National Institute for Health Research (NIHR) Devices for Dignity (D4D) MIC[1] – Written evidence (INQ0065)

 

  1. Devices for Dignity (D4D) is a national MedTech Co-operative embedded in the heart of the NHS. Since 2008 it has acted as a catalyst of, and collaborator in, the development of new technology and connected health solutions to meet clinical needs. Many of these needs are associated with loss of dignity and independence, often affecting older people. Crucially, D4D operates in multi-stakeholder partnerships from across health and care and industry, and with the patient and public voice at its heart.

 

Scientific basis

 

  1. Q1) We believe that the process of ageing is highly multi-factorial and not based solely on biology. However, others will undoubtedly provide more qualified and in-depth responses regarding the scientific understanding of biological processes.

 

  1. Q2a) The impediments to acting on public health advice include:
    1. Poverty, educational inequality, poor quality housing stock or homes of unsuitable design.
    2. Inaccessible public health advice e.g. not reaching the homeless, the disenfranchised, those who cannot read or cannot read the language in which it is provided, those without a GP or dentist, those who have lost hope and joy in living etc.

 

  1. Q2b) Scotland has developed good practice and shown success in reducing violence (including knife crime) by taking a public health approach to related factors such as alcohol mis-use and drug addiction [1]:

 

  1. Q3) Upcoming developments in biomedical science include:
    1. Improved monitoring of existing health conditions, improved identification of individual risk by large population monitoring programmes, alternatives to antibiotics

 

  1. Q4) Understanding of behavioural determinants and social determinants of health in old age is not complete. Evidence demonstrates that to effectively apply technology to improve health, it is not a simple case of designing and introducing technology. There is a need for a holistic approach that puts together effective design and engineering, whilst understanding and embedding user needs. Understanding the motivations to engage in healthy behaviours and use a particularly technology is critical to successful solution development particularly when looking to encourage behaviour change and / or self-management.

 

Technologies

 

  1.                                                                                                                                                                                                            D4D contributed to the ‘Technology for health and wellbeing: an NHS perspective’ piece in the Agile Ageing Alliance ‘Neighbourhoods of the Future’ White paper [3]

 

  1. Q5) Technologies needed for ageing and ageing-related disease. It will be important to improve or develop incontinence management technologies. Incontinence is still the second most common reason for people not remaining independent at home and becoming dependent in care/nursing homes and is a key factor for older people becoming socially isolated and depressed. Ideally new therapeutic medical devices or interventions to cure incontinence are needed. Importantly, it will be important to improve access to effective continence management products that are on the market but not funded. Medical device technologies for continence do not appear to get the investment required and simple devices such as pads are being rationed to the point where people have to reuse wet pads.

 

  1. Q6) While technologies can play an important role to help people live independently for longer, there seems to be a disproportionate emphasis on ‘there must be an App for that’ as a substitute for human interaction. There are high-tech developments in the pipeline such as robotic aids but the readiness states are too early for the least able older people in most need of support. The best technologies are those that have involved users in their design so that older people want to use them. We should not ignore the seemingly low-tech technology just because their uses are perceived as unglamorous issues, e.g. continence or assisting with personal hygiene. Cost drivers sadly often result in unglamorous and barely effective solutions.

 

  1. Technologies need to be developed to make a significant and lasting contribution to the quality of life and independence for both people with disabilities & long term health conditions as well as the ageing population, in order to help the transform the way that health and care services are provided. The emphasis should be on the consequences of living with conditions, healthy ageing, rather than on the conditions themselves. It is about developing technologies that are fit for purpose, the technology pull rather than the technology push. Assistive technologies should be there to support the health and independence of people in their own homes and communities.
    1. enhance the ability to self-manage health conditions and to function independently of professional carers.
    2. empower people to be as independent as possible in any environment in which they would like to be – including, homes, communities, schools, colleges and places of work.
    3. specialist equipment such as communication aids and home control systems
    4. assistive and companion robots to support daily tasks within the home.
    5. target technologies that assist people in managing and living with the symptoms and consequences of their (perhaps multiple) conditions, communication problems, low mood, etc., and which assist people in following management strategies such as lifestyle changes and therapeutic activities.

 

  1. Q7). We believe that others will be better qualified to comment on the technologies needed to improve mental health and reduce loneliness for older people

 

  1. Q8) Barriers to development of the technology cited above include
    1. Health economic factors
    2. Perceived commercial return
    3. The economic drivers of the purchaser

 

  1. Q8:Barriers to implementation / adoption can include:
    1. Whether a technology is needed for medical reasons, or as a consumer item
    2. Who the purchaser of the technology is and whether there is funding available
    3. Availability and conclusions drawn in evidence of effectiveness
    4. User acceptability
    5. User burden
    6. Perceived benefits to user
    7. Compatibility with existing systems
    8. Data handling, governance, and ownership
    9. Speed of technology intervention
    10. Sensitivity and specificity of tests
    11. Physical size of technology
    12. Storage and disposal of consumables
    13. Availability of technology to users
    14. Logistics
    15. Access to supply chain and knowledge of how to do this, including timetables
    16. Manufacturability
    17. Regulations
    18. Cost savings for NHS linked to new technology are not the same as profits raised by commercial entities
    19. Regulations and processes around ‘off label’ uses of technologies

 

  1. Q8a) Overcoming the barriers above will require taking a systems approach to technology adoption and assessing the overall impact and value of technology in making adoption decisions. Companies will not invest in cutting-edge R&D if their products will not be adopted.

 

  1. The development of new medical technology is a complex and lengthy process requiring collaboration across numerous stakeholder groups. Adding to the complexity is the fact that the views and needs of the many stakeholders are often not only complex, but contradictory and need to be heard throughout the research and development process. Creating the environment where all relevant individuals are involved in the innovation process at the right time is essential.

 

  1. Establishing relationships with research users, acknowledging the expertise and active roles played by research users in making impact happen, involving users at all stages of the research, developing good understanding of policy/practice contexts and encouraging users to bring knowledge of context to research and involve intermediaries and knowledge brokers as translators, amplifiers, network providers at times.

 

  1. Specific examples include:
    1. Better integration of procurement processes as part of innovation cycle
    2. Greater investment into larger system health economics studies
    3. User-centric design within technology development
    4. Clarity on purchase routes i.e. ‘who is the customer’ across systems
    5. Better measures for impact
    6. Better mechanisms to spread knowledge of innovations
    7. Mandated reviewing and updating of professional practices to include new innovations

 

  1. Q8b) We believe that socio-economic factors greatly affect access and use of technology by older people but expect that others will be better-placed to provide supportive evidence.

Industrial strategy

 

  1. Q9) Others are better placed to respond to the industrial opportunities question. .

 

  1. Q10) UK companies would benefit from a more seamless approach for support of, and funding for, clinical evidence generation to support commercialisation. For example NICE has established processes for health technology assessment that is recognised and valued internationally but companies struggle to undertake the trials that would demonstrate the safety and effectiveness of their new inventions. Without such evidence products fail to penetrate the market. NHS England has funded the NHS adoption of individual products from some UK companies through innovation and technology payments (ITP). The quality of evidence has been variable and not necessarily as robust as required for NICE assessment processes. Improving the evidence generation process would help to expedite regulatory approvals and speed up the process to enable medical devices to be tested for new applications. New EU regulations (MDR from 26 May 2020) have raised the bar for clinical evidence and quality.

 

  1. The network of Academic Health Science Networks (AHSNs) was created to act as the innovation arm of the NHS and to connect NHS and academic organisations, local authorities, the third sector and industry companies. Their role is to act as catalysts and they are driven by improving health and generating economic growth. They have the funding to help but not the capacity as innovation delivery happens outside of the AHSNs. There would be benefit from putting greater resource into developing networks and expertise into NHS-led adoption and spread; the clinical expertise and practice is within the NHS, but the capitalisation of research outcomes and innovation developments is often largely removed from the NHS. Innovation arising from the health/education sector can stall as adoption and spread is under-resourced and not a smooth progression once research projects have ended. As such, technologies that provide NHS cost savings but low profits are most at risk as companies will not invest in taking them forward.

 

  1. A gradual cultural shift, where innovation and updates to practice become routine and are well supported, would be helpful; currently, innovation and changes to practice often meet resistance and indifference.

 

  1. Q11 Achieving the Government’s aim to provide five more years of health and independence in old age by 2035 is unlikely to be feasible unless there is a rapid improvement in avoidable longer term health risks e.g. obesity, alcohol consumption and drug addiction.

 

  1. Q11a) The 2035 goal will require a fundamental review and revisit of the psycho-social factors influencing lack of exercise, continued smoking and poor diet, drug taking and poor mental health. Some are likely to be poverty-related, e.g. financial uncertainties from ‘gig economy’ working. People like to have control in their lives. Maslow’s ‘hierarchy of needs’ [2] from the 1940’s still explains many of the reasons behind poor mental health in the UK at present e.g. fundamental needs such as safety, social belonging and self-esteem are not being met,.

 

  1. 11b) Revisiting current drug enforcement strategy and laws will be needed.

 

  1. Q12) Inequalities are a major barrier to achieving the Ageing Society Grand Challenge. There is already significant post-code related disparity in life expectancy with higher economic areas living longer than those in more economically deprived areas.
    1. 12a) Whether inequality is exacerbated or reduced depends on how five more years of healthy and independent life is measured. Targets should be developed to include minimising differences between areas.

 

  1. Q13) A paradigm shift to people leading healthier lives for longer, and spending less time suffering ill health is likely to lead to:
    1. Reduced demand on social services
    2. Less demand on overstretched hospital services
    3. Older people would be better able to continue working (if they wished), especially in more physically demanding careers or ones requiring mental concentration
    4. Older people may wish to contribute to society in other ways: voluntary work, mentoring younger people, aiding childcare, travelling, being consumers
    5. May need to redesign working patterns to create jobs for younger people. If older people continue to work longer then there will be fewer jobs for younger people arising unless typical weekly working hours are reduced.
    6. May need to redesign pension schemes to include part-retirement or to allow sabbaticals where people can take an extended career break returning to work later in life.
    7. Productivity may well increase with a reduction in working hours. Part-time working is currently perceived as being less ‘worthy’ by many managers yet for many it delivers improved quality of life and higher productivity.

 

REFERENCES

  1. https://www.gov.scot/policies/crime-prevention-and-reduction/violence-knife-crime/
  2. Maslow, A.H. (1943)."A theory of human motivation". Psychological Review.50(4): 370–96.
  3. Tindale WB. and Hedey-Takhar P. ‘Technology for health and wellbeing: an NHS perspective’. In Neighbourhoods of the Future: Creating a brighter future for our older selves White Paper. Agile Ageing Alliance, 2019, pp278-282: https://www.agileageing.org/site_files/5944/upload_files/NeighbourhoodsoftheFuture2019_250119.pdf?dl=1

 

20 September 2019

[1] MIC are the MedTech and In vitro diagnostic Co-operatives