Cura-B Self Evaluation by Arend Roos

CURA-B SELF-EVALUATION REPORT 2014

ÂŠ Copyright Anglia Ruskin University and CURA-B Partners | April 2014

EXECUTIVE SUMMARY Necessity is the mother of invention. Europe, faced with declining healthcare budgets, a rapidly ageing population and a shrinking workforce, urgently needs radical change to keep healthcare systems affordable. New technologies, innovative approaches and new business models need to be combined in a fresh market approach. CURA-B has been a three year INTERREG IVA 2 Seas collaboration researching and implementing pilot projects that will help SMEs with innovative Assistive Technology products and services to enter the care market. It has taken place through the collaboration of eleven partners across four European regions: Nord Pas de Calais, West Flanders, Zeeland and the East of England with a total budget amounting to € 2.7 million. The objective for the regions participating in CURA-B has been to improve efficiencies in their healthcare sectors by enhancing business development for regional SMEs in order to better meet patient needs. This self- evaluation report explains how CURA-B has done this by identifying the major blockages that face SMEs and then taking action in a series of partner driven pilot projects to bring the public sector, knowledge centres and SMEs (the so called ‘Triple Helix’) together to overcome these blockages and finally to ‘bridge the gap’ between business on the one hand and the world of health and social care on the other. The unique approach of CURA-B has been to introduce a practical model of ‘Open Innovation’ to co-create solutions for the care market. The overall project has had a direct impact through the establishment of regional networks, networking events and trials of new technologies and services that have brought the three elements of the Triple Helix together as equal and open partners to overcome long established barriers in the national health care systems. CURA-B has identified a particular and important role needed for the Triple Helix Co-Creation to work – that of the ‘System Integrator’ and the need for some form of Open Innovation Centres for the development and the application of Assistive Technology.

ACKNOWLEDGEMENTS This self-evaluation has been prepared by the CURA-B team from Lord Ashcroft International Business School (LAIBS), Anglia Ruskin University in Cambridge. Anglia Ruskin’s participation in the CURA B project was initiated in 2010 by Dr Terry Mughan, at that time Professor of International Management in LAIBS. He and his Anglia Ruskin team worked closely with Arend Roos from Impuls and the other project partners to conceptualise and implement an Open Innovation based approach to the achievement of the project aims and guided the project team through Activity 1 and the first part of Activity 2, including the drafting of Stage 1 and 2 evaluation reports. He then left Anglia Ruskin to take up a new post at the University of Victoria, Canada, where he continues to work on new forms of innovation and internationalisation. The directorship of the second half of the project was then taken over by Professor of International Enterprise Strategy at LAIBS, Lester Lloyd-Reason, who guided the team through Activity 3 and the final evaluation stage helped by contributions from Professor Chris Ivory, Professor Ruth McNally, Dr. Stephanie Russell, Dr. Janet Palmer, Dr. Muriel Cadilhac, Ricardo Carolas, Saeed Sadighi, Sandra Selmanovic and Dr. Greg O’Shea. The Anglia Ruskin team at LAIBS would like to thank the partner organisations in CURA-B for their contributions, without which this report would have been impossible. Therefore we would like to officially acknowledge: • At Economische Impuls Zeeland: the contributions of Arend Roos, Martijn Warmerdam and Mira Weber • At Vives in West Flanders: the contributions of: Christa Defrenne, Dries Grymonpré, Michèle Inghelbrecht, Vincent Vergalle and Leslie Vincke • At POM West Flanders: the contributions of Ann Overmeire, Inge Tailleu and Layla Cornelissen. • At Resoc Brugge: the contributions of Sarah Vandekerckhove and Tine Decuypere • At Resoc MWV: the contribution of Inge Vromant and Julie Verhooghe • At HEE: the contributions of Dr.Anne Blackwood, Collette Johnson and Nick Offer • At SCC: the contributions of Jo Cowley, Jason Joseph, Martin Owen and Clare Smith • At WSH: the contributions of Seema Moss and Nick McDonnell • At Eurasanté: the contribution of Sébastien Vermandel And the contributions of Brigitte Smessaert and Peter Deboutte For all of their help and commitment in the last three years.

PARTNERS CURA-B Partners 2010-20141 N.V. Economische Impuls Zeeland (PP1 – Lead Partner) NV Economische Impuls Zeeland (Impuls), established on 2 July 2007, is the development authority of the Province of Zeeland, which has the aim to strengthen the dynamics of Zeeland’s economy. Buitenruststraat 225 4337 ER Middelburg The Netherlands www.impulszeeland.nl Eurasanté (PP2) Eurasanté is an economic development agency focusing on biotech, nutrition and healthcare activities in Northern France. 310 Avenue Eugene Avinée 59120 Loos-lez-Lille France www.eurasante.com (POM) Provinciale Ontwikkelingsmaatschappij West-Vlaanderen (PP3) The Provincial Development West Flanders promotes entrepreneurship by encouraging between businesses and their organizations, knowledge institutions, the regional management bodies and the social partners, to achieve a sustainable, innovative and internationally oriented economic fabric. Koning Leopold III-laan 66 8200 Sint-Andries/Brugge Belgium Flanders www.pomwvl.be IN-HAM - Innovation Centre in Housing for Adapted Movement (PP4) An advice and innovation center for assistive technology. Koolskampstraat 24 8830 Hooglede-Gits Belgium Flanders www.in-ham.be 1 IN-HAM left after about 1 year in the project.

CHAPTER 1

Katholieke Hogeschool VIVES (formerly KATHO) (PP5)

Anglia Ruskin University Higher Education Corporation (PP9)

VIVES is a Catholic College of Higher Education (knowledge centre) offering Bachelor’s Degree programmes and specialisations in biotechnology, healthcare, commerce and business, industrial science and technology, education and social work.

Anglia Ruskin University is one of the largest universities in the East of England with campuses located in Cambridge, Chelmsford and Peterborough.

Since September 2013, KATHO (PP5) and KHBO (PP11) have become VIVES University College as a result of the cooperation between KATHO (with campuses in Kortrijk, Roeselare, Tielt and Torhout) and KHBO (with campuses in Brugge and Oostende). Campus Kortrijk Doorniksesteenweg 145 8500 Kortrijk Belgium Flanders www.vives.be RESOC Midden-West-Vlaanderen (PP6) The aim of RESOC (Regional Socio-Economi Consultation) Midden-West-Vlaanderen is to create a strategic vision of socio-economic development of the region. Regional House Roeselare-Tielt Peter Benoîtstraat 13 8800 Roeselare Belgium Flanders www.resoc.be Suffolk County Council (PP7) Publicly funded governing organisation which includes elected officials and which provides public and social services for the county of Suffolk. Endeavour House Russell Road Ipswich Suffolk IP1 2BX United Kingdom www.suffolk.gov.uk HEE (Health Enterprise East) Ltd. (PP8) Health Enterprise East Limited (HEE) is the NHS Innovation Hub for the East of England and assists with accelerating the development and uptake of innovative medical technology products and services that improve the quality of healthcare delivery. Cambourne Business Park Cambourne Cambridge www.hee.org.uk

East Road Cambridge CB1 1PT United Kingdom www.anglia.ac.uk West Suffolk Hospital NHS Trust (PP10) West Suffolk Hospital is an approximately 430 bed facility serving a population of around 275,000 people within area of approximately 600 square miles. The hospital also treats patients living outside this area who actively choose to be referred to it. Trust Office, Hardwick Lane Bury St. Edmunds Suffolk United Kingdom IP33 2QZ www.wsh.nhs.uk VIVES University College (formerly KHBO) (PP11) VIVES is a Catholic College of Higher Education offering Bachelor’s Degree programmes and specialisations in biotechnology, healthcare, commerce and business, industrial science and technology, education and social work. Since September 2013, KATHO (PP5) and KHBO (PP11) have become VIVES University College as a result of the cooperation between KATHO (with campuses in Kortrijk, Roeselare, Tielt and Torhout) and KHBO (with campuses in Brugge and Oostende). Campus Brugge Xaverianenstraat 10 B-8200 Brugge Belgium www.khbo.be/international RESOC Brugge (PP12) The aim and purpose of RESOC (Regional SocioEconomi Consultation) Brugge is to create a strategic vision of socio-economic development of the region. Streekhuis Kasteel Tillegem Tillegemstraat 81 8200 Brugge Belgium Flanders www.resoc.be

TABLE OF CONTENTS EXECUTIVE SUMMARY 3 ACKNOWLEDGEMENTS 4 CHAPTER 1 11 CHAPTER 2 17 CHAPTER 3 43 CHAPTER 4 53 CHAPTER 5 93 CHAPTER 6 103 CHAPTER 7 125 APPENDICES 141 GLOSSARY 186 REFERENCES 187

CHAPTER 1

LIST OF TABLES Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table

1: Overview of the Data Received Across All Regions 2: Revenue in Total across All Regions 3: Revenue by Region 4: Activities that SMEs are Involved In 5: Types of Products which SMEs Sell 6: Cross-Regional Comparison of the Main Group of Customers for SMEs 7: Example of the Customers in West Flanders 8: SMEs and the Procurement Processes in the Four Regions 9: Difficulties in the Fragmented System Region by Region 10: Finding Customers and Selling in the Four Regions 11: How SMEs Gather End User Needs? 12: How SMEs Gather Customer Feedback 13: Care Provider Responses: Involvement with SMEs and AT 14: Care Provider Attitudes to SMEs and Innovation 15: Obstacles to Care Providers to Adopting AT 16: Workshops Held in Four Regions 17: Participants that Took Part in the Research 18: The Nine CURA-B Pilots 19: The Business Model Canvas 20: The Business Model Canvas and Key Questions to Ask 21: Practical Application of the Case Study Method in International Business 22: 1 - The Network Builders 23: IMPULS Pilot Project - ‘Santé Zeeland’ 24: 2 - Building Business Models 25: Example Output – Eurasanté Facilitated BMC for Entrance Project 26: Business Model Canvas - VIVES (KATHO) - Resoc Bruges-POM 27: 3 - Facilitators of Triple Helix Collaboration 28: adapted Business Model Canvas - Impuls Pilot: De Zeeuwse Huiskamer 29: Facilitating Co-Creation: WSH Pilot 'Bluetooth Diabetes Monitor' 30: VIVES (KHBO): 'Lighting in a West Flanders Care Home' 31 Facilitating Co-Creation: Dragon’s Den Event 32: Overall Learnings from Pilot 33: Separated-Control Based Development 34: Open Innovation Value Network Approach in CURA-B 35: Triple Helix - Open Innovation in CURA B 36: Multi-sided Open Innovation in Value Networks

19 20 20 21 21 22 23 26 27 29 30 30 31 32 33 44 45 55 56 57 58 62 64 66 68 69 73 75 78 81 86 90 95 95 98 99

CHAPTER 1

TABLE OF FIGURES Figure Figure Figure Figure Figure Figure Figure Figure Figure

1: 2: 3: 4: 5: 6: 7: 8: 9:

Percentage of Active SMEs in AT Pie Chart Showing the Number of Different Products Sold by SMEs Pie Chart Showing the Main Customers SME Obstacles for Getting Products to the Market (Across the Regions) Support Needed by SMEs to Gain Access to New Markets RI 1 Synthesis Model Pie Chart Illustrating the % of Participants in the Workshops Activity 2 'Insights' from the Workshops Synthesis Model of Obstacles Facing SMEs

19 22 23 24 25 28 45 45 46

Chapter 1

CHAPTER 1

Background The CURA-B project (acCURAte-Business) is a three year priority 1 EU ERDF project part-funded through the Secrétariat Technique Conjoint INTERREG IVA 2 Mers programme to promote entrepreneurship and the development of new cross-border initiatives. The project has sought to develop best practice models for the procurement, development and deployment of innovative AT-led (Assistive Technology) service solutions for the social and health care markets (often referred to as tele-health, tele-medicine and/or tele-care). The CURA-B project is led by Economische Impuls Zeeland (Impuls) a regional development agency located in Zeeland in the Netherlands. Impuls brings together organizations in the West Flanders region of Belgium, the North Pas De Calais region of France and Suffolk and Cambridgeshire counties in the East of England region of the UK.

Objectives of CURA-B The objective for all regions participating in the project has been the improvement of well-being through the enhanced use of Assistive Technology (AT) in tele-healthcare market segments. If effectively applied, AT solutions have the potential to better meet patients’ needs, to improve efficiency in the healthcare sector and to lower the cost of health and social care. A concurrent objective then of CURA-B has been to enhance AT business development by improving access for SMEs wishing to contribute innovative AT products and services to tele-healthcare market segments. The CURA-B project is thus focused on enabling the innovative power of entrepreneurs to strengthen services in health and social care markets. The four regions taking part have common challenges: ageing populations, shrinking work forces, greater demands on health services from chronic conditions, large rural areas across which they need to provide health services and shrinking budgets. Few of the many innovative products, services and concepts that have been developed in the regions have reached the market for healthcare and social care. For the most part, the entrepreneurial strategies used by companies wishing to enter the market have not been sufficiently effective. A major challenge has been to understand the financial, governmental (including regulatory), and organizational context of health and social care in order to forge greater collaboration between businesses who can offer solutions to this sector. A new market approach has been necessary in order to let everyone win in the business chain, from inventor to end-user. CURA-B has aimed to develop and test new market entry approaches and business models, communicative interactions and strategies for a winwin implementation of innovative AT products and services to the social care market.

The more specific aims of the project have been to bridge the gap between SME producers and end users through the creation of a model that improves SME access to the care market and drives down the cost of improved health care and wellbeing. The strategy has been to do this by improving opportunities for business development and innovation within the health and social care sectors while at the same time increasing awareness of the applications of Assistive Technology for all stakeholders. This has been done through cross-border learning about different tele-health and tele-care ‘ecosystems’ and between pilot case studies engaged in by the project partners. This learning includes a better understanding of the financial, governmental (including regulatory) and organizational context of health and social care and through the development and testing of new business models.

Funding for CURA-B The CURA-B project is 50% funded by the European Regional Development Fund (ERDF) under the INTERREG IVA 2 Seas program. The total budget for the CURA-B project was € 2.7 million. The CURA-B Partners by Region are: Zeeland, one partner (Lead Partner): • Economische Impuls Zeeland (‘Impuls’) Nord Pas De Calais, one partner: • Eurasanté West Flanders, four (formerly five) partners: • VIVES ( formerly KATHO – Katholieke Hogeschool Zuid- West Vlaanderen and KHBO – Katholieke Hogeschool Brugge-Ostend) • Resoc (Regionaal Sociaal-Economisch Overlegcomité) Brugge • Resoc Midden West Vlaanderen (‘Resoc MWV’) • Provinciale Ontwikkelingsmaatschappij WestVlaanderen (‘POM’) East of England, four partners: • • • •

Health Enterprise East (‘HEE’) Anglia Ruskin University (‘ARU’) West Suffolk Hospital (‘WSH’) Suffolk County Council (‘SCC’)

For more information about the project and its partners, please visit the CURA-B website.1

12 1 www.cura-b.eu

CHAPTER 1

The Partner organizations represent public sector providers, regional economic development specialists, innovation support specialists and higher education knowledge centres. Regional Economic Development agencies: • Impuls, Eurasanté, POM, RESOC MWV and RESOC Brugge Business accelerator / innovation hub / business support organizations: • INHAM a West Flanders knowledge centre for Assistive Technology (was a partner in CURA-B from January 2011 to July 2012), and • HEE is an innovation hub for healthcare in the East of England Healthcare Providers: • WSH and SCC Higher Education institutes: • KATHO and KHBO now merged together to become VIVES in West Flanders • ARU in Cambridge, UK

CURA-B Project Activities CURA-B took place as a three phase project between January 2011 and December 2013 with an additional short phase for reflection and evaluation between January 2014 and March 2014. The project terminology refers to the three phases as: Activity 1, Activity 2 and Activity 3. The three Activity Periods spanned approximately 1 year each with some inherent overlap in focus. In this way CURA-B can be viewed as an extended Action Research project: seeking first to understand the current state and key challenges for SMEs ( Activity 1); second, to generate possible options for actions (Activity 2); third, to implement some of these actions (Activity 3) and finally, to reflect, evaluate and suggest further actions (final reflection phase).

CURA-B Beneficiaries The main beneficiaries have been and will continue to be: • SMEs: working in the field of assistive technologies and in the field of innovative health services and SMEs not yet working in the sector but who are developing products that have an application in the sector • Healthcare providers including Public Hospitals; Private Hospitals and Clinics; Public and private insurance providers; Nursing homes; Home based care for elderly people; Residential care for elderly • Elderly and chronically diseased persons who form part of the end user group as they will use the product/service and gain benefits from doing so and remain independent for a longer period of time.

CHAPTER 1

ACTIVITY 1: DEFINING THE GAP Research on challenges, best practices and methods led by Health Enterprise East UK

In order to stimulate cross border ideas and trade a cross border conference was organised and held with the 2 Seas Trade project in Kent, UK which took place in October 2013.

The main aim at the outset was to understand the perspectives and needs of public sector providers as well as the obstacles facing SMEs in entering the AT market in order to ‘define the gap.’ The context of health and social care in the four regions was mapped from a financial, governmental and organizational perspective and three pieces of research were performed: a survey of SMEs, interviews with SMEs and interviews with Providers followed by an interim report.

ACTIVITY 3: BRIDGING THE GAP SCC was responsible for the coordination of this Implementation/taking Action phase

ACTIVITY 2: BRIDGING THE GAPS IN THE CHAIN. Ideas / Possible Actions phase (led by In-Ham West Flanders, a former partner in the project) via a series of workshops to generate ideas as to possible actions to take to improve the system and to ‘Bridge the Gap’. The main aim of this activity was to learn from the perceptions and experiences of different stakeholders in the innovation chain of product and service development. To achieve this, the information gathered in the first activity on impediments in the chain from SME to patient was used alongside information on best practices in the participating regions which led to the generation of ideas for possible actions. The output of the workshops consisted of the practical experience and knowledge from partners who are doing business in the care and cure market and based on this ‘real life’ information new improved business ‘models’ were developed that led to new ideas that were tested in the pilot projects in Activity 3.

Nine pilot projects took place which actioned the ideas generated in Activity 2 in order to bridge the gap. The project partners worked with new business partners and approaches and SMEs were challenged to deliver new solutions, preferably based on existing products or services, but in new product/market combinations or by using new business models. The Pilot cases were vehicles for input to the ‘CURA-B Business Handbook’ and were a key part of the final reflections, learnings and self-evaluation. The details of the pilot projects are shown in chapter 4 but certain elements should be highlighted here namely the ‘fertilising of the soil’ through the establishment of sustainable regional networks for providers, local authorities, SMEs and for the influencing of policy. A final conference was held in Middelburg in March 2014 at which the CURA-B Business Handbook for doing accurate business in the health and social care sectors was presented.

CHAPTER 1

2014 Jan to March Reflection on Action phase led by ARU/Impuls Lessons and recommendations on how to Bridge the Gap The main aim in this final phase was to document the key aspects of the pilots, reflecting on lessons learned and to recommend next steps.

CURA-B Communication and Dissemination The general internal aims have been to establish smooth communication and sharing within the project team. The objective of external communication has been to inform SMEs as to how to do business in the field of healthcare and social care and therefore to effectively engage with business support organizations, healthcare actors, regional and local public authorities, European and national health and social care stakeholders and to an extent the patients that were involved in pilot trials. Eurasanté were responsible for developing the communication and dissemination strategy until October 2012. From October 2012, Impuls became responsible for this. Key players in this strategy have also been the four coordinating partners: Impuls, Eurasanté, POM and Suffolk County Council. Each coordinator has been responsible for external communication in its own region and together they have been responsible for developing the communication strategy and the CURA-B website. Results dissemination has been focused at the end of project especially through the publication of the business handbook and the organisation of the final conference presenting to stakeholders, the EU commission and the media.

website. It has however been vital to the project to constantly monitor the progress or any deviations of all foreseen actions and their relevance to the goals which were set out at the start of the project.

For the Sustainability and Legacy of CURA-B It is anticipated that CURA-B will forge partnerships between SMEs and the healthcare sector and between and within regions that will continue to develop beyond the lifetime of the project. A particular focus on cross-border partnerships would prove beneficial as it would help to maintain relationships and partners could assist one another with future developments, innovative products/services or sharing best practice.

Layout of report • Chapter 2 details the activities and insights that took place and which were derived from the research in Activity 1 • Chapter 3 details the activities and insights that took place and which were derived from the research in Activity 2 • Chapter 4 details the activities and insights that took place and which were derived from the actions and the research in Activity 3 • Chapter 5 details the reflections and learnings from the 3 phases of CURA-B • Chapter 6 details the evaluation of benefits and costs in the pilots • Chapter 7 details the value added by CURA-B and the conclusions and suggested next steps to continue the work of the project

CURA-B Project Management and Coordination The project management has been the responsibility of Impuls Zeeland. There has been a Project Management Team comprised of Impuls, Eurasanté, POM, SCC and ARU. The Project Management Team has met 4 times per year. All CURA-B partners form the Steering Committee. This group has met twice per year.

CURA-B and Project self-evaluation Anglia Ruskin University has undertaken a selfevaluation of the project and the evaluation will propose further actions that could be taken by the partners. This self-evaluation took place in the last stage of the project and is published on the CURA-B

Chapter 2

CHAPTER 2

ACTIVITY 1 AND DEFINING THE GAP This chapter is based on the activities that took place in Activity 1 and includes information on the field work conducted in all 4 CURA-B partner regions in 2011. This data collection involved SMEs and Care Providers. Data was generated through three research instruments (RI): an online survey completed by 177 respondents (Research Instrument 1), 48 interviews of SMEs (Research Instrument 2) and 54 interviews of care providers (Research Instrument 3). Similar research instruments were used in all 4 countries, and then translated into Dutch for Zeeland and West Flanders, and French for Lille/Pas-de-Calais. Common reporting documents were also used with the Dutch and French data being translated into English by the investigating partners. RI1 (the quantitative study) was distributed and data collected in each market by the responsible partners and passed on to Anglia Ruskin University for analysis. Individual reports were produced for each country and a synthesis analysis for the 4 countries was carried out and written up. RI2 and RI3 comprised interviews (qualitative studies) and were carried out by partners in each region. An initial analysis of each interview was undertaken, and then

the data was analysed within each region. All the data was then sent to Anglia Ruskin for aggregated analysis including data matching and triangulation. The objectives of the research and some initial questions were as follows: To understand the obstacles facing SMEs • How do SMEs find customers and find out about procurement requests? • What challenges exist for them when selling the product/service and in the collaboration process with end users and providers? • How would they improve the collaboration process and more easily succeed when attempting to sell their products? To understand the perspectives of providers of healthcare • What experience do providers have working with SMEs? Do they have constraints on the size of companies they work with and what kind of externalization strategy do they have? • How does their strategy involve the local economy? • What is their approach to innovation and IPR in general? • What key challenges do they see facing SMEs and what advice would they give them?

General overview of the research instruments used Online Survey with SMEs

targeting or trading in that market space.

Research Instrument 1 (RI1) was a survey of SMEs conducted across the four regions, with the aim being to identify the main obstacles that SMEs have encountered in the areas of innovation, internationalization and product marketing. In addition to the survey, a profile of the SMEs was also acquired in terms of their total revenue, revenue in assistive technology (AT) and information about employees. The survey consisted of 22 questions and these were produced by Survey Monkey. In total 175 responses were received from SMEs. 123 SMEs out of 175 were active in AT but only 107 SMEs (out of 123) returned analysable data.

From the 50 companies identified above, combined with domestic companies known to the respective CURA-B country partner, each participating country was to identify and interview at least 13 Private Industry companies offering qualified Telehealth care product solutions to Health and Social care Providers. The companies to be interviewed were preferably to be SME’s (Small to Medium-sized Enterprises) but in exceptional circumstances and when particularly beneficial to meet the interview objectives, a large organization could be included.

Interviews with SMEs The second stage of the research involved in-depth interviews with SMEs in order to identify the extent to which they collaborate with end users and Care Providers, in the design and selling for AT products/ services. This part of the research enabled the key barriers to market entry and success to be analysed. The aim was that across the four participating countries, at least 75 private industry companies would be surveyed with an aim of identifying a mix of 50 companies who conduct business with the social and/or healthcare sector and 25 who are not presently

In total 48 interviews were conducted across the regions; 12 from the East of England, 12 from Zeeland, 13 from West Flanders and 11 from NordPas-de-Calais. The SMEs ranged in size from 1 person organizations (in the Dutch and Flemish interviews) to an approximately 850 person organization in the UK. In terms of turnover they ranged in size from €2k to €34m (both in Zeeland). The interviews were conducted face to face using a semi-structured template of 14 questions. There was a general summary from the interviewer on key or critical issues. The format of the questions was kept uniform across the participant countries, to allow for an easier collection of information, for the final country and cross-border reports.

CHAPTER 2

Interviews with Care Providers

Some challenges were faced when conducting the interviews:

The third stage of the research comprised of interviews with Care Providers. The Care Providers ranged in size from 1 to 20,000 persons and from £100k to €304m in terms of turnover. The provider interviews focused more on their experience of working with SMEs, their approach to collaborating locally and their approach to innovation. In total there were 54 providers interviewed: 16 from the East of England, 14 from Zeeland, 15 from West Flanders and 9 from the Nord-Pas-de-Calais region. The interviews were performed on a face to face basis using a structured template of 22 questions and finished with a general summary. Similar to the SME interviews, the format of the questionnaire was kept uniform across the participating regions, in order to make the final cross-border reports more easily comparable.

• Some of the interview questions were more relevant to some interviewees than others and this resulted in responses of ‘not applicable’ which did not add substantially to the findings. • There is a potential risk that the interviewee could have been influenced by the interviewer which may have lead them to answer the questions in a way that they thought would please the interviewer, rather than with a response that reflected their own views/opinions. Language and interpretation: • The interview format was in English and then translated. The interview responses were given in the interviewees’ native language and then translated into English - therefore there may have been a lack of uniformity in the words used to describe a particular situation or phenomenon. The analysis has to in some cases presume that certain words or descriptions mean the same thing or a similar thing across the four regions.

Results from the Survey The table below presents a breakdown of the responses by SMEs within each region when asked whether they are active in the AT market.

Table 1: Overview of the Data Received Across All Regions Region

SMEs not involved in AT and not interested in getting involved

SMEs not involved in AT but interested in getting involved

SMEs active in AT

Total

West Flanders

Nord-Pas-de-Calais

Zeeland

East of England

107

159

The bar chart below provides a visual indication of the percentage of active SMEs in the AT market within each of the four regions. It is clear to see that West Flanders has the highest percentage of SMEs who are active in the market, followed by the East of England who has 27. These 2 regions can be

compared to Nord-Pas-de-Calais whose returnable data suggests that only 7 SMEs are active. In all four regions, the SMEs who are active do however outweigh those who are not involved and who are also not interested in getting involved.

Figure 1: Percentage of Active SMEs in AT

CHAPTER 2

Limitations and challenges relating to the data collection:

Flanders and 27 from the UK. These response rates are somewhat uneven, even taking into account the different demographics of the respective regions. The findings acquired can therefore not be fully generalizable due to the small sample involved in the research. However, the responses and information that was acquired provided sufficient detail to illustrate the differences between each region.

The collection and analysis of the data did cause some challenges. For example, at the beginning of the research, the online survey tool was in Flemish and it had to be translated into the other three regional languages, and then translated into English to be analysed. This may have resulted in some misunderstanding and a lack of clarity as the responses had to be interpreted according to the translations provided.

In all regions there were incomplete responses which meant that the respondents did not answer the questions accurately or in full. The analysis software automatically excluded cases with inadequate data with explains why not all of the information provided by the regions could be used.

The number of analysable responses varied across the four regions; there were only 7 analysable responses from France, 13 from the Netherlands, 60 from

Profile of the SMEs (Cross regional & Regional) SME Profiles The table below provides a profile of the collated information gathered on the SMEs across the four regions who were active in AT. It shows that the average revenue for all 107 SMEs was €3.7m; the

largest revenue was €30m and the smallest was €55k. The data also indicates that in all SMEs, half of their total revenue was received from the AT sector and more than 55% of employees were active in AT.

Table 2: Revenue in Total across All Regions Total number of SMEs

107

Total Revenue

Average % Revenue in AT

Average Size

Average % of employees active in AT

Foreign sales office

Foreign production or development facilities

Average revenue €3.7m

50% of the total revenue is from AT

37 employees

Approximately 55%

18%

Approximately 20%

(€55k-€30m)

(0%-100%)

The table below adds further insight to the information provided above, but is specific to each region and provides a comparative overview in relation to the regions’ involvement in AT. As

(0%-100%)

is evident from the data, Zeeland (70%) and the East of England (59%) had the two highest average percentages of revenue coming from the AT sector.

Table 3: Revenue by Region Total number of SMEs

Region

Total Revenue

Average % Revenue in AT

No of employees

Average % of employees active in AT

Foreign sales office

Foreign production or development facilities

West Flanders

Average revenue €4.8m

44%

Approximately 26%

19%

Approximately 17%

18%

Approximately 18%

20%

Approximately 27%

14%

Approximately 18%

(€45k-€30m) 14

Nord-Pas-deCalais

Average revenue €1.8m (€90k-€2.6m)

Zeeland

Average revenue €4.6m (€86k-€16m)

East of England

Average revenue €3.6m (€150k-€20m)

(0%-100%) 26%

(0%-100%) 14

(22%-30%) 70%

(4%-20%) 40

(6%-100%) 59% (0%-100%)

Approximately 12%

Approximately 65% (6%-100%)

Approximately 82% (0%-100%)

CHAPTER 2

The table below illustrates the types of activities in the AT sector within each region, and the total percentage of each activity. The main activity for each region is production, and in particular, the production of goods. Table 4: Activities that SMEs are Involved In

Region

Distribution of goods

Production of goods

Other types of activities

Production of service

West Flanders

43%

37%

11%

Nord-Pas-de-Calais

18%

46%

18%

Zeeland

75%

25%

East of England

26%

63%

Total % of activities in AT across each region

16.6%

46%

15%

22.5%

There are however distinct differences between each region: • West Flanders and Nord-Pas-de-Calais – the main activities of the SMEs are based on the production and distribution of goods. In the Nord-Pas-deCalais region, SMEs need more support with consumer and market research and with new technology and domestic networking. • Zeeland – the main focus is on the production of goods and other activities. In this region, SMEs need support with consumer and market research and foreign networking.

• East of England – SMEs are focused on the production of services. In this region, SMEs need support in terms of consumer and market research; internationalization and gaining access to foreign markets.

Experiences of SMEs in the AT market The following section of this report will outline the experiences of SMEs when they are active in the Care Market. This will include details on what the SMEs sell; their main customers and the challenges they face when innovating and trying to enter into the Care Market. What do SMEs sell? When SMEs were asked in the survey to identify the main products that they sell, respondents indicated that the products were predominantly inclusive

of three main types: aids for communication and information; aids for personal mobility, and aids for personal medical treatment. The top three products and the percentage sold by SMEs across the four regions when the data is combined are displayed in the table below. The table indicates that the most frequently sold products are aids for personal medical treatment; this could involve items such as a glucose meter and a blood pressure reader.

Table 5: Types of Products which SMEs Sell

Types of products

Percentage for each product

Aids for personal medical treatment

25%

Aids for personal mobility

22%

Aids for communication and information

18%

CHAPTER 2

The pie chart below illustrates a wider variety of AT devices which respondents identified as the products that they sold. It is evident that items such as ‘aids for housekeeping’ and ‘aids for training in skills’ were less commonly purchased. This may be due to them not being standard AT devices, and it is also dependent on the type of target group which the SME was selling to.

The numbers represented on the pie chart are the result of SMEs answering the questions from a Likert scale, with responses ranging from minimum - 0, to maximum - 5.

Figure 2: Pie Chart Showing the Number of Different Products Sold by SMEs

Who are the main customers for SMEs? As the table below shows, all four regions had the majority of their customers as Government/health organizations, with only West Flanders having ‘other companies’ (48%) as higher than any other customer.

In the East of England region, ‘end users’ were the highest ranked customer (34%), compared to West Flanders who were least likely to sell to this target group (2%).

Table 6: Cross-Regional Comparison of the Main Group of Customers for SMEs

Region

Companies

Government/health organizations

End Users

Other

West Flanders

14%

36%

48%

Nord-Pas-de-Calais

22%

45%

22%

11%

Zeeland

77%

15%

N/A

East of England

52%

34%

CHAPTER 2

The pie chart below indicates that more than 50% of the 107 SMEs who provided usable information, had their main customer as Government and/or public sector health organizations. This suggests that SMEs are more likely to target the health sector directly in order to distribute their AT products, rather than

attempt to sell to end users or other companies. The challenge of selling directly to the end user, is that this may not be the person who will eventually end up using the product, but instead, could be a health care professional, a carer, or a relative of the patient.

Figure 3: Pie Chart Showing the Main Customers

West Flanders: An example of SMEs engagement with the AT market During the data collection, it became apparent that the information acquired from West Flanders was particularly rich in detail and although it is specific to the region, it does provide an insight which could be used to enhance understanding and knowledge

of the experiences of SMEs in the Care Market. The following table indicates the key features from this region in terms of the health sector customers and end users.

Table 7: Example of the Customers in West Flanders SMEs active in Care Market

Health care customers

End Users

Pro-active monitoring

Pharmaceutical companies, CEOs of hospitals and GPs

GPâ&#x20AC;&#x2122;s and patients with chronic illnesses

Social networking/communications

End User

People with disabilities (old/young/ active/unemployed)

Short-term care: CEOs of hospitals

Nurses, CEOs, elderly/patients

Remote technology

Stand Alone Technology Alarms

Long-term care: CEOs of elderly homes Independent living: CEOs of home care organizations and assistance homes Well-Being Sauna

CEOs of rehabilitation centres and elderly homes

SMEs motivation to enter a new market and the obstacles faced when putting products and services into the Care Market. The Care Market is complex, and within the four regions, each market has its own specific procedures and requirements. The online survey and the interviews conducted with SMEs show that there are

Elderly, patients on rehabilitation and preventive care for healthy people

different characteristics and obstacles faced by the companies when trying to enter the market.

CHAPTER 2

Results from the online survey on SMEs obstacles to market: The survey used a five point Likert scale (1=not at all; 2=slightly; 3=somewhat; 4=very; 5=extremely) to measure the extent to which SMEs experienced each item as an obstacle. SMEs were asked to choose their main obstacles from the list below: • Customers need to be convinced of a new product/service

• Strong competition by current suppliers • Difficulty breaking up long running contracts and entering new products • Fragmentation of the market, multiple decision makers on customer level • Difficulties concerning distribution channels • Subsidized market dealing with its own, specific procedures • Uncertainty/doubts about market potential

Figure 4: SME Obstacles for Getting Products to the Market (Across the Regions)

Source: CURA-B manual (Chapter 2)

As the figure shows, the main obstacles for SMEs in getting their products/services to market are: • Customers need to be convinced of a new product/service • Fragmentation of the market with multiple decision makers on customer level • Subsidised market dealing with its own, specific procedures • Strong competition by current suppliers According to these findings and from the data collected through interviews with SMEs and Care Providers, it is apparent that companies who seek to gain access to new markets will face challenges when trying to break into long standing contracts and to convince Care Providers and GPs of the value or their new product/service. For example, when discussing the obstacles with respondents in the East of England, it was mentioned that the NHS/Social Care Organizations tend to hold SMEs at ‘arm’s length’ and become a gatekeeper for those companies wanting to gain access to the Care Market. Additionally, commissioners tend to commission what they understand, rather than a product or service which will help the end user. These challenges have resulted in SMEs in the UK being reluctant to sell in foreign markets; some of them commented that the UK market is ‘large enough’ and if they were to sell abroad, it would be through a distributor/channel partner, rather than through direct sales.

In West Flanders, SMEs were motivated to enter a new market when this was based on profitability, the market size and the opportunities it would provide for the company to develop and grow. However, some SMEs in this region did not want to enter a new market, but they just wanted to focus on offering new services. The challenges experienced by SMEs in Nord-Pas-deCalais and the Netherlands were similar with regards to them struggling to find ways to reach end-users and to ensure that they were involved in the innovation process. In the Netherlands, it was recognised that the end user is not always the individual that pays for the product/service which means that it can become more of a challenge to gain access to them and acquire their input. In Nord-Pas-de-Calais, SMEs also found it a challenge to get funding for their innovation and to also find a relevant Business Model which was applicable to health-care and ICT. Challenges to Innovation Key challenges by SMEs in the innovation process were found to be: • Availability of Internal Resources (Internal factor) • Too high cost of innovation and/or investment (Internal factor) • Finding external resources (External factor) • Too high economic risks (External factor)

CHAPTER 2

The interviews with SMEs did not focus specifically on the challenges to innovation, but the interviews with Care Providers identified that they faced difficulties with adopting innovative solutions and products. The key obstacles here were government policy and funding. Providers also lack defined policies on their approach to innovation and adaptation and IPR. Obstacles to Internationalisation In the interviews with SMEs, challenges in the internationalisation process were also discussed. Key challenges were identified as: • Local Legislation and Regulation • Finding Capital or Means of Financing • Lack of International Cooperation or Partner The interviews only contained one question specifically about internationalisation and focused primarily on how SMEs internationalised rather than the challenges that they faced. Only in France did they mention any challenges and these were related to language and the organizational cultures in different European health systems. France’s response to

internationalisation can be distinguished from others because they had a particular concern about being able to engage in business related discussions when they were less confident using the English language. As was discussed earlier (page 12), the data acquired was translated from the different regional languages into English in order to analyse it. The UK tended to presume that other regional partners would be able to converse in English, even though it was not their native language. This caused a number of challenges, especially because interactions between partners were not only about having basic discussions, but it was also more importantly related to building strong relationships. If partners were unable to talk and understand each other coherently then connections and collaboration related to their business was unlikely to come to fruition. To try and overcome the challenges faced by SMEs, there was a requirement for specific support to be provided and this is shown in Figure 5; the numbers represent the answers provided by respondents from a Likert scale. They need most support in the areas of: ‘consumer and market research’, foreign networking’, and ‘domestic networking’.

Figure 5: Support Needed by SMEs to Gain Access to New Markets

Support needed within each region: Flanders

Netherlands:

• In this region the respondents needed the majority of support in terms of ‘consumer and market research’, ‘domestic networking’, and ‘foreign networking’. France:

• In this region the respondents needed more support mostly in terms of: ‘foreign networking’ and ‘consumer and market research’. UK:

• In this region the respondents needed most support in terms of: ‘consumer and market research’, ‘knowledge of new technology’, and ‘domestic networking’. This return distinguishes this region from others.

• In this region the respondents needed support most in the areas of: ‘consumer and market research’ and ‘internationalization and foreign markets’.

CHAPTER 2

FINDINGS FROM THE SME INTERVIEWS: Results from SME Interviews The 48 SMEs interviewed across the regions in terms of challenges or obstacles (12 from the East of England region, 12 from Zeeland, 13 from West Flanders and 11 from Nord Pas de Calais) were asked the following question:

“What are the ‘Difficulties in conducting business with the health sector” SMEs felt that a major difficulty was the public procurement process itself, which involves formal public tenders. SMEs find it difficult to have any influence on this public procurement and tendering process and it is particularly slow and burdensome for small

cots. When trying to enter the care market with new AT products and services, SMEs find that they have limitations in their access to end users and purchasing bodies who act on behalf of care providers. This lack of contact with possible users and buyers prevents them from designing and selling their products and services to match the users’ requirements. Cross Regional Summary In the UK and the Netherlands 16 of the 24 SMEs interviewed felt that they cannot influence the procurement process and in the UK they expressly noted the ‘gatekeeper’ role of commissioners and clinicians. In the UK especially, 6 SMEs felt that the tendering process was cumbersome and slow. In France 7 of the 11 felt that they were ‘influenced by’ or affected by the tendering process. There is a contrast here with Flanders where 7 of the 13 noted that they CAN influence the procurement process and that the process is dynamic.

Table 8: SMEs and the Procurement Processes in the Four Regions

Challenges in procurement process

West Flanders Nord-Pasde-Calais

SMEs CANNOT influence procurement process

Tendering process is slow and needs to be better managed

SMEs CAN influence the process

Zeeland

East of England

X X

Source: CURA-B SME interviews autumn 2011

Region by Region summaries East of England

West Flanders

• Majority of the SMEs felt that they cannot influence a cumbersome and slow procurement process • ‘Gatekeeper’ role of commissioners and clinicians – a ‘them’ and ‘us’ attitude. • Care Providers are risk averse and tend to commission for what they might know or understand, rather than what might be possible. SMEs feel that Commissioners decide beforehand who they want to work with and responding to tenders can be viewed as a waste of time and expensive • Specifications often narrowly defined, overly prescriptive and designed to reach the lowest common denominator on price

• Majority of SMEs noted that they can influence a dynamic procurement process • Level of influence is dependent on having good personal contacts and lobbying the right people within Care Provider organizations.

Zeeland and Nord-Pas-de-Calais • Majority of the SMEs felt that they cannot influence the procurement process • Process of responding to procurement tenders remains long and burdensome due to specific regulations and financing structures for small businesses.

Source: CURA-B manual chapter 2 and SME interviews autumn 2011

Obstacles caused by a fragmented system The Care Market consists of multiple stakeholders and many small to medium sized Care Providers so SMEs find it difficult to know who the purchasing decision makers are and they have difficulties in getting close to end users. Across the four regions, SMEs felt that they need to be more aware of how the Care Market operates, but this is less applicable for West Flanders.

CHAPTER 2

Table 9: Difficulties in the Fragmented System Region by Region

Difficulties faced by SMEs

West Flanders

Nord-Pas-de-Calais

Zeeland

East of England

Care Market is fragmented and unclear, conservative and risk averse

Care Market is nonparticipative and difficult to get close to decision makers and end users

SMEs do not understand system well enough

Market needs fresh ideas on financing for research and development to help SMEs

SMEs needs new business models to enter market

Source: CURA-B SME interviews autumn 2011

Cross regional Summary When trying to enter the Care Market with new AT products and services, SMEs find that they have limitations in their access to end users and to purchasing bodies who act on behalf of Care Providers. This lack of contact with possible users and buyers prevents them from designing and selling their products and services more effectively. There is a general lack of participation and consultation with SMEs. Region by Region Summaries Nord-Pas-de-Calais • Healthcare system is complex, especially when it comes to reimbursement issues and requires SMEs to create and implement complex business models. • SMEs must demonstrate and convince possible buyers of the effectiveness and benefits of their products. Zeeland • Care Market felt to be fragmented and unclear. The user is very often not the person who pays for the product or the service. • Difficulties in getting closer to decision makers and end users - a lack of participation and consultation with SMES. • SMEs noted a lack of entrepreneurship within healthcare providers and a lack of desire to invest in innovative projects. Market is conservative and risk averse. East of England

• The official publication of a tender can be influenced on three levels: -- The inclusion of the technical product specifications (via ‘study bureaus’) -- Functionalities/technical specifications via the technical directors of care institutions -- Price setting via equipment installers/ electricians • Success is dependent on good personal contacts and so lobbying is vital.

• There is a lack of standardisation around procurement processes • Getting close to decision makers can be difficult. Flanders • SMEs have much more influence on the contents of a tender. SMEs are usually notified of new procurements well in advance

CHAPTER 2

Synthesis model The ‘Synthesis Model’ below summarises those three main obstacles and SMEs characteristics and capabilities as below: Figure 6: RI 1 Synthesis Model

The diagram illustrates that SMEs face obstacles to innovation which can be classified into both internal and external factors, and they are related to getting products to market, as well as challenges regarding internationalisation. For example, an external obstacle for SMEs attempting to get their product to market is trying to ‘convince customers of the new product’ as this is a factor that the company cannot internally control. This is comparable to an internal factor impacting on innovation, such as ‘cost of innovation or investment which is ‘too high’ which can be directly influenced by the activities which the SME engages in.

How SMEs find customers, sell into the market, and find out about procurement requests Respondents were initially asked who their typical ‘customers’ are. In the Netherlands and Flanders more than 75% of respondents said that customers were Care Organizations or Care Homes. In Flanders and France there were instances of the main customers also being ‘health professionals’. In the UK, in contrast, most customers were ‘Primary Care Trusts’/

hospitals. Respondents across the region, in the main, saw their ‘Users’ as being ‘Elderly’/those in ’Long Term Care’ / ‘Disabled’. To distinguish the differences between the regions, SMEs were asked to:

“Describe how products/services are sold and how they find out about procurement requests and find customers” The analysis of the responses indicated that across the four regions, SMEs are using two core methods for finding customers and selling to customers: • The public procurement method through tenders • The private sales method (based on the traditional sales method using networking, attending trade fairs, conferences, symposia and direct prospecting from a sales force)

CHAPTER 2

There are regional differences that became apparent after analysing the responses to the above question. In France, Netherlands and Flanders, the interviewees indicated that they were proactive and interested (29/46) in gaining information and access to procurement requests and finding customers, whilst in the UK only a minority (5 of 12) said that they were interested or proactive. In total 34 of the 48 in the region said that they were proactive particularly

in Flanders and the Netherlands (18 of 24) with the main process across the region of finding ‘foreign’ customers being through agents or consultants (13) and then networking/conferences/trade fairs (12). In France 3 respondents mentioned ‘via the Internet’. Across the regions, only 6 organizations said that they used trade organizations specifically and these instances were 2 organizations in the UK and 4 in Flanders.

Table 10: Finding Customers and Selling in the Four Regions

West Flanders

Nord-Pas-de-Calais

Zeeland

East of England

Public Procurement Sales: Customers are found via public procurement announcements

Sales via tendering

Private Sales: Customers from direct selling using the processes below

Direct prospecting and sales visits

Place their products for free into schools, hospitals

Direct information of the market through word of mouth and networking

Symposia and seminars

e-trade

X X

Source: CURA-B SME interviews autumn 2011

Region by Region Summaries West Flanders

East of England

Taking part in tendering is important for a sizeable minority of the SMEs interviewed. The majority interviewed use methods other than public procurement announcements for example through a sales force and by attending symposia and conferences.

As in West Flanders, a sizeable minority of SMEs interviewed said that they find customers and sell via public procurement notices i.e. by monitoring public procurement websites and announcements and taking part in tenders. The majority said that they found customers and sold services and products through networking, attending conferences and having a sales force.

Zeeland Customers mainly found through making contacts and through networks, ‘Networking’ was the largest single explanation given from the SMEs interviewed as to how they sell. Sales performed also through contractors Nord-Pas-de-Calais Customers mainly found through sales forces calling, prospecting and making contacts. A few SMEs follow database announcements. Most SMES follow a ‘traditional’ process of selling through sales calls, sales demonstration and equipment loans. One of the respondents sold through ‘E-Trade’.

Obstacles caused by a fragmented system For the SME wanting to place products into the Care Market, the market consists of multiple stakeholders and many small to medium sized Care Providers. SMEs find it difficult to know who the purchasing decision makers are and they have difficulties in getting close to end users.

CHAPTER 2

What challenges exist for them during the process of selling their product/service and in the collaboration process with end users and providers? The SMEs were asked in the interviews:

The main regional difference was the UK where most respondents (10 from 12) did NOT have any formal method and in the UK 4 said specifically that they would like the possibility to get closer to users, i.e. to have a better access and a more conscious method. In the Netherlands also, 4 from 12 said that obtaining end user needs was difficult.

“How do you gather end user needs and do you obtain feedback from purchasers and consumers?” The analysis shows that across the four regions, the majority of SMEs (33 of the 48) said that they had some form of conscious method for gathering user needs. Table 11: How SMEs Gather End User Needs?

Gathering End User Needs

West Flanders

Formal methods to gather X end user needs

Nord-Pas-de-Calais

Zeeland

East of England

(minority)

Informal - No formal method

Would like to get closer to users

Source: CURA-B SME interviews autumn 2011

There are a variety of methods used to gather end user needs • These ranged from design meetings, to field interviews through to questionnaires and testing. • Informal methods were used in the East of England. These are less conscious methods like networking, attending seminars and symposiums.

The analysis of responses for ‘gathering customer feedback’ showed that the majority of SMEs in the region (42 out of 48) had a regular method within their sales and development processes.

Table 12: How SMEs Gather Customer Feedback

Obtaining customer feedback

West Flanders

Nord-Pas-de-Calais

Zeeland

Regular method

Feedback process is constant & iterative

Collect feedback via intermediary

East of England X

Source: CURA-B SME interviews autumn 2011

• In West Flanders and Nord Pas de Calais all SME respondents thought that the customer feedback process was constant and iterative. • Also in Zeeland almost all had a formal process (11 from 12) • In the UK only 7 of the 12 SMEs said that they had a formal or regular feedback process. 3 SMEs expressed a disappointment that obtaining customer feedback was difficult and 9 of the 12 SMEs had to collect such feedback via an intermediary, for

example clinicians/commissioners, who in some cases acted as ‘gatekeepers’ to SME access to and from ‘customers’.

CHAPTER 2

SECTION 2: EXPERIENCES OF CARE PROVIDERS The third part of the research involved interviews with Care Providers where the focus was on their attitudes regarding Assistive Technology and also how willing they were to work with SMEs. As Assistive Technology encompasses many different products and services, the definition used in the interview guide was: AT is any device or system that delivers the following benefits: • Improves the independence, life-style and care provision for both patient and carer by allowing an individual to carry out a task they could not otherwise do, or receive care in a local and convenient environment • Increases choice of care pathways • Reduces risk of harm

• Reduces the potential of further care episodes by prevention and early intervention • Allows health and social care professionals to monitor the condition and well-being of an individual • Provides health and social care professionals with data that will assist in the delivery of care and the development of future care pathways. “ The four objectives of the interviews with the Care Providers were as follows: • Who are the providers and what is their involvement with AT? • How do they work with SMEs? • What is their approach to innovation? • What advice do they have for SMEs?

Care Providers and their involvement with SMEs The majority of care providers in the four regions described their sector as being in social, home or residential care. In the East of England they mainly classified themselves as primary care/medical. The findings presented in the table below indicate that the majority of care providers interviewed in Zeeland were working or had worked with SMEs. In West Flanders and in Nord Pas de Calais a majority of SMEs had some experience, and in the East of England a small minority had worked with SMEs. In all four regions, this involvement was primarily in testing and development.

Care Providers across the regions said that there were no constraints on the size of SME or company that they could work with, though in all of the countries there were some constraints caused by a necessity to follow certain tender requirements. Care Providers across the regions have a positive policy towards externalisation, especially to patient and care groups, the majority of care providers had a positive approach to the local economy in that they try to use local staff and local suppliers. Across the region the majority of respondents felt that they had a positive approach to the local economy with 39 of the 54 employing local staff and 20 of the 54 purposely using local suppliers. Again, only 1 organization (in Flanders) had a definite policy of using local SMEs.

Table 13: Care Provider Responses: Involvement with SMEs and AT

Questions to Care providers What is your previous experience of working with SMEs? Has your organization ever been involved in innovation and/or telehealthcare projects? Are there any constraints on type or size of companies you can collaborate with?

West Flanders

Nord-Pas-deCalais

Zeeland

East of England

Half have considerable experience ‘ half have some experience

Majority have Majority have limited experience experience with SMEs as suppliers

Minority had had experience with SMEs

Majority had been involved on several occasions- mainly in Testing and Call/alarm systems

Majority had been involved through some form of project or testing and development

Half of providers had been involved through some form of testing and development

Majority had been involved through some form of project or testing and development

In general - No

CHAPTER 2

No but some Providers Does your organization need to follow have any funding procurement or constraints or policies? tendering rules

Majority need to follow some form of public tender requirements

No but some Providers need to follow procurement or tendering rules

Does your organization Yes – with patient and have an externalization care groups strategy?

Yes – with patient and care groups

What is your Positive – use local staff organization’s approach and suppliers regarding responsibility to the local economy?

Positive – use local staff and suppliers

Source: CURA-B Care provider interviews autumn 2011

How do Care Providers approach innovation and IPR? The attitudes of Care Providers to innovation are important for SMEs hoping to develop or sell AT products in the care market. Table 14: Care Provider Attitudes to SMEs and Innovation

Question asked to Care provider

West Flanders

Nord-Pas-de-Calais

Zeeland

What is your organization’s approach to innovation?

Positive approach towards innovation

Positive approach Generally positive towards approach towards innovation innovation

Majority want clear added value, feasible, affordable

Majority want clear value for money in line with financial considerations

Half are pragmatic, case by case basis in line with innovation policy

When a company offers a new product or service, what is your decision making process Minority to accept or not this mentioned innovation? that should be innovative

Does your organization have a policy on the adaptation of existing solutions for new services?

Does your organization have awareness or knowledge of the progress, success or failure of other pilot AT projects? What is your organization’s policy on intellectual property rights?

Innovation should be qualified

Small minority were conservative and had no specific policy

Management initiatives

Majority had a case by case method based on merit

Majority have a policy or principle of some form

Majority want some form of policy – they are open to ideas

Almost half said they have no policy

Minority had no policy or the question not yet so applicable

More than three quarters said successful or partially successful

Almost 40% said successful , majority felt question not yet applicable

Yes as part of a general constant development policy and via EQFM, specific internal groups or doctors pushing initiatives

More than half said no specific policy – many rely on what is in a yearly plan

Almost half said question not applicable and a sizeable minority said NO benefit

Only one third said successful , others either no or not yet applicable

Majority had no formal policy towards IPR

Majority had no Majority had no formal policy towards formal policy IPR or that question towards IPR was not yet applicable

Source: CURA-B Care Provider interviews autumn 2011

East of England

Majority had no formal policy towards IPR or that question was not yet applicable

CHAPTER 2

The analysis from the findings in the table above indicate that the majority of Care Providers had a positive attitude to innovation, but only 1 of the Care Providers (in the UK) responded that they had a formal policy for innovation. In West Flanders, respondents felt that there was a general development towards policies, driven mainly by doctors, interest groups and EQFM requirements. In Nord-Pas-deCalais, the majority of Care Providers had no form of policy on innovation and within all regions a policy on Intellectual Property Rights was minimal. When the Care Providers were asked how they decided to accept new products or services, in West Flanders, the responses were based on affordability, added value and feasibility. In Nord-Pas-de-Calais they also wanted value for money in line with financial considerations. In Zeeland, innovation was dealt with on a case by case basis, and new product adoption often came from management initiatives.

Obstacles to the deployment of new services - responses by Care Providers Care Provider responses: obstacles to deployment of new services The Care Providers were asked:

“What challenges or barriers have prevented you entering the health market, or impacted on the success of previous projects?” The following prompts were given: • • • •

Government policy Procurement policy Insufficient contacts within the health sector Insufficient market knowledge or supporting data

Table 15: Obstacles to Care Providers to Adopting AT

Obstacles

West Flanders Nord-Pas-de-Calais Zeeland East of England

Government policy

Procurement policy/Tender regulations

Insufficient contacts within the health sector Insufficient market knowledge or supporting data

Conservatism, lack of knowledge of patients/users Funds/financial issues

X X

Compatibility with other technology

Current ways of working

Region by Region Summaries West Flanders

Nord-Pas-de-Calais

• Rigid Government legislation and regulattions is a barrier to Care Providers as they look to adopt AT. However, at the same time Care Provider organizations are being pushed by government policy to develop new projects through project calls. • Lack of knowledge about projects in AT is another barrier. Information on AT development is found through visiting fairs, conferences and reading professional literature. Care provider organizations also often make use of exchange of experiences with partner organizations which they are related to in group structures or which they know from networking events. • Further barriers are insufficient staff, insufficient funding and worries about the efficiency of after sales service.

• The main barriers to AT innovation for care providers are government policy and a lack of funds. • The main barriers to SME collaboration are a lack of time and staff and a lack of knowledge combined with a conservative attitude. Zeeland • Care Providers interviewed mentioned financial regulations and difficulties in avoiding them in order that they are able take risks and invest in technology. • General reluctance due to many projects in other regions having failed for financial reasons. • It is difficult to make people change and to bring social innovation into their organizations.

CHAPTER 2

• Importance of cooperation between several care providers, especially related to technical infrastructure. The infrastructure should be shared by more providers and investment would definitely make sense, but there is not enough urgency. East of England • SMES are not perceived as being in sufficient contact with the market, leading to the following problems: • Seeking a market for a product and not designing for the market • Inappropriate presentation of the product (issues of labelling, over/under packaging, instructions) • Poor grasp of pricing and ensuring a wholesaler’s percentage • Little attention to training both end users and professionals in the appropriate use of their equipment. • Not understanding the attractiveness of a datacollecting package with more complicated monitoring/medicating products. • Need for after-sales service

The recurring issue highlighted across the four regions with regards to the obstacles faced by SMEs is based on the acquisition of, or lack of knowledge regarding end-users, the procurement process or the AT market in general. This has been discussed in scholarly articles, regarding how ‘knowledge spillovers’ are believed to ease firm interactions and knowledge diffusion (Autant-Bernard et al, 2013: p196). It could be argued that if SMEs are geographically distanced from their end-users or providers, then this could impact negatively on the extent to which they are able to create effective knowledge flows, but one has to also take into account culture, behaviours and the institutional context (Autant-Bermand et al, 2013: p198).

CHAPTER 2

SECTION 3: CARE PROVIDER ADVICE FOR SMES

•

In each region care providers were asked to give general comments and advice in their interviews to SMEs. These comments are summarised below. Therefore in each there are region-to-region differences in the style of responses.

• •

West Flanders

•

• Overall Care Provider advice is to listen to users, discover their needs, understand the market and collaborate with the stakeholders and be prepared to offer after sales service. • Future projects will be around consolidation of market share amongst care providers and expansion plans towards home care which can be seen in the residential care organizations. Future plans on assistive technology are automated pharmacy logistics, mobile patient care files, care registration (for benchmarking) and detection and/or prevention of wandering. • Care providers advise SMEs to provide full information about the offered assistive technology. This includes all costs as there are purchase and total costs of ownership and also the cost of implementation e.g. for customization and staff training. Products should have added value for staff and end users and be simple to use • Care Providers further advise SMEs to deliver products that are adapted to the user’s needs and therefore to cooperate with care provider organizations during all development phases including the development phase. Delivering good after-sales service is also an important issue. Nord-Pas-de-Calais • Most of the care providers interviewed have been or are currently involved in innovation projects. Some providers are ready and willing to collaborate with SMEs early in the process of innovation, in order to express their needs for the development of new products. They are also willing to be involved downstream in the innovation process to test products in their facilities. • Care Providers are using ICT for health in a variety of ways: • To share medical information through the creation of “shared” patient files for people over 60 years to understand their care evolution and postpone or prevent nursing home placement of patients. • To create special units for people suffering from Alzheimer’s • To create social networking for the elderly • To create nursing homes with high technology rooms (with computers, internet, webcam etc.)

• •

in collaboration with French enterprises from the ICT sector. Care providers expect SMEs to show evidence of real effectiveness (tested products or pilot cases) and a high benefit / cost ratio. Care providers expect innovative products to: Fit their specific needs Provide measurable benefits for the end users e.g. comfort, ease of use, effectiveness Allow employees to work in better conditions and more effectively Allow them to save time and money Allow them to differentiate themselves by offering innovative services or better

Zeeland • Care Provider initiatives are affected by the Dutch healthcare system and the demand for services which enable the elderly to remain in their private homes as long as possible. This challenges traditional providers of residential elderlycare to create separate living and care services. This movement towards ‘extramuralisation’ also creates a shift towards a more demandbased offering of care-services and stresses the importance of services which are used to interact and communicate with the patient. Most care providers are aware of the need for change, and implementation of smart services in order to communicate in a more efficient way. Many care providers are involved in building processes together with housing corporations in order to establish apartments in which the elderly are free to acquire the healthcare services they need. • Patient-centred innovation is affecting a significant number of providers in how they connect the care offer to the care demands of the client. Some care providers have methods to establish such care, e.g. Perception-Oriented Care or Positively Passive. This presupposes a changing role towards patient empowerment. Attempts to connect to the patient are of crucial importance in order to find support for other innovations and patient centred innovation should be given a place in development projects. The strand of ‘well-being for elderly’ could serve as a good starting point for that. This supports the academic literature by Lasagni (2012) • Some smaller care providers have a more niche strategy and innovate by strengthening the personal connection in healthcare in that technology plays a less prominent role. The majority of care providers are willing to participate in common project development in ‘social media’, ‘e-health’ (from scheduling appointments online to offering online treatments), ‘domotics’ and ‘use of screen to screen services’.

CHAPTER 2

• There is a strong feeling that many technological solutions e.g. for domotica and telehealth are too strongly focused on technology and are not necessarily an answer to a demand from the market. Care Providers are keen on joint development and in general most care providers interviewed are willing to speak with SMEs on their constraints and explain what they are expecting. • SMEs need to make clear what the value added by the technology used is, how to use the technology and the importance of social innovation. In significant procurement processes, price and quality are more important drivers. SMEs need to teach employees to work with these instruments and appeal to the hearts of the nurses. East of England • The role of commissioners - both care providers and health providers revealed in interviews that their activities are controlled to a large degree by commissioners of services. An understanding of this barrier is needed and it is essential to include this in the field research. The commissioners identified were local government and the NHS Trusts. • Poor penetration of assistive technology there are still few informed customers and therefore demand.

• Challenge of Virtual wards - Treatment tariffs need to be heeded. E.g. hospitals involved in continuing healthcare have, in addition to serving health needs, to remain in sustainable business. If dependency on telehealth increases, and it is effective, the throughput of patients at those hospitals will decline. In consequence the income of the hospitals will decline. • Insight into limitations of SMEs • Some SMEs are not sufficiently in contact with the market. Problems included: • Seeking a market for a product, not designing for a market • Inappropriate presentation of the product (issues of labelling, over/under packaging, instructions) • Poor grasp of pricing and ensuring a wholesaler’s percentage • SMEs should be aware of need for after-sales service • Little attention to training both end users and professionals in the appropriate use of their equipment. • Not understanding the attractiveness of a datacollecting package with more complicated monitoring/medicating products.

Inventory of existing methods and business models ‘to bridge the gaps in the chain’ This section of the evaluation report will draw on material from SMEs to identify suggestions and ideas on how to ‘bridge the gaps in the chain’ discussed in earlier sections of the report. A consideration of appropriate business models will also be discussed. The main challenges and obstacles identified by SMEs have been classified into three headings: • ‘Customers need to be convinced of a new product/service’ • ‘There is fragmentation in the market and multiple decision makers’ • ‘The market is subsidised and has its own procedures’ Follow up discussions with stakeholders led to suggestions on how to overcome these obstacles. The insights provided have the potential to instigate change and in doing so, to ‘bridge the gaps’ between the different SMEs and healthcare professionals. ‘Customers need to be convinced of a new product/service’ • SMEs commented that gaining access to endusers is challenging and it would be more effective if they were involved from the design stage. To improve this, end-user education in AT

would be beneficial and would allow Telecare/ Telehealth to flourish and provide a mechanism by which clinicians, patients and carers would be able to communicate. • GPs would be more informed of the opportunities available for patients who want/need to use AT and with enhanced knowledge and understanding, GPs would be better placed to provide the appropriate medical advice and information. • There is a lack of coordination and collaboration between different stakeholders within the business ecosystem. This creates a barrier for SMEs as they are unable to discuss their innovation with healthcare professionals; the latter of which would be more likely to dismiss it due to their lack of understanding. To bridge the gap between these two groups, it would be beneficial to empower the end-user so they knew themselves which AT product would be suitable for them, and why. A representative patient forum or organization would be effective to undertake this supportive role. • The ‘convincing of customers’ (and in some cases staff) and the belief that the system is risk averse was noted especially in the Netherlands in the Care Provider interviews.

CHAPTER 2

‘There is fragmentation in the market and multiple decision makers’ • Across the four regions, it was identified that the AT market is fragmented, with a lack of networks to assist SMEs in the innovation process. It was also clear that there was a lack of an appropriate business model/plan for Telecare services. By using a Business model, organizations would be better informed about how to reach their target group, what their main costs/benefits were and what opportunities their product would provide for end-users. More than one business model may be necessary as each would be focused on a particular solution to the issue being addressed. • There needs to be more support at regional levels to compensate for the decline and removal of organizations such as the Regional Development Agencies in the UK. Without these centralised associations, SMEs have a lack of support and are often unaware of who to refer to for advice. A regional ‘knowledge hub’ would assist with supporting communication between various partner organizations and also play the role of monitoring and exchanging user experiences for quality control and best practice. • SMEs require a stronger network to establish contacts and co-create solutions to improve innovation. They need to be able to access end-users from the design stage, through to procurement. • In the UK and Netherlands in particular, SMEs noted that finding decision makers was difficult and that the market was fragmented. ‘The market is subsidised and has its own procedures’ • SMEs find the process of acquiring funding a bureaucratic procedure and are not always aware of who to gain access to in order to budget for their innovation. The budget for Telecare needs to be more efficiently distributed amongst SMEs, but also to consider whether the ‘care bill’ is appropriate for each patient, tailored to their specific needs and requirements. • Clinical trials of products are needed to gain sufficient information and show the benefits of using Telecare. This would assist commissioners who are currently focusing on products/services which they might know and understand, rather than considering what might be possible. • SMEs need to have knowledge of the markets in which they operate and this can include crossborder activity whereby additional learning can be sought. For example, the level of coordination in the Netherlands is more coherent and standardised than in the UK and as they still have Regional Development Agencies, this could provide a potential source of important information and enable the sharing of best practice across regions.

• ‘Own specific procedures’ is supported especially from the UK and the Netherlands where a majority of SMEs interviewed felt that they cannot influence the procurement process. It is difficult for them to get close to decision makers and in France the majority felt that they were ‘influenced by’ the process, rather than being able to contribute to it. In the UK especially, SMEs felt that the tendering process was cumbersome and slow. As is seen from the findings above, there are existing practices in place which SMEs find are preventing them from being as productive and efficient in the care market as they could be. There is a need across all four regions to bring SMEs into a network in order to support their innovation and provide them with the opportunity to speak to multiple stakeholders. This will go some way towards ‘bridging the gap’ between all parties in order to facilitate communication and collaboration. In addition, SMEs require help in producing appropriate business models which will enable them to enter the care market. A finding that also emerged in relation to SMEs gaining access to the market was from the discussions with care providers and SMEs regarding the interrelationship between how the market operates and how SMEs respond. If SMEs have a business model which enables them to innovate a product/ service and adapt it to the market, then the market also has to ensure that they are responsive to that innovation. In other words, there has to be a coinnovation model occurring between these two parties; the innovation can be market-driven in the first place but the market has to know what to demand, and this stems from the feedback and suggestions via SMEs. Neither demand nor supply exists in a vacuum and this is useful to consider when recommending improvements as both parties contribute to the overall introduction and inclusion of a new innovation.

CHAPTER 2

Inventory of already existing best practices This section of the evaluation report identifies existing ‘best practice’ which SMEs and Care Providers are undertaking and also considers recommendations for improvements to occur. These can be used by other SMEs who seek to gain access to the care market. The research undertaken during the CURA-B project has identified that a new model needs to be conceptualised which would assist SMEs to become more effective and efficient when innovating in the field of AT. The challenges faced and evidence of ‘best practice’ is identified below: • SMEs lack a strong network in the healthcare market and find it challenging to gain access to stakeholders during the design and procurement of their product or service. They also have limited access to end users which makes it difficult to develop solutions and be ‘user-centred’. Von Hippel (2005) argues that the focus on the user or ‘customer’ during an innovative product/ service design process indicates that users are increasingly regarded not just as passive recipients of innovations, but as active engagers who can participate in deciding which products are most suitable. The recommendation is therefore to provide prototypes of the items that users will be expected to adopt and then SMEs can evaluate what they have learnt from users’ feedback (ibid). • Related to the above is also the notion that a best practice suggestion would be to provide a basic

training course in the field of AT in order to assist nurses, occupational therapists and opticians who are key participants when trialling and using AT products. By informing healthcare professionals about AT products would enable a more coherent and efficient dialogue between all stakeholders. • A ‘think tank’ and/or ‘Best Practice’ centre would help to facilitate and stimulate innovation and collaboration between stakeholders. SMEs would be provided with the support and guidance required in order to painlessly negotiate the process of innovation. An ‘integrator’ would be independent to the SME but work as an advisor to ‘bridge the gap’ between SMEs and healthcare professionals, and also stimulate collaboration between different parties in the system. The learning acquired through this process has been referred to as a ‘mentoring’ or ‘tutoring’ role where competence is developed in one region or organization and then applied to innovations happening elsewhere (Cooke et al, 1997: 484). • A rethink on how innovation can be stimulated and financed would assist SMEs wanting to enter the care market. The evaluation provided by SMEs across the four regions made it clear that finding ways to get their innovation funded was challenging and bureaucratic. The transfer of IP to the government in order to encourage initial investment would facilitate collaboration and ensure that SMEs were not kept at ‘arm’s length’.

Regional SME profiles – current best practice West Flanders:

UK - Suffolk

• Compared to the UK, West Flanders has a very different approach to engaging with end users. • All SMEs consult with end users; it is part of integral product development and some SMEs consult with users in the concept phase. Developers have been known to be present in hospitals and residential homes to see the needs of users in real life. • After the development of the prototype all SMEs consult their end users – this could be in the form of a pilot or by filming the user with the prototype which then forms the basis of a discussion. • All SMEs also have discussions with their purchasers and this was deemed to be an effective way to integrate feedback into the development process. • West Flanders could be used as a model for ‘best practice’ is this area of consultation, especially regarding the interaction between SMEs, end users and healthcare providers.

• Some of the SMEs in the UK were traditional Telehealth companies and tended to view their product for the clinicians, rather than the patient (passive monitoring devices). This is compared to mobile technology platforms which are driven by the end user perspective. The companies in this field of innovation focused on social isolation and the extent to which a product could assist the patient, but also enable carers to go back to work and provide reassurance. • Both types of product could exist in the market, but a recommendation would be that clinicians need to be informed and have access to the tools and information which would allow them to make decisions about patient treatment, which may involve non-traditional methods (e.g. using AT). • It is essential that patients are informed, empowered and involved in decision making when communicating with the clinician.

CHAPTER 2

France: • Research indicated that they appeared to struggle with gaining access to end users – drawing on best practice ideas from West Flanders for example may assist them with this • A challenge in this region for SMEs was the need to meet end-users’ needs and integrate feedback from them into their product design. Concerns also existed over how best to communicate with the elderly. Zeeland • Similar to France and the UK, this region also faced challenges in terms of gaining access to end users and this was made more difficult because end users are often not the one who pays for the product/service • SMEs found that Healthcare Providers favoured large-scale enterprises which limited the extent to which they could gain access to the market. • However, SMEs did acknowledge that barriers offer opportunities to distinguish from competitors. In addition to the specific practices evident within each region, there was also evidence of differences in the level of understanding and collaboration between stakeholders in the innovation system. A greater awareness of the system for innovation as a whole was shown in France, the Netherlands and Flanders where such issues were more easily conceptualized by respondents. In contrast, in the UK, SMEs found it challenging to gain access to stakeholders, especially healthcare professionals who appeared to be reluctant to engage in discussions about the possibility of integrating AT in to the health sector. Procurement was bureaucratic and there was a reported lack of standardization in terms of the route to market as SMEs had to negotiate different healthcare professionals and decision makers, all of who had varying opinions on the product/service being discussed.

In the Netherlands the system was felt to be fragmented and unclear, conservative and riskaverse. In the Netherlands there are difficulties in getting close to decision makers and end users and a lack of participation and consultation with SMEs. For example, The SME who created the Memoricare product (a chest of drawers with activities to assist patients with dementia and their families) found it particularly challenging to get their product into the market because as they say: “…in healthcare it takes a long time, longer than I am used to. There are 8 parties that have to say ‘it is alright’, medical staff, activity people, nurse, patient director, location director, and they all have to say ‘yes’ and then you’re nearly at the end and then they change the location director so you have to go back to them and start over again” From this quote one can assume that the procurement process is not straightforward and that despite there being slightly different challenges within each region, the overall perception of the process is that gaining access to the healthcare sector is not easy, regardless of which region one is in. As a result of this, a new business model which focuses on open innovation and collaboration would be effective for all parties involved, and any policy initiatives which are applicable to all nations would also be beneficial. For instance, in Flanders and France there were requests for a fresh consideration of how the system could work in terms of financing for research and development in AT and how national systems could reimburse users. A critical challenge was to identify an improved working business model that would be used by all partners across the regions to encourage more collaboration.

Evaluation of Data Integration and Analysis Feasibility • The three research instruments used in the CURA-B project were designed to investigate different dimensions of the same problem which is, essentially, market failure. It would therefore be ideal to be able to correlate the findings directly against each other. This is not however possible because the three research instruments were designed separately by teams assembled from across the CURA-B partnership. • The three methods of investigation used in CURA-B can be triangulated and the findings from each have been substantial in depth to

analyse and identify the main themes which became apparent. • The number of SMEs and Care Providers that took part provided generalisable data, especially as the online survey involved 125 SMEs of which 107 responses could be used, and 48 interviews of SMES were conducted, alongside 54 Provider interviews.

CHAPTER 2

CONCLUSIONS Activity 1 yielded some robust patterns of data and insights which gave value to the aims of the CURA-B project and the Assistive Technologies market in the 2 Seas area. Issues preventing SMEs from gaining full access to the assistive technologies market, most notably limitations in their access to lead-users, end-users and purchasing bodies which would prevent them from designing and selling their products and services more effectively, have been identified. Patterns reflecting such obstacles in all national markets covered by the study have been uncovered and phenomena and trends which are specific to individual markets have been separated out. In addition, internal characteristics of SMEs in this sector and shortcomings in their interactions with healthcare providers which inhibit their progress in the market have been discussed. The findings which are presented in this chapter were shared with the partners of the CURA-B project, the majority of who are themselves practitioners or experts in the healthcare field. These professionals were invited to consider sub-sections of the first stages of the main Activity reports and say whether the data roughly matches their impressions of the field based on their own contacts with stakeholders and knowledge of their regional market. The replies were largely affirmative and the data in many cases exhibited linkages and causes and effects which had previously escaped their attention. All partners felt able to move towards planning Activity 2 of the project using the findings to validate and fine-tune their understanding of the market. In addition to adding to knowledge of regional markets, the findings revealed patterns of behaviour and phenomena across all four countries which were previously not available in data format to project members. In this respect, this data can contribute to an understanding of a transnational healthcare market in the 2 Seas area of Europe and possibly beyond. Beginning to formulate the characteristics of this market and the obstacles and opportunities it contains is an important part of the project objectives which will come into greater focus in Activity 3.

The Activity 1 findings of the CURA-B project represent a valuable contribution to the general understanding of the market for AT. In particular because of its relatively strong focus on the nature of the market rather than on the medical institutions and conditions it addresses and the scientific innovations underpinning the treatment of those conditions. Other studies have been carried out and where appropriate, comparisons with CURA-B have occurred. For example, a recent Eucomed conference1 called for ‘concrete measures to close the gaps that hinder healthcare innovation through the adoption of SME-friendly regulation, and simpler reimbursement policies and procurement practice’ and Panel recommendations include actions in the field of SME-friendly regulation, reimbursement policies and procurement practices. It goes on to recommend ‘the establishment of a centralised innovation network’, something which might well be informed by this report’s recommendation for ‘the formation of a ‘Think Tank’ and/ or ‘Best Practice’ centre’. These declarations validate the keys findings of Activity 1 and through the reporting on best practices and the mechanisms by which the ‘gaps’ can be bridged , Activity 1 can go some way to improving the relationship with healthcare providers.

1 ‘Innovation in Healthcare without Borders’, Brussels, 16-17 April 2012

Chapter 3

CHAPTER 3

ACTIVITY 2 | IDEAS TO BRIDGE THE GAP Activity 2 consisted of focus group style interviews which were conducted in all four CURA-B regions during 2012 and this field work primarily took the form of partner – local stakeholder workshops. Data was generated through two research instruments : an online survey to record the planning information created for the workshops (Research Instrument or ‘RI’ 4) and an online survey to record the results from the workshops in the form of attendees, attendee feedback and insights generated (Research Instrument or ‘RI’ 5). Workshop organisers were asked to

complete the two online surveys. Common research instruments were used in all 4 countries. Both RI4 and RI5 were distributed to the CURA-B partners by ARU and data was collected in each market by the local responsible partners and passed back to ARU for analysis. This part of the self-evaluation report includes background information on the workshops, details of their objectives and the key insights acquired from each one. The chapter outlines each workshop by region as this provides a clearer means by which to compare and analyse the similarities and differences between each one. The table below shows the information ARU received regarding the workshops held in the four regions:

Table 16: Workshops Held in Four Regions Region

Workshop title

Planning report submitted

Post-event workshop report submitted

Funding instrument for elderly & dependence

Yes

Value creating business models for the mature market 1

Yes

Value creating business models for the mature market 2

Yes

Developing food products for the elderly people

Yes

How to communicate with elderly people?

Yes

Procurement & access to products

Yes

End user engagement

Yes

Selling assistive technology

Yes

Healthcare technology in residential homes & homes for the elderly

Yes

Impact of telecare on the isolation of elderly people

Yes

Non-medical services for vulnerable clients

Yes

Role of wellness rehabilitation & preventative healthcare

Yes

Masterclass entrepreneurship in healthcare

Yes

E-health and serious games

Yes

Combining care and welfare services

Yes

Care environment

Yes

Nutrition & healthcare

Yes

Nord Pas de Calais

Suffolk

West Flanders

Zeeland

TOTAL

Choice of a Target Group The workshop organisers were asked to indicate the target groups that had been invited. Choice of a target group The workshop organisers were asked to indicate the target groups that had been invited. SMEs were the most important target group (80% of respondents identified them as one of their target groups), followed by providers (50%). Other participants invited were commissioners, end users and lead users. Some organisers also invited engineering

companies, government bodies, larger companies producing technology, private and public insurance companies, as well as a clinical consultant and a GP practice manager. Workshop organisers were asked to identify the elements driving the choice of their target groups. Local knowledge was the most important factor determining the choice of target group with 90% of respondents naming it as a justification for the selection of workshop participants. This was followed by ‘Activity 1 research findings’ which had contributed to the selection of target groups in 70% of cases.

CHAPTER 3

Some workshop organisers identified potential participants during the interviews conducted as part of Activity 1. Others used their organisations’ databases to source suitable participants. Workshop participants Excluding project partners who attended, a total of 141 participants attended CURA-B workshops across the four regions. As expected, SMEs and Providers made up the largest proportion of participants with 43% and 18.5% of participants respectively. Other noteworthy groups are commissioners (14%), end users (5.5%) and lead users (5%). Figure 7: Pie Chart Illustrating the % of Participants in the Workshops

Table 17: Participants that Took Part in the Research

Participants

Numbers

Percentage

SMEs

43%

Providers

18.5%

Commissioners

14%

End users

5.5%

Lead users

Large enterprises

University

1.5%

Innovation facilitator

1.5%

Development agencies 5

3.5%

Health organizations

GP practice manager

0.75%

Clinical consultant

0.75%

Total

141

Main Insights arising from the Workshops There are a number of key insights from the workshops conducted and these will be identified below. Having provided these general insights, more specific issues will be highlighted in relation to each region.

General Insights From the analysis of the survey performed in Activity 1 a model was constructed to show the key obstacles facing the SMEs (‘Go to Market’, ‘Innovation’ and ‘Internationalisation’) and key sub-obstacles.

From RI 4 and 5, a total of 34 insights were recorded. Nine ‘General Insights were documented in total. These were related to the first of the key obstacles noted from the analysis of RI 1 i.e. ‘Getting to Market’. 19 ‘SME’ insights were documented. 16 of these related to ‘Getting to Market’ and 3 relate to ‘Innovation’. 2 ‘Provider’ Insights were documented both of which related to ‘Getting to Market’. 4 ‘Commissioner’ Insights were documented all of which related to ‘Getting to Market’.

Figure 8: Activity 2 'Insights' from the Workshops

CHAPTER 3

Figure 9: Synthesis Model of Obstacles Facing SMEs

SME

From the synthesis model above, it became apparent that there were some general insights gathered from workshop participants. The issues related specifically to three main sub-obstacles: ‘customers need to be convinced of a product/service’; ‘there is fragmentation of the market’ and ‘the market is subsidised and has its own procedures’ General Insights: Customers need to be convinced of a new product or service • End-user’s education (About AT and tele-care) could be considered as one of the most important factors that will allow tele-care to flourish and will help increase patient and clinician confidence in the systems • Need for a quality control mechanism (QC) to pay attention to the quality of service given by a service provider and an independent control body needed for such Quality labelling • Need for increasing accessibility; lowering barriers for end users of non-medical services and lowering the barriers for service providers. • Need for intensive collaboration between care and technical suppliers; there is a need to inform and empower the end-user and create a collaborative relationship between care and technical suppliers (SMEs) in order to develop the best device for the end-user. Stakeholders (in the workshops) need patient organisations and representatives of elderly people, public insurances, social services and the media to inform the care sector and the end-user regarding the benefits of tele-care.

Fragmentation of the market and multiple decision makers • Need for the developing of business plans for telecare services and well-defined marketing plans; it is necessary to be able to inform the end-user about the available offers of tele-care devices. Importantly there is a need to find the correct way to reach the different target groups. Stakeholders need to be able to reach end-users and their close environment: medical experts, marketers, experts in healthcare systems and media. • Need for local anchoring (regionally bound services) • Need for one access point (communication hub): Centralising communication for all service providers (SMEs), centralising communication for service/care clients (end users), answering the needs of the end user, creation of the "care coordinator" and exchanging user experiences for quality control. ‘The market is subsidised and has its own procedures’ • A need to redistribute the budget of the healthcare system: it is vital to have more budget available for alternative tele-care services and a more efficient distribution of the budget for the cost of medical services; a lower 'care bill' would empower elderly people. • Tailored healthcare for the profile of every person; a care which is strongly person centred; preventing overconsumption of ‘technical’ medical care. • It would help to conduct evidence-based pilots to show the benefits of using tele-care; using the previous pilots and studies could also help. In addition to the general insights acquired, there were also specific issues identified from SMEs, Commissioners and Providers:

CHAPTER 3

SME insights 19 SME insights were documented. 16 of these related to ‘Getting to Market’ and 3 were related to ‘Innovation’. • SMEs need an ideal care hotel as an enterprise • Need knowledge of the potential markets • AT is being improved and technology acceptance starts now • New developments and buildings should have more flexible structures corresponding to the AT infrastructure • In the tender process there are a lot of rules which could be minimised and therefore currently it is very difficult to include and use this care technology • Networks and good contacts in world of providers are essential • Better insight in the structure and financial aspect of healthcare • A one-time pre-qualification process is required • A forum where all stakeholders can discuss needs • SMEs need a commitment to purchase should a solution meet or exceed the specification • SMEs and end users need to be involved throughout the life-cycle of the procurement, development process • SMEs need a raft of solutions to give users choice • Better knowledge of elderly needs in terms of food and nutrition • SMEs need to be able to work efficiently on case studies • Ideas are needed to launch new products • They need information about the elderly and dependence market (how many people are SMEs catering for?) • Help to build a business model. To reach all parts of the market that would improve from a greater presence of AT more than one business model would be necessary. That is each model would have inbuilt reasons to be a partial solution.

Commissioner insights All of the Commissioner Insights related to the ‘Getting to Market’ obstacle. • They need detailed / consistent case study reports to allow informed decision • They need bottom-up approach to develop solutions fast, using their expert knowledge These two insights correlate with the analysis from Research Instrument 3 (Provider Interviews) which found 6 key challenges and needs: 1. No formal externalisation strategy for dealing with SMEs 2. Few examples of formal IPR policies, innovation policies, adaptation policies 3. More than 40% had not had successful AT projects

4. Government policy, funding and regulation felt to be the main obstacles to adoption of AT 5. SMES need to engage with stakeholders more especially users/providers and develop products that show clear added value to users in terms of cost benefit and compatibility with existing solutions 6. Build relationships with key stakeholders Numbers 5 and 6 were the same insights as noted from the workshops

Provider insights All of the Provider Insights related to the ‘Getting to Market’ obstacle. • They need the positive effect of healing environment • They need exchange of information concerning the needs of products and services • They need further cooperation between stakeholders, e.g. a win-win outcome The following section of this chapter on the stakeholder workshops held in Activity 2 will outline the details of each workshop conducted within the four regions, and will provide insights into the findings acquired. Nord-Pas-de-Calais The objective of the first session conducted by Eurasanté on 21st February 2012 was based on providing information to SMEs working in the AT sector about business models, and in particular, advice and guidance on how to formalise a business model. The aim of doing this was to enhance their opportunities of entering the AT market, and minimising as many challenges as possible. • The value of the workshop became evident when SMEs provided feedback to Eurasanté indicating that they felt more confident in terms of having the ‘tools’ to enter the AT market. The opportunity to discuss their concerns, and acquire advice from other attendees was also valued. • Emerging from the workshop were a number of insights: SMEs identified that they needed assistance with how to communicate efficiently with their end-user target group; which content would be most appropriate to discuss with stakeholders, and through which particular method the message for stakeholders and endusers should be communicated. Following on from the first session and in order to address the insights gathered, a second workshop was conducted by Eurasanté in April 2012. The objective was to expand and apply the information received from the first set of workshops and SMEs were provided with a ‘coach’ or ‘mentor’ who assisted them with formulating their business model.

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• The feedback received from SMEs was positive. The value of the second session was that they were able to apply the lessons learnt in the first workshop through practical activities and discussions. • In depth knowledge and understanding was acquired in terms of how business models can be adapted to suit particular requirements for each SME. This made it more valuable for each company and also enabled them to share best practice. In addition to the business model, workshops were also conducted which addressed SME’s concerns about how to communicate with the elderly which was their main target group: • The workshop involved discussions, case studies and practical activities to enhance knowledge of how to develop food products adapted for elderly people. • SMEs felt that this was productive because it provided them with the chance to engage in idea generation which assisted them with the launching of new products. An evaluation from the workshops conducted by Eurasanté indicates that whilst the majority of them were positive and a source of learning, some workshops lacked generalisability, especially as participants were unable to see how the information acquired could be used to assist with cross-border activities in different regions. It was evident that each region knew why the discussions and activities were relevant to their local companies, but found it more challenging to apply it to other partners. This finding suggests that within each region, more guidance and support could have been provided to highlight how and why cross-border activity is important. The sharing of best practice is an effective strategy to assist SMEs who need help with networking and collaboration; the findings from Zeeland (discussed further on in this report) indicate that Impuls made an effort to follow up with participants from the workshops and continued to assist them in relation to cross-border activities. In this way, not only did it meet one of the CURA-B objectives, but it also provided much needed support for companies who were struggling to innovate due to minimal connections with providers. Suffolk/Cambridge The workshops held within Suffolk/Cambridge were co-ordinated by Health Enterprise East (HEE) and took place in March 2012. The objective was to focus on end-user needs and explore how best to involve users in a collaborative partnership. The workshop also considered ways of improving empowerment and personalisation for end-users and patients. The elderly COPD (Chronic obstructive pulmonary disease) population were the main target group, with

the primary focus being on their use of a technology application in the home. The perspective of the NHS was also a key focal point. Three main themes were developed throughout the workshop: • End user involvement opens up opportunities for engagement and platform technologies in the home • System performance and individual system needs open up opportunities for the increased uptake of integrated care systems • Collaborative partnerships will enable data to be gained for the purpose of evaluation and improvement There were a number of findings and insights acquired from the discussion, in particular, the debates focused on key drivers and needs in engaging the end user and involving them in improving the systems. Education was deemed important in order to ensure that patients were able to ‘self-manage’. This involves patients knowing how and when their disease may progress and what they can do to monitor and manage it effectively. Media was suggested as an appropriate means by which to educate patients, as well as pamphlets, patient forums (where educated patients help others) and education based media. Once a technology is provided to patients, it is essential that they are aware of how to use it to monitor their disease. It requires both patients and clinicians to be ‘proactive’ in their use of technology and by understanding the norm, patients are then able to identify when a change occurs. The level of patient engagement is associated with the quality and quantity of data acquired and this can be viewed as empowering for the patient, especially if they feel in control of their condition. Clinician engagement was related to user engagement but this would only be effective if a cultural change occurred so that clinicians were more willing to engage with technology. This was related to helping clinicians see the benefits of home monitoring systems which would lead them to incentivise patients to use them. The platform system being used for AT is not always appropriate for each patient and one has to take into account the age of the patient, progression of the disease and frequency of data collection. The workshop participants discussed how a platform had to accommodate changing patient needs and ensure that complexity of use and monitoring was kept to a minimum. The second theme discussed was based on system performance and individual needs. This discussion explored the need to ensure that systems which hold patient data are integrated and not fragmented, as this makes it challenging to assess patients when their medical history is not stored in one place.

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• Systems which ‘talk’ to one another are more likely to help professionals make informed decisions about patients’ health, and also assist patients in deciding which information they want to share. • When technology is used to engage patients there must be a consideration as to who else needs to be educated in the use of it. The end user is not always the individual who is or who should be educated. It may be the family, carers or clinicians and workshop participants questioned the extent to which the community plays a supportive role and should be actively involved in the process. The third theme discussed at the workshop was based on collaborative partnerships: • As the level of understanding and use of technology grows, the apathetic culture associated with it is likely to decline too. Patients will be more willing to try a technology and clinicians will be more supportive of it. At the workshop, participants recommended that websites, magazines and groups would be beneficial in improving the perception of technology. • Short and long-term strategies need to be identified by organizations and the NHS in order to identify who are the main ‘champions’ of the technology and to give clarity where necessary. This will contribute to more effective collaborative partnerships. The insights identified above from the HEE event provide a clear and in-depth example of the key themes which are of a concern to stakeholders attempting to gain access into the AT market. The workshop was valuable for participants as it encouraged them to focus on particular themes which they felt they could address. All participants prioritised areas and there was an agreement that end-user engagement and self-management was very important, as well as providing assistance to clinicians and patients on how to use the technology, hence increasing their confidence in accelerating the usage of AT. Source: HEE workshop notes (2012)

Suffolk County Council (SCC) SCC conducted a workshop called ‘Selling Assistive Technology’ and this was based on exploring the particular business models considered appropriate for selling in the AT market. Obstacles had been identified prior to this workshop occurring, so the role of SCC was to encourage participants to discuss solutions to the challenges identified previously. The participants who attended originated from SMEs, Providers, Commissioners and End-Users. Following interviews with different stakeholders during Activity 1 of the CURA-B project, it was discovered that:

• SMEs found it challenging to enter the AT market • Retailers only had a few products involved with AT • Customers knew little about which AT product would be suitable for them or where to find out more • Larger producers were able to dominate the market • Commissioners were unable to see the difference between cost and value for money in AT As a result of the findings from the interviews, the following insights were gained from the workshop: • A requirement to reach all parts of the market and to improve the presence of AT. More than one business model may be needed. • Participants wanted to create networks regionally that would have AT as a key focal point. • Integrating tele-care and tele-health together within one model. West Flanders There were four main workshops which took place in West Flanders. The first workshop focused on the ‘role of wellness in rehabilitation and preventive healthcare’. The main participants were SMEs and Care Providers. The workshop participants discussed three concepts: 1. The positive effect of a ‘healing environment’ 2. The ideal care hotel as an enterprise 3. Co-operation e.g. a win-win There was a distinction made in the workshops between what SMEs needed and what Providers required. SMEs identified that their knowledge of the market was limited and they needed to gain more understanding of who their target group was and how to access them. Providers required products and services with a low threshold and the ability to exchange information concerning the needs of products/services. When participants were asked whether any of the themes discussed were valuable and relevant to other CURA-B partners, the response was ‘the positive effect of the healing environment’. The argument in relation to this is that it would be beneficial for all partners to be able to understand the conditions required to improve wellbeing and health through amending and changing the environment in which patients existed. This was especially applicable for rehabilitation and preventive healthcare.

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West Flanders – VIVES (KATHO). The second workshop conducted in West Flanders was run by KATHO where the focus was on nonmedical services for vulnerable clients. The objective was to define the needs and barriers of offering non-medical services in the home; these were related both to suppliers and end-users. Workshop participants formulated a number of proposals and innovative solutions to meet the needs of end-users/ care institutions. This workshop generated insights which related specifically to the CURA-B project plan as it sought to ‘bridge the gap’ between different stakeholders in the care sector and suppliers of non-medical equipment. It also encouraged a discussion on how to make the system of healthcare more integrated. Insights and suggestions from the workshop: • Need for local anchoring – one access point with a centralised communication hub for all service providers. The end user needed support and their needs answered promptly. • Creation of a ‘care coordinator’ – central point of contact which would assist end users and link to quality control • Independent monitor for quality control • Increased accessibility – minimise the barriers for end-users and suppliers of non-medical services West Flanders – IN-HAM Former partner IN-HAM conducted a workshop titled ‘The impact of tele-care on isolation of elderly people’. This workshop aimed to answer the question of how tele-care could support the daily duties of caregivers and be an opportunity for elderly people to remain independent. The target groups present at the workshops included Providers, Commissioners, Lead Users and private and public insurance companies. The justification for the choice of participants was based on wanting to acquire in depth insights into the experiences and lessons learnt regarding the implementation of technology in the home. By including a multidimensional participant group, it was deemed more possible to gain both pragmatic and academic view points as well as apply knowledge from various stakeholders on how to develop a future orientated business model. 3 main insights were acquired: 1. Tele-care should be organised based on the needs of end-users: this would ensure that they were customised to the patient and would encourage effective self-management. The limitations of this were that a lot of devices are not accessible for the patients and the usefulness of some of them were questioned.

2. A solution to this was discussed in terms of creating a collaborative partnership between users and providers in order that a product was designed which matched the needs of the user. Tele-care should also be promoted more by the media. 3. A business model/plan was developed which included a clear marketing plan, outlining the benefits of AT and the importance of being able to address the needs of each target group. This would be beneficial as each user would be introduced to different products/services which they may not be aware of. The limitations are however that a marketing plan is expensive and it requires time and effort to bring stakeholders together to create an integrated platform. 4. A lower ‘care bill’ was seen as being able to assist with the redistribution of the care budget and enable tailored health care for the elderly. The budget should be patient centred and enable free choice. Solutions to this challenge were discussed in terms of engaging with other European partners/regions to identify how this has been achieved (or is being achieved) and to therefore adopt some best practice examples. This approach resonates with the relevance the workshop had to other CURA-B partners as it involved cross-border activity. West Flanders - POM The fourth workshop conducted in West Flanders was held by POM and was related to the one of the objectives of CURA-B which was to ‘bridge the gap’ between different stakeholders. A set of recommendations on how AT can be implemented in residential/care homes was also a key focal issue. This workshop was interesting in the fact that it was the first time that Lead Users, SMEs and engineering bureaus were together and had the opportunity to discuss the challenges they faced. The main insights were: • In West Flanders, nurses are subsidised so AT is not reimbursed • AT is recently developed so its usage and adaptation is currently minimal • New buildings have to be built with the consideration of how to accommodate AT • Tenders are deemed bureaucratic and rule-based • Reliance on care directors of institutions to realise the significance of this technology and its possibilities The outcome of this workshop was a set of concrete proposals which would contribute to a greater clarity and improved integration of care technology in the residential sector. The proposals were provided to Flanders Care which has a policy influencing role.

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Zeeland: Impuls

The first workshop was called ‘Masterclass Entrepreneurship in Care: Impediments in the world of care’. The objective was to inform entrepreneurs about CURA-B and to engage them in discussions about the challenges they have or might experience when attempting to innovate.

positive feedback about the event. The SMEs particularly found the workshops valuable in terms of being able to ‘connect with providers’ and create international links through networking. This directly feeds into part of the CURA-B project about the value of cross-border activity. There was also the chance to review a number of initiatives and projects around homecare for the elderly in Zeeland; many of which had not been considered by SMEs prior to them attending.

The findings from the workshop indicated that SMEs found it challenging to establish, enter and remain in a network which consisted of providers and this resulted in them being unable to gain access to the AT market. Their lack of knowledge about the structure of healthcare also posed problems when attempting to innovate.

All of the workshops undertaken by Impuls were followed up by asking participants about what they aimed to do with the information they had acquired and of what value it was to them. Impuls committed to assisting SMEs with the advice and support they needed and would connect them to other regional/ international partners.

The workshops conducted in Zeeland were all undertaken by Impuls.

The second workshop focused on ‘Nutrition and Healthcare’. It explored the ways in which healthcare institutions (regionally) could be inspired to reflect on how nutrition affects the well-being of clients. This objective directly links into the aims of Impuls which is to strengthen the healthcare of the economy. By establishing networks and partnerships through this workshop the objective was more likely to be achievable. The third workshop conducted was titled ‘Care Environment’ and it sought to provide information on future developments in the Dutch rules and regulations around separation of housing and healthcare, and to inform and inspire housing corporations to collaborate with Care Providers and Government. The workshop followed up on the discussions conducted in Activity 1 of the project and also had a direct focus on creating and sustaining smaller networks of SMEs in order to encourage them into Zeeland. A workshop titled ‘E-health and serious games’ attempted to inspire and inform participants on e-health and gaming in terms of connecting the welfare and health sector with SMEs and local government to create innovative pilot projects. Participants in this event included 21 representatives from the healthcare sector; 22 from SMEs; 6 from research institutes and other multi-sectoral organizations. In total there were 56 people present. The feedback from this workshop was positive; 36 participants commented that they had been inspired and left feeling more informed. The most valuable aspect was the networking which occurred mainly during the day, through breaks and lunch time, but also this continued once the participants had left. The final workshop conducted by Impuls involved discussions with SMEs and providers about ‘combining care and welfare services’ which involved inviting several keynote speakers to the workshop. There was a focus on interaction and networking during breakout sessions and all attendees provided

CONCLUSION This chapter on the stakeholder workshops conducted within each region participating in the CURA-B project illustrated some interesting points of comparison, but also similarities. It is apparent that SMEs who were involved in the workshops, regardless of the region, were concerned with a need to develop strong networks and collaboration to assist them with the innovation process. The objective was to also ensure a service solution which would identify the patient’s needs, but at the same time, encourage stakeholders to engage users throughout the development and procurement cycle to ensure that the product/service is suitable and fit for purpose. A finding that was evident amongst the workshop participants and particularly important regarding the objectives of CURA-B was that SMEs would value a ‘communication hub’, consisting of a facilitator who would help with the exchange of ideas, service needs and product development. For example, in the UK, such a forum could exist in the East Anglia region, or could be developed nationally. Embedded within this ‘hub’ would be a champion whose responsibility it would be to coordinate and link stakeholders together. End-users would also benefit from this as it would enable them to be more proactive and to have a voice regarding the use of AT and the ability to engage with providers of healthcare solutions. This role will be discussed further in chapter 4 and chapter 5. As a result of the workshops, the stakeholders had the opportunity to give feed back to the partner institutions and this resulted in their key issues becoming the focus of the CURA-B project and attempts were then made to continue to support SMEs throughout the innovation process. As stated in this chapter, Impuls was one example of a partner who attempted to facilitate collaboration between their workshop participants in order to sustain some form of networking, even once the main event was over. It also stimulated interactions between cross border partners.

Chapter 4

CHAPTER 4

ACTIVITY 3 | ACTIONS TAKEN TO BRIDGE THE GAP IN THE CURA-B PILOTS In the previous chapters we discovered how SMEs are prevented from gaining full access to the AT market. This chapter explains the pilot cases that were undertaken to bridge this gap and to understand how better to bridge the gap in the future. In order to motivate SMEs to enter the healthcare market, SMEs must be able to overcome the challenges and uncertainties of technology development as well as to understand end user needs and the environment. The previous chapters looked at the current models for entering the care market in the four regions including the critical challenges, the most common approaches and the results of ideation workshops to bridge the gap. The series of workshops organised in Activity 2 brought stakeholders together to try to find answers to these challenges. These suggestions were used to create and action nine pilot studies, introduced here. This chapter will explain the content of the pilot cases, how they were researched and some new approaches for SMEs to enter the market, to develop their products and services and to sell to customers. Based on these practical examples it is hoped SMEs will be better equipped to deal with existing barriers, to widen their knowledge of the innovation landscape and extend their networks. The key challenges in the current model that prevent SMEs from gaining full access to the AT market are limitations in their access to lead-users, end-users and purchasing bodies which prevent them from designing and selling their products and services more effectively. We could call these blockages in the value system. • SMEs recognise these issues themselves and in Activity 1 suggested the following elements of an improved general way of doing business which would effectively be a re-conceptualisation of the system of working together with other stakeholders within the AT ‘Eco-system’ (‘Eco – system meaning all those stakeholders interested in AT including government, local government, private sector organizations, user organizations, users, public and private sector providers, knowledge centres etc.) • SMEs need to be allowed to have more open collaboration between the stakeholders in the design and procurement processes and especially more and earlier involvement with end users to develop solutions at the beginning of the design process – fundamentally they need a strong network of key stakeholders in this field • They would like to see the formation of a ‘Best Practice’ centre to facilitate and make more equitable the collaboration between stakeholders. The ’centre’ would facilitate possible collaboration

between SMEs looking to enter and negotiate the system and therefore help SMEs enter the system more painlessly. • They would like to see a system ‘Integrator’ as a specific role in developing the above. These system integrators would be independent advisors who could play a role regarding ICT/AT possibilities in the health care sector to bridge the gap between both worlds. • They would like to see fresh ideas on how to stimulate innovation, how to finance innovation, how to finance development of AT and how to reimburse stakeholders within the system. Fundamentally they would like to see new ‘business models’ in this sector.

Cura-B pilot projects to develop the insights from stakeholder workshops From the SME suggestions in Activity 1 and from the workshop ideas in Activity 2, nine pilots were organised: • 3 in Zeeland • 1 in Nord Pas de Calais • 2 in West Flanders • 3 in the east of England. The 9 pilots can be categorised into 3 groups: 1. Network development: There is a need to create networks that can provide a collaborative base, hosted /facilitated by a system integrator to bring stakeholders together and to help SMEs enter the market. This idea was developed into a pilot by: • Impuls in Zeeland with Santé Zeeland network • HEE in the East of England with the East of England AT network 2. New Business models: There is a need to help SMES understand a fresh approach to creating business models and business cases to enter the care market. Four partners conducted this as a pilot project: • Eurasanté in Nord Pas de Calais with the Entrance project • VIVES-RESOC Brugge-POM in West Flanders with ‘Non-Medical Services’ 3. Co-Creation through Collaboration: There is a need to bring SMEs and Care Providers together to co create solutions for end users. 6 partners conducted this form of pilot: • Impuls in Zeeland with the Memory Test project and the Concept Homes project • VIVES-RESOC MWV-POM with ‘lighting in a care home’ in West Flanders • WSH with ‘Diagnostic service for paediatric Diabetes’ in the East of England • SCC via the Dragon’s Den project also in the East of England

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Table 18: The Nine CURA-B Pilots

Business Model Innovation and SMEs A Business Model refers to the logic of a commercial enterprise or idea - how the idea will operate and create and capture value for stakeholders. Business model innovation bears major advantages for SMEs in particular as SMEs usually find it easier than large enterprises to adapt their organisational and operational structures and could therefore use business model innovation to create or enhance competitive advantage. A 5-year study conducted by Achtenhagen and Olof (2010) demonstrated that SMEs which respond to exogenous challenges (e.g. changes in competition landscape, markets or technologies) through adapting their business models are generally more successful than those that do not (Achtenhagen and Olof, 2010 in Knopf and MayerScholl, 2013). Enterprises with minimal engagement in business model innovation often consider technological innovation as a key to success for SMEs, however, if business model innovation is not

pursued in parallel, managers may face difficulties to successfully commercialise technological inventions (Teece, 2010). Business model innovation has gained prominence among social entrepreneurship researchers and practitioners. Jenkins (2009) identifies three main elements of corporate social opportunity (defined as “commercially viable activities which also advance environmental and social sustainability”), namely “[…] innovation in products and services, serving unserved markets and building new business models” (Jenkins, 2009, p.21). Jenkins’ study focuses on SMEs and Corporate Social Responsibility (CSR) and finds that “[…] real CSR is about building new business models”, while at the same time suggesting that governments need to provide support to SMEs to develop “[…] certain organizational capabilities, such as learning, networking and innovation […]” for the successful implementation and adaptation of business models (Jenkins, 2009, p.34).

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The importance of innovative business models for SMEs has also been acknowledged at EU level and is reflected in the strategic priorities of Horizon 2020. For example, the research funding opportunity INSO10-2015-1 recognises the value of business model innovation for SME competitiveness and growth and emphasises its relevance for social enterprises: â&#x20AC;&#x153;Many current, widely applied business models, have developed for big companies and may be not-fitting or not-serving well the needs of SMEs nor be inspired by new knowledge on innovation in business models. In addition to this, small community-oriented companies, using their profits primarily for social objectives, can build their growth on business model innovation. The specific challenge addressed by this topic is to enable SMEs [â&#x20AC;Ś] to innovate and grow across traditional boundaries, through new business models and organizational changeâ&#x20AC;? (European Commission, 2013).

The Business Model Canvas (Osterwalder and Pigneur, 2010) is a structured and at the same time simple to use framework for understanding the logic of a business idea. The canvas is a graphic tool that assists enterprises in clarifying and communicating how they create, deliver and capture value. The Business Model Canvas can help SMEs working in Assistive Technology to innovate and articulate new or existing business models more effectively. They are particularly relevant for SMEs as they allow them to increase an understanding of their current business models and identify needs for and ways of business model innovation, while at the same time helping to embed the latter in their overall business strategy (Osterwalder and Pigneur, 2010). The diagram below shows the components of a Business Model Canvas which has 9 elements:

A study of 35 European and North-American SMEs and their 97 business models during the period 20082012 confirms that most surveyed SMEs engage in business model innovation in various ways, however they rarely have a structured approach towards it and do not embed business model innovation in their overall business strategy (Lindgren, 2012). Table 19: The Business Model Canvas

The elements contain questions to provoke thinking on how a particular model of doing business can create value, deliver value and capture value: The template above as well as an explanatory video can be downloaded via the following link: http://www. businessmodelgeneration.com/canvas.

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Table 20: The Business Model Canvas and Key Questions to Ask

Key Partners

Key Activities

Value Propositions

• Who are our Key Partners/ suppliers?

• What Key Activities do: Our Value Propositions require?

• What value do we deliver to the customer? Which one of our customer’s problems are we helping to solve?

• Which Key Resources are we acquiring from Partners? • Which Key activities do Partners perform?

Customer Relationships

Customer Segments

• What • For whom are we relationship creating value? does each of • Who are our our Customer most important Segments expect • Our Distribution • What bundles of products customers? us to establish Channels? do we offer each customer and maintain? segment? Which ones have • Our Customer we established? Relationships? Channels Our revenue • How are they • Through which channels streams? integrated with do our Customer the rest of our Segments want to be business model? reached? How costly are they? • How are we reaching them now? How are our Key Resources / Channels integrated? Competences • Which ones: work best are • What Key most cost-effective? Resources • How are we integrating do our Value them with customer Propositions routines? require? • Our Distribution Channels? Customer Relationships? • Revenue Streams?

Cost Structure

Revenue Streams

• What are the most important costs inherent in our business model?

• For what value are our customers really willing to pay?

• Which Key Resources/Competencies are most expensive?

• For what do they currently pay and how are they currently paying?

• Which Key Activities are most expensive?

• How would they prefer to pay? • How much does each Revenue Stream contribute to overall revenues?

The Social Lean Canvas (SLC) (Yeoman and Moskovitz, 2013) is an adaptation of Osterwalder and Pigneur’s Business Model Canvas and aims at helping social entrepreneurs by augmenting the thinking tools for the ‘Lean Startup Social Enterprise’. The model places particular focus on two elements ‘Purpose’ and ‘Social benefit’ thereby extending the value proposition of the original BMC to all stakeholders (as opposed mainly to customers) and is characterized by the need to articulate the “desired social profits through a comprehensive eco-system view” (Yunus et al., 2010, p.318). Both tools, BMC and SLC, are useful for assisting social enterprise companies in innovating their business models.

Early stage social enterprises often have difficulties communicating both a solid business idea and a social value proposition. For the pilots in CURA-B we used the general template of the Business Model Canvas and borrowed two critical areas from the Social Lean Canvas, i.e. defining a clear and strong purpose and a clear social benefit. These two key elements helped to bind the key partners in the pilot together at a time when it was not readily apparent how good ideas with good purpose will get to the market and provide monetary benefits. The BMC and the SLC represent ideal tools for a structured approach towards business model definition and innovation.

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The pilot cases presented here try to illustrate how the partners posed the Business Model question during exploration projects (Borrowed from an idea in Chanal, V (2011) ‘Rethinking Business Models for Innovation’) meaning that the aim has been to produce knowledge about how to ‘bridge a gap’ and to take steps towards bridging that gap by working with local SMEs, Providers and Knowledge Centres in new styles of partnership, and through the creation of networks whilst trying to implement a new vision or the concept of a new offer which is still at the ‘unclearly defined’ phase. The pilots have therefore been exploring an inherently fuzzy situation and context. In these exploration phases the pilots have been attempting to define one ( or perhaps several) potential and or possible Business Models whilst at the same time creating a product or service and at the same time thinking of how the pilot project itself is a form of ‘business model’ for future forms of collaboration . Whilst respecting the structure of the BMC for the most part , as stated above, we also explored the ‘Purpose’ and ‘Social benefit’ and adjusted some of the questions to fit the contexts of the pilots especially concerning the potential of the work done in the pilot to deliver and capture future value . The use of these adapted BMC for CURA-B pilots was intended to provoke the partners in the pilots to think about how their pilot projects were organised to create value, to deliver value and to capture value whilst at the same time mutually creating and confirming their core purpose and the overall social benefit of the pilot. Fundamentally the pilots have been focused on how value will be created by the actors who contributed to the pilot. The categories of the pilot projects chosen also shows us that the CURA-B pilots were strongest in this area of ‘creating value’ i.e. in creating partnerships, collecting resources and competences, performing key activities and creating value propositions. The pilots were much less strong in ‘delivering value’ (i.e. considering customer segments, creating customer relationships and using channels) and even less strong in ‘capturing value’ (i.e. ensuring that revenue streams were greater than costs/investment outlays) and this is because the majority of the pilots focused on the early or extremely early stages of business development/innovation:

• initial exploratory networking – creating the conditions for beginning to create value (Networking Pilots- Impuls and HEE) • initial possible business modelling exploring the creation of value and delivery of value (Business Modelling Pilots – VIVES (KATHO) and Eurasanté) • early stage creation of value through co-creation of a product/ service or concept (facilitating introduction and collaboration of SMEs and Providers –Impuls) The remaining pilots focused on the process of introducing pre created products or services to POSSIBLE buyers (Providers and Users) by: • taking those products through a live validation process with providers (early stage SME product testing in a provider live environment - VIVES (KHBO) and West Suffolk Hospital • facilitating SME product introductions/ presentations to POSSIBLE Providers (Suffolk County Council) The CURA-B business model canvases documented for the pilots then are stronger in showing how the pilots created value as opposed to delivered and captured value.

Researching the Pilots: Methodology The pilots were treated as a set of case studies and the Case Study method (Yin, 1994) was used as basis to collect qualitative data. The use of case studies in international business and for SME research is a widely accepted method (Chetty, 1996). Vissak et al. (2007) applied the case study method to research the relevance of knowledge as a motivating factor for the internationalisation of Baltic firms. They justify the suitability of the case study method by stating that it surpasses local boundaries of the considered cases, captures new facets of reality, and allows for empirically valid and testable insights into theory and practice (Vissak et al., 2007 in Deprey, 2010). Fletcher and Plakoyiannaki (2009) confirm that case study research is particularly suited to international business research, especially for understanding complex cross border and cultural settings. The table below provides a sample of studies that have employed the case study method.

Table 21: Practical Application of the Case Study Method in International Business Topic

Author(s)

Internationalization process of the firm

Johanson and Vahlne (1977)

Multinational corporations

Bartlett and Ghoshal (1987)

International strategy

Porter (1990)

International growth

Penrose (1960)

Entry modes in international markets

Ellis and Pecotich (2001)

International new ventures

Coviello (2006)

Source: Fletcher and Plakoyiannaki (2009, p.171)

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Creswell (2007) defines case study research as “a qualitative approach in which the investigator explores a bounded system (a case) or multiple bounded systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information (e.g. observations, interviews, audiovisual material and documents and reports), and reports a case description and case-based themes” (Creswell, 2007, p.73). Undertaking case studies ‘is a way of investigating an empirical topic by following a set of pre-specified procedures’ (Yin, 1994, p. 15). Case study research thus benefits from the theoretical propositions that guide data collection and analysis. According to Yin (1994, p. 10 and cf. pp.30-32), the goal of the case study is to ‘expand and generalize theories (analytical generalization) and not to enumerate frequencies (statistical generalization)’. Yin (1994) recommends that case studies should have a common theoretical base. In the 9 pilots we used the adapted Business Model Canvas (BMC) as theoretical (and practical template) through which to investigate the pilots. We made use of the following sources of evidence for the case studies: primary documents, secondary documents, and systematic interviewing. Even though, in general, case studies can include quantitative evidence (cf. Yin, 1994, p. 14) they are overwhelmingly limited here to qualitative evidence. For the pilots each context and environment is different. The intention of using the BMC was to create comparative case studies which could help us evaluate whether the individual pilot and CURA-B as a whole programme have achieved objectives to help partners and where possible associated SMEs to understand the logic of business modelling. A challenge in any multiple case study research is that some cases will provide more data than others and some cases will go further and earlier to achieving objectives than others and therefore implementation will differ. The questions that prompt the elements of the BMC served as a semi structured interview template for the 9 pilot cases. In Cura-B the key business model questions used to describe and later analyse were: For Creating Value: • Core Purpose: What is the core purpose of this pilot, what problem are you solving here, what overarching purpose brings the partners together? • Value Proposition: What value is this pilot bringing to SMEs, providers? What need or desire are you fulfilling for the customer and end user? • Key Partnerships: What partners are most critical? Why? For what? If you have partners, how tightly do they map to the Key Activities? What roles do the partners play as representatives of the ‘Triple Helix’? ( see chapter 5)

• Key Resources: What key resources are needed, key competences, key talent in critical areas of expertise and accumulated intellectual property related to the offering • Key Activities: What is needed to make the collaboration and co-creation work? How will the partners work together to bring the idea to market? (This probably includes ongoing learning about users and new techniques to build better products).

For Delivering Value: • Customer Segments: Who are the beneficiaries? Who are the possible customers and users? • Future Channels / Customer Relationships: What relationship does the pilot have to the care market? How does or could the customer interact with you? How can the Value Proposition be delivered to the customer? How do you or could you sell to the customer?

For Capturing Value: • Revenue Streams: What are the possible (future) revenue streams? Are there potential cost savings for the partners, users, customers? If this were a business, how would the business generate revenues? • Cost Structure: What are the key costs incurred? What key investments need to be made? Who will fund these costs and investments? Who will fund the costs of collaboration and of the facilitator? • What is the social benefit of this project, what are the longer term social benefits? In CURA-B the aim was to capture as much data around the pilot as possible to give as rich a picture as possible and therefore extra information was sought to ‘wrap around’ and complement the adapted BMC: • the history and the innovation/development/go to market process within the pilot • the partners in the pilot and their details • the future opportunities and challenges for the pilot including the market context • the conclusions and next steps for the pilot The initial aim at the beginning of Activity 3 (beginning 2013) was to interview the partners responsible for the pilots on a face to face basis at least twice where possible and again to interview a connected SME at least once. Where a face to face interview was not possible a proforma adapted BMC was given to the partner.

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The following semi structured interviews were conducted:

Impuls - Sante Zeeland

KATHO (now VIVES) – Resoc Brugge-POM

• November 2013 interview meeting with Arend Roos and Greg O’Shea in London (1 hrs noted)

• March 2013 interview meeting with Sarah Vandekerckhove, Filip Declerq, Vincent Vergalle, Janet Palmer, Saaed Sadighi, Greg O’Shea in Kortrijk (2 hrs – minuted on flipchart, recorded and transcribed) • April 2013 interview meeting with Sarah Vandekerckhove, Filip Declerq, Vincent Vergalle, Janet Palmer, Saaed Sadighi, Inge Tailleu,Greg O’Shea in Kortrijk (2 – minuted on flipchart, recorded and transcribed) • November 2013 additional information requested and provided by template KHBO (now VIVES) – Resoc MWF- POM • March 2013 interview meeting with Inge Vromant, Michele Inghelbrecht, Dries Grymonpre, Leslie Vincke, Janet Palmer, Saaed Sadighi, Greg O’Shea in Kortrijk (2 hrs – minuted on flipchart, recorded and transcribed) • April 2013 interview meeting with Inge Vromant, Michele Inghelbrecht, Dries Grymonpre, Leslie Vincke, Janet Palmer, Saaed Sadighi, Inge Tailleu ,Greg O’Shea in Kortrijk (2 hrs – minuted on flipchart, recorded and transcribed) • November 2013 additional information requested and provided by template Tronixx • May 2013 interview meeting with Tony Decavele , Raphael Pauwels, Dries Grymonpre, Chris Ivory, Greg O’Shea in Kortrijk (1.5 hr recorded and transcribed) • August 2013 interview meeting with Tony Decavele, Julie Verhooghe, Dries Grymonpre, Chris Ivory, Greg O’Shea in Meulebeke (1 hrs – recorded and transcribed) Care Home Meulebeke • August 2013 interview meeting with Maike VanAcker, Julie Verhooghe, Dries Grymonpre, Chris Ivory, Greg O’Shea in Meulebeke (1 hrs – recorded and transcribed) Impuls - Memory Test • April 2013 interview meeting with Mira Weber, Janet Palmer, Saeed Sadighi, Greg O’Shea in Middelburg (1 hr recorded and transcribed) • May 2013 additional information requested and provided by template • November 2013 interview meeting with Mira Weber and Greg O’Shea in Middelburg (0.5 hrs – recorded and transcribed) • November 2013 additional information requested and provided by template MemorieCare • October 2013 meeting with Erna Verstraaten, Martin de Klerk and Greg O’Shea in Canterbury (1 hr noted) • November 2013 interview meeting with Mira Weber , Erna Verstraaten and Greg O’Shea in Middelburg (1hrs – recorded and transcribed) Impuls - Concept Homes • November 2013 interview meeting with Arend Roos and Greg O’Shea in London (1 hrs noted) • November 2013 additional information requested and provided by template

• November 2013 additional information requested and provided by template Eurasanté • November 2013 interview meeting with Stephanie Russell, Sebastien Vermandel and SMEs in Lille (3.5 hrs recorded , transcribed and noted) • November 2013 interview meeting with Greg O’Shea , Sebastien Vermandel and SMEs in Lille (3.5 hrs recorded, transcribed and noted) • November 2013 additional information requested and provided by template Suffolk County Council • June 2013 interview meeting with Martin Owen, Janet Palmer, Saeed Sadighi, Greg O’Shea in Lille ( 1.5 hrs recorded, transcribed, flip chart noted) • September Dragons Den event 2013 attended by Stephanie Russell, Janet Palmer, Chris Ivory in Ipswich (3.5 hrs recorded and noted) • October Dragons Den event 2013 attended by Stephanie Russell, Janet Palmer, Chris Ivory in Ipswich (3.5 hrs recorded and noted) • November Dragons Den event 2013 attended by Stephanie Russell, Janet Palmer, Chris Ivory, Ricardo Carolas, Greg O’Shea in Ipswich (3.5 hrs recorded and noted) • February 2014 telephone interview Stephanie Russell and Martin Owen ( noted) Health Enterprise East • May 2013 interview meeting with Collette Johnson, Nick Offer, Janet Palmer, Saeed Sadighi and Greg O’Shea in Cambridge(1hr noted, recorded, transcribed) • June 2013 interview meeting with Collette Johnson, Nick Offer, Janet Palmer, Saeed Sadighi and Greg O’Shea in Cambridge(1hr noted, recorded, transcribed) • August 2013 telephone interview meeting with Collette Johnson, Janet Palmer and Greg O’Shea(1hr noted) • August 2013 additional information requested and provided by template West Suffolk Hospital • April 2013 interview meeting with Chris Ivory and Seema Moss in Bury St Edmunds (1hr noted, recorded, transcribed) • May 2013 interview meeting with Chris Ivory and Seema Moss in Bury St Edmunds (1hr noted, recorded, transcribed) • June 2013 interview meeting with Chris Ivory and Seema Moss in Bury St Edmunds (1hr noted, recorded, transcribed) • September 2013 interview meeting with Chris Ivory and Seema Moss in Bury St Edmunds (1hr noted, recorded, transcribed) • November 2013 interview meeting with Greg O’Shea, Chris Ivory and Seema Moss in Bury St Edmunds (1hr noted, recorded, transcribed)

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After the data gathering process the first stage was to document the pilots through the BMC and to reflect back to the partners. The second stage was to categorise (with the help of the lead partner Impuls). The use of the categories within the pilots is to help us compare and contrast pilots that are derived from different context and have been implemented differently. The pilots in the categories were then compared to explore: • How did the pilot bridge the gaps defined in activity 1 • How did the pilot generate value for SMEs and Partners • What is the innovation/development/market process within the pilot and what can be understood through theory • Outstanding challenges

The Pilot cases that follow are set out within the categories followed by a series of evaluations and learnings 1. The Network Builders: • HEE and the East of England AT network • Impuls and Sante Zeeland • Evaluations and learnings The Business Modellers: • Eurasanté and the Entrance project • VIVES (KATHO),Resoc Brugge and POM on the Non-Medical Services business case • Evaluations and learnings The SME Co-Creation and collaboration facilitators: • Impuls: Memory Test and Zeeland Concept Home • Evaluations and learnings • VIVES (KHBO) and healing environment (Lighting in care home) and WSH and diagnostic service for paediatric Diabetes • Evaluations and learnings • SCC and Dragon’s Den events • Evaluations and learning

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1. THE NETWORK BUILDERS Table 22: 1 - The Network Builders adapted Business Model Canvas: Health Enterprise East - The East of England Assistive Technology Network Core problem we are solving: How to create an Assistive Technology (AT) network in the east of England (E of E) that SMEs were calling for in the field research of Activity 1 and the stakeholder workshops of Activity 2 Core purpose of what we are doing: To create a network for AT Care providers, SMEs, Knowledge Centres, User groups within the east of England to promote AT for innovation and adoption

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Additional information surrounding the pilot History of this pilot process

Main Partner details:

• Original need/opportunity identification -- The original need for this pilot and the idea for the pilot were found through holding a stakeholder workshop as part of Cura-B Activity 2. The idea for the network was to get people into the same room and have a collaborative approach. The events are designed to be part technology showcases, part patient/clinician education • Bringing partners together -- HEE brought the stakeholders/possible participants together in the above workshop. • Research and design of product/service -- Cura-B funded the holding of the original workshop and funds the work done by HEE to organise the network • ‘Sales and implementation’ -- HEE contacts ( from their own contacts listings) the participants

HEE: Health Enterprise East Limited is the NHS Innovation Hub for the East of England and assists with accelerating the development and uptake of innovative medical technology products and services that improve the quality of healthcare delivery. SCC: Suffolk County Council is the administrative authority for the county of Suffolk and is responsible (amongst other things) for the provision of social care in the county for example care for older people who are physically or mentally infirm or have a mental health problem and those with physical or learning disabilities and children and families who need protection and support. ARU: Anglia Ruskin University is one of the largest universities in the East of England and a provider of undergraduate and postgraduate education as well as a range of professional qualifications in particular nursing. WSH: West Suffolk Hospital NHS Trust is a large district general hospital in Bury St Edmunds, Suffolk.

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Table 23: IMPULS Pilot Project - ‘Santé Zeeland’ adapted Business Model Canvas: IMPULS pilot project for CURA-B: ‘Santé Zeeland’ Core problem we are solving: Need for more open contact between the different stakeholders in innovation for health Core purpose of what we are doing: Bringing people together on a regular basis to let them inspire each other Key Partners

Key Activities

Impuls

• Facilitating informal meetings.

• Regional development agency; Not-for-profit organization, owned by regional and local authorities, universities and school, private businesses and providers of health and social care. • Stimulating innovation in general. One of the domains is health. GGD Zeeland • Public health authority in Zeeland • Like Impuls keen on enhancing innovation for health. IZ-Zeeland Platform for innovation in health.

• Bring in inspiration by inviting people to pitch or present a project. • tThese two activities are combined in informal drinks in which also people present projects and ideas and are challenged to bring in new ideas. • Hosting and writing a weblog and inviting people to contribute.

Value Propositions

Customer Relationships

Customer Segments

• A forum where stakeholders can meet other stakeholders and to meet people that will know how to bring project ideas forward.

• Some are shareholder of Impuls and GGD Zeeland.

• Local authorities (city councils)

• Between city councils and providers of social care there are procurement • Stimulate new relationships projects and (councils break down procuring care barriers between from providers) sectors and organizations in Zeeland

Key Resources/Competencies

Channels

• Time needed and given by the partners

• Knowledge exchange

• •

Funding for refreshments Designing logo and corporate

style

• Webhosting

• SMEs • Welfare organizations • Provincial authority • Large companies

• Weblog (www. santezeeland.nl) • Informal networking

Cost Structure

Revenue Streams

• Refreshments for meetings (ongoing)

•

• •

• Providers of health and social care

Web- and logo design (once) Web-hosting (yearly costs)

• •

Assumption is that there is a need to keep the threshold low - So refreshments are free and offered to the participants. GGD Zeeland was willing to pay for these drinks for one year. For the following years new sponsors need to be found. IZ-Zeeland is willing to invest time in it, to continue this after CURA-B.

Social benefit that we are providing Establishing a new network. New partnerships and knowledge exchange. New meetings Possible Future Challenges

Possible Future Opportunities

Possible future challenges / opportunities”

Have an infrastructure off-the-road. This is an addition to other events and networks. Because more sectors are involved and there are good chances to show this added value.

Key challenge is to remain relevant. The network has to be fed with inspiration. Networks are easy to start and generate positive attention. To endure can be challenging, because each meeting and each item on the blog has to add value. Next steps

Value of Cura-B Pilot to SMES

To sustain this with support of GGD Zeeland and IZ-Zeeland

The network creates a connection between SMEs, care organizations, users, end users and is a forum to bridge the traditional gaps and a place to meet possible prospects, to exchange knowledge and ideas and to greater understand stakeholder needs

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History of this pilot process • Original need/opportunity identification As in the HEE example the original need for this pilot and the idea for the pilot came from (1) the request of SMEs and health providers to facilitate the network and (2) from other initiatives (e.g. in renewable energy and sustainability) to have informal drinks as a carrier of the network. • Bringing partners together Impuls is itself already a combination of public, private sector and knowledge centre so was ideally situated to bring the stakeholders/possible participants together in the above network meetings. • Research and design of product/service Cura-B funded the holding of the original network meeting and funds the work done by Impuls to organise the network • ‘Sales and implementation’ Impuls contacts (from their own contacts listings) the participants

Main Partner details: Impuls: is the development authority of the Province of Zeeland which aims to strengthen the dynamics of Zeeland's economy. Impuls attracts and involves people from both inside and outside Zeeland in revolutionary ways that hopefully lead to new economic initiatives with the long term aim of developing Zeeland into a province that is innovative and healthy. GGD: Public health authority in Zeeland ID: Innovatieve Zorg in Zeeland (IZ-Zeeland) is the innovation platform for Zeelandic providers of health and social care. These organizations participating in this network represent public healthcare, hospitals, residential care for elderly, home care and GPs.

Evaluation of the Network pilots Both Network pilots are examples of creating the conditions (for creating value) through initial exploratory networking between stakeholders in an open, neutral environment. Both pilots have succeeded in bringing in particular SMEs and Providers together and have therefore helped to bridge that gap. They are an example of early ‘Creation of Value’ in terms of the dimensions of the Business Model Canvas, creating conditions for later more concrete creation of value in co-creation projects. The networks will hopefully lead to the next step in the development process which would be sharing and understanding business models and co-creation, co delivery and co capture of value.

For SMEs: The networks provide a pathway into business and Improve relationships between SMEs, care providers and clinicians. They provide a meeting place to meet possible prospects and exchange of knowledge and experiences. The network creates a connection between SMEs, care organizations, users, end users and is a forum to bridge the traditional gaps and a place. The format is ‘relating but not selling’. The networks provide selling situation for SMEs. Both networks have helped SMES looking to do business in this field save some of the costs of doing their own marketing, prospecting and sales presenting. For Partners: In organising the networks their role has been as a ‘bridge’ - a bridging role which is objective, trusted and neutral - a new, important and valued role in the system. Both pilots show the value of the stakeholder workshops held as part of CURA-B Activity 2 The idea for the network was to bring people into the same room and have a collaborative approach and this has been implemented. We saw from activity 1 that providers and the tendering process ensured that SMEs are often kept apart from end-users. This strategy has made it difficult for SMEs to create and deliver the most relevant products and services. This practice is based on the conception of the ‘management’ of a value chain with a controlled chain of activities mostly internal to the organization and control of the other external parts of the chain by the dominant link in the chain. In AT this control is often exerted by Providers/ Public sector Commissioners. From the network pilots, the value of the network is in seeing the series of relationships as an open and participative network which can provide value to all participants by taking away the controls inherent in the current value chain and improving value flows for example in: • The development of positive , equal status relationships and trust • The exchange of products and services openly and transparently • The flow of information and ideas for new service offerings coming from customers (users and providers), SME developers and knowledge centre facilitators and researchers. • The increasing influence and power of the network for example in influencing regulators and regional or national policy.

Overall Challenges The main future challenges will be the funding the work that goes into organising the network and maintaining the relevance of the network going forward.

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THE BUSINESS MODELLERS Table 24: 2 - Building Business Models

These next two pilots are focussed on helping the creation of business models and business plans -

Eurasanté’s Entrance project and VIVES- RESOC Brugge- POM pilot on ‘Non-Medical Environment’

adapted Business Model Canvas: Eurasanté pilot project for Cura-B: A common Business Model for the Entrance Project Core Problem to be solved in this pilot: How to create a common business model for the Entrance Project Core Purpose: To create a common business model canvas for the Entrance project and with it a common understanding of how to collaborate to make Entrance a success

Partners in the pilot and their roles

Most important activities in the pilot

Value proposition of the pilot

Customer/market relationships

Eurasanté: BMC facilitators

For the Cura-B pilot:

Eurasanté bringing together the partners to create a mutual and common understanding of the BMC for Entrance - a preliminary working business model is defined taking into account the particular needs and expectations of the SMEs/Research organizations.

Eurasanté facilitate the development of a common and mutually co created ‘Business Model Canvas that enables co-creation of the Entrance concept and mutual benefits

For the Cura-B pilot: For the Cura-B pilot: The pilot is the work that takes place Future EU project in bringing the partners SMEs and research Local SMEs organizations together and helping Local AT them understand stakeholders and agree the possible future market and customer relationships

CEA Research Paris Lodron University of Salzburg Research 3Autonom’Lab ALab End User Organization

Future Customer Segments

Eurasanté develop for themselves a key competence in the proposed ‘system The final business Integrator’ role which For Eurasanté this GeoMobile SME models will be SMES feel is needed in is an opportunity to specialise in Business combined as the AT- Care market GFTH SME Model facilitation part of the overall and be known within Idées 3Com business model for the local market and Possible Future SME ENTRANCE for EU projects as Distribution Splitted-Desktop Most Important having this expertise Channels Resources Systems SME and experience For the Cura-B For the Cura-B pilot: pilot: This is an Facilitation resource important skill and from Eurasanté competence set that is being developed by BMC expertise from Eurasanté - a system Eurasanté integrator using/ facilitating the BMC Meeting facilities as a framework for Cost of time and travel co-creation of AT of the attendees products and services 50Plus GmbH 50+ End User Organization

The likely channels would be future or existing local and international networks , conferences & European projects Table continued overleaf

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Investments

Possible Revenue Streams/savings

For the Cura-B pilot:

• Facilitation resource from Eurasanté • BMC expertise from Eurasanté • Meeting facilities • Cost of time and travel of the attendees

Possible ‘consulting’ income for Eurasanté , project management income for Eurasanté

Possible Future Challenges

Possible Future Opportunities

For the Cura-B pilot:

Concretising and convincing of the value of the BMC facilitation provided by Eurasanté so that such services could be marketed and/or funded in the future

BMC expertise and consulting/project management services for Eurasanté

Next Steps

Value of Cura-B to SME ( SMEs)

For the Cura-B pilot:

Eurasanté will be involved in facilitating some of the work pack ages of the Entrance project mainly in WP1 - the management and dissemination tasks needed for the success of the project including the business model creation and confirmation.

SMEs have the possibility to engage in a structured co-creation project professionally facilitated by Eurasanté

Social / Environmental Benefit For the Cura-B pilot: he network pilots bring stakeholders together in an environment that they can begin to start possible alliances and partnerships. This pilot is an example of the value of bringing together in a more structured and concrete way a group of SMEs and researchers to co create a product and set of services, to co create a way to deliver those products and services and to co create the way that the value can be captured by the partners in the project – as such it is a valuable template and best practice example for concretising projects and alliances that are tentatively formed in networks

SMEs experience the process and project managed by Eurasanté thus saving costs associated with professional services

Additional information surrounding the pilot History of this pilot process • Original need/opportunity identification • Unlike the other pilots within Cura-B, this pilot project was itself about creating a common business model canvas between the partners in the Entrance project. Eurasanté offered to facilitate the development of a common and mutually co created ‘Business Model Canvas ‘ for the Entrance project • Activity 1 SME interviews in the region showed that SMES wanted to understand and experience different business models. Eurasanté conducted stakeholder workshops around business modelling in Activity 2

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Table 25: Example Output – Eurasanté Facilitated BMC for Entrance Project

The Business Model Canvas

Partner details: • • • • • • • • •

Eurasanté: BMC facilitators CEA Research Paris Lodron University of Salzburg Research 3Autonom’Lab ALab End User Organization 50Plus GmbH 50+ End User Organization GeoMobile SME GFTH SME Idées 3Com SME Splitted-Desktop Systems SME

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Table 26: Business Model Canvas - VIVES (KATHO) - Resoc Bruges-POM adapted Business Model Canvas: VIVES (KATHO) –Resoc Bruges- POM pilot project for Cura-B: Business Model for online platform for non-medical services Core Problem to be solved in this pilot: How to create a business case for an online platform for non-medical services in West Flanders Core Purpose: To investigate how a business model and business case could work for a online platform for non-medical services similar to ‘Check a trade’ Partners in the pilot and their roles

Most important activities in the pilot

Value proposition of the pilot

KATHO-VIVES and RESOC-BRUGES

KATHO - Creation of the pilot through researching needs and holding workshops

Future Customer/ market relationships for proposed product in pilot

Value of pilot in Cura-B

Sale (membership)

Business development

Social media & other media (website; printed directories; …)- After care (processing user experience

as knowledge centres and broker/facilitators to facilitate the pilot, initiate collaboration, generate the strategy to move forward – visioning to catalyse via the activity 2 workshops and ideate POSSIBLE PARTNERS TO IMPLEMENT PILOT CONCEPT IN FUTURE Local & Provincial authorities Families/Networks of family care givers Partner organizations (social workers in local authorities; Day care centres; GPs; chamber of commerce; trade unions...) Organizations of users Microsoft Innovation Center Flanders IT companies (software & webhosting) IT-equipment supplier Social Economy/’WellBeing’ vouchers

The “knowledge” within the research is built upon a review on the subject (on-going, done by KATHO, supported by RESOC Brugge), conversations with stakeholders and the focus group in activity 2. Research, meetings with other businesses (for example checkatrade and boekeenafspraak) and stakeholder meetings. A business model has been created (2013) - Information from the literature research and the market study have been integrated into it Information on the development of a business plan was gathered. POSSIBLE FUTURE ACTIVITIES NEEDED TO IMPLEMENT RUNNING THE BUSINESS ADMINISTRATION Quality Process customer feedback and ongoing quality control Marketing (promoting service) Build & maintain website -update website data go between: partner organizations; user - SME -user organizations

incubator / facilitator Informing, inspiring, initiating

Future Customer segments for proposed product

focus on elderly 60+, not in residential care Disabled/different ability clients Carers (“custodial” carers)

Performing the early phase of the innovation process – researching, discovering and defining needs, designing concept and turning into a business model and business case

online & phone assistance Social workers in home care & Gifts / incentives

POSSIBLE VALUE PROPOSITION OF PRODUCT

Most important resources in pilot

Helps SME-branding (reputation/ reliability)

Time, knowledge, collaborative facilitation skills of VIVES, RESOC

Local authorities(municipality: OCMW = public social welfare centre) SMEs offering nonmedical servicesT Future Distribution channels for the proposed service Roadshows for SMEs/ university college

Time savings)

Partner organizations

Quality check, Code of conduct for SMEs, follow up Quality of service - Trust”-relationship with (vetted) SMEs Reliability and reputation of service providers through user experience feedback (cf trip advisor)

social workers in local authorities

Publicity platform :

Word of mouth

Bridge between clients and service providers -Providing a searchable database of reliable service providers of nonmedical services (SMEs)

Website/links

Day care centres; GPs; chamber of commerce; trade unions training

Targeted magazines

User friendly Graphical UI and easy accessible search engine - online & phone support

Table continued overleaf

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Possible Future Investments needed for proposed product promotional materials & actions Website (code)- Website (layout)Webhosting- IT-equipment

Possible Revenue Streams/savings for proposed product Brokerage fee Advertising space Governmental support

Staff costs(fixed/variable)

Subscription for SMEs- win more offers

Office running costs

Social / Environmental Benefit

Education & training- employees

The proposed platform makes the search for reliable service providers easier. The easiness and the reliability both have a positive and direct impact on the well-being of the user (the elderly, intermediates and/or carer)

Roadshows, networking

Additionally the platform is a timesaver (easy search, more efficient way of working for intermediates). For the service provider, a new market segment emerges which influences business directly. Indirectly the platform will help people stay longer in their homes which implies a financial impact on social security (the expenses for residential care and medical care can diminish). The fact that people stay longer at home adds up to their psychological well-being (increased autonomy and reassurance). This aspect also affects the medical expenses (decrease). The platform also enforces the community in the neighbourhoods which positively influences social well-being of the individual and the community itself. Possible Future Challenges for proposed product Possible local Legislation and Regulation, Government policy Finding Capital or Means of Financing, funding for the product For an SME, the availability of Internal Resources and finding External Resources

Possible Future Opportunities for proposed product Market segments: Evolution of the index of 65-plussers (base 2010 is 100) around 180 in 2060 for Belgium and its regions. In 2020 the number of 65-plusser with difficulties to perform activities of daily life will have increased to 265,000 by 2020. Carers (via “mantelzorgpremie”) - 600,000 carers in Flanders

Customers will need to be Convinced of a New Product or Service

Social intermediates: Home Care coordinators at the Public Centres for Social Welfare (OCMW), Social services at the institutions for home care, Home care organizations

Maintenance of this group of Cura-B partners as system integrators after the Cura-B project has finished

Service providers: self-employed and SMEs. In 2011, 31% of the SME’s in Flanders act within the service sector, followed by the sector of construction and industry (respectively 13% and 12% of the market).

Next Steps

Value of Cura-B to SME ( SMEs)

Important future resources needed to implement product

There is a future value to local self-employed and SMEs. In 2011, 31% of the SME’s in Flanders act within the service sector, followed by the sector of construction and industry (respectively 13% and 12% of the market).

Website (code, content)- Web space (servers, equipment, web domain) IT equipment (general use Knowledge and expertise Staff Offices

Future opportunities for the platform are a larger scope of market segments e.g. people that are younger than 60 may also benefit from the advantages of the platform. The platform itself may expand continuously by a growing offer of SME’s and services. Technically, the platform may be available on different devices and apps can be developed.

Service (insurance support /administration) Start-up budget

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Additional information surrounding the pilot History /Innovation process in this pilot

Main Partners

Original Idea vs. Research/Need

VIVES (KATHO)

This pilot case was initiated by an idea that emerged from informal conversations with stakeholders and knowledge of the research group at KATHO. The idea was evaluated at a focus group, held at KATHO in February 2012. A research activity was setup to substantiate the idea. The “knowledge” within the research is built upon a review on the subject (on-going, done by KATHO, supported by RESOC Brugge), conversations with stakeholders and the focus group in Cura-B activity 2.

Katholieke Hogeschool Zuid-West-Vlaanderen (KATHO) is a private state-recognized and statefinanced higher education institution with campuses in Kortrijk, Roeselare, Tielt and Torhout. KATHO has as its core business is to ensure higher education for students at bachelor level in applied engineering, technology and informatics, biotechnology, commercial sciences and business management, education, health care and applied social studies. KATHO has nearly 9000 students and more than 900 staff members

Development Process: Research Early 2012- preparation, realisation and processing focus group concerning non-medical services for vulnerable clients; Summarize brainstorm focus group non-medical services for vulnerable clients- Draft proof of concept for activity 2 non-medical services for vulnerable clients. Second half of 2012- preparation, realisation and processing Interviews with different stakeholders Design phase Second half of 2012 research, meetings with other businesses (for example check trade and boekeenafspraak) and stakeholder meetings -fact finding trip (Suffolk) and cross border activities concerning non-medical services and late 2012 further market research. Completion Phase January to July finalising Business Model Canvas and November 2013- report document on pilot case Technology used

RESOC Bruges RESOC Bruges is the regional social-economic consulting committee of the region of Bruges. It supports local development for socio-economic subjects. The partners of RESOC are the Province of West-Flanders, local authorities, social partners and other relevant socio-economic stakeholders in the region. RESOC Bruges has opted to create a network for partner organizations in health care which started in 2011: Trefpunt ZORG. In CURA-B. RESOC Bruges’ role was to connect different players in the field of health care and keep a wide view on the pilot case to keep the idea feasible for all stakeholders. POM West-Vlaanderen The West Flanders Development Agency (POM West Flanders) implements the social-economic policy of the Province of West Flanders. POM West Flanders initiates, and coordinates and realizes activities and projects focusing on sustainable entrepreneurship, business infrastructure, transport & logistics, innovation and international business support. The aim is to reinforce West Flanders as an internationally orientated, dynamic, competitive and innovative region with a positive working climate and an attractive environment.

The Pilot case is based on an online available database. The technology used consists of background technology, driving the database itself and foreground technology driving the website for accessing the database. MySQL would be used for the DBMS. The website would be created using a website content management system (WCMS) as this offers the possibility for non-technical staff to maintain the website. Main disadvantage is set-up costs, main advantage is lower maintenance costs and the use of up-to-date web standards and technologies.

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Evaluation of the Business Modelling pilots • Both pilots are examples of how helping to understand new business models could work through facilitation and reflection via the Business Model Canvas and are bridging the gap posed by Activity 1 that new business models need to be understood and created. Eurasanté have succeeded in bringing particular SMEs and knowledge centres together to mutually construct a common business model. The network pilots bring stakeholders together in an environment that they can begin to start possible alliances and partnerships. This pilot is an example of the value of bringing together in a more structured and concrete way a group of SMEs and researchers to co create a product and set of services, to co create a way to deliver those products and services and to co create the way that the value can be captured by the partners in the project – as such it is a valuable template and best practice example for concretising projects and alliances that are tentatively formed in networks • VIVES (KATHO) -RESOC Bruges-POM have used their own research and knowledge and particularly the impetus given by activity 2 workshops to create a detailed business idea and plan which could be given to an interested SME to develop as a business in itself similar to ‘Checkatrade’. Such SME co-operation with the care sector and knowledge institutes for developing new products and services was low before CURA-B. There is also the future value to all local self-employed and SMEs in the West Flanders region. In 2011, 31% of the SME’s in Flanders act within the service sector, followed by the sector of construction and industry (respectively 13% and 12% of the market). • Both pilots show the value of the identifying challenges/gaps for SMEs in Activity 1 and the Activity 2 workshops on how to bridge the gaps. VIVES (KATHO)-RESOC Bruges-POM are an example of best practice collaboration within the region the knowledge centre and economic development expertise and the importance of collaborative research to take an idea forward into a business plan and support SMEs. One of the key ideas suggested to bridge the gap is that there is a need for a ‘system integrator’. CURA-B pilots show that this is a critical role which requires multiple competences and it is unlikely that these can be found in any one organisation. Therefore the integrator role may have to be played by an alliance of organizations and VIVES (KATHO)RESOC Bruges-POM have proved an exemplar for this. • The pilots support the findings from other research into the usefulness of business modelling. An SME with an unclear strategy or a poorly communicated model of how it creates value (within the value network) needs to first make

explicit its business model, so it has a firm foundation for moving towards sustainability and sharing its plan for a new future. The challenge for SMEs is to have the competence and the time to develop their business model. These two pilots have helped to develop those competences and in the Eurasanté case provided the competences as a facilitator’s template to kick off a project for local (and international) SMEs

Overall Challenges For the Eurasanté pilot: Concretising and convincing of the value of the Business Model Canvas facilitation provided by Eurasanté so that such services could be marketed and/or funded in the future For the VIVES-Resoc-POM pilot the maintenance of this group of Cura-B partners as system integrators after the Cura-B project has finished For the product idea proposed in the pilot: Finding Capital or Means of Financing and funding for the product, the availability of Internal Resources and necessary external resources including marketing resource in the event that customers will need to be Convinced of a New Product or Service.

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THE SME CO-CREATION AND COLLABORATION FACILITATORS: Table 27: 3 - Facilitators of Triple Helix Collaboration

(a) Co-creation of idea to possible product/service Impuls with the Memory Test pilot and the Concept homes pilot adapted Business Model Canvas : IMPULS pilot project for Cura-B: ‘Memory Test’ Core Problem to be solved in this pilot: How to take the hospital memory test conducted on paper (TYM test) and make it available as a digital test to be used by carers and nurses in the home Core Purpose: To take the concept from the university and turn into a product /service with the help of the SME - to bring the SME and university together Partners in the pilot and their roles

Most important activities in the pilot

Value proposition of the pilot

Impuls:

Organising meetings

as knowledge centre and broker/facilitator

Networking, connecting partners

Joint Venture with SMEhospital-university and Impuls

To facilitate the pilot, initiate collaboration, generate the strategy to move forward visioning

Discussions with SMEs who can digitalise data

To catalyse via the activity 2 workshops and ideate University

Suggesting actions for Role in Cura-B: Informing, other organizations inspiring, initiating Facilitating, consulting role – guiding collaboration - a collaborative glue

as knowledge centre and as a buyer of SME service- (Gerda Andringa) Provides the research in the innovation process Needs definition with Impuls SME- Memorie Care Design, produce, sell, train users and provide after sales

Impuls as catalyst for collaboration, partnership initiator, partnership facilitator

Value proposition of the product Assisting healthcare providers / nurses to work remotely in patient homes

Future Customer/ market relationships

Future Customer segments for the product

Cocreation/ collaboration between university and SME- university researching needs by direct contact with possible customers ( nurses, carers)

Nurses

Future Sales will be performed by SME in traditional way once product is ready i.e. by prospecting, meeting the customer segments

Users Insurance Companies Municipalities Care providers GPs

Most important resources Time, knowledge, collaborative facilitation skills, IT/ computer, patients/ clients for feedback

Future Distribution channels

University students

Care providers

Research by the University and Design by Memorie Care

End users

Local care networks

Insurance providers

Impuls as facilitator resource Table continued overleaf

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Costs/Investment

Possible Revenue Streams/savings

Staff costs at University for Research

Early detection cost savings = health savings - Insurance provider - preventing, lowering their costs - - shorter hospital stay and longer home stay (same benefits for Government )

Development of SW and the digital back office for the test Facilitating costs incurred by Impuls

Patient convenience / family convenience (savings in their time and travel costs)

Future Costs :

Tests used will give revenue to MemorieCare (SME)

Future legal costs, IPR - licensing – distribution/sales

Social / Environmental Benefit

Future cost of marketing , branding

The benefits of the PROCESS of the pilot – lose or flatten the traditional hierarchy of this kind of cooperation – lose the we buy you sell mentality and become co creative- changing of cooperation between providers and SME The benefits of the CONTENT of the pilot- to improve the early detection of dementia. Early detection: beneficiary is dementing person and carer(s)

Possible Future Challenges

Possible Future Opportunities

If no funding, the pilot will continue on small scale with local GPs in Zeeland- the roll out will be much slower and smaller

If the research takes place and is positive, the test can be embraced in the Netherlands. The test will be used for early detection throughout the country

Next Steps

Overall Value of Cura-B to SME ( SMEs)

March 2014 the pilot confirmed that it will have funding to continue a project manager is to be provided by Impuls to take the test forward with the SME and the local hospital commercially

-Connection of SME to care organizations- to help with contacts - To create trust and the possibility to sell to care organizations - To create new knowledge and expertise in digitalisation - Possibility to listen to users, end users and understand their needs

Additional information surrounding the pilot History of this pilot /Innovation process in this pilot • Original need/opportunity identification – performed by the university (university did the research) • Bringing partners together • Impuls brought the partners together so that all 3 partners started the concepting process – began through the Cura-B Activity 2 workshops – inspiration sessions • Research and design of product/service • EU knowledge grant funded SME to develop product/service • Sales and implementation • Buyers should be care providers, mutual insurance companies • After sales • SME will do the training and after sales • Main users will be nurses for care providers

Partner details: • NV Economic Impuls Zeeland, Mira Weber: project manager, miraweber@impulszeeland.nl • MemorieCare, Erna Verstraaten, erna@ memoriecare.nl • University College Roosevelt, Gerda Andringa, g.andringa@ucr.nl • ZorgSaam, Diny van der Staal, d.v.d.staal@zzv.nl

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Table 28: adapted Business Model Canvas - Impuls Pilot: De Zeeuwse Huiskamer adapted Business Model Canvas: Impuls pilot: De Zeeuwse Huiskamer Core problem we are solving: The need for a test lab for innovations and new partnerships in health and social care. Core purpose of what we are doing: Establishing three homes in which partners can experience the challenges of (health) care of the future and are challenged to find answers and implement innovative solutions.

Key Partners

Key Activities

Value Propositions

Impuls

Facilitate access to the three homes.

Bring partners together and assist them in defining Shareholder of innovative solutions. Impuls.

Regional development agency. Not-for-profit organization, owned by regional and local authorities, universities and school, private businesses and providers of health and social care. Stimulating innovation in general. One of the domains is health. IZ-Zeeland

Invite guests to the houses to live there. Keep a weblog to communicate about the results of the project. Facilitate one corporate style in communication. Key Resources/ Competencies

Platform for innovation in Time (of facilitators) health. Time (of participating Delta/Zeelandnet organizations: Regional Internet Service providers; authorities; SMEs; housing Provider, with a market corporations etc.) share of >90% A project manager Software for expertise management 3 houses Software/hardware Domotics

Exchange of experiences and knowledge. Involve universities and centres of expertise. Open an environment in which the demands of future health and social care are clarified. Assist city councils in dealing with disruptive changes in the Dutch health system in which they will have to take up more responsibility with smaller budgets.

Possible Customer Relationships

Providers of health and social care are participating in IZ-Zeeland. Between city councils and providers of social care there are procurement relationships (councils procuring care from providers)

Possible Customer Segments Local authorities (city councils) Providers of health and social care SMEs Welfare organizations Housing corporations Provincial authority Large companies

Possible Channels Project Meetings SantĂŠ Zeeland Weblog Social media E-Mail

Table continued overleaf

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Cost Structure

Revenue Streams

Cost of the houses

We distinguish costs related to the pilots from the costs of the top-level project.

Time of participants Project manager Communication tools

All costs in individual pilots have to be covered by funding in natura from the participating organizations. Top-level: project management, expertise management en communication: For this a subsidy from the Provincial authority is requested. Later innovation funds will be found. Social benefit that we are providing Positive atmosphere in a world in which people have learned to complain about the decline of healthcare facilities. Bringing people together and teach them to collaborate.

Possible Future Challenges

Possible Future Opportunities

Attract new stakeholders. Some stakeholders (e.g. healthcare) are keen on the project. However, this only can work well, if all interests are participating or at least formally and substantially represented.

This is a unique infrastructure in which several pilots are sharing expertise and experiences. This way of sharing is a great opportunity and can develop further into a new method of innovation in the social domain.

Next steps

Value of Cura-B to SMEs

Start up the project and find other funding opportunities.

- Value of Pilot to SMEs

Connect other pilots (in and outside Zeeland) - An opportunity to use this pilot to involve more centres of expertise outside Zeeland.

This pilot helps SMEs to learn what the needs of the future are and allows them to design and develop solutions.

Additional information surrounding the pilot Brief history of pilot – where the idea came from (1) The observation that many organizations are willing to start tests. (2) The concept room in North-France (Eurasanté), in which SMEs and universities were joining in development of the hospital room of the future.

Main Partner details: Impuls: is the development authority of the Province of Zeeland which aims to strengthen the dynamics of Zeeland's economy. Impuls attracts and involves people from both inside and outside Zeeland in revolutionary ways that hopefully lead to new economic initiatives with the long term aim of developing Zeeland into a province that is innovative and healthy. ID: Innovatieve Zorg in Zeeland (IZ-Zeeland) is the innovation platform for Zeelandic providers of health

and social care. These organizations participating in this network represent public healthcare, hospitals, residential care for elderly, home care and GPs. Delta Zeelandnet: Local Zeeland internet service provider

Evaluation of the co-creation pilots: idea to product / service • Both pilots are examples of facilitating SMEs, Knowledge Centres and Providers to co create a solution from an initial idea therefore bridging the gap and providing the opportunity and the project environment to collaborate openly and on equal status. • For SMEs: In the Memory Test pilot, the connection of SMEs to care organizations and helping with contacts creates trust and the possibility to sell to care organizations. There is also the possibility to listen to users, end users and understand their needs and the creation of new

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knowledge and expertise in digitalisation. In the Concept homes pilot Impuls has created a unique infrastructure in which several pilots are sharing expertise and experiences. This way of sharing is an opportunity and can develop further into a new method of innovation in the social domain. Fundamentally this pilot helps SMEs to learn what the needs of the future are and allows them to design and develop solutions. • For Impuls the two pilots have provided further opportunity to brand themselves as a ‘system integrator’ in Zeeland (following on from their Networks pilot) and to reinforce within themselves the co-creation/facilitation skills and mindset and to work closely with SMEs and knowledge centres. • The pilots again show the value of the Activity 2 stakeholder workshops and the ideas generated on how to bridge the gaps. In Zeeland there was a strong call for more open and equal collaboration (which is provided here in the pilots) and for a rethink of the system of developing AT as a whole. ‘Co-creation’ is the practice of product or service development that is collaboratively

executed by developers and customers (and knowledge centres) together. A challenge in this ‘Open Innovation’ form of development is what information can be shared with partners in the process and how can partners protect their own special information and knowledge such that they can benefit or get value from this knowledge. The role of Impuls is to create a high level of trust and openness by acting as a neutral catalyst to bring parties together. As such this is a critical role in acting as a bridge between knowledge centre, SME and provider and re-shapes the way in which products are developed from ideas, blurring the boundaries between research and development.

Overall Challenges • Funding for the Memory Test pilot to continue was confirmed in March 2014. • For the Concept homes it will be the finding of other funding opportunities.

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Table 29: Facilitating Co-Creation: WSH Pilot 'Bluetooth Diabetes Monitor'

Facilitating Co-creation: (b) From Product into Test/Validation phase

adapted Business Model Canvas : WSH pilot project for Cura-B: ‘Bluetooth Diabetes monitor’ Core Problem to be solved in this pilot: Diabetes patients vary greatly in their reliability with regard to collecting data on their blood sugar. This data is essential to help clinicians monitor and manage the patient’s illness. Creating a monitor that ‘Bluetoothed’ the patient’s blood sugar readings removed a step in the data transfer process making it easier for patients. It also meant that clinicians had real-time data (a steady stream of data from 4 points in each day) with which to monitor patient health. Core Purpose: To trial new monitor at WSH. Partners in the pilot and their roles West Suffolk Hospital Entrehealth (US) Medvivo (UK)

Most important activities in the pilot Develop improved specification for new glucose monitor for under 19s in conjunction with patients and clinicians Test new monitor with clinicians, patients and their families Gather information on the functioning of the new monitor Report back to hospital administration regarding the functioning of the monitor Most important resources Commitment to innovation of WSH Open innovation approach CURA-B funding to pay for blood sugar monitors, mobile phones and WSH staff time. Availability of WSH clinicians and patients for trial

Value proposition of the pilot

Activities/ Future Customer relationships in the segments Generate evidence for WSH market administration of the value of Other hospital an easier to use monitor. New relationship trusts between WSH and Other health Medvivo providers Demonstrate the value of a New innovative monitor that collects better data relationship in for clinicians which an SME offered not just a product to WSH Improve data for clinicians but also ‘technical – better quality and more triage’ support for frequent (daily rather than 3 the technology monthly reporting). supplied. Generate knowledge about barriers to the adoption of such a monitor - E.g. desire to preserve existing care pathways.

Future Distribution channels Develop contract with WSH to supply and support the technology

New relationship between Medvivo and Entrehealth in the US (Medvivo wrote the App to support Entrehealths blue tooth monitor) Medvivo became the distributor of Entrehealth’s monitor.

Develop contacts with other trusts in the region and beyond. Use CURA-B or Biz for health as a vehicle to develop contacts in two seas region.

Table continued overleaf

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Investments

Possible Revenue Streams

App development costs

sale of goods and services / consultancy

Specification development

more effective ways of capturing care tariff income

Project management

Attracting more patients to service as a consequence of higher quality service.

Clinician time Patient time Costs of networking Costs of facilitating/bridging

Social / Environmental Benefit non monetised benefits for diabetes sufferers ( quality of life) re-designed care pathways that reduce costs Long term savings for regional health authorities due to increased wellbeing, fewer emergencies

Possible Future Challenges

Possible Future Opportunities

Barriers for future exploitation of this technology

General market conditions â&#x20AC;&#x201C; number of possible users, customers

The financial support for health provision is fairly Growing obesity means that diabetes is a growing market rigid, based on care tariffs (payment per contact). Consequently, reducing contact through technology can result in a loss of revenue. Impact of case, possibilities/opportunities for the future Influencing hospital senior management Clinicians are often conservative, particularly around the preservation of existing care pathways. For technologies to bring savings to the hospital, they must disturb care pathways.

Influencing and interesting clinicians in new ways of delivering services using new technology

Next Steps

Value of Cura-B for SME

Final report on the trial will be distributed to senior management at WSH

MedVivo has had contact with a young patient group with which it was not previously familiar. This has meant learning for them. MedVivo has adapted its CoPD app to use with diabetes patients

Additional information surrounding the pilot The Study was promoted as follows:

What is the purpose of the study? This is a feasibility study to see if the use of assistive technology amongst children and young people can enable a more convenient way to manage their diabetes improving care and quality of life through real-time monitoring. The assistive technology being investigated is a glucometer with the ability to transmit the information to a mobile device. The blood glucose readings are to be performed as part of a personâ&#x20AC;&#x2122;s normal diabetes care. These blood glucose readings will be managed by the person as usual however this same information will also be transferred electronically to the people involved in your diabetes care at the West Suffolk Hospital.

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Specification development and rationale for the trial To develop the specification the team chose a participative approach, drawing on the views of a GP, a schools representative, a representative of Diabetes UK and X patients. Views were sought through a structured 2 hour workshop focused around education, communication, monitoring and technology. The views of clinicians were sought separately. Workshop with Clinicians, school representative and GP Practice Manager July 2012: To discuss using Assistive Technology to improve Paediatric Diabetes for Workshop in October 2012. Chair: Colin Lainson (CL) & Seema Moss (SM) attended by school representative, Clinical, Dietician, and GP Practice Manager Workshop with parents, children and adolescents The patients identified ease of use and Bluetooth as a desirable improvement. They were, at the time, using diaries to record blood sugar data or printing out from USBs for their three monthly consultations. The USBs were not reliable and the diaries not always complete. The clinicians stressed the need for reliable complete data. They suspected that a number of patients made up their results, or at least filled in the gaps in the data, prior to consultations. Technology development A Technology supplier was sought for a Bluetooth glucose monitor. None could be found in the UK so a US firm Entrehealth was identified that was prepared to collaborate. A UK firm the experience in medical patient-use applications (Medvivo) was identified and became the UK supplier of the hardware. Entrehealth provided the technology (glucose monitors) and Medvivo the adapted an existing (Chronic Obstructive Pulmonary Disease (CoPD) application to run with it.

Technology trial

The trial involved introducing a Bluetooth-based glucose monitor alongside their existing monitor. The ‘existing’ technology consisted of the patient (or their carer) using a monitor to obtain a blood sugar reading, recording that in a paper diary and then presenting the diary at scheduled clinic visits (four per year) for discussion. Some had the option to print results of for consultations using a USB drive.

Focus groups Three focus groups were held at the end of the trial period; two with patients and one with the clinical group. Group 1 Feasibility study Focus Group with Clinicians 11th December 2013: Focus group to discuss experiences, Facilitator: Seema Moss (SM); Attendees: Diabetes Clinical Nurse Specialist (JP), Dietician, (RW), Diabetes Clinical Nurse Specialist (JH) Paediatric Diabetes Consultant (BA), Diabetes Research Nurse (SD) Group 2 Feasibility study Focus Group for Parents/Carers & Participants 14th December 2013: Participant Focus group to discuss experiences, Facilitator: Seema Moss (SM) Attendees: Parent (LP), Parent (KP), Participant (008), Parent (DA1), Parent (DA2), Participant (013) Diabetes Research Nurse (SD) Group 3 Feasibility study Focus Group for Parents/Carers & Participants 14th December 2013: Participant Focus group 2 to discuss experiences, Facilitator: Seema Moss (SM); Attendees: Parent (MW), Parent (DW), Participant (009), Parent (LG), Participant (005) Diabetes Research Nurse (SD)

All those who fitted the criteria were sent a patient information sheet to consult and if they were interested in taking part they were to contact the research nurse to be consented. • Recruitment finished in the first week of October The trial recruited 17 participants - two were adolescents • Trial started on the 16th September • Trial finished by the 26th December with 11 participants remaining

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Table 30: VIVES (KHBO): 'Lighting in a West Flanders Care Home' adapted Business Model Canvas : VIVES (KHBO) pilot project for Cura-B: ‘Lighting in a West Flanders Care Home’ Core Problem to be solved in this pilot: How to trial ‘Tunable White’ lighting in a live setting in a Care Home in west Flanders by getting Tronixx (SME) and the Care Home to collaborate Core Purpose: To take the concept from the SME (Tronixx), match them with a Care Home and prove the value of Tunable White thereby improving lives of people in care homes Partners in the pilot and their roles Private sector local SME entrepreneur in the healing environment lighting installer ( SME Tronixx)

Most important activities in the pilot

Value proposition of the pilot

Initial research by VIVES and organization of the project and bringing the partners together (VIVES,Resoc,POM)

Bridging/facilitating entrepreneurs into the market through Co-creation with the care home to:

Ongoing facilitation of the partners - the bridge role

lighting solutions sales and marketing (SME ‘Sales’ process initiated by Tronixx) Tronixx to convince the care home Private sector lighting manufacturer (Tridonicssupplier to Tronixx)

Care home – the provider of care services ( also a private sector provider)

Planning, Installation, after-sales service, solution design and applications ( Tronixx)

Manufacturing of Tunable White lighting (Tridonics)

KHBO as the knowledge centre Funding from Cura-B and and facilitator ( in future from regional now VIVES) government (EU) RESOC midWest Flanders as facilitator POM West Flanders as facilitator

Most important resources Knowledge /expertise concerning effective use of lighting

-Improve wellbeing of people with dementia in the care home - Improve wellbeing of clinicians working in the care home

To obtain validation for the lighting concept

Activities/ relationships in the market Lobbying regional government Public relations / networks “Health net Flanders”

Future Customer segments Residential care institutions Private Public People undergoing care in the care homes

KHBO Trusted partner Expertisecentra Regional dementie” Government (knowledge center) Private homes Customer contact via associations e.g.

Belgian Association for Future Distribution channels Gerontology and Geriatrics Local networks Alzheimerliga Sales representatives Sales and KHBO ‘consultants’ marketing by telephone, by Regional calls personal visits from Tronixx Local workshops and seminars

Presence at regional fairs in the Publications in professional journals and non- professional construction sector (Batibouw) and magazines fairs care sector (REVA)

Free use of the lighting and installation during the pilot Cura-B funding Cura-B partners as facilitator resource Positive attitude of care provider to change and to the lighting possibilities

Table continued overleaf

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Investments

Possible Revenue Streams

Research and development costs for Tridonics and adaptation costs for Tronixx though they are providing the lighting for the pilot for free (loaning)

sale of goods and services / consultancy

Costs related to knowledge/ expertise center (FTE, travel costs, …..) in initial research

non monetised benefits for dementia sufferers ( quality of life) Perhaps fewer staff for care homes Care home savings medium to longer term on energy and lighting replacement costs Long term savings for regional government due to increased wellbeing, fewer emergencies

Costs of networking and workshops

Social / Environmental Benefit

Costs of facilitating/bridging between the partners in the pilot

Improved living conditions for Dementia sufferers in care homes

Possible Future Challenges

Possible Future Opportunities

Improved working conditions for nursing staff in care homes

Financial support in general towards General market conditions the residential care setting Approximately 135 registered nursing homes in Flanders and approximately 101.000 people with Dementia in Flanders estimated to be 129.000 by 2020 and an increase of the 80+( in relation to the population of 65+) of 23% in 2005 to 40 % in 2050. The number of 85+ living in nursing homes will double because of and two thirds of residents in nursing homes have a form of dementia- the Flemish government expect an increase of people with dementia living in nursing homes People with dementia living in nursing homes (but also staff and visitors) will benefit from adapted light/lighting and the design principles towards the wellconsidered use of light/lighting can be transferred to the community Impact of case, possibilities/opportunities for the future Influencing the government: The results of the screening of current governmental standards in relation to light/lighting standards for residential care and the evidence based/best practice available will lead to the recommendation for more specific criteria concerning the use/installation of light/lighting. Transfer of the expertise towards the community, the people with dementia (and their caregivers) living at home. Next Steps

Value of Cura-B for SME

Dissemination of the pilot case: SME product (Tunable White lighting) credibility. The results of the study will be The reduced the gap between the SME and the Care Provider has enabled the communicated in different ways to creation of a common vision and a shared narrative. public, entrepreneurs, government and care sector - ResponsibleVIVES, Resoc MWFl, POM in cooperation with Residential Care Center SintVincentius, Tronixx and ARU

Additional information surrounding the pilots History of this pilot process Original need/opportunity identification Initial ideas and research: February/March 2012 (Activity 2 – CURA-B) • From the outcomes of the workshop ‘Well-being: role of wellness in rehab and preventative health care’ held as part of Activity 2, the pilot case ‘Healing Environment and care technology in the residential care’ was selected. The residential

care center Sint – Vincentius (Meulebeke, WestFlanders) volunteered to cooperate with the pilot case. Mieke Van Acker, the managing director of the nursing home had already conducted a review concerning the healing environment and the importance of a well-considered use of colours (colour as an element of a healing environment) in the built environment in the care of people (with or without dementia). The main participants in this part of the process were KHBO, Resoc MWFL and care institutions. This stage of the project was the responsibility of Resoc MWFL

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Actions based on needs and research: Research - Current State • An initial (inter)national review on the subject Healing Environment performed by KHBO in May 2012 and then a meeting with Mieke Van Acker to evaluate the needs of the residential care settings concerning enhancing the HE concept. From the outcome of this meeting, the use of lighting (lighting as an element of a HE) in the care of people with dementia was selected. Lighting was chosen because it is an element of a HE and West-Flanders has 40 lighting companies. Therefore there would be enough SMEs to conduct an open call at a later stage of the pilot (Responsible: POM and Resoc MWFl). Dementia was chosen because as people live longer experts predict dementia will rise significantly. The Flemish government expected an increase in the nursing homes of the group of the eldest elderly and so an increase of people with dementia living in nursing homes • An (inter)national review was conducted by VIVES (August-October 2012)concerning the importance of the built environment in enhancing the quality of life of people with dementia and the importance of a well-considered use of light(ing) in the care of people with dementia. At the same time VIVES conducted a screening of current governmental standards for physical environment for residential care for people with dementia Ideas – What can be done? Resoc MWF then organized and conducted a workshop on the use of light(ing) in the care of people with dementia (December 2012) the objectives of which were to share the evidence-based/best practice available, design principles and recommendations with care institutions and other knowledge centers and to check whether the findings from the review could be recognized in the practice of the care centers. The workshop generated in-depth insights into the design principles and recommendations concerning thoughtful use of lighting in the care for people with dementia and also a sense of urgency to deliver more specific governmental standards for the residential care for people with dementia as this would influence the need of financial support of the residential care settings. Implementing – bringing the SME and Provider together • Meeting was held with the care provider in January 2013 to deliver a framework for testing the pilot case. With Resoc MWFL and VIVES Alongside this an (inter)national review was conducted on the relationship of adapted light/ lighting-sundowning syndrome and then the delivery of evidence-based questionnaires to evaluate the impact of light/lighting on the

well-being (HE) of clients with dementia (and sundowning syndrome ) to and visitors of the residential care home Sint-Vincentius during January – February 2013 (Responsible: VIVES) • A call was then made designed and made for a lighting company in February -March2013 (Responsible: Resoc MWFl and POM). Of two candidates, Modular and Tronixx, Tronixx were selected and the preparation of the installation of (adapted) lighting began in April, 2013 (Tronixx, in collaboration with KHBO, Residential Care Center Sint-Vincentius and Resoc MWFl Preparing the Business Model • Construction of a business model concerning the pilot case (Business Model Canvas, first draft) January 2013 (Responsible: POM (I-Propeller), KHBO and Resoc MWFl ) and then fine tuning of the Business Model Canvas during March to May 2013 (Responsible: ARU, VIVES, Resoc MWFl) These research and development actions in the pilot have been financed by: • For VIVES: co-financing CURA-B and VIVES (Mainly staff costs) • For Resoc MWFl: co-financing CURA-B and Resoc MWFl (Mainly staff costs) • For POM: co-financing CURA-B and POM (Mainly staff costs) • For Tronixx: Funding by Tronixx

Partners There are 5 partners involved: • POM West-Vlaanderen: The West Flanders Development Agency (POM West Flanders) implements the social-economic policy of the Province of West Flanders. POM West Flanders initiates, and coordinates and realizes activities and projects focusing on sustainable entrepreneurship, business infrastructure, transport & logistics, innovation and international business support. The aim is to reinforce West Flanders as an internationally orientated, dynamic, competitive and innovative region with a positive working climate and an attractive environment. • RESOC Midden-West-Vlaanderen: RESOC (Regional Economic - Social Concertation Committee) is a 'tripartite' organization, composed of representatives of the public authorities (province and local) and the social partners (employers - and employeesassociations). RESOC's mission is to develop, stimulate and implement a joint socio - economic policy for the region. RESOC stimulates and supports regional authorities and organizations to harmonize their policies and join forces with regard to important and sensitive regional economic issues.

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• VIVES (KHBO): Katholieke Hogeschool Brugge–Oostende (Catholic University College of Bruges–Ostend) provides a whole range of professionally and academically oriented study programs at the level of Bachelor and Master. Catholic University College of Bruges-Ostend is the result of a merger of 5 former independent colleges of higher education in Bruges and Ostend (Approx. 3800 students and 400 members of staff (330 FTE)). There are 4 faculties: Engineering Technology, Education and Teacher Training, Management and Business Studies, Health Care. The Faculty of health Care its mission is to expand its expertise on the development of an integrated caring environment. • Residential Care setting Sint-Vincentius: is one of the 8 residential care settings of ‘the GVO (Gast Vrij Omgeven) - the residential care group’. It has 96 rooms for permanent residency and 10 short stay homes. They use an integrated approach involving all disciplines work together to increase the wellbeing of the residents with dementia. They are focused on healing environment: they want to create an optimal physical environment of colour, door, light, sound, nature, orientation • Tronixx Belgium is a company based in West Flanders, founded in 2003 by Tony Decavele. The main business activity is to offer customized light solutions. The company has international alliances with other companies. This cooperation results in sharing knowledge and innovation, for example with the Austrian company Lumitech which is specialized in the field of LED technology and Tridonic which leads to sharing expertise about the development of light solutions. Tronixx is a product distributor for those two companies. Two comparison pictures showing the care home hallway before and after the new lighting intervention:

CHAPTER 4

Evaluation of the co-creation pilots: Product / service to the Market – testing and Validation • Both pilots are examples of facilitating SMEs, Knowledge Centres and Providers to co create the delivery process / implementation process of a concrete product into the market via testing and validation thereby bridging the gap between care providers and SMEs • For SMEs: for Tronixx as a particular SME, the pilot has given Tunable White lighting (the product) credibility. The introduction of the neutral broker (VIVES) in the creation of their mutual business model has reduced the gap between the SME and the Care Provider and has enabled the creation of a common vision and a shared narrative and the opportunity to work with a neutral opinion and neutral research on the product so that the SME can approach customers with evidence based ‘truth’. The Lighting pilot has shown some best practices for doing business in the care sector and how an SME can develop its product in an evidence-based way. • In the West Flanders region SME’s were not very aware of the business opportunities associated with the ageing population and the possibility of co-operation with the care sector and knowledge institutes for developing new products and services. CURA-B has raised awareness of the opportunities of doing business in the care sector, and stimulated co-operation between SME’s, care institutes and knowledge partners. • For Partners: CURA-B has created awareness with political and other stakeholders in West Flanders of the benefits for the local economy in doing business in healthcare, whilst at the same time responding to a societal challenge. CURA-B has shown that co-operation between SME’s, care institutes and education/knowledge centres is still in its infancy and that a neutral party like POM West-Flanders is required to facilitate this co-operation. CURA-B has generated contacts and co-operation amongst the university colleges KATHO and KHBO (now joined in Katholieke Hogeschool Vives). It has helped these university colleges to define long term topics for applied research, responding to the needs of local businesses and care actors. There is more awareness within SME’s, care institutes and education/knowledge centres that co-operation is needed to innovate and develop products and services that really make a difference for the elderly. • VIVES (KATHO)-RESOC MWV-POM in this pilot are another example of best practice collaboration within the region using knowledge centre and economic development expertise and again the importance of collaborative research this time to take a concrete product forward into a live

test setting with a provider. The integrator role is being played again in west Flanders by an alliance of organizations and VIVES (KHBO)-RESOC MWV-POM have proved an exemplar for this. The POM facilitation of this alliance was also a vital factor in the pilot and POM will continue to raise awareness and stimulate co-operation between SME’s, care institutes and knowledge partners. • The pilots again show the value of the Activity 2 stakeholder workshops and the ideas generated on how to bridge the gaps. The Lighting pilot in particular is an example of how the knowledge center ( VIVES) and the regional economic organization RESOC can share the initial research, idea generation, business modelling and integrator functions necessary to help the SME take a product to a provider and deliver live testing for the market, facilitated by the strategic economic organization – POM. As with the Zeelandic pilots, the role of POM here is to create a high level of trust and openness by acting as a neutral catalyst to bring parties together – the knowledge centre, the regional economic development organization, the SME and the provider, again playing a critical role in acting as a bridge between the stakeholders and facilitating VIVES and Resoc to work together with themselves as ‘system’ integrators.

Overall Challenges/Conclusions on the test Financial support in general towards the residential care setting. The pilot has produced concrete recommendations for the healing environment (source: Final conference presentation) Respect the minimum values for the light intensity • Adjust the light intensity manual • Avoid significant differences of light intensity between their room and adjacent spaces • Work pre-emptive on the occurrence of agitation • Make judicious use of colour temperature • Go into dialogue with health professionals, companies and institutions

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Table 31 Facilitating Co-Creation: Dragon’s Den Event

(c)From Product to Market through Presentation and feedback sessions Adapted Business Model Canvas: Suffolk County Council and the Dragon’s Den Event Core Problem to be solved in this pilot: To use the Dragon’s Den (DD) events to help Suffolk County Council (SCC) identify new assistive technology (AT) products and services and to assist SMEs to understand user needs and Local Authority requirements Core Purpose: How can SMEs provide AT services and products that assist people with dementia in Suffolk- what infrastructure is needed to help facilitate SMEs to work in this area Partners in the pilot and their roles

Most important activities in the pilot

SMEs at different stages of technology /innovation development in the telehealth/assistive technology sector (often linked with the HEE network) working in:

Arrangement and organization of the DD event by SCC

pro-active monitoring

Funding from Cura-B and in future from regional government (EU)

reactive monitoring

Follow up Market Engagement event to summarise DD event and receive feedback in roundtable discussion

social networking / social isolation

SCC acting as a quasi-consultant in the DD events SCC commissioners

SCC can identify new products and services as they help to bridge/ facilitate SMEs into the market by putting them into contact with user groups, representatives and with commissioners

Customer/Market relationships

Future user and customer segments

SCC creating links and facilitating engagement between SMEs, healthcare providers, dementia specialists and commissioners

Local authorities, regional government

Focus group with individuals who have dementia (end users)

Users of AT and their carers

Dementia Specialists and societies (Alzheimer’s society)

Private homes

Contact established between SMEs, Alzheimer’s Forum and AT specialists Local Authority highlights their requirements in the AT sector

AT and Dementia specialists Alzheimer’s society user support forum and AT champions

Value proposition of the pilot

Most important resources

Future Distribution channels

SCC as the main facilitator, and HEE support

Market engagement events held by SCC to raise profile of new products/services to professionalsthrough this building a relationship with distributors/resellers of SME products

Knowledge/expertise from Dementia and AT specialists /champions Cura-B funding SMEs to participate in DD event

Improved relationship with Suffolk Careline (as a future distributor of SME products)

Table continued overleaf

CHAPTER 4

Investments

Possible Revenue Streams

Costs related to SCC for hosting the event – staff, time, travel, advertising costs

Long term savings for regional government due to increased wellbeing, fewer emergencies if these products by DD participants are designed/sold and therefore contribution to fewer hospital admissions

Cost external to SCC – SMEs had costs to attend DD event – minimum resources and time available Costs of networking for all companies involved

For SCC benefit due to the embedding of learning into a sustainable process

Comments on Costs/Revenues/Social benefits

Gain new products/services for SCC in AT field

SCC have to reassess the value of the DD event. For example many of the SMEs felt that they should include an incentive. One such incentive could be the a pilot testing/trialling of the winning products

SCC has contributed to establishing a ‘community of practice’ by bringing SMEs together who share a common purpose

SCC could ask for the assistance of another county council in terms of gaining access to users/providers prior to the DD event occurring There is a cost also to the SMEs in taking part , for example the cost of working days lost to attend the events and the cost of travelling to the events

Regional institutions like Suffolk Careline will benefitCareline is used more by SMEs who can draw on them to commission their product Social / Environmental Benefit Improved living conditions for dementia patients. Non monetised benefits for dementia sufferers ( quality of life) SCC has assisted SMEs, through the DD event to meet user/LA requirements

Possible Future Challenges

Possible Future Opportunities

Clarifying the output of the events to keep the process relevant for SMEs to take part

SCC could repeat the DD event in 2014, taking on board the feedback received from the Market Engagement Event

SMEs would require more time to prepare (2-3months)

SCC could provide more opportunities for SMEs to network with commissioners in SCC region

SMEs expressed concern regarding the cost of attending the event (time, resources, staff) Limited incentives for SMEs to participate in this event and how to improve the incentives going forward Would have valued the chance for the winner to either receive monetary rewards, or for a testing, prototype opportunity to be available The event would probably have needed different categories for each SME/innovator (pre-start up, 3-5years etc.) Next Steps

Value of Cura-B to SMEs at this point

SCC will embed learning points into SCC and revise for future events

Based on feedback from the DD event, SMEs commented that:

Engage in more active cross border activities – posing the question of what SCC can learn from comparing themselves to other municipal or regional governments in the UK and/or abroad

They valued feedback on their presentations and design of product in terms of affordability, ease of use and aesthetics The DD events provided the space and opportunity to network with others who shared a common purpose/ interest

Additional information for the pilot HEE: Health Enterprise East Limited is the NHS Innovation Hub for the East of England and assists with accelerating the development and uptake of innovative medical technology products and services that improve the quality of healthcare delivery. SCC: Suffolk County Council is the administrative authority for the county of Suffolk and

is responsible (amongst other things) for the provision of social care in the county for example care for older people who are physically or mentally infirm or have a mental health problem and those with physical or learning disabilities and children and families who need protection and support.

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History of this pilot process • SCC sent an ‘Expression of Interest’ to 70 SMEs for the overall Dragons Den event. 34 SMEs responded and 19 took part in the competition. 8 were shortlisted of which 4 became finalists. • First Dragons Den panel included representatives from AT and Dementia specialists and Dragons Den panel 2 and 3 included Alzheimer’s society user support forum and AT champions=

Evaluation of the co-creation pilot: SMEs presenting products and services into the market – Co Marketing • The Dragon’s Den pilot is an example of facilitating a proactive marketing space where SMEs can present to and get feedback from possible Providers and Users • For SMEs: the value of the pilot has been in the opportunity to present to different stakeholders, and to get feedback on their products and services. The events have provided a ‘real’ opportunity to receive validation for the product and improvement suggestions to go forward. The events have also provided an opportunity to see other new concepts ‘in the flesh’ and build partnerships with other, providers and end users/ end user organizations. For the Partner: the pilot has helped SCC find a new role - SCC will continue to invest in future Hackathons / Dragon’s Dens, alongside another UK partner, HEE. SCC have been acting as a form of marketing consultant in how they could they assist SMEs. This is a fundamental change in how SCC have

viewed their role as being responsible for the provision of care services and how they have been viewed within the system. • This pilot took shape at late stage in Activity 3 but again showed the value of the ideas generated on how to bridge the gaps. It shows a transition in the thinking of the partner and are evaluation of their own role in products entering the AT market. It is a valuable example of co-creation but this time in the form of co-marketing or perhaps co- testing. As with the other co-creation pilots the partner role here is to create a level of trust and openness by acting where possible as a neutral catalyst (though they are also an interested party) to bring stakeholders together. The pilot shows another necessary competence of the system integrator role – that of helping SME products and services to the market through organising a form of interactive exhibition (Dragon’s Den).

Overall Challenges This pilot received varied and transparent feedback in the final Dragon’s Den feedback session which was facilitated by ARU. Some of the key challenges were detailed in the canvas above but in summary: • SMEs would like the objectives and outcomes of the events to be clearer in terms of rewards and incentives i.e. prizes, opportunities to pitch to commissioners of services and products and a concrete path towards pilots and finally sales • Rather than bringing existing solutions which was the case of the Dragon’s Dens, state a problem and bring people along to work through the problem together (Hackathon)

Technology provides greater independence for those living with dementia

well. Stuart Arnott from Mindings said that the idea had stemmed from a personal need to keep in touch with his father.

Suffolk County Council: Published on: 12 Dec 2013.

For the full article, please go to: http://www. suffolk.gov.uk/your-council/about-suffolk-countycouncil/news/show/technology-provides-greaterindependence-for-those-living-with-dementia/

Those living with dementia and their families will start to benefit from greater independence thanks to technology developed by small and medium businesses. A technology market engagement day held in Kesgrave saw small and medium sized enterprises present their innovative products to a panel of health and social care professionals in a ‘dragon’s den style’ competition, with the hope of seeing their products promoted to those living with dementia. The winner was a company called Mindings, whose product was deemed to be straightforward to use and helpful in supporting families to stay in touch and in providing reassurance that their family member is

Award winners collecting their awards

CHAPTER 4

OVERALL LEARNINGS FROM THE 9 PILOTS • The 9 pilots can be viewed as different categories which have sought to bridge some of the gaps outlined in Activity 1 and implement some of the ideas developed in the stakeholder workshops of Activity 2 • If we look at the concept of a business model using the lens and the framework of the Business Model Canvas: • 6 of the pilots were mostly focused on work that ‘creates’ value • value network by HEE and Impuls • new business models ( VIVES, Resoc, POM and Eurasanté) • co-creation of product/service/concept IDEAS with SME, provider, knowledge centre (Impuls) • 3 of the pilots were mostly focused on work that ‘delivers’ value • live product test for SME products with possible purchaser/provider (VIVES, Resoc, POM and WSH) • live marketing/presentation sessions to possible purchasers (SCC) • None of the pilots were mostly focused on work that ‘captures’ value • The gaps that have been bridged as part of the pilots: • Create common purpose and relationships for open innovation in a value network by HEE and Impuls • Facilitating new business models and the creation of value propositions and partnerships (VIVES,Resoc,POM and Eurasanté) • Facilitating co-creation of product/service/concept IDEAS with SME, provider, knowledge centre later to become fully fledged product (Impuls) • Facilitating open collaboration for live product test for SME products with possible purchaser/ provider (VIVES, Resoc, POM and WSH) • Facilitating open collaboration for live marketing/ presentation sessions to possible purchasers (SCC)

These are: • Network Organiser ( HEE and Impuls) • Business Modelling Expert ( VIVES-Resoc-POM and Eurasanté) • Idea Facilitator/Incubator ( Impuls) • New product/service Integrator (into purchasers/ providers processes by testing) (VIVES-ResocPOM and WSH) • Marketer ( SCC) And these roles will help us to identify what a system Integrator could look like If we think of the product/service development and Getting to Market process as a series of steps that add value to the SME then: • Network Organising ( HEE and Impuls) creates the conditions for the SME to be able to co create through an Open Innovation process by helping relationship building and trust that allows for knowledge and idea sharing • Business Modelling ( VIVES-Resoc-POM and Eurasanté) fundamentally focuses on creating value propositions based on a combination of ideas, competences and market research • Idea Facilitating/Incubating ( Impuls) allows cocreation of ideas and development into products • New product/service Integrating takes prototype products into a live environment giving credibility to the product and the SME and reduces the risk for the purchaser/provider (VIVES-Resoc-POM and WSH) • Facilitating the Marketing of ready for market products ( SCC) gives SMEs market awareness and possible customer feedback The final parts of the process would be facilitating the SME to sell the final products and services, facilitating the SME in the organization of after sales and facilitating the SME in cash flow management and later funding opportunities for growth. The CURA-B pilots did not address this ‘capturing’ value phase. CURA-B partners did not therefore perform these roles i.e. agenting, broking, financial advising and funding advising.

The partners have played critical roles in the pilots which we could describe as part of the competence set needed or the roles that are needed to be played by the ‘system integrator’

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Table 32: Overall Learnings from Pilot

Chapter 5

CHAPTER 5

REFLECTION AND LEARNINGS FROM THE PILOTS The purpose of this chapter is to reflect on the learning process undertaken within the CURA-B project and particularly from the review of the CURA-B pilots. It describes new systems of development and approaches to market that will help re-shape relationships between industry, end users and the public sector and explores key learnings from the CURA-B pilots which have been shown to be a strong factor in stimulating innovation in each region. It is hoped these suggestions will help SMEs overcome some of the commonly experienced challenges and take the steps needed to develop better business in health and social care. Open versus Closed Models of Innovation Traditional business models have tended to focus on the experience and processes conducted by one organisation, without taking into account the interactions and collaboration between different stakeholders and the steps taken towards developing innovative products/services and gaining access to market. The traditional model would view the process of innovation and ‘Getting To Market’ as separate procedures, rather than considering the interactions occurring between stakeholders which could lead to a more efficient and productive process. In CURA-B we saw from Activity 1 that providers and the public sector tendering process ensured that SMEs are often kept apart from end-users and that SMEs innovated independently of other stakeholders. The process of selling the product or service was also restricted as they were unable to reach the target market and received minimal feedback from users due to their lack of participation. The traditional model would have the SME conducting various steps within the development and ‘Go To Market’ process separately from the Provider and End Users This traditional model is based on the concept of a value chain with a value creating logic as a linked chain of activities, a perspective that leads to the development of strategies focused on controlling the chain. In AT this control is often exerted by Providers/ Public sector Commissioners. Providers determine what products and services they need, procure them and integrate them into their activities. Historically, when the technology and consumer preferences of a product or service were well understood, then an organisation could either conduct internal development or engage in traditional contracting for that work (the closed model) but when the technology, design and innovation approaches have yet to be established or when customer needs are highly varied or not yet fully understood, then opening up the innovation to a community

or network can have considerable advantages (Chesbrough, 2003). In the past decade there has been a great shift from closed innovation models that are usually performed strictly in-house to the so-called open innovation model (Chesbrough, 2003). Open innovation is about involving several internal and external parties in the innovation and development process and can be defined as combining “internal research with external ideas […] to deploy these ideas both within their own business and also through other companies’ businesses” (Chesbrough, 2003, p.63). Since the mid-1990s, and as described by Rosenfeld (1996) and Hagedoorn et al. (2000), not only multinational firms but also small and mediumsized firms are establishing more and tighter relationships with other companies in order to achieve economies of scale, market strength, or to exploit new opportunities. A recent study of 64 firms in the UK found that SMEs could create and maintain competitive advantages by engaging in open innovation through closer collaboration with academia and other enterprises (Wynarczyk, 2013). These findings are in line with a similar study published a year earlier, which investigated the innovation performance of 500 SMEs in six European countries, firmly concluding that those involved in open innovation or close relationships with suppliers and customers usually display higher degrees of innovativeness (Lasagni, 2012). There is now a significant amount of literature that supports the idea that innovation success is achievable by the presence of relationships, networks, alliances, and other different forms of interaction with external sources of Knowledge (pg. 310). The use of external relationships is increasingly interpreted as a key factor in enhancing the innovation performance of modern enterprises. Several works confirm that network ties can be valuable tools for fostering innovation performance (pg. 311).

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Table 33: Separated-Control Based Development

Separated-Control Based Development Research

PROVIDER

Ideate

Distribute

Develop

Retail

Test

Train

Produce

SME

Market/Sell

User

After Sales 1 www.cura-b.eu

Open innovation strategies can be implemented with the support of different innovation partnerships. One of the most widely studied subjects in this area is the so-called external networking that is “a firm’s set of relationships with other organizations” (pg. 314). In the CURA-B pilots we have tried to extend the analysis away from viewing the value creation stream from the perspective of any one organization as an isolated unit towards looking at how the SME and the partners create value within the context of the network. With the value network concept, value is co-created by a combination of players in the network working through an Open Innovation model.

The recommendation would be to replace existing business models with a model that reflects ‘open innovation’ and supports the use of external relationships which is a key factor in enhancing the innovation performance of modern enterprises (Lasangi, 2012: p312). This would stimulate interaction, engagement and minimize the barriers existing between different stakeholders in the market. Open innovation involves more than one organisation that interacts and shares information; this is based on a high level of trust and openness. The Open Innovation model is a more suitable means of encouraging SMEs to interact with other stakeholders and to establish a coherent and strong network of collaboration. This would also involve end users that would have an active role in contributing to the final product design and be involved in the testing and feedback of it (Van de Vrande, 2009). We can see from diagram xxxx that in the CURA-B pilots the steps within the Development and Getting To Market process were performed by various organizations: Knowledge Centres (KC), SMEs, Providers (PRO), Users, System Integrators (SI) and also certain steps were being performed by many organizations at the same time. In CURA-B the process also begins with the forming of a network and a seeking for partners. This may have been through networking or stakeholder workshops around researched challenges.

Table 34: Open Innovation Value Network Approach in CURA-B OPEN INNOVATION: VALUE NETWORK APPROACH IN CURA-B

NETWORK Pre requisites:

Relate - Share - Trust Common Purpose

Research KC Ideate KC/SME/SI/PRO/USER Develop SME Test PRO/USER SME SI KC

Actors in the process Knowledge centre (KC) SME Providers (PRO) Users

Produce SME

System Integrator (SI)

Market SI SME PRO

NOT PART OF PILOTS

Distribute/Retail

NOT PART OF CURA B PILOTS

Train After sales 2

www.cura-b.eu

Allee (2003) defines value networks as any web of relationships that generates both tangible and intangible value through complex dynamic exchanges between two or more individuals, groups or organizations. Any organization or group of organizations engaged in both tangible and intangible exchanges can be viewed as a value network, whether private industry, government or public sector.

Historically, private-public networks have involved significant transaction and information costs to get started, e.g. selecting partners, preparing documents (Buono, 2003). The CURA-B pilots have proved that this is not essential. Fundamentally they have been relatively cheap to organise and to maintain because they are open and voluntary.

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One of the values of the network is in seeing the series of relationships as a network rather than as a chain and that the network can provide value to all participants by taking away the controls inherent in value chains and improving value flows (by the development of positive relationships and trust) in for example the exchange of products and services and the flow of information and ideas for new service offerings coming from customers (users and providers), SME developers and knowledge centre facilitators and researchers. We could call this a collaborative network or collaborative community. Collaborative communities are perhaps best known through open-source software development that are governed loosely by social norms and “soft” rules to encourage open access to information, transparency, joint development and the sharing of intellectual property. Communities require mechanisms that facilitate and encourage knowledge exchange and interactions among members, which will then engender a culture of sharing (and learning), a sense of affiliation (as well as identity and status), a norm of reciprocity (and other types of norms regarding conduct, participation, work quality and effort) and perhaps even personal relationships among the participants. One of the challenges in Open Innovation and especially in the community style (or multisided Open Innovation) is what information can be shared with partners in the process and how can partners protect their own special information and knowledge such that they can benefit or get value from this knowledge. What is needed is a high level of trust and openness. ‘Co Creation’ (Vargo et al., 2008; Fueller, 2010) is the practice of product or service development that is collaboratively executed by developers and customers together. The aim of co-creation is to enhance SME knowledge processes by involving the customer, in this case the provider, in the creation of value through meeting end user and customer needs. Co-creation blurs the boundaries of the SME, the knowledge centre and the provider by ‘outsourcing’ some parts of the innovation process and value creation to the customer and to the knowledge centre. Co-creation transforms the end user into an active partner for the creation of future value. This mutual relationship affects all involved parties, i.e. the customer, end user and SME. It re-shapes the way in which we think, interact, innovate and commercialise our products or services. For the SME, involving customers and end users in the development process leads to a blurring of boundaries between research and development, marketing, consumer research and the sales process. Users and customers now enjoy access to the SME’s innovation process, and this access is now reciprocated by the suppliers and users. Customers (and Users) now share their own roadmaps with the SME giving it much better insight into the customers’ future requirements.

In CURA-B the parties to this co-creation come from the Care Providers (generally Public sector), the SMEs (private companies) and Knowledge Centres – the so called Triple Helix. The Triple Helix concept (Etzkowitz and Leydesdorff, 2000) comprises three basic elements: - a more prominent role for the knowledge centre in innovation, on a par with industry and government in a knowledge– based society; - a movement toward collaborative relationships among the three major institutional spheres, in which innovation policy is increasingly an outcome of interaction rather than a prescription from government; - in addition to fulfilling their traditional functions, each institutional sphere also “takes the role of the other” performing new roles as well as their traditional function. Institutions taking non-traditional roles are viewed as a major potential source of innovation in the Triple Helix. Initially, industry operates in the Triple Helix as the producer of products and services; the public sector as the source of contractual relations/ funding/ procurement; the university as a source of new knowledge and technology. The increased importance of knowledge and the role of the university in incubation of technology-based firms have given it a more prominent place in the eco-system. Universities, heretofore primarily seen as a source of human resources and knowledge, are now looked to for technology as well. Universities are also extending their teaching capabilities from educating individuals to shaping organizations in entrepreneurial education and incubation programmes. A critical role in CURA-B has also been played by intermediate organisations/brokers (here system integrators) acting as facilitators of this Triple Helix collaboration like POM and the Resocs in West Flanders, Impuls in Zeeland, HEE in the East of England and Eurasanté in Nord Pas de Calais. Several studies have proposed the addition of a fourth helix to the Triple Helix Model, whereby the propositions differ in terms of the nature of this new element, ranging from “intermediate organizations as innovation-enabler organizations”, which “act as brokers and networkers between the TH organizations” (Liljemark 2004 in Arnkil et al., 2010, p.14) to the “civil society” (Carayannis & Campbell, 2009; Lindberg et al. 2012; Colapinto and Porlezza, 2012), or the broader public (Yawson, 2009 in Arnkil et al., 2010). User-driven innovation is used to extend the TH model by including the “user” component as a fourth helix, as proposed by Arnkil et al. (2010) in their Quadruple Helix approach.

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Adding the user as a fourth helix to the model represents a type of open innovation whereby external parties are integrated into the innovation process (Pascau and van Lieshout, 2009). This is particularly relevant in the context of AT and healthcare where the ‘Living Labs’ /Concept home pilot provides another useful example of open innovation and the Quadruple Helix in action. Among a plethora of definitions for Living Labs, the following seems to best capture their nature: “the Living Lab collaboration is an open innovation environment in a real-life setting, in which user-driven innovation is fully integrated within the co-creation process of new services, products and societal infrastructures” (European Commission, 2009). The Triple Helix model could be more consciously extended by an additional helix, i.e. the users in order to reflect their vast importance for the innovation process. In some of the pilots users are being represented by user groups and they are taking part in product testing o ther concepts, such as ‘internationalisation’ can also be envisaged as a fourth helix, especially in times of large-scale internationalization of value chains and in theory one could extend the model by an n-tuple of helices. The number and nature of additional helices depends on the specifics of the context in which the model is applied and on operationalization considerations (Leydesdorff, 2012).

Open Innovation, Co Creation and the Triple Helix Building stakeholder networks through events and ideation workshops allows SMEs to reach into the broader community of industry, academia and the public sector. The lack of ‘knowing who’ has been preventing some SMEs from considering to enter the market. Even when those with strategic influence are identified, it has been almost impossible historically for SMEs to gain access, and this is also recognised as a challenge by providers themselves. SMEs within the CURA-B project therefore indicated that there was a need to create a network of organizations who shared similar aims and objectives within the healthcare market. Co-creation projects stand or fall on whether the people involved trust the relationships within them. So the co-creation community needs to meet purposefully and regularly in order to build up mutual respect, trust and confidence. Large scale networks like the E of E AT holds monthly breakfast/brunch meetings for commissioners, heads of services, SMEs, Clinicians and academics to discuss and problem-solve as a joined-up group having round the table direct access and conversations. Specific co-creation workshops with up to 20 members of stakeholder groups can come together to learn about the aims of CURA-B,

test out research and prototype methods and generate new ideas through collaborative working. An similar example of this is form of project would be NESTA, a registered charity in the UK, whose aim is to create a core vision which is disseminated across as wide a group of people as possible. The objective is to redesign a network system in which all stakeholders, including end users, are encouraged to play an active role in the process (Nesta, 2012).

A Common Purpose Previous research has shown that network cooperation is difficult because of conflicting interest and expectations (Buono, 2003). To evaluate the potential for stimulating open innovation and cocreation amongst SMEs, it can be argued that there is a requirement for a common purpose and a shared culture and an open dialogue to be created. A lack of common social and cultural understanding can impede relations between close actors as high trust and understanding is necessary to communicate tacit knowledge, (Doloreux 2002: pg. 250). Sharing ideas is easier in the context when firms have the same values, background, and understanding of technical and commercial problems. Tacit knowledge is more difficult to share because it implies new meaning in the form of new methods and new products. Until this kind of knowledge is codified over time, it is even more challenging for firms to communicate and share experiences and emphasises the need for a strong common purpose acting as a ‘glue’ to keep the network together. This is a key issue to consider when attempting to assist SMEs with building collaborative relationships.

Shared Culture For open innovation to be effective, a shared culture must be evident as this will avoid hierarchical relationships being established which would lead to a ‘them and us’ situation. To encourage an open style of working, members of a network need to be supportive of one another’s ideas and assist them where possible, rather than viewing the process as a means by which to dominate. The focus should be on achieving consensus. An example of this would be the Dragon’s Den event held by Suffolk County Council whereby the participants were displaying their Intellectual Property by presenting ideas and product prototypes to the rest of the market. This illustrates that there was a high level of trust and support between the SMEs and commissioners present, without the concern that their idea would be replicated or used by a counterpart. This event illustrates the role that networks can have in terms of creating a shared learning space that builds expertise.

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Open Dialogue All participants in a network need to find ways to create an open flow of communication and dialogue with their partners. This could take the form of sharing data, joint meetings or co-locating services and professionals. The challenges experienced by SMEs and health care professionals in CURA-B were that access to data was at times restricted and the information held by GPs was difficult to capture. GPs also found it hard to acquire a ‘big picture’ of a patient’s health, often when it was related to diabetes because the patient did not always attend their 6 weekly consultations. A pilot conducted by West Suffolk hospital in the UK found that by using AT in the form of a glucose meter, patients who had diabetes were able to record their own information and provide the data to the GP, without necessarily having to attend the clinic. This was beneficial for both the GP and the patient and this pilot illustrates the value of open dialogue which can be achieved when a patient’s health record is easily shared with

other professionals who are treating them (following the patient’s permission). This gives the GP a fuller picture of the individual’s medical state and most appropriate form of treatment. Open dialogue is possible when networks and partnerships are ‘informal’, rather than formalized. Networks do not always have to develop formal legal and governance structures to operate; a too tightly regulated structure can be draining and inefficient. A balance has to be struck between formalization and inclusivity, with attention being paid to the extent to which partners are able to work collaboratively with one another. In order to establish trust as a basis for co-creation projects, partners need to have equal status - there can be no ‘them and us’. Co-produced decisions mean that there is no hierarchy and no one person or organization is dictating terms to the others. Decisions have to come from consensus. This requires high level of openness particularly from the Care Providers.

Table 35: Triple Helix - Open Innovation in CURA B

Triple Helix – Open innovation in CURA B TRADITIONAL MODEL “Closed Value Chain”

PREREQUISITES

CURA B VALUE NETWORK

Fundamental ways of working o

Network meetings A community of collaboration Stakeholder workshops

Controlled steps in chain

CLOSED SYSTEM

o o o

Common purpose Openness Trust Equality

Need for Triple Helix in AT

Co-create solutions o Create value

Co-create Business Models

Role of pilot

projects

 Research need o Testing need o Private sector development o Public sector development

o Deliver Value o Capture value

OPEN SYSTEM

Quadruple Helix where possible

www.cura-b.eu

System Integrator Our findings from CURA-B validate the idea from Chesborough, Vanhaverbeke and West (2005) that value creation and value capture from Open Innovation in value networks only work if a central organization acts as an ‘orchestrator’. In CURA-B we have called this critical role the ‘System Integrator’, to act as a single, respected, neutral advisor to bridge the gap between stakeholders and facilitate the

development and Go To Market processes. This role has many elements as can be seen in the next table. • • • • • • •

Network organizer BMC Expert Facilitator/Ideator Incubator Integrator Marketer Agent/Broker

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The majority of the above have been practiced in the pilot projects. We can see from this list of elements that the role requires a wide set of competences and in CURA-B, rather than all elements being played by one organisation a variety of organisations have taken on various elements depending on their own competence set and depending on the needs of their pilot case: • An alliance of organisations in west Flanders (strategic regional development agencies for example POM and the RESOC organisations) • Impuls in Zeeland • Eurasanté in nord Pas de Calais • HEE in the East of England. A System Integrator will act on behalf of all institutional spheres as a neutral entity focused on knowledge sharing for growth and bringing people together who would not usually meet. The role will bring much needed transparent advice to directors of care institutions. It will connect SMEs with other organisations to catalyse innovation and co-understanding and prepare them for negotiating the system. It will do this through events and networks and by acting as a crucial repository for

ideas. As a central access point the System Integrator will be critical in the re-conceptualisation of the innovation ecosystem not only to create fresh routes for stakeholder partnerships, but as a keeper of best practice. This central role/position must be fully committed to making the best use of the knowledge in the health and social care sectors by reinventing and improving the system. A strong understanding of funding and healthcare systems, industry issues and awareness of current societal and economic challenges while retaining a neutral position is key. As such, the System Integrator needs clear definition and considerable consideration as to the best organization to take on this pivotal role. The System Integrator will also play an important role in helping stakeholders communicate value. As we have seen from the research, real-world examples incentivise SMEs to innovate by showing them, through the experience of others, that the challenges are surmountable and support is available. Case studies developed by this respected source will also help demonstrate new ways of working and the benefits of tele-care to providers.

Table 36: Multi-sided Open Innovation in Value Networks

The Open Innovation model in CURA-B: Multisided Open Innovation in value networks There is a particular value in Triple Helix cooperation in AT development. There is often a need for medical, technological and user needs research and the need for thorough testing of prototypes and concepts the procurement of which will be done by or funded by

the Public Sector. The pilot projects have shown how Triple Helix partners collaborate and what ‘steps’ SMEs should go through in order to co create and deliver AT products and services more efficiently into the market. The initial steps in the Open Innovation co-ccreation process are:

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Collaborating to CREATE VALUE

Co-CAPTURE VALUE

Network

Co-Capture value – mutually agree revenue streams, agree cost partitions, use funding specialists

• Attend local networks and attend where possible idea generation workshops in order to define end user needs and generate possible solutions. Build relationships. Define possible Business Model and especially the Value Proposition • Where possible and at an early stage SMEs need to understand their own business model especially in terms of key activities and key partners and meet with possible partners to establish possible, mutual business models (the Eurasanté pilot in particular showed what an effective tool the Business Model Canvas can be for creating a common understanding of a mutual business model). It is beneficial if partners can share business models and develop a common canvas so that each partner can benefit. This can only be done by making all aspects of the BMC transparent to the partners. Co-create value: Ideas to products • Possible solutions (for example from workshops) are then researched, refined and deepened by the Knowledge centre and other Cura-B system integrators facilitating the development process alongside the SME and providers by acting as an incubator.

Co creation is used not just to generate ideas on needs and how to satisfy needs via a product or service but also to recognise how all partners can benefit from and through their business models and how a common sales and marketing process can work. Here the System Integrator could also work as agents for SMEs and help SMEs, KCs and providers co create the segment, channel and customer relationship strategy for the common business model. Sharing the benefit and risk in the start-up period is a key to success. There needs to be a mutual benefit and recognition that in AT collaboration it could be that return on investment and the profit margins are small and that other benefits have to be found to compensate for that loss. The System Integrator ideally would be able to facilitate this negotiation of getting to market actions and benefits through the Business Model Canvas. To some extent this was being done by Eurasanté (or will be done after CURA-B).The System Integrator would also be able to advise on funding options through the whole Open Innovation process and advise on funding for later growth for the SMEs.

Co-DELIVER VALUE Co-deliver through collaborative testing, finding customers, defining segments, channels Other research shows that companies have started to engage, both formally and informally, in joint activities such as co-marketing, co-production, shared resources, or joint development (Bönte and Keilbach, 2005). In CURA-B SMEs work alongside providers and knowledge centres to test and further the solution in live environments and validate whether and how their products can be integrated into existing provider processes - again facilitated by System Integrators. System Integrators can then take fully developed SME products and work with alongside commissioners of services to market SME products in front of prospective buyers creating the conditions for SMEs to pitch their products and gain feedback.

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COSTS AND BENEFITS IN CURA-B The objective of this chapter is to understand the costs (actual and potential) incurred as well as the benefits (actual and potential) produced by some of the participating pilot projects and to comment on a potential Cost Benefit Analysis for the activities in Activity 3 what we have learned that may be useful for future similar projects.

What is a Cost-Benefit Analysis? Cost-Benefit Analysis (CBA) can be understood as a decision-making tool that allows the comparison of costs and benefits before making a decision to advance in the implementation of a social programme, new medicine, or a new education programme (Quah and Toh, 2012). The objective of performing a Cost-Benefit Analysis (CBA) in projects like CURA-B would be to understand how the benefits to society (e.g. lives saved or protected from disability) may or may not exceed the costs of its implementation (e.g. costs for taxpayers, developers and technology companies; cf. Revesz and Livermore, 2008). This analysis is most useful if we are trying to either analyse the benefits of one programme/policy or comparing alternative programmes to see which one provides the most social benefits (Cellini and Kee, 2010). CBA is also performed whenever it is necessary to weigh up advantages and disadvantages of a project involving public expenditure (McIntosh, 2010). In order to perform a CBA for the pilot projects in CURA-B, it was important to obtain information with regards to the actual and potential costs as well as the actual and potential (both real and perceived) benefits of those pilots. CBA usually requires attributing a monetary value to potential costs and outcomes of a programme (Davalos et al. 2009). These include both tangible (e.g. the cost of employees; hourly rate of carers) as well as intangible factors (e.g. wellbeing; improvement in quality of life). In terms of cost estimation for assistive technology projects it is recommended to account for “design time, materials, construction time, testing, follow-up and troubleshooting” (RESNA, 1998; cited in.Duff and Dolphin, 2007a). Evidence suggests that attributing a monetary value to each and every item may not always be possible (e.g. Duff and Dolphin, 2007a; Cellini and Kee, 2010). However, the importance of providing as detailed information as possible has been acknowledged. Previous research has shown that economic evaluations of telecare programmes are not an easy matter and, in the case of CBA, some caution has been recommended when it comes to choosing such a method. Bergmo (2009) conducted a review

of the quality and validity of economic evaluations in telemedicine and showed that these types of evaluations vary considerably in terms of the contexts in which they are undertaken (e.g. cardiology, psychiatry and dermatology) as well as in the methods applied. The author goes on to conclude that “few economic evaluations of telemedicine can be trusted to provide reliable information for decision making” and also that economic evaluations of telemedicine would benefit if there was clarity with regards to the objective, comparators, perspective and design of the evaluation. In the particular context of CBA, Cellinni and Kee (2010, p. 528) argued that such forms of analysis, due to their complexity and potentially biased assumptions, should not be regarded as a panacea for decision-making in policy making, for instance healthcare policy. They further claim that the technique may as well be “more art than science”. Golzweig et al. (2009) reviewed 182 studies with the aim of assessing the published evidence with regards to the costs and benefits of clinical health information technologies (IT). They found that there is very little evidence supporting the prediction that healthcare IT will change healthcare delivery. Supporting evidence (when it exists) comes from large organisations who have developed local solutions and spent “years developing, implementing and refining these systems”, largely benefiting from having IT champions who helped with developing, implementing and evaluation of those systems. (2009, p. 283). The authors recognise that little evidence exists for cost-benefit calculations of IT implementation which negatively influences the business case for health IT adoption. Bashshur et al. (2005; cited in Davalos et al., 2009), for instance, argue that the elusive number of economic studies (e.g. CBA) is due to the multidimensionality of telemedicine, lack of funding for big projects and the fast improvement of telemedicine technologies. Because this field develops so fast there is the risk of some conclusions losing validity quite quickly (e.g. equipment prices decline too fast) which makes it difficult to collect a reliable body of evidence. According to Davalos et al. (2009), the a priori definition of the perspective from which any economic evaluation will be undertaken (i.e. patient; provider; taxpayer; employer; insurers) is of the utmost importance, as it should help with defining analytical boundaries. Nevertheless, it cannot be forgotten that economic (or social) benefits from the perspective of one group of stakeholders may represent economic costs to another group (e.g. when an insurance company pays for a treatment). Also, given the heterogeneity of telemedicine programs, most of the results cannot be generalized and most economic evaluations are lacking a uniform methodology or guidelines to conduct standardized telemedicine evaluations.

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Regardless of the existence of studies about the effects of using telecare, the need for evidence still exists as most studies fail to meet methodological quality standards (Duffin, 2013). Because evidence for the use of telecare is still emerging (due to it being a new area) it makes it difficult to draw conclusions on the factors that may count as either costs or benefits in developing these technologies. As Cruickshank and Paxman (2013, p. 42) noted “it is taking longer than hoped to demonstrate robust business cases to commissioners for telemedicine and telecoaching services”. Finally, it is important to acknowledge that successful CBA requires information from different stakeholders as well as information at both micro (e.g. the cost for patients / carers that use a technology) and macro levels (e.g. the national hourly average cost per patient for care in the Netherlands). For instance, national social and health policies may influence the rates of new technology uptake in healthcare as well as the costs for patients of using that technology in different countries. In the context of CURA-B, a CBA has some parallels with the challenges presented on the development of a CBA framework performed for the project ENABLE (http://www.enableproject.org/), an initiative aimed at understanding the benefit of the use of technology by people suffering from Dementia (Duff and Dolphin, 2007a; 2007b). This was one of the first attempts to assess AT utilising CBA and it was based on the experience of both users and carers. In ENABLE the objectives of the CBA were to identify analytical factors such as: “the economic costs associated with using these technologies; any social costs associated with using these technologies; any economic benefits associated with using technologies; any social benefits associated with using these technologies” (Duff and Dolphin, 2007a, p.73-74). Although these aims may serve as a guide to conducting a CBA of CURA-B’s pilot projects, it became clear that we would not be able to obtain similar results as for those in ENABLE as a core goal of ENABLE was to develop a methodological framework to conduct CBA in AT for people with Dementia through having a consistency across countries, making comparisons of costs and benefits much easier. Also within the ENABLE project it was possible to obtain data from key stakeholders in terms of monetary value of benefits, by making use of an index – Willingness To Pay (WTP) – which is a “method to determine the maximum amount of money that an individual accepts to pay to avail of a product with benefit(s) that are uncertain but have specified probabilities” (Duff and Dolphin, 2007b, p. 84). Different stakeholders (e.g. Patients, Carers) should be asked whether they would be willing to pay for a particular product / service and, if so, what would be the maximum amount that they would pay. This is a method considered useful in helping

to monetise benefits as it may give a perception of a person’s true preference with regards to a new service/ preference. In CURA-B’s case we did not have this information, so to use such an index would not have been possible. At the beginning of the Activity 3 phase (the CURA –B pilots) it was clear that the pilots could not be treated in the same way as a traditional CBA. Firstly, a CBA is usually performed at a social and economic context level that the pilot projects being studied did not possess (CBA tends to be used as a decision making tool at a national / international level). Secondly, CBA entails either: (a) the comparison of costs and benefits to decide whether a new programme can go forward (e.g. a new medicine); or (b) whenever two programmes are being compared and only one can go forward (e.g. should dialysis treatments be provided at hospital or at home). Specific to CURA-B was that the purpose and the outcomes of the pilots differed greatly and so there was no reliable mode of comparison i.e. the same pilot was not being launched / tested in different countries; each region created its own pilots and the pilots also represented differing stages in the development and marketing process for a product or service: • Some pilots were creating value through networks so costs relate to setting up and organising the network and benefits relate to SMEs being able to build relationships with Providers • Some pilots were helping SMEs to develop business models so the costs relate to the meetings held and the facilitation work done by the business model researchers/facilitators and benefits relate to possible sales for an SME or group of SMEs and savings to Providers / Users by using the proposed future service • Some pilots were helping to develop products from ideas so costs relate to research done by knowledge centres, facilitation performed by a system integrator and SME original development work and benefits relate to possible sales of the product for the SME and savings for Providers/ Users when they use the product • Some pilots then were taking fully fledged products and helping them deliver value by collaborating with possible customers (providers and local authorities) to test the products and to present/market them so costs relate to research by a knowledge centre, development costs for the SME, costs of testing, costs of facilitating by the system integrator and costs of staging presentations (in the case of Dragon’s Den events) versus possible benefits of sales to SMEs and savings for Providers/Users.

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The other major complicating factor for CURA-B CBA is that whereas in traditional innovation/market processes there are discreet steps being performed by discreet entities who cost their own part of the process, add a margin and sell onto the next entity in the chain, in CURA-B we had different forms of CoCreation taking place so that though the steps in the innovation/market process are similar and discreet as in the traditional method, the entities taking part in the steps are not discreet, in fact the steps are being performed by several entities at the same time. It is still important to be able to present some possible costs involved in the pilots, the purpose being to provide some guidelines that could be referred to in terms of orientation for anyone wanting to learn from CURA-B’s pilots and to try something similar in the future. The identification of the different relevant categories of costs and benefits per pilot is important for two reasons. On the one hand it provides a notion of which costs / benefits can be easily quantified. On the other, and based on the known costs/benefits monetized, it should be possible to assess whether an analysis like CBA is suitable for a project like CURA-B. The dimension of the pilots may also have an influence on the prediction of costs. Due to the small size of the pilots it is expected that the costs incurred by the partner organisations are likely to be small and information at the macro levels of analysis may tend to be overlooked. The main interest in this chapter is to provide an understanding of the possible benefits of the pilots, with the clear view that these would be extremely difficult (if not impossible) to quantify. As agreed with the lead partner, the objective of a type of CBA within CURA-B would be to produce a qualitative section in the overall self- evaluation report aiming at formulating an idea of what type of costs were experienced in the pilots, and the possible benefits of the pilot projects in terms of their value propositions. In this case, “value proposition” may be perceived as the offer that a business provides to a particular market or, in the words of Kaplan and Norton (1996, cited in Roehrich and Llerena, 2011, p.134) as “the description of the unique mix of product, price, service, relation and image that a company offers to a group of targeted clients. It must explain what the company thinks it is capable of doing for its clients better or differently from its competitors”. Taking into account that companies working within the same industry may end up developing similar products, the challenge is for companies to prove that their value proposition is unique and that can better benefit potential customers and users. The value proposition and the benefit of a particular product / service are intimately connected, if benefit

is perceived as the advantage obtained by a customer through using a particular product (i.e. a consequence of use; cf. Roehrich and Llerena, 2011). In the context of telecare if the value proposition of a particular technology is, for instance, blood pressure monitoring at a distance, the benefit for someone who makes use of that technology would be the freedom of not needing to go to the hospital or GP practice as often. With this in mind, and in order to try and conduct a CBA in CURA-B, partner organisations were informed that: • The aim was to provide an idea of the types of actual and potential costs and benefits that each pilot project may have incurred, or was likely to produce in the future. • Due to the specific contexts of different pilots, should partners feel that the items described in the workbook of costs and benefits were not enough and that an important factor was missing, they could add whatever they perceived could be an important cost or benefit for that particular pilot. • Where possible, actual costs of the pilots would be captured if they were known and could be easily estimated and then also the possible costs involved in the pilots • Possible benefits (or perhaps even actual benefits) would be more difficult to know and estimate- but again – wherever partners could foresee a benefit they should estimate that benefit. If precise or reasonably precise numbers were known for costs incurred as part of the pilot these should have been included in Euros. • Possible benefits may well be occurring after the pilot project and after CURA-B has finished • In terms of cost and benefits for other stakeholders it was important to have a notion of what may be perceived as such. For instance, if the benefit of using a particular service allows more time for the carer, this should be stated. A spreadsheet was sent to participating partners from the four participating regions that included a set of items constituting common cost and outcomes categories that projects of a similar nature (e.g. telemedicine) usually tend to show. These categories were adapted from Davalos et al. (2009) review of economic evaluations methods, which emphasize a series of guidelines on how to conduct rigorous Cost-Benefit Analysis. The items (both costs and benefits) were those that each partner should keep in mind when responding and that could guide them on, firstly, identifying whether the category of cost/ benefit was relevant for the pilot project and, secondly, whenever known, to give an estimation of the monetary value to the category of cost/benefit. The cost and benefits presented below were considered from the point of view of different stakeholders:

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Costs: For SMEs/Developers - For Providers - For Knowledge Centres (if involved) â&#x20AC;&#x201C; For Facilitators / System Integrators. 1. Cost of Equipment / Technology to buy 2. Cost of Equipment / Technology to rent/hire 3. Costs of equipment/technology to develop 4. Cost of software to buy (capital investment) 5. Costs of software to develop 6. Costs of software to rent/hire 7. Cost of facilities (Office Space) 8. Staff costs 9. Administration costs 10. Telecoms Costs 11. Other Expenses 12. Costs of outsourcing Staff 13. Consulting costs 14. Cost of Training in the new service / technology 15. Costs of Promoting the new service / Technology 16. Travel Costs incurred 17. Costs of any other Supplies For OTHER STAKEHOLDERS 1. Is the taxpayer contributing for the technology / Service? 2. Is there a monetary contribution from a governmental initiative? 3. Is there a monetary contribution from an insurer? 4. Are members of the family taking extra time off of work? (E.g. to attend training on how to use the technology?) For the PATIENT 1. Any costs for using the service? (e.g. Pay Per Service; Monthly fee) 2. Cost of any travel time required? 3. Cost of time taken off of work Cost of lost wages

Benefits: For the PATIENT/END USER, could the use of the service/product: 1. 2. 3. 4. 5. 6. 7.

Reduce morbidity? Avoid mortality? Increase access to healthcare? Increase own health knowledge/ability for self-care Provide faster/accurate diagnosis and treatment? Reduce waiting and/or consultation time Increase medication adherence improve quality of life?

8. Increase the time spent in employment / leisure / classroom? 9. Help reduce or avoid travel expenditure / accommodation / other expenses? 10. Decrease the time away from work / school? For the PROVIDER- could the use of the service/ product: 1. 2. 3. 4. 5.

Reduce length of hospital stays Avoid hospitalisations Avoid hospital readmissions Avoid emergency room visits Avoid patient transportation to healthcare facilities 6. Avoid physician office/clinic visits 7. Reduce length of consultations 8. Increase knowledge transfer among practitioners 9. Increase accuracy and faster diagnosis and treatment 10. Increase patient satisfaction 11. Decrease travel and/or home visits for staff 12. Avoid travel expenditures: transportation, accommodation and per diem For OTHER STAKEHOLDERS could the use of the service/product: 1. Increased productivity of family members? (less travel, less illness) 2. Improve quality of life? 3. Increase the time spent in employment / leisure / classroom? 4. Help reduce or avoid travel expenditure / accommodation / other expenses? 5. Decrease the time away from work / school? For the SME or SMEs involved could the actions in the pilot: 1. Provide them with a way to co create the needed service/product with providers 2. Provide them with a way to co create the needed service/product with users 3. Introduce them to other stakeholders in the triple helix like public sector providers and knowledge centres 4. Improve their route to market 5. Help them bridge the gap between public sector providers, users and themselves 6. Help them achieve actual sales 7. Help them research the benefits of their product or service 8. Help them prove their product or service works and provides real added value

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RESULTS As stated above because different partners in different countries were creating different technologies / projects and due to the nature of CBA and the inherent difficulties reported in numerous studies it was decided to review each pilot programme individually instead of the entire set of pilots. • During the pilot activities of CURA--B most effort has gone into co-creating value by setting up partnerships and forms of collaboration rather than delivering a product or service to the market which would then be bought by a Provider/User. It is then easy to understand why a clear idea of costs and monetary benefits was difficult to find. From the responses obtained it was clear that it would only be possible to capture an idea of costs, not an exact value. It can be said that both categories – costs and benefits - were assessed based on perceptions of what could be a potential cost or benefit. • Pilots are different from mainstream services, and one of the aspects where that difference shows is in the type of resources needed during the different stages of the development/market process, e.g. developing technologies for a pilot comes at a different price than when the service is up and running and more resources may be available for production (the cost per unit of producing a single mobile phone is much higher than if two million mobiles are produced). The same logic is true for the benefits. Some of the benefits also may only become clear after months or even years of using a particular service / product (cf. Barlow, 2007). • Even when monetary values were provided (which only happened in two cases from the responses obtained), it could be claimed that those costs are real only for the pilot stage. It may be difficult to know the exact cost of the “real” service. • From the results obtained, the perception of potential costs and benefits was being given by different type of stakeholders in different pilots (e.g. SMEs, Providers, Knowledge Centres, Facilitators, Hospital) and in qualitative terms (i.e. the majority of responses obtained considered how likely it would be for a particular item to be a cost or a benefit, without a numeric value being given). This creates a situation where what is perceived as an important cost (or benefit) for a particular pilot may not be considered for the other participant pilots. By looking at the results table it can clearly be seen that different partners had prioritised different types of costs / benefits. • By having an unclear monetary value for costs, it is difficult to predict what costs may be incurred in future projects (within the same line of business). In terms of benefits, there is a higher probability that these could constitute a better prediction for projects of a similar nature to the ones portrayed

in this analysis. It has been shown that, even within a CBA framework, benefits can be better understood by relying on qualitative information (cf. Duff and Dolphin, 2007b). It is also easy to see how, even when benefits are discussed in qualitative terms, two projects working in the same sector of tele-healthcare (e.g. blood pressure monitoring in the home) may provide similar benefits in the long term. With this regard, one can say that the benefits identified by partners’ organisations may well be similar to the benefits that SMEs working within similar industries may deal with in the future. • The dimensions of the pilots may be influencing the results in particular the type of costs and benefits considered to be worth including. As mentioned above, it may be that because we are dealing with small sized pilots, within a localised context, the perceived costs and benefits only look “real” during the pilot stage. It may be that both long term costs and benefits would be considerably varied should the pilot projects become real live services. The most concrete of the responses relate to those pilots that are bringing ideas into production (Impuls Memory Test) and which refer directly to products which were being tested for entry into the market ( WSH Diabetes monitor and VIVES-Resoc MWV –POM Lighting Pilot). In the Impuls Zeeuwse Huiskamer (Living Lab) pilot the set up costs to the partners are known. The other responses relate to less ‘tangible’ pilots (Networks of Impuls and HEE), bringing products to market (SCC Dragon’s Den) and Business Modelling/Business case (of VIVES-Resoc Brugge - POM) and these results are given by knowledge centres, facilitators or regional development agencies sometimes on behalf of a third-party.

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TABLE OF RESULTS Costs Responses from partner spreadsheets and discussions

Impuls memory Test

SCC Dragon’s Den

Impuls Living Lab

Eura santé

HEE E of E AT network

Impuls Sante Zeeland

Cost of Equipment / Technology to buy

Known to developer

Yes

Yes €6000

Not yet

If service developed then Yes

Cost of Equipment / Technology to rent/hire

As above

Yes

Not yet

As above

Costs of equipment/ technology to develop

As above

Yes

Not yet

As above

Cost of software to buy (capital investment)

As above

Yes

Not yet

As above

Costs of software to develop

As above

Yes

Yes €16500

Not yet

As above

Costs of software to rent/ hire

As above

Not yet

Cost of facilities (Office Space)

As above

Yes

Not yet

If service developed then Yes

Staff costs

As above

Yes

Yes 50 hrs @ €70

Yes

Not yet

As above

Not directly involved in pilot

Administration costs

As above

Yes

Not yet

As above

Telecoms Costs

As above

Yes

Not yet

As above

Other Expenses

As above

Not yet

As above

Costs of outsourcing Staff

As above

Not yet

Not direct involved in pilot

Not directly involved in pilot

SMEs / Developers Are the costs below worth considering?

Consulting costs

As above

Yes

Cost of Training in the new service / technology

As above

Yes

Costs of Promoting the new service / Technology

As above

Yes

No Not yet Not yet

Travel Costs incurred

As above

Yes

Yes €500

Costs of any other Supplies.

As above

Not yet

Yes

Not yet

VIVES-Resoc Brugge-POM Business Case

VIVES-Resoc MWV-POM Lighting in care home

WSH Diabetes test

Table 6.1 SME costs

As above Yes As above Yes As above Yes As above Yes As above Yes

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SCC Dragon’s Den

Impuls Living Lab

VIVES-Resoc Brugge-POM Business Case

Eura santé

HEE E of E AT network

Impuls Sante Zeeland

Impuls memory Test

VIVES-Resoc MWV-POM Lighting in care home

For the Provider,

WSH Diabetes test

Table 6.2 Provider Costs

No special equipment needed

Not yet

N/A

No special equipment needed

Not yet

N/A

No special equipment needed

Not yet

N/A

Cost of software to buy (capital investment)

N/A

No special SW needed

Not yet

N/A

Costs of software to develop

N/A

No special SW needed

Not yet

N/A

Costs of software to rent/hire

N/A

No special SW needed

Not yet

N/A

Cost of facilities (Office Space)

N/A

No special SW needed

Not yet

N/A

Not yet

N/A

Not directly involved in pilot

Organising events

Not yet

N/A

Organising events

Not yet

N/A

Cost of Equipment / Technology to buy

c.£44.000 (equipment, test/ develop technical triage training and software from the SME)

Cost of Equipment / Technology to rent/hire

N/A

Costs of equipment/ technology to develop

Staff costs

Yes

Loan to the pilot, so No

Yes

Administration costs

Yes

Telecoms Costs

Yes

Other Expenses

N/A

No costs yet as product not on market

Are the costs below worth considering?

Community Care Practitioners & Dementia Cluster Commissioners

N/A

Not yet

N/A

Not yet

N/A

Costs of outsourcing Staff

N/A

1 project manager full time for six months

Consulting costs

N/A

Not yet

N/A

Cost of Training in the new service / technology

N/A

Yes

N/A

Not yet

N/A

Not yet

N/A

Costs of Promoting the new service / TechNology

The cost was really in time- it caused a slight increase in work.

Yes

Set up focus groups, Dragons den and market engagement event, plus time for specialists to meet and review documentation

Travel Costs incurred

N/A

Events held locally

Not yet

N/A

Not directly involved in pilot

Costs of any other Supplies.

MyGlucohealth Meters bought for testing and a developer KIT approximately £500

N/A

Not yet

N/A

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HEE E of E AT network

Impuls Sante Zeeland

Not yet

N/A

Not yet

N/A

Yes €1000,00

N/A

Not yet

N/A

Not yet

N/A

Not yet

N/A

Cost of facilities (Office Space)

N/A

Not yet

Yes

N/A

Staff costs

N/A

160 hr. €11.200

N/A

Not yet

Yes

N/A

Administration costs

N/A

see office costs

N/A

Not yet

Yes

N/A

Telecoms Costs

N/A

see office costs

N/A

Not yet

Yes

N/A

Other Expenses

N/A

see office costs

N/A

Not yet

Yes

N/A

Costs of outsourcing Staff

N/A

Not yet

Yes

N/A

Consulting costs

N/A

N.A

N/A

Not yet

Yes

N/A

Cost of Training in the new service / technology

N/A

Not yet

Yes

N/A

Costs of Promoting the new service / Technology

N/A

Not yet

Yes

N/A

Travel Costs incurred

N/A

€ 500,00

N/A

Not yet

Yes

N/A

Costs of any other Supplies.

N/A

Not yet

N/A

Impuls Living Lab

Not directly involved in pilot

SCC Dragon’s Den

Not directly involved in pilot

Impuls memory Test

Not directly involved in pilot

Are the costs below worth considering?

WSH Diabetes test

Eura santé

VIVES-Resoc Brugge-POM Business Case

For the Knowledge Centre

VIVES-Resoc MWV-POM Lighting in care home

TABLE 6.3 – COSTS FOR THE KNOWLEDGE CENTRE (IF INVOLVED)

Cost of Equipment / Technology to buy

N/A

Not yet

Cost of Equipment / Technology to rent/hire

N/A

Costs of equipment/ technology to develop

N/A

Cost of software to buy (capital investment)

N/A

Costs of software to develop

N/A

Costs of software to rent/ hire

Yes €8000,00

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WSH Diabetes test

VIVES-Resoc MWVPOM Lighting in care home

Impuls memory Test

SCC Dragon’s Den

Impuls Living Lab

VIVES-Resoc BruggePOM Business Case

Eura santé

HEE E of E AT network

Impuls Sante Zeeland

TABLE 6.4 – COSTS FOR THE FACILITATOR /INTEGRATOR

Cost of Equipment / Technology to buy

N/A

Cost of Equipment / Technology to rent/hire

N/A

Costs of equipment/ technology to develop

N/A

Cost of software to buy (capital investment)

N/A

Costs of software to develop

N/A

Costs of software to rent/hire

N/A

Cost of facilities (Office Space)

N/A

office costs are €200 per month

N/A

Impuls acted as facilitator

Yes

ES has acted as facilitator

HEE acted as facilitator

Impuls acted as facilitator

Staff costs

N/A

Yes

70 hr * €70 per hour

Facilitator costed as provider

As above

Yes

As above

Administration costs

N/A

see office costs

N/A

As above

Yes

As above

Telecoms Costs

N/A

Yes

see office costs

N/A

As above

Yes

As above

Other Expenses

N/A

teambuilding activities: €300

N/A

Yes

N/A

Costs of outsourcing Staff

N/A

Yes

N/A

Consulting costs

N/A

Yes

N/A

Cost of Training in the new service / technology

N/A

Yes

N/A

Yes

N/A

Costs of Promoting the new service / Technology

N/A

Yes

€1000,00

N/A

Yes

N/A

Travel Costs incurred

N/A

€500,00

N/A

Impuls as facilitator

Yes

ES as facilitator

Costs of any other Supplies.

N/A

For the Facilitator/ Catalyser Are the costs below worth considering?

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SCC Dragon’s Den

Impuls Living Lab

Eura santé

HEE E of E AT network

Not directly

Yes

Not directly

Region will contribute to Living Lab

Yes

Not directly

Is there a monetary contribution from a governmental initiative?

As above

Yes

Not in pilot phase

As above

Not yet

Are the costs below worth considering?

IS there a monetary contribution from an insurer?

Yes- idea in future is test will be paid by health insurance. €20 a test

Are members of the family taking extra time off of work? (e.g. to attend training on how to use the technology?)

Impuls Sante Zeeland

Impuls memory Test

Is the taxpayer contributing for the technology / Service?

For Other Stakeholders

WSH Diabetes test

VIVES-Resoc MWV-POM Lighting in care home

VIVES-Resoc Brugge-POM Business Case

TABLE 6.5– COSTS FOR OTHER STAKEHOLDERS

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Impuls Sante Zeeland

VIVES-Resoc BruggePOM Business Case

Impuls memory Test N/A

N/A

Not yet

Yes if developed

Cost of any travel time required?

N.A

Not yet

N/A

Cost of time taken off of work

N.A

Not yet

N/A

Cost of lost wages

N/A

Not yet

N/A

HEE E of E AT network

Eura santé

Impuls Living Lab

Any costs for using the service? (e.g. Pay Per Service; Monthly fee)

SCC Dragon’s Den

Are the costs below worth considering?

WSH Diabetes test

For the Patient

VIVES-Resoc MWV-POM Lighting in care home

TABLE 6.6– COSTS FOR THE PATIENT

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TABLE 6.7 – BENEFITS FOR THE PATIENT / END USER VIVES-Resoc MWV-POM Lighting in care home

SCC Dragon’s Den

Impuls Living Lab

VIVES-Resoc Brugge-POM Business Case

Eura santé

HEE E of E AT network

Impuls Sante Zeeland

Reduce morbidity?

N.A

Yes

N/A

Indirectly in future

Yes if developed

N.A

Indirectly in future

Avoid mortality?

N.A

Yes

N/A

As above

Yes if developed

N.A

As above

Increase access to healthcare?

N.A

Yes through early detection

As above

N.A

As above

Yes

knowledge on the inside cause of memory complaints

As above

Indirectly in future

As above

N.A

As above

Could the use of the service/ product:

Increase own health knowledge/ability for self-care

Possibly

Impuls memory Test

WSH Diabetes test

For the PATIENT/End User,

Provide faster/ accurate diagnosis and treatment?

N.A

yes: test gives more accurate diagnosis, use in home situations gives early diagnosis

Reduce waiting and/ or consultation time

N.A

yes: test completed at home

As above

N.A

As above

Yes

N.A

As above

Increase medication adherence

N.A

yes: if medication related to memory problems

Improve quality of life?

N.A

Yes

As above

Yes

Indirectly in future

As above

Increase the time spent in employment / leisure / classroom?

N.A

Yes

N/A

As above

Yes

Indirectly in future

As above

Help reduce or avoid travel expenditure / accommodation / other expenses?

Possibly

Yes

yes: test completed at home

As above

Yes

N.A

As above

Decrease the time away from work / school?

Possibly

Yes

N/A

As above

Yes

N.A

As above

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VIVES-Resoc MWVPOM Lighting in care home

Impuls memory Test

SCC Dragon’s Den

Impuls Living Lab

HEE E of E AT network

Impuls Sante Zeeland

Reduce length of hospital stays

Indirectly

Yes

Indirectly

In future

Yes if developed

N/A

Indirectly

Avoid hospitalisations

As above

Yes

As above

N/A

As above

Avoid hospital readmissions

As above

Yes

As above

In future

As above

N/A

As above

Avoid emergency room visits

As above

N/A

As above

Avoid patient transportation to healthcare facilities

As above

In future

N/A

As above

Avoid physician office/clinic visits

Possibly

As above

N/A

As above

Reduce length of consultations

N/A

As above

In future

N/A

As above

Increase knowledge transfer among practitioners

N/A

As above

N/A

As above

Increase accuracy and faster diagnosis and treatment

N/A

As above

In future

N/A

As above

Increase patient satisfaction

Possibly

As above

In future

Indirectly

As above

Decrease travel and/or home visits for staff

Possibly

As above

In future

N/A

As above

Avoid travel expenditures: transportation, accommodation and per diem

Possibly

As above

In future

N/A

As above

Could the use of the service/ product:

Eura santé

WSH Diabetes test

For the PROVIDER

VIVES-Resoc BruggePOM Business Case

TABLE 6.8 – BENEFITS FOR THE PROVIDER

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Could the use of the service/ product:

WSH Diabetes test

VIVES-Resoc MWV-POM Lighting in care home

Impuls memory Test

SCC Dragon’s Den

Impuls Living Lab

Eura santé

HEE E of E AT network

Impuls Sante Zeeland

For OTHER STAKEHOLDERS

VIVES-Resoc Brugge-POM Business Case

TABLE 6.9 – BENEFITS FOR OTHER STAKEHOLDERS

Increased productivity of family members? (less travel, less illness)

Possibly

Yes

Indirectly

Yes if developed

N/A

Indirectly

Improve quality of life?

Possibly

Yes

Indirectly

As above

Yes if developed

Indirectly

As above

Increase time spent in employment / leisure / classroom?

N/A

Yes

Indirectly

As above

Yes if developed

Indirectly

As above

Help reduce or avoid travel expenditure / accommodation / other expenses?

Possibly

Yes

Indirectly

As above

Yes if developed

N/A

As above

Decrease time away from work / school?

Possibly

Yes

Indirectly

As above

Yes if developed

N/A

As above

For the Knowledge Centre: Pilot helps research capacity - students experience doing research and pilot gives means for researching Provides instructors with inside knowledge in medical practice Knowledge exchange between medical professionals and education professionals.

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Yes

Insights into user needs via feedback from end users/carers at Dragons Den

In future

If service developed

Indirectly

Yes – as first steps

Yes

Insight and awareness of Local Authority needs

As above

If service developed

Indirectly

Yes

Potential access to trial = more info on functionality/ service requirements for technology roadmap and proposition building

As above

If service developed

Indirectly

Yes

As above

If service developed

Indirectly

Yes

As above

If service developed

Indirectly

Yes – as first steps

As above

Already done in pilot

N/A

Perhaps if trials result

As above

Already done in pilot

N/A

Perhaps if trials result

Help bridge gap between providers, users and themselves

Yes

Continued relationship building with practitioners in field

Help achieve actual sales

Yes

Possibly

Indirectly

Help research benefits of product or service Help prove product/ service provides added value

Possibly

Yes

VIVES-Resoc BruggePOM Business Case

Impuls Sante Zeeland

Yes

HEE E of E AT network

Yes

Eura santé

Improve their route to market

Possibly

Yes

Impuls Living Lab

Introduce them to other stakeholders in the Triple Helix

Possibly

SCC Dragon’s Den

Provide them with a way to co create the needed service/ product with users

Impuls memory Test

Could the actions in the pilot:

VIVES-Resoc MWVPOM Lighting in care home

For the SME or SMEs involved

WSH Diabetes test

TABLE 6.10 – BENEFITS FOR SME or SMEs involved

Yes

N/A

Indirectly

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COMMENTARIES 1. WSH: Development of a Bluetoothbased Glucose Monitor: In this pilot WSH is acting as a provider of services procuring/ co developing Bluetooth based Diabetes monittor and then testing the monitor for the benefits it provides over and above the current process. Costs (Tables 6.1 to 6.6) Given Costs for Provider (WSH): Equipment, testing, developing technical triage, Training and software from the SME (£44000)

€54.000

Two meters for testing and a developer KIT TOTAL Given Costs for PROVIDER:

€600 € 54,600

There could also have been the internal costs experienced by the Provider’s staff in organising the pilot. SME costs are known to the developer and are charged on to the Provider. Knowledge centre and specific facilitators were not involved – the provider WSH facilitated the process of the pilot and there were no additional costs for patients/users taking part Benefits (Tables 6.7 to 6.10): From the Patient point of view this technology has the potential to contribute to:

2. VIVES- Resoc MWV- POM: Tunable White Lighting Test in a Care Home in Meulebeke Costs (Tables 6.1 to 6.6) In this pilot the SME the product development costs are undertaken by its partner company Tridonics and the SME had costs of installing and setting up the lighting plus travelling to meetings to take part in the organising of the pilot . For the Provider (Care Home) the largest cost would have been the purchase, installation and setup of the lighting. For the pilot case these costs were not charged as the product was ‘loaned’ to the care home. The provider would also have had costs for attending meetings and taking part in the pilot project. For the ‘systems integrators’ (here played by POM, VIVES and Resoc MWV) there are the staff costs of organising and controlling the pilot. A specific knowledge centre did not take part, though VIVES have played the role of specialist researcher. The ‘patient’ or user taking part in the pilot in the care home had no extra costs. Only one category of costs has been perceived worth considering from the perspective of Other Stakeholders, which was whether the taxpayer would contribute for the technology / service.

• Increase own health knowledge/ability for self-care • Help reduce or avoid travel expenditure/ accommodation/other expenses • Decrease the time away from work / school

Going forward the lighting will not remain in the care home unless the care home can find the investment funds and this fundamental challenge highlighted already in Activity 1 is seen also in the Impuls memory Test pilot (below), that there is a need to engage a new funding model.

From the Provider point of view, the use of the technology is perceived as potentially contributing to:

Benefits (Tables 6.7 to 6.10)

• • • •

Avoid hospitalisations and hospital readmissions Avoid physician office / clinic visits Increase patient satisfaction Decrease travel and/or home visits for staff.

For the SME that provided the Bluetooth solution there were the benefits of being able to co- develop/ co- test a solution with a provider (WSH). It should be highlighted that these results are part of a pilot where the product is being tested before being taken to the market so caution should be taken when trying to generalise these specific costs to similar projects.

In terms of Benefits, and from the Patient / End User point of view, the use of the service is expected to: Reduce morbidity, Increase own health knowledge/ ability for self-care, provide faster/accurate diagnosis and treatment, Increase medication adherence and improve quality of life (see Table 6.7). From the Provider’s perspective, the benefits of using the service include: Reduce length of hospital stays, avoid hospitalisations, avoid hospital readmissions, avoid patient transportation to healthcare facilities, avoid physician office/clinic visits, increase knowledge transfer among practitioners, Increase accuracy and faster diagnosis and treatment and increase patient satisfaction. No benefits were identified for any other stakeholders.

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3. Impuls: Memory Test Pilot in Zeeland In this pilot Impuls helped a local SME Memorie Care and a local university research section to develop and test a new diagnosis ‘test’ for Dementia. From this pilot we have the most concrete idea of costs. Costs (Tables 6.1 to 6.6) From the Knowledge Centre perspective, the categories worth considering for costing were: Cost of software to buy (capital investment) 160 hours for Staff Costs

€1000 €11.200

Office costs

€8000

Travel costs

€500

TOTAL for KC:

€20700

The costs incurred by the Facilitator (System Integrator) were: Office Space (2013)

€2400

Staff work at €70,00 per hour x 70

€4900

Team building activities

€300

Cost of promoting the new service/technology €1000 Travel costs TOTAL Facilitator/system Integrator (SI):

€500 €9100

The Costs incurred by SME /developer were: Cost of equipment

€6000

Own work at €70,00 per hour x 50

€3500

Cost of software development Travel costs

€16500 €500

TOTAL SME

€26500

Total partners in the project

€56300

There are no specific provider costs (product is not yet on the market).

waiting and / or consultation time since the test will be completed at home. This characteristic (completion of the test at home) is directly linked with the “Travel time and expenses are reduced” From the knowledge centre point of view the project was perceived as: • Allowing for increased research capacity • Providing students with experience in doing the research as well as an important means for conducting research. Instructors were given the chance to develop knowledge in medical practice and medical professionals and education professionals had the chance to exchange knowledge. This project predicts that in the future the test will be paid for by health insurance organisations at a unitary cost of €20 per test which would become a revenue stream for the SME and on a very simple level the SME would have to sell more than 1325 monitors for the project to break even notwithstanding the future cost of sales, administration, marketing, possible future production and development (to find a true margin for the product) to bring those 1325 monitors to the market. In terms of a possible CBA this pilot provides an idea of a market price for the product at €20. The challenge for any project like this pilot where several partners co create a solution is that in traditional models one of the partners takes on the role of lead in the system and buys from the others – our traditional value chain style model– in this model in the pilot– they have to negotiate the benefits/ value capture element of a business model. In the traditional model the SME (rather than the Knowledge centre or Facilitator/Integrator) would probably have commissioned the research and then commissioned the services of the facilitator but in practice could the SME have paid the €30,000 to organise the project in such a way that there was a chance of success? In the pilot as part of the co-creation model (and because the pilot is part financed by CURA-B) the partners share the risk and would need to negotiate also how to share the future benefits.

Benefits (Tables 6.7 to 6.10): The Memory Test pilot project is perceived, at this stage, as providing benefits for the Patient and Knowledge Centre: For the patient the benefits are as follows: • By allowing early detection / diagnosis the test will increase access to healthcare • The test is also considered to be positively linked with increasing own health knowledge / ability for self-care as well as contributing to reduced

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4. SCC and the Dragon’s Den Events In this pilot SCC organised a Dragon’s Den style competition for local SMEs to have the chance to pitch in front of prospective providers, commissioners and user groups and to obtain feedback on their products and services. Costs (Tables 6.1 to 6.6) The largest set of costs are incurred by SCC acting as organiser (officially as a provider/commissioner) in terms of staff and related costs for example the resources to set up focus groups, the Dragons Den competition and market engagement event (this was undertaken by one project manager full time for six months plus additional time for specialists to attend meetings and review documentation) SMEs did have travel costs although the events themselves were free. Benefits (Tables 6.7 to 6.10): In terms of benefits, SCC perceived that the use of the service could at some point in the future (and therefore indirectly) bring benefits for all the different types of stakeholders involved: patients would have the benefit of “Improved quality of life”.

5. Impuls: Zeeuwse Huiskamer (Living Lab) Costs (Tables 6.1 to 6.6) The Costs of the project in 2014 were estimated to be €500,000. Most of the costs are covered by contributions from the partners taking part in the project. In this particular case, the money which was put into the project by the Province of Zeeland (€75,000) was for management of the project and communication. Benefits (Tables 6.7 to 6.10): Future benefits/revenues are in stimulating and boosting new innovation projects in health. Exchanging knowledge and expertise will avoid partners to spoil money by having similar tests and experiments, without knowing what solutions are available already. Especially when other partners are joining (and the number of subprojects will increase from 3 to 10) it will be useful to partner-organisations. By letting them pay for their own subprojects, the organisation makes sure that the actions are relevant to them, and that they will be committed.

The SMEs benefit because participation in the pilot is perceived as a way to “Provide them with a way to co create the needed service/product with users”, “Introduce them to other stakeholders in the triple helix like public sector providers and knowledge centres”, “Improve their route to market” and “Help them bridge the gap between public sector providers, users and themselves”. Other stakeholders (e.g. carers) can also benefit from the service, as this is perceived as a future way to “Help reduce or avoid travel expenditure / accommodation / other expenses”, The main benefit for the provider is to “Increase knowledge transfer among practitioners”, as through acting as facilitator creates an in-depth knowledge of innovative applications and services that can be applied at least in the local area.

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6. VIVES- Resoc Brugge – POM: Business case for Non- Medical Services

7. Eurasanté: Business Modelling for the Entrance project

Costs (Tables 6.1 to 6.6)

In this pilot the Vives and Resoc Brugge ( with the help of POM) constructed a business case for the development of an internet portal through which elderly and disabled persons living at home could find SMEs providing non-medical services that they might need in their homes.

In this pilot Eurasante facilitated business modelling for a consortium of SMEs and Research organisations using the Business Model Canvas. The costs of the pilot are therefore mainly based on the meetings and research work done by the partners in the pilot to create the business model (though these costs are being incurred in the Entrance project apart from Eurasante’s facilitation work)

The costs of the pilot are therefore mainly based on the meetings and research work done by the partners in the pilot to create the business case. The Facilitator / Integrator and the Knowledge Centre are perceived as incurring the following costs: “Staff Costs”; “Telecom Costs”; “Cost of Training in the new service / technology”; and “Costs of Promoting the new service / Technology.” For “Other Stakeholders”, it is believed that the technology / service has monetary contributions from both governmental initiatives as well as from the taxpayer. The Patient is not perceived as incurring any potential costs. If an SME/Developer could take the project forward there would be several of the development costs mentioned. However these have not occurred so far as the project ended with the completion of the business case.

For the SMEs there would be the costs of travelling to the meetings and liaising with the main facilitator – Eurasanté. There are research centres and these have the same costs as for the SMEs. Neither the SMEs nor the research/Knowledge centres are having direct costs in the CURA-B pilot as they are taking part in the Entrance project. There are no patient costs. Benefits (Tables 6.7 to 6.10): Patients/Users will benefit indirectly from the work of this pilot in the future as it is facilitating the creation of a business model for the Entrance project. The benefits for the SMEs involved are more tangible in that Eurasante is helping to bring them together in a co-creation project with other parts of the Triple Helix.

Benefits (Tables 6.7 to 6.10): If the service is developed from the business case then: • from the Patient / End User perspective (see Table 6.7), the use of the service technology appears to: “reduce morbidity”; “avoid mortality”; “Increase own health knowledge/ability for self-care”; “improve quality of life”; “increase the time spent in employment / leisure / classroom”; “help to reduce or avoid travel expenditure / accommodation / other expenses”; and “decrease the time away from work / school.” • from the Provider’s point of view, using the service / technology appears to: “reduce length of hospital stays”; “avoid hospitalisations” and “avoid hospital readmissions” (Table 6.8). • other stakeholders (see Table 6.9) the benefits appear to be related with: “increased productivity of family members (less travel, less illness)”; “improved quality of life”; “increase on the time spent in employment / leisure / classroom”; “helping to reduce or avoid travel expenditure / accommodation / other expenses”; and “decrease the time away from work / school”.

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8. HEE: East of England AT Network.

9. Impuls: SantĂŠ Zeeland network

Costs (Tables 6.1 to 6.6)

Costs incurred refer to the organising provided for the network meetings and the facilitating of the meetings performed by HEE. HEE estimate the costs to be approximately 70 man days per year.

Costs incurred refer to the refreshments provided for the events and the time used for organising/ facilitating the events by Impuls. No figure is given for this but HEE in a similar pilot estimate the costs to be approximately 70 man days per year.

SMEs and Providers etc. attending the meetings do themselves incur travel and staff costs indirectly. Benefits (Tables 6.7 to 6.10): Network events are free of charge, although there is a possible future revenue stream provided by subscriptions, projects generated for HEE and also the attendees and possible consulting projects for HEE. HEE estimates that SMEs looking to do business in this field save the costs of doing their own prospecting as the AT network provides a pathway into business.

Benefits (Tables 6.7 to 6.10): The benefits are perceived as less tangible, since there is no formal measure of what is transferred between the several attendants. However, it has been acknowledged that because the costs are rather low, and participants highly appreciate the events then the relatively small costs are worthwhile.

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Chapter 7

CHAPTER 7

SELF-EVALUATION THE ADDED VALUE OF CURA-B AND CONCLUSIONS

The purpose of this chapter is to evaluate the added value of CURA-B for SMEs, for the regions and for cross border activity. The chapter then links the stages of CURA- B together to show how Activity 1 led to Activity 2 and Activity 2 led to the pilots in Activity 3. Finally the chapter seeks to conclude on CURA-B and to make some recommendations as to what policy makers and partners could do next.

Self-Evaluation The self-evaluation is to add value to the overall project. Impuls Zeeland has ensured compliance as the Lead Partner and Anglia Ruskin University’s role has been to help to achieve added value. The added value in CURA-B has taken place on several levels: • For the partners: opportunities for new learning and the acquisition of new competences which will improve individual and organizational capabilities and regional and cross border relationships which can be maintained beyond the life of the project. • For other Stakeholders: a combination of health, business and economic benefits; methodological breakthroughs in supporting SMEs which can be replicated; and findings which provide new models of innovation and business development that influence and reflect emerging thinking. When we talk of ‘value added’ activities, it is important to know what ‘value’ actually refers to in healthcare. Normann (2001) distinguished between values which emerge when a firm relieves another actor from having to conduct certain activities or when a customer achieves or receives the results or outcome they were hoping for. There is a close connection between value-added for the customer, but also the provider of the product or service as it is their responsibility to establish a network of actors who make the product/service available and attractive in the first place (Ramierez and Wallin, 2000). However, to avoid the traditional style of innovation whereby firms simply focused on producing the innovation through their own technology and design process, considering the ‘value-added’ nature of CURA-B it becomes clear that end users (customers) are a key part of this and they should be actively involved in co-creating the product or service and that drawing on the advice of other actors (including competitors) is going to be beneficial to enhance the quality of the final delivered output (Normann, 2001). It is these inter-relationships between stakeholders and the value-added activities which emerge from them that will be evaluated in this chapter, and suggestions for improvements to occur will be discussed. How has CURA-B been evaluated? The scope of the evaluation varies depending on a variety of factors such as scale of the project,

contextual changes, the anticipated future for the project and the time and budget for the evaluation. Fundamentally the self-evaluation has the objective of documenting what has happened in CURA-B, conceptualising what has happened through theoretical frameworks and evaluating what has happened against CURA-B objectives. The selfevaluation has been performed: • In an on-going manner (not as an end-ofproject activity) • By sharing an understanding of CURA-B objectives, processes and values. This form of project collaboration requires trust, selfknowledge and knowledge of others, alongside clarity about all of the partners’ aims and desired outcomes for themselves as well as for the project. • By locating CURA-B in a theory and practice framework which enhances its relevance and visibility to others. For theoretical frameworks we chose ‘Open Innovation’ (and Co Creation within the Triple Helix) and the development of models of business through the Business Model Canvas and these were described in chapters 4 and 5. For the CURA-B project the adoption of an Open Innovation philosophy meant that we aimed to achieve our objectives by building innovation networks (some might call these systems) in the regions ( which in the future could be become trans regional). The form of network pictured above is based on the idea that in the market there is always a supply (the left side) and a demand (the right side). In our CURA-B networks we see that supply is provided by a combination of the innovators (normally SMEs but may also be knowledge centres), Producers (SMEs), Offerers (probably SMES but can also be Providers and Public organisations like SCC or our System Integrators) and the demand side of Payers/Needers (normally Providers, Health Carers) and Users. The network should meet the care needs of users, the strategic needs of the SMEs and the learning needs of all network members and must have feedback loops and connections between the two sides facilitated by the System Integrators. They needed to be open and transparent but at the same time clearly grounded in the business logic of the sector.

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A value proposition based on an “innovation network” model.

Source: Chanal, V. (2011)

THE ADDED VALUE OF CURA-B This next section looks at the added value of CURA-B for SMEs, the regions and for cross border activity.

The Added Value of CURA-B for SMEs We can see from the canvas models created for the pilots that the partners and SMEs involved on the whole gave positive feedback as to the value added by CURA- B. Alongside the interviews that were performed as part of the process to understand and evaluate the pilots, further semi structured interviews were also carried out with a regional partner (see appendix for interview template): • POM for west Flanders • Impuls for Zeeland • HEE for the east of England • Eurasanté for Nord Pas de Calais The one hour interviews took place face to face for HEE and Impuls and by telephone and email for POM (transcribed and documented by ARU). Eurasanté have not been able to take part in a face to face interview or an email interview. Face to face interviews also took place with the SMEs Tronixx in West Flanders (two sessions of one hour), with the Care home Meulebeke ( one hour)with MemorieCare in Zeeland( one hour) and an email interview took place with Mindings in the East of

England (documented by ARU). Several SMEs took part in the focus group debrief session which took place after the final Dragon’s Den event in Ipswich and they gave valuable feedback on the benefit of the Cura B pilot (and suggestions for improvement). This focus group session took 90 minutes and was facilitated, transcribed and documented by ARU. In the face to face and email interview the interviewees were asked how CURA–B has helped SMEs and what tangible affect or advice CURA B has generated for SMES.

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SMEs in Zeeland Activity 1 showed that SMEs lacked good contacts with Care providers so that the Zeelandic focus has been to help SMES through the contacting and development process and then give them chances to pitch in front of providers. SMEs are now in a recognised network with providers in Santé Zeeland (Impuls interview, 2013) and the true value of CURA-B is that more partners are convinced of the ‘new’ approach being taken to bring SMEs towards the market and of the role of the central player (‘the integrator’) in the region who needs to concretise the key issues and bring people together with a ‘round table’ attitude to look for consensus (Impuls interview, 2013) In the interview with the Zeelandic SME involved in the Memory Test pilot it was clear that without the intervention of Impuls through CURA-B the Memory Test project would never have existed. The SME was also impressed with the benefits of the Santé Zeeland network in that it saves them marketing/sales time and money: “Without Cura B then we would never have got started with this project – we would never have known about the Roosevelt academy- we would have had no ideas about the project- so I’m glad for Cura B….(Impuls) introduced me to the network, people want to join, they want to there, it’s an easier start, saves time and money.” Source: Memorie care interview November 2012. (Focus group feedback after Dragon’s Den event November 2013)

SMEs in the East of England In the East of England the East of England network for AT came from the suggestion in an Activity 2 workshop on SME challenges. The network began with 25 and has now grown in size to 150 regular members and has held 9 meetings showing that it has become a permanent part of the ‘Eco-System’ in the region ( HEE interview October 2013). The format is ‘relating’ as opposed to ‘selling’ and allows for User/Clinician to SME interface. The interview with a regional SME showed that the network was considered to be a good selling situation for SMEs a great source of knowledge-gathering and contactmaking. An important benefit for that particular SME was to be able through HEE to organise a clinical trial for their service (Mindings interview January 2014)

SMEs were equally complementary to the role played by SCC as a form of ‘market entry’ consultant ( Focus group feedback after Dragon’s Den event November 2013) and the SME interviewed separately remarked on the opportunity to gather knowledge about the AT industry and network . The particular SME won the event and that provided them with the chance to present to a wider European audience and strong validation when presenting to potential partners and investors. They now have the possibility of working with a Belgian healthcare company because they have been validated by Belgian and wider European peers. They are also about to begin a trial with the SCC social care team using their product with some SCC clients living with dementia. In concrete terms the advice for SMEs was to know the market and understand the importance of informal marketing and how it helps to get past the inherent distrust in the NHS system (HEE interview October 2013). SMEs in West Flanders SMEs in West Flanders were impressed with the added value provided by Activity 1 in that the interviews conducted gave more understanding of the barriers that SME’s encounter in entering the care market. CURA-B as a whole has raised awareness of the opportunities of doing business in the care sector and stimulated co-operation between SME’s, care institutes and knowledge partners (POM interview December 2013). Before CURA-B west Flemish SMEs were less aware of the international business opportunities associated with the ageing population and co-operation with the care sector and knowledge institutes for developing new products and services was low. The pilot cases have shown how ideas ( from workshops) and best practices of doing business in care can be developed from the two cases on adapted light (developing a product in an evidence based way )for elderly people with Dementia and a possible platform for non-medical services to elderly people living at home. In addition, POM have developed policy recommendations how to improve the introduction of technology in the care market (POM interview December 2013).

The Dragons Den event organised by SCC gave SMEs the opportunity to present their products and services different stakeholders and receive feedback on the idea on how to take their ideas forward (Focus group feedback after Dragon’s Den event November 2013 ): “A real opportunity to get validation for the product… Opportunity to build partnerships and from that to come to events”.

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The SME interviewed in West Flanders felt that there were certain particular benefits to their participation in CURA –B. As a commercial business, to be able to receive a trusted neutral opinion and neutral research on their products (provided by VIVES) gave an excellent pathway into the market. They could now approach customers with an evidence-based ‘truth’ about the value of their product in a live setting (Tronixx interview August 2013). They were also impressed with the co creation style adopted within their pilot:

And for concrete advice:

“Cura-B has been a good project for us to be part of. The key to our cooperation (in Cura-B) is a desire to cooperate, that we have same goals, helping people with Dementia….to deliver the products”

(POM interview December 2013)

As evidence for CURA-B’s added value to SMEs POM cited: • The Business Manual which creates insights into the healthcare market • The best practice of the SME, Tronixx and the pilot case on adapted lighting • The pilot case on insights into the opportunity of a platform for non-medical services

• Involve end users at the earliest level of product/ service development; • Give full information on total cost of ownership of your product or service; • Provide in effective after sales service; • Your product/service should allow to save time and money; • Allow employees to work in better conditions and more effectively; • Provide measurable benefits for the end users. Conclusions on Added Value for SMES At the fundamental and practical level CURA-B has revealed the key barriers facing SMEs to enter the market and given advice on how to overcome these barriers in an SME focused business handbook. It has created a new approach to doing business in general in this sector by developing networks which give SMEs access to contacts, to introduction situations, to interfaces in the system and the opportunity to co create with partners in the Triple Helix on an open and equal level.

Added Value of CURA-B for the Regions “Fertilising the soil for sustainable Accurate Business in the regions establishing sustainable regional networks for providers, authorities and businesses. Influencing policy and setting up regional networks.” Regional innovation systems consist of knowledgeproducing and knowledge-sharing activities and institutions (Cooke, 1992). These actors engage with one another in a network in order to use the knowledge acquired to achieve their objectives which often include innovation, or further learning or product refinements. In successful regional innovation systems, it can be argued that the interaction between firms and their network partners are strong enough to effectively facilitate the innovation potential of all actors and can enhance technological development (Doloreux and Parto, 2005). This is made more effective if there are specific regional policy interventions which promote what Asheim and Gertler (2006) call a ‘regionally networked innovation system’. Each network partner is encouraged to adopt practices in line with the policy initiative because it becomes the driving force behind the innovation. Consequently, it can be argued that policy could contribute to a wider and faster distribution of knowledge ‘spillovers’ by stimulating cooperative relationships and motivating actors to participate in competitive market structures (Fritsch and Franke, 2004: 246). Lundquist and Trippl (2009: 2) state that cross border regional innovation systems are the ‘last and most advanced form of cross-border integration, building on the success of previous incremental

and less innovation-oriented modes of integration’. In CURA-B the importance of the concept of the regional network was agreed upon after Activity 1 and building relationships within the networks became a priority already in Activity 2 and more concretely in Activity 3. The specific value added nature stemming from each region is discussed below. Regional Added Value: East of England In the East of England, which included the partners WSH, SCC and HEE, there was evidence of a common goal and objective associated with innovation which encouraged a feeling of familiarity and trust and reflected the characteristics associated with effective networking and collaborative partnerships. By working closely together, the separate partners in the East of England learnt how to interact with clinicians and users, and in doing so, began to overcome the barriers in the regulatory system. This was especially applicable for SMEs who were able to learn from others, such as the case study ‘Mindings’ which enabled them to examine how best to approach the AT market and negotiate the challenges which they faced. SMEs who attended the Dragon’s Den event run by SCC gained valuable advice and support and were able to use the event to network and share best practice. The lead partner Impuls (Zeeland) also recognised the value of the Dragon’s Den even and SCC in being one of the main sources of collaborative support provided for SMEs and a true reflection of what CURA-B could add to a region.

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Regional Added Value: West Flanders

Regional Added Value: Zeeland

In West Flanders it is evident that CURA-B has contributed to the care economy by creating awareness amongst politicians and healthcare professionals regarding the value of AT and benefits it could bring to the economic health of the region. Prior to CURA-B there was no policy or strategy as healthcare was perceived as a subsidized sector. SMEs and care institutes are now attempting to work more collaboratively together and by creating innovation hubs and knowledge centres such as POM, then the transference of ideas, advice and support is more effective and possible. CURA-B has also contributed to the West Flanders region by encouraging contacts amongst the University colleges KATHO and KHBO (now joined in Katholieke Hogeschool Vives). It has helped these university colleges to define long term topics for applied research, responding to the needs of local businesses and care actors. The links between the Universities, care providers and SMEs has promoted the development of a ‘triple helix’ (Leydesdorff, 2012). The helix includes institutions, enterprises, government (and civil society through user representative groups though less so in the CURA-B pilots) and represents a shift towards open and user-centred innovation policy. The helix has moved from being linear and top-down to one that is more conducive to co-creation and interaction.

The lead partner of CURA-B, Impuls which is located in Zeeland, has an advisory board which already represents the Triple Helix structure within CURA-B. The SMEs, university and the pilot study involved in the Memory Test project were encouraged to work closely together and establish collaborative and cooperative partnerships which will assist with them being able to develop a new product. The Triple Helix model and the Living lab project in Zeeland are two examples of how they have involved the strengths of the local stakeholders within CURA-B.

As a result of CURA-B, in West Flanders the deputy for economy of the province of West-Flanders has included the care economy in his economic policy plan for the period 2013-2018. The budget has been made available to develop a strategy and an action plan. The Flemish authorities (Flanders Care and contactpunt zorgeconomie of the Enterprise Agency) will follow the development and rollout of the provincial strategy for the care economy.

Regional Added Value for Nord Pas de Calais In the Nord-Pas-de-Calais region, CURA-B has been supporting SMEs who were attempting to collaborate and form a Triple Helix model. This was evident through the Eurasanté pilot as it provided the opportunity for SMEs who shared specific competences to group together and learn from one another. Conclusions from the added value to the regions At the fundamental and practical level CURA-B has shed light on the innovation process within AT and how parts of the Triple Helix have cooperated historically and the issues that this can potentially cause, especially if there has not been a tradition of collaboration. As a response to this CURA-B created networks and partnerships and there is a greater awareness of the need for Triple Helix style collaboration. CURA-B has also led to the development of strong partnerships and relationships amongst the regional partners in the East of England and in West Flanders where the partners now have an awareness of a common goal and have developed an understanding and the competences to take on new roles to facilitate the Triple Helix collaboration (as system integrators) thereby forging a strong new identity.

CURA-B and Added Value to Cross Border Partnerships This section of the chapter will be outlining the value added activities which occurred in the CURA-B project and which were specifically related to crossborder events. Cross border regions differ greatly in size, competences, finance and commitment. Klatt and Herrmann (2011) argue that cooperation is often confined to a limited number of issues as it is unlikely that firms will agree, or be able to establish coherence on all of the objectives that they would seek to achieve. Complementarities in the economic structure, socio-economic institutions and innovation capabilities between the neighbouring regions, are often seen as the main drivers of cross-border activity and cooperation (Van Den Broek and Smulders, 2013). The importance of considering cross-border

activity is that it is closely related to innovation, which has clearly been an important feature of the CURA-B project. In practice CURA-B did not address cross border issues as strongly as it did the other challenges facing SMEs which were discovered in Activity 1. From Activity 1 we saw that there were 3 critical barriers to internationalisation. • Local Legislation and Regulation • Finding Capital or Means of Financing • Lack of International Cooperation or Partner

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Cross-border activities can be challenging, especially because both formal and informal institutions are involved; the former being associated with laws and rules, and the latter being characterised by values, norms and routines (Boschma, 2005; Mattes, 2012). Firms have different value systems, depending on their home country/region, and this can impede effective collaboration and minimise knowledge transfer. This is particularly applicable to healthcare because there are different ways of approaching innovation. For example, there is a tradition in the UK for clinicians to be less entrepreneurial and perceptive to Assistive Technology, compared to those in the Netherlands. This means that not only will cross-border activity be restricted between these two nations, but the degree of understanding between healthcare professionals would also be minimal, especially if one clinician was supportive of the process, compared to their counterpart in another region/nation who was not. Regional borders can act as a barrier to cross border activity, including learning, innovation and knowledge sharing. Boschma (2005) found that cultural differences had a significant impact on the quality of relationships established, especially if the ‘proximity’ between partners results in the ‘notinvented-here’ syndrome. This implies that firms are reluctant to engage in a transaction with other firms located outside of their own nation (Jos Van Den Broek and Smulders, 2013). It is recognised that SMEs tend not to engage with other actors outside of their own region and networking relationships are difficult to establish; as Hamburg (2010: 23) commented ‘cultural differences [become] an obstacle instead of a source of synergy and a stimulus for knowledge transfer and mutual learning’. The establishment of a network which consists of trust, knowledge sharing and the opportunity to build a community is hampered when a political dividing line with economic and social challenges prevent the development of cross-border innovation. Lundquist and Trippl (2011) argue that cross-border regions risk acquiring ‘institutional gaps’ which separate nations and prevent people participating in solving common problems and exchanging necessary knowledge and advice. Hansen en Serin (2010) suggested that to improve the ‘institutional gaps’ in the cross-border activities, there should be a process of ‘patching up’ whereby relationships are either developed with new institutions in another nation, or they are rebuilt with existing ones to make the relationship stronger. The challenge associated with building these crossborder relationships is that the intentions of both parties are unclear, and it is not evident how either side will benefit. In healthcare, for example, the ways in which innovation is perceived by healthcare professionals is different and this leads to several institutional gaps occurring.

Cross-border activity was promoted throughout the CURA-B project via a number of different events and initiatives. The driver towards encouraging this sort of activity was to assist SMEs to become competitive internationally in terms of financing growth and ensuring that they could participate in innovative activities. These are also the objectives outlined by Horizon 2020 ‘Innovation in SMEs’ which is a programme that seeks to provide support, development and innovative projects, with the intention to establish ‘a favourable ecosystem for SME innovation and growth’ (Horizon 2020). As part of this project, SMEs are included in a budget which supports the EUREKA/Euro-stars initiative that provides funding for transnational collaborative projects of research-intensive SMEs and encourages cross-border activity to occur. There were a number of beneficial and positive contributions from the CURA-B partners in terms of engagement regarding cross-border activity. For example, the 2 seas trade conference took place on 3rd October 2013 in Sandwich, Kent. The intention of it was to encourage firms, providers and suppliers to make contact with others in the health and/or social care field and establish relationships which would assist with their innovation and international contacts. The objective of the event was to assist SMEs on a range of topics, including Economic Development and Social Inclusion. Firms acquired knowledge and understanding of how to market their products and services in another country, including an interior design show in Kortrijk in West Flanders and a trade fair in Lille. Ten companies from the partner regions attended to share the stand and exhibit their products. It was also a best practice example for other firms who wanted to commence cross-border activity (Van de Vrande et al (2009). The value of attending the 2 Seas trade conference was not only based on networking but it provided contacts with institutions such as Enterprise Europe which was named as one of the biggest network support agencies in the EU with the role being to connect SMEs to a potential partner (supplier, provider, University). The engagement between partners at the conference could be said to be reflective of a ‘community of practice’ (Wenger, 1998) which creates learning alliances, regional clusters and global networks. The building blocks of learning equip the participants to engage in a ‘cross-border community’ which is characterised by open innovation (Lasagni, 2012) which supports the idea that innovation is more productive when there is the presence of relationships, networks, alliances, and varying forms of interaction with external sources of knowledge. Open innovation improves firms’ innovative abilities and their ‘absorptive capacity’ (Cohen and Levinthal, 1990). This is a term that relates to firms’ ability to assimilate, use and value new information over time which is received by their counterparts (Cohen and Levinthal, 1990).

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In addition to the conference, cross border activity became a key activity for Impuls (Zeeland) who was the lead partner in CURA-B. As part of their stakeholder workshops (see chapter 3), they found that participants valued the opportunity to maintain the relationships they had developed, even when the event had finished: • Impuls aimed to maintain contact with their workshop participants and engage in follow up discussions. Participants were contacted after the event and asked what they aimed to do with the information they had acquired and of what value it was to them. • Impuls was committed to assisting SMEs with the advice and support they needed and aimed to connect them to other regional/international partners in an attempt to maintain the contacts they had established at the workshop. Aside from Impuls, SCC had attempted to engage with partners located in Europe and this took place on 25th October 2012. The event involved representatives from RESOC; KATHO, and KBHO. • The event involved a number of presentations related to checkatrade.com (http://www. checkatrade.com). It is a directory of trades and services who have been inspected and tested to the highest standards, for example by having the insurance, qualifications and professional membership of the trade verified. • Members of the public are encouraged to review the quality and service of the workmanship they have been provided with and submit reviews which are monitored by checkatrade.com. SCC used this service in order to assist the CURA-B partner KATHO (West Flanders) in their pilot case 'Non-medical services for the elderly’ which aimed to offer a platform for non-medical services to the elderly living at home. • This project involved cooperation between VIVES University College, the Department of Healthcare and the Department of Industrial Sciences and Technology, campus Kortrijk (previously HIVV and VHTI) and RESOC Bruges. SCC assisted by providing contacts via checkatrade.com in order that KATHO could use reputable workmen for the jobs they required. KATHO were able to follow up with calls to the presenter of the workshop which they reported was very beneficial. • A further example of cross-border activity was related to the work by Suffolk County Council (SCC) in organising a visit to BT Adastral Park in January 2013. To advance SCC’s cross-border activity, they expressed an interest in finding out which actors were involved in the regional innovation system in the Netherlands. As Regional Development Agencies are a key body in assisting SMEs in the Netherlands, but were no longer in existence in the UK, comparisons could be made between the two nations. SCC commented that this

would have assisted them in terms of knowing who to draw upon for additional support and advice during the pilot projects. Cross-border activity is not a straightforward or easy process for firms to engage in, most notably because inter-firm networking involves different cultural and institutional differences between firms. Events such as the 2 seas conference provided the foundation from which to ‘…develop skills of using the world on both sides of the border’ (Lofgren, 2008: 196). Challenges to cross-border activity are common, most notably when they relate to cooperation and engagement between multiple actors because this influences how national partnerships are established. When reflecting on the experiences of cross-bordering amongst the CURA-B partners, it was evident that there was less concern over the challenges, but more about how improvements could occur if they were to undertake more cross-border activity. The following issues could be considered: • Local connections need to take place and be linked to regional/international links • Challenge of language barriers – a UK SME could not sell products in Northern France without being able to speak French • Organisational thinness whereby peripheral regions are weakly developed, there are a lack of supportive institutions and insufficient research and development capabilities • Risk of lock-in where large firms dominate and SMEs have become overspecialised in their field of innovation resulting in them being noncompetitive. To improve this, a focus has to be placed on encouraging foreign investment; institutional change and strong network ties. • Different methods of procurement (e.g in Sweden SMEs are provided with a guarantee that their product will be funded by an institution and a commitment to buy a certain quantity is agreed upon. In the UK this is not the case which means that there is a higher risk of SMEs producing a product which is then redundant as providers and sellers can find no use for it). • Increase the use of learning by facilitating collaborations with firms and consultants providing knowledge-intensive service activities, for example using “innovation vouchers” for SMEs. To address the potential improvements identified above, firms must focus on the formation of social and human capital (trust, education, interaction). Masiello et al (2013) discuss how SMEs must seek to establish and maintain a shared vision with the partners that they engage with. This will generate additional value through transferring innovative ideas to the market. Enkel et al (2009) has referred to this as ‘co-creation’ whereby complementary partners jointly develop and commercialise innovation.

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‘Co-creation’ or ‘co-option’ (Dunford, 2010) involves different partners from different regions forming and sustaining a positive relationship and drawing on the advice and support of each other to assist in future innovative products/services. It is important for any co-creation activity to recognise potential limiting factors such as the existence of different languages and the impact this has on interpretation and business related discussions. The additional learning and shared repertoire that is gained through cross-bordering can however assist firms to develop and refine their product by facilitating the flow of information and making organisational and national boundaries more permeable.

When cross border activity was discussed with the firms in CURA-B, it became clear that what was required was more support and assistance on how best to engage with international partners. The opportunities available to them to meet and form connections with their future counterparts proved challenging as there was simply insufficient time and resources to plan or attend more events. A suggestion to improve this would be that international networks could be established at the beginning of the project as this would provide the foundation for individuals to begin engaging with different regional partners, rather than attempting to build relationships from scratch towards the end of the project.

The Three Activity Stages and the Logic of CURA-B The internal logic of CURA-B as we mentioned in chapter 1 has been to follow the phases of an Action Research project: to understand the current state or position (Activity 1), to generate some ideas for possible action ( Activity 2), to take action in the pilots ( Activity 3) and then to reflect on those actions. The first two columns recap on the key challenges faced by SMEs revealed in Activity 1. The next section of columns shows what workshops were held in which regions and by which partners in order to generate ideas to resolve those challenges. We can see that the workshops covered for the most part those key challenges except in the area of internationalisation. From the workshops a series of possible ideas/actions were suggested that corresponded to the original challenges identified and some of these were then turned into pilot actions except: • for internationalisation (though there was cross border activity, a cross border conference and a cross border business manual) • for the challenge of the cumbersome tendering process ( though to some extent this is being circumvented by using a ‘co creation’ model) • for the need for different funding models. This remains a problem to be solved. Learnings were then generated by the pilot projects undertaken, documented through the Business Model Canvas and mutually reflected upon by the partners and by ARU for each of the pilots.

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CONCLUSIONS AND RECOMMENDATIONS This section of the chapter will summarise the main recommendations which have stemmed from the CURA-B project based on the learnings and evaluation from the three sets of activities. These suggestions have been reviewed by the CURA-B partners and especially with the lead partner

Impuls and HEE in the UK as both organisations play to some extent the role of a ‘system integrator’ which has proven to be a mechanism of advice and support to encourage SMEs to bring their innovation product/service idea to the market. Though SMES have faced challenges with ‘going to market’ and with the fragmented and inaccessible healthcare sectors, the recommendations proposed are a step towards overcoming these struggles and being able to transform what were ‘near market’ ideas, into products and services that appeal to the health marketplace.

EXPLORATION vs EXPLOITATION: Co-create and Co-deliver value versus Co-capturing value A recommendation emerging from the pilots would be that more emphasis should be placed on the distinction between the ‘exploration’ and the ‘exploitation’ phase of innovation which appeared disjointed in the project. Whilst there was evidence of a co-creation regarding the value proposition and delivering to the customer, there was an absence of co-creation regarding how an SME captures the value, that is, how all stakeholders benefit and make a margin. SMEs would need support in terms of the actual implementation and selling phase in terms of being able to know who they could draw on for support and advice in order to achieve this objective. In a recent study by Van Hermert et al (2013) innovation involved these two different features; one being exploration which is based on recognising an innovation and developing it, thereby renewing the system, and exploitation is derived from using what already exists for further incremental innovation. Exploitation is therefore focused on production and commercialisation. • At the exploration stage, SMEs in general are most likely to use external partnerships such as research institutes and universities in order to produce something different to what already exists, and thereby gain access to markets and sales channels (Luukkonen, 2005; Edwards et al, 2005). • What can be learnt from this research is that SMEs wanting to engage in open innovation should consider undertaking it at the commercialization stage as well as at the beginning of their innovation (Lee et al, 2010). Lifelong relationships throughout their innovation cycle are going to be more valuable to them compared to short-term, one-off connections. • If SMEs focused on open innovation during the production and commercialization phase, as well as the stage of design and implementation, then they would benefit from building alliances and contacts with a network of different partners who could assist them with challenges such

as technological change, market requirements and point them in the direction of appropriate flows of information. • A more effective strategy for innovation would be possible over the long-term compared to only perceiving open innovation as applicable to the beginning of the innovation process. Using open innovation throughout the lifecycle of a product/service is a valuable recommendation for policy makers to consider who are involved in the regional healthcare and innovation sectors. By focusing on establishing policy and practice related to the later innovation stage of exploitation, it would assist SMEs with appropriate flows of information by encouraging them to engage in strategic choices with other firms, thus strengthening their competitive advantage (Van Hermert et al, 2013). In the Netherlands for example in 2004 an ‘innovation voucher programme’ was launched which encouraged collaborative partnerships between SMEs and knowledge institutes, from the beginning to the end of their product/service. By the end of 2009, 28,400 vouchers were distributed and allowed SMEs to ‘buy’ research and advice from knowledge centres and a selection of European knowledge institutes which enabled them to be successful through commercialisation (Van Hermert et al, 2013).

Crossborder Collaboration Cross-border collaboration is a key feature of improving future innovations in the healthcare sector because it entails a more specific focus on the ways in which to gain entry into new markets and strengthen existing market positions, both at home and abroad. SMEs in CURA-B often had limited resources and contacts outside of their own region which meant that diversifying internationally would have been beneficial as they could have had opportunities to grow and expand their business outside of the home market.

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This is especially important if the regional market has become saturated. Mola and Carugati (2012) recognise that international cross-border activity for SMEs is successful if the relationships between firms are developed first and foremost because development is contingent on others’ resources. The firm-specific advantages which each SME has is less important; it is the networking and the relationships acquired from that which is most valuable to gain market access. It must also be recognised that it is not just SMEs which need assistance to form collaborative partnerships, but that those with whom they seek to engage with also need to be ‘taught’ how best to engage with SMEs. Care providers and healthcare professionals do not always consider SMEs as the most appropriate partners as they do not ‘…advance cutting-edge knowledge’ (Mayer and Blaas, 2002). SMEs are often perceived as one homogeneous group, rather than being viewed as having specific needs and competences; this tends to hinder effective relationships being established because policies and initiatives are not applicable to all firms. As discussed earlier, Boschma (2005) found that cultural differences had a significant impact on the quality of relationships established. SMEs in CURA-B felt that international markets were too far away and the ‘proximity’ between partners resulted in firms being reluctant to engage in a transaction with others located outside of their own region/nation due to the challenges of maintaining effective engagement, being able to interpret the market, and even concerns with differences in management style (Jos Van Den Broek and Smulders, 2013). Although co-creation is a desirable process, it brings its own concerns as SMEs have to consider their IP and how to protect it. Co-creation encourages firms to share their own knowledge but how do they protect it when it is more mobile? Any recommendation to encourage open innovation should take into account that knowledge cannot be accessed by every organisation in the same way as they all differ in their ability to make use of the new knowledge; this is referred to as ‘absorptive capacity’ and refers to the ability to recognise the value of other information and use it to commercial ends (Bessant and Tidd, 2011). Recommendations for enhancing open innovation and cross-border activity therefore have to consider the most appropriate form of structure which would engender greater innovation between partners and assist all firms, regardless of their capacity to internalise and utilise the knowledge available to them. On the one hand, it is argued that a closed structure consisting of strong, cohesive ties would be ideal because it represents trust, social control and positive exchanges (Masiello, 2013). On the other hand, Granovetter (1973 cited in Masiello, 2013) has suggested that weak ties are best because they consist of low reciprocity and intimacy and have low levels of emotional commitment. Even though this may

appear to be non-conducive to network formation and collaborative partnerships, the ‘strength of weak ties’ is that it can provide wider sources of knowledge and learning and therefore stimulate more innovation (Tsai, 2000). This could be a point to consider with regards to recommendations for the future as SMEs may benefit from directly being involved in engaging in networks which have ‘weak ties’ and that call for a different approach in sustaining collaborative partnerships. Innovation would involve the interactions between people, rather than ‘…the formal, documented and bureaucratic aspects of innovation projects’ (Masiello et al, 2013: 19). R There are also benefits from interacting with partners as early as possible in an innovation project because this allows for the development of a stronger relationship which grows over time. This is something which the CURA-B SMEs did not achieve as many of them sought to engage in a network towards the end of the project, only to discover that they knew nothing about the partners they wanted to engage with, or even whether they would be of value to them. The system integrator discussed later would contribute significantly to enhancing these activities. Cross-border collaboration would become one of its key roles and would assist with the facilitation of links between key stakeholders (GPs, buyers, care providers) and in doing so make the most of the knowledge available internationally and in home markets.

Networks and Collaboration Drawing on the discussion above, a recommendation for SMEs in the future would be to draw upon strategies which would minimise barriers to collaborative working and ensure that open innovation was a key feature of their product/service lifecycle. Bessant and Tidd (2011) identified three factors which firms should take into consideration when developing their open innovation strategies. These were referred to as: ‘opening up of search’; ‘opening up of engagement’ and ‘opening up stakeholder participation’. These converging areas reflect the active role taken by different actors within the networking system and the focus of activities which SMEs should concentrate on. There was evidence in all four regions of both weak and strong interactions between stakeholders which impacted on the ease through which the network of interactions occurred. SMEs in the UK for example felt that healthcare professionals were reluctant to work with new technology so they struggled to convince them of the value of innovation, even when the added value for end users was evident. Standardisation over procurement was perceived as being bureaucratic and lengthy which contributed to making SMEs’ experience of innovating and gaining access to the market difficult.

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When first evaluating the partners, it appeared that the UK had a particularly disjointed healthcare system with minimal collaboration between SMEs and healthcare professionals, but when investigating the same practices in the Netherlands, it was evident that similar processes were in place there too. For example, an SME who had designed a product and tried to discuss it with healthcare professionals spent nearly two years attempting to gain access to them and had to go through eight different decision makers before being able to effectively get their product ‘in the market’. The SME also faced challenges to gain access to the end user. The similar challenges experienced within the four regions suggest that a change in policy directed towards innovation and which focused on open innovation that was specifically funded and directed towards assisting SMEs would prove beneficial.

As the pilot studies illustrated, the challenges for SMEs to gain access to the market and build relationships were more pronounced when they had minimal experience of working with the healthcare sector as they were unable to build upon existing contacts and networks. The result was that learning opportunities for SMEs and care providers were hampered and consequently the sharing of knowledge, visions and interests became restricted and resulted in a market which was fragmented. Janssen and Moors (2013: 1365) referred to these relationships which were too tightly knit as leading to ‘myopia’ meaning that GPs and healthcare professionals would tend to bypass new innovations and concentrate only on those practices which they knew had worked in the past.

Innovation Centres As a result of the insights acquired regarding the added value to the regions, it leads on to consider how to achieve the aim of enhancing open innovation and improving co-creation between partners. In order to do this, there has to be a reconsideration of how innovation can be seen as an interactive phenomenon that is based on close cooperation between all actors involved. In order to concretise the idea of an innovation network (described and pictured below) a possible framework was established in May 2012 for a regional network based around an Innovation Centre, which describes the key role that the partners could play in providing a series of services to SMEs, the Public Sector and the Knowledge Centres. In Activity 3 this role has been funded by CURA-B. A critical challenge going forward will be to find ways to fund this role in the future. In the East of England a regional innovation system example is the MedTech

campus which reflects how breakthrough support can be provided for innovations within the medical technology and assisted living sectors. MedTech is in the process of opening up MedBIC which is specifically for SMEs and spin-out companies and involves a global partnership between Anglia Ruskin University and the Postgraduate Medical Institute, providing a network of over 20 acute hospitals, mental health and community based providers, and also three local authorities in the region (Chelmsford City, Harlow District and Southend-On-Sea Borough councils). The driver for the MedTech campus is to stimulate network facilities, help SMEs to learn how to overcome barriers to growth and innovation and move ideas forward for all industry participants involved, but especially SMEs and start-up firms.

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Although MedTech is not part of CURA-B it provides a model to draw upon as best practice in terms of assisting SMEs. SMEs in all four regions needed to improve their ability to test their products/ services and using a mechanism like MedTech, there would be direct links already established with NHS trusts ( or other national medical services) where clinical trials can take place. Participants in the Suffolk Dragon’s Den event struggled to gain access to end users or focus groups, thus preventing them from being able to test their product/service. The direct links already established through MedTech would minimise the challenges associated with gaining access to the NHS which all regions commented on was a barrier to overcome. The fact that a model of this nature is already in place in the form of the MedTech campus provides sufficient and encouraging evidence to indicate that such improvements are possible. Each regional innovation system will have experienced its own unique challenges which may require more in depth analysis as to the specific procedures through which improvements could occur and be applicable to sector specific SMEs. However, of a more general nature, the MedTech campus should be a point of departure and a source of best practice for all regions to consider how they would replicate this model to assist their own innovative SMEs. In the East of England region, other examples are the Unilever Colworth science park run as a joint venture between Unilever and a property company which gives the opportunity for large company R and D, knowledge centres in the form of local universities and entrepreneurial SMEs to be part of the innovation eco-system and to network and collaborate and hopefully stimulate more disruptive innovation. Glaxo Smith Kline also have a collaborative agreement with the University of Cambridge to build an ‘Academic Incubator’ concept whereby Glaxo Smith Kline (GSK) team up with the knowledge centre to optimise the early clinical development of GSK compounds through a shared risk/reward model. In Zeeland the Living Lab ( Concept Home) project is another example of an ‘Innovation Centre’ in action , organised by Impuls and funded ‘ in kind’ through the work of local SMEs, housing associations and local government. The estimated first year cost is around €500k. The payback for all of these innovation centre initiatives is shared learning and the key driver is the realisation that disruptive innovation requires a new eco system model.

System Integrator In Chapter 5, the suggestion of a ‘system integrator’ was discussed which would take the form of a central organisation which acted as an ‘orchestrator’ (Chesborough et al, 2005) in the AT innovation eco system. The system integrator would bridge the gap between stakeholders and assist firms as they attempted to enter the care market, to facilitate effective networking, collaborative relationships and find funding opportunities. The ways in which this role of the ‘system facilitator’ would be funded is a key question. The interesting aspect in relation to this implementation is that it replicates the work conducted in the Netherlands by Impuls who were committed to providing SMEs with an ‘incubator’ facility. Once a week SMEs are invited to attend and meet representatives from larger firms, insurance companies, banks and lawyers who would share knowledge and provide support in relation to innovation. The stakeholders present would offer free advice and there would be no monetary commitment to maintain the relationship; this is a valuable means by which to assist in network relationships and often resulted in SMEs using the alliances they had made to leverage further connections into the market. Impuls is funded by local Triple Helix stakeholders in Zeeland. As the UK no longer has RDA’s, the example of Impuls would benefit UK SMEs in particular by enabling them to draw on an independent, neutral body for advice and support. Considerations would have to take place in terms of how the system integrator was funded, but like Impuls, it can assist SMEs to acquire a personal loan with the expectation that it would be paid back in three years. Another route could be through broad industry and venture capital groups such as The UK Angel Investment Network (used by MedTech) that join the network and expand the integrator’s fund, as well as establish a follow-on investment programme. The value of this angel investor is that the opportunity arises for both investor and entrepreneur to work together to decide which package of investment options would be most appropriate and viable. In the East of England HEE performed a similar service in the CURA-B project to that given by Impuls and already plays the System Integrator role in its work in providing SME innovation funding advice, market entry help and expertise in dealing with the NHS. HEE is a ‘Membership’ organisation funded by fees paid by its members and by consulting fees paid for its market entry services. In West Flanders the System Integrator role was played by several organisations working in partnership: POM, the two Resoc organisations and VIVES as the centre of expertise/knowledge centre. In West Flanders the partners are now part of a network. Flanders has a regional care economy strategy with POM being a regional organisation that will continue

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to promote the care economy by developing activities in projects. These activities will respond to the strategy which has been developed in consultation with stakeholders from companies, care institutes, education and knowledge centres and will continue to raise awareness and stimulate co-operation between SMEâ&#x20AC;&#x2122;s, care institutions and knowledge partners. In the East of England, HEE have developed the East of England AT network in a structured way and SCC will continue to invest in future Hackathons and Dragons Dens alongside HEE. In Zeeland, Sante Zeeland will continue with the Living Lab project and the Memory Test project won funding for testing and development.

â&#x20AC;&#x153;What is the real value of CURA-B?... Understanding the process of this form of cross border/cross organisational collaboration, understanding the role of the helix, understanding the process of networks and the people in them, their roles and personalities.â&#x20AC;? Source: Impuls interview November 2

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LIST OF APPENDICES APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX

I - RI 1: Online Questionnaire II - Industry Interviews III – Activity 1 – RI 3 IV – Research instrument 4 V – Research instrument 5 VI – Value added interviews VII – Pilot 1 VIII – Pilot 2 VX – Pilot 3 X – Pilot 4 XI – Pilot 5 XII – Pilot 6 XIII – Pilot 7 XIV – Pilot 8 XV – VIVES (KHBO) Article 1 XVI – VIVES (KHBO) Article 2

129 134 139 141 142 143 144 145 146 148 151 153 155 157 158 165

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APPENDIX I - RESEARCH INSTRUMENT 1: ONLINE QUESTIONNAIRE (UK) ACTIVITY 1 – RI 1 Provide this text as an introduction to question 1: “Assistive technology” groups all technological solutions for people with limitations, caused by age or handicap (prostheses, text-based phones, stair elevators…) 1. Is your company involved with assistive technology? This is a single choice question. • Yes • No, but I wish to get involved in this market • No, and I’m not interested in getting involved in this market. 2. To what extent, these elements are obstacles to getting active in assistive technology? Provide a scale per item: 1: not at all/2: slightly/3: somewhat/4: very/5: extremely/6: not applicable or no opinion. For “Other, please specify”, provide a free-text field (obligatory). • Lack of skilled staff • Lack of market knowledge and customer needs • Lack of time to explore this path • Lack of network or partners • Lack of advice and support • Lack of knowledge on relevant legislation issues • Other, please specify 3. What products or services does your company produce or sell? Provide this text as an introduction to question 3: Please indicate your main product with 1, the second main with 2, etc. The numbering link to the ISO 9999-code (“Assistive products for persons with disability”). For more information and examples of this classification, click here (please provide a hyperlink) Provide a scale per item: 1à 12 (do not remove or change the numbering, as it links to ISO 9999) For “Other, please specify”, provide a free-text field (obligatory). • 04. Aids for personal medical treatment (e.g. glucose meter) • 05. Aids for training in skills (e.g. Braille reader) • 06. Orthotics and prostheses • 09. Aids for personal care and protection (e.g. absorbent pads) • 12. Aids for personal mobility (e.g. wheelchair) • 15. Aids for housekeeping (e.g. adapted cutlery) • 18. Furnishing and adaptation to homes and other premises (e.g. shower seat) • 22. Aids for communication, information (e.g. magnifying glasses) • 24. Aids handling products and goods (e.g. anti-slippery mats) • 27. Aids for equipment for environmental improvement, tools and machines (e.g. working post) • 30. Aids for recreation (e.g. home trainer) • Other, please specify

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4. Please indicate category that is the most applicable to your activities in assistive technology. This is a single choice question. For “Other, please specify”, provide a free-text field (obligatory). • Production of goods • Production of services • Distribution of goods • Other, please specify 5. At this point in time, what is the profile of your main group of customers? This is a single choice question. For “Other, please specify”, provide a free-text field (obligatory). • Companies • Governmental and/or health organisations • End users • Other, please specify 6. To what extent, these elements are obstacles to putting your product or service on the market? Provide a scale per item: 1: not at all/2: slightly/3: somewhat/4: very/5: extremely/6: not applicable or no opinion. For “Other, please specify”, provide a free-text field (obligatory). • Customers need to be convinced of a new product/service • Strong competition by current suppliers • Long running customer contracts prevent entering new products • Fragmentation on the market, multiple decision makers on customer level • Difficulties concerning distribution channels • Subsidized market dealing with its own, specific procedures • Uncertainty about market potential • Other, please specify Provide this text as an introduction to question 7: Following questions concern innovation in your company (strategy, product, process) 7. How would you best describe your innovation strategy since 2008? This is a single choice question. For “Other, please specify”, provide a free-text field (obligatory). • Conscious/deliberate innovation strategy • Spontaneous innovation • No innovation at all • Other, please specify Provide this text as an introduction to question 8: A product or service innovation is the introduction to the market of new goods or services or strongly improved goods or services with regard to its characteristics, such as improved software, user friendliness, new components… • The innovation needs to be new for your company, but not necessarily for your sector or market. • It is irrelevant whether the innovation has originally been developed by you or by another company. 8. Has your company introduced new or strongly improved products or services during the period 20082010? These are 2 lines of single choice questions. Provide twice the options Yes – No – N/A. • Goods • Services

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9. Were any of these products or service innovations…? These are 2 lines of single choice questions. Provide twice the options Yes – No – N/A. • New for your company (they were earlier put on the market by competitors) • New for your market space (even if they existed already on another market space) Provide this text as an introduction to question 8: A process innovation is the application of a new or strongly improved production process, distribution method or supporting activity for your goods or services. • The innovation needs to be new for your company, but not necessarily for your sector or market. • It is irrelevant whether the innovation has originally been developed by you or by another company. 10. Has your company improved or introduced one of the following processes since 2008? These are 3 lines of single choice questions. Provide three times the options Yes – No – N/A. • Production methods for goods or services • Logistic or distribution methods for inputs, goods or services • Supporting activities such as maintenance, purchase, accountancy 11. In what way your company has been implementing innovation since 2008? These are 4 lines of single choice questions. Provide four times the options Yes – No – N/A. For “Other, please specify”, provide a free-text field (obligatory). • In house, with proper staff and means • Mainly in house, but in cooperation with other external partners • Using only external experts • Other, please specify 12. Who are your main partners for these innovation activities? Please indicate your main partner with 1, the second main with 2, etc. Provide a scale per item: 1à 8 For “Other, please specify”, provide a free-text field (obligatory). • Other companies within your Group • Suppliers of equipment, material, components or software. • Customers • Competitors or other companies within your sector. • Consultants, commercial labs or private research centres. • Universities or college universities. • Governmental or public research centres. • Other, please specify 13. Has your company received any kind of governmental support for innovation activities from one of these public bodies since 2008? Please adapt to your national/regional situation This question also relates to financial support such as tax reduction, tax credits, subsidies/grants, subsidized loans, loan guaranties… The question does not relate to research or other innovation activities that were performed on a contractual basis entirely for the government. These are all lines of single choice questions. Provide each time the options Yes – No – N/A. For “Other, please specify”, provide a free-text field (obligatory). • Local authority/province/county • Regional government • National government • EU • Other, please specify

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14. To what extent, these elements are obstacles to your innovation projects? Provide a scale per item: 1: not at all/2: slightly/3: somewhat/4: very/5: extremely/6: not applicable or no opinion. For “Other, please specify”, provide a free-text field (obligatory). • Availability of internal resources (people, time, money) • Finding external resources • Too high cost of innovation and/or investment • Too high economic risks • Too few qualified staff • Lack of information on new technologies • Insufficient knowledge of the market • Lack of space for experiments • Finding partners in innovation • Dominance of existing companies • Market demand • Other, please specify 15. Does your company have...? These are 2 lines of single choice questions. Provide twice the options Yes – No – N/A. • foreign production or development facilities • foreign sales offices 16. Does your company sell product or services abroad? This is a single choice question. Provide the options Yes – No 17. To what extent, these elements are obstacles to your international operations? Provide a scale per item: 1: not at all/2: slightly/3: somewhat/4: very/5: extremely/6: not applicable or no opinion. For “Other, please specify”, provide a free-text field (obligatory). • Product insufficiently adapted to foreign market • Price setting not in line with foreign standards • Cost of internationalisation (transportation, …) • Finding capital or means of financing • Insufficient skills staff/management • Local legislation and regulation • Lack of advice and coaching in export activities • Lack of international cooperation/partners • Cultural differences • Other, please specify 18. To what extent do you need support for…? Provide a scale per item: 1: not at all/2: slightly/3: somewhat/4: very/5: extremely/6: not applicable or no opinion. For “Other, please specify”, provide a free-text field (obligatory). • Specific accommodation (demo space, labs, meeting rooms, …) • Knowledge of new technology • Consumer and market research • Internationalisation and foreign markets • Domestic networking • Foreign networking • Financial advise • Legal advise • Other, please specify

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19. Please fill in the table regarding revenue and employment details. These data remain anonymous, and are merely meant to map out the economic importance of this sector. Provide a field to fill in data for 1) the year 2009 and 2) Evolution 2005-2009 (in %) • Total revenue (in €) • Revenue in assistive technology (% of Total) • Total number of employees • Number of employees working in assistive technology (% of Total) 20. Divide your revenue in assistive technology over different geographic markets (in %) Provide a field to fill in a percentage per item. Optionally, you can add a field/rule to check for 100% • In your own country • In the European Union (EU27) • In other (non-EU) countries 21. Finally, we would like to ask you to name a number of other companies, known to you to be working on assistive technology (suppliers, colleagues, distributors …) Through this, we would like to get a more complete view on the companies that are active in this sector. Provide a free text field or provide some lines to fill in e.g. name of company, country, and main activity in assistive technology. 22. If you have any other questions or remarks, please feel free to indicate them below. Provide a free text field.

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APPENDIX II - GUIDELINES FOR INDUSTRY INTERVIEWS ACTIVITY 1 â&#x20AC;&#x201C; RI 2 Mr Michael Garrison Michael.garrison@hee.org.uk Health Enterprise East Ltd. CTBI, Papworth Hospital NHS Foundation Trust Papworth Everard, Cambridge CB23 3RE, United Kingdom Enquiries@hee.org.uk Tel. +44 (0)1480 364925 Fax. +44 (0)1480 364681 www.hee.org.uk

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Introduction General objective of the project:

‘Assistive Technology’ & ‘Tele-healthcare’:

The objective for all regions participating in the project is to improve efficiency in the healthcare sector (by lowering costs and increasing customer/ patient wellbeing), to meet patients’ requirements and to enhance business development in the healthcare sector. Specific objectives of the project: The CURA-B or “accurate business in the cure & care market” project will be led by Impuls Zeeland (regional development agency, Netherlands) and bring together organisations in West Flanders (Belgium), northern France and Suffolk. With ageing populations, and a shrinking work force, it’s a challenge for society to provide high quality care and optimal living conditions for older people, at affordable cost. There are also greater demands on health services to deal with crises caused by suboptimal management of chronic health conditions with the focus firmly on developing strategies to prevent these events from arising whilst involving the individual in their care through personalisation and self-empowerment. The introduction of both innovative products and services and new organisation concepts in the healthcare sector will be crucial to meet these challenges. This is an important trend and business opportunity, which has been recognised by many companies. A new market approach is necessary in order to let everybody win in the business chain, from inventor to end-user. The aim of Cura-B could be described as ‘the improvement of wellbeing via Assistive Technologies in the Telehealthcare market segments.’ For the success of the project, Cura B needs to find ways to optimise participation of three stakeholder groups:

“Assistive Technology is any product or service designed to enable independence for disabled and older people.” This UK definition was drafted in 2001 at a King’s Fund meeting by a broad group of voluntary sector organisations representing disabled and older people in order to prioritise personal outcomes set by the user of technology within a framework of ‘independence’. This definition is now used by the UK Department of Health and can represent a proposed definition for adoption by the Cura-B project. The difficulty arises however, in that the definition embraces a wide range of products and services, both high and low tech so the limits are difficult to specify. Under the broad definition of Assistive Technologies sits a relatively new term referred to as Telehealthcare comprised of: • Telecare: use of electronic sensors and aids that make the home environment safer, enabling people to live at home, independently, for longer. Sensors automatically raise alarms through call centres, wardens or friends and family. • Telehealth: use of electronic sensors or equipment to monitor people’s health in their own homes (e.g. blood pressure, weight, oxygen levels). Information can be monitored by clinicians without the individual leaving their home. • Telemedicine: use of sensors and electronic devices for communication to aid diagnosis and management of health (e.g. consultations between various health professionals and the patient via video conferencing) Within the context of Cura-B and the Industry Interviews that are addressed herein, it has been proposed that interviews are conducted with organisations that sell finished Telehealthcare products to Providers. They can be located anywhere within the nation of the interviewing Cura-B partner and preferably will be SME’s. The Telehealthcare product scope for Cura-B that was proposed at our kick-off meeting in Bruges, Belgium is listed below:

• Social Care providers (‘Provider’) • Health Care providers (‘Provider’) • Private Industry offering technology product solutions to Providers Currently these three active agents find it difficult to collaborate for the common goal of providing and implementing successful solutions: social and health agents are often unhappy with the offerings from industry, and private industry finds it difficult to work with both social and health care organisations. The aim of the Industry Survey in Activity 1 is to characterise the experience, frustrations and future desires of Private Industry in understanding the needs of Social and Health care Providers, engaging with the providers successfully in proposing solutions and transacting business (contracting, sale and implementation) of their solutions via Provider procurement initiatives.

In Scope Remote technology; • Pro-active monitoring (individual participates by in-putting data) • Re-active monitoring (individuals are monitored remotely) • Social networking Stand-alone technology • Alarms • Controls – e.g. managing medication Out of Scope Traditional aids to daily living Bed based services

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Interview and Reporting Instructions 1. From each of the four participating countries, at least 75 Private Industry companies will be surveyed with an aim of identifying a mix of 50 companies who conduct business with the social and/or healthcare sector and 25 who are not presently targeting or trading in that market space. The survey will be discussed in separate documentation. 2. From the 50 companies identified from item 1 above, combined with domestic companies known to the respective CURA-B country partner, each participating country will identify and interview at least 13 Private Industry companies offering qualified Telehealthcare product solutions to Health and Social care Providers as described herein. Interviews will be conducted and reported on by the regional Cura-B partner organisations. The responsible partner organisation from each country will be agreed within the project. 3. The companies to be interviewed should preferably be SME’s (Small Medium Enterprises) but in exceptional circumstances and when particularly beneficial to interview aims can include a large organisation. 4. The companies selected have to be active in Assistive Technologies and preferentially in Telehealthcare and offering finished innovative product solutions. The companies must have been active in that sector presently, at some time during the past 2 years or have clear business plans for starting activities during 2011. The person/people to be interviewed in each company should have responsibilities covering the management and delivery of business solutions to commissioning (purchasing) bodies and end users (i.e., General Management, Business Development or Marketing). Their responses may be supplemented by R&D personnel when appropriate. 5. The companies need to have an operational presence in the country of the interviewing partner organisation, in order to ensure that the information provided is relevant and reflects the practices of each country. 6. It is planned that this interview guideline document will be finalised, following input from the partners, on 1 June 2011 and all interviews to be completed by 15 September 2011.

7. The form of the interview is close to what is usually called ‘semi-structured’. That means that answers to some set questions may not appear very illuminating though you suspect the respondent might have something important to say if prompted. Your job is to try and extract this further information by using prompts such as ‘Can you tell me more about that? /can you just go back to your earlier point about.... and give me an example of what you mean?’ Notes about replies to these requests can be made separately from the individual question space and collated into a short report (maximum 600 words). In some instances the prior completion of the industry survey may provide sufficient information for specific questions with appropriate notes being inserted in your interview text. NOTE: Please limit your written interview comments to concise notes following each specific question with a target length for each to approximately 25 words to assist post interview assessment. 8. The format of the questionnaire must be kept uniform across the participant countries and all the interviews, to allow for the easier collection of information for the final country and cross-border reports. A suggested country report template is provided with this draft interview guide. 9. Although the interviews in each country will most likely be held in the local language along with the recording of the questionnaire, the resulting country reports should be submitted to Terry Mughan at Anglia Ruskin University in English by 1 October 2011 who will dispatch all of them along with the aggregated cross-border report on 15 October 2011. 10. Additional information can be provided in the form of electronic attachments (PDF’s or similar), although the questionnaire still needs to be completed, i.e. do not only complete half the questionnaire and bundle it with a series of attachments (i.e., ‘information to be found’) as this will make any future interrogation more difficult. 11. Please feel free to contact HEE as questions arise.

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Questionnaire (Please insert underneath each question as much space as needed to document the response. However please do bear in mind that succinct answers allow for easier data analysis for the final report) Q.1 Describe your organisation (Only if survey was not completed or available information is insufficient) Year company was founded in this country Number of staff in this country Country turnover (Annual Sales) Who do you consider to be your main competitors and why Has your company received any public funding (i.e., grants, etc.) to the best of your knowledge Q.2 Why did your organisation select your key customer market? What is your overall organisation’s main market focus (Can be within or outside of Healthcare)? Why or how did your company come to select or target that market segment? What would persuade your company to enter alternative or new customer markets? Q.3 Who are your key health sector customers? (Only if survey was not completed or available information is insufficient) What is the profile of your most important health sector customers (market segment and organisation) and how significant is each to your present and future business plans. Q.4 Who are your company’s typical health sector End Users? (Only if survey was not completed or available information is insufficient) E.g. Elderly, people with Long Term Conditions (LTC), mental health, children, active or unemployed, disabled or other. Assess in detail, what patient independence issues the company is trying solve with its products/services. Q.5 What process does your company tend to follow in understanding new and/or foreign markets? Explain what steps and key sources of information you would turn to in assembling sufficient information to warrant investing in the new or foreign market. Do you have any government, trade association, market report suppliers or consultants that you routinely consult for this type of information and in what order would you go about it? Do you have any case examples that you can explain?

Is your decision to enter new markets generally as a result of a proactive or reactive response to market or company conditions? Q.6 Gathering of end user needs In developing innovative product solutions in the health and social care market space, do you routinely consult with end users (i.e., patients) to secure their feedback on areas of product development, product specifications or usability? If yes, when does this process begin and how does it impact on product concepts and specifications? Do you incorporate any assessment of the impact that your product will have on the end user’s sense of wellness? Please provide case example if available. If no, why not and what tools or initiatives, if they were available, would encourage you to use them and make contact with end users? Q.7 How does your Company find out about procurement requests from social and health care providers? What are your key sources of information? Are there key improvements you would you like to see on publication of the requests or the content of their specifications? Q.8 Influence on procurement specifications? Do you have any experience where you or your company may have shaped or clarified the product specification or purchaser’s needs in a procurement call or request for tender? Can you describe an example and specifically how the dialogue with the purchaser was initiated and how it was maintained through the process? (NB: Confidentiality of company, product, examples, etc. must be reassured especially as it will be protected in any summary report arising from the Cura-B project.) Is the process routinely static (you have no influence) or dynamic (active dialogue) and what would be your preference and would you like any changes? Q.9 Development of new IP and Knowhow Has your organisation generated new Intellectual Property (‘IP’, i.e., patents, trademarks or copyright) as a result of information gained directly from health or social care providers or end users? If so, can you describe the situation (case example)? If you have generated IP in this way, did the other party obtain any rights or license to the new IP? If yes, please describe the type of rights granted and whether it was guided by an agreement with the provider or end user entered into prior to the

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exchange of any information. Q.10 How does your Company find its customers? Sales force, published bids, approached by social or healthcare organisations? By any other means? Q.11 Describe a typical sale process Do you normally sell your products through private sales or by bids/tender to publicly funded organisations? If through bids/tender to publicly funded organisations: What is the bid process? Please describe the process of notification, time for submission and award, whether your company often has to customise products or services to meet the bid requirements. Are the aims and needs of the provider/purchaser and consumer clearly specified? Is the procurement process too difficult, slow or time compressed? After delivery, do you pursue any follow up or ongoing customer service with the customer? What aspect of the process would you like to see changed and why? Q.12 Describe how your company obtains feedback from purchasers and consumers Do staff from your company hold one to one (direct) meetings with purchasers and/or consumers? If yes: At what stage in the sale process does this happen? Do you meet with the final consumer after the deployment of your companyâ&#x20AC;&#x2122;s product? Do public sector purchasers provide your company with feedback about similar and related projects enabling you to benchmark or compare your companyâ&#x20AC;&#x2122;s performance? Are you invited to provide similar information to the public sector purchasers? Q.13 Difficulties in conducting business with the health sector Please describe how the process of collaborating and conducting business with social and healthcare providers could be made more efficient for your company, the providers and the commissioners. Q.14 Free text Space for additional information. Please do not exceed 300 words.

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APPENDIX III – ACTIVITY 1 – RI 3

Introduction Project overview: Specific project objectives for all participating regions are to develop innovative new care pathways that are patient and carer focused that will: 1. Improve efficiency in the health and social care sectors 2. Improve quality of care and outcomes for patient and carer 3. Reduce the cost of delivering health and social care 4. Increase awareness and prominence of Assistive Technology for all stakeholders 5. Improve the opportunities for business development and innovation within the healthcare and social care sectors for small and medium size enterprises (SMEs) The CURA-B or “accurate business in the cure & care market” project is led by Impuls Zeeland (regional development agency, Netherlands) and brings together organisations in West Flanders (Belgium), northern France and Suffolk. With ageing populations, and a shrinking work force, it’s a challenge for society to provide high quality health and social care services and improve the quality of life for older people, at an affordable cost. There are also greater demands on health services to follow a strategy for early intervention and prevention whilst involving the individual in their care through personalisation and self-empowerment. The introduction of both innovative products and services and new organisation concepts in the health and social care sectors will be crucial to meet these challenges. This is an important trend and business opportunity, which has been recognised by many companies. The aim of Cura-B could be described as ‘the improvement of well-being via Assistive Technologies

(AT) in the Tele-healthcare market segments.’ Telehealthcare is a broad term that may also be called ‘Tele-care’, ‘Tele-health’ or ‘Tele-medicine’. For the success of the project, Cura-B needs to find ways to increase the collaboration of three stakeholder groups: • Health and Social Care providers (‘Provider’) • Patients and carers who are or potentially will use AT within a service • Private Industry offering technology product solutions to Providers Currently these three active agents find it difficult to collaborate for the common goal of providing and implementing successful solutions: social and health agents are often unhappy with the offerings from industry, and private industry finds it difficult to work with both social and health care organisations. The aim of this Provider Questionnaire is to identify the experiences, barriers and future ambitions of private industry in understanding the needs of Public Sector Social and Health care Providers, engaging with the Providers in proposing solutions, innovating and transacting business (contracting, procurement and implementation) of their solutions via the Public Sector. Definition of Assistive Technology (AT) AT is any device or system that delivers the following benefits: 1. Improve the independence, life-style and care provision for both patient and carer by allowing an individual to carry out a task they could not otherwise do, or receive care in a local and convenient environment 2. Increase choice of care pathways 3. Reduce risk of harm

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4. Reduce the potential of further care episodes by prevention and early intervention 5. Allow health and social care professionals to monitor the condition and well-being of an individual 6. Provide health and social care professionals with data that will assist in the delivery of care and the development of future care pathways.

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Contact Details When completed please return this questionnaire by email or post, details below. The West Suffolk Hospital NHS Trust would like to thank you for completing this questionnaire; the project will benefit greatly from your co-operation. If you have any queries regarding this document please do not hesitate to contact Colin Lainson. Colin Lainson Cura-B Project Manager Transformation Team West Suffolk Hospital NHS Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ Email: colin.lainson@wsh.nhs.uk Telephone: 01284 713699

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APPENDIX IV – RESEARCH INSTRUMENT 4 ACTIVITY 2 – RI 4 1. What is your region? 2. Who is co-ordinating the workshop? 3. Where will the workshop take place? 4. Date of the workshop 5. What is the title of your workshop? 6. What is the objective of your workshop? 7. How is your workshop linked to the CURA-B project plan? 8. What is the target group to be invited? 9. What is the justification for the selection of the target group? 10. How will you capture key information shared on the day?

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APPENDIX V â&#x20AC;&#x201C; RESEARCH INSTRUMENT 5 ACTIVITY 2 â&#x20AC;&#x201C; RI 5 1. What was the title of the workshop and who coordinated it? 2. How many representatives of your target group attended on the day? 1

SMEs

Providers Commissioners End users Lead users Other (please specify):

3. Do you believe you achieved your objectives? 4. If so, can you give evidence of how/why you did so? 5. Did you receive positive feedback from the attenders? 6. Name and rank the top 3 insights you gained from the day for each stakeholder group. You may list less than 3 insights per stakeholder group. For example: SMEs need Insight 1: x Insight 2: y Insight 3: z Providers need Insight 4: a Insight 5: b Insight 6: c Etc. 7. Now you have listed your key insights for each stakeholder group in question 6, please rate them in terms of their impact on Activity 3 regardless of the stakeholder group. You may list up to 9 insights. Insight 1 Insight 2 Insight 3 Insight 4 Insight 5 Insight 6 Insight 7 Insight 8

Tenuous links with Activity 3

Could be addressed in Activity 3

Must be addressed in Activity 3

Insight 9

8. Are any of these insights of relevance to all (cross-border) CURA-B partners? 9. If the answer is yes, which ones? 10. How would you propose to take your learnings from the workshop forward? What is your action plan?

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APPENDIX VI – VALUE ADDED INTERVIEWS ACTIVITY 3 – RI 6

October – December 2013 1. Added value of Cura B for SMEs • Describe how Cura B has helped SMES - In Region - Across the 2 seas region - What was the situation for SMEs before Cura B came along to help - What ideas has Cura B helped to formulate, inspire, draw out - What concrete advice has Cura B produced for SMEs - What are tangible results from Cura B - What are intangible results from Cura B - What will happen after Cura B - What evidence can we give for Cura B’s added value to SMEs - What key advice would you give to SMES trying to enter the care market 2. Added value of Cura B for the region • Describe how Cura B has helped the region - What was the situation before Cura B came along to help - What ideas has Cura B helped to formulate, inspire, draw out - What concrete advice/recommendations has Cura B produced for the region - What are tangible results from Cura B - What are intangible results from Cura B - What will happen after Cura B - What evidence can we give for Cura B’s added value to Zeeland 3. Cura B and the Triple Helix • Describe how Cura B has used the Triple Helix concept - In the region - Across the 2 Seas area - What was the situation for Zeeland before Cura B came along to help - What ideas has Cura B helped to formulate, inspire, draw out about Helix working especially in Zeeland - What concrete advice/recommendations has Cura B produced for Helix working - What are the keys to Helix working - What will happen after Cura B - What evidence can we give for Cura B’s contribution to Helix working Zeeland

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APPENDIX VII – PILOT 1 IMPULS - Santé Zeeland

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APPENDIX VIII – PILOT 2 IMPULS - Early Detection of Dementia in Homecare Situations

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APPENDIX VX – PILOT 3 Impulse: De Zeeuwse Huskamer

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APPENDIX X – PILOT 4 EURASANTE – Facilitating the Entrance Project

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APPENDIX XI – PILOT 5 POM – Non-medical Services and Adapting Light(ing)

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APPENDIX XII – PILOT 6 Suffolk County Council – “Dragon’s Den”

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APPENDIX XIII – PILOT 7 Health Enterprise East – Assistive Technology Network

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APPENDIX XIV – PILOT 8 West Suffolk Hospital – Paediatric and Adolescent Diabetes

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APPENDIX XV – VIVES (KHBO) ARTICLE 1 The Astute Use of Light for Residents with Dementia. Let there be light! In March 2013, at the West-Flemish retirement home (RH) Sint-Vincentius in Meulebeke, a pilot case study was started on bespoke lighting for people with dementia. This study was part of the general CURA B project: acCURAte Business in healthcare. This is a cross-border cooperation project between West-Flanders (BE), Zeeland (NL), Nord-Pas de Calais (FR) and Suffolk (UK) which is funded by the INTERREG IV A ‘2 Seas’ programme1’ and with financial support from the Provincial Government of West-Flanders. The aim of the CURA-B project is to stimulate the regional care economy. It looks at how the gap between care facilities, small and midsize companies (SMEs) and centres of knowledge from one and same region can be bridged. In this way, SMEs can develop and offer targeted services and/or products that are better tailored to the health needs of their users. Under the impetus of the Regional Socio-economic Consultative Committee for Mid West-Flanders (RESOC MWV) and the West-Flanders Development Agency (POM), three different parties were brought together to undertake a joint project. More specifically, a nursing home (Sint-Vincentius, Meulebeke), a WestFlemish lighting firm (Tronixx Belgium) and a centre of knowledge (VIVES, university college, department of healthcare, Bruges campus, the former KHBO) elaborated a lighting plan. This lighting plan is based on scientific knowledge and helps sustain the well-being of the residents, visitors and personnel. Greater need of light People with dementia have a greater need of light. Normal ageing of the eye causes deterioration of vision. That’s why old people need a three times higher lighting level to see properly (1). In addition to this, Alzheimer’s disease (the commonest form of dementia) impairs vision further (2). This is characterized by a drop in visual acuity, contrast sensitivity and colour- and depth perception (3). Light also has a role in regulating the biological rhythm (4, 5). A disturbance in this rhythm is regarded as a key aetiological factor for ‘sundowning’ (6). Sundowning indicates the occurrence of increased agitation, restlessness and mental confusion in people with dementia and this from the late afternoon onwards (7, 8, 6). To prevent this, optimization and/ 1

http://www.interreg4a-2mers.eu/nl

or normalization of the biological rhythm through contact with daylight is essential. Residents in a retirement home are considerably less exposed to daylight than elderly people living at home (9, 10). Furthermore, lighting levels in retirement homes are, quite frequently, not tailored to the needs of the residents (9, 11, 12). Too little light In May 2013, the light conditions at dwelling unit X in the Sint-Vincentius retirement home were critically evaluated. Measurement of illuminance levels, interviews taken of employees and visitors and the latest scientific insights showed that the lighting situation was insufficiently tailored to the needs of the residents, employees and visitors. Table 4 (p. 6) shows the illuminance (expressed in lux) measured in the various rooms. The moot points that emerged from interviewing staff and visitors are listed in table 1. Table 1: Results of the measurements beforehand and how the lighting situation is perceived among employees and visitors. • the possibility to alter the amount of artificial light in all areas; • the possibility to alter the amount of daylight in all areas; • the experience of insufficient natural light/ sunlight in the corridor; • the experience of blinding natural light/sunlight in the main living area; • the view outside from in the corridor. Bearing in mind the current layout of the built-up environment, the scope to heighten the perception of adequate natural light/sunlight and increasing the number of outside views is limited. Going by the perceptions of employees and visitors, this action point is probably worth including in the new (re) building plans.

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The analysis also revealed that a large proportion of staff experienced irritated or stinging eyes, headaches, the blues and/or unusual fatigue. The measurements beforehand, however, failed to prove causality between the lighting situation and these symptoms. Other factors, maybe, e.g. the physical home environment (the air humidity, temperature, acoustic comfort) and personal factors (e.g. the perceived workload) play a role in this. The luminous intensity in a human and/or work environment should be tailored to people’s needs. The fact that people with dementia need more light to perceive and observe their surroundings makes compliance with minimum levels of illuminance a must. These levels should be expressly tailored to the respective rooms and the daily activities that go on there. That way, the comfort of the residents is also ensured. Furthermore, higher illuminance levels lead to a reduction in the number of fall incidents and also facilitate the serving of meals so that the risk of malnutrition is mitigated (13, 14). Increasing the illuminance level also has an effect on the regulation of the biological rhythm. By providing high lux values (> 1000 lux) in places where the residents with dementia often are, the Management can help support and/or normalize this rhythm (15). The visual advantages of a higher illuminance level also support staff in the execution of their duties (16, 17). After all, too little light may lead them to make mistakes. This causal link has been established, for example, in the area of medication management (16, 18, 19). Likewise, a human and/or work environment in a retirement home should be uniformly illuminated. A big difference in one and the same room or between different rooms tries the employees’ eyes. In people with dementia, the capacity of the pupil to adjust itself to changes in light is greatly reduced, resulting in dazzling or temporary blindness (20). This reduces living comfort and increases the risk of falling (13). An uneven distribution of light across the room also creates shadows and darker areas. This may lead to distorted observations among the residents, not to mention illusions and deceptive impressions of reality (21). By way of illustration, fig. 1 (p.4) shows the lighting situation in the corridor before the intervention. An analysis leads to the conclusion that the lighting is inappropriate for people with dementia because of: a blinding light at the end of the corridor, a low light intensity, irregular distribution of the light along the corridor and reflection of light on the floor. The situation after the various modifications is shown in fig. 2 (p.4): by choosing a suitable ratio for the illuminance between the corridor and main living area, the glare has diminished. The corridor is brighter now and the distribution of the light down the corridor has become more uniform. The reflection on the floor, however, is still a problem.

Fig. 1: Lighting situation in the corridor before

Fig. 2: Lighting situation in the corridor after the intervention

New technology, new possibilities New lighting has been installed in the dwelling unit. Based on recommendations distilled from the available scientific research, the technical know-how of the lighting firm and feedback from the employees, several interventions were done between April and October. A dynamic lighting system was installed in the corridor, the main living area and the residents’ private rooms. With this system, the lighting can be regulated throughout the day. For example, a programmed lighting schedule ensures that, at any moment in the day, the light level in the corridor and rooms is tailored to the users’ needs. In addition, in the main living area, the system enables changes in the colour temperature.

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We did, admittedly, depart from an existing situation. This brought with it a few limitations. Due to the old, dilapidated ceiling in the main living area, it was, for example, not possible to install new lighting fixtures. So the new LED technology had to be fitted into the pre-existing power points of the light connections. In the residents’ private rooms we were not allowed

to use indirect light. NB: generating high light levels using indirect light works better to prevent a sudden glare of light on a bedridden resident. In the corridor, a very shiny floor caused the light to be reflected. Despite these limitations, there were enough technical alternatives to significantly improve the light conditions.

Table 3 (p.5) gives an overview of the interventions per room. Room

Interventions Introduction of a dynamic lighting system: Tunable White/PI-LED (full spectrum). With this technology, it is possible to:

Main living area

•

generate high lux values;

•

change the colour temperature (from 2700 to 6500 degrees Kelvin);

•

use a DALI protocol (so that a preset lighting schedule can be executed).

The residents spend most of the day in the main living area. So investments were made, in this room, to harness the full potential of the LED technology. Result: a custom programmed lighting schedule for the RH which simulates the natural progression of daylight. Modes of operation: a programmed lighting schedule; manual adjustment is possible via operating controls in the main living area. Fast and simple adjustment is not possible though. Introduction of a dynamic lighting system LED lighting (normal LED spectrum). With this technology, it is possible to:

Residents’ private rooms

•

generate high lux values;

•

use a DALI protocol (so that a preset lighting schedule can be executed).

The colour temperature is constant (3000 degrees Kelvin). In this care home block, they operate a ‘community group’. Consequently, the residents spend most of the day in the main living area. So to install a dearer lighting system in each private room is not cost-effective. The positive effects of a higher colour temperature take place, therefore, in the main living area. The lighting system provides an even distribution of light throughout the private room. Modes of operation: a programmed lighting schedule; manual adjustment is possible via operating controls in the infirmary. Fast and simple adjustment is not possible though. There is also a motion detector. This causes the light level to increase gradually so that the resident does not get a sudden scare. Introduction of LED lighting (normal LED spectrum). With this technology, it is possible to:

Corridor

•

generate high lux values;

•

use a DALI protocol (so that a preset lighting schedule can be executed).

The colour temperature is constant (3000 degrees Kelvin). The lighting system provides an even distribution of light along the corridor. Modes of operation: a programmed lighting schedule; manual adjustment is possible via operating controls in the infirmary. Fast and simple adjustment is not possible though. Boundary between the main living area/corridor

The ratio of light levels between the rooms is not greater than 1 to 3.

Introduction of LED lighting (normal LED spectrum). Infirmary

With this lighting system, it is possible to generate high lux values. Operation of the lights: automatic via a motion detector Introduction of LED lighting (normal LED spectrum).

Rinsing room

With this lighting system, it is possible to generate high lux values. Operation of the lights: automatic via a motion detector

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The right amount of light, in the right place Ideally, the activities in each room determine the light level. Also, considering the possibilities to make each room as dementia-friendly as possible deserves attention. The RH corridor, for example, is not viewed merely as a transfer zone. Indeed, the residents with dementia use the corridor as a space in which to move, explore and meet people. These residents need to feel safe and experience as few frustrations as possible due to their environment. There is more to a dementia-friendly environment than just providing adequate light. Installing points of reference, for example, helps. Resting places

entice people to rest up a while, because the trip is too long. Bespoke lighting is a facilitating factor in that respect. Indeed, people with dementia prefer well-lit places because it is easier for them to find their bearings there (22). A well-lit room (e.g. the corridor) becomes, therefore, an aesthetically and psychologically attractive place to be. Conversely, Management can leave certain rooms dark as a delimiting measure. Based on the available guidelines, specifically for old people with dementia (23,24), the illuminance level in the various rooms was adapted (see table 4).

Table 4: Lux values before and after implementation of the lighting plan - a lot of incident daylight at the moment the ‘measurement beforehand’ was taken.

Main living area: above the table

Inventory of the activities per room

Measurement beforehand

After the intervention

Reading, writing, fine craft activities… by the residents.

250 lux

1300 lux

Supervision of activities by staff (fun & games, supervision at mealtimes, reminiscence…). Taking their meals. Main living area: periphery

Areas in which to walk, move, explore…

80-250 lux

> 500 lux

The corridor

A space used as an area in which to walk, move and explore by the residents.

80 – 300 lux

1250 lux

Reading, writing, fine craft activities…

600 lux *

1000 lux

Where residents take their morning meal.

70 lux

1000 lux

A space where preparatory work is done by staff (medication management, inspecting files, collecting materials…). A space for contacting residents and for mobilization. Bedroom: above the table Bedroom: above the bed Execution of job-specific actions of staff (hygiene care, nursing actions, mobilization and ADL training). Contacting residents.

The right amount of light at the right time A dynamic lighting system was installed in the rooms (refer also to table 3—intervention in the resident’s private room). The lighting plan was tailored to the resident’s pace of life. Waking up occurs under the influence of a relaxing light which builds up gradually in intensity. So the scare of a sudden shaft of incident light is avoided. That way, the resident gets more time to awaken peacefully. The set-up ensures that staff have enough light, on time, at their disposal, to perform their care tasks in the residents’ private rooms. The luminous intensity is programmed at 20% capacity between 14.00 and 17.00 h. A choice motivated by the fact that the residents are usually in the main living area during those hours. Fig. 3 shows the dynamic lighting system in the residents’ private rooms.

By day, the residents reside chiefly in the main living area. So investments were made, in this room, to harness the full potential of the LED technology. The lighting system makes it possible to simulate the progression of natural daylight. This underpins the residents’ biological rhythm. Fig. 1 outlines the progression of the light intensity in the main living areas.

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Fig. 3: The dynamic lighting system in the residentâ&#x20AC;&#x2122;s private room

Fig. 1: The progression of the light intensity in the main living area.

It concerns a custom programmed lighting schedule for the RH that simulates the natural progression of daylight. The light level is maximal at mealtimes and during other activities. The light level decreases between afternoon and evening in preparation for the rest period. Fig. 2 shows the progression of the colour temperature in the main living area. The colour temperature of the light rises from a reddish-orange (warm and relaxing) to a blue (cold, activating) hue. The activation hereof supports the residents in the performance of their activities. This is because shortwave light (at a high

colour temperature, like when being exposed to daylight) suppresses sleepiness (30). Due to the ageing process, a clouding of the (eye) lens may occur. So, in old people anyhow, shortwave light will find it harder to reach the retina (25,26). The colour temperature diminishes between afternoon and evening in preparation for the rest period. At mealtimes we opted for lighting with a nice, warm glow in order to create a warmer and more congenial atmosphere. This conduces to a good meal experience with a favourable effect on the eating habits of residents with dementia (27).

Fig. 2: The progression of the colour temperature in the main living area

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The lighting schedule in the corridor ensures high light levels during periods (or moments) of active use. Outside these periods, the light intensity diminishes in order to save on energy bills. The light has a warm colour temperature all the time. This choice is due to the existing architecture in the RH. Making this narrow corridor feel ‘cool’ would not, you see, conduce to its attractiveness as a place in which to live and work. What about the staff: is it a matter of one size fits all? The question arises whether the higher light levels for the residents also redound to the well-being of the staff. Based on interviews both before and after the intervention, their levels of satisfaction were recorded, for future reference. The results of the pilot case study are promising. These indicate that the lighting redounds to sensory comfort. Staff are, for example, happier now about the available light when doing fine crafts and during activities that require deep concentration. The employees do not regard high light levels as too bright or glaring. They did, however, need time to let their eyes adapt to the new situation. By optimizing the light conditions, the experience of irritated eyes, headache and/or a feeling of the blues did decrease. However, the multicausality of these phenomena precludes firm conclusions on this. Being able to control the level of artificial light, particularly in the residents’ private rooms, is a wish that was clearly expressed. Residents and visitors could benefit from this too. For instance, the light level could be better attuned to the activities and/ or a person’s spirits or mood at a specific moment.

The visitors’ perception of the lighting situation in the rooms has improved favourably, to some extent. It can be deduced, from the programmed lighting schedule in the residents’ private rooms that the light intensity falls to 20% between 14.00 and 17.00 h. A choice motivated by the fact that the resident, during that period, is usually in the main living area. Visitors express the wish to control the level of artificial light so that the light intensity can match the needs of the moment.

Conclusion This pilot case study proves that the cooperation between a lighting firm, a RH and a knowledge centre conduces to the provision of personalized healthcare. The new lighting plan was based on recommendations mined from the available scientific research, the technical expertise of the lighting firm and feedback from staff during the implementation period (AprilOctober 2013). The lighting plan was also shaped by the existing architectural possibilities and constraints and by the project budget. The pilot case study also shows that the living environment of RH-residents can be successfully adapted, without having to wait for an entirely new structure. The astute use of light constitutes one element in creating a dementia-friendly environment. Further interventions can be implemented, step for step. Think big, start small… Finally, this pilot project shows that technology and human care can go hand in hand. Investing in healthcare technology also means, therefore, investing in the well-being of its users.

Relevant literature • van Hoof, J., Kort,H., Duijnstee, M., Schoutens, A., Hensen, J. (2010a). Binnenmilieu en installaties in het verpleeghuis. TVVL Magazine, 24-27 • Torrington, JM., Tregenza, PR. (2007). Lighting for people with dementia. Lighting Res. Technol.,39,1, pp 81-97 • Jones & Van der Eerden, 2008; Boyce (2003), Cronin-Colomb & Gilmore (2003), Rizzo et al (2000), van Rhijn et al (2004), Mendez et al (1996), Cernin et al (2003), in Torrington, JM., Tregenza, PR. (2007). Lighting for people with dementia. Lighting Res.Technol.,39,1, pp 81-97 • Stuart, N. & Rusell, G. (2010). The circadian clock, Springer Science, pp. 105-114. • Hanford, N. & Figueiro, M. (2013). Light therapy and Alzheimer’s disease and related dementia: past, present and future. Journal of Alzheimer’s disease, 33, pp.913-922 • Khachiyants, N. Trinkle, D., Joon Son, S., Kim, K., (2011). Sundown Syndrome in

•

• •

•

Persons with Dementia: An Update. Psychiatry Investig, 8 , pp.275-287 Dewing, J. (2003). Sundowning in older people with dementia: evidence base, nursing assessment and interventions. Nursing older people, 15, pp.24-31 Sparks, M., Fellow, N. (2011). Preventing and managing sundowning. LTL Magazine, pp. 58-61 Noell-Waggoner, E. (2006) Lighting in Nursing Homes – The unmet need. (Proceedings of the 2nd CIE Expert Symposium on Lighting and Health, Ottawa, Ontario, Canada). Geconsulteerd op http://www.centerofdesign.org Mandemaker, T. (2007). Licht voor ouderen en mensen met dementie, Factsheet Zorg & Technologie voor bestuurders en managers in de zorg, Vilans

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• De Lepeleire, J., Bouwen, A., De Coninck, L., Buntinck, F.(2007). Insufficient lighting in nursing homes. Journal of the American Medical Directors Association, 8(5), pp .314-317 • Sinno, M. van Hoof, J., Kort. S.M. (2011). Lighting conditions for older adults, a description of light assessment in nursing homes. (Symposium proceedings Light and Care, 2010, Eindhoven). Geconsulteerd op: www.solg.nl. • Sturnieks, D.L., George, R. St Lord, S.R.(2008). Balance disorders in the elderly. Clinical Neurophysiology,38, pp. 467-478 • Brush, 2002 in van Hoof, J., Kort, H.S.M., Duijnstee, M.S.H, Rutten, P.G.S, Hensen, J.H.M. (2010b). The indoor environment and the integrated design of homes for older people with dementia. Building and Environment, 45(5), pp. 1244-1261 • Riemersma-van der Lek, R.F., Swaab, D.F.,Twisk, J.; et al., (2008). Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: A randomized controlled trial. The Journal of the American Medical Association, 299(22), pp. 2642-2655 • Bouwcollege (2008). Kwaliteit van de fysieke zorgomgeving. Culembor: Twin Media bv. • Huisman, E.R.C.M, Morales, E., van Hoof, J., Kort, H.S.M. (2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58, pp.70-80 • Mahmood, A. Chaudhury H. Gaumont A.(2009). Environmental issues related to medication errors in long-term care: lessons from the literature. Herd, 2(2), pp. 42-59 • Booker & Roseman (1995); Buchanan et al

•

• •

(1991), in Huisman, E.R.C.M, Morales, E., van Hoof, J., Kort, H.S.M. (2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58, pp.70-80 Torrington, JM., Tregenza, PR. (2007). Lighting for people with dementia.Lighting Res. Technol,39,1, pp 81-97 Hadjuk, 2004 in Sharer, J. (2008). Tackling Sundowning in a patient with Alzheimer’s disease. Medsurg Nursing, 17, pp. 27-29 Stroobants, E. & Verhaest, P. (2012). Architectonica. Een thuis voor mensen met dementie. Berchem: EOP vzw Evans, 2000 in De Lepeleire, J., Bouwen, A., De Coninck, L., Buntinck, F. (2007). Insufficient lighting in nursing homes. Journal of the American Medical Directors Association, 8(5), pp .314-317 van Hoof, J., Kort, H.S.M., Duijnstee, M.S.H, Rutten, P.G.S, Hensen, J.H.M. (2010b). The indoor environment and the integrated design of homes for older people with dementia. Building and Environment, 45(5), pp. 1244-1261 van Hoof, J. Schoutens, A.M.C., Aarts, M.P.J. (2009). High colour temperature lighting for institutionalized older people with dementia. Building and Environment, 44, pp.1959-1969 Visser, R.(2009). Verlichting in de zorg. TVLL magazine, 2. pp. 18-21 van Staveren, W. & de Groot, C. (2007). Aandacht voor de ambiance van maaltijden in verpleeghuizen een medische noodzaak?! Tijdschrift voor gerontologie en geriatrie, 38, 2, pp.54-56.

Authors: Dries Grymonpré (Catholic College of Higher Education VIVES, Healthcare Department, Bruges campus) Michèle Inghelbrecht (Catholic College of Higher Education VIVES, Healthcare Department, Bruges campus) Leslie Vincke (Catholic College of Higher Education VIVES, Healthcare Department, Bruges campus)

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APPENDIX XVI – VIVES (KHBO) ARTICLE 2 The Astute use of Light for Residents with Dementia: Throwing some Light on Lighting Standards. In March-April 2013, at the West-Flemish retirement home (RH) Sint-Vincentius in Meulebeke, a pilot case study was started on bespoke lighting for people with dementia. This study was part of the general CURA B project: acCURAte Business in healthcare. This is a cross-border cooperation project between West-Flanders (BE), Zeeland (NL), Nord-Pas de Calais (FR) and Suffolk (UK) which is funded by the INTERREG IV A ‘2 Seas’ programme2’ and with financial support from the Provincial Government of West-Flanders. The aim of the CURA-B project is to stimulate the regional care economy. It looks at how the gap between care facilities, small and midsize companies (SMEs) and centres of knowledge from one and same region can be bridged. In this way, SMEs can develop and offer targeted services and/or products that are better tailored to the health needs of their users. Under the impetus of the Regional Socio-economic Consultative Committee for Mid West-Flanders (RESOC MWV) and the West-Flanders Development Agency (POM), three different parties were brought together to undertake a joint project. More specifically, a nursing home (SintVincentius, Meulebeke), a West-Flemish lighting firm (Tronixx Belgium) and a centre of knowledge (VIVES, university college, department of healthcare, Bruges campus, the former KHBO) elaborated a lighting plan. This lighting plan is based on scientific knowledge and helps sustain the well-being of the residents, visitors and personnel. The number of old peole in Belgium is on the rise. The oldest group in particular, the over-80s, will increase substantially in the years to come. Because the population is getting ever older, the number of people with dementia will rise sharply in the future. In the group of the over-85s, more than one in three suffers from dementia. In view of demographic developments, the number of people with dementia will have risen by almost a third by 2020 (1). Despite the fact that old people prefer home care to a residential facility, the number of ‘collectively residing over-85s’ is expected to double due to the rise in the eldest category of old people (2, 1). The resident population in RHs will be increasingly composed of extremely frail old people, a large proportion of whom 2 http://www.interreg4a-2mers.eu/nl

will be suffering from dementia. (Re-) building work to cater for those with dementia is essential (3). RH managers are trying, more and more, to sustain the well-being of residents with dementia from the perspective of the physical environment. The latter encompasses every aspect of architecture, design and sensory stimuli (4). We can truly speak of a ‘healing environment’ if that environment redounds to the physical, mental and social well-being of the users. These users are the residents and visitors, but also the people who work in the building (5). The creation of a ‘healing environment’ results from several interventions. For example, a dementiafriendly interior provides an instantly recognizable, homely environment, whereby a meaningful interpretation is assigned to the respective rooms (6). Furthermore, the architecture, interior design and layout support the specific needs for safety, privacy and orientation among the residents with dementia. Finally, there are interventions that focus on the astute use of smell, sound, air-conditioning and light (5). So light is but one aspect that can conduce to a ‘healing environment’. Well-considered choices about the use of light sustain the well-being of the residents with dementia, the personnel and the visitors. Greater need of light among people with dementia. People with dementia have a greater need of light. The normal ageing of the eye causes visual impairment. That is why old people need up to three times more lighting to see things clearly (7). In addition to this, Alzheimer’s disease (the commonest form of dementia) impairs vision further (8). This is characterized by a drop in visual acuity, contrast sensitivity and colour- and depth perception (9). Light also has a role in regulating the circadian rhythm (10, 11). The process of dementia can disturb this sleep-wake rhythm and thus affect a person’s cognition, good spirits, sleeping pattern and behaviour (12,13). Providing daylight has a positive effect on the regulation of the biological rhythm (14). In people with dementia, this results in a more regular day/night rhythm and an improvement in mood and behaviour (12). The accreditation standards for retirement homes elucidated. An old people’s home is governed by federal and Flemish legislation. The current standard for accreditation as a RH and/or as a residential and nursing home for the elderly contains, among other things, provisions related to indoor lighting (table 1).

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Table 1: Architectural standards and conditions for the infrastructure in relation to the lighting. • In all rooms, the heating, ventilation and lighting should be adapted to match the intended use of the room (15). • The rooms that are accessible to the residents should be continuously lit in such a way that the comfort of the residents is assured (16). • At night, the rooms and the corridors should be lit in such a way that residents can move about safely (16). • Every room should have adequate artificial lighting that the resident can operate from their bed and which is tailored to the local conditions (16). • The resident should be able to operate a light from their bed (17). Heed minimum levels of illuminance in the daytime

These standards focus on bespoke lighting in the different rooms in order to ensure the comfort and safety of the residents. Admittedly, what’s lacking are practical, verifiable guidelines that monitor the quality of the light on offer. The benchmark is defined with empty phrases like ‘adequate’, ‘bespoke, ‘safe’ and ‘comfort guaranteed’. So care facilities that want to pursue this further have no idea of what this exactly entails. This begs the question to what extent the facilities succeed in providing ‘adequate and bespoke’ lighting for their users. In 2007, the light intensity was inventoried in eight Flemish RHs. This intensity was compared against a theoretically derived standard on the need for light among old people, specifically adapted to the activities that occur in each room in use. The light intensity was usually inadequate, apparently, to meet the visual needs of old people (18). Suggestions for bespoke lighting. Scientific knowledge about the use of lighting by the elderly is one of the main pillars in the rollout of a dementia-friendly home environment. Based on current scientific opinion, practical, verifiable recommendations can be framed. In the following paragraphs, some suggestions are given for a better yardstick to interpret the standard correctly.

The finding that people with dementia need more light to properly see their environment means that the minimum levels for light intensity (expressed in lux) must be observed. These levels should be tailored to the different rooms and the daily activities that take place there. That way, the comfort of the residents is assured as well. In addition, a higher illuminance level (viz. a brighter room) leads to a drop in the number of falls. It also facilitates the serving of meals so that the risk of malnutrition is mitigated (19,20). The visual advantages of a higher illuminance level also support staff in the execution of their duties (21,22). Increasing the illuminance level also has an effect on the regulation of the biological rhythm. By providing high lux values (> 1000 lux) in places where the residents with dementia often are, the Management can help support and/or normalize this rhythm (12). A new guideline for lux values in a RH has been drawn up (18) based on the European standard for indoor workplace lighting. It took account of the greater need for light when people grow old (23). As discussed earlier, the process of dementia may impair vision further. This implies an even greater need for light, resulting in a revised guideline for lux values (24). Table 2 shows the recommended illuminance levels in the various rooms.

Table 2: Guidelines for illuminance levels Room

European standard

Guideline for old people (18)

Guideline for old people with dementia (24)

Entrance hall

200 lux

310 lux

Reading and sitting area

500 lux

775 lux

1000-2500 lux

Corridor

200 lux

310 lux

100-300 lux

Bathroom and toilets for the residents

200 lux

310 lux

>200 lux

Dining-room, cafeteria

200 lux

310 lux

500-1000 lux

Stairs, lift

150 lux

232.5 lux

>200 lux

Resident’s private room (general)

100 lux

155 lux

100-300 lux

Resident’s private room (lighting above the table and chair)

500 lux

775 lux

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Heed minimum levels of illuminance levels at night Night-time lighting in the room ensures that residents can reach the toilet safely. In addition, this lighting has a fear-reducing effect on people with dementia (24, 25). A light intensity of 50 lux suffices (24). Residents with dementia who tend to go astray can also use the corridor safely at night. Installing points of reference helps. Visually attractive resting places entice people to rest up a while, because the trip is too long. Bespoke lighting is a facilitating factor in that respect and improves night-time safety. A light intensity of 77.5 lux suffices (18). Provide a switch to manually adjust the light intensity A switch (or other device) to manually adjust the light intensity is advisable. In this way, the light can be tailored to the type of activity (e.g. active versus quiet activities in the resident’s private room or in the main living area) and to the specific needs of the resident and visitor). The employee also benefits from a switch to adjust the light intensity. For every (care) activity, the employee can therefore preset the desired brightness. Avoid big differences in illuminance levels across the room and between adjoining rooms The adaptability of the pupil from light to dark (and from dark to light) decreases due to ageing (8). The reduced adaptive capacity may mean that the old person, at a boundary from a light to a dark space and vice-versa, is blinded for a minute or longer (18). Consequently, big differences in illuminance levels across the room, but also between different adjoining rooms are best avoided. Experts recommend a ratio of light levels which is not greater than 1 to 3 (26). Act preventively to stop agitation, caused by harsh light/lighting. Minimizing the potentially agitating effect of light on people with dementia undoubtedly conduces to less animosity. Malfunctioning lighting can, for example, make someone with dementia very agitated (27). In addition, impaired vision may lead to distorted observations. The lighting should be designed to minimize harsh shadowing. Shadows, you see, can evoke illusions and deceptive impressions of reality, making people anxious (28). Also, avoid using, wherever possible, the kind of lighting that turns on and off automatically, so as not to scare the resident (29). Make astute use of colour temperature Besides light intensity, colour temperature plays a part in regulating the biological rhythm. Shortwave light (at a high colour temperature, like when

being exposed to daylight) suppresses sleepiness (30). A high colour temperature can also be induced artificially so that residents are exposed to it for longer. Due to the ageing process, a clouding of the (eye) lens may occur. So, in old people anyhow, shortwave light will find it harder to reach the retina (30, 31). Over the last ten years, several research reports and reviews have been published on the relationship between the intensity and colour temperature of light (32). The main focus of this research is to establish the ideal ratio between the two in order to optimally sustain the biological rhythm. A high light intensity and colour temperature increases, it seems, the efficacy of light therapy (30). More research is needed, however, to give greater transparency. Use daylight to the full Residents in a RH are materially less exposed to daylight than elderly people living at home (33, 34). So optimizing the incident daylight deserves attention. For example, seats are, wherever possible, placed near to windows. In addition, an easy-toaccess, dementia-friendly garden encourages people with dementia (and their visitors) to go outside. Identify the care needs of people with dementia Due to the process of dementia, a resident with dementia will no longer be able to operate the light on their own or to ask a member of staff to do this. It is then up to the healthcare professionals to estimate how much light the person with dementia needs and to adjust the light level accordingly. The use of dynamic lighting, based on the ‘dawn-dusk’ principle, can help in that respect. This is the (automatic) gradual increase/decrease in light intensity and/or light-colour, tailored to the individual living- and sleeping habits of a person (35,36).

Conclusion Improving the light conditions for RH-residents is an essential part of dementia-friendly (re-)building. The advent of new LED technology affords RH-managers the opportunity to install efficient, top-quality lighting tailored to the needs of residents with dementia, the visitors and staff of a residential care facility. Customizing the lighting plan, whereby the light meets the needs of all users, ensures that the support function of light finds its full expression. The standards for lighting in RHs are currently written in vague terms and are of limited scope. So putting this clearly—in the form of supplements to the current standards—would appear to be a priority. Granted, the astute use of light is but one aspect

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when creating a ‘healing environment’. Retirement homes, themselves, can explore how they can astutely redesign the RH-environment so that it conduces to the residents’ well-being. For the moment, the principles of a ‘healing environment’ have not fully permeated into the legislation (state subsidies and new standards). But this does not mean that RHs should wait around for this. Efforts on this score can be part of the quality policy of every centre.

Furthermore, the creation of a high-quality living experience goes hand in hand with the provision of top-quality care. Without an appropriate approach to people with dementia, a first-class home environment will not produce the desired results. On the other hand, a good home environment can help the healthcare provider due to the effect of that environment on the residents’ behaviour.

Relevant literature • Kabinet van Vlaams minister van Welzijn, Volksgezondheid en Gezin , Jo Vandeurzen (2010). Naar een dementievriendelijke Vlaanderen: dementieplan Vlaanderen. Geconsulteerd op 06/11/13 op http://www.zorg-en-gezondheid. be/uploadedFiles/NLsite_v2/Nieuws/2011/ Dementieplan%20Vlaanderen%202010-2014%20 (PDF).pdf • Vanden Boer & Vanderleyden, 2004; Van Meerbeeck, 2003 in Van Audenhove, C. , Spruytte, N. , Detroyer, E., De Coster, I., Declercq, A., Ylieff, M., Squelard, G., Misotten, P. (2009). De zorg voor personen met dementie: perspectieven en uitdagingen. Brussel: Koning Bouwdewijnstichting. • Van Audenhove, C. , Spruytte, N. , Detroyer, E., De Coster, I., Declercq, A., Ylieff, M., Squelard, G., Misotten, P. (2009). De zorg voor personen met dementie: perspectieven en uitdagingen. Brussel: Koning Bouwdewijnstichting. • Grand, J.H., Caspar, S. & MacDonald, S.W. (2011). Clinical features and multidisciplinary approaches to dementia care. Journal of Multidisciplinary Healthcare, pp. 125-147 • Kenniscentrum Wonen-Zorg. (sd). Healing Environment. Geconsulteerd op 23/10/2012 op http://www.kcwz.nl/dossiers/healing_environment • Stroobants, E. & Verhaest, P. (2012). Architectonica. Een thuis voor mensen met dementie. Berchem: EOP vzw. • van Hoof, J., Kort,H., Duijnstee, M., Schoutens, A., Hensen, J. (2010a). Binnenmilieu en installaties in het verpleeghuis. TVVL Magazine, 24-27 • Torrington, JM., Tregenza, PR. (2007). Lighting for people with dementia. Lighting Res. Technol.,39,1, pp 81-97. • Jones & Van der Eerden, 2008; Boyce (2003), Cronin-Colomb & Gilmore (2003), Rizzo et al (2000), van Rhijn et al (2004), Mendez et al (1996), Cernin et al (2003), in Torrington, JM., Tregenza, PR. (2007). Lighting for people with dementia. Lighting Res.Technol.,39,1, pp 81-97 • Stuart, N. & Rusell, G. (2010). The circadian clock. Springer Science, pp. 105-114

• Hanford, N. & Figueiro, M. (2013). Light therapy and Alzheimer’s disease and related dementia: past, present and future. Journal of Alzheimer’s disease, 33, pp.913-922 • Riemersma-van der Lek, R.F., Swaab, D.F.,Twisk, J.; et al., (2008). Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: A randomized controlled trial. The Journal of the American Medical Association, 299(22), pp. 2642-2655 • Khachiyants,N. Trinkle, D., Joon Son, S., Kim, K., (2011). Sundowning Syndrome in Persons with Dementia: An Update. Psychiatry Investig, 8, pp. 275-287 • Shirani, A., St.louis, E. (2009). Illuminating rationale and uses for light therapy. Journal of clinical sleep medicine. 5(2), pp. 155-163. • Besluit van de Vlaamse Regering van 24 juli 2009 betreffende de programmatie, de erkenningsvoorwaarden en de subsidieregeling voor woonzorgvoorzieningen en verenigingen van gebruikers en mantelzorgers. Bijlage XII artikel 45, 6°. Geconsulteerd op 06/11/13 op http://www.juriwel.be • Het koninklijk besluit van 21 september 2004 houdende de vaststelling van de normen voor de bijzondere erkenning als rust- en verzorgingstehuis, als centrum voor dagverzorging of als centrum voor niet-aangeboren hersenletsels, gewijzigd bij de koninklijke besluiten van 4 juni 2008 en 7 juni 2009. Art. N1 Bijlage 1. Rust- en Verzorgingstehuizen. B1. Architectonische normen – l). Geconsulteerd op 06/11/2013 op http://www.ejustice.just.fgov.be • Besluit van de Vlaamse Regering van 24 juli 2009 betreffende de programmatie, de erkenningsvoorwaarden en de subsidieregeling voor woonzorgvoorzieningen en verenigingen van gebruikers en mantelzorgers. Bijlage XII artikel 45, 13°. Geconsulteerd op 06/11/13 op http://www.juriwel.be • De Lepeleire, J., Bouwen, A., De Coninck, L., Buntinck, F. (2007). Insufficient lighting in nursing homes. Journal of the American Medical Directors Association, 8(5), pp .314-317

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• Sturnieks, D.L., George, R. St Lord, S.R.(2008). Balance disorders in the elderly. Clinical Neurophysiology,38, pp. 467-478 • Brush, 2002 in van Hoof, J., Kort, H.S.M., Duijnstee, M.S.H, Rutten, P.G.S, Hensen, J.H.M. (2010b). The indoor environment and the integrated design of homes for older people with dementia. Building and Environment, 45(5), pp. 1244-1261 • Bouwcollege (2008). Kwaliteit van de fysieke zorgomgeving. Culembor: Twin Media bv. • Huisman, E.R.C.M, Morales, E., van Hoof, J., Kort, H.S.M. (2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58, pp.70-80 • Evans, 2000 in De Lepeleire, J., Bouwen, A., De Coninck, L., Buntinck, F. (2007). Insufficient lighting in nursing homes. Journal of the American Medical Directors Association, 8(5), pp .314-317 • van Hoof, J., Kort, H.S.M., Duijnstee, M.S.H, Rutten, P.G.S, Hensen, J.H.M. (2010b). The indoor environment and the integrated design of homes for older people with dementia. Building and Environment, 45(5), pp. 1244-1261 • Morley, J.E. (2013) Behavioral management in the person with dementia. The Journal of Nutrition, Health & Aging, 17 , 1, pp.35-38 • Aarts, M., Chraibi, S., Tenner, A.(2011). Lighting design for institutionalized people with dementia symptoms. Proceedings of the light & care symposium, 10 november 2010, Eindhoven, The Netherlands, pp. 20-24 • Brawley, 2006 in van Hoof, J., Kort, H.S.M., Duijnstee, M.S.H, Rutten, P.G.S, Hensen, J.H.M. (2010b). The indoor environment and the integrated design of homes for older people

•

• •

•

with dementia. Building and Environment, 45(5), pp. 1244-1261. Hadjuk, 2004 in Sharer, J. (2008). Tackling Sundowning in a patient with Alzheimer’s disease. Medsurg Nursing, 17, pp. 27-29 van Hoof, J., Kort,H., Duijnstee, M., Schoutens, A., Hensen, J. (2010a). Binnenmilieu en installaties in het verpleeghuis. TVVL Magazine, 24-27 van Hoof, J. Schoutens, A.M.C., Aarts, M.P.J. (2009). High colour temperature lighting for institutionalised older people with dementia. Building and Environment, 44, pp.1959-1969 Visser, R.(2009). Verlichting in de zorg. TVLL magazine, 2. pp. 18-21 Aarts, M., Aries, M., van Hoof, J.(2013). Dynamische verlichting in de zorg: de feiten. TVVL Magazine,1, pp.22-25. Noell-Waggoner, E. (2006). Lighting in Nursing Homes – The unmet need. (proceedings of the 2nd CIE Expert Symposium on Lighting an Health, Ottawa, Ontario, Canada). Geconsulteerd op http://www.centerofdesign.org. Mandemaker, T. (2007). Licht voor ouderen en mensen met dementie, Factsheet Zorg & Technologie voor bestuurders en managers in de zorg. Vilans Gasio, P., Kräuchi, K, Cajochen, C., van Someren, E., Alrhein, I., Pache, M., Savaskan, E., WirzJustice, A., (2003). Dawn-dusk simulation light therapy of disturbed cirdadian rest – activity cycles in demented elderly. Experimental Gerontology, 38, pp. 207-2016 Skjerve, A., Bjorvatn, B., Holsten, F. (2004). Light therapy for behavioral and psychological symptoms of dementia. International Journal of Geriatric Psychiatry, 19, pp. 516-522

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GLOSSARY Activity 1,2,3

Activity phases in CURA-B roughly corresponding to year 1,2,3

ARU

Anglia Ruskin University

Assistive Technology

BMC

Business Model Canvas

Commissioners

Commissioners of health services

CURA- B

acCURAte Business

Eurasante

Regional Development Agency centred on healthcare in Lille Partner Organisation

General Practitioner

HEE

Health Enterprise East- Partner organisation

Impuls

Economische Impuls Zeeland – Regional Development Agency for Zeeland and lead partner in CURA-B

INTERREG IVA 2 Seas programme

Promotes crossborder cooperation between the coastal regions of 4 Member States: France (Nord-Pas de Calais), England (SW, SE, E), Belgium (Flanders) and The Netherlands (South coastal area).

Knowledge Centres

Research Centres, Universities

Living Lab

Concept home/room in Zeeland

NHS

National Health Service

Open Innovation

POM

Provinciale Ontwikkelingsmaatschappij West-Vlaanderen Partner Organisation

Research Instrument

Resoc Brugge

Resoc (Regionaal Sociaal-Economisch Overlegcomité) Brugge – Partner Organisation

Resoc MWV

Resoc (Regionaal Sociaal-Economisch Overlegcomité) Midden West Vlaanderen - Partner Organisation

SCC

Suffolk County Council- Partner Organisation

SLC

Social Lean Canvas

SMEs

Small, Medium Enterprise

Triple Helix

Collaboration of private sector, public sector and knowledge centres Knowledge Centres (Research Centres, Universities)

VIVES

VIVES ( formerly KATHO – Katholieke Hogeschool Zuid- West Vlaanderen and KHBO – Katholieke Hogeschool Brugge-Ostend) Partner Organisation

WSH

West Suffolk Hospital – Partner Organisation

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APPENDICES

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