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Assistive Technology Dementia - DOC

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									                    and




                  DRAFT
 Identified Opportunities for the use of the
Assistive Technology Strategic Capital Grant
                  2006/07


               January 2007




               Lead Officers:
              Ben Chico (PCT)
            John Harding (RMBC)




                                               1
                         Assistive Technology
                   Identified Funding Opportunities
                      for Strategic Capital Grant

Overview


This document builds upon the Joint Strategy for Assistive Technology agreed between
Rotherham MBC and Rotherham PCT in June 2006, by outlining identified opportunities
for the spending of the assistive technology strategic capital grant within Rotherham. It is
set out in two sections:


   1. Project Considerations
       Defining Assistive Technology
       Assistive Technology Priorities
       Funding
       Assistive Technology Evidence

   2. Identified Opportunities for Investment
       Manual Handling and Tissue Viability equipment
       COPD Specialist equipment
       Environmental Controls equipment
       Childrens Specialist equipment
       Telehealth Evaluation




                                                                                           2
1.Project Considerations

What is Assistive Technology

There are a number of definitions offered for assistive technology, due to the
broad nature of the term. The below gives two of the more widely quoted
interpretations.

“Assistive Technology is an umbrella term for any device or system that allows
an individual to perform a task they would otherwise be unable to do or increase
the ease & safety with which the task can be performed.”
(Cowan & Turner-Smith, Royal Commission on long Term Care 1999).

“Assistive Technology (AT) is any product or service designed to enable
independence for disabled and older people.”
(King's Fund consultation, 2001)

The following table shows the various ways in which AT can be used to support
people‟s independence. These can be broken down into supportive, responsive
and preventative methods.

Exhibit 1: Ways in which AT can support independence




                                                                                   3
Zone   User characteristics            Possible AT provision
A      People supplied with            Blood pressure monitor
       equipment to support earlier
       discharge from hospital
                                        Fall detector
                                        „Panic‟ pendant
                                        Environmental control systems
B      Patient with muscular sclerosis Wheelchair with integrated
                                        electronic technology
       People receiving palliative care Environmental control systems
       at home
C      People undergoing needs          Simple equipment to support
       assessment, perhaps following activities of daily living
       a change in personal             Environmental control systems
       circumstances
AB     People who require some          „Panic‟ pendant
       basic assurances and support
       in order to lead an independent
       lifestyle in their own homes –
       „well older people‟
                                        Fall detector
                                        Video doorbell
                                        Medicine
                                        dispenser/compliance unit
BC     People with dementia requiring Reminder unit
       support to lead an independent
       life in their own homes or in
       supervised accommodation
                                        General long-term monitoring
AC     Older person living at home      „Panic‟ pendant
       requiring reassurance
                                        Chair occupancy monitor
                                        Room occupancy monitor
                                        Security system
                                        Event analysis system
                                        Fall detector
ABC    People at risk of accident or    Equipment for daily living
       relapse
       People with physical             Reminder unit
       disabilities
       People with chronic conditions, Fall detector
       such as diabetes, heart failure
       or respiratory disease


                                                                4
                              People with dementia           Environmental control system
                              Anyone attracted by the design Chair occupancy monitor
                              or convenience of assistive
                              technology
                                                             Room occupancy monitor
                                                             Medicine
                                                             dispenser/compliance unit
                                                             Virtual consultations


1. NB: Several of the mentioned AT listed above, such as panic alarms, fall detectors,
   medicine dispensers etc, will be covered through the Preventative Technology (PT)
   grant, which is being managed as a separate work stream. Most of the identified
   opportunities within this document can be defined as equipment for supporting
   activities of daily living.

Assistive Technology Priorities


The PCT and Social Services have focused on AT which can provide preventative and
responsive benefits to patients/users, to support teams in meeting national priorities as
set out in the following;

      NHS Plan (2000) which advocates one-stop health and social care services and
       outlined infrastructure proposals to support these;
      National Service Framework for Older People (2001) which sets out nine
       standards for the care of older people across health and social care;
      Wanless Report (2002) which identifies the need for a „whole systems‟ approach
       to the reform of health and social care;
      NHS Improvement Plan - Putting People at the Heart of Public Services (2004)
       sets priorities for improving care for people with long term conditions and moving
       from reactive to proactive care;
      Supporting People with Long Term Conditions (2005) which outlines a model to
       support local innovation and integration for the management of long term
       conditions;
      Independence, Wellbeing and Choice (2005) which sets out a vision for the
       future of social care for adults over the next 10-15 years with a set of key
       objectives and how they might be achieved.
      Our health, our care, our say (2006) which sets out a new direction for
       community health and social care services and outlines proposals for improving
       the quality of services, the need to increase independence and the need for
       better use of technology to support people at home.
      A Sure Start to Later Life (2006) which focuses on preventing exclusion and
       promoting wellbeing in later life by addressing poor health, poverty and social
       exclusion, with effective services at key times;
      Direction of Travel for Urgent Care (2006) a discussion document seeking views
       from NHS and social care stakeholders about future arrangements for the
       provision of urgent care services.



                                                                                            5
These reports highlight several “hard” targets for the local health and social community,
including;

      reducing the growth in emergency hospital admissions to less than 1% and
       eliminating growth in re-admissions;

      supporting older people with long term conditions by:

       -       improving care in primary care and community settings, to reduce
               emergency bed days in hospital by 5% by 2008;
       -       improving their health outcomes by offering a personalised care plan for
               those who are vulnerable and most at risk;
       -       improving access to services;

      improving the quality of life and independence of vulnerable older people by:

       -       increasing the proportion of older people being supported to live in their
               own home by 1% annually in 2007 and 2008; and
       -       increasing by 2008 the proportion of older people supported intensively to
               live at home to 34% of the total of those being supported at home or in
               residential care;

In planning for AT opportunities, several factors were taken into account in prioritising
bids. These included:

   1) There is evidence to support that the assistive technology would assist the
      relevant teams in meeting the above targets. Example, a bid from the sensory
      impairment team was agreed not to fall within the scope of the project, as the
      benefits would be purely qualitative to users.
   2) There is at least one individual in place to sponsor the equipment and be
      responsible for its utilisation and performance management in order to capture
      outcomes.
   3) The assistive technology meets the requirements of the funding. Example; there
      will be no unplanned revenue costs after April 2008 (see below).
   4) There is a balance between investing in “new” assistive technology with little UK
      evidence (eg. telehealth), with more conventional technology where relevant
      teams have identified a gap in service provision (eg. manual handling
      equipment).

The opportunities identified in this document are based on bids received to the Assistive
Technology task group. Rotherham Foundation Trust and Yorkshire Ambulance Trust
were both approached regarding opportunities, but did not identify any equipment which
could support the above aims. Doncaster and South Humber (DASH) Mental Health
Trust were also approached, and have linked into the separate strategy on telecare.

Funding

The PCT submitted a strategic capital bid to the SHA in 2005/06 for £500k to increase
the amount of assistive technology available within Rotherham. This was confirmed in
March 2006.



                                                                                            6
The SCG will be transferred to the council under s.28a arrangement prior to March 2007.
This is a set up to facilitate a more holistic approach to health/social care funding. The
council will then purchase the identified technology on joint behalf.

Social Services have been given a Preventative Technology grant of £422K, as part of a
national drive to increase the number of people with access to telecare. This grant is not
ring-fenced, and is to be spent on capital or revenue prior to April 2008. The Council
have confirmed that they will make up to £100K of this funding available to be cost
shunted with the SCG to support revenue costs associated with the strategic capital
grant opportunities.

The spending of the PT grant will be outlined in a separate document by March 2007.

£360,000 of the SCG has been allotted to opportunities which can be purchased prior to
April 2007. The remaining £140K will be carried over into 2007/08, to be used to fund a
pilot of telehealth equipment, plus its expansion if the evaluation is successful, or for
other opportunities if not.

Procurement will be managed between the Supplies Agency based at Rotherham
Foundation Trust, and the Social Services finance team.

Public and Patient Involvement

All initiatives outlined in this document were developed with the agreement of the Health
Network, comprising representatives from many voluntary organisations and service
users. Additionally, a service user sits as a core member of the telehealth task group, to
ensure that the pilot delivery is successful.

Evidence to support Assistive Technology


Research evidence is commonly graded according to a system widely used in the
formulation of guidelines and standards of care.


Level of evidence    Type of evidence
1a                   Meta-analysis of randomised controlled trials (RCTs)
1b                   At least one RCT
2a                   At least one well-designed, controlled trial but without
                     randomization
2b                   At least one well-designed, quasi-experimental study
3                    At least one well-designed, non-experimental descriptive study (for
                     example, comparative studies, longitudinal studies, correlation
                     studies, case studies)
4                    Expert committee reports, opinions and/or experience or respected
                     authorities

Most of the evidence to support investment in AT is at levels 3 and 4. There are few
examples of randomised controlled trials for AT because developing outcome measures
is difficult. The services by their nature are often preventative and many users have



                                                                                         7
progressively deteriorating conditions. Moreover, there is a difference between efficacy
(what works in perfect conditions) and effectiveness (what works in the real world). The
effectiveness of AT chiefly depends on whether it is used as intended. This problem
extends to other areas of clinical research: for example, non-compliance with medication
regimes is known to be a major problem (and yet no one would declare a new medicine
to be useless if it did not achieve its purpose because a patient has not taken it
correctly).

In order for any assistive technology to be successful, it needs to become embedded in
an integrated package of care for the patient user. It should be noted therefore that that
technology can never be a total substitute for human contact, and there will always be a
great value in staff being able to spend “quality time” with vulnerable adults.




                                                                                             8
2. Identified Assistive Technology Funding Opportunities
The following opportunities have been developed based on either an identified block to
existing service provision, or where services could be redesigned to assist teams in
meeting local and national targets.




                                                                                         9
Tissue Viability/Manual Handling Equipment
It is well known that the demographics of our society are changing, with those over 85
being the fastest growing section of the population. Many older people have more than
one long-term condition and associated risk factors. With increased chronic disease
comes increased debilitation and decreased ability to self-care and mobilize in general.
This therefore has a huge impact on Tissue Viability trends, associated care needs and
incidence of adult protection issues. In deed, the total number of reported Tissue
Viability adult protection cases and associated deaths in Rotherham has more than
doubled over the past calendar year.

Although the PCT currently owns or lends more than 6,500 pieces of Tissue Viability
equipment, it does not have the comprehensive variety of differing levels of equipment
required to treat advanced wounds and prevent further deterioration of acquired
pressure sores. (See below model) This results in long waiting times for equipment to be
provided and therefore has a direct impact on hospital admission/discharge. Therefore,
specialist electronic equipment for disabled & older people with complex needs is
required to enable people to be live safely at home especially for those people in excess
of 20stone.



                            Total Number of Pressure Relieving Equipment
                                  Currently owned/loaned by the PCT



                                       128
                                               435




                                                            999
                  2348


                                                                           Therapeutic/Specialist
                                                                           High Risk
                                                                           Medium Risk
                                                                           Low Risk
                                                                           Cushions and Boots




                                                2681




There are currently 65 patients suffering from pressure sores in Rotherham. Pressure
sores are assessed between levels one and four, with level four being the most serious.
At level four, the average cost of healthcare has been assessed by NICE at £40,000,
based on an average six month treatment programme.


The following equipment is required to provide a holistic range of Tissue Viability and
manual handling equipment allowing a structure which provides both preventative and




                                                                                                    10
treatment options, reducing the risk of patients reaching level four pressure sores within
the community.

Specific Equipment with Capital Costs

    Equipment           Number                 Addressed Need                     Cost
 Cairwave Mattress        6           Therapeutic treatment of high grade         £30,000
                                                      sores
  Trinova Mattress          8         Therapeutic treatment of high grade         £32,000
                                                      sores
 Airwave Mattress          10       High risk and Bar iatric patients + some
  (Reconditioned)                   treatment (increased weight ratio up to
                                                    30stone)                       £5,887
Overture Mattress          50         High risk prevention and treatment          £50,000
Harvest Bar iatric          2         Therapeutic treatment and high risk
mattress and width                   prevention for Bar iatric patients up to
  adjusting sides                                   40stone                       £16,000
Lisscare Bar iatric         2          High risk prevention for Bar iatric
     mattress                                patients up to 41stone
                                                                                    £8,000
 Dynamic Overlay            5         High risk prevention and treatment            £8,813
      Mattress
 Soft Form Premier         50              Medium risk static system              £10,000
  Solution Chair           30        Low/medium risk cushion for patients          £6,000
      Cushion                        who sit out for long periods/ reducing
                                           level of mattress required
    Image Chair            30       Medium risk cushion for patients who sit        £6,000
      Cushion                        out for long periods/ reducing level of
                                                mattress required
  Vascular Assist           1       Advanced Leg Ulcer/Advanced Wound               £6,000
                                                   Care Clinics
       Flotron              2         Leg Ulcer treatment with associated         £16,000
                                                     oedema
  1200mm XXXL               2             To support bar iatric patients            £4,150
 Profiling Bed with
      Castors
  1400mm XXXL               2            To support bar iatric patients             £4,308
 Profiling Bed with
      Castors
1200mm Pro-Bario            2            To support bar iatric patients             £3,096
   Profiling bed +
       castors
    Mobile Hoist            6            To support bar iatric patients           £12,000
 Presence 227kgs
   Tracking Hoist           2            To support bar iatric patients             £3,000
       250kgs
Weighing Scales to          1            To support bar iatric patients               £500
use with Hoist and
        Sling
  655 Wheelchair            1            To support bar iatric patients             £1,195


                                                                                        11
    scale 300kg
Hoist Presence with         1             To support bar iatric patients             £3,035
weighing scale
227kgs
  HLB550 Probed             1             To support bar iatric patients             £2,912
   Home care bed
  Kelly Stand plus          6             To support bar iatric patients             £7,200
        slings
 Mangar Elks up to          2             To support bar iatric patients             £1,800
      70 stone
Mangar Camel (with          2             To support bar iatric patients             £3,400
  back rest) up to
       50stone
  Electric Powered          2             To support bar iatric patients             £4,000
 postural arm chair
 Powered Recliner           1             To support bar iatric patients             £3,000
 Chair tilt in space
 Bar iatric Powered         1             To support bar iatric patients             £8,000
  Wheelchair front
     wheel drive
 Bar iatric Powered         1             To support bar iatric patients             £8,000
  Wheelchair rear
     wheel drive
       TOTAL                                                                       £264,396

Protocols for Equipment

A new review structure will be introduced for the equipment, based on the Waterlow
score assessment criteria (see below). Any issues will be escalated to the Specialist
Tissue Viability nurse practitioner for complex assessment.

Any training will be provided by Tissue Viability Specialist Nurse Practitioner or other
Tissue Viability staff.

Communication of new capacity to review and enhance or decrease levels of equipment
will be cascaded via a variety of communication methods:

      District Nurse Team Meetings
      Specialist Nurse Team Meetings
      PLT
      Joint planning groups
      Social services commissioning teams
      Production of a pressure prevention equipment catalogue

Equipment will be managed by the Rotherham Equipment and Wheelchair service
(REWs)




                                                                                           12
                             Equipment Provision Structure
                        Initial patient assessment including
                        Water Low Score



                             Referral for equipment using Equipment
                                      Prescription Catalogue



                             Discussed and assessed by Tissue Viability
                                  Team/Equipment Co-ordinator



                         Equipment requested from REWS and
                         review date booked


                         Equipment, and routine information
                         provided to patient and carers etc



                                    Monthly review conducted

                                                                           Review date
                                                                           booked

                                   Equipment no longer                Equipment still required

                                   required

Assessment for alternative            Arrange for return to
        system                              REWS


Discharge from system                                                            13
Revenue consequences

Maintenance will be covered within REWS budget.

Evidence/Performance Management

Investment in the above should lead to:

      Increased number of people receiving care at home
      Reduced number of avoidable admissions
      Reduced number of delayed/poor discharges due to lack of equipment
      Reduced cost in treating advanced pressure ulcers
      Reduced staffing time
      Reduced risk of staff injury
      Reduced unnecessary outpatients appointments for wound care
      Reduced wound care formulary costs (average £40,000 to treat one grade 4
       sore)
      Reduction in identified adult protection cases relating to tissue viability
      Avoidance of potential litigation

PASA conducted a research project into profiling beds in June 2003, which was mainly
based on hospital trusts. However, the findings are still relevant to primary care.

Performance of the equipment will be reported on to;
    Integrated Community Equipment Project Board (Quarterly)
    PCT Directors (As requested)
    Joint Planning Board (As requested)
    Existing Clinical Governance Reporting process

Statistics will be managed through;

      REWS database
      Monthly Pressure Ulcer/Complex Wounds stats
      Commissioning statistics re CTR outpatient attendance

Responsibility for the equipment will be taken by;

      Senior Manager for Specialist Clinical Services
      Tissue Viability Nurse Practitioner
      REWS Manager

Sponsor: Paula Hill/Lynn Keirs




                                                                                     14
COPD Primary Care Equipment
As part of the Rotherham Breathing Space project, the following equipment has been
identified to assist the specialist COPD nurse team support the estimated 5,600 patients
suffering from moderate to severe COPD.

      Portable Blood Gas Analyser x 2 with 1 x printer, downloader, electronic
       simulator
      Desktop Spirometer x 4. 3. Portable Spirometer x 2
      Calibration Syringe 3litres x 1
      Calibration Syringe 1 litre x 1
      Pulse Oximeters x 10
      Portable pulse oximeters x 4
      Nebuliser Compressors x 100

Estimated Costs - £45,000

Rationale

The above equipment will support the Breathing Space team in the following ways;

   1. Blood Gas Analyser – Allows the team to perform Oxygen Assessments at
      Breathing Space, therefore reducing referrals to secondary care.
   2. Spirometers – Offers the flexibility to diagnose COPD at people‟s homes.
   3. Pulse Oximeters – These will allow the team to screen patients prior to oxygen
      assessment. Required to assess whether or not hospital admission is necessary.
   4. Nebuliser Compressors - Currently no organisation or standardisation of long
      term nebuliser usage exists in Rotherham. This will be an attempt to objectively
      assess and organise the home nebuliser service (coordinated from Breathing
      Space).

Revenue Implications

Maintenance of equipment is covered within the Breathing Space business case.

Protocols

The Breathing Space Nurse Consultant will be responsible for the central management
of equipment.

Performance Management

      A database will be managed by the nurse consultant showing utilisation of
       equipment. Database to be reported as part of Breathing Space performance
       management.
      Patient satisfaction with equipment will also be included in qualitative surveys
       produced as part of wider Breathing Space performance review.

Equipment Sponsor: Gail South


                                                                                          15
Specialist Children’s Equipment
The following equipment will support the Community Children‟s nursing team in
managing approximately 30 patients with complex health needs within the community.

      Syringe driver to facilitate intravenous drug administration at home.
      2 x Suction units (Portable Devilbiss)
      2 x Pulse oximeters (Portable x 1, Mains x 1)

Estimated Cost - £5,000

Rationale

The above equipment will support the Children‟s nursing team in the following ways;

   1. Syringe Driver – Enables home administration of intravenous drugs, facilitating
      early discharge and preventing admissions.
   2. Suction Units – Utilised for end of life care at home and for children with
      tracheotomies/suction needs. Lack of equipment at REWs means children stay in
      hospital or have to be admitted to hospital.
   3. Pulse Oximeters – These will enable traces to be performed at home instead of
      on the ward. Portable unit will enhance diagnosis for most vulnerable of children.

Revenue Implications

Maintenance of all equipment via BME at RFT as per other team equipment. Not
incremental due to small amount of equipment.

Protocols

Training for syringe driver to be managed within PCT with support from supplier. Pulse
Oximeter training update required only from supplier.

Avoidable admissions data to be recorded on EPEX under screens “alternative to
hospital/SP” as appropriate with links to venous care, monitoring of condition or technical
nurse intervention.

Equipment will be logged on team‟s equipment data record. All equipment will be
registered with BME and serviced/maintained/repaired by them. Equipment usage will
be documented in child‟s records.

Protocols for use will be based upon manufacturer‟s guidance. Information on use to be
kept with all equipment.

Problem‟s identified hazards or deficits in equipment will be liaised and reported as per
PCT policy.
Performance Management

Team Leader for Children and Young People with Complex Health Needs will be
responsible for performance management.


                                                                                            16
Collation of statistics in relation to avoidable admissions will be undertaken monthly in
line with current audits.

This information will be provided on a quarterly basis to the Children‟s Services
Manager.

Equipment Sponsor: Julie Devine




                                                                                            17
Environmental Controls Equipment
The following equipment will support the Community OT team in managing
approximately 10-15 severely disabled patients within their own home. The equipment
incorporates;

      Central control units
      Associated peripheries (ie hands free telephone, connections to door intercom)

Estimated Cost - £45,000 (10 x £4,500 each)

Rationale

The above equipment will support the community OT team to;

      To increase the number of people maintained successfully at home
      To reduce the number of avoidable admissions to hospital
      To reduce the number of delayed discharges due to the lack of appropriate
       equipment
      To reduce the number of people supported through continuing care

Revenue Implications

There is a monthly maintenance of around £52 per unit which will be managed under
provider services existing environmental controls budget.

Protocols

The environmental control specialist would manage the process for assessment and
application of the equipment.

Complex assessment criteria are already in place, and would feed into the SAP process.


Performance Management


Collation of statistics in relation to avoidable admissions will be undertaken monthly in
line with current audits.

This information will be provided on a quarterly basis to the Integrated Community
Equipment Project Board.

Equipment Sponsor: Lynn Keirs




                                                                                            18
Telehealth Pilot
“Telehealth” (or telemedicine) is a form of telecare focused at managing a user‟s medical
condition. It is the remote exchange of physiological data between a patient at home and
medical staff at hospital or in primary care to assist in diagnosis and monitoring of
chronic conditions. It includes (amongst other things) a home unit to measure and
monitor temperature, blood pressure, and other vital signs for clinical review at a remote
location (for example, an office or health centre) using phone lines or wireless
technology. It can also be monitored through a call centre using specifically agreed
protocols for response in the event of vital signs falling outside of set parameters.

This is a relatively new technology in the UK, with significant changes in current
protocols required to facilitate its usage.

The PCT in partnership with Adult Social Services will look to pilot 30 telecare monitors
across COPD and CHF patients (15 across each group) for six month pilot from March
2007. This will then allow the PCT to evaluate its benefits at a local level prior to making
a decision as to whether to invest further in the technology.

Estimated Cost – Pilot £20,000. If successful, PCT to recommend whether further units
should be purchased up to value of £116,000 (remainder of grant).

Rationale

The above equipment is aimed at support the COPD and CHF specialist nurse teams in
the following ways;

      To reduce the number of avoidable admissions to hospital
      To reduce the number of delayed discharges
      To reduce the amount of time needed with each patient to manage their needs,
       through active self-management.

Evidence

The potential of telehealth in ameliorating a large proportion of the factors triggering
increased levels of care and support has recently been shown in a systematic literature
review (Brownsell et al 2005, Aldred et al 2005). The systematic review carried out by
Barlow et al begins to demonstrate where there is evidence for this potential.

There is already a range of evidence for the various types of telehealth application, for
example telehealth aimed at specific chronic health conditions or telecare to support
safety and security in the home. This is based on the many technology trials and small
scale schemes from around the world, and is reported in specialist journals. However,
the quality of the evidence varies considerably, depending on the focus of the tele health
application and what type of evidence has been collected (Barlow et al 2005)

Therefore, a pilot is seen as the best way to establish whether telehealth can support
local patients effectively, with a ring-fenced resource to extend the service provision if
successful.


                                                                                             19
Revenue Implications

2007/08 monitoring/maintenance revenue costs covered within pilot costs.

Protocols

To be developed within pilot guidelines. Please see “A Pilot Study into the effects of
telehealth on COPD and CHF patients in the Community”.

Performance Management

Developed within pilot guidelines Please see “A Pilot Study into the effects of telehealth
on COPD and CHF patients in the Community”.

Equipment Sponsor: Ben Chico/Gail South/Marion Jones




                                                                                         20
Conclusion

Through the above opportunities, more patients will be managed n the community,
improving their independence and reducing the burden on secondary care.

Due to the low level of quantitative evidence currently available to support assistive
technology generally, the White Paper „Our health, our care, our say: a new direction for
community services‟ noted the need to build the evidence base for community services
and this is likely to result in an increased focus on evaluation of a wide range of assistive
technology across the country.

It is therefore a requirement of these investments that the equipment sponsor takes
responsibility for ensuring that the technology is performance managed against the
outcomes that have been identified, to inform future commissioning decisions for
investment.




References

      DoH Research and Development Work Relating to Assistive Technology 2005-06
       Presented pursuant to c.44 1970 Section 22
      Assistive Technology, Audit Commission 2004
      AT Home with Assistive Technology Kings College London April 2004
      NHS Plan (2000)
      National Service Framework for Older People (2001)
      Wanless Report (2002)
      NHS Improvement Plan - Putting People at the Heart of Public Services (2004)
      Supporting People with Long Term Conditions (2005)
      Independence, Wellbeing and Choice (2005)
      Our health, our care, our say (2006)
      A Sure Start to Later Life (2006)
      Direction of Travel for Urgent Care (2006)
      NSF Long Term conditions DOH, March 2005
      Evaluation into Profiling Beds (PASA Evaluation review 2003)




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