Latest data suggests that in the UK ~10% of the annual NHS £100 billion budget is spent on treating diabetes, equating to £192 million a week. Of this, nearly 80% is spent on treating irreversible, but preventable diabetes-related complications. Currently there are 3.8 million people diagnosed with diabetes, an estimated 900,000 are yet to be diagnosed, and in 2030 it is expected that more than 5 million people in the UK will have diabetes (as 80-85% of cases of type 2 diabetes is caused by obesity). Uncontrolled diabetes in older people leads to a range of problems. Hypoglycaemia (low blood glucose) causes a slowing of cognition and may result in acute confusion, accidents and falls and an increased risk of developing dementia. Conversely, hyperglycaemia (high blood glucose) increases the risk of infections, dehydration, and in the longer-term can lead to a significantly higher loss of muscle quality and strength (sarcopenia) as well as irreversible damage to eyes, kidneys, and nerves supplying the feet. This places significant demands on NHS services including GP callouts, ambulance services, A&E attendances and lengthy hospital admissions. Increasing physical activity levels in people with diabetes would lead to better outcomes in terms of less diabetes-related complications, less depression, slower rates of cognitive decline, lower rates of cardiovascular disease and ultimately less healthcare resource use. However, some people with diabetes find it hard to exercise as the risk of hypoglycaemia is increased. The complex relationship between diabetes, physical and cognitive decline, and ageing is not well understood (understudied) often leading to sub-optimal management of people with diabetes as they get older. This in turn results in higher risk of diabetes related complications and increased incidence of morbidity and disability in this population in later years. The aim of this proposal is to provide a single technology platform that will implement a data-driven approach to the analysis of this complex relationship via automated machine learning (ML)-driven analytics based on the real-time remote monitoring of the key diabetes markers (Blood Glucose, Insulin, Carbohydrates) and incorporating physical activity measures, as well as cognitive assessment scores. This integrated environment will provide decision support for optimal diabetes management and service planning and provision for healthcare, social and community care. This will enable a shift from the current unsustainable, static and reactive management model, to a future-proof dynamic, intelligent proactive model that will impact in the following ways, for: - Patients: a personalisation of support to enable pro-active engagement and empowerment; improved quality of life; healthier ageing. - Clinicians / Carers: remote monitoring; decision support; prioritisation of those most in need; improved cognitive screening. - CCG and commissioners / wider NHS / Social service: optimised use of limited healthcare and social care resources; optimal pathways of care.

Chronic wounds, as typified in the development of pressure ulcers (PUs) and diabetic foot ulcers, represent a huge problem for many patients, their families and the carers. Indeed, the management of such wounds can prove problematic and in some cases can be life threatening. Non-healing wounds continue to be a major issue in all health care systems, resulting in considerable distress to patients and carers and providing an estimated financial burden to the NHS of £4 billion pa. They are caused when parts of the body involving soft tissues, namely skin, muscle and fat, are exposed to prolonged mechanical loading. Although commonly involving immobile subjects who are bedridden or confined to chairs, these ulcers can arise in many other situations in which interventional medical devices introduce potentially damaging loads at the skin surface, afflicting patients of all ages. Indeed device-related ulcers represent a major healthcare problem, accounting for over 30% of hospital-acquired PUs. Current devices are based on designs employing traditional materials which are relatively stiff/rigid and do not match the compliance of fragile skin tissues. Accordingly the Network will provide a technological platform for novel designs of medical devices, incorporating suitable materials to make contact with fragile skin tissues, and manufacturing capability, which will protect them from device related injury. The network is designed to integrate expertise from the NHS, healthcare industry, engineering consultancy and academia. It will provide cutting edge technologies and scientific understanding in order to ensure safety of vulnerable skin in situations arising from medical devices. As an example the Network will utilise imaging techniques and simple robust biomarkers to evaluate the health of loaded skin. The Network will also develop computer generated models to test device performance prior to evaluation on vulnerable patients. Materials developed in other engineering applications will be evaluated for their suitability in new and existing device designs. Three proposed studies provide exemplars of devices attached to skin tissues; to provide breathing assistance for pre-term infants, protection for infants and adults with inherited disease and incontinence management for males. The network will engage with other partners and in particular our two supporting HTCs in Wound Prevention & Treatment and Devices for Dignity, who will prioritise subsequent activities based on identified clinical needs. These will inevitably involve engagement with other academic, clinical and industrial partners, which the Network will fully encourage. Activity within the Network will provide benefits to patient-centric Quality of Life. Improving device design will reduce discomfort and lower the occurrence of lifelong scarring and disfigurement injuries. This will also offer the opportunity for the NHS to reduce costs associated with treatment of medical-device related skin damage and their potential recurrence. This, in turn, will attract interest from the healthcare industry to reinvest in a range of safe devices with novel materials and designs which can prevent damage to vulnerable tissues. The Network aims to extend the success of UK plc in the advanced wound dressing market, which currently embraces over 20% of the global market, into the wound prevention or avoidance market. The wide dissemination strategy will attract other academics in the UK and Internationally to offer additional expertise to the innovation platform in the form of methodological or theoretical techniques and engage with the Network. In addition, activities from the Network will attract interest from additional Health Technology Cooperatives, thereby enhancing its scope and increasing its associations with the wider academic and clinical communities. The Network will also establish key links with organisations, such as the MHRA who regulate the medical device industry.

Faecal Incontinence (FI) is defined as the inability to fully control the passage of faeces through the anus. This may arise due to a weakened anal sphincter muscle (typically following child birth), problems with nerve supply (e.g. stroke, multiple sclerosis), or in association with other gastrointestinal conditions (e.g. irritable bowel syndrome). It is a common and distressing condition that causes shame, embarrassment, depression, social isolation, secrecy, poor self-esteem, and sexual avoidance. As a result, more than 54% of patients with FI have not discussed their symptoms with a physician , and only one-quarter of patients with FI are referred by their GP for specialist treatment . Its exact prevalence is difficult to determine but best estimates suggest that in the adult population it is around 10%, and that 0.5% - 1% below 65 years and 3% - 8% over 65 years experience regular faecal incontinence. Urinary Incontinence (UI) is defined as involuntary leakage of urine, UI presents a major burden on NHS resources. It is a common and distressing condition, which impacts of quality of life. The main forms of UI are stress incontinence (SUI), which is leakage with physical exertion, and urge incontinence (UUI), which is leakage with a strong desire to void. Mixed urinary incontinence is a combination of SUI and UUI. The prevalence of UI increases with age and is higher in institutionalised adults, who tend to be older and suffer associated co-morbidity. It is more often a problem for females, with prevalence rates of UI ranging from 4.5% to 53% in women, as compared to 1.5% and 24% in men. Although previously considered in isolation, it is increasingly recognised that many forms of FI and UI share a common underlying pathophysiology and frequently co-exist with pelvic organ prolapse Incontinence places a massive burden on the NHS and impacts significantly on quality of life for thousands of patients in the UK. Whilst many areas of medical engineering share a growth in the engagement of engineers and scientists to push forward the exploitation of emerging technologies it is arguably the case that the nature of this disease prevents engineering and science research leaders seeing the potential for some rich research challenges. This proposed network will provide a step change in the increased engagement of leading UK technologists (from academia and industry) to provide a substantial impact to incontinence sufferers.

Global and local (UK) populations are ageing and this has contributed to an increase in demand for health and welfare services. Chronic and long-term conditions are also on the increase, leading to increased costs of health and social care and wide-ranging changes to the nature of health interventions. As a result, it is increasingly desirable to keep people out of hospital, treating people nearer to, or in their home. For reasons of cost, convenience and dignity it is also sometimes desirable that patients engage in self-care or carer-delivered care. Care independence has long been a feature of some diagnosis and treatment regimes: most medications are taken by the patient themselves; diabetic patients regularly monitor blood sugar levels and inject themselves. This work aims to extend these concepts of self care to a boarder range of health conditions, and their associated technologies, that are not currently expected to be delivered by the patient or their carer. The network consists of four academic centres: * Cambridge Engineering Design Centre, University of Cambridge; * CHI+MED, Collaboration led by University College London (UCL); * Loughborough Design School, Loughborough University and * Helen Hamlyn Centre for Design, Royal College of Art and three Healthcare Technology Cooperatives (HTCs) * Devices for Dignity, (D4D) Sheffield Teaching Hospitals NHS Foundation Trust; * MindTech HTC, Nottinghamshire Healthcare NHS Trust and Institute of Psychiatry and * Brain Injury HTC, Cambridge Universities Hospitals NHS Foundation Trust. This network of design researchers and healthcare technology specialists will carry out a series of design-led pilot projects to explore solutions to care independence challenges. The aim of the pilot projects is to encourage innovation in order to find radical new ways of using technologies to allow sustainable patient independence while maintaining clinical quality, safety and patient and carer experience while reducing costs. The pilot projects will be need driven and will be selected as part of the networking with NIHR Healthcare Technology Cooperatives. The pilot project outputs will be conceptual designs that can be further developed (not funded by the network) or definitions of research need that can be developed into research proposals.

TIDAL Mapping (WS1). Guided by our consultations with partners we will carry out a series of short focused projects. The first two will focus on the regulatory landscape for AT post-Brexit and will review successful translation of EPSRC-funded research into AT products and services. Three further short projects, focused on key barriers and enablers will be developed by the Network. TIDAL community development (WS2) will establish the Network and maintain inclusive engagement. A major activity will be running the Annual Symposia and Doctoral Colloquium, with the first focussed on Responsible Engineering. TIDAL Research (WS3). We fund up to eight research projects of up to £65k (aiming for 2 per theme) to interdisciplinary teams who have an excellent research hypothesis for solving a clear unmet need. There will be three steps of development: 1) an agenda setting workshop 2) targeted calls and a team building workshop (i.e. mini sandpit); 3) review and select proposals for funding. All research projects will have a business mentor and we will also support industry placements (2 months maximum) for academics, and encourage industry-funded placements into academia. Guided by initial consultations with partners we will begin the Network+ with three themes. 1) Responsible Engineering 2) Sensors and Data Science for Communication Aids 3) Design & Digital Manufacturing Systems (DMS) & Physical Devices. An additional theme will be added as TIDAL N+ grows. WS4: Network Education & Dissemination (WS4) : The TIDAL project is led by Holloway, who co-leads the £19.8million AT2030 Programme (www.at2030.org) and the Global Disability Innovation Hub (GDI Hub) Academic Research Centre. These initiatives already have excellent networks for communication and dissemination and TIDAL will take advantage of these. Specific activities will include the development of policy notes based on the work in WS1-3, engagement with local innovators, colleges and schools through hackathons and GDI Hub Live events themed to TIDAL N+.