HBS Management Challenge - Telemedicine for Prisons Final

Henley
Business
School
University
of
Reading
An
investigation
into
the
provision
of
primary
healthcare
services
to
HM
Prisons
using
Cisco
HealthPresence™
for
telemedicine
applications.
Situl
Shah
Management
Challenge
Report
submitted
in
partial
fulfilment
of
the
requirements
for
the
degree
of
Master
of
Business
Administration
2010
Henley
Business
School
MBA
Programme
at
the
University
of
Reading.
Disclaimer:
(This
report
is
not
intended
to
be
overly
critical
of
national
Government
policy
on
provision
of
healthcare
for
UK
citizens
and
residents,
as
this
is
outside
the
scope
of
this
study.)

Acknowledgements
I would like to thank all staff of the UK Public Sector Healthcare and Justice
Organisations who participated in the interviews, and various teams from
Cisco, who has provided support and encouragement.
I would also like to thank my fellow Henley MBA programme members,
faculty staff and programme leader, Alison Llewellyn for providing the
support and motivation during the various challenges of the course.
Very special thanks go to my project supervisor, Dr David Paskins for this
guidance and support throughout this detailed study.
However, my greatest thanks go to my loving wife, Bina for all her ongoing
support, dedication, guidance and generosity throughout this journey.
Without this, the study could not be completed.
Situl Shah

Purpose:
This report outlines a strategic ‘business case’ for an important Central
Government Department, the Ministry of Justice and its executive agencies,
the National Offender Management Service, NOMS, and HM Prisons
Service, HMPS.
The intention is to assist deployment of collaboration solutions including tools
to drive operational efficiencies and provide quality primary health treatment
to the Prison population.
Terms
of
Reference
The issue of public sector budgets and finances has been widely reported in
general media over the past few months, especially since the recent bailout
of the Banking Industry last October 2008 resulting in the need for UK and
other major Western Governments to rebalance their National Finances over
the next 5 years.
The
Author:
Situl Shah is a strategic marketing professional from the technology &
communications industries for over 17 years holding a variety of Global roles
across Enterprise, Commercial & Government sectors.
The
Client:
Cisco Systems is the world leader of internet networking solutions. The
company is currently investigating key activities into the Public sector across
the European Union to address the needs of Governments in helping reduce
their national financial deficits through the use of technology solutions to
improve access to health care.

Table
of
Contents
Acknowledgements
.................................................................................................................
2
Executive
Summary:
................................................................................................................
8
1.0
Introduction
....................................................................................................................
10
1.1
Background
.................................................................................................................
10
1.1.1
Prison
Population
Growth.
-‐
Why
the
increase?
.....................................................
13
1.2
Operational
Effectiveness
...........................................................................................
14
1.2.1
Strategy:
...............................................................................................................
14
1.2.2
Structure
..............................................................................................................
15
1.2.3
Systems
................................................................................................................
15
1.2.4
Style
......................................................................................................................
15
1.3
Key
challenges:
............................................................................................................
16
1.3.1-‐Managing
the
Increasing
prison
population:
.......................................................
16
1.3.2-‐
Improving
overall
efficiencies
and
effectiveness:
...............................................
16
1.3.3-‐
Other
challenges.
-‐
Improving
the
system:
.........................................................
16
1.4
IT
is
considered
a
low
priority
for
healthcare
providers.
............................................
17
1.5
Funding
restraints
.......................................................................................................
18
1.6
Achieving
cost
savings
through
Return
on
Investment
...............................................
18
1.7
The
general
marketplace
for
technology
in
prisons
....................................................
19
1.8
Summary
of
key
challenges
and
marketplace
for
technology
in
prisons.
...................
21
1.9
Key
technology
trends
for
Healthcare
in
Prisons
........................................................
22
1.9.1
Summary
of
key
trends.
...........................................................................................
25
2.0
Literature
Review
............................................................................................................
27
2.1
Overview
.....................................................................................................................
27
2.2
Introduction
................................................................................................................
27
2.3
Objectives
of
literature
review
....................................................................................
27

2.4
Concepts:
.....................................................................................................................
28
2.5
Basic
definitions
used
in
literature
review
..................................................................
30
2.6
Key
findings
from
the
literature
review
......................................................................
31
2.7
Organisational
culture
in
the
Public
Sector.
................................................................
32
2.8
Strategies
for
complex
public
sector
organisations.
...................................................
33
2.9
Strategies
for
implementing
technology
based
solutions
into
the
Public
sector
........
34
3.0
Strategic
Alliances
&
Partnerships
...............................................................................
35
3.1
International
perspectives:
.........................................................................................
37
3.2
Financial
implications
for
government.
.......................................................................
39
3.2
Using
video
conferencing
&
‘Presence’
technology
for
telemedicine.
........................
39
3.3
Relevance
of
current
thinking.
....................................................................................
43
3.4
Examples
of
current
thinking:
.....................................................................................
45
3.5
Summary
of
findings
from
the
literature
review.
........................................................
47
4.0
Research:
Gathering
Information,
interviews,
key
findings
&
analysis.
..........................
48
4.1
Overview
.....................................................................................................................
48
4.2
Key
research
objectives
for
this
management
challenge
include;
..............................
49
4.3
Methodology
...............................................................................................................
49
4.3.1
Reasons
for
this
approach
include;
..........................................................................
50
4.3.2
Sampling.
..................................................................................................................
51
4.3.3
Cross
Section
............................................................................................................
51
4.3.4
Surveys
.....................................................................................................................
52
4.3.5
Deductive
&
Inductive
processes
.............................................................................
52
4.3.6
Quality:
.....................................................................................................................
53
4.3.7
Reliability:
.................................................................................................................
53
4.3.8
Validity:
....................................................................................................................
53
4.3.9
Generalisability:
.......................................................................................................
53
4.4
Limitations
of
the
Research
Approach
........................................................................
54

4.4.1
Interview
Selection
Process
.....................................................................................
55
5.0
The
Research
Question:
..............................................................................................
56
5.1
Key
findings
from
primary
research
............................................................................
57
5.2
Varying
costs
of
healthcare
provision.
....................................................................
57
5.3
Using
technologies
for
Telemedicine
......................................................................
58
5.4
Cost
effectiveness
for
the
payer
for
primary
health
treatment.
.............................
60
5.4
Other
findings
..............................................................................................................
61
5.5
User
experiences
with
ICT
vendors
.........................................................................
61
5.6
Increasing
staff
productivity
....................................................................................
62
5.7
Increasing
accountability
and
transparency
for
Prison
operations,
e.g.
Prisoner
transfers
between
establishments
................................................................................
62
5.8
Prisoner
transportation
between
courts,
hospitals
&
other
facilities.
....................
63
5.9
Helping
achieve
specific
initiatives
for
Prisoner
Healthcare
management,
Education,
&
reduce
wastage
from
‘old’
working
practices.
.........................................
63
5.9.1
Summary
of
findings:
...............................................................................................
64
6.0
Conclusions
.................................................................................................................
66
6.1
Key
Recommendations
................................................................................................
67
7.0
Reflections
.......................................................................................................................
70
7.1
An
evaluation
of
my
findings
.......................................................................................
70
7.2
Experience
of
the
research
process
............................................................................
72
7.3
Personal
development
objectives
...............................................................................
75
8.0
References
.......................................................................................................................
76
Appendices
............................................................................................................................
82
Key
Definitions:
.................................................................................................................
82
Appendix
1-‐
Industry
Five
forces
.......................................................................................
84
Appendix
2
-‐
Market
Opportunities
..................................................................................
85
Appendix
3
-‐
Market
forecast
............................................................................................
86
Appendix
4
–
ICT
Spending
Overview:
..............................................................................
87

Appendix
5-‐
Return
on
Investment
...................................................................................
88
Appendix
6
-‐
Research
Questions
for
HM
Prisons
Service
Transcripts
of
interviews
with
Healthcare
managers
and
Governors
/
Deputy
Governors.
..............................................
89
Appendix
-‐7
Value
chain
for
NOMS
&
HM
Prison
Service.
................................................
94
Appendix
8-‐Prison
Population
...........................................................................................
95
Appendix
9
-‐
Healthcare
Escorts
&
Bedwatches
...............................................................
98
National
Tariff
2008-‐09
.....................................................................................................
98
Escort
Events
.................................................................................................................
98
Bedwatch
Events
...........................................................................................................
98
One-‐off
..............................................................................................................................
98
Hourly
Rate
...........................................................................................................................
98
One-‐off
..............................................................................................................................
98
Hourly
Rate
...........................................................................................................................
98
AREA
RATES
.......................................................................................................................
98
RATE
1
...............................................................................................................................
98
RATE
4
...............................................................................................................................
98
Aylesbury
...........................................................................................................................
98
Bullwood
Hall
................................................................................................................
98
Appendix
10
–
Financial
Accounts
...................................................................................
101
Appendix
11
–
Stakeholder
map
of
NHS
contacts
&
departments
for
Prisoner
Healthcare.
........................................................................................................................................
102

Executive
Summary:
Following several years of general increases in the prison population and
rising health care costs across major economies of the world, there is an
increased awareness of the need for a strategic approach to managing this
situation based on economics, rather than ideology alone.
The UK and other major countries in the developed economies have seen a
steady rise in the overall Prison population which had more than doubled
since 1993 to an imprisonment rate of 154 per 100,000 in England & Wales
and is now Western Europe’s biggest incarcerator. Further, between 1995
and 2009, the prison population in England & Wales grew by 32,500 or 66%,
despite an extra 20,000 prison places provided since 1997 an increase of
33%.
This is presents various challenges in the provision of key services to this
segment of the general population while managing risk and ensuring public
safety.
Transformative technology solutions including Cisco HealthPresence™ and
related collaboration tools such as Cisco WebEx™, & Unified Contact
Center™ offer an excellent alternative to the current status by enabling
operators to provide multiple services over a highly reliable network platform.
This ultimately reduces costs and drives efficiency savings throughout the
organisations and presents opportunities to government for new ways of
collaborating with the wider public and interested parties.
By combining medical devices with these collaboration tools, Cisco
HealthPresence™ offers exciting opportunities for healthcare provision
through enabling live and interactive face to face consultations across
geographical boundaries with medical experts.

Key benefits include:
• Expanding access to cost effective healthcare to the Prison population
• Optimising scarce resources and reducing travel costs for healthcare &
justice professionals
• Reducing risks to and from Prisoners and Offenders through the provision
of care in a secure custodial environment
• Increasing operational effectiveness through effective, team based
collaborations with related sectors. Health, Police, Probation, and
Rehabilitation services.
Users and operators benefit from faster responses to primary care issues
including mental health and basic medical procedures including dermatology
& cardiology with specialists who can be located around the world on a 24
hour, 7 day basis.
The impact of using such technologies in the application of Telemedicine can
also be served as a model for other countries internationally where budgets
for prisoner care from private and public sources are facing increased
pressure for greater efficiency.

1.0
Introduction
The original scope of this management challenge report was deemed far too
broad and with the agreement of the supervisor, was narrowed down to
focus on using Cisco HealthPresence™ as a key enabler for healthcare
provision. This is an adapted version of commercially proven Telepresence 1
systems to deliver primary healthcare using Telemedicine 2 to the prison
population and act as an enabler for improving operational efficiencies.
1.1
Background
Traditionally, the UK Government and related agencies such as the
Probation Service, Police Service and the Courts service operated in silos in
determining custodial sentencing and the provision of any rehabilitation
programmes required. This was considered by many experts as only partially
effective in reducing overall crime.
During 2005/6, a strategic review was conducted and from May 2007, the UK
Home Office was split in two which represented an important structural
change over the past few years in this sector. The former Department of
Constitutional Affairs, DCA, took responsibility for probation and the
prevention of reoffending and then renamed as the Ministry of Justice,
(MOJ), serving under the Lord Chancellor & Minister for Justice. Hence,
since 2007, the Ministry of Justice was created by an act of Parliament and
for the 1st time brought together overall responsibility for the Justice system,
1 Telepresence refers to a set of technologies which allow a person to feel as if they were present, to give the
appearance that they were present, or to have an effect, at a location other than their true location.
Telepresence videotelephony is a higher level of videoconferencing, deploying greater technical sophistication and
improved fidelity of both video and audio.
2 Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred
through the phone or the Internet and sometimes other networks for the purpose of consulting, and sometimes
remote medical procedures or examinations.

including HM Courts, Police, Prisons and Probation services to work in
partnership for greater public confidence and improved decision making.
From this strategic shift in Government policy, a new department, the
National Offender Management Service, (NOMS) was created in July 2008,
and now holds management responsibility for the overall Prisons Service in
the Public & Private Sectors.
This shift in moving responsibility for Prisons into the MOJ is in line with
recent trends in all 47 countries of the Council of Europe3, except Spain, and
is also the position in most of North & South America and some parts of
Africa & Asia. A notable exception is in the Middle East where the prisons
are managed by each respective Country’s Interior Ministry.
According to the International Centre for Prison Studies, January 2009, there
are currently 158 Prisons in the UK, of which 11 are currently managed by
private operators including Serco, G4S, & Kalyx. Since November 2009, a
new, category C prison, HMP Bure, in Norfolk opened resulting in a total of
140 Prisons in England & Wales. (This will be privately operated & managed
using a private finance initiative, PFI sourcing model). Source: NOMS
Five forces analysis summary
Variable factor Rating Reasons
Supplier power High
Significant penalties exist for NOMS to 'break out' of any existing
contracts.
Buyer power Medium MOJ – The main government agency that holds judicial responsibility to Parliament
Medium
NAO - National Audit Office – Independent body that monitors major government
spending
New entrants High
There is a growing threat from the private sector to the management of Prisons
operations
Substitutes Medium Using disruptive technologies such as Telepresence, VC & RFID electronic tagging.
Low Financial penalties to family & friends if a prisoner fails to comply with sentencing terms.
Summary table of key factors affecting HM Prisons - Adapted from M Porter
(1995)
3
The Council of Europe is one of the oldest international organisations towards European integration.
It has particular emphasis on legal standards, human rights & democratic development under the rule
of law & co-operation. It has 47 member states with some 800 million citizens.

To put this into context and appreciate some of the wider macro factors
affecting this public sector organisation, figure 1 illustrates the total UK Public
sector borrowing as a % of gross domestic product (GDP) which is currently
at an all time high.
Figure 1
Current thinking and indications from UK Central Government suggests that
this trend will continue until 2011/12 before reducing. This is in agreement
with leading consultancies who predict higher than average public sector
deficits for the next few years. Source: IHS Global Insight (2009).
There is also a drive by all main political parties to reducing the estimated
national debt burden of £178bn which is translated to 12% of Gross
Domestic Product. (GDP) Source: HM Treasury. (2009).
It is widely expected that any incoming government from the 2010 general
elections will be considering alternative options to help reduce this over the
longer term and one significant method of doing so may be offering large
Public Sector outsourcing contracts and increasing efficiency savings.

1.1.1
Prison
Population
Growth.
-‐
Why
the
increase?
Due to a variety of reasons, including higher conviction rates, the UK prison
population is predicted to rise to over 96,000 by 2012 and exceed 100,000
by 2014. (Office of National Statistics, July 2009). 4 To partly address this,
in 2007, the Ministry of Justice, via its agencies, NOMS & HMPS, has acted
on key recommendations from Lord Carter’s Review, and embarked on a
“Capacity Development Programme” to ensure an additional 10,500 prison
places are created and available by 2014.
One of the aims of this programme is to help reduce overcrowding rates
while providing more efficient care and prisoner management for increased
public confidence and safety.
Whether this is achievable is doubtful partly due to funding restrictions
imposed HM Treasury following the effective bailout of the Banking sector by
some £80bn during autumn 2008 and throughout 2009 by the Chancellor,
the Right Honourable Alistair Darling, MP. As a result, funding resources to
the Prison service has been significantly reduced.
This report aims to show that the provision and delivery of primary
healthcare services to the prison population can be done effectively using
Telemedicine applications.
Adaptations of market leading solutions including Cisco HealthPresence ™
will significantly reduce operational costs and provide additional benefits for
users and operators.
4 This figure also includes offenders who are attending prison on a temporary basis, as well
as those who have electronic tagging orders and are under house arrest.

1.2
Operational
Effectiveness
To understand how NOMS & HPMS can benefit from a greater use of
strategic technology in its future operations, the diagram below helps assess
overall effectiveness through several interrelated elements for the use of
telemedicine.
Systems
Ensuring relevant procedures
are used for effective
custody management.
Strategy
Cost reduction & efficiency savings.
Partnering with industry for increasing capacity.
Adapted from McKinsey’s ‘7 S’ Framework.
Values
Government led
Political &
Vendor neutral.
Staff
Style
Non profit operations
moving to PFI model
Closed culture & red tape
Structure
140 in Public ownership
in England & Wales
Skills
Some training required for
using video systems for
telemedicine applications
Ensuring sufficient leadership talent.
Adapted from McKinsey
Source
McKinsey
2009
1.2.1
Strategy:
For NOMS & HMPS, the effective strategy of the organisation may determine
the structure of its operations, and in turn, it’s systems. It should be noted
that in practice these dependencies are not linear or mechanistic. Long, T.
(2006).

1.2.2
Structure
The current structure of HM Prisons service is still hierarchical in nature with
many departments operating in silos with low levels of communications
between them. Partly due to changes in the wider economy, strategic
initiatives by government, and proposed spending cuts, NOMS & HMPS has
introduced a flatter organisational structure by removing several layers of
management. This can improve levels of empowerment for local
‘management’ teams in making decisions and helping increase overall
efficiency and raising productivity. Drucker (1984)
1.2.3
Systems
Despite recent changes by NOMS, there are still too many decisions made
through bureaucratic ways. Examples include arranging visits by members of
the public. In many cases, Bureaucratic management is sometimes referred
to as ‘classical management’ and often characterised by Weberian
bureaucracy as dependant on rules and procedures that lead to a hierarchy
and clear division of labour. Weber, M (1864 -1920).
1.2.4
Style
The management style at NOMS & HPMS is a ‘top down’ approach with top
management dictating business strategy. From Central Government policy
recommendations Gershon (2004), there is also a need for openness that
supports learning from change with a more open management style,
encouraging initiative. Changes made towards a flatter structure would lead
to best practice in the public sector and NOMS should also embrace a
bottom up approach to compliment this. This would enable ‘top’
management to provide improved leadership and coach teams and individual
contributors to facilitate necessary changes. To succeed in a global, 21st
century environment, managers will have to adopt a trust and empower style
and recognise that the role of work in people’s lives has shifted radically.
Peters, T (1992)

1.3
Key
challenges:
There are a number of key challenges for NOMS including; 5
1.3.1-‐Managing
the
Increasing
prison
population:
The UK prison population has been rising steadily since 1995, to 2009 by
32,500 or 66% presenting a significant challenge for Government
departments including the Criminal Justice System and Health services. The
huge increase in adult prisoners and young offenders has resulted in the use
of emergency measures such as using police & court cells as short term
facilities; resulting in expensive & tactical management of prisoners.
1.3.2-‐
Improving
overall
efficiencies
and
effectiveness:
This includes delivering key reforms including driving efficiency in prison &
probation providers through improved contract management & benchmarking
to achieve savings of £200m in 2010/11.
1.3.3-‐
Other
challenges.
-‐
Improving
the
system:
This includes the provision of healthcare and other related services in a cost
effective and efficient manner. E.g. Using Telemedicine/Telehealth
applications for primary health, education and rehabilitation services.
For vendors seeking to work extensively with Public sector departments and
agencies including HM Prisons and Healthcare, it is vital to offer solutions
that offer long term value for money through reduced operational
expenditures from the outset.
5
Ministry of Justice et al (2009) NOMS Strategic and Business Plans 2009-10 to 2010-11,
p7

(Valdez, G) states that Technology is constantly evolving and provides
tangible benefits to users and providers (vendors) in many ways such as the
new opportunities in learning and self care.
To put this into context, most vendors agree that Healthcare is generally
defined as a large vertical market with many different players including
primary care trusts (payers), insurance providers, strategic health authorities
and government. The general public and healthcare professionals also have
some influence on the provision of key services at reasonable cost.
To help contain some of these overall costs, investments for Telehealth &
eHealth systems & services are gradually being increased to 5% of overall
health budgets from the current 1-2%. This will save time and money over
the longer term through increased efficiencies in diagnosis, treatments and
faster decision making. Source: Business Insights (2005)
To support this growth, leading vendors operating in the Justice and
Healthcare markets including GE, Philips, HP, Polycom and Cisco are
investing in new and innovative products to address market opportunities
and optimise scarce resources.
However, there are also many barriers faced by technology vendors
including funding constraints, a lack of internal and external markets,
priorities (and perceptions) given to IT by healthcare managers, and the
difficulty in proving a fast return on investment (ROI).
1.4
IT
is
considered
a
low
priority
for
healthcare
providers.
Although some IT solutions can have a direct impact on medical practices
including the speed and efficiency in the provision of care treatments, this is
mainly indirect with staff training usually required at additional expense.
However the main priority for healthcare providers remains the provision of
healthcare, not administration and it is the nature of decision making by
primary care trusts and strategic health authorities which makes it difficult to

justify IT spending when there are other valid uses of financial resources. For
example, if choices are to be made between IT systems and critical medical
equipment, then a medical professional will normally opt for the latter.
In addition, many healthcare professionals are still not very comfortable with
some types of modern technology including personal computers, and
handheld wireless devices, video IP telephones and are reluctant to use
newer technologies such as Telepresence systems, unless they are
customised for simplicity of operation.
1.5
Funding
restraints
Although the current Department of Health’s NHS budget of £110 billion for
2010-11 appears to be secure by the current government administration,
some hospitals and clinics have difficulty in obtaining funding for substantial
technology projects. This is partly due to increased red tape from the
Government’s own reform agenda and increased scrutiny from key
stakeholder groups including the Taxpayers Alliance and other interested
parties. Given the political issues surrounding healthcare funding in the UK,
and with an upcoming general election to be held in 2010, these restraints
may increase over time.
1.6
Achieving
cost
savings
through
Return
on
Investment
A key reason for IT investments is achieving cost savings through increased
operational efficiencies with associated job cuts. In general, some public
sector organisations including Health Primary Care Trust’s and
NOMS/HMPS have found it very challenging to generate cost savings from
IT initiatives and also downsize non essential staff. Historically, it is the
nature of the public sector in general that employee’s trade in higher salaries
for relative job security, and therefore, until some administration workers

retire or leave, primary care trusts and related service providers (such as
prisoner health trusts) cannot achieve the expected savings required.
However, there is a movement towards using Telehealth & Telemedicine by
government and backed by the European Commission. Cost savings can be
achieved by no longer recruiting replacement staff, rather than reducing
staffing levels.
As a result, a key restraint for ICT investment into segments of the public
sector is expected to be reduced over the next few years.
A combination of factors including those already described, contribute to the
challenge for vendors & IT service providers to demonstrate a clear ROI and
especially in areas where it is difficult to quantify such as internal meetings
and learning activities.
One leading company, Cisco Systems, has developed a comprehensive ROI
tool that clearly demonstrates the Cisco HealthPresence™ system as a very
strong alternative to traditional delivery of care services with additional
applications for even greater utilisation and increased operational
efficiencies.
Therefore, a demonstrating clear and fast ROI measurement for any ICT
investment remains a key priority in the decision making process and is in
line with practices in the general commercial environment.
1.7
The
general
marketplace
for
technology
in
prisons
This section briefly describes the general technology marketplace in this
segment of the Public Sector, with major challenges, key trends and new
market opportunities etc.
As previously described in this report, as of December 2009, there are over
84,231 adults held in custody throughout the Prison establishments at an

estimated average cost to the taxpayer of £41,000, up from £37,500 in 2007,
and equating to £34,534,710 pa. Source: Prison Reform Trust (2009)
According to the MOJ & NOMS, there are a number of concerns for reducing
risks and related security concerns in prisoner transfers between offsite visits
to hospitals and other medical and judicial facilities. This is combined with a
need for increasing accountability and transparency in Prison operations
including e.g. Prisoner transfers, accurate records management, and health
services etc. By supporting the use of technology, for education and
management, there is an overall reduction in re-offending rates and
improvements in the provision of effective healthcare. Scharf (2008).
From this lens, and especially during the current economic climate, Her
Majesty’s Prison Service is ripe for the introduction of new technologies
including Cisco HealthPresence™ and associated services that provide
multiple benefits such as reduce operational costs, increase efficiency and
improve productivity in the provision of primary healthcare delivery which are
highly labour intensive activities.
Although market drivers are high, there are several barriers to overcome
including;
• Reductions in operational budget allocations by HM Treasury and a key
measure which should be considered by respective vendors.
• Lack of technology familiarity and use by staff activities. E.g. Using paper
based record keeping of prisoner movements & related treatments,
instead of an internet based online management system which can be
viewed and amended only by authorised persons. E.g. Medical Doctor,
Head of Health services etc. Therefore, any solutions should be simplified
for staff and visitors to increase adoption & use.
• Pressure by unions and other interested parties, (representative groups)
to use their staff instead of technology to avoid necessary reductions in
some job roles. E.g. The need for high levels of administration staff.

• Some psychological perceptions from a greater use of technology such
as lack of personal contact and face to face dealings.
• Political interference – both in the technology procurement and budgeting
processes by different Government agencies and opposition parties.
An underlying issue of organisational culture and resistance should not be
discounted for any business that wishes to work with NOMS & HMPS, and
offer new products & services while simultaneously improving their prisoner
care activities.
1.8
Summary
of
key
challenges
and
marketplace
for
technology
in
prisons.
It can be seen that there are a number of very significant challenges faced
by government departs such as MOJ & NHS in funding and maintaining
health services cost effectively over the long term. Improved partnerships
with the private and third sector can help address these shortcomings by
working with leading companies such as Cisco to benefit from global
technology expertise and business leadership.
Using adapted technologies from field proven Telepresence™ systems can
provide excellent user experiences in the prison & health service
environments and yet demonstrate a fast return on investment (ROI),
through multiple applications including learning, learning and rehabilitation
programmes.
The implementation and management of such technologies can be complex,
and the use of third party outsourcing contracts is already commonplace with
organizations including HP, Steria, Cable & Wireless, Serco and others
holding proven track records. This is an area that is likely to continue but with
the added challenge of large scale Public Sector ICT contracts being
reduced due to commitments made by the main political parties.

1.9
Key
technology
trends
for
Healthcare
in
Prisons
This section highlights a few trends that are emerging in this solution and
how the use of strategic technology can aid operational efficiencies in the
Prison Service.
TECHNOLOGIES DESIGNED TO ACHIEVE COST SAVINGS
Institutional Systems Community
Mature
Technologies
Prison & Offender
Management
Prisoner Records
Management
Video Surveillance
CCTV
Emerging
Technologies
RFID & Biometric
Health
Management
Integrated Criminal
Records management
with Health &
Education
management.
GPS based tagging
Remote Dentistry
Remote Ophthalmology &
Optometry
Remote Dermatology
Disruptive
Technologies
Bio-Identification
Telepresence &
various
adaptations.
Risk Assessment Behaviour Management
Of key value to vendors and users for the general uptake of Telepresence, is
system interoperability. Put simply, this means where one vendor’s systems
will work with another vendors across open standards. By using such an
approach, it very is likely to increase usage of such solutions and vertical
market adaptations (i.e. Cisco HealthPresence™) over time and will further

drive use for real time collaborations, discussions, trainings, counselling &
other team based activities over a more integrated supply chain.
Therefore, the issue of greater interoperability as a basic requirement for
organisations is very important for increasing overall market adoption.
However, it should be noted some vendors are unwilling to share aspects of
their proprietary systems expertise with competitors for their own commercial
and technical reasons including patent applications.
Many organisations are also enabling workforces to engage with customers,
and the wider supply chain through different technologies including audio &
video conferencing, virtual private networks (VPN) access, contact centres &
unified communications. This may also act as a driver of Telepresence
systems to be fully open standards compliant and thereby help overall
adoption of such systems.
Another growing trend is for managed services. 6 This offers organisations
increased choice of services with improved flexibility and much lower risk of
hardware & software procurement from a variety of “service providers”
including BT, CW, Global Crossing, AT&T, Orange Business Services etc.
This also serves as an important channel for mainstream vendors such as
Cisco, (including Tandberg), HP, Polycom, Lifesize, Teliris etc and will also
form the start of the service providers’ own versions of Telepresence being
positioned to customers in different vertical markets.
Alternative “service providers” could also be established using existing
operational outsourcers including Serco and G4S which already hold
national prisoner transportation contracts with NOMS. However, to date,
these alternative providers do not possess the necessary in-house business
and technical expertise to offer this service as part of their portfolio.
Wider background research suggests there are two main segments for
Telepresence solutions.
6
The centralised and publicly consolidated nature of UK healthcare means that government
policy has a more direct effect on IT spending than other countries.

1- Room based suites that consist of all physical hardware, & software as
technology and other elements including furniture, air conditioning,
heating, lighting, spatial sound acoustics & dedicated power.
2- “One off” builds for room design, planning, implementation,
commissioning, testing and training – This also may include additional
options for network provisioning, configurations, monitoring, maintenance
and support.
The main application for Telepresence based solutions are holding
organisational meetings by dispersed teams that help reduce travel costs
considerably.
In light of strategic and operational activities in the wider Public Sector, more
specific uses are emerging for tailored applications of this technology
including legal healthcare (including telemedicine), recruitment, training and
education.
This includes designing and building specific versions of Telepresence for
Healthcare and Learning, i.e. a “Service Presence” or “Health Presence”.
Another important trend is that of tagging using electronic devices such as
RFID – Radio Frequency Identification for monitoring low risk prisoners
during their offender management programmes.
Although RFID has been in existence for some time already, until now it has
not been a viable offering due to its unreliability from radio signal interference
in a contained environment such as prisons or jails.
Due to developments over recent years, this has changed with different radio
frequencies being available and improved supporting equipment and more
sophisticated, smaller tags that informs the authorities if the offender does
not report back to the prison or police station or within a set timeframe.

Storage – As information regarding prisoner health is moving to being
recorded electronically in accordance to general legislation, data records
management and security is a trend that is likely to continue in the future.
This raises important questions about the supporting infrastructure including
communications bandwidth and the reliability of the IP network which needs
to be robust and scalable enough to cope.
According to EMC, a leading information management company, information
held electronically is increasing at exponential rates and set to continue with
the growing acceptance of ‘cloud computing’ in Government departments.
Source: EMC (2008)
1.9.1
Summary
of
key
trends.
As the wider technology market for Telepresence systems evolves, fuelled
by organisational initiatives to reduce travel expenses & environmental
impact to society, several trends including Telemedicine, Home Monitoring,
Long range Ethernet Connectivity, and Private Networks are emerging for
specific systems that offer vendors, business partners and third parties
profitable opportunities to expand their offerings; capture market share and
gain competitive advantages through being first to market with proven
solutions such as Cisco HealthPresence™.

Summary of ICT solutions for healthcare
Source: Business Insights (2005)
These trends are increasingly relevant for major vendors such as Cisco
which include the provision of robust and scalable networks that can be
utilised for multiple applications. E.g. Cisco HealthPresence™ and Unified
Communications. It can be argued that future versions can be adapted for
Learning and Legal services.
As a basis for EU directives on eHealth,7 it is necessary to have high speed,
and reliable networks due to the huge amount of confidential data being
processed and stored at any given time. Therefore, these networks must be
highly secure and robust. However, at the same time, budgets for
healthcare and operations are being constrained in many parts of the public
sector, including the Prisons Service which necessitates a strong case for
using alternatives to the provision of key services including primary
healthcare using Telemedicine. There are many advantages in doing this,
mostly cost advantages and increased operational efficiencies by using
shared networks with improved staff productivity and care as a result.
7
Commission communication “Telemedicine for the benefit of patients, healthcare systems
and society”, COM(2008) 689 final, 4.11.2008.
http://ec.europa.eu/information_society/activities/health/policy/telemedicine/index_en.htm

2.0
Literature
Review
2.1
Overview
This section highlights an under use of specific technologies by NOMS and
HMPS for the primary health treatment of prisoners as part of their
operational strategies. Also revealed are a number of questions linked to the
under use of high speed internet & video based technology with key benefits
including increased efficiencies, higher productivity gains & faster access to
primary and specialist healthcare.
2.2
Introduction
The subjects of Internet based high definition video technology systems
(Telepresence), vertical market adaptations, (Cisco HealthPresence™),
Telemedicine and the Prisons Sector were chosen due to business
relevance by the sponsoring client and current thinking from Government
departments as possible conduits of efficiency measures to operate more
‘business like’.
The review shows possible avenues for government and the private sector to
work in partnership for achieving strategic objectives including improved
delivery of services, achieving efficiency gains and reductions in the cost of
delivering prisoner health services.
2.3
Objectives
of
literature
review
These include;
• Identifying costs in provision of primary healthcare to prisoners
• Investigating ways of increasing efficiency of key services including
healthcare

This aims to highlight areas of potential efficiency in providing primary
healthcare to prisoners and discover areas where improvements can be
made through the use of telemedicine applications using proven IT solutions.
However, before making a case for the use of Telemedicine, and indirectly,
Telepresence, it is important to briefly explore these concepts.
2.4
Concepts:
Telehealth is typically referred to describe technology applications that are
used between different and often remote parts of a country for initial
consultations and assessments.
Telemedicine is widely known as the provision of healthcare, usually primary
over long distances using a range of digital technologies including video
conferencing, live internet web chat & IP telephony.
Telehealth is a generally accepted term for remote health and often used
interchangeably with Telemedicine, however a key difference is that with
minor surgical procedures including basic dentistry and dermatology can be
performed with Telemedicine.
Telepresence is widely referred to as a set of technologies including internet
broadband connectivity, IT hardware, (high definition video systems, spatial
sound, personal computers), software, firmware, call centre systems and 3rd
party peripherals that allows a person to feel as if they were present in real
time, in a location other than their true location, and with a greater technical
sophistication & improved fidelity. Leading IT vendors of Telepresence
systems include Cisco, HP, Polycom, Teliris and others have their own
versions of Telepresence systems. Cisco is the current market leader of such
systems with an estimated market share exceeding 31% excluding the
recent acquisition of Tandberg.*
Cisco HealthPresence™ is an adapted and ruggedized version of the Cisco
TelePresence™ solution with third party medical grade accessories for
primary health treatments.

Although the use of technologies by businesses, consumers and public
sector organisations has been around for some time, its use as a strategic
enabler is fairly recent.
Strategic technologies including Telepresence & Cisco HealthPresence™ is
hereby referred to as a key enabler for NOMS & HMPS to aid the
management of its activities more efficiently. In doing so, this can help
improve the delivery of key services including healthcare, learning, and
rehabilitation within a secure environment.
A review was undertaken comprising of a number of core subject areas;
telemedicine, organisational strategy, public sector culture, & leadership.
The main reason for studying these topics this review is that there is
increasing relevance of using Telepresence solutions as part of telemedicine
for efficient delivery of healthcare.
Key sources of this literature review information include:
Ministry of Justice departments (NOMS & HM Prisons Service)
HM Treasury
Office of National Statistics
National Audit Office
Various technology company reports, e.g. Cisco, HP, BT, Tandberg,
Polycom, Philips, Lifesize.
Journal of Telehealth and Telemedicine
Various Internet sites & articles: e.g. http://www.mwbex.com/industry-news/
index.php/2008/06/27/the-costs-of-telepresence-technology/
www.getintohealth.com
Social networks & special interest groups, e.g. www.linkedin.com
The Economist Newspaper

The Economist Intelligence Unit (EIU)
Harvard Business Review
2.5
Basic
definitions
used
in
literature
review
1-The word technology itself originates from the Greek word “Technolgia”,
defined as the interaction between elements or artifacts and the practices
that can be realised through these artifacts. (Flores, et al 1988).
This term was first used by Leavitt and Whisler in 1958 to highlight the role of
computers in supporting decision making processes and information
management (Benunan –Fich, 2002). The focus on managerial abilities in
the use of technology and hence its strategic value to organisations and
individuals.
2- Strategic technology is of key interest and defined as a dynamic &
reflective process that organizations engage in for deriving maximum
potential of emerging and advanced technologies. This stresses the need
for technology to be integrated as part of an organisation’s strategic plans
and operational processes to ensure key objectives are met. This enables
key stakeholders to gain short and long term value for their respective
organization that gives its importance.
3-Flynn (2002), defines Public Sector Organisations, (PSO’s) as those who
receive funding wholly or partly by taxation and generally refers government
agencies, departments and other non- profit entities.
4- Key stakeholders (for this report) refer to those who provide services and
benefit from public sector organizations. These include NOMS, HMPS, NHS,
Strategic Health Authorities (StHA’s), PCT’s, Third sector charities,
commercial vendor companies, and the general public.
Therefore a focused approach is necessary to ensure relevant material from
a range of sources is considered and represented.

2.6
Key
findings
from
the
literature
review
From this review, some main themes may be drawn upon including but not
limited to research showing a general inertia by public sector organizations
to the concept of using technology and related management tools, despite
proven efficiencies and best practices from other countries, notably Canada
and Australia. J.R Moehr et al (2005).
In general terms, there is a misalignment in using technology as part of
organisational strategy; partly due to perceptions by some key decision
makers that technology is mainly a support function, instead of a strategic
tool that can be used as a key differentiator in delivering vital public services.
(Gershon 2004) (From Sir Peter Gershon’s report on Public Sector
improvements as part of an e-government agenda.)
Although a clear strategic direction on the role of technology is provided by
HM Government, the largest key stakeholder, it is not effectively utilised by
NOMS & HMPS, and it seems unclear on how to use specific video based
systems & tools to pursue strategic its objectives including protecting the
general public from criminals, and providing custodial facilities with education
and health care opportunities for eventual resettlement.
This raises more questions about the political structure and culture of the
Prison service & NOMS, and how this is very relevant in overall change
initiatives.

2.7
Organisational
culture
in
the
Public
Sector.
Practices
Knowledge
creation,
sharing
&
use.
Behaviours
Norms
Values
Adapted from Long, D & Fahey, L. (2000)
David W. De Long and Liam Fahey (2000) investigated and researched over
50 companies on how they share knowledge and discovered organisational
culture is the main barrier to creating and using knowledge based assets.
This suggests that culture is intangible & often determines what is
recognised as useful or important in a public sector organisation. In turn, this
directly and indirectly affects the use of technology by individuals for their
daily operational activities. This is especially apparent when management
tries to encourage individuals in using strategic technology to improve their
operations & become more effective.
Wang (2004) suggests that employees who refuse using modern technology
could be seen as fearful of change. Of possible, greater significance is that
this is also linked to organizational culture and behaviour traits. It seems an
organisations’ culture and interdependent relationships with its subcultures
play a significant role in the greater use and adoption of technology and how
it is distributed throughout.

2.8
Strategies
for
complex
public
sector
organisations.
Drucker (1994) believes organisations must continuously create advantage
through leaderships in four main areas including;
Price & quality, knowledge & timing, creating strongholds and large resource
pockets.
Further, he believes this requires the destruction of old advantages to enable
the organisation to create multiple short term advantages on a constant
basis instead and is supported by examples where organisations &
commercial companies can find themselves stagnating in crisis situations.
As organisations become more successful, they tend to take existing
theories as normal practice or behavior, suggesting they need to be tested
regularly. An organisation must systematically monitor itself and test its own
“theory of the business” by building in the ability for it to change itself.
For complex and larger organisations, there is a need for early and regular
reviews so that it can be reorganised if required. This is in order to change
policies and practices in line with its operating environment, gain new
competencies and develop existing ones.
Porter (1996) argues that the heart of the problem of organisational change
often lies in the failure to distinguish between operational effectiveness and
long term organizational strategy.
Operational Effectiveness (OE) means performing key activities much better
than rivals however, an organization can only outperform competitors if it can
establish a clear difference which can be preserved and maintained by
developing a unique position.
The organisational strategy depends on some unique elements including
choosing a different set of activities to deliver unique value.

An alternative to Porter is by Ohmae (1982) for a generic strategy that
focuses on 3 ‘C’s, Customers, Competition and Corporations. He argues
that customers cannot be treated as masses and specific needs should be
identified and targeted. Many competitors will differentiate their key offerings
and by doing do, will incur additional costs. The way corporations are
structured and managed can have a significant impact on their products &
services offered.
However, Kotter (1996) believes that applying a simplified process for driving
change throughout the organization including;
• Having a strategy with Leadership support & ongoing sponsorship
• Helping individuals eliminate obstacles and encourage a degree of
risk taking
• Repeatedly communicating throughout the organisation and beyond
to reference successes, and to a lesser extent, any negative stories to
learn from.
2.9
Strategies
for
implementing
technology
based
solutions
into
the
Public
sector
Given the nature of technology as a strategic enabler for organisations, there
are notable examples where telemedicine is being utilised successfully for
the application of medical services. Studies by the Centre for Rural Health,
University of Aberdeenshire (2009) and the Scottish Centre for Telehealth
(2008) show that up to 90% of patients reported a positive experience for
primary care treatments using Cisco HealthPresence™. This incorporates
rich media video, audio & contact centre technology with diagnostic medical
equipment over a high speed IP network platform. In addition, today’s more
advanced systems with media rich features including high definition displays,
advanced audio and efficient lighting & heating systems provide a more
engaging experience for users.

This is of major benefit to remote communities where the cost of time &
travel between facilities can be expensive with unnecessary environmental
impact through increased carbon emissions; as well as interpersonal
relationships between, medical practitioners, staff & prisoner patients.
Cost effective methods for deploying these solutions would be through
packaging the equipment, related software, internet services and required
medical devices into a single offering that can be paid for by the user
organisation, (Prisons service & PCT’s) and cost of capital can be recouped
using existing capital leasing arrangements from leading financial providers
or large vendors.
3.0
Strategic
Alliances
&
Partnerships
As Cisco HealthPresence™ is an excellent offering for providing primary
healthcare services to the prison population, any strategic alliances &
partnerships can have a significant impact in overall adoption of this solution
into the wider criminal justice system.
A Strategic Alliance is defined as the joint of effort of two or more companies
or organisations that are linked together in the supply chain to reduce the
total cost of acquisition, possession and disposal of goods and services for
the benefit of all parties concerned. (Underhill, 1996). These alliances enable
organisations of all sizes to focus on their core competencies so that the
main benefits are derived from shared resources including people,
processes, systems, & information exchange. This enables organisations to
adapt and respond quickly to new threats and opportunities. (Thompson and
Martin, 2005)
However any alliances & partnerships between two or more organisations
may also need to deal with potential conflicts and the extent of activity
between them.

Strategic Alliance Topology
Pre
Competitive
Alliances
e.g.
Cisco
&
AAP3
Cisco
&
Philips
Competitive
Alliances
e.g.
Microsoft
&
HP
Pro
Competitive
Alliances
e.g.
Cisco
&
Tribal
UK
Cisco
&
Civica Plc
Cisco
&
Serco
Non
Competitive
Alliances
e.g. BT
&
Cisco
Cisco
&
Global
Crossing
LOW
Conflict
Potential HIGH
LOW
Extent
of
Organisational
Interactions HIGH
Adapted from Yoshino & Rangan (1995)
Pro competitive alliances are by their very nature inter industry, vertical
market based relationships between manufacturers, suppliers or go to
market distributors/resellers. E.g. Cisco & Tribal UK etc
Pre Competitive alliances typically enable organisations with different
backgrounds to work together on well defined activities including technology
developments, sales & marketing programmes etc. E.g. Cisco & Philips
Non Competitive alliances tend to be those with intra industry links between
non competing firms, e.g. BT & Cisco, or Global Crossing & Cisco
Competitive alliances are similar to non competitive alliances for joint
activities, except in the partners are suited to be direct competitors in the
final product. E.g. HP & Microsoft
As the value chain acts as a source of competitive advantages, individual
organisations such as Cisco, can build interrelationships with others by
having distinctive value chains through using strategic alliances &
partnerships.

3.1
International
perspectives:
Examples from other countries including Australia, Canada, USA, New
Zealand and parts of the Asia, are ensuring strategic technology is adopted
in playing a role in transforming operational activities with resulting greater
efficiencies.
Rowe et al (2008) suggests there are wide ranging benefits from the use of
video conferencing in the primary health treatment of remote communities
who cannot get access to medical facilities due to a variety of reasons.
Experience from other countries, notably Canada and Australia, supports the
view that costs and people resources are the main factors in the ability of
providing care to communities. The strategic use of technology for
telemedicine applications is central to successful heath service delivery.
This is supported by Reynolds et al (2008) who states videoconferencing has
been widely used to provide distant advice in many healthcare specialties
across the word. This has been extended to support distance learning and
has been evaluated through a number of educational projects.
To maximise the full impact of technology, strategic partnerships may need
to be developed further between the public, private and third sectors to help
achieve key objectives, targets in overall efficiency improvements.
Governments in countries including Canada, USA, India, Australia & parts of
the EU are using technology strategically to transform their internal and
external functions in order to reduce their public sector costs and implement
new internet based services for greater collaboration with the population.

An example of greater use of technology for healthcare is in India where
there is growing spending on private healthcare from $40 billion in 2008 to
over $323 billion by 2023, encouraged by government, and partly due to
rising demand from an increasing middle class. Source: Technopak
Healthcare (2009)
Source: Health care spending as a % of GDP. Economist 2009
From the World Bank Indicators, the UK currently spends up to 7% of its
GDP on public sector healthcare in comparison to emerging countries such
as China and India which spend less than 2% and 1 % in public healthcare.
As an example of greater investments in technology, the bar chart shows
there is a correlation to increased private healthcare spend of 2.1% for China
and 3.2% of GDP for India, mostly from private firms and charities which is a
higher share that any other country.

3.2
Financial
implications
for
government.
Given the state of the public finances in the UK, one approach being
seriously considered is based on cost reduction through the use of
standardised infrastructure that can support multiple government offerings
with access to new and existing and services. Datamonitor (2008)
This approach is also likely to lead to significant cost reductions in other
areas of public sector spending and encourage the further adoption of
strategic partnerships to reduce risk, share key IT services and offer joint
solutions including comprehensive telemedicine.
Many successful companies such as Cisco, IBM, BT, HP & SAP etc are
already using Telepresence technology as enablers for organisational
change and operational improvements. It is the ability of key public sector
organisations including NOMS & HMPS to align this strategic technology with
their own organisational strategy for improved efficiencies that is in question.
It is also important to understand how these public sector organisations, i.e.
NOMS and PCT’s use strategic technologies for telemedicine to assess the
full impact this can have on their activities and overall improvements in their
operations.
3.2
Using
video
conferencing
&
‘Presence’
technology
for
telemedicine.
Andrew (1980) and Borgeois (1988) state that effective business strategy
should reflect on decisions which align corporate resources and capabilities
to external threats and approaches, thereby enabling complex organizations
to increase efficiencies. Although this may seem simple, organisations may
find it difficult to implement new technologies as part of wider initiatives due

to many reasons, including inherent organisational culture, fear & resistance
to change, and possible staff training requirements.
This raises the question of why key public sector organisations are not using
these resources effectively and efficiently. – Could it be a lack of
management understanding to the value of strategic technologies to
organisational effectiveness or the inability of measuring financial returns on
investment?
Experience from the Correctional Facilities Program in Iowa, USA
demonstrate significant cost savings up to 87% can be achieved using video
conferencing as the primary method of telemedicine based healthcare.
These costs vary considerably depending on the distance between the
health care facility and the prison, number of inmates traveling to receive
care per trip and the number and salaries of custodial officers and drivers
involved. Zollo (1999)
The issue of personnel is briefly explored as two key roles in providing
telemedicine services are that of a coordinator and a video communications
expert. Telemedicine requires a different approach in consulting and the staff
providing the service must also be interested in the technology itself to
understand key differences. Depending on the size and complexity of the
telemedicine programme, allocation of existing personnel will be required.
Using modern systems such as Cisco HealthPresence™ and other tools
such as call centre applications and system integration management tools
can ensure simple and effective operations by regular staff including prison
officers and administrators. This would result in no ‘specialists’ being
required as long as sufficient training is given.
This implies a fast ROI that can be measured in months or even weeks,
rather than years.
However, there are less quantifiable benefits of telemedicine that need to be
considered such as having medical doctors present (from other locations)

during the consultation and less misunderstanding of a doctor’s advice from
clear and real time communications. Zollo (1999)
This is in line with findings from the Scottish Centre for Telehealth which
showed that up to 90% of patients reported a positive experience in their
treatments. This has the ability to transform access to services and improve
the effectiveness of delivery across a wider number of patients with greatly
reduced costs of provision.
Critics including Tapscott (2001) believe it is largely the inability to clearly
measure returns on investment that is hindering technology investment in the
Public Sector and widely reported IT project failures by the media is
hindering greater technology adoption. This is especially relevant at a time
when there are likely to be large scale public sector budget cuts imposed by
any Government affecting all Public Sector organisations to operate more
efficiently.
The term ‘disruptive technology’ or ‘disruptive innovation’ generally describes
any new technology or innovation that evolves to challenge and then replace
existing technology. Christensen (1995)
In doing so, it effectively changes people’s behaviour into new and different
ways of activity. Over time, there are many examples including the mobile
phone, personal computers, television, MP3 players and the modern car.
It can be argued that Telepresence & Cisco HealthPresence™ as a part of
wider collaborative technologies are forms of disruptive innovation that will
fundamentally shift the balance of power in whole industries and markets,
which can often spell the end of established vendors.

Recent examples of “Disruptive technologies” are highlighted below.
Technology Timeline Disruptive impact
PCs 1980s Personal computers and the client-server architecture model started the end of most
existing mainframes and minicomputers, hence creating new markets for mobile
computing.
Mobile
phones
1990s-present
The mobile phone has significantly changed the entire telecommunications industry,
and has essentially become a must have technology. More recently, the rise of
smart phones including the Blackberry™ and iPhone™ is adding to further
disruption creating an additional new wave of modern communications.
VoIP 2000-
present
Initially voice over IP or VoIP, was limited and had well known quality issues.
Leading companies including Cisco™ and Skype™ were pioneers of this form
disruptive technology. Over time, greatly improved performance, free voice calls,
and simpler pricing models have impacted telecoms service provider revenues and
indirectly created a new generation of handsets.
Therefore, technologies over recent years from the private and military
sectors, combined with new approaches to measuring ROI for investments,
can aid public sector leaders on which solutions to invest into, e.g. video,
collaboration networks etc. There are many ‘hard’ & ‘soft’ benefits including
reductions in travel related expenses, time management and improved staff
productivity. These can also be combined with softer factors including
reduced disruption to medical facilities by unplanned hospital visits and
instant online interaction between medical staff and prisoners. Ultimately,
disruptive technologies such as Telemedicine applications become cost
effective as the volume of remote consultations increases. Zollo (1999)
However critics including De Mayer (1988), call for strategic approaches to
managing technology investments in organizations with the creation of
strong links between the business environment and developing and
maintaining its technological base. This is essential for building strong
synergies between public sector organisations and partnerships with the
private sector for access to wider expertise and resources.

3.3
Relevance
of
current
thinking.
For the purpose of the study, it is assumed collaboration technologies
including Telepresence, Cisco HealthPresence™, video conferencing,
contact center, IP telephony etc should be widely used for improving
organisational activities operational efficiencies that ultimately represent
better value for money for taxpayers. The importance of the custodial
environment is respected in promoting multiple uses of technology for
healthcare services and other uses including, remote court appearances,
rehabilitation activities and internal staff meetings in a cost effective way.
These include, but are not limited to remote psychiatry, counseling, cognitive
behavioral therapy, remote learning, interactive training, mentoring & health
assessments. Many of these services have been successfully delivered on
countries including the USA, Canada and Australia. Mary Ann Liebert Inc.
(2009)
By adapting existing products from established vendors, new tailored
solutions can be offered through a choice of systems that have their
respective advantages and disadvantages. The main three vendors are
Cisco,8 HP, & Polycom with Cisco having a clear lead in terms of scale,
network reliability, existing commercial customer mindshare at senior
management level, especially after the recent acquisition of Tandberg, and
strong global partnerships with companies including BT, Cable & Wireless
and Global Crossing; who provide internet connectivity & managed services
offerings.
Another major advocate of Telepresence solutions is from HP, one of the
biggest technology companies with revenues exceeding $114 billion, and
8
As of 1st October 2009, Tandberg was in process of being acquired by Cisco for approximately $3.4 billion, subject
to regulatory approvals.

No. 1 overall IT market share (Gartner 2009). HP has extensive experience
with a very large customer base, including complex government accounts,
large enterprise customers and small businesses combined with extensive
research and development resources. The HP HALO™ studio system is
generally more expensive than the Cisco TelePresence™ solution; however
it is regarded by customers as having a higher quality room solution with the
better performance of its HVEN™ network. The addition of the HP Meeting
Collaboration solution has further improved the overall flexibility of HP
solutions. Frost & Sullivan (2008).
The next major player in this market is Polycom™ who is traditionally known
as an advanced audio video conferencing company specialising in affordable
voice & video communications. It is the smallest of these three players with
net revenues of $699 million for year ended 30th September 2009. Polycom
has offered Telepresence systems since 2007 through its acquisition of
Destiny Conferencing and has established its position in the general
videoconferencing sector to gain an approximate 12% market share. It has
the ability to offer full interoperability across its product range which provides
its customers with an easy to use, open standards based, compelling value
proposition that will grow over time.
The company also has an extensive partner and distribution network that
enables it to deliver and support complex requirements of a Telepresence
solution with organisations including BT, Avaya, Cisco, IBM, Juniper,
Microsoft and Siemens.
However, due to the recent Cisco acquisition of Tandberg, another leading
competitor, the relationship is likely to deteriorate due to Cisco’s strength in
sales and marketing channels, customer & partner base, new product
development and strategic alliances with IBM, BT and others.

Another leading player is Teliris, and one of the most established vendors
and which has benefited from the recent focus by Cisco & HP in promoting
the wider benefits of high definition video conferencing by increasing its
market share to approximately 16.9%. It is set to grow further by developing
“gateway” systems to support interoperability with existing video
conferencing systems and also offers held devices including Smart phones.
Over recent years, Teliris has expanded in EMEA & Asia where it sees
strong growth potential due to higher travel costs and a greater
environmental awareness. As a result, of solid sales growth, it has built new
video network centre facilities to complement existing ones in London and
New York.
The company has invested in strategies to increase its market share by
developing new global partnerships and accelerate its marketing activities
through more specialist channels for education, healthcare, manufacturing
and defence.
3.4
Examples
of
current
thinking:
From discussions and briefings held with Cisco, NOMS and Health service
representatives during August to December 2009, current thinking suggests
the following areas are being considered.
• Adopting Telehealth & Telemedicine as practical alternatives to
provide types of primary health care to the prison population.
• Experience of trials in other countries, notably the USA, Canada,
India, and Australia indicates there are tangible benefits including cost
savings & faster access to health specialists for treatments in a secure
environment.

• Innovation and practices from developing countries, notably, India &
Brazil suggests Telemedicine is far more likely to be adopted in
emerging markets where the costs of healthcare are generally paid for
by private insurers & individuals, rather than governments. How this
affects health treatments to the respective prison population remains
to be seen.
• Discussions with various Cisco and industry representatives indicate a
significant number of prisoners should be treated using an adapted
version of their successful HealthPresence™ so that the solution is
cost effective. At time of writing, this could be approximately 30
sessions per month or 360 per annum based on the existing offsite
visits conducted from the current data sample. Further, by increasing
system utilization rates for learning activities, internal staff & visitor
meetings, suggests even greater cost savings through reduced travel
expenses between multiple sites resulting in even lower running costs
and faster returns on investments.
“From my discussions with the Scottish Centre of Telehealth, it
appears the key application they see is ‘mental health/primary’ care in
prisons…” Corinne Marsolier, Cisco (2009)
• Industry sources including Business Insights (2009), suggest global
demand for collaboration solutions using suite based Telepresence
systems is growing at a compound annual growth rate of 4% (2008-
2013), due to a number of factors including: the need to improve
communications between remote teams & individuals, combined with
need to maintain business continuity, reduce travel costs &
environmental impact. By adapting Telepresence for telemedicine
applications with additional medical devices, specific hardware &
bespoke software, ‘new’ markets can be addressed by vendors.
However, the high cost of these systems is slowing its growth,
especially in the cost sensitive public sector.

3.5
Summary
of
findings
from
the
literature
review.
• There is some misalignment in part of the Government’s agenda for using
technology to improve services in this segment of the Public Sector.
• A general lack of understanding about the important role video and
internet based collaboration technologies can play in improving
operational efficiencies and delivering key services at lower costs into the
Prison Service.
• There is a lack of measureable benefit of using specific technology
investments. E.g. Cisco HealthPresence™ for Telemedicine.
• There is a secretive and suspicious organisational culture in HM Prisons
Service that is acting as a major barrier to accepting and improving
behavioural change.
• There are positive examples from Scotland, Canada, India, USA &
Australia of using Telemedicine to successfully provide primary health
services to remote communities, which can be applied into the Prison
environment.
These findings serve as a basis to assess the use of Telemedicine as part of
ICT collaboration systems in the Prison sector.

4.0
Research:
Gathering
Information,
interviews,
key
findings
&
analysis.
This section focuses on analysing information gathered from interviews,
discussions and other meetings with key decision makers from parts of
NOMS & Healthcare sectors.
It shows some key findings and insights in areas where tangible operational
efficiencies can be improved & cost savings achieved using solutions
including Cisco HealthPresence™
4.1
Overview
Given the sensitive nature of this government agency and related
departments some information provided about Prisoners cannot be
disclosed. However, special attention was given to identifying and engaging
with Prison Governors and Healthcare managers for assistance.
In addition, there is a naturally secretive organisational culture present at
NOMS & HMPS which is very challenging for vendors, consultants & other
interested parties in gathering support from individual stakeholders to
engage with in an open and unbiased manner.
Key findings show an insight into a current segment of public sector’s
management thinking. Also highlighted are their perceptions of collaboration
technologies as an enabler for operational efficiencies in the provision of key
services to HM Prisons.

4.2
Key
research
objectives
for
this
management
challenge
include;
• To identify the costs involved in providing primary health treatment to
prisoners
• To understand if Prisons are open to using telemedicine for primary
health treatments.
• Additional objectives include ways to increase efficiencies of prison
operations using Cisco HealthPresence™ and Telemedicine as enablers
for improving internal processes.
4.3
Methodology
By considering different research methods available, a qualitative research
based methodology was used by adopting the ‘research onion’ framework,
Saunders et al, (2005). An additional and extensive literature review was
conducted, supported by semi structured interviews and supplementary data
from industry professionals. Analysing findings from semi structured
interviews and making key assumptions were also deemed necessary.

Research strategies
Sampling Realism
&
InterpretivisRea
Cross
section
Surveys
&
Case
studies.
Deductive
&
Inductive
Timelines
Use of primary & secondary data
Interviews and Survey’s
Observations
Realism & Interpretivism
Data
collection
Adapted from Saunders, (2005).
4.3.1
Reasons
for
this
approach
include;
• Identifying the needs of using disruptive technology including Cisco
HealthPresence™, to improve the provision of primary healthcare to
prisoners cost effectively.
• Exploring additional uses of this technology for other services that
provide value for money. E.g. education, learning, counseling, remote
visitation and discussions with supply chain stakeholders.
Where necessary, further meetings with relevant 3rd parties, e.g. Mental
Health Trusts & Prison Reform charities were conducted to help validate
some of the findings.

1- Summarising information gathered and presenting key
recommendations. (In line with scope of study). E.g. Using video
based systems and aspects of telemedicine to improve access for
prisoner healthcare (mental and dermatology).
2- Using a pilot case study in the UK, the Scottish Centre of Telehealth
and the Royal Aberdeen Infirmary model as a possible best practice
example for a HealthPresence technology based solution and
benefits.
4.3.2
Sampling.
From the current HM Prison estate of 140 establishments in England &
Wales, a sample of 16 were identified and chosen based on their inmate
profile, location and security category rating; A-D, where A is defined as a
maximum security closed prison and D, is an ‘open’ prison that allows
inmates to conduct community service and other activities as part of any
offender management programmes.
4.3.3
Cross
Section
From the sample of 16 prisons, 8 were visited over a 100 day period
between August to November 2009 based on category and location.
Interviews were held with key decision makers including Governors, Deputy
Governors, Healthcare managers over a 120 day period. In addition,
meetings and follow ups discussions were held with 8 health managers from
local Primary Care Trusts up to December 2009. Due to logistical & time
constraints all Prisons in England & Wales could not be visited in person,
therefore qualitative methods were primarily used with direct meetings with
Prison & Health managers.

4.3.4
Surveys
From agreement with respective managers in NOMS, HMPS & local PCT’s,
a short questionnaire was sent to each decision maker, e.g. Healthcare
manager, Governors etc, before arranged meetings to ensure participants
were comfortable about the questions asked. In nearly all cases, several
follow ups by telephone & email were required to ensure the questionnaire
was received, understood and subsequent appointments scheduled. See
appendix 6.
4.3.5
Deductive
&
Inductive
processes
During the meetings, it was very important to understand the nature of each
prison’s operations within the context of their respective inmate population.
This provided a valuable insight on their challenges for providing health and
related services with local budgets & plans in line with Government policies.
Although national guidelines & policies for healthcare are provided by the
Department of Health via the National Health Service, it is the delivery of
these health services that is dependent on the local primary care trusts for
each prison and their allocated resources.
Some establishments including HMP Pentonville have a relatively high
turnover of prisoners serving short term sentences of less than 30 days and
indicated that only basic care may be required & therefore a full Cisco
HealthPresence™ system may not be appropriate. In comparison, a “ low
turnover ”, high security prison such as HMP Belmarsh could benefit greatly
from telemedicine applications using Cisco HealthPresence™ offering due to
high risk prisoners, length of sentences served and the high levels of field
resources required in moving prisoners between various courts, police and
medical facilities.

This suggests a two tier approach may be required with high security
Category A&B prisons benefiting greatly from the immediate use of Cisco
HealthPresence™ systems and also Category C&D to a lesser extent.
4.3.6
Quality:
To ensure collected data & other relevant information could withstand
validation; emphasis was given to the criteria used to assess the accuracy of
findings. These were discussed with members of NOMS & the Healthcare
profession, who agreed they were in line with their own internal data.
4.3.7
Reliability:
To ensure consistent data collection & analysis were consistent, the
following was done;
For primary data collection the sample of Prison manager chosen for
interview was selected based on prisoner profiles and risk categories A-D. (A
= a high security facility and D = an open prison). Other factors that
influenced the decision on selecting which prisons interviewed included
geographical location with good public transport links and recommendations
from respective PCT’s.
Secondary data was also used from a few public sources including MOJ
accounts, NOM’s Strategic Plans, & wider technology market reports.
4.3.8
Validity:
To minimise chances of producing any analyses that are biased, the
questions used in the field work were chosen and developed carefully from
the wider subject theme of Telemedicine readings, Healthcare & IT, and the
literature review.
4.3.9
Generalisability:
Saunders et al (2005), states that a concern of the researcher when
designing the research in the context to which the findings may be equally
applied to other settings. It is accepted by the researcher, that in conducting

this research study, the level of generalisation is reduced significantly and
recognises its merit in doing so.
Of key interest is understanding the main costs of providing primary levels of
healthcare to HM prison population and identifying practical ways of
providing this more efficiently with additional longer term benefits. Although
the study is within the operational environment of NOMS and the respective
PCT’s, I can see the results and conclusions would be similar for other public
sector organisations that may be facing significant budget cuts.
4.4
Limitations
of
the
Research
Approach
As a result of some members of NOMS & HMPS, some resistance was
encountered during investigations, possibly as they may have felt the author
was “another management consultant looking to disrupt their activities”.
However, after a period of identifying key stakeholders & working with
supportive line managers, I was able to gain meetings with key decision
makers through their facilitation.
Nearly all primary research has certain limitations, and this is no exception
with the research data limited from experts in the Prison & Health Service
that have been interviewed.
Also, due to time constraints and the nature of the Prison Service &
Healthcare industries, this does not include the opinion of the entire custodial
& medical service professions.

4.4.1
Interview
Selection
Process
The chosen managers identified & selected for interview are professionals
within NOMS/HMPS & PCT’s who provided their perspectives on the
research question.
The first stage of this process was to gain an “Executive manager’s” support
within NOMS and act as an internal sponsor. Once achieved, the second
stage was to enlist the support of a line manager to work with on a regular
basis and help facilitate relevant meetings. For discussions with local PCT’s,
this was done independently as they were more receptive to engaging with
MBA students. The respondent names have not been disclosed due to
confidentiality; however their position & organisations are listed.
Summary table of interviews with NOMS, HMPS & key vendors.
Position / Role Organisation
Product Manager Cisco
Governor HMPS/NOMS
Deputy Governor HMPS/NOMS
Operations Manager NOMS
Health Services Manager NOMS
Operations Budget Manager NOMS
Project Lead, Offender Health Department of Heath
Contracts & Finance Manager BT
ICT Manager Birmingham East & North Primary
Care Trust
Bid Pricing Manager Orange Business Services
Health Services Manager Wandsworth Teaching PCT

Pharmacy Manager West Herts NHS PCT
Health Services Manager Barnet, Enfield and Haringey Mental
Health Trust
Interim Commissioner, Offender
Health & LD Services
NHS Greenwich
Project manager, Offender
Learning Services
Imperial College NHS Trust
Operations Manager Cambridge University Hospital NHS
Foundation Trust
5.0
The
Research
Question:
Research is defined as the systematic collection and interpretation of
information for a clear purpose to find things out (Saunders et al 2005)
For the purpose of this study, primary research is to find out the following;
Q- “What are the key factors and costs for providing primary health to
the prison population and can this be reduced by using technologies
such as Cisco HealthPresence™ & Telemedicine as ways of helping
improve overall efficiencies?”
Although the question is simple, there are a number of sub questions which
are detailed as:
• What are the costs of providing primary health services into the Prisons?
• Does the concept of using new technologies such as Cisco
HealthPresence™ and /or video conferencing as part of an overall push
towards Telemedicine seem acceptable?
• How would this be beneficial and cost effective in the current
environment?

This was further segmented into the following;
Q1a - “What are the key costs for providing primary health to the
prisoners
Q1b – How can technologies such as HealthPresence for Telemedicine
applications be acceptably used?
Q1c - Would this be cost effective to the payer? (NHS Primary Care
Trusts?)
This highlights a case for using Cisco HealthPresence™ solutions providing
primary health services into the prison population. This segment of the Public
sector is ripe for the introduction of disruptive technologies that can change
an organisations behaviour and culture. Christensen (1995).
5.1
Key
findings
from
primary
research
This section addresses the main findings from the qualitative primary
research from the questions posed by the author for key factors & costs in
providing primary healthcare to prisoners. This also clarifies senior
managers’ understanding of MOJ & DH strategies and provides a valuable
insight into long term challenges faced for operational activities. Specifically,
I asked how much is the average cost of sending a prisoner to a local
hospital for primary medical treatments and if Telemedicine could be used as
a viable alternative to traditional methods.
5.2
Varying
costs
of
healthcare
provision.
The average cost of providing primary care to the prison population varies
between £695 to £2000 at each establishment for each offsite visit according
to need & type to treatment required.

This is based on a number of factors including, historical agreements with
regional Health Authorities. There are also national agreements in place for
higher risk prisoners by the Department of Health & NOMS for Category A
prisons that usually located near specialist hospitals. E.g. HMP Whitemoor &
Cambridge University Trust Hospital.
5.3
Using
technologies
for
Telemedicine
From interviews with HM Prison Governors, Healthcare Managers and
Professionals 7 out of 8 respondents indicated they were open to the
concept of using new technologies for improving health services to prisoners.
One interviewee indicated he would avoid this as prisoners were only in
custody at his establishment for a short period of time anyway and would
receive healthcare treatments after release into society anyway. From all
respondents there was general concern that any technologies must be
simple to use and provide excellent value for money.
By using adapted technology based solutions such as Cisco
HealthPresence™, the varying costs of providing some healthcare to
prisoners can be substantially reduced while achieving similar “face to face”
experiences with medical professionals.
A notable example in the UK is the Scottish Centre for Telehealth, who
completed trials in 2008 for treating patients with ear, nose & throat
problems, minor cuts & burns, using telemedicine with positive experiences
by over 90% of respondents. This shows there is a real possibility that
primary healthcare can be provided to the prisoner population with no
detrimental effect in the quality of care.

Example of a pilot system used in early trials. Source: Cisco (2009)
Several types of primary care exist with some varying forms.
• Mental Health including Psychiatry, Psychology & Counseling
• Dermatology
• Dentistry
• Basic Ophthalmology and Optometry (Eye care)
• Cognitive Behavioural Therapy
• Basic Cardiology, e.g. Heart monitoring,
These conditions can be fully or partially treated using telemedicine with
proven examples in other countries including the USA, Canada, Australia
and New Zealand.

Example of remote dentistry using telemedicine equipment.
Source: Kings College, London (2009)
5.4
Cost
effectiveness
for
the
payer
for
primary
health
treatment.
Given the nature of each prisons operations and profile of each inmate held
in custody, the actual costs of providing primary care treatment varies greatly
by each establishment from £695 to £2000 for each offsite visit to a nearby
hospital. (The higher offsite visit costs are representative of limited category
‘A’ prisons holding high risk inmates such as HMP Belmarsh, Liverpool,
Whitemoor, etc.)

The table below summaries the average costs for each offsite visits per
month to a local hospital for primary health treatment.
HMPS Visits
Prison Establishment Ave cost of offsite prisoner healthcare Ave no of offsite c voistitss, epaecr hm toimnteh..
£ (for Primary Health treatments).
Wormwood ScrubsB £ 695.00 50.00 34750
Pentonville C £ 1,200.00 40.00 48000
Brixton C £ 900.00 20.00 18000
Whitemoor B £ 1,200.00 40.00 48000
The Mount C £ 800.00 24.00 19200
Grendon B £ 1,800.00 40.00 72000
Belmarsh A £ 2,000.00 10.00 20000
Leeds B £ 1,500.00 35.00 52500
10095.00 259.00 £ 312,450.00
£ 1,261.87 32.37
£ 1,261.00 32.00 £ 41,184.00
£ 494,208.00
Information from meetings held with Prisons August to November 2009.
5.4
Other
findings
5.5
User
experiences
with
ICT
vendors
During meetings with decision makers, a series of questions were asked
about current experiences of IT from established vendors including, HP,
EDS, Orange, BT, C&W, Microsoft etc. EDS was frequently mentioned by
HMPS & Healthcare managers as especially challenging to work with in
resolving support issues & providing a consistent quality of service. This
suggests that for any vendors operating in this segment of the public sector

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