The Columba Project to Provide Intermediate 2021

Care and Telecare in North West Surrey

CASE STUDY 5.1 The Columba project to provide intermediate care and telecare in
north west Surrey, UK

As a concept, Columba was relatively straightforward. Frail elderly people who had been
admitted into hospital and who might otherwise have been discharged straight into
residential care would be supported in their own home by a new package of care services,
including telecare. By using telecare, the risks associated with independent living
would be reduced. The project mixed short term intensive residential rehabilitation (the
service element of the innovation) with telecare (the technology element). The rehabilitation
component was to be delivered in a residential care home, where an independent four-bed
rehabilitation unit would be built. This was designed to replicate home conditions and
familiarise the elderly users with the same telecare systems to be installed in their own
homes.

Background

When it was first mooted in 1999, there was a considerable R&D activity on ‘smart homes’
technologies. Companies around the world were developing electronic devices to help
control the functions of homes, such as heating, lighting and audio-visual entertainment.
Prototype smart homes and demonstration projects had been set up in many countries. As
well as creating products for the high end of the domestic market, attention was also being
paid to the needs of highly disabled and elderly people. It was argued that if their homes
could be made more readily usable, they could achieve greater independence and avoid
having to move to institutional care. At the same time, it had become clear that in the UK, the
extensive network of social alarms (fall detectors) and local monitoring centres, could be
used as a basis for a more advanced telecare network. Around a quarter of the entire global
user population of social alarms was said to be in the UK — over 1.5 million people — so the
potential to use this to leverage telecare into the social and healthcare systems was evident.

Project objectives and partners

Columba’s objective was to reduce the need for residential home admissions by frail
elderly people and help tackle the problem of delayed discharges from hospital. It
played into a narrative in health and social care policy and practice about the importance of
providing people with greater choice over care options and increased independence in
their homes. It was also partly motivated by the local social services’ objective of
reducing the number of residential care beds in the area by 25%. Initial estimates
suggested that of the 100 frail elderly people discharged each year from the local acute
hospital to a social services funded residential home, about a quarter would be suitable for
the Columba care package.

The project’s core partners were the customer (the local NHS acute hospital
trust), the suppliers of telecare and related services (the local
community hospital, the social alarm monitoring centre and the equipment
manufacturer), and the funders (the local social services authority and two NHS
primary care trusts).

James Barlow (2017) Managing Innovation in Healthcare Page 1

 The Columba Project to Provide Intermediate 2021
Care and Telecare in North West Surrey

Project development

In December 1999, a group of senior clinical and social service staff met to discuss the
development of older people’s services in the local area. Several members had knowledge
of telecare and formed a project steering group to consider how it might be used. This led to
a project proposal in October 2000 to use some local health authority funds, which were
available for stimulating the development of remote care. A project manager was appointed
in February 2001, and an early task involved bringing together local care teams. As the
project manager put it, ‘reluctant consent’ for Columba had been achieved by summer 2001.
The concerns were largely about additional workload and cost.

By October 2001, a revised project plan had been agreed. This proposed recruitment of the
first patients by September 2002. Some of the intervening time would involve creating the
four-bed rehabilitation unit in the existing residential care home. During the first half of 2002,
the service specification and care processes for Columba were created. However, what
became clear during this period was that a much larger range of different stakeholders from
across the local care system needed to be brought on board to ensure Columba was
implemented. A large number of individuals and groups within the core partners had to be
engaged in order to develop the service model and ensure it was implemented. These
included hospital discharge co-ordinators and care managers, members of the occupational
therapy teams from social services and primary care, the managers of the local residential
care home, the intermediate care and ‘home from hospital’ teams, and the community social
care team. Representatives of service users, their families and informal carers were also
involved. All these became involved in the design of the project on a sequential basis, as it
became clear there were gaps in the Columba core team’s knowledge about the detail of
care pathways for elderly people. This slowed the pace of development.

There were also delays in sanctioning expenditure for upgrading the social alarm
system to accommodate telecare sensors. Another problem was that this phase in
Columba’s development coincided with a major national restructuring of health and
social care services, which made it hard to engage stakeholders, who had other
concerns. The project manager then left the team in July 2002. Further delays occurred
during the autumn when workshops for operational staff were organised. Columba
was eventually launched some four months late. However, there were severe problems in
identifying and recruiting appropriate patients for the scheme. While these were partly
overcome by establishing a dedicated coordinator role to work across the boundaries in the
local care system, it took much of 2003 to build local awareness of Columba.

By April 2004, only 22 people had been through the scheme (after this pilot stage, the
project was closed).

The innovation lessons from Columba

James Barlow (2017) Managing Innovation in Healthcare Page 2

 The Columba Project to Provide Intermediate 2021
Care and Telecare in North West Surrey

The Columba project was developed in the early days of

telecare, and there was little experience and knowledge for
its protagonist to go on. It did, however, provide useful lessons that
showed how designing and operating a complex innovation involving a hybrid
of technological innovation, organisational change and new service delivery
models can be much harder than initially envisaged, not necessarily because
of technical problems. Columba demonstrates the way an innovation with
seemingly straightforward objectives and using relatively simple technology is
heavily influenced by the interactions between the innovation, the local actors
involved and the wider context.

Columba was designed from the outset to allow for scaling-up and ‘normalisation’. This
would be achieved through future organic expansion, after collection of positive evidence
from a small-scale trial. However, it was not possible to move to full-scale
implementation. This was for several reasons :

The organisational and operational complexity of integrating

remote care into the existing care system was poorly understood at
the project’s inception. What appeared to be a relatively simple concept adding
simple telecare technology to the existing processes for discharging elderly patients from
hospital in fact had a series of unforeseen implications for the roles and responsibilities of
the health and social care authorities, and for the distribution of costs and
benefits between them.
• As knowledge about the local implications of remote care became clearer during the
planning stages, an increasing
range and number of stakeholders
needed to be involved in the project, beyond the initial partners . This
led to severe delays in the development and implementation of the
trial.

• The project
manager, who was based within the primary care organisation, did not
have authority across stakeholders from other services there were
many points in the planning and decision-making chain where
others could veto decisions.

• It became clear as the trial progressed that stakeholders

from primary, acute
and social care services held different perceptions of risk and what
they saw as convincing evidence for the benefits . This not only meant that
some were more sceptical about the project , and hence less

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 The Columba Project to Provide Intermediate 2021
Care and Telecare in North West Surrey

engaged, but it also damaged the potential to scale-up the project on

completion of the trial.
Problems were also caused by the fast moving external context for the
Columba project. Local and national health policy priorities and
targets were evolving. As the project developed, pressure grew to free
hospital beds ‘blocked’ by elderly patients unable to return home .
The overall goal of Columba therefore shifted from one which
aimed to enable elderly people to remain generally independent
towards one more narrowly designed to address ‘bed blocking’ .
Consequently, the target population changed towards older and
frailer patients. This meant that referrals into the scheme were
inappropriate for the existing technology and its abilities — they
were too old and frail. The change in type of patients not only
affected health and social care stakeholders’ views of the risks
associated with the technology, but changes to the patient
population also meant that the evidence collected in the trial on
costs and benefits was ambiguous. Modelling work suggested that the
timescales over which any financial, clinical or quality of life benefit might be
delivered were unclear, making it hard to justify decisions to scale-up the
scheme, which was eventually abandoned.

Questions for discussion:

 What type of innovation would you class Columba and why?

 Identify the main barriers to adoption and suggest ways to overcome them from the
perspectives of the different stakeholders involved in planning and implementing
Columba.
 What strategies might the partners have used to improve the process of
implementing the Columba project, and helping to scale it up?
 What were the key characteristics of Columba that helped its introduction?
 What similarities have you identified with your telecare programme?

James Barlow (2017) Managing Innovation in Healthcare Page 4

 The Columba Project to Provide Intermediate 2021
Care and Telecare in North West Surrey

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