Healthy  Ageing  Strategic  Implementation 
Plan2. We define horizontal integration as the situation where similar organisations/units at 
the same level join together (e.g. two hospitals) and vertical integration as the combination 
of different organizations/units at different level (e.g. hospital, primary care and social care). 

1   Kodner, D. (2009). All together now A conceptual Exploration of Integrated Care.  
2   http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/steering-group/operational_plan.pdf (page 27) 

1 

 
 
  
                                                      
Table of Contents 

CASE OUTLOOK .................................................................................................................................................. 4 

1  BACKGROUND ............................................................................................................................................. 5 
SCOTTISH SOCIAL AND HEALTH CARE SERVICES ............................................................................................................ 5 
SCOTLAND (UK) ................................................................................................................................................................... 6 
THE TDP CASE ...................................................................................................................................................................... 7 

1.1 
1.2 
1.3 

2 

INTEGRATED CARE ANALYSIS ................................................................................................................ 8 
DIMENSIONS OF INTEGRATION .......................................................................................................................................... 8 
IMPACT .................................................................................................................................................................................... 9 
DRIVERS AND BARRIERS ................................................................................................................................................... 10 
ORGANISATION, HEALTH PROFESSIONAL AND PATIENTS .......................................................................................... 12 
INFORMATION AND COMMUNICATION TECHNOLOGIES ............................................................................................. 13 
GOVERNANCE ...................................................................................................................................................................... 14 
ORGANISATIONAL PROCESSES ........................................................................................................................................ 16 
REIMBURSEMENT MODEL AND ECONOMIC FLOW ....................................................................................................... 18 

2.1 
2.2 
2.3 
2.4 
2.5 
2.6 
2.7 
2.8 

3  TRANSFERABILITY .................................................................................................................................. 19 

4  CONCLUSIONS ......................................................................................................................................... 20 

REFERENCES .................................................................................................................................................... 23 

ANNEX 1. STATUS OF THE IMPLEMENTATION OF 31 CASES OF TELECARE SERVICES ........... 24 

2 

 
 
 
 
 
LIST OF TABLES 

Table 1:  

Scotland (UK) health care system and demographic characteristics ........................................... 6 

Table 2:  

Telecare services deployment ............................................................................................................................. 9 

Table 3:  

Dimensions of Paradigm Shift ......................................................................................................................... 12 

Table 4:   Weakly costs for the patients .......................................................................................................................... 19 

LIST OF FIGURES 

Figure 1:   Scottish National Health System characterization .................................................................................. 6 

Figure 2:  

Example of ICT integration in the TDP funded projects .................................................................... 13 

Figure 3:  

TDP Governance model ........................................................................................................................................ 15 

Figure 4:  

TDP Integrated care facilitators ...................................................................................................................... 22 

3 

 
 
 
Case outlook 

The  Telecare  Development  Programme  (TDP)  case  in  Scotland  (UK)  is  a  patient-centred 
Integrated  Care  management  process  targeting  the  65+  population  in  the  country.  It 
particularly addresses vulnerable subgroups of patients and patients with complex illnesses 
within the 32 communities across Scotland. The TDP case is a funding initiative developed 
between 2006 and 2011 by the Scottish Government in order to drive the adoption of the 
telecare  by  health  and  social  care  services.  It  sought  to  demonstrate  how  telecare  could 
contribute to the safety and quality of life of older people and enable them to live at home 
longer, while significantly reducing the cost of health and social care services provisioning. 
During the period of 2006-2011, no less than 51 telecare projects were operating within all 
32 Communities, covering the whole population of Scotland. The starting point of the TDP 
case  was  a  change  in  the  policy  context  that  required  a  shift  from  a  healthcare  system 
oriented  towards  hospital-based  treatment  to  a  system  based  on  preventive  care  to 
manage long-term  conditions.  TDP enables vertical integration within the  Communities  of 
Health Partnerships (CHPs), but should also promote full integration in a short to medium-
term perspective, especially as the new legislative framework coming into force in March-
April  2015  aims  to  integrate  health  and  social  care  units,  as  a  consequence  of  a  recent 
health care spending review.  

A key driver of the TDP case is the strong commitment of both the local authority and the 
local  health  and  social  care  actors.  Indeed,  the  most  successful  cases  of  telecare 
implementation were those with well-established Community of Health Partnerships (CHPs), 
capable  of  combining  primary  and  community  services  and  sharing  responsibility  for 
planning  and  delivering  personalised  home  care  assistance.  A  strong  performance 
evaluation culture  can  also  be considered  an important driver  for  the success of the TDP 
funding initiative. Barriers to the diffusion of the TDP case are numerous: lack of equipment 
interoperability;  difficulties  with  respect  to  recruitment  and  training;  lack  of  engagement 
amongst stakeholders in the implementation process; difficulties in understanding the role 
of telecare in wider agendas. 

4 

 
 
 
 
1  Background 

1.1  Scottish social and health care services 

Health  services  in  Scotland  are  largely  free  at  the  point  of  delivery,  available  to  all 
inhabitants and financed through general taxation. The responsibility for health and health-
related  services  lies  with  the  Cabinet  Secretary  for  Health  and  Wellbeing.  The  Scottish 
Parliament, however, plays a huge role in scrutinizing the health system via its Ministers, as 
well  as  through  a  parliamentary  Health  Committee,  Audit  Scotland  and  Health  Care 
Improvement Scotland, within a broadly held National Performance Framework. Next to the 
National  Health  System  there  is  a  private  not-for-profit  health  care  sector,  which  is 
independent and financed through private contributions. It comprises 7 acute medical and 
surgical  hospitals,  10  mental  health  hospitals  and  clinics,  15  voluntary  hospices  and  2 
specialist clinics.  

The  Scottish  Government  determines  the  allocation  of  the  budget  between  the  NHS  and 
other  social  services,  such  as  education  and  sport.  Once  the  budget  is  split,  the  Cabinet 
Secretary,  advised  by  the  Scottish  Government  Directorate  for  Health  and  Social  Care, 
decides on the deployment of the funds allocated to health and social care and monitors its 
use. The Scottish Government Directorate for Health and Social Care retains responsibility 
for  health  and  social  care  policy,  while  managing  the  NHS  and  monitoring  social  care 
services  as  provided  by  local  authorities,  as  well  as  private  and  third  sectors.  This 
Directorate is led by a Director General who is also the Chief Executive of the NHS, and who 
is  supported  by  professional  advisers.  The  Directorate  defines  objectives  and  policies  for 
health protection, sets targets, provides a statutory and financial framework for the NHS. It 
also intervenes in  the event of problems or  deficiencies  at local level.  Most  of the  health 
budget is distributed among 14 geographically-based NHS boards that are in charge of the 
planning and delivery of services in order to meet the healthcare needs of the population 
living in each region. The NHS boards retain significant powers in terms of patterns of local 
care provision and the setting of local priorities.   

The boards provide strategic leadership and performance management of the entire local 
NHS system. Responsibility for service delivery is delegated to operating divisions for acute 
services  and  to  specific  committees  (CHPS)  for  community  and  primary  care  services. 
Through  the  CHPs,  the  boards  engage  in  contracts  with  independent  professionals  in 
primary  care,  such  as  GPs,  dentists  or  community  pharmacists,  who  are  reimbursed  in 
accordance to the services provided by them for the NHS.  

In  addition,  there  are  nine  national  bodies  in  charge  of  services  provided  to  the  entire 
country, which are in turn supported by territorial boards. These focus on delivering services 
best  provided  by  a  single  entity,  e.g.  ambulance  transport,  information,  education  and 
training, as well as quality improvement.  

However, there is no purchaser-provider split applicable in the system. Most of the primary 
care providers function as independent contractors and are reimbursed in accordance with 
their specific contracts for the services provided. The NHS boards employ the staff working 
in hospitals and in the community directly on a salary basis.  

5 

 
 
 
 
 
Figure 1: Scottish National Health System characterization 

1.2  Scotland (UK) 

Source: Steel & Cylus (2012) 

Scotland has a territory of about 78,387 km2 and a population of 5.2 million habitants, with 
a density of about 67 habitants per km2. It is located in the North of the United Kingdom. 
Scotland has an annual GDP of more than €166 billion, with an annual GDP per capita of 
€31,569.  The  average  age  of  the  Scottish  population  is  about  44  years,  with  17%  of 
individuals above the age of 64.  Current projections suggest that the population will age 
significantly,  with  the  number  of  people  aged 65  and  over  increasing by  59%,  from  0.93 
million  to  1.47  million  by  that  time.  The  key  characteristics  of  the  health  care  system  in 
Scotland are summarised in Table 1. 

Table 1: Scotland (UK) health care system and demographic characteristics 

Geographical coverage km2 
Inhabitants per km2 
Number of inhabitants 
Life expectancy at birth years 
Regional GDP (2012) billion € 
Regional GDP per inhabitant (2012) €/inhabitants 
General Practitioners /1.000 inhabitants (2010) 
Specialists /1.000 inhabitants (2010) 
Regional Budget for Health services management (2013) billion € 
Health care professionals / 100.000 inhabitants 
Regional health care budget € per inhabitants (2013) 
Hospital beds (2012) 
Hospital beds/1.000 habitants (2012) 

78,387 
67 
5,254,800 
80.09 males – 85.1 females 
166  
31,590  
0.79 
1.94 
10  
294 
1,903 
24,800 
4.7 

Source: Scottish Government – Health and Social care 

6 

 
 
 
1.3  The TDP case  

The Telecare Development Programme (TDP) case is a funding initiative developed over a 
period of six years  (2006  – 2011)  by the Scottish Government in  order  to encourage  the 
adoption of telecare by local health and social care providers. It sought to demonstrate how 
telecare could contribute to the safety and quality of life of older people and enabling them 
to live at home longer, while significantly reducing costs of health and social care services 
provisioning. Simultaneously, the local governments of England, Wales and Northern Ireland 
engaged in promoting similar initiatives.   

The objective of the TDP funding initiative was to encourage the 32 local communities of 
Scotland to develop an integrated care approach that would enable a shift from a hospital-
based system to a system funded on preventive care to manage the long-term conditions 
of the ageing population.  

The strategy behind the TDP funding initiative envisaged the rethinking and reorganisation 
of the existing home care services by means of a two-step funding programme. The first 
funding  programme  (2006-2008)  aimed  to  distribute  an  average  amount  of  about 
£100,000  to  each  initiative  addressing  the  specifications  of  the  bid.  The  second  funding 
programme  (2008-2011)  targeted  projects  in  which  the  developments  made  were 
considered  satisfactory  and  where  the  new  funding  scheme  was  based  on  the  degree  of 
the mainstreaming potential of the cases.  

The objectives of the funding strategy were twofold: in the first wave of funding, the TDP 
initiative aimed to motivate all local communities to adopt integrated home care initiatives. 
The second funding wave aimed to provide adequate pre-conditions for effective uptake of 
initiatives with high potential of diffusion across the entire local population. 

From  this  perspective,  the  TDP  case  study  is  an  interesting  example  of  how  a  fully 
committed national government, in strict collaboration with its national health system, has 
developed an integrated care approach with its own funds and capabilities that is currently 
being  spread  across  the  whole  country,  with  significant  mainstreamed  examples  and 
important achievements that in the short/medium-term perspective could lead to structural 
changes in the entire health care system of Scotland.  

The  full  list  of  co-funded  projects  represents  an  overall  amount  of  £8.35  million  for  the 
period 2006-2008, provided by the Joint Improvement Team (JIT, 2008). An additional £8 
million were made available to these initiatives during the period of 2008-2010 as capital 
funding to secure further mainstreaming of telecare services.  

The  initiative  of  Renfrewshire  Telecare  Service  serves  an  as  interesting  example  that  is 
considered by both JTI (2013) and University of York (2013) as one of the cases with better 
chances of diffusion across the whole local context. 

The Renfrewshire telecare service was approved in 2006 by the Scottish Executive Telecare 
Development Funds (TDP) with funding of £241,000. It was provided by the Renfrewshire 
Council and integrated into the existing Community Alarm Service. The local Council agreed 
to  mainstream  the  service  when  the  TDP  funding  ceased.  In  January  2008,  the  local 
Community  Alarm  and  Telecare  Service  became  part  of  the  new  service  called 
“Renfrewshire Care 24”. The service comprises care and support for vulnerable people that 
enables them to live at home as long as possible. During April 2012, the service achieved 
platinum member status in all elements of service provided including referral, service user 

7 

 
 
profiling,  installation  and  response.  Currently,  Renfrewshire  Care  24  works  in  partnership 
with the NHS, and with housing and independent services.  

2  Integrated care analysis 

2.1  Dimensions of integration 

The  target  population  addressed  by  the  initial  TDP-funded  projects  comprised  elderly 
people in Scotland, who represent about 17% of the overall population of 65 years or older, 
10% of whom are officially diagnosed to have dementia. During the period of 2006-2011, 
about 44,0003 users benefited from the services provided by the telecare projects funded 
under  the Telecare Development Programme Initiative. The 51 funded  projects addressed 
Integrated Home Care Management in several domains, such as:  

  Use of medication dispensers (Aberdeen, Falkirk, Fife and Renfrewshire). 
  Falls  management  programmes  (East  Ayrshire,  Edinburgh,  Falkirk,  Fife,  Perth  & 

Kinross and South Ayrshire). 

  Chronic  Obstructive  Pulmonary  Disease  (COPD)  projects  (Inverclyde,  Moray,  North 

Lanarkshire, Renfrewshire, Stirling and West Lothian). 

  Home pod units (Argyll & Bute).  
  Diabetes monitoring (Edinburgh).  
  Childhood obesity management (West Lothian).  
  Fitness in older people (Moray). 

In  all  the  above  cases,  the  TDP-funded  projects  considered  vulnerable  subgroups  of 
patients and patients with complex illnesses. The main target pathologies considered by the 
projects under the TDP funding initiative were chronic disease, cognitive impairment, frailty 
and related comorbidities. The characteristics of the telecare cases implemented under the 
TDP funding scheme present several types of integration. The most important one is service 
integration,  which  becomes  evident  when  looking  at  the  majority  of  the  TDP-funded 
projects, given that most of them strived to integrate the entire home care service delivery 
chain. To this end, each local community supports the integration of the health and social 
care professionals. In the most successful cases, innovative ways were found to cooperate 
and sometimes organisational integration among health and social care organisations was 
possible.  For  example,  the  Renfrewshire  community  established  as  a  result  of  the 
Renfrewshire  24  initiative,  partnerships  among  the  local  NHS,  representing  district  and 
practice  nurses  and  primary  care  organisations,  housing  and  independent  services.  It  is 
important to note that service integration, and organisational and professional integration 
will  play  an  ever  more  important  role  when  the  new  legislation,4 which  aims  to  integrate 
health and social care, comes into force at the beginning of 2015. 

All the TDP-funded telecare services initiatives further promoted vertical integration among 
the local health and social care actors. To this end, especially in the mainstreamed projects, 

3   JIT  (2010)  and  JIT  (2011)  report  that  in  the  period  2006-2010  the  number  of  people  benefitting  from  the  service 

4  

were 29,000 (of which 7,300 subsequently abandoned the programme).  
i.e.  “Joint  Working  (Scotland)  –  Act 2014  which  “is  seen  as  a  framework  to  support  improvement  in  the  quality  and 
consistency in the delivery of health and social care services in Scotland  – to be achieved through formal integration 
of services for adults….”. In particular the Regulation and Orders section of the Act sets out: “those functions of a Local 
Authority that must be delegated in support of the integration of health and social care services. 

8 

 
 
                                                      
the local hospitals, practice nurses and GPs have developed clear protocols of co-operation 
that  facilitate  coordination  between  hospital  discharge  and  home  care  service  from  the 
primary  care  professionals.  At  the  same  time,  primary  care  professionals  act  as  multiple 
sources of contact for monitoring the health status of patients at home, in order to avoid 
unplanned  emergency  admissions  to  the  local  hospitals.  In  the  current  mainstreamed 
Integrated Home Care Services funded by the TDP scheme, no evidence could be found of 
horizontal  integration  across  the  care  actors  of  the  same  tier.  All  the  TDP-funded  cases 
analysed  have  a  medium  degree  of  integration,  which  underlines  the  presence  of  strong 
organisational  and  professional  cooperation  among  the  health  and  social  care  actors 
operating  in  the  Integrated  Home  Care  management  initiatives.  No  evidence  of  resource 
sharing among the actors involved in the service provisioning could, however, be identified. 
Full integration appears to be achievable in the short to medium-term, taking into account 
the  legislative4  changes  anticipated.  The  following  table  summarises  the  level  of 
deployment of the 32 local partnerships at the end of the first funding period (2006-2009). 
The scale used ranges from 1-10, measuring the extent to which the 32 local partnerships 
had embedded telecare services into various key processes and services, ranging from 1 = 
“not  started  yet”  to  10  =  “already  completed”.    Only  22%  (6  of  32)  of  the  projects  were 
mainstreamed (score 9 and 10 in the table) at the end of the funding period, and 5 of them 
addressed  care  at  home  services,  of  which  only  2  aimed  to  manage  long  term  care  and 
dementia. 

Table 2: Telecare services deployment  

Source: JIT (2010) 

2.2  Impact 

Impact evaluation of the TDP funding programme was conducted both at national and local 
level during the entire implementation period. Despite the lack of counterfactual evidence, 
the  JIT  (2010)  published  the  following  statistics  of  the  TDP  outcomes  for  the  period  of 
2006-2010, derived from the 51 TDP-funded cases: 

  1,500 hospital discharges avoided. 
  6,600 hospital admissions avoided. 

9 

 
 
 
 
  2,650 care home admissions avoided. 

The  JIT  estimated  that  the  overall  savings  of  the  TDP  initiative  during  the  period  2006-
2010 reached about £48.4 million. That means about net savings of £2,230 per patient in 
the period (£446/patient/year). 

However,  it  is  important  to  note  that  most  of  these  savings  are  only  nominal,  unless 
structural changes in the health and social care systems are implemented and the number 
of hospital beds reduced.  

Moreover,  the  JIT  (2011)  reported  that  in  overall  terms,  19%  of  the  people  aged  65  or 
more in  the 32 local communities  were using community alarm  systems, 3.5% had more 
sophisticated social care packages and 1% (about 1,000 individuals) could benefit from a 
telehealth  package  by  that  time.  A  total  of  44,000  of  these  people  had  been  engaged 
through the TDP initiative. 

Another  interesting  evaluation  of  the  TDP  funding  initiative  was  a  five  year  evaluation 
process performed by Newhaven Research (2011). It reported a total cost of £19.5 million 
of the telecare projects, of which TDP funding covered £13.6 million. The number of users 
covered was around 44,000 people, but around 13,000 of these subsequently stopped the 
services5. The estimated net savings in the five years under observation amounted to about 
£78 million (£1,770 in five years or £355/year per user) although the report stressed that 
the achieved impacts have to be regarded as purely hypothetical, unless structural changes 
within the Scottish local government are implemented. 

2.3  Drivers and Barriers 

Drivers of the TDP funding initiative largely depend on respective local characteristics and 
contexts.  However,  the  literature  review  underlined  that  in  terms  of  mainstreamed  TDP 
funded  initiatives,  the  key  driver  was  strong  commitment  from  both  local  authority  and 
local health and social care actors.  

It  was  further  recognised  that  the  most  successful  cases  of  implementation  were  those 
with  well-established  Community  of  Health  Partnerships  (CHPs)  that  would  be  capable  of 
combining  primary  and  community  services  with  a  shared  responsibility  for  planning  and 
delivery  of  personalised  home  care  assistance.  A  strong  performance  evaluation  culture 
was  also  an  important  driver  for  the  success  of  the  TDP  funding  initiative.  This  became 
evident  in  the  funding  allocation  process  organised  by  the  Scottish  Government  to 
stimulate the implementation of funded initiatives. In particular, initial funding distribution 
to all 32 local communities across Scotland was based on the compliance  of the funding 
requests to the bid specifications. It followed that during the first 3 years (2006-2007) of 
implementation,  the  evaluation  conducted  by  the  Scottish  Government  aimed  to  identify 
whether  funded  projects  could  be  mainstreamed.  The  most  successful  projects  received 
funding from the National Government under the TDP initiative for another 3 years (2008-
2011), so that these initiatives could reach critical mass, ensuring the sustainability of the 
services  once  the  funding  ceased.  The  degree of  funds  allocated  in  this  respect  reflected 
the  proportional  stage  of  development  of  the  projects.    Thus,  only  5  of  the  32  local 
communities received the maximum level of funding during the second funding period. 

5   JIT (2010) reports a figure of over 29,000 (7% with dementia, but the number is considered underestimated) people 
that  began  a  telecare  service  through  the  TDP  funding  over  the  period  2006-2010.  Over  the  whole  period  around 
7,300 (25%) subsequently stopped receiving a service. 

10 

 
 
                                                      
Barriers  for  the  implementation  of  TDP-funded  initiatives  are  also  largely  influenced  by 
local  context  characteristics.  Barriers  can  be  divided  into  two  groups  depending  on  the 
stage of development of the funded project: implementation stage and mainstream stage 
in the local community. The most important barriers of the implementation stage comprise: 

  Lack of clarity about expected outcomes. This is a typical barrier that highlights 
the lack of cohesion among the local health and social care players in agreeing on 
expected  results  of  the  project.  This  disagreement  in  many  cases  hindered  the 
achievement  of  a  strong  commitment  among  the  parties  involved  and  led  to 
unsuccessful implementation of the initiatives in question. 

  Limited,  inconsistent  or  poor  project  management.  Inadequate  project 
management  is  another  important  barrier  to  the  implementation  of  the  telecare 
projects,  especially  in  those  initiatives,  where  the  care  organisations  involved 
maintained control  over their staff members within the implementation team.  The 
most successful telecare projects, however, were those with fully established CHPs. 
In  these  cases,  the  main  local  care  actors  perform  previously  agreed  roles  and 
responsibilities in the project implementation within the CHPs. The manager of the 
CHP would in most cases be in charge of the management of the funded initiative 
on integrated home care. 

  Lack of cluster sponsorship/engagement by senior decision makers. This is a 
typical barrier arising from care managers' resistance to change.  They perceive the 
new,  more  integrated  initiative  as  a  dangerous  situation  for  their  established 
organisational  power.  Again,  the  most  successful  initiatives  funded  had  well 
established CHPs, where the organisational barriers across local health care actors 
where already to a large extent overcome. 

  Fear of the consequences of “getting it wrong”. This barrier was a problem in 
cases,  where  weak  project  management  coupled  with  limited  telecare  skilling 
capabilities  in  the  project  team,  have  hindered  the  possibility  to  implement  an 
integrated home care service re-design. 

  No  clear  purchasing  scheme  and  difficulties 

in  risk  sharing  of 
implementation  cost.  This  barrier  produced  significant  delay 
the 
implementation of the local initiatives and in some cases stopped their development 
entirely.  

in 

The  barriers  that  have  been  identified  during  the  telecare  project  mainstreaming  process 
comprised: 

  Lack of equipment interoperability, equipment reliability and infrastructure 
gaps. These barriers were mainly a consequence of limited skills, or lack of them, in 
the  project  team  for  telecare  service  re-design,  that  in  many  instances  failed  to 
provide  technical  specifications  to  direct  technological  providers  to  find  solutions 
supporting  interoperability  with  the  existing  legacy  systems,  and  to  provide 
technological  solutions  with  a  high  degree  of  reliability  in  real  conditions  of  use. 
Infrastructural gaps, mainly related to the lack of connectivity and bandwidth, also 
represented important barriers to the successful mainstreaming of telecare projects. 
These gaps have made it impossible to provide integrated home care services to the 
local target population accordingly. 

  Lack  of  engagement  among  stakeholders  in  the  implementation  process. 
This  important  barrier  was  due  to  the  lack  of  strong  vertical  integration  among 

11 

 
 
primary  care providers, social  care  organisations  and secondary  care  units.  On  the 
other  hand,  the  most  successful  mainstreaming  initiatives  had  well  established 
CHPs,  which  were  fully  entitled  to  drive  integrated  home  care  service  processes 
forward and to facilitate collaboration amongst all the local care actors.  

  Limited  commitment  to  telecare  from  senior  managers  is  a  continuing 
problem. In some cases, telecare projects have been implemented successfully, but 
local  senior  managers  lack  interest  in  transforming  the  project  results  into  fully 
sustainable  services.  It  can  be  assumed  that  the  main  reason  for  this  is  the 
additional  effort  needed  on  the  part  of  the  local  actors  in  terms  of  level  of 
organisational integration, and the promotion of structural changes in the local care 
processes  that  could  imply  permanent  shift  of  balance  of  care  from  secondary  to 
primary providers in the management of long-term conditions for older people.   
  Difficulties  with  respect  to  recruitment  and  training,  which  in  the  new  care 
services provided, constitute a fundamental element for success and sustainability 
of the telecare initiative. It is highly related to commitment and implies the need to 
define  adequate 
into  account  the  additional 
responsibilities  that the new  health care service delivery  processes demand of the 
primary care actors.   

incentive  schemes  that  take 

2.4  Organisation, health professional and patients  

In general terms, the organisational models implemented in the 51 TDP-funded projects of 
the 32 Scottish local partnerships are based on the paradigm summarised in the following 
Table 3. 

Table 3: Dimensions of Paradigm Shift  

Source: Sergeant (2010) 

The  key  elements  of  the  new  paradigm  are  the  preventive  care  actions  to  reduce 
emergency  situations  in  long-term  chronic  disease  management.  To  this  end,  integrated 
services among primary, secondary and social care are implemented so as to guarantee a 
continuum of care for patients across different tiers of care. 

Following the above principles, in most of the TDP-funded initiatives, GPs and nurses played 
a pivotal role in guaranteeing multiple points of access to the care system. Moreover, the 
telecare technologies made important contributions to continuously monitoring patients at 
home  and  to  preventing  emergency  visits.  These  new  and  more  integrated  ways  of 
providing  care  services  require  a  multidimensional  team  composed  of  GPs,  nurses,  social 

12 

Summary of Telecare Services - March 2010                          7 4.0 The Telecare Development Programme in Context  From the 1990’s, with the introduction of Community Care, the national agenda in Scotland has established a strong commitment to supporting people within their own homes and local communities.  A significant number of policy documents, linking the use of technologies to service redesign and improvement have been published since 1998, with such publications becoming more prevalent in recent years.  A National Framework for Service Change in the NHS in Scotland (2005); Managing Long-term Conditions (2007); Better Health, Better Care; Action Plan (2007); Seizing the Opportunity: Telecare Strategy 2008-2010 (2008); The NHS eHealth Strategy (2009), all emphasis the need to address the increasing demands on service provision; resulting from the demographic changes and the need to develop innovative models which encourage and promote self-care and self management.  The model of change promoted through Delivering for Health (2005) advanced the shift from reactive service provision to proactive intervention (see Fig. 1).  This model promoted an approach to individual need, including the user in decision making and active intervention, utilising a process of education and use of technology to develop self-care and self-management of their own condition.    Fig.1 – Dimensions of Paradigm Shift indicated in Delivering for Health (2005)  Whilst the emphasis in earlier policy documentation was on the provision of health service redesign, there were a number of local authorities beginning to explore the potential use of telecare, through pilot projects, building on the platform of established Community Alarm Services.  The evidence which was collected from such pilot projects was limited and considered too restricted to provide a significant evidence base (Alaszewsji A and Cappello R 2006).  The limited evidence base did however indicate the potential use of telecare as a tool in assisting the increasing challenge of meeting need in a changing service environment, promoted by the demographic changes and users wish to remain within in their own homes, where possible.  It was recognised that to achieve widespread implementation of technologies across the country, and an evidence base of the benefits of the application, there was a need to provide investment, from a Government perspective.   
 
 
care providers and social housing representatives. The main  advantage of these teams  is 
that  they  set  up  and  follow  more  personalised care  processes  that  take  into  account  the 
needs of both patients, families and caregivers.  

The role of health care specialists and hospital doctors in the new care process is important, 
albeit limited to the validation of the diagnosis of chronic conditions of patients provided by 
care teams, and the definition of personalised home care pathways to be followed within 
long-term disease management processes.  

In  the  more  successful  initiatives  mainstreamed  in  the  local  communities,  CHPs  played  a 
fundamental  role  in  ensuring  cooperation  between  tiers  of  care,  and  they  stimulated  the 
information-sharing  between  all  actors  involved  in  the  care  process  management.  In 
particular,  the  most  advanced  cases  found  solutions  to  stabilise  the  telecare  teams  in 
permanent organisations set up through partnerships of local health and social care actors. 
This  was  the  case  of  the  Renfrewshire  telecare  services,  which,  together  with  the  local 
community alarm, formed the new service under Renfrewshire Care 24 as soon as the TDP 
funding ceased. It was set up as a partnership amongst local NHS, representing the primary 
care  professionals,  (GPs,  district  and  practices  nurses)  and  the  housing  and  independent 
service departments of the local government. 

2.5  Information and Communication Technologies  

The telecare technology used in TDP-funded telecare projects had an important impact on 
implementing and mainstreaming sustainable services. Figure 2 depicts the different roles 
performed by technology in TDP-funded telecare initiatives. 

Figure 2: Example of ICT integration in the TDP funded projects 

Source: SSAC, 2009 

The figure illustrates how technology performs four specific roles in telecare services:  

  Sensors  and  triggers.  These  are  fundamental  for  automatic  monitoring  of  the 
environmental  conditions  of  patients’  homes  and  for  preventing  risks  (e.g.  if  the 
the  house  without  warning,  uses  home  appliances 
patient  falls, 
unexpectedly).  The  use  of  these  technological  tools  can  reduce  the  workload  of 

leaves 

13 

 
 
 
 
formal and informal careers, while at same time increasing the  amount of context 
and patient-related information that can be used to prevent risks.  

  Feedbacks and controls are technological tools that perform two main functions. 
On  the  one  hand,  they  pre-process  information  collected  by  the  sensors  and 
subsequently trigger  specific  countermeasures in  the most  advanced technological 
configurations (e.g. turn off the natural gas if the sensor detects an increasing level 
within the home environment), or inform the alarm handling and monitoring centre 
through the home gateway. On the other hand, they manage recovery actions based 
on feedback received from the monitoring centre.  

  Home  gateway  is  an  interoperable  tool  that  guarantees  interaction  between  the 
sensors,  the  triggers  and  the  home  controls  system,  and  the  alarm  handling  and 
monitoring centre.  

  Alarm  handling  and  monitoring  centre  technological  facilities.  They 
constitute  the  heart  of  the  telecare  system,  where  all  the  patients’  and  home 
environment information are processed and provided to the relevant care actors for 
immediate recovery actions. 

The  51  cases  of  TDP-funded  projects  (see  Annex  1)  have  developed  the  above 
technological  features  to  different  degrees.  In  some  cases,  the  technological  choice  was 
focused  on  the  purchase  of  novel  triggers  and  sensors  that  would  enable  assistance  to 
more  patients  through  integrated  home  care  services.  This  occurred  in  local  communities 
where the telecare services were already in place and the alarm handling and monitoring 
centre  already  operational  (e.g.  in  Angus;  Argyll&Bute;  East  Ayrshire;  Glasgow  city;  Moray; 
and Renfrewshire). 

In some other cases, the projects allocated their funding to establishing an alarm handling 
and monitoring centre and to supporting a few cases of telecare home assistance to test 
the  new  integrated  care  management  approaches  (e.g.  in  the  City  of  Edinburgh;  Fife; 
Highland; Inverclyde; and South Lanarkshire). Further cases looked at the technology  used 
in equipping social houses with telecare (e.g. in Aberdeen city case and Western Isles). 

Lastly, some cases preferred to limit or disregard the purchase of technology and instead 
concentrated  their  funding  on  the  training  of  care  professionals  and  the  setting  up  of 
integrated  care  service process  from  an  organisational  point  of  view  (e.g.  in  Dundee  City; 
East Lothian; and East Renfrewshire). 

Thus,  in  terms  of  technology  used  in  the  TDP-funded  projects,  it  can  be  concluded  that 
there  are  telecare  and  telehealth  systems  that  support  patients  and  professionals  by 
reducing  emergency  admissions  to  hospitals  and  at  the  same  time  guarantee  24/7 
monitoring  of  patients,  without  increasing  the  workload  of  the  carers.  Nevertheless,  no 
evidence  of  interoperable  information  systems  to  enhance  the  communication  across  the 
continuum  of  care  could  be  found.  The  information  collected  on  patients,  their  home 
environments  and  care  procedures,  is  not  automatically  shared  between  primary  and 
secondary care units, even if monitored by the alarm handling and monitoring centre. 

2.6  Governance 

To understand how the governance of the TDP case has been organised, it is necessary to 
distinguish  between  the  TDP  funding  allocation  management  process and  the  design  and 
development of TDP-funded projects. 

14 

 
 
The  governance  of  the  funding  process  is  mainly  the  responsibility  of  the  Scottish 
Government  (Scottish  Government  Health  and  Social  Care  Directorate)  that  acted  as 
promoter  and  founder  of  the  initiative.  Since  2006,  it  allocated  about  £20  million  to 
stimulate  the  diffusion  of  telecare  practices  across  Scotland.  Additional  funds  were 
allocated by the Government to mainstream the most promising initiatives of the 32 local 
partnerships as established in the preceding period. The second national governance actor 
of  the  initiative  is  NHS  Scotland,  which  represents  the  health  care  actors  involved  in  the 
telecare  service  delivery  processes.  In  the  governance  of  the  TDP  funding  initiative,  it 
performed  an  advisory  role  in  relation  to  the  choice  of  the  projects  to  be  funded  and  in 
terms of assessment of the results achieved. 

The design and development of TDP-funded projects depends largely on the local context in 
which the telecare projects are implemented. In general terms, the main players comprise: 
the  housing  and  social  care  departments  of  the  Local  Councils,  which are  responsible  for 
the  social  service  delivery  to  the  local  communities;  the  local  NHS  organisations  that 
represent the health care professionals (GPs, district and practices nurses, hospital doctors 
and specialists) in charge of service provisioning. Together, they promoted and designed the 
telecare  project  to  be  funded  by  the  National  Government  and  helped  drive  its 
implementation  in  the  local  contexts.  In  more  advanced  situations,  this  governance 
underpinned  the  establishment  of  the  Communities  of  Health  Partnerships  (CHPs).    Their 
task is to facilitate the integration of primary care, specialist services and social care so as 
to ensure that TDP-funded projects meet the objectives set for them.  

The following figure sketches the governance model. 

Figure 3: TDP Governance model 

Source: Authors' elaboration 

15 

 
 
 
 
 
Enabling organisations that the National Governance used to steer the initiative comprise: 

Scottish Centre for Telehealth and Telecare (SCTT). The Scottish Centre for Telehealth 
and  Telecare  was  established  to  support  and  guide  the  development  of  telehealth  and 
telecare  throughout  Scotland  and  forms  part  of  NHS  24.    The  Centre’s  role  is  to  provide 
support  and  advice  to  all  these  key  stakeholders,  and  to  help  evaluate  the  potential 
benefits of new technologies, with the view to making Scotland a recognised global leader 
in telehealth and telecare. Specifically, its tasks comprised: 

  Disseminating best practice. 
  Providing practical support, both clinical and technical. 
  Co-ordinating the evaluation of projects. 
  Evaluating the impact of telehealth and telecare on service redesign. 
  Developing inter-operable standards and protocols. 

Joint  Improvement  Team  (JIT). The Joint Improvement Team  is a partnership  between 
the  Scottish  Government,  NHS  Scotland,  the  Convention  of  Scottish  Local  Authorities 
(COSLA),  and  the  Independent  and  Housing  Sector.  It  provides  a  range  of  practical 
improvement  support  structures,  including  knowledge  exchange,  development  innovation, 
improvement capacity and direct practical support to local health, housing and social care 
partnerships  across  Scotland,  in  order  to  implement  the  innovative  care  approaches, 
including those related to Telecare services. 

National Telehealth and Telecare Advisory Board (NTTAB) established by the Scottish 
Government to drive forward the telecare agenda. NTTAB was primarily responsible for the 
strategic development of the National Telecare Programme. The Board is made up of senior 
members  of  the  main  stakeholders  of  the  telecare  programme  (e.g.  Carers  Scotland; 
Chartered  Institute  of  Housing,  JIT;  Scottish  Centre  for  Telehealth;  Telecare  Service 
Association; Scottish Government; NHS24). The Board advises and supports Senior Officers 
in the management of the Telecare Development Fund. 

Telecare  Services  Association  (TSA).  The  Telecare  Services  Association  (TSA)  is 
the industry body  for  telecare and telehealth,  and the largest industry-specific  network in 
Europe.  It is a not-for-profit, membership-based organisation, with a current membership 
of over 370 organisations. TSA promotes and supports the telecare and telehealth industry, 
highlighting  the  benefits  of  telecare  and  telehealth  for  commissioners  across  health  and 
social  care,  service  users,  their  families  and  carers.  The  TSA  is  the  nationally  recognised 
Standards Body for the delivery of technology-enabled care and support services for both 
telecare  and  telehealth  in  the  UK.  It  has  facilitated  the  development  of  a  new  technical 
standard  –  BS8521,  which  seeks  to  further  enhance  the  interoperability  of  telecare 
products.   

2.7  Organisational processes 

After  the  implementation  of  the  TDP  funding  initiative,  the  organisational  processes 
underpinning local telecare services in Scotland have been reorganised, especially in those 
cases  where  the  funded  projects  were  due  to  become  mainstream  services  for  the  local 
communities. As already discussed in §2.4, the new organisational model implemented by 
the  TDP  funding  initiative  is  influenced  by  the  paradigm  shift  from  hospital  care 
management-centred  processes  to  more  patient-centred  processes.  This  was  apparent  in 
most  examples  of  TDP-funded  project  implementation,  but  especially  in  those  initiatives 

16 

 
 
which were mainstreamed at local level after the funding period expired. In these cases, the 
integrated home care processes for chronic disease management can be organised in four 
main steps: referral, assessment, installation and service provision: 

1.  Referrals.  With  the  TDP  funding  initiative,  this  area  has  been  improved 
significantly. To some extent, it can be regarded as the most important step in the 
chronic disease home care management process, as it aims to identify people who 
are at high risk of emergency admission to hospital, and who therefore really need 
home telecare services. In the reorganised chronic disease management process, a 
given  patient's  need  for  the  telecare  service  can  be  assessed  by  various 
organisations  and  professionals,  such  as  a  Social  Work  Area  Team,  Housing  and 
Housing  Associations,  the  Local  Health  System,  GPs,  district  and  practices  nurses, 
etc.  All  of  them  function  as  multiple  points  of  access  to  the  telecare  service,  and 
increase the possibility of providing quality telecare service to the patients and thus 
avoid or delay hospitalisation.  

2.  Assessment  of  the  potential  service  user.    This  task  is  organised  by  the 
telecare service coordination unit. This can be a permanent dedicated team as in the 
case  of  Renfrewshire  24,  or  by  a  team  composed  of  both  health  and  social  care 
professionals  who  belong  to  different  organisations,  as  in  the  case  of  Moray 
Community. In any case, the assessment of the potential user of telecare services is 
undertaken  by  a  multidisciplinary  team  that  uses  a  shared-needs  assessment 
protocol to evaluate the multiple facets of the needs for assistance of patients and 
their  families.    This  step  in  the  telecare  management  process  has  been  renewed 
with  the  TDP-funded  projects,  and  it  allows  a  more  integrated  evaluation  of  the 
patient through health and social care operators. The main advantages of this step 
are to make assistance services more personalized to the patient and to reduce the 
coordination costs among the organisational units in charge of service configuration 
and delivery. The assessment of patients’ and their families’ needs also includes a 
visit by the Assessment Team to patients’ homes to discuss the available options, so 
as  to  provide  a  tailor-made  package  of  telecare  equipment  and  explain  the 
installation processes in detail.  

3.  Set-up. This step simply entails the installation of the agreed equipment, which is 
undertaken by qualified engineers. The equipment is routinely  checked by the local 
organisation in charge of the telecare service delivery. No significant changes have 
been made in the framework of TDP-funded projects for this step. 

4.  The  last  step  is  the  provision,  24  hours/365  days  per  year,  of  the  following 

services: 
  Community Alarm and Telecare Services. This is the standard service offered by 
the  telecare  management  process.  When  an  alarm  is  raised,  the  service  is 
mainly provided by a minimum of two volunteer key holders living close to the 
patient.  In  addition,  the  community  care  assistant  nurses  who  provide 
intermediate care also offer a telecare response service whenever possible. The 
use of key safes, where deemed appropriate, complements the voluntary nature 
of  these  particular  response  mechanisms.  Where  an  emergency  or  crisis 
situation has been confirmed by the contact centre staff and no volunteer key 
holders are available to attend an incident, then response will usually default to 
the relevant emergency service. 

  Additional  non-standard  services  provided  under  the  telecare  management 

processes comprise: 

17 

 
 
o  Single  Point  of  Access  –  this  provides  a  single  entry  point  to  Intermediate 
Care  Services  in  the  local  community  (e.g.  Care  Homes  and  Day  Centres; 
Department  of  Medicine  for  the  Elderly  Day  Hospital;  GPs;  Nurses;  Hospital 
Consultants;  Psychogeriatric  Day  Hospital;  Social  Work  Area  Teams;  Social 
Work at Royal Alexandria Hospital. 

o  Rapid  Response  –  this  joint  health  and  social  care  service  can  provide 
personal care, domestic services and housing support for up to two weeks to 
help  a  person  remain  in  his  or  her  own  home  after  an  emergency  and  to 
prevent further referral to the hospital. 

o  Out  of  Hours  Homecare  Management  Support  –  this  service  includes 
assessment  of  needs,  arranging  care  services,  responding  to  enquiries  or 
problems  and  supporting  staff  with  any  difficulties  in  delivering  planned 
care. 

o  Overnight  Homecare  –  this  service  provides  personal  care  and  support, 
domestic  service  and  housing  support  tasks  between  10pm  and  6am,  365 
days a year. 

The  four  step  process  for  chronic  disease  home  care  management  process,  organised 
through  the  TDP  funding  initiatives,  enables  a  very  high  degree  of  integration  between 
health and social care services, at least in the local communities, where the projects were 
mainstreamed  after  the  funding  period.  Moreover,  it  is  evident  that  the  new  services 
provide  a  continuum  of  care,  where  all  the  actors  can  act  as  point  of  contacts  to  both 
continuously assess the patients’ and their families’ needs, and raise warnings to support 
the  telecare  management  team  on  a  personalised  service.  Vertical  integration  is  ensured 
across  primary and secondary care, thanks to the telecare centre  supporting information-
sharing  among  health  care  professionals  involved  in  the  chronic  disease  management 
process of a given patient. 

2.8  Reimbursement model and economic flow 

The reimbursement models for GPs and the other health care providers in Scotland are still 
based  on  a  bundled  payment  plus  coordination  fee  for  the  implementation  of  specific 
activities, such as the one foreseen for the telecare service management process. Currently, 
no innovative reimbursement model has been applied and no outcome-oriented incentives 
are foreseen for the care managers and health care professionals involved in the delivery 
process.  The  Telecare  management  process  does  not  affect  the  cost  of  the  services 
provided  to  patients.  These  remain  unchanged and  are  based  on  current  practices,  where 
the  cost  of  the  service  depends  on  the  typology  of  the  disease  and  the  socio-economic 
characteristics of the patient and his/her family.  

It  is  important  to  note  that  each  local  community  applies  a  different  pricing  policy  for 
telecare service provision. For example, in Renfrewshire, the telecare service currently costs 
users  £3.10  per  week,  which  is  a  contribution  to  the  running  of  the  responder  service. 
Weekly  costs  vary  across  Scotland,  and  some  Councils  do  not  levy  any  charge  on  their 
telecare  users.  A  complete  list  of  the  service  costs  for  the  users  is  provided  by  Sergeant 
(2010), see Table 4. The fragmentation of telecare cost across the 32 local communities is 
not only an additional barrier to the diffusion of common health care practice, but presents 
some concerns in relation to the equality of the services provision to the citizens/patients 
across the country.  

18 

 
 
 
 
Table 4: Weekly costs for the patients  

Source: Sergeant (2010) 

3  Transferability 

TDP  initiatives  have  been  funded  in  the  recent  past  throughout  all  32  local  communities 
across Scotland, but only a few of them are now mainstreamed services for their respective 
local communities. The degree of transferability of the most successful telecare initiatives 
in  other  Scottish  local  context  can  therefore  be  regarded  as  rather  difficult.  The  main 
barriers this process have been discussed in §2.3. However, in terms of transferability the 
most important barriers relate to local management's resistance to change and the lack of 
skills  in  telecare  technological  issues  and  related  delivery  service  processes.  The  National 
Government  of  Scotland  is  trying  to  overcome  these  barriers  through  a  new  national 

19 

Summary of Telecare Services - March 2010                          119 APPENDIX 4  Summary of Partnership Charging for Community Alarm/Telecare Services (April 2009)  Partnership Charge Per week Comments Aberdeen City £1.30 Basic charge for Community Alarm Service (CAS).  Telecare free of charge. Aberdeenshire £1.00 Basic charge for CAS.  Telecare free of charge Angus £1.00 Flat fee for CAS and telecare Argyll & Bute £4.00 Basic charge for CAS.  No charge for telecare. Clackmannanshire Free  Dumfries & Galloway  £2.80 Charge is for calls handling service.  If the user is assessed as having a cognitive impairment or dementia and unable to use the pendant, service is provided for free. Dundee £1.50  Basic charge for CAS.  No charge for telecare. East Ayrshire £3.75  Basic charge for CAS.  Charge subject to financial assessment. East Dunbartonshire  £3.42 Basic charge for those who request CAS.  If user assessed as needing service, this is free of charge.  Issues regarding charging for telecare still to be addressed. East Lothian £1.33 No charge for telecare. East Renfrewshire £1.50 Basic charge for CAS.  Charging for telecare subject of further consideration.   Edinburgh £4.70 - £6.75 Basic charge for CAS.  Additional charge for telecare made up to total of £6.75 per week for CAS + telecare. Falkirk Free  Fife £1.00 Basic charge for CAS.  No charge for telecare. Glasgow Free Currently being reviewed with a view to introducing a charging policy in this financial year. Highland £5.00 Basic charge for CAS.  No charge for telecare. Inverclyde Free  Midlothian Free Requires further consideration. Moray  Free Subject to regular reviews as service develops. North Ayrshire £3.00 Basic charge for CAS.  No charge for telecare.  This is currently under review. North Lanarkshire Free  Orkney Islands Free  Perth & Kinross £3.15 Basic charge for CAS, which is subject of financial assessment.  No charge for telecare provision, however this will be subject of review. Renfrewshire £3.10 Basic charge for responder service. Scottish Borders £2.16 Core charge for CAS and low level need.  No charge for users under 16 years of age or who access palliative care.  Currently no charge for telecare. Shetland Islands  Free  South Ayrshire £2.78 Basic charge for CAS.  No charge for telecare.   South Lanarkshire Not supplied Not supplied Stirling £1.50 Basic charge for equipment.  Currently being reviewed with a view to abolishing charge. West Dunbartonshire £2.00 Basic charge for CAS.  No charge for telecare.   Western Isles £1.50 Basic charge for calls handling and maintenance of  
 
 
telecare plan for Scotland. The key objectives of the new programming period (2013-2015) 
are: 

  To promote telecare services for an additional 300,000 people. 
  To create awareness around telecare use. 
  To develop  innovation through integration of academia, care professionals, service 

providers and industry. 

  To  increase  international  transferability  of  the  Scottish  telehealth  and  telecare 

solution and good practices.  

Regarding  the  last  of  the  above  objectives,  the  National  Government  of  Scotland  has 
acknowledged that Scotland  could  become a reference point for  the EU in  telehealth and 
telecare so they are willing to put these types of initiatives high on the agenda.  As a result 
of  this  in  April  2013,  the  Scottish  Government  announced  £2.8  million  funding  for  two 
major telecare programmes, namely United4Health6 and  SmartCare.7 The programmes 
are funded jointly by the European Commission and the Scottish Government as part of the 
Digital Health and Care Innovation Partnership. The programmes support people with long-
term  conditions  living  in  Ayrshire,  Renfrewshire  and  Lanarkshire.  Its  objectives  are  to 
enlarge  the  number  of  chronic  patients  that  can  benefit  from  telecare  services  in  these 
local communities and to transfer the experiences of Scottish telecare across the EU28. 

The  Scottish  Government's  new  funding  initiatives  suggest  that  there  is  a  transferability 
cost  for  the  telecare  initiatives  from  local  communities  with  mainstreamed  services  to 
other  local  contexts.  Most  probably,  knowledge  transfers  would  prove  difficult  without  a 
significant  economic  contribution  from  the  National  Government.  Therefore,  beside  the 
already  discussed  barriers  to  the  diffusion  of  the  telecare  service  at  local  level,  the 
investment cost for the technological equipment has to be taken into account as a further 
issue that can potentially prevent the wider adoption of such services. 

The new funding initiative can thus be regarded as an attempt by the National Government 
to encourage the local communities to leverage more integrated care services to overcome 
the  traditional  hospital-centred  care  delivery  model.  They  could  thus  achieve  savings  in 
chronic disease management which, when the funding period expires, could guarantee the 
sustainability of telecare service in the local communities. 

The same considerations can be made with regard to transferability to the rest of the EU28. 
Transferring experience gained in the mainstreamed TDP-funded initiatives partly relies on 
the  capability  of  the  National/Regional  Governments  to  economically  support  their  local 
communities  in  purchasing  telecare  equipment.    At  the  same  time,  local  actors  must 
commit  themselves  to  creating  favourable  conditions  for  the  adoption  of  this  innovative 
chronic disease management approach.  

4  Conclusions 

The  TDP  case  in  Scotland  is  a  patient-centred  integrated  care  management  process 
targeting the 65+ population in the country. It focuses on vulnerable subgroups of patients 
and patients with complex illnesses in the 32 communities across Scotland. 

6    See: http://www.united4health.org/  
7    See: http://pilotsmartcare.eu/home/  

20 

 
 
                                                      
This funding initiative was developed between 2006 and 2011 by the Scottish Government 
to encourage the adoption of telecare by health and social care services.  It demonstrates 
the  contribution  of  telecare  can  make  to  the  safety  and  quality  of  life  of  the  elderly  by 
enabling them to live at home longer, significantly reducing the cost  of  health and social 
care services provisioning.  

Between  2006  and  2011,  51  telecare  projects  operated  by  32  partnerships  were  funded 
across Scotland. A total TDP funding of £8.35 million was provided for the period between 
2006 and 2008, and an additional £8 million was made available during the period 2008-
2010,  in  order  to mainstream  more  telecare services. However, by  the end of the second 
funding wave only 5 local communities created mainstreamed homecare telecare services 
for their local population. 

In the TDP case, GPs and nurses provide the gateways to services.  They play a pivotal role 
in  service  implementation  in  Community  Health  Partnerships.    The  TDP  projects  were 
promoted and founded by the Scottish Government, which continues to be fully committed, 
together  with  the  Scottish  NHS  National  and  Local  Organisations  to  supporting  and 
diffusing the approach across Scottish communities.   

A  key  element  of  the  funded  telecare  projects  is  the  ICTs  supporting  the  mainstreamed 
telecare  services,  as  developed  through  the  TDP  funding  scheme.  These  have  four  main 
components:  (1)  sensors  and  triggers,  (2)  feedbacks  and  controls,  (3)  home  gateway  and 
alarm handling, and (4) the technological facilities of the monitoring centres. Together, they 
represent  significant  investment  costs  that  have  to  be  borne  by  the  local  communities, 
especially  when  the  equipment  has  to  be  provided  to  the  whole  target  population.  The 
importance of reducing the service's start-up costs is reflected by the support provided by 
the Scottish Government, which still applies in the current programming period 2013-2015. 
High  investment  costs  are  also  an  important  issue  that  could  prevent  the  transfer  of 
mainstreamed initiatives to other Scottish and EU local contexts. Therefore, the possibility 
that National/Regional funding could be used to transfer the experiences to similar contexts 
should  be  considered  in  order  to  help  reduce  the  costs  of  the  equipment.  Resistance  to 
organisational change by senior managers of the local care organisations and the lack of 
telecare skills are also important barriers that need to be addressed. 

The barriers to telecare services at local level are summarised below: 

  Lack of equipment interoperability, equipment reliability and infrastructure gaps.  
  Lack of engagement amongst stakeholders in the implementation process.  
  Limited commitment to telecare from senior managers is a continuing problem.  
  Difficulties with recruitment and training of professionals. 
  Lack of adequate incentive schemes.  

Figure  4  below  provides  a  summary  of  the  contribution  of  the  8  facilitators  to  the 
development  of  the  TDP  initiative.  National  investment  and  funding  programmes  play  a 
pivotal role in steering the initiative, largely due to the significant investment necessary to 
purchase  the  telecare  equipment  and  to  support  wide  deployment  of  the  service  at  local 
level. Patient focus is another facilitator that has driven the local communities to reconsider 
their  chronic  care  services  at  home  in  a  more  integrated  and  effective  way.  Governance 
mechanisms and policy commitments follow as facilitators mainly for local communities to 
implement  and  mainstream  integrated  home  telecare  services.  Together,  these  factors 
supported the reorganisation of service processes, which has helped health care actors to 

21 

 
 
define more patient-oriented services with a high degree of vertical integration across all 
the care tiers. Interoperable information systems, however, seem to provide only moderate 
impetus  to  the  implementation  of  the  home  telecare  service  processes.  However,  it  could 
gain importance as soon as a telecare service is widely adopted in the local context. In this 
situation,  only  fully  reorganised  and  integrated  services  enabled  by  interoperable 
infrastructure could guarantee cost savings and high quality service to the patients at the 
same  time.  The  benefits  that  could  be  gained  by  this  kind  of  integration  remain  purely 
the  health  care  systems  at 
reorganisation  of 
hypothetical  without  effective 
national/regional level. Lastly, incentives and  funding for  the health care professionals do 
not appear to be important facilitators in the development of the initiatives.  

Figure 4: TDP Integrated care facilitators 

Source: Authors' elaboration 

22 

 
 
 
 
 
References 

Audit  Scotland,  (2013).  A  review  of  telehealth  impact  report.  Report  prepared  by  Audit 
Scotland for the Auditor general for Scotland and the Accounts Commission. 

JIT,  (2007).  Telecare  Development  Programme.  Summary  of  the  Proposals.  Status  of  the 
implementation  of  the  proposals  for  partnership  in  Scotland  for  improving  and 
developing Telecare services. Report prepared by the Joint Improvement Team.  

JIT, (2008). Seizing the opportunity. Telecare Strategy 2008-2010. Report prepared by the 

Joint Improvement Team for the Scottish Government. 

JIT, (2010). An assessment of the development of telecare in Scotland in the period 2006-
2010. Report prepared by the Joint Improvement Team for the Scottish Government. 

JIT,  (2012).  Telacare  2012.  An  Action  Plan  for  Scotland.  Report  prepared  by  the  Joint 

Improvement Team for the Scottish Government. 

Newhaven  Research,  (2011).  The  Telecare  Development  Programme  in  Scotland  2006  - 

2011. 

OGC, (2007). OGC GatewayTM process. Review 2: Delivery strategy. OGC Best Practices. OGC 

report available at: 
https://www.gov.uk/.../Gateway_2_Workbook_Word_Template_v2.0.doc.  

Payne, J., (2013). eHealth Scotland. Report prepared by SPICEìe. 

Scottish Government, (2012). A National Telehealth and Telecare Delivery Plan for Scotland 
2015.  Driving  improvement,  Integration  and  Innovation.  Report  prepared  by  COSLA 
and NHSS Scotland for the Scottish Government. 

Scottish Government – Health and Social care: http://www.scotland.gov.uk/Topics/Health 

SSAC,  (2009).  Telehealthcare:  time  for  action.  One-Day  Forum  on  Telehealthcare 

Technologies for Assisted Living organised by the Scottish Science Advisory Council. 

Steel  D,  Cylus  J.  United  Kingdom  (Scotland):  Health  system  review.    Health Systems  in 

Transition, 2012; 14(9): 1–150. 

Sergeant, E, (2010). Summary of telecare Services in Scotland, JIT report. 

YEHC, (2013). Resources, Cost and Benefits Associated with Implementing Anticipatory Care 
Plans  including  Polypharmacy  Review  in  Scotland.  Final  report  for  the  Health  and 
Social Care Directorate of Scottish Government. 

York University, (2009). Evaluation of the Telecare Development Programme: Final Report. 
Report  prepared  by  the  University  of  York  for  the  Scottish  Centre  for 
Telehealth&Telecare and the Joint Improvement Team. 

York  University,  (2013).  Telecare  for  People  with  Dementia:  Evaluation  of  Renfrewshire 
Project.  Final  Evaluation  Report.  Report  prepared  by  the  University  of  York  for  the 
Scottish Centre for Telehealth & Telecare and the Joint Improvement Team. 

23 

 
 
 
 
Annex 1:  Status  of  the  implementation  of  31  cases  of 

telecare services  

Project 
(initial funds 
allocation for the 
period 2006-2008)  
(population) (further 
funds allocation in 
2008-2009) 

Aberdeenshire 
(236.260) (£316,248) 

Aberdeen City 
(206.880) (£266,174) 

Angus (109.320) 
(£154,741) 

Argyll&Bute (91.390) 
(£141,953) 

Clackmannanshire 
(48.900) (£75.000) 
Dumfries & Galloway 
(148.030)  (£219,964) 
Dundee City 
(142.170)   
(£ 141,755) 

East Ayrshire 
(119.290) (£181,500) 
East Dunbartonshire 
(105.460) (£143,260) 

East Lothian (92.830) 
(£82,401)  
East Renfrewshire 
(89.290) (£125,176) 

Focus 

Development of the 
initiative 

Management of the initiative 

Village  model; 
Virtual 
Care 
expansion  of 
Intermediate  Care 
Provision;  management  long  term 
conditions 
Expansion  of  a  Rehabilitation  step-
down  project  with  an  additional  5 
flats  fully  equipped  with  Telecare; 
review  of  the  existing  community 
alarm service 
Videophones  to  undertake  virtual 
visits/wellbeing  checks  and  social 
interactions;  door  side  bogus  caller 
alarms  system  integrated  with  the 
call  centre;  long  terms  conditions 
telehealth  trial;  rural  virtual  clinics; 
intermediate care at home 
funds  have  been  used  to 
The 
complement 
community 
other 
equipment  of  the  existing  Telecare 
Response Service 
Equipping  5  houses  for  telecare 
assistance. 
Long  term  Conditions  management; 
sheltered housing upgrade 
Interim  Lifestyle  Monitoring  ;  bogus 
caller  alarms  for  100  household; 
provision  of  assistive  technology; 
200 carer training 
Provision of Assistive technology  

Upgrading the Hourcare 24  service; 
provision of assistive technologies  

Training  and  awareness 
provision of assistive technologies 
Training  and  awareness 
provision of assistive technologies 

raising; 

raising; 

Community 
Planning Board 

Older People Management Team 

Joint Operational 
Management Group 

Telecare  Development  Office  was 
appointed for the initiative 

Angus Community 
Planning 
partnership 

Argyll & Bute 
telecare Strategy 
Group 

Clackmannanshire 
CHP 
Telacare 
management group 
Dundee Health & 
Local Authority 
Forum 

East Ayrshire Joint 
Future Partnership 
East Dunbartonshire 
Joint Planning 
Forum 
East Lothian 
Partnership 
East Renfrewshire 
CHCP 

Constituted  by  a  programme 
reference  group  constituted  by 
Community  health  Partnership 
Manager;  head  of  Angus  Council 
Housing  Division  and  Head  of 
Angus  Council  Older 
People 
Services 
Argyll  &  Bute  Strategic  Health  and 
Social Care Partnership 

Clackmannanshire CHP 

Joint  Future  Senior  Management 
Group 
Telecare Programme Development 
Group 

Future 

Implementation 

Joint 
Group 
Joint  Older  People  Planning  & 
Performance Strategy Group 

Telecare Project Board 

Older  People  and  Long  Term 
Condition Group 

24 

 
 
 
 
Project 
(initial funds 
allocation for the 
period 2006-2008)  
(population) 
(further funds 
allocation in 2008-
2009) 

City of Edinburgh 
(463.510) 

Falkirk (149.680) 
(£197,162) 

Fife (358.930) 
(£485,376) 

City of Glasgow 
(580.690) 
(£911,102) 

Highland (215.310) 
(£331,527) 

Inverclyde (81.540) 
(£123,922) 

Midlothian (79.290) 
(£111,845) 

Moray (86.750) 
(£121,280) 

North Ayrshire 
(135.490) 
(£131,140) 
North Lanarkshire 
(323.780) 
(£452,127) 
(200.000£ was 
given in 2008) 

Focus 

Development of 
the initiative 

Management of 
the initiative 

passive 

Upgrade  the  community  alarm  software;  upgrade  of 
in  sheltered  properties;  supporting 
call  systems 
people  housing  support  provides  to  reduce  waking 
night  or  sleepover; 
improve  hospital  discharge 
performances  using  communication  dispenser  linked 
with  community  alarm  technology  and  existing 
locking  system; 
support  services.  Remote  door 
provision of assistive technologies 
Replacement 
alarm  with  more 
of 
sophisticated  trigger  device  to  the  5,700  community 
increase  fall  detection  programme; 
alarm  users; 
sheltered housing smoke alarms provision of assistive 
technologies 
Intermediate  care  service  development; 
lifestyle 
monitoring  integrated  with  telehealth;  expansion  of 
existing telecare services to an additional 280 users. 
Purchase of core packages of 750 service users (unit, 
pendant,  smoke  alarm,  bed  sensors,  PIT  detectors, 
temperature  extreme  sensors),  plus  around  150 
enhanced packages including fall, flood, gas detectors 
Upgrade  of  existing  community  alarm  service; 
enhanced  telecare  services;  cost-benefit  analysis  of 
the  sample  to  extend  the  service  in  the  whole 
territory 
3  telecare  demonstration  centres;  upgrade  the 
community  alarm;  10  additional  mobile  telecare 
packages 
Purchase of core packages of 170 service users (unit, 
pendant,  smoke  alarm,  bed  sensors,  PIT  detectors, 
temperature extreme sensors) 

Provision  of  services  to  the  people  at  risk  of 
readmission  as  identified  by  SPARRA;  enhance  the 
community  alarm  service  with  additional  sensors 
(unit,  pendant,  smoke  alarm,  bed  sensors,  PIT 
detectors, temperature extreme sensors) for 110 new 
users  
Provision  of  telecare  assistance  to  20  Older  people 
with  complex  needs  who  require  care  management 
and additional support to stay at home 
Upgrade of existing alarm system, installation of video 
cameras in 17 shelter housing complexes; equipment 
for intermediate care service, telemedicine pages and 
locators 

City of Edinburgh 
partnership 

Telecare 
Programme 
Management 
Group 

Forth Valley Health 
and Falkirk Council 
Housing and Social 
Work services 

Forth  Valley  Health 
and  Falkirk  Council 
Housing  and  Social 
Work services 

Fife Community 
Planning 
Partnership 
Glasgow 
Community 
Planning 
partnership 
Joint Committee for 
Action in 
Community Care 

Joint Care ELPA 

Midlothian 
Community Care 
Partnership 

Community health 
and Social Care 
Partnership 
Committee 

Health  & 
Care Partnership 

Social 

Glasgow 
Community 
Planning 
partnership 
Highland 
Community 
Partnership 

Care 

Joint  Care  Board 
and 
Joint 
the 
Future Partnership 
Community 
Joint 
Partnership 
Care 
and  Telecare  Joint 
Forum 
Management group 
constituted  by  the 
key stakeholders 

North Ayrshire 
Older People 
Partnership 
North Lanarkshire  
Health and Care 
Partnership 

people 
in  North 

Older 
Services 
Ayrshire 
North  Lanarkshire  
Health  and  Care 
Partnership 

25 

 
 
 
 
Project 
(initial funds 
allocation for the 
period 2006-2008) 
(population) (further 
funds allocation in 
2008-2009) 

South Lanarkshire 
(305.410) (£419,728) 
(additional 
200.000£ was given in 
2008) 
Orkney Islands 
(19.770) (£75,000) 

Perth & Kinross 
(140.190) (£190,825) 

Renfrewshire 
(169.590) (£241,048) 

Scottish Borders 
(110.240) (£159,932) 

Shetland (21.880) 
(£50,000) 

South Ayrshire 
(111.670) (£157,400) 

Stirling (87.810) 
(£122,527) 

West Dunbartonshire 
(91.240) (£142,429) 

West Lothian 
(165.700) (£220,163) 

Western Isles (26.350) 
(£75,000) 

Focus 

Development of the 
initiative 

Management of the 
initiative 

Transforming  the  current  ad  hoc  telecare  service 
arrangement 
into  a  robust  telecare  strategic 
infrastructure.  

South Lanarkshire 
telecare Initiative 

Joint  Future  Older 
People group 

Orkney Community 
Planning 
Partnership  

Perth & Kinross and 
Wellbeing 
Partnership 
Renfrewshire 
Community Health 
Partnership 

Scottish Borders 
Community 
Planning Structure 
“New Ways” 
Community Health 
Partnership  

Joint  Management 
Team  supported  by 
care, 
social 
the 
housing 
the 
voluntary sector 
Telecare  Working 
Group 

and 

Older  Peoples’  Joint 
Planning 
and 
Performance 
Improvement Group 
Telecare 
Development Group 

Older  People  Service 
team 

South Ayrshire Joint 
Future Planning 
Partnership  
Community Health 
Partnership and the 
Forth Valley older 
people strategy 
group 
Older People 
Strategy Group 

West Lothian 
Community Health 
& Care Partnership 
Board 
Western Isles 
Partnership 

South  Ayrshire  Joint 
Future 
Planning 
Partnership 
Older 
development group 

people 

Health Improvement 
and Social Justice 
Partnership 

Home Safety Service 

Health  and  Social 
Care Project Group 

Training and telecare equipment purchase. 

telecare  packages 

Provide  1000 
(module, 
pendant,  smoke  alarm,  health  sensitive  monitor, 
flood detector 2 PIT movement detector) 
Additional 150 service user will receive enhanced 
packages of telecare service (lifestyle monitoring, 
medication  alarms,  chair  occupancy,  dementia 
clocks, audio/visual controls) 
Develop a more integrated systems for telehealth 
and telemedicine and provision of a basic telacare 
package  to  3150  users  and  complex  telecare 
package to 250 users 
Reshaping  the  on-call,  out  of  hours  response 
services  and  upgrading  the  current  community 
alarm  service  by  providing  enhanced  telecare 
the 
to  15  vulnerable  people 
services 
community and 5 people with dementia 
Upgrade  the  existing  telecare  services  with 
training  and  information  workshops;  provision  of 
telecare services to additional 300 people 
Training  programme  for  staff;  new  telecare 
equipment,  enhancement  of 
the  existing 
community  alarm  service;  50  new  service  users 
assisted 

in 

New 
smart 
telecare  equipment;  upgrading 
technology to a sheltered housing complex; use of 
telecare in the wider community using a variety of 
sensors; 
introduction  of  mobile  assessment 
packages; 350 new service users assisted 
Expansion  of  existing  telecare  core  package  to  a 
further  500  service  users;  extension  of  lifestyle 
monitoring to 100 service users in the community 
to help to identify the early on-set of illness 
Undertake training for existing call centre staff on 
the  use  of  full  range  of  telecare  equipment; 
purchase  of  telecare  equipment;  increase  the 
range  of  existing  services  including  dementia; 
support 25 new service users with complex needs 
and  up  to  existing  users  being  reassessed  for  a 
wider  range  of  equipment  supply  (with  special 
attention to those with dementia) 

26 

 
 
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European Commission 
EUR 27273 EN – Joint Research Centre – Institute for Prospective Technological Studies 

Title: Strategic Intelligence Monitor  on Personal Health Systems Phase 3 (SIMPHS3)  - TDP (United Kingdom) Case Study 
Report 

Authors: Francisco Lupiañez-Villanueva, Alexandra Theben 

Luxembourg: Publications Office of the European Union 
2015 – 26 pp. – 21.0 x 29.7 cm 

EUR – Scientific and Technical Research series – ISSN 1831-9424 (online) 
ISBN 978-92-79-48402-5 (PDF) 
doi:10.2791/28067 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
L
F
-
N
A
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2
7
2
7
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JRC Mission 

As the Commission’s  
in-house science service,  
the Joint Research Centre’s  
mission is to provide EU  
policies with independent,  
evidence-based scientific  
and technical support  
throughout the whole  
policy cycle. 

Working in close  
cooperation with policy  
Directorates-General,  
the JRC addresses key  
societal challenges while  
stimulating innovation  
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and standards, and sharing  
its know-how with  
the Member States,  
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Serving society  
Stimulating innovation  
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doi:10.2791/28067 
ISBN 978-92-79-48402-5