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BMJ Open, Vol Research Archive Citation for published version: Trisha Greenhalgh, et al, ‘SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context’, BMJ Open, Vol. 6 (2): e010208, February 2016. DOI: http://dx.doi.org/10.1136/bmjopen-2015-010208 Document Version: This is the Published version. Copyright and Reuse: Published by the BMJ Publishing Group Limited. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ Enquiries If you believe this document infringes copyright, please contact the Research & Scholarly Communications Team at [email protected] Downloaded from http://bmjopen.bmj.com/ on February 5, 2018 - Published by group.bmj.com Open Access Protocol SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context Trisha Greenhalgh,1 Sara Shaw,1 Joe Wherton,2 Gemma Hughes,1 Jenni Lynch,3 Christine A’Court,1 Sue Hinder,2 Nick Fahy,1 Emma Byrne,2 Alexander Finlayson,1 Tom Sorell,3 Rob Procter,4 Rob Stones5 To cite: Greenhalgh T, ABSTRACT et al Strengths and limitations of this study Shaw S, Wherton J, . Introduction: Research to date into assisted living SCALS: a fourth-generation technologies broadly consists of 3 generations: ▪ ‘ ’ study of assisted living Introduces and applies the fourth generation technical design, experimental trials and qualitative technologies in their approach to the study of assisted living technolo- organisational, social, studies of the patient experience. We describe a fourth- gies in organisational, social and political political and policy context. generation paradigm: studies of assisted living context. BMJ Open 2016;6:e010208. technologies in their organisational, social, political and ▪ Aims to collect rich qualitative data at three doi:10.1136/bmjopen-2015- policy context. Fourth-generation studies are levels: micro (the patient experience), meso 010208 necessarily organic and emergent; they view (organisational routines and processes) and technology as part of a dynamic, networked and macro (policy and industry context). ▸ Prepublication history for potentially unstable system. They use co-design ▪ Analysis views the technology as part of a this paper is available online. methods to generate and stabilise local solutions, dynamic, networked and unstable system. To view these files please taking account of context. ▪ Includes an action research component to gener- visit the journal online Methods and analysis: SCALS (Studies in Co- ate local solutions and produce cross-case prac- (http://dx.doi.org/10.1136/ creating Assisted Living Solutions) consists (currently) tical learning. bmjopen-2015-010208). of 5 organisational case studies, each an English health ▪ Designed to highlight situated behaviours and or social care organisation striving to introduce Received 8 October 2015 transferable insights to comparable settings. ▪ ‘ ’ Revised 16 November 2015 technology-supported services to support independent Not designed to generate an effect size or for- Accepted 23 November 2015 living in people with health and/or social care needs. mulaic service solution. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We organisations, policymakers, designers and employ a co-design approach informed by the service users. principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of people’s experience of assisted living technologies (micro level), embedded in evolving INTRODUCTION organisational case studies that use interviews, Background ethnography and document analysis (meso level), and It is more than 20 years since Mark Weiser exploring the wider national and international context first mooted the idea of the ‘smart home’,in for assisted living technologies and policy (macro which computer technologies, built unobtru- level). Data will be analysed using a sociotechnical sively into the domestic environment, would framework developed from structuration theory. improve people’s quality of life in numerous Ethics and dissemination: Research ethics approval ways (including security, energy consump- for the first 4 case studies has been granted. An tion, leisure opportunities, health and well- important outcome will be lessons learned from being).1 A generation of research into home- individual co-design case studies. We will document based assisted living technologies—which the studies’ credibility and rigour, and assess the For numbered affiliations see transferability of findings to other settings while also include telecare (alarms and sensors that end of article. recognising unique aspects of the contexts in which detect emergencies such as falls or environ- they were generated. Academic outputs will include a mental hazards such as smoke or carbon Correspondence to cross-case analysis and progress in theory and method monoxide) and telehealth (remote monitor- Professor Trisha Greenhalgh; of fourth-generation assisted living technology ing of biomedical markers such as blood [email protected] research. We will produce practical guidance for pressure, weight or oxygen levels)—has Greenhalgh T, et al. BMJ Open 2016;6:e010208. doi:10.1136/bmjopen-2015-010208 1 Downloaded from http://bmjopen.bmj.com/ on February 5, 2018 - Published by group.bmj.com Open Access produced many prototypes, along with predictions of evolving, and defies taxonomy.13 Today’s published improved health status, patient empowerment and a research always relates to yesterday’s version of the tech- better, safer, more integrated and more efficient health nology. Research into one technology in one context – service.2 4 will not predict the effectiveness or acceptability of Despite this research (and, some would argue, with another technology in a different context. There is thus the single exception of pendant alarms), assisted living a sense of ‘sorcerer’s apprentice’—a field that is outstrip- technologies have been characterised by limited uptake, ping the capacity of researchers to understand and test high rates of abandonment and numerous challenges it.28 Neither assisted living technologies nor the people (economic, operational, technical, ethical, clinical) who use them can be studied effectively in isolation when attempts have been made to embed them into from the complex sociotechnical system in which they – routine health and social care services.3 14 The policy- are (perhaps imperfectly) embedded. In particular, makers’ prediction in 2012 that ‘3 million lives’ would when randomised trial designs are used to ‘control for’ be saved through assistive technologies developed the multiple organisational, social, cultural and political through a ‘concordat’ between government and the influences on which this embedding depends, the exter- technology industry15 has yet to materialise. In short, nal validity of any effect size becomes questionable.29 these technologies represent a classic—though complex Technical descriptions and trials of ‘technology on’ —case study of the non-adoption of technological versus ‘technology off’ reflect technological determinism innovations. (the notion that the introduction of a technology can Research to date into assisted living technologies can determine a particular outcome)—a perspective that has be divided, broadly speaking, into three overlapping long been discredited by sociologists of science.30 31 ‘generations’. First came technical design: studies under- Technologies may create opportunities but they do not, taken largely by computer scientists to develop technolo- in and of themselves, cause personal, organisational or gies and demonstrate proof of concept (ie, that the social change.32 Qualitative studies documenting the technologies ‘worked’ in controlled conditions).7816 design–reality gap on a case-by-case basis may inform, Second came experiments—especially randomised con- but they do not produce, solutions to this gap. trolled trials, designed and conducted mostly by doctors For all these reasons, it is time for a paradigm shift. (who viewed the clinical trial as the most robust way to We propose a fourth generation of assisted living tech- test anything that was offered to a patient). Participants nology research, with five key characteristics. First, were typically assigned to an intervention (‘technology unlike the previous three generations (which, with some plus usual care’) or control (‘usual care’) arm and fol- rare exceptions described below, were more or less uni- lowed up against predefined outcome measures (such as disciplinary traditions in computer science, biomedicine health status, mortality, use of services and cost).514 and social science, respectively), the fourth generation Notably, the large Whole System Demonstrator trial in paradigm is interdisciplinary—drawing on, and synthesis- the UK showed that participants randomised to tele- ing, these previous perspectives along with input from health or telecare had significantly fewer hospital admis- (among other disciplines) management studies, bioeth- sions and lower mortality in the subsequent year—but ics and political science. that these benefits were achieved
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