a report on the anchor trust/bt telecare research project · acknowledgements during the course of...

A report on the Anchor Trust/BT TelecareResearch Projectby Jeremy Porteus and Simon Brownsell

Exploring Technologies for Independent Living for Older PeopleA report on the Anchor Trust/BT Telecare Research Project

Jeremy Porteus and Simon Brownsell

Published by:Anchor Trust

Fountain CourtOxford Spires Business Park

KidlingtonOxon OX5 1NZ

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Registered Charity No. 1052183Company No. 3147851

First published 2000

©Anchor Trust, 2000.Anchor Trust and The Housing Corporation have asserted their rights under the Copyright,

Designs and Patents Act, 1988 to be identified as the authors of this work.

ISBN 0906178 56 8

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Produced for Anchor Trust by Pavilion Publishing (Brighton) Ltd

Using Telecare Anchor Trust 2000

AcknowledgementsDuring the course of the research project on which this report is based, Anchor Trust's ProjectManagement Team has received considerable assistance from a number of colleagues, otherorganisations and individuals to whom we would like to express our thanks.

We are particularly indebted to all the residents and carers who volunteered to participate in theprogramme and gave their permission to develop, test and monitor the effectiveness of telecare intheir homes and gave their time to be interviewed and complete a questionnaire.

Special thanks are also due to the following for their contribution during different stages of theproject: Dr Andrew Sixsmith, at the Institute for Human Ageing, University of Liverpool forundertaking an independent evaluation; Paul Garner, Dr Nick Edwards, Nigel Barnes, Ian Scott andDuncan Rose, of BT Martlesham Laboratories for undertaking the development, installation,functionality, and monitoring of the telecare system; Shorrocks Security Systems and AndoverControls for their technical guidance and use of their sensors; the City of Nottingham and KnowsleyMetropolitan Borough Council for their involvement.

Finally we are grateful to The Housing Corporation for funding the research project from itsInnovation and Good Practice Grant. We are especially grateful to Steve Ongeri of the HousingCorporation for his advice and encouragement throughout. We are also thankful to Anchor Trust'sProject Management Team for their on-going support and commitment and, in particular, GrahamBrownsell, Dave Smith and Mary Cave for their assistance in the drafting of this report. However,the responsibility for the completed version rests solely with the authors.

Using Telecare Anchor Trust 2000 03

About the Authors

Jeremy Porteus is the Corporate Strategy Manager at Anchor Trust. He has worked in housing forover fifteen years. Prior to joining Anchor in 1997, he managed the Royal National Institute for theBlind's housing service. At Anchor, Jeremy contributes to the development of housing, health andcommunity care polices and managing research and innovative projects on preventive services andthe use of new technology in the home to take these forward. For the past two years, Jeremy hasproject managed the Anchor telecare research project, in conjunction with BT. He also chairs theDepartment of Trade and Industry's Task Force on Design for Daily Living under the ForesightProgramme's Ageing Population Panel.

Simon Brownsell is currently conducting his doctoral research at the University of Abertay, Dundeewhere he is investigating several aspects of the telematics field. He is author of a number ofpublished research papers and has a particular interest in the development of telecare systems forolder people. Based on research with community alarm users his recent work has been concentratingon developing telecare models. His research has indicated that there is a demand for telecareservices by today's community alarm users and that telecare is sustainable, both financially and froma service delivery viewpoint.

Simon Brownsell gratefully acknowledges the support of his research sponsors and supervisor inenabling him to contribute to this work.


Contents page

Chapter Summaries 7

Section OneChapter 1 The role of technology 9

Why technology is being investigated 9Existing Technology: its scope and limitations 12Conclusions 13Summary points 13

Chapter 2 The policy context for the development of telecare 15

Government Policies 15 New Deal for Communities 16 Better Government for Older People 16 Preventive agenda 16 Supporting People 17 Sheltered Housing 18 Conclusions 18 Summary points 18

Chapter 3 Understanding the technical concepts 20

Telemedicine 20 Telecare 20 Assistive Technology 21 Smart home technologies 21 Generations of telecare 22 Conclusions 23 Summary points 24

Section TwoChapter 4 The Anchor Trust/BT telecare project 25

Project partners 26 Phases of the project 26 Implementation 27 Ethical Issues 27 Summary points 28


Chapter 5 The Lifestyle Monitoring System trial 29The Lifestyle Monitoring System (LMS) 29Methodology 32Implementation of the trial 33Implementation issues 34Summary points 36

Chapter 6 Field trial results 37Participant expectations before implementation 37Field trial 38Participant experiences 39Carers experiences 42Summary points 43

Chapter 7 Biomedical Monitoring 45Background 45Methodology 46Focus groups 47Results 48Conclusions 49Summary points

Section Three

Chapter 8 Framework for customer applicationWhat are the implications of introducing telecare

Chapter 9 Conclusions and RecommendationsWere the project objectives met?Cost effectivenessRecommendations

Appendix 1

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5960 61 62

64


Chapter Summaries

This report is written in three clear sections. The first section introduces the concept of telecare andplaces telecare in the context of recent policy changes. The second section describes the systemdeveloped by Anchor Trust and British Telecom, concluding with the results of an actual field trial. Thethird section suggests what implications the widespread deployment of telecare may have and suggestswhat various organisations and individuals must do if telecare is to be successful in the future.

Section One

Chapter 1: The role of technology

There are a number of factors driving the development of new technology as a way ofsupporting independence. The main factors are discussed and the present technology,community alarms, described.

Chapter 2: The policy context for the development of telecare

The government recognises that there is an increasing demand on health, care and housing providersand that telecare has the potential to help prevent, reduce, delay and/or meet part or all of thesedemands. Recent government policy changes influencing the debate on telecare are highlighted.

Chapter 3: Understanding the technical concepts

As in any subject matter there are technical words and concepts that if not understood, confuseand bewilder. Definitions are given for the technical concepts commonly used together withexamples of community care technologies and application areas.

Section Two

Chapter 4: The Anchor Trust/BT telecare project

The project partners are described along with the goals and objectives of the two-year project.Consideration is also given to the ethical and moral issues arising from a project of this nature.


Chapter 5: The lifestyle monitoring system trial

A description is given as to what the lifestyle monitoring system (LMS) actually did and how itcompared daily activity patterns with a 'normal' profile in order to raise an alert call. Detailsare given of the implementation procedures followed and some of the issues arising fromintroducing such technology.

Chapter 6: Field trial results

The expectations before the field trial commenced and the experiences of those older peopleinvolved in the field trial are presented. In addition to the end users perspective (the olderperson) the opinions of the people actually responding to alert calls generated by the systemare also presented.

Chapter 7: Biomedical monitoring

Monitoring medical parameters such as blood pressure, heart rate etc. from the home areincreasingly being investigated. The purpose is to prevent or reduce illness and enabledischarge from hospital to be earlier than presently possible. Two commercially availablesystems were described to participants and the responses to such monitoring and relatedtechnologies presented.

Section Three

Chapter 8: Framework for customer application

The research identified a number of key issues for Registered Social Landlords (RSLs) andother providers relating to the future developments of telecare. The chapter includes learningtips for organisations seeking to install telecare systems and presents the many valuablelessons learnt in a customer focused framework.

Chapter 9: Conclusions and recommendations

The final chapter demonstrates that the initial goals and objectives of the project have beenmet. Thought is also given to the cost-effectiveness of such systems, concluding with keyrecommendations for organisations and individuals if telecare is to continue to progress and bea welcome component of service delivery in the future.


Section One

Chapter 1

The role oftechnology

The Anchor Trust/BT telecare project washighly innovative and sought to increase therange of support offered to older people.Through the monitoring of a person's lifestylein the home, the project sought to provide anautomated and reliable way of providingassistance whenever a significant change inlifestyle was observed, such a change beingindicative of a possible health or socialproblem.

It should be stated early on that it is notenvisaged that technology will replace humancontact, although the Japanese are currentlydeveloping robots to undertake some caringand rehabilitation tasks,1 Technology cannotequate to the support a person can providebut technology can be used very effectively toprovide monitoring when a carer cannot bepresent. Few people would choose to have acarer following their movements to ensuretheir well being 24 hours a day, 7 days aweek. However, it is thought that providingthis level of monitoring through technologywould be more acceptable to users andprovides the possibility of providing a highlevel of support to many potential users.

Telecare has many definitions but for thepurposes of this document telecare is defined as:

The remote or enhanced delivery ofhealth and social care services to peoplein their own home by means oftelecommunications and computer-basedsystems.2

Why technology is beinginvestigated

There are a number of factors that are drivingthe development of new technology as a wayof supporting independence.

• Older people are increasingly usingtechnology to aid their independence.There is evidence to suggest that olderpeople, and in particular community alarmusers, are increasingly encounteringeveryday technology, for example onesurvey of residents in sheltered housingrevealed that 44% of residents had theirown video machines and 45% their own


Section One

microwave ovens.3 The same survey alsoshowed that when discussing new andemerging technologies, 77% would welcomethe automatic detection of falls and 68%would welcome lifestyle monitoring (thedetection of the changes in the pattern ofbehaviour). Take-up of technology by olderpeople is not related solely to chronologicalage, however it is true that familiarity with atechnology makes it easier to learn. With thisin mind the Royal Commission for LongTerm Care expects future older people to beas comfortable with computer controls as thepresent generation is with telephones.4 Theview that older people do not wanttechnology and cannot use it is becomingdated. Many older people are seeking thebenefits of technology and if a direct benefitcan be derived from its use then there doesnot appear to be an obstacle in acceptance.Indeed users can actually become drivers forthe new technology.

• Support needs to be given to peoplewhere required - namely in their ownhomes.The emphasis for supporting older people(and other groups) has moved away frominstitutions to the community. The modelfor the provision of care and support ischanging: no longer are people beinggrouped together and support provided inone location. Increasingly steps are beingtaken to enable people to stay in their ownhomes for as long as possible and moves

into residential and nursing care are increasinglyonly being used after other possibilities have beenexhausted. Older people themselves are becomingmore consumerist and seek choice andindependence with the majority of them, around80%, choosing to remain independent in theirown homes for as long as possible.5 Many of thosewho choose to stay in their own homes foreseetechnology as a possible way of enabling theirindependence, security and well being.

• Technology can improve lifestyles.This was recognised by the aforementioned RoyalCommission report. 'People constantly look tomodern technology to improve their lifestyles.One of the ways in which life could improve forolder people is in the harnessing of newtechnology in new, imaginative and profitableways.4 For example through access toinformation, services and leisure pursuits.

• An ageing society.It is well known that demographic change isresulting in an ageing society. In 1995 there wereless than 9 million people aged over 65 in theUK; by 2030 there will be almost 50% more.6The European Commission has predicted thatbetween 1995 and 2025 the UK will see a 44%increase in the 60 and over age range.7 Whilstpeople are living longer than ever before, at thesame time fertility rates are declining. Thedependency ratio, expressed

10


Chapter 1. The role of technology

•

as the ratio of the number of persons agedbetween 16 and 65 to those aged 65 and over, isexpected to reduce from almost 4:1 in 1961 to 2:1by 2040.8 This pattern is evident throughout muchof the developed world and is highlighted inFigure 1.1.9The cumulative result of this changemay result in fewer people able to provide care, bethat by formal or informal means, whilstsimultaneously a smaller proportion of people inwork will have to finance a growing number ofolder people.

Increasing healthcare costs as society ages.When the National Health Service began, lifeexpectancy was around 50 years and 60% of thepopulation was under 20.6 Today life expectancy iscloser to 80 and soon 50% of the population willbe over 50.6 This is a tremendous tribute todevelopments in medicine and to improved socialconditions. However, the healthcare costs for olderpeople are significantly higher than those of otherage groups as indicated in Figure 1.29 By way ofillustration, the proportion of 65s and overaccounted for only 16% of the population in 1993,but more than half, £6.4 billion, of the annualexpenditure on hospital and community healthservices.10

Those aged 85 and over are the heaviestconsumers of all. The average per capita spendingon services for this group is five

times that of the whole of the 50-64 age group11

while the number of people aged 85 and over isthe fastest growing cohort. In the 10 years from1995 to 2005 there will be 400,000 more peopleover the age of 85. 12 It is therefore apparent thatwith an increase in the number of older peoplethe healthcare costs will also increase. Throughthe greater use of technology it is believed thatprevention can play a growing role. If potentialdifficulties can be observed at an earlier pointthen assistance can be provided and consequentlywe move from a reactive to a preventive systemthat should result in a reduction in healthcarecosts per head.13

Technology could play an increasinglyimportant role in the future as it provides thepossibility of giving people more choice andindependence. We have seen that peopleincreasingly want to stay in their own homes andtherefore care and support needs to be given insuch locations. Technology could be employed tomeet this requirement and increasingly olderpeople are becoming aware of the benefits oftechnology. In the future they may in factbecome drivers in its development. In addition,as society ages the growth in the number of olderpeople and the related financial implicationsassociated with this will inevitably lead to servicesbeing increasingly stretched. As indicated,technology could result in financial savings


Section One

as through its use situations could beobserved and support provided earlier thanat present. Therefore there is a demand fortechnology to be investigated, from both auser's and provider's perspective. AnchorTrust, as the leading supplier of care,support and housing services to olderpeople in the UK, wanted to be at theforefront of any investigation.

Existing technology: itsscope and limitationsCurrently the technology employed to providecomfort and security to users is known ascommunity alarms. It is estimated that thereare in excess of 260 community alarm controlcentres in the UK 14 serving a total of1,160,000 users,15 which represents about 11%of people 65 and over.16 Community alarms arenot new. They were first introduced in 1948where residents on a sheltered housingscheme in Devon activated a bell that wouldsound in the warden's home. In the 1970stransportable speech systems becameavailable.17 However, despite more recentimprovements in reliability and speed ofresponse, the basic mode of operation has notsignificantly changed in the last 15 years.18 Inorder to call for assistance users typicallyhave a radio activated pendant which can beworn on the body or fixed pullcords

positioned throughout the home. Uponactivation a control centre is contacted wherethe necessary support and assistance can beprovided as represented in Figure 1.3. 19

Community alarms are, and for theforeseeable future will continue to be, verysuccessful. They provide cost-effective supportto users 24 hours a day. Nevertheless there is amajor limitation with the system; the usermust initiate the call. Until the user activatesthe alarm call the warden or control centre isunaware of a problem and no assistance canbe provided. There are two main reasons whya user may not activate an alarm call.

1. They may be unable to activate the alarm. Ifthe user is unconscious then obviously analarm call cannot be generated. But even ifthe user is in a state of consciousness theymay still be unable to activate an alarm call.Both the pendant and pullcord methods sufferfrom limitations. The pendant has provedpopular as it can be hidden under a jumper,and when worn, can summons assistance fromanywhere in the dwelling. However, theportability of the pendant is also an area ofconcern where research has indicated thatbetween 27%20 and 40%21 of users 'never' or'just occasionally' wear their pendants. Ifassistance is required and the pendant is notbeing worn then activating a call for help canbe difficult if not impossible.


Chapter 1. The role of technology

Pullcords provide a permanent location foralarm activation and thus do not suffer fromthe possibility of the user misplacing or notwearing their pendant. However, it is notuncommon to find users who have tied thepullcords up to the ceiling 'so they don't getin the way'. A survey of Anchor Trust tenantsin 1984 discovered that 59% of tenants had atleast one pullcord tied up.22 If a fall occurs inthe room where a pullcord is tied up and theoccupant is unable to regain their feet it maybe impossible for them to raise the alarm.Even if the nearest pullcord is fully accessiblethe user may still have to physically move to itto raise an alarm.

2. They may not consider themselves in need ofassistance.Analysis of calls received at Anchor Trust'scontrol centre, Anchorcall, reveals there arepeople who appear to be unsure whether ornot they should have activated their alarm.There are many examples where the alarmhas been activated and the caller is expectingthe control centre operator to make a decisionupon the appropriate cause of action. Whilstthere are such people presenting themselves atthe control centre, it would seem likely thatthere are also people who are not inclined tocall for help. The present system is unable tohelp such people.

Community alarms are an active system, inso much as the user must take action forassistance and support to be provided. Inaddition to this active system it is believedthat a passive system is required that can callfor assistance without the need for the user toinitiate the action. The limitations of thecommunity alarm technology can then beminimised and assistance provided to peoplewhen they need it.

ConclusionsThe factors highlighted are recognised bymany housing and care organisations, andfeature in the strategic options of many ofthem. For example The Housing Corporationstates that 'the links between the ageingprocess and health and disability are wellknown. There are some areas where designand technological development can help olderpeople deal with the effects of ageing.

Technological advances can contribute to theeffective use and management of housing.'23

The challenge facing service providers andpolicy makers is to provide support when it isneeded to people where they are located,namely in their homes. As more peoplecontinue to live for longer, providing supportto everyone in the required amounts willprove increasingly difficult. Telecaretechnology could enable many people to besupported in their own homes by monitoring24 hours a day, 7 days a week if necessary.Detecting situations as they occur will enablepeople to be treated before the situationworsens and consequently we move from areactive to a preventive system that shouldresult in a reduction in healthcare costs per head.

Summary points: Chapter 1

With over 1 millon users in the UK,community alarms are, and will continue tobe, very sucessful. However, they sufferfrom one major limitation in that the usermust initiate the alarm call and for variousreasons they may be unable or unwilling todo this.

Advanced technology is being investigatedbecause:

• older people are increasingly usingtechnology to aid their independence

• support and care needs to be providedto people where they require it. Forthe majority of people this will be intheir own homes

• technology can improve the user'slifestyle and reduce costs by acting ina preventive role

• society is ageing: the percentage ofpeople aged between 16 and 65 tothose aged 65 and over is expected toreduce from 4:1 in 1961 to 2:1 by2040. Consequently there may bedifficulties in finding enough peopleto provide the necessary support andcare

• as society ages healthcare costs willincrease, especially with respect tothose aged 85 and over whocoincidentally are the fastest growingcohort. Technology could be used toreduce costs by acting in a preventiverole.


Section One

References

1. http://www.labs.bt.com/library/cochrane/papers/computer.htm

2. Barnes, N.M., Edwards, NH., Rose,D.A.D. & Garner, P. (1998). Lifestylemonitoring - technology for supportedindependence. IEE Computing andControl Engineering Journal. 9 (4), pp.169-174.

3. Brownsell, S., Bradley, D.A., Bragg, R.,Catlin, P. & Carlier J. (16th October1999). Do Users Want Telecare and CanIt Be Cost-effective? Presented at theEMBS/BMES International Conference,Atlanta USA. And unpublished data.

4. Royal Commission on Long Term Care(1999). With Respect to Old Age: LongTerm Care - Rights and Responsibilities.London: The Stationery Office.

5. McCafferty, P. (1994). LivingIndependently: A Study of the HousingNeeds of Elderly and Disabled People.London: HMSO.

6. Age Concern (1998). A Guide to theDebate of the Age - Your Say in theFuture.

7. The Guardian 5 March 1996.8. Exchange on Ageing, Law and Ethics.

(1998). Debate on the Age: 10 Key facts.6 (5), p. 7.

9. Ermish, J. (1990). Fewer Babies, LongerLives. York: Joseph Rowntree Trust.

10. Warnes,A. (1993). The Demography ofAgeing in the United Kingdom of GreatBritain and Northern Ireland, p. 81.London: Age Concern Institute ofGerontology and the Department ofGeography, Kings College, University ofLondon.

11. Glending, C. & Mclaughlin, E. (1993).Paying for Care: Lessons from Europe.Social Security Advisory Committee,research paper 5, pp. 14-27.

12. Graham S. (April 1997). Once just 'goodneighbours', wardens are playing a pivotalrole in community care. Housing, pp. 32-33.

13. Department of Health (1999). PromotingIndependence: Partnership, Preventionand Carers - Conditions and Allocations1999/2000 (LAC (99) 13). London:Department of Health.

14. Riseborough, M. (1997). CommunityAlarm Services Today and Tomorrow.Kidlington: Anchor Trust.

15. Audit Commission. (1998). Home Alone:the Role of Housing in Community Care,pp. 6-7. London: Audit Commission.

16.Thie, J. (1998). A pan-European socialalarm system. Journal of Telemedicine andTelecare, 4 (Supplement 1) pp. 60-61.

17. Parry, I. & Thompson L. (1993). EffectiveSheltered Housing: a handbook, p. 12.Harlow: Longman & Coventry: CharteredInstitute of Housing.

18. Brownsell, S., Poole, P. & Brownsell, G.New Alarm Technology: Will it Lead toData Overload? Presented at the Centrefor Sheltered Housing Studies, TheTechnical Future for Sheltered Housing,June 10th 1998.

19. Brownsell, S., Williams, G., Bradley, D.A.,Bragg, R., Catlin, P. & Carlier J. (1999).Future systems for remote health care.Journal of Telemedicine and Telecare. 5,pp. 141-152.

20. Breen,T (1992). Community alarmssystems. In A.S, Dibner (Ed) PersonalResponse Systems: An InternationalReport of a New Home Care Service.New York: Haworth.

21. Research Institute for Consumer Affairs(RICA). (1986). Dispersed Alarms: AGuide for Organisations InstallingSystems. London: RICA.

22. Fennell, G. (1984). Anchor's OlderPeople, p. 37. Kidlington: Anchor Trust.

23. The Housing Corporation (1996).Housing for Older People. London: TheHousing Corporation.


Chapter 2The policycontext forthedevelopmentof telecare

Since the start of the Anchor Trust/BTtelecare project in April 1997, there has beena significant change in government policytowards providing better-integrated serviceprovision between health, social services andhousing. The current government has soughtto bring down the 'Berlin Wall' betweengovernment departments and, at a local level,statutory providers and their partners. Thishas seen the emergence of a number of policyproposals, to improve the mapping andassessment of need, to reform existingfunding mechanisms, and to enable greatertransparency and integration of serviceprovision. These proposals will also enableusers, including older people, to have moresay and choice about the services delivered.

The government, through a number ofinitiatives outlined below, recognises thatthere is an increasing demand on health, careand housing providers, as it is actively seekingways to help prevent, reduce, delay and/ormeet part or all of these demands. Telecarehas the potential to help prevent, reduce,delay and/or meet part or all of thesedemands.

Government PoliciesAn increasing emphasis on the greaterparticipation of older people, the developmentof preventive strategies and partnershipsbetween agencies has influenced a number ofrecent policy documents.


Section One

Better Government for Older People

This is a new national programme led by theCabinet Office. The programme consists of 28pilot projects to develop, test, monitor andevaluate integrated strategies for and with anageing population to provide them with:

- clearer and more accessible informationon their rights

- more say in the type of services they canget

- simplified access to services- improved linkages between different

agencies- better opportunities to contribute

actively in their local community.

The pilot projects are led by localauthorities but involve a wide range ofpartnerships with central government and thevoluntary and private sectors, as well as olderpeople themselves. They cover a variety ofthemes from healthcare to lifelong learning,crime prevention to leisure activities. The useof telecare is not specific to the programmebut there is evidence that the use ofinformation and assisted technology is a toolthat many older people are beginning to use toaccess information and their immediateenvironment. As technology develops andolder people become more familiar with itsuse there will undoubtedly be improvedcommunication flows and links between olderpeople and service providers.

Preventive agenda

The preventive agenda is gaining momentumand clearer strategic plans are being made forthe increasing percentage of older people insociety. 1 Indeed prevention is now high on thepolitical agenda and the government isincreasingly seeking to identify preventivestrategies and services for older people withinnational policy objectives, such as the recentlypublished Department of Health White PaperSaving Lives: Our Healthier Nation2.

It has been estimated that if morbidity ratescan be reduced by 1% per annum, thenpublicly funded care costs can be reduced by30%, or £6.3 billion, per annum by 2030.3There is therefore a tremendous incentive tomake prevention work. However, due to thetightening of eligibility criteria for community

care services, the trend has been that thoseolder people in need of lower level services,such as home help, have seen their servicescut at a time when they require a healthy andsupportive home environment. With thesupport of a Housing Corporation Innovationand Good Practice Grant, Anchor Trust iscurrently undertaking a major study on thecost effectiveness of preventive strategies in ahousing setting. This is expected to bepublished in 2000.

Within the context of health and socialcare, prevention has tended to be divided intothree categories:4

• primary prevention or 'health promotion'and the prevention of disease

• secondary prevention or 'screening', beingthe identification and treatment of disease

• tertiary prevention, being the effectivemanagement of existing disease to limit itsimpact on life, or to slow down the rate ofdeterioration.

Depending on an individual'scircumstances, telecare systems can fall intoone or more of the preventive services. Iftelemedicine is included, where medical data isgathered remotely in a preventive way, then thedelivery of health and social care to assistindependent living can be regarded as apreventive package. This could enable manypeople to remain in their own homes,preventing the need to move on to accessother costly services.

New Deal for Communities

In its report Bringing Britain Together: ANational Strategy for Neighbourhood Renewal,5

the Social Exclusion Unit (SEU) identifiedinformation technology as one of the keyaction areas for tackling exclusion in deprivedneighbourhoods. For many older peopleisolated in the community, information andcommunications technologies can improvetheir social activities both formally, ie withtheir carers and warden, and informally, iewith family and friends. Consequently,networks of contacts are vital for maintainingan older person's well being, in a social,physical and psychological sense. It must alsobe recognised that the development ofinformation and communication technologiescan have a negative impact. It can create


Chapter 2. The policy context for the development of telecare

further exclusion for those who choose not to, orwho cannot, embrace such initiatives.

Social exclusion can be defined as loss of accessto the most important life chances that a modernsociety offers, where those chances connectindividuals to the mainstream of life in that society.6In other words, the ability to participate effectively ineconomic, social, political and cultural life.Loneliness can result from exclusion and Table 2.1demonstrates that at any particular time throughoutEurope there are varying proportions of olderpeople who are feeling lonely. 7 This is particularlyimportant when appreciating that loneliness andisolation can lead to depression and poor healthand may even result in mortality as there is someevidence suggesting a link between low levels ofsocial contact and subsequent mortality.8,9

There is a close link between tackling socialexclusion and the adoption of preventive strategies.This is largely around the way future resources arelikely to be allocated so that instead of providingcurative services such as medicine, policing or cashbenefits, there is earlier intervention to minimisethe risks of social exclusion. New technology andthe use of telecare services are able to assist in thisprocess, whether in the delivery of primary care orin housing management. Furthermore, a significantfactor will be the increasing opportunities for olderpeople to use new computing and digitaltechnologies to access information from theInternet, set the parameters for monitoring theirlifestyles or control their immediate homeenvironment.

Supporting People

In December 1998, the government published a newconsultation document10 that proposes widespreadchanges to the funding of local

services to vulnerable people from April 2003,with a transitional period based on currentspending levels of approximately £800m in theinterim. It considers that the present fundingstreams are complicated, uncoordinated andoverlapping.

The document proposes the bringing togetherof Housing Benefit paid for supported housing,including sheltered housing, and certain otherfunding streams (Housing Corporation SupportedHousing Management Grant, Home OfficeProbation Accommodation Grant and DETRfunding for Home Improvement Agencies) into asingle 'corporate' pot. This will be distributed tolocal authorities to plan, commission and fundsupport services at a local level on the basis ofindividual need. The government's stated aim is'to enable more flexible responses to theindividual needs and housing preferences ofvulnerable people'. It recognises the importantinterrelationship of housing and support, butwants to ensure that provision can be made in abroad range of accommodation settings. Thiswould make it easier to respond to changes inindividuals' support needs without requiring themto move. Moreover, by giving housing, socialservices and probation services a joint role inapplying the resources, the government'sproposals aim to provide an integrated strategy bypromoting joint decision-making at the local level.

In the light of the above, it is highly likely thatthis will have an affect on the funding mechanismof telecare, both under the transitionalarrangements from 2000 and in the longer term.At present, community alarm charges areregarded as an eligible cost for Housing Benefitpurposes and are likely to remain so under thetransitional arrangements. However, the case forthe revenue funding of a telecare service underthese arrangements, even if linked to acommunity alarm service, still needs to be made.Similarly, subject to eligibility criteria yet to bedetermined and the scope and financial thresholdof a personal telecare service, the proposed futurefunding system requires clarification as towhether the costs of telecare, especially ifdelivered through an integrated housing, care andsupport service, will be met. This will bestrengthened if telecare can demonstrate that itmeets the

Percentage Country

< 5 Denmark

5-9 Germany, Netherlands, UK

10-14 Belgium, France, Ireland,

Luxembourg, Spain

15-19 Italy

20+ Portugal, Greece

Table 2.1 older people Percentage of who are lonely in Europe


Section One

government's objectives, notably prevention,and can demonstrate that it is cost-effective.Clarification is therefore required from therelevant government departments(Department of the Environment, Transportand the Regions/Department of Health andDepartment of Social Security) and localgovernment associations on whether telecarewill be built into the scope of eligible supportservices under Supporting People. This willinfluence providers' future investmentdecisions.

Sheltered Housing

While sheltered housing is a key componentof meeting the housing and care needs ofolder people, it must be remembered that itonly consists of a small proportion of theaccommodation older people occupy.Approximately 90% of older people live inordinary accommodation either owned bythemselves or rented, whilst only 5% live insheltered housing with a resident warden and5% live in some form of institutional care.11 TheAudit Commission's recent report on the roleof housing in community care12 suggests that(local authority) sheltered housing is failing toprovide an effective alternative to eitherresidential or nursing care, or 'staying put' inone's own home. It points to the lack ofclarity of vision on the future role ofpredominantly local authority shelteredhousing, a vision that should focus onprevention and enabling vulnerable people toremain in their own home with appropriatelevels of care and support.

Assistive technologies, whether to monitorthe lifestyle and well being of an individual,and thereby aid in the delivery of personalcare services, or to assist personal mobilityand functionality, will inevitably have a crucialrole to play in reshaping sheltered housing.Sheltered housing could therefore become amore flexible provision able to adapt to thechanging care needs of its users. In order toachieve this flexible provision existingsheltered housing and support networks needto be remodelled incorporating the newtechnology.

ConclusionsOver recent years there has been a significantchange in government policy towards providingbetter-integrated service provision between health,social services and housing. Policy statements havebeen made to enable more people to be supportedin the community and greater emphasis has beengiven to prevention. Particular reference has beenmade to reduce morbidity and loneliness levels, andtelecare could have an important role to play inmeeting these proposals. However, there isuncertainty over the funding of telecare systems butit would appear funding could be met, especially ifdelivered through an integrated housing, care andsupport service. The policy statements highlightedsuggest that the government recognises theimportant role technology could play in the future.

18


Recent policy developments have influenced thedebate on telecare andassistive technologies:

• Better Government for Older People - acentral theme is to provide an ageingpopulation with better services and moreinformation. Technology, and inparticular the Internet is well suited tosuch tasks

• New Deal for Communities: SocialExclusion and New Technology - thenew Social Exclusion Unit has beenestablished to improve governmentaction to reduce social exclusion andtechnology could play a significant rolethrough the Internet and teleconferencing

• Supporting People - the proposedreform of housing benefit with theseparation of housing and care/supportemphasises a shift to supporting peoplein the community according to their needs

• sheltered housing - The AuditCommission's recent report pointed to alack of clarity of the vision for the futureof sheltered housing. Assistivetechnologies have a crucial role to playin reshaping sheltered housing.


Chapter 2. The policy context for the development of telecare

References

1. Lewis, H. et a/., (1999). Promoting Well-Being, Developing a PreventativeApproach with Older People. Kidlington:Anchor Trust

2. Department of Health (1998). SavingLives Our Healthier Nation: A Contractfor Health. HMSO: London

3. Prophet, H. (Ed) (1998). Fit for theFuture: the Prevention of Dependency inLater Life. London: Continuing CareConference.

4. Wistow, G. & Lewis, H. (1997).Preventive Services for Older People:Current Approaches and FutureOpportunities. Kidlington: Anchor Trust.

5. Social Exclusion Unit (1998) BringingBritain Together: A National Strategy forNeighbourhood Renewal. HMSO: London

6. Dahrendorf, R. (1979). Life Chances:Approaches to Social and Political Theory.Chicago: University of Chicago Press.

7. Ageing International (Dec 1993).Attitudes of Europeans Toward Age.Ageing International. Vol. XX No.4.

8. Welin, L., Larsson, B., Svardsudd, K.,Tibblin, B. & Tibblin G. (1992). Socialnetwork and activities in relation tomortality from cardiovascular diseases,cancer, and other causes: a 12-year followup of the study of men born in 1913 and1923. Journal of Epidemiology andCommunity Health. 46 (8), pp. 127-132.

9. Sugisawa, H., Laing, J. & Liu X. (1994).Social networks, social support, andmortality among older people in Japan.Journal of Gerontology. 49 (1). S3-S13.

10. Department of Social Security (1998). Anew policy and funding framework forsupport services. Interdepartmentalreview of funding for supportedaccommodation. London: Crown.

11. Tinker, A. (1997). Older People inModern Society, pp. 110. Harlow: Longman.

12. Audit Commission (1998). Home Alone:The Role of Housing in CommunityCare. London: Audit Commission.


Section One

Chapter 3

Understandingthe technicalconcepts

In the areas of telecare and telemedicine there hasbeen considerable financial investment over recentyears in Europe and the UK, some details of whichare provided in Appendix 1. Telecare encompassesmany terms and concepts that could be investigatedwhich have an impact on older people and serviceprovision and thus would merit further investigation.Work carried out within the European Commission's(EC) Technology Initiative for Disabled and ElderlyPeople (TIDE) programme perhaps gives the mostcomprehensive picture of community caretechnologies and the application areas aresummarised in Table 3.1.12

However, the focus of this document is on telecareas it is thought this has the greatest potential to assistthe people Anchor Trust serves. Definitions oftelecare, related themes, and the development of newgenerations of telecare services are provided below.

Telemedicine

'Tele' derives from the Greek word for 'far' and, asthe name suggests, telemedicine

involves linking together medical practitionerswith each other or linking medical practitionerswith patients. As such the geographical locationof the two or more parties is irrelevant. For thepurposes of this document telemedicine isdefined as the practise of medical care usinginteractive audio-visual and datacommunications. This includes medical caredelivery, diagnosis, consultation and treatment,as well as education and the transfer of medicaldata.3

Telecare

Telecare is a similar concept to telemedicine andat the beginning of this document we definedtelecare as the remote or enhanced delivery ofhealth and social care services to people in theirown home by means of telecommunicationsand computer-based systems.4

Because telecare and telemedicine are similarconcepts which both seek to deliver healthcareservices at different locations using Informationand Communications Technologies (ICTs), thetwo phrases are


Chapter 3. Understanding the technical concepts

Technology area ApplicationsSupporting life at home Smart house

Multimedia environmental control Systems tosupport cognitively impaired people AssistivedevicesAids for daily living 'Design for all' products

Remote care and services Alarms/securityMonitoring systemsTelemedicine

Mobility and transport Navigation systems within large buildingsAccessibility information systemsAdvanced wheelchairsRoad transport informatics

Control and manipulation Compensatory devicesAssessment tools

Restoration and enhancement of function Optimised hearing instrumentsPortable communication equipmentRehabilitation systemsFitness devices

Interpersonal communication VoiceTextVideo

Alternative media Text interpretationElectronic newspapersTelevision text captions and audio descriptionMultimedia translation systemsAlternative interfaces

Access from a distance Information accessTeleshoppingTeleworkDistance learningEntertainment and leisure

Table 3.1 Key areas of research and development in community care technologies

sometimes used interchangeably. Thedifference between them is that when one ofthe locations is the patient's home or othernon-institutional setting this is referred to astelecare.5 Evidently when developingtechnology and services for older people intheir own homes we are developing a telecareservice.

Assistive Technology

This is an umbrella term for any device orsystem that allows an individual to perform atask they would otherwise be unable to do orincreases the ease and safety with which thetask can be performed. 6Examples vary fromthe technically simple, for example a walkingstick, to complex technical aids such as

intelligent wheelchairs or electronic height-adjustable sink and kitchen units.

Smart home technologies, intelligenthouses or domotics

This is the integration of services andtechnologies, applied to houses andapartments, with the purpose of automatingand obtaining an increase in safety, security,comfort, communication and technicalmanagement.7 The emphasis of the Smarthome is to assist the user in activities in theirown homes,8 Recent demonstration sites bythe Joseph Rowntree Trust9 and EdinvarHousing Association10 have indicated potentialbenefits. Keyless doorlocks, door andwindow opening mechanisms, intelligent


Section One

bathroom controls and video entryphones arejust some of the devices used. The Integercompany also pioneers new technologysystems alongside more efficient constructionmethods and green energy-saving techniques.The company estimates that its new homes,including some Smart home management,would cost around 15% more to build thantraditional homes. Over 30 landlordorganisations are sponsoring Integer,including The Housing Corporation.11 Therange of services offered by Smart homes isvast and some examples are given in Table 3.2.

Generations of telecare

It has been proposed that the community caretechnology available, and what is likely toappear in the future, falls into three distinctgenerations of devlopment.12

1st generation systemsCommunity alarms are the technologycurrently in use today and have been referredto as a 1st generation system. Technicallysimple, they have proved themselves to beboth reliable and welcomed by users. Aspreviously indicated, despite their widespreaduse they suffer from a major limitation. Theuser must initiate the call for assistance, whichthey may be unable or unwilling to do. Suchsystems have no embedded intelligence andare solely reliant on the user activating a callfor help.

2nd generation systemsDespite the limitations of 1st generationsystems it must be acknowledged that they areand will continue to be very successful,enabling support to be provided when the userrequests it. Second generation systems mayhave all of the features of the 1st generationsystem but will provide some level of localintelligence in the home or dispersed in thesystem. For example, sensors might bepositioned both on the user, or in the home,which can effectively detect alert situationsand instigate a call for assistance if required.Second generation systems therefore moveinto pro-active systems that can generate alertcalls if the user is unable to do so. The goal ofthe Anchor Trust /BT project was to developsuch a 2nd generation system in order toaddress the limitations of the precedingsystem. This is outlined in Chapter 4.

3rd generation systemsThird generation systems are currently theultimate goal of the technologists. They mayencompass the detection parameters of theprevious systems and indeed add additionaldetection capabilities, but they will alsocontribute to an improvement in the quality ofthe users life by using tele-services. The kindsof services that could be delivered remotelyare numerous but could consist of:

• banking• shopping

Service Group Examples includeBuilding - based onmonitoring theperformance of thebuilding

Heating andenergy efficiency

Gas/water supply External and internal lighting

Fire alarm

Security - based onthe safety and securityof residents

Doors and windowopening/closing/locking

Selective access Personal alarmscontrol

Intruder alarms

Home control -operated by theindividual to facilitateindependent living

Doors and windowopening/closing

Opening/closing Turning on andcurtains off lights

Usingequipment

Telecommunication -provide access toinformation andcommunication services

Information onrecreation andlocal services

Library services Shopping services Meals services

Table 3.2 Examples of the range of services offered by Smart homes


22

Chapter 3. Understanding the technical concepts

• interactive exercise• medical diagnosis• integration with other people

- teleconferencing.

The 3rd generation system focuses aroundthe widespread use of telecommunications andintroduces the concept of virtualneighbourhoods.13 Here, irrespective ofgeographical location, people and organisationscan be linked together and the social networkof an individual extended to anyone connectedto the system. Services can then be delivereddirectly into the home and greater efforts madeto reduce loneliness and isolation.

The three generations of telecare arerepresented in Figure 3.1. It is important tonote that both 2nd and 3rd generation systemsare not commercially available at present andthus they represent an area of uncertainty.Community alarms have proved successful, butthe implications of increasing the technology inpeople's homes to the levels prescribed by the3rd generation system, in particular, need to beunderstood. Increasing the role of technologymay provide more choice to users and aidindependence but issues concerning theacceptability and intrusion of such systemsneed to be addressed, as does the implicationsfor service delivery. It is not enough for thetechnology

simply to gather and transmit data from thehome; the data must be interpreted, andsufficient services must be available to respondto the results obtained.

ConclusionsCommunity care technologies cover many areasof research and development, all of which havethe potential to assist older people. However, byconcentrating solely on telecare it is hoped moreof the people Anchor Trust serves can beassisted and given the greater choice andindependence the use of technology suggests.

The evaluation of the three generations oftelecare provides a useful insight into potentialdevelopments in the future. Currently we are inbetween the 1st and 2nd generation systems andthe implications on service delivery and theassociated acceptance levels of the introductionof such technologies is not clearly understood.The preceding chapters have indicated thattechnology and telecare in particular meritsfurther investigation and it is hoped byinvestigating 2nd generation systems AnchorTrust and other providers can learn whether ornot technical advances are merited in thedelivery of services to older people.


Section One

4. Barnes, N.M., Edwards, N.H., Rose,D.A.D. & Garner P. (1998). Lifestylemonitoring - technology for supportedindependence. IEE Computing andControl Engineering Journal. 9 (4),pp. 169-174.

5. Department of Health. (1998).Supplementary information on the ICTresearch initiative.http://www.doh.gov.uk/ict.htm: 6.

6. Royal Commission on Long Term Care.(1999). With Respect to Old Age: LongTerm Care - Rights and Responsibilities.London: The Stationery Office.

7. Ad van Berlo. 22/23 Feb 1999.International Conference on SmartHomes and Telematics. ProgramAbstracts. Netherlands. Ppl.

8. Tang, P., Gann, D.M, & Curry, D. (2000)Telecare: New Ideas for Care and Support@ Home. Bristol: Policy Press.

9. Joseph Rowntree Foundation. Winter1998. Smart Moves. Search 31, pp. 14-15.York: Joseph Rowntree Foundation.

10. Edinvar Housing Association. (1998). Aid


Of all the community care technologies thatcould be investigated, telecare appears tooffer the greatest rewards to both users andservice providers alike. Smart homes alsoshow significant potential but considerableresearch has already taken place in thisfield.

The 1st generation telecare systems(community alarms) in use today are usedby over 1 million people in the UK but haveno system intelligence within them and onlywork after the user instigates a call for help.The 2nd generation system describedincorporates a degree of intelligence so thatalert situations can be automaticallyrecognised and assistance provided withoutthe user having to explicitly raise an alarm.Such 2nd generation systems are notcommercially available and it is at this levelthat Anchor/BT sought to investigate theuse of telecare systems.

References

1. European Commission. (1994).Technology Initiative for Disabled andElderly People: Bridge Phase SynopsesDGXIII. Brussels: EC.

2. Mart. (1996). Applications ofTelecommunications for Elderly andDisabled People. Dublin: Work ResearchCentre.

3. Advisor on Informatics of the WorldHealth Organisation. (1997). Report bythe WHO Director General to the 99thsession of the executive board. (Ref:EB99/30)

House - Assisted Interactive Dwelling -House. Publicity leaflet.

11. Roof (Nov/Dec 1998). Chips witheverything. Roof, p. 34.

12. Doughty, K., Cameron, K. & Garner P.(1996). Three generations of telecare ofthe elderly. Journal of Telemedicine andTelecare. 2, pp. 71-80.

13. Doughty, K., Cameron, K.H. &Matthews, M. (1995).The virtualneighbourhood. Geriatric Medicine. 25,pp. 18-19.


Section Two

Chapter 4

The AnchorTrust/BTtelecareproject

Over recent years, throughout Europe andthe UK, technology and community alarmequipment has developed but it is still notpossible to purchase a second generationtelecare system. The majority of researchand projects have tended to concentrate onspecific key areas and, while veryimportant, the benefits that could be offeredto many people, and in particularcommunity alarm users, has perhaps notbeen given the attention deserved. Whilethe potential of new technologies to assistolder people to live independently isacknowledged, there remains littleconvincing evidence about the way thesesystems impact upon the everyday lives ofusers.1 It is also important thattechnological solutions are not 'technologydriven' but are based on an understandingof the needs, requirements and preferencesof potential users. It is against thisbackdrop that Anchor Trust felt it couldmake a valuable contribution to the fieldand more

importantly aid in the development ofservices for the older people it serves.

The project started in April 1997 withfinance provided by British Telecom (BT)and The Housing Corporation via anInnovation and Good Practice Grant. Theprimary aim of the project was to:

Harness the application of newtechnology in a non intrusive way toservice the needs and wishes of olderor vulnerable people, central to whichis that of maintaining independenceand choice.

The stated objectives of the project werefivefold:

1. Develop and implement new technologyto find out if such technology can reliablyand automatically call for assistance if theuser is unable to activate an alarm callthemselves.


Section Two

2. Test and evaluate the benefits/disadvantagesof new technology in supporting older orvulnerable people in their own homes.

3. Explore, consider and assess the issuesconnected to or resulting from its use witholder people themselves. In particular toinvestigate how intrusive such technologiesare and whether or not users want them.

4. Explore the formal and informal networksof carers who support older people, so thatservices of this kind can meet the needsand wishes of both users and carers.

5. Investigate the hypothesis that greater useof technology can enable older people tostay in their own homes for longer in acost-effective manner.

Project partnersIn order to achieve the objectives of the projectit was necessary to form a consortium. Thisconsisted of the following organisations:

• Anchor TrustAnchor Trust is the leading supplier of care,support and housing services to older peoplein the UK. With an extensive customer basein many forms of housing type and tenure itwas uniquely placed to offer a wide range oftrial sites.

• British TelecomBT is the leading supplier oftelecommunications products and services inthe UK. Its technical abilities and history ofdevelopments in telemedicine and relatedfields could provide the technicalrequirements for such an innovative project.

• Other partners have also provided time,materials, equipment, expertise orresources and their contributions aregratefully acknowledged. They include:- Andover Controls- Initial Shorrocks Controls- Knowsley MBC- Nottingham City Council

Phases of the projectThe project sought to investigate threedistinct phases:

Phase 1 - Lifestyle monitoring.

Phase 2 - Biomedical monitoring.

Phase 3 - Information services.

Phase 1

This phase of the project concentrated ondeveloping a lifestyle monitoring system. Thepurpose of this initial phase was to develop,implement and evaluate a system that couldmonitor the lifestyles of people in their ownhomes and look for deviations from a 'normal'pattern of behaviour. If these deviations weresuch that they could indicate that the userrequired assistance then an alert would begenerated. If a situation needed investigating thena system was required that could provide therelevant information to the appropriateorganisation. When the system had beenimplemented and trialed, the participants wouldbe examined so as to understand their perceptionof the system and the possible merits ofdeveloping a system for the wider public. In total,an initial 20 residents were to be supplied withthe system developed, increasing to 60 after anyinitial problems had been eliminated.

In order to achieve Phase 1, there was arequirement to investigate available and possibletechnology that could be used in the trial. As withany innovative project, understanding what theusers and providers actually require was a keyconsideration, as was investigating whattechnology is available and what would bepossible. It should be noted that at thecommencement of this project no-one was fullyaware of what users actually wanted from anadvanced system and understanding what thesystem should do and how to achieve this was akey element of the initial phase.

Phase 2

Various trials have taken place with telemedicinethroughout much of the world,2 The purpose ofPhase 2 was to build upon the initial phase andinvestigate the potential of telemedicine inrespect to older people. Through the use of aseries of biomedical sensors the potential fordetecting illness at an earlier stage than presentlypossible was to be investigated. Examples of theparameters to


Chapter 4. The Anchor Trust/BT telecare project

be investigated include heart rate, blood flow,blood oxygen levels, blood pressure, bodytemperature and blood glucose levels.

It was decided early on that this projectwould not investigate the potential for theimplantation of sensors, where sensors areplaced under the skin, but would ratherconcentrate on the user either wearing abracelet-like device or using a stand-alonepiece of equipment at prescribed intervals.Although implanted sensors have beendeveloped at the Oak Ridge NationalLaboratory in Tennessee for example3, thistrial was more interested in what the usersviews were towards medical monitoring andthe feasibility of using results in theprevention of ill health.

Phase 3

By using voice messaging and/or the Internetthe provision of information andentertainment would be investigated. Thepurpose of this phase of the project was toinvestigate how useful such technologies wereto older people, what benefits they couldderive from them and how easily they coulduse the technology. Access would be either bytelephone to recorded messages (selected bypressing keys on the telephone in response tovoice prompts) or by aid of a simple WorldWide Web (WWW) browser such as the BTEasy Terminal. This facilitates WWWnavigation using a teletext remote control. Asan additional element to the Internet throughthe use of an intra-home network, sensors inthe home could be controlled remotely. Thiswould give either the user or their carer thecapability to control the home environment,perhaps by being able to open or close doorsremotely, turn lights on and off or useelectrical appliances. The potential benefitswere to be investigated with particularreference to the ability to respond toemergencies, perhaps by turning an applianceor the water off.

In addition to this, video conferencing orteleconferencing was to be included. Herepeople can both see and speak to one anotherremotely through information andcommunication technologies. The purposewas to discover if such systems could be usedin reducing feelings of isolation and loneliness.

ImplementationPhase 1 was successfully completed and isdescribed fully in Chapters 5 and 6. Phase 2was also investigated and is described inChapter 7. Phase 3 was the final phase of theproject and was to be introduced after theinitial phases. However, it became apparentthat others were conducting similar researchand therefore Phase 3 was not implemented.In particular SeniorWeb, which is based inHolland (http://www.seniorweb.nl/gb/framez.html) has very similar goals to Phase 3 of thisproject. Its stated objective as an independentorganisation is to draw attention to whatInformation and Communication Technology(ICT) can offer to older people and thoseinterested in what they are involved in.Twenty-five Internet cafes are to be openedacross Holland in residential homes, with thefirst two being located in Eindhoven andMeppel. In a similar fashion to Phase 3 of theAnchor Trust project, researchers intend toconduct surveys to determine what influencethe Internet has on the independence andwell being of residents. The results are yet tobe published but details of their currentactivities can be found at the web site addressabove.

Ethical IssuesThere are clearly a number of ethical andmoral issues that arise with a project of thisnature. In order to progress in a sensitive andresponsible way discussions were held withparties from Anchor Trust's staff, older peopleoutside of Anchor Trust, the technologists,and representatives from social services andhealth organisations. Most importantly,however, focus groups were held with thoseolder people involved in the trial. Throughoutthe project it was made clear that theparticipants' involvement was voluntary andat any time they could remove themselvesfrom the project. The ethical issues arisingfrom monitoring people through the use oftechnology include:

• avoiding the dangers of the use of technicaljargon, whilst not assuming that olderpeople do not wish to embrace newtechnology

• accepting that there is a gradual decline ofactivity in the home with increasing frailty,


Section Two

and that we are not attempting to measure thisdecline in itself

• being sensitive to the roles of spouses,carers, neighbours and others in relation to theusers

• respect of the privacy and dignity ofindividuals, and minimising personalintrusion both in the introducing andmaintaining of equipment and the actualuse of data gathered from the monitoringsystem

• enhancing a sense of safety for individuals, butaccepting that there is a risk attached if thisincreases dependency. Users could becomedependant on the system and considerthemselves not at risk if the system does notcall for assistance. This is particularly relevantwith telemedicine where users may not seekmedical attention because the technology doesnot deem that their condition requires it.

When the technologists discuss anddemonstrate new technology to service providersand older people the important issue of intrusionalmost inevitably arises. Fisk4 has argued thatintelligent systems can be acceptable providedthat some basic issues are addressed.

Attitude to technology - clients must not regardnew hardware as an outward sign of dependencyon external aids, ie a badge of disability.

Promotion and marketing - it is important that thepositive aspects of new devices become the focusrather than the negative associations of fear,anxiety, falls, illness etc.

Aesthetic design - reducing the visibility of theequipment to the point where it blends into thebackground.

Client empowerment - ensuring that control overthe transmission of data out of the home rests atthe hands of the client.

Automatic operation - limiting the need for theclient to interact with the equipment so that itappears less intrusive.

Throughout the project efforts have beenmade to try and minimise intrusion, althoughdue to the very nature of a developmentalproject, this has at times proved difficult. For

example, early on in the project, afterconsultation and agreement with residents,ri

R

1.

2.

3.

4.

28

epeated access to properties was required tonstall and reposition sensors in the home.


In collaboration with BT and othermanufacturers, Anchor Trust set out to contributeto the development of telecare systems and toinvestigate this technology in respect to olderpeople and service provision. The project'sprimary aim was to:

Harness the application of newtechnology in a non intrusive way toservice the needs and wishes of olderor vulnerable people, central to which isthat of maintaining independence andchoice.

The project had 3 clear phases, of which phases 1and 2 have been implemented.

Phase 1 - lifestyle monitoring - monitoringpatterns of movement in the home.Phase 2 - biomedical monitoring -monitoringhealth parameters.Phase 3 - information services - providing accessto additional information sources.

eferences

Roulestone, A. (1998). EnablingTechnologies: Disabled People, Work andNew Technology. Milton Keynes: OpenUniversity Press.Wright, D. (1998). Telemedicine anddeveloping countries. Journal ofTelemedicine and Telecare, 4 (Supplement2) pp. 38-73.The Times. 21 May 1997. Fingertip chipscan reveal all to doctors.Fisk, M. (14/15 November 1996).Telecare equipment in the home: issue ofintrusiveness and control. Proc. TeleMed96. London.


Chapter 5

TheLifestyleMonitoringSystemtrial

If technology is to be used more in supporting peopleliving independently there is a need to develop asystem which overcomes the need for the user toinstigate the call for assistance. In addition, both thecurrent community alarm pendants and pullcords arelimited with up to 40% of people not wearing theirpendant, and users possibly unable to reach apullcord when they require assistance. The purposeof the LMS (Lifestyle Monitoring System) was toassist users by the automatic activation of alert callsso that if support was required and the user had notalready activated their community alarm, assistancewould still be provided. The LMS was designed towork in parallel with the existing community alarmsystem but provide a backup when the existingsystem could not provide the support required. Withpeople not wearing their pendants and the difficultiesof reaching a pullcord one of the constraints

on the LMS was to enable the automatic detectionof problems that did not require the user to wear adevice.

The Lifestyle MonitoringSystem (LMS)The home environment

With input from Anchor Trust, BT has developeda system that is capable of monitoring people'smovements and looking for deviations from a'normal' pattern of behaviour that may indicate apotential problem. In order to achieve this withoutthe need for the user to physically wear a devicesensors are required in each room. Severalcomponents are used to monitor a user's activitybut the key component required in


Section Two

each room is a passive infrared (PIR) movementdetector. This technology used commonly withburglar alarms and security lights was familiar toparticipants and thus many did not consider thetechnology to be intrusive. It should be notedthat a PIR only detects movement, it does notprovide a picture or information about what aperson is actually doing and at this stage it wasfelt this would be the least intrusive method ofacquiring the required information. As well asPIRs, magnetic proximity switches were placedon the refrigerator and entry doors thereforeallowing the system to monitor the occupancywithin the home.

In addition to monitoring patterns ofbehaviour the LMS also sought to reduce therisks of hypothermia. In 1996/7 there were 4,800excess winter deaths including 356 deaths fromhypothermia amongst those aged 65 and over inEngland and Wales.1 A temperature sensor wastherefore placed in the main living area so that ifthe room temperature became unadvisedly low,leading to a risk of hypothermia, advice could begiven.

The final piece of equipment in the user'shome is a control box which receives data fromall of the sensors in the home, stores the datalocally and transmits the data through thetelephone network for subsequent analysis.Throughout the project the data was sent to theBT laboratories in Martlesham Heath. The PIR'scontrol box and fridge sensors used in the trialcan be seen in Figures 5.1, 5.2, and 5.3. TheLMS is capable of being installed in any dwellingtype but for the purposes of demonstration atypical sheltered housing installation is shown inFigure 5.42.

For the majority of participants, in order tominimise disruption, wireless communicationtechnologies were employed, enabling the sensorsto be located throughout the home without theneed for additional wiring or redecoration afterinstallation. Obviously for new build theinfrastructure and cabling can be incorporatedinto the shell of the building without any futuredisruption to the occupant(s).

In order to maintain user confidentiality eachparticipant could turn off the system by diallinga designated telephone number. This is animportant issue as the technology should

Resident activating fridge sensor


Chapter 5. The Lifestyle Monitoring System trial

never impose living constraints on the user. Control ofthe system must always be in the hands of the personthe technology is trying to help.

Data collection

Upon a sensor being activated this data is timestamped and stored at the control box until retrievedby the BT computer. Throughout the trial noprocessing was carried out in the participants home,instead all of the data was sent to the BT laboratoriesfor processing. As such, three ways of transmittingthe data were investigated.

• Transmit on event: when a sensor isactivated the data is sent immediately tothe BT computer. Effectively this is acontinuous data stream and is demandingin terms of communications. However, itdoes allow the data to be processed withminimum delay.

• Call-out periodically: in this case thecontrol box must store all of the datagenerated in a specific time period or eventsequence and periodically transmit thedata. The constraint imposed by thismethod is that the BT computer must becapable of processing this data whenreceived, else blockages could result.

• Call-in periodically: the BT computerdecides when it needs the data from theusers home and will act to retrieve the dataautomatically. This method alleviates thepotential blockage problems encounteredby the call-out periodically method.

Throughout the field trials the 'call-inperiodically' method was employed as thisprovided the most controlled way of gainingaccess to the data gathered in people's homes.Throughout the field trials a number of optionsfor data collection were investigated and thisultimately resulted in an additional telephoneline being installed solely for the control box,with data being retrieved at 30 minute intervals.

Data analysis

Over a relatively short period of time datagathered from a participant's home could be usedto generate a 'normal' profile of their lifestyle. Forexample, many of the participants would both goto bed and get up at regular times. Likewise, thetimes that people went into the kitchen and usedthe refrigerator did not deviate significantly fromone week to the next. Once a 'normal' profile hasbeen generated, new data is compared to thisprofile to look for deviations. In a simplified state,this is depicted in Figure 5.5. Evidently from15:00 hours activity would be expected, howeverin this example no activity is detected until 20:00.Between 15:00 and 20:00 an alert call would begenerated as the activity profile is notcomparable to the 'normal' profile. The exacttime of the alert call depends on the level ofsensitivity required.

In the trial, the following alert situations weresearched for:

• the person was still in bed after the time thatmovement would normally be detected


Section Two

• less activity was detected than usual• the use of the refrigerator was noticeably

different• the room temperature was too low• a change in the pattern of movements

within the dwelling.

Alert call

If a deviation exists between the received data andthe 'normal' profile which is outside of theallowable parameters then an alert call would begenerated. Providing an accurate description of thesituation to the most appropriate person is equallyas important as detecting the alert condition.Throughout the trial automated telephonemessages were sent with information regardingthe nature of the alert to people on the participantslist. As the project was a trial, participants wereencouraged to be the first point of contact.Therefore, if the call did not require attention,services would not be unnecessarily sent to theiraid. The message system was developed by BT3

and upon a participant receiving a telephone alertcall they would be provided with a description ofthe situation and asked to respond. For example:

"Hello. This is a care system call for MrJones. No activity has been detected inyour home recently. If you are well anddo not require assistance, press 1 or ifyou need help from your carer press 2."

If '1' was pressed on the participantstelephone the call would be ended. If however '2'was pressed or the call was not answered then anominated carer would be contacted with amessage such as:

"Hello, This is a care system call for MrsSmith. Mr Jones has not been active

since 4.30pm on the 20th November. Thetelephone number for Mr Jones is 01234567890, that is 01234 567890. To takeresponsibility for the call press 1, to pass thecall to another carer press 2. "

This process would continue until all of thenominated carers on the participants list hadbeen contacted or a carer had indicated that theycould respond. In the trial if all of the carers wereunable to respond no assistance was provided.Obviously this is unacceptable in practicebecause upon the detection of a possible problemthere is a 'duty of care' to respond to thisinformation and someone must respond.Community alarm control centres are wellpositioned to act either as the first port of call oras a default if no carer can respond. It should benoted that the project did not set out to create afinished, polished project, but rather to learn theissues that must be addressed if successfulproducts are to be brought to market. This is onearea that must be resolved before products of thisnature are used more widely.

Overall system architectureThe elements described above constitute thefull Lifestyle Monitoring System and this isrepresented in Figure 5.6.

MethodologyThe trial was independently evaluated by DrAndrew Sixsmith of the Institute of HumanAgeing at Liverpool University. Thisevaluation aimed to provide key informationon a range of issues such as quality of lifeoutcomes and the ability to remainindependent. A multi-method approach wasutilised involving both qualitative andquantitative research in order to gain themaximum insight.

The evaluation was conducted in two phases.

Preliminary phase - this was performed priorto installation of the LMS in order to gain anappreciation of participants' expectations andcomprised of workshops and focus groups.

Core phase - This investigated the LMS trialand the attitudes of participants afterexperiencing the system and comprised of

Comparing data with 'normal' profile



questionnaires with older people and carers,and follow up interviews.

Implementation of the trialIn the development and implementation ofthe LMS Anchor Trust had responsibility for:

• providing access to a range of older peopleliving in different settings

• providing experience in housing,management, care and support activities

• technical and management support for theproject

• organising the field trial.

BT had responsibility for:• developing the hardware and software

components of the system to beimplemented

• supplying and maintaining equipment• installing the system• operating the system.

The overall structure of the project wasclearly defined; Anchor Trust would work withusers to understand the requirements of theLifestyle Monitoring Systems and then workwith BT to develop the system. When thesystem was ready for field trials Anchor Trusthad responsibility for meeting and explainingthe system to potential participants andagreeing on which participants to include in thetrial. In consultation with participants BTwould then install the necessary equipment andmonitor its performance. An overview of theproject structure is expressed in Figure 5.7.Issues for RSLs and other providers arisingfrom this are discussed further in Chapter 8.


Section Two

34

When potential participants had indicated awillingness to be involved in the project it wasimportant to carry out one-to-one discussionsto ensure that they were aware of exactlywhat the project entailed and what their rolewould be. If after these discussions theywanted to be included in the trial thenconsent forms were signed and a technicalevaluation of the site carried out. The purposeof this was to indicate the kinds and numberof sensors required at me installation stage. Itwas also necessary to obtain details of carers,both formal and informal, who may beprepared to be contacted if the LMS detectedsituations that required further investigation.These carers were then informed about thetrial and their details confirmed if they wishedto be involved. Following consent fromparticipants and their carers, BT would thenorganise an appropriate time for installationand commencement of the field trial. Theprocess used is developed in Figure 5.8.Further implementation issues are highlightedin Chapter 8.

Following agreement from all parties, thenext step was to install the equipment. BThad responsibility for this and details of the

installation procedure are provided in Figure5.9. Chapter 8 will provide advice fororganisations seeking to install telecaresystems.

Implementation issuesThe project was highly innovative bringingtechnology and a system to trial that hadnever before been tested. Consequently therewere inevitably complications that needed tobe addressed throughout the project and fieldtrial.

Control box

Some of the technology supplied by thecommunity alarm manufacturers was limitedby the number of additional sensors thatcould be connected to them. When trialingthe equipment it was evident that the limitednumber of sensors was a stumbling block andconsequently it was not possible to generate arealistic picture of the participant's lifestyle. Inorder for the community alarm equipment tobe enhanced sufficiently, considerabledevelopment costs would have to be incurred



and therefore BT developed their own controlbox which had a similar function to thedispersed alarm, but had greater capacity. The'box' developed and used in this trial was aprototype and is further highlighted in Figure5.10. Future developments would result in theminiaturisation of the 'box' and the 'box' itselfwould become more appealing to the eye.Because during the trial time data wasretrieved at 30-minute intervals it was feltnecessary to add an additional telephone lineto each dwelling, solely for the control box. Itwas also necessary to replace someparticipant's telephones as a 'tone' telephonewas required to respond to the automaticallygenerated messages.

Generating the user profile

Although people do tend to follow dailyroutines that indicate a 'normal' pattern ofbehaviour there was considerably moredeviation than originally expected. Forexample, if a special event was on thetelevision, perhaps late at night or at a timewhen the person might normally have anafternoon lie down, the pattern of behaviourwould deviate from the 'normal' but thiswould not constitute the need to call forassistance. Finding the balance betweendetecting what is a deviation from the normalrequiring an alert call and what does not wasparticularly difficult to solve. Over time, asmore data was received on lifestyle patterns,this became easier to detect.

PIR conflicts

The positioning of the PIRs is particularlyimportant as it is possible for two or morePIRs to be active at the same time. Forexample, depending on where an individual isin the dwelling and the locations of the PIRs,movements could be detected simultaneouslyby several PIRs. This is depicted in Figure 5.11where because of the locations of the PIRs inthe bedroom and the hall, movements withinthe conflict zone will be recognised both bythe bedroom and hall PIR. It is thereforenecessary to develop practices and proceduresthat remove this conflict, either by the carefulsittings of sensors or intelligent decision-making software. It was also discovered thatwhen leaving windows open the wind could


Section Two

blow curtains or blinds and provide anadditional conflict.

Recruitment of participants

Four sites were chosen to trial the LSM and therewere therefore a limited number of people thatcould be used in the trial. Despite meetings beingheld on the purpose of the project and the roleparticipants would play there were somedifficulties in recruiting volunteers. It wouldappear that there were several reasons for this.

• Many prospective participants found itdifficult to visualise the LSM system.

• People did not want to be used as 'guineapigs' and would rather wait for the systemto be developed and then participate in atrial. This project sought to develop andtrial the system with the same people andthere was some discomfort with thisapproach.

• The length of time needed to involvepeople. Although detailed information wasprovided to partner agencies, residents andwardens, and meetings held discussing theproject it would appear that at times theproject moved too fast for some. Findingthe balance between development speedand the engagement of everyone is critical.

• While some prospective volunteers werewilling to participate because it would"benefit future generations of olderpeople", some informal carers, such asneighbours and relatives/family were unableto commit themselves.

References

1. Anchor Trust. (1998). Killer Homes: Facingup to Poor Housing as a Cause of OlderPeople's Ill Health. Kidlington: Anchor Trust.

2. Adapted from Brownsell, S. & Doughty, K.(November 1997). Healthcare in the Home -The Impact of Technology on the Delivery ofServices. Baseline - Journal of BritishAssociation for Service to the Elderly. No65, pp. 3-17, and Barnes, N.M., Edwards,N.H., Rose, D.A.D. & Garner, P. (1998).Lifestyle monitoring - technology forsupported independence. IEE Computingand Control Engineering Journal. 9 (4), pp.169-174.

3. http://innovate.bt.com/showcase/laureate.

BT had responsibility for:

• developing the hardware and softwarecomponents of the system to beimplemented

• supplying and maintaining equipment• installing the system• operating the system.

With such an innovative project therewere inevitably complications that had tobe resolved. The practical complicationswere:

• recruitment of participants - there wassome difficulty in recruiting people to trial theequipment.

While the technical complications were:

• control box - ensuring sufficient capacity for additional sensors• generating the user profile - developing

the algorithms to analyse the data gathered• PIR conflict - the reliability of the LMS

critically depends on the positioning ofsensors.

3


The Lifestyle Monitoring System removesthe constraint of the user having to wear adevice and can generate alert calls withoutthe user having to activate their alarm. Ittherefore moves from a 1st to a 2ndgeneration telecare system. Throughoutthe project Anchor Trust hadresponsibility for:• providing access to a range of older

people living in different settings• providing experience in housing,

management, care and supportactivities

• technical and management support forthe project

• organising the field trial.


Chapter 6

Field trialresults

In total 22 older people trialed the LifestyleMonitoring System. While this numberappears small, this is one of the largest socialaction telecare research projects conducted inEngland. The individuals involved in the trialwere quite diverse, in order to test the systemin a number of different circumstances. Forexample, the age of participants ranged fromearly 60s to over 85 with most, more than80%, aged between 75 and 84. The locationsof participants also differed as indicated byFigure 6.1.

There were an equal number of male andfemales and the majority of participantsindicated they had some health difficulties.Eight suggested they had significant healthproblems and nine reported they had someminor health problems. In terms of the level

of assistance given to participants in the trial,eight people received home help servicesthough 14 indicated that they needed help atleast some of the time. Evidently theparticipants represented a broad spectrum ofusers which it was felt would effectively testthe system in a number of circumstances.

Participant expectationsbefore implementationEvidence from the workshops and focusgroups revealed that potential users thoughtthe LMS was a system capable of providingassistance to a whole range of people. Inparticular it was thought that the system wasparticularly suitable for people:

Location/Participant Newcastle Ipswich Nottingham Knowsley

Anchor Trust resident 8 5 - -

Local authority resident - - - 5Other eg owneroccupier - - 4 -

Total 8 5 4 5Figure 6.1 Participants by geographical location


Section Two

• suffering from dementia• who were inactive or had disabilities• who may damage or hurt themselves ie

were more prone to falls and accidents• suffering from illness• in the community in their own properties.

One of the comments made was 'There area lot of people living on their own now intheir own property and they would be veryvulnerable and would really benefit fromsomething like this.'

The benefits of the proposed system revealedhigh expectations, in particular older peoplethought that the LMS would help them and otherolder people by:

• reducing anxiety, not just for them but alsofor their family

• enabling people to stay in their ownhome/avoid residential care

• helping to shorten the length of time inhospital

• providing a safety level for people who donot want to spend money on heating -referring to the temperature monitoring.

There were, however, some reservations. A fewpeople thought that they might find the systemintrusive, with a potential loss of privacy and thefeeling of being watched. Also, some wereconcerned about what would happen at the end ofthe trial if the system proved very successful. Forexample, one person commented that ifsuccessful the system could be installed ineveryone's house and if so who would pay for it.

There was also concern raised about the levelsof technology being introduced and some peoplefelt that the ultimate aim of the system was toremove the need for personal care and/orwardens. This was perceived as a bad thing andthere was concern that technology could replacepeople. A further fear was that the aim of theproject was to reduce costs and this could reducecare levels rather than investigating how newtechnology could enhance the delivery of careand support.

Field trialAt the end of the field trial more than 5,000 daysof data had been gathered from 22

participants and 60 alert calls had been generated.When an unusual pattern of behaviour wasdetected an alert call would be generated in one oftwo different categories:

• an unusual pattern of behaviour is detectedbut the user does not require assistance

• the user's unusual pattern of behaviour isthe result of an emergency and assistance isrequired.

The difficulty in recognising the differencebetween these two alert call categories is bestillustrated by an example. Consider the situationwhere a person gets up during the night, say 3am,makes a cup of tea and sits in the lounge watchingtelevision for several hours. These actions can bedetected but interpreting this data can be verydifficult. The same data could represent two verydifferent situations.

Scenario 1The individual concerned could not sleep, so gotup, had a cup of tea and watched television. Afterfinishing their cup of tea they fell asleep on thesofa. As such, this unusual activity should berecognised by the system but, at this stage, there isno need to generate an alert call.

Scenario 2The individual concerned had felt ill during mostof the day, but during the night the situationworsened. By 3am the individual concerned feltthey needed to call the doctor, but before doing sothey thought they would have a cup of tea and seeif that improved the situation. After sitting down inthe lounge with their cup of tea a dizzy spell cameover them and it would be some time before theycould recover and raise the alarm. In this situationan alert call should be generated and assistanceprovided at the earliest possible opportunity.

Throughout the trial the alert calls fell into thefirst category. Unusual activity was detected butthis was not considered as constituting anemergency where action was needed. This is notsurprising because if assistance were to be neededby the people involved in the trial, in mostsituations they could use the telephone or theircommunity alarm. Such methods of raising analarm would in general be quicker than theLifestyle


Chapter 6. Field trial results

Monitoring System as the individual can make thedecision and raise the alarm before the LMS canaccurately analyse the actions and realise that itneeds to take action on the users behalf. This doesnot mean that the LMS has no purpose, rather thatthe intent of the system is to act as a back up toconventional technologies when they are unable toassist.

In the trial two participants fell and the LMShad not raised an alert call. This was because inboth cases the people who had fallen used theircommunity alarms immediately, thus the LMS hadinsufficient time to recognise the problem.However, importantly, the results of the trialindicate that in these circumstances if the user hadbeen unable to generate the alert call then the LMSwould have detected this situation, contacted acarer and, as a consequence, the user would nothave been left lying on the floor indefinitely.

doesn't have to do anything... The thing Ilike is the certainty, never mind the buttonor warden. You would be certain to bepicked up if there was anything wrong'

In terms of qualitative research, at the end ofthe trial 86% thought new technology was agood thing, while the remainder were unsure. Itshould be noted that no-one thought that newtechnology was a bad thing. Evidently the trialenthused those involved in it and satisfactionlevels were high with 80% either very or fairlysatisfied with the LMS. Consequently,participants thought the system was importantwith 46% deeming the LMS as either essential orvery important as shown in Table 6.2.

Participant experiences

A successful system

Many service providers are aware of the benefits ofenhancing the technology offered to older peoplebut until users can have practical experience ofthese technologies no-one can fully appreciate boththe benefits and limitations. At the end of the fieldtrial evidence from qualitative and quantitativemeasures indicate that older people believe thesystem to be advantageous. Some of the viewsexpressed by residents are provided below.

‘I am quite impressed by the way itworks. I think it is a very good idea... Iwould recommend it to anybody living ontheir own.'

'The push button system (communityalarm) is excellent. I fell in the bathroomand 1 pushed the button on the pendant toManchester Anchorcall headquarters.They got an ambulance to me within 15minutes. It was very efficient I thought.But some people won't wear them. TheAnchorBT system is not so immediate,but it is infallible, because the person

This is an important result that demonstratesthat lifestyle monitoring should be available notonly to those in assessed need, but to those whofeel vulnerable. Removing fear is an essentialfoundation to enabling people to remain in theirown homes, stimulating independence andassisting in preventive measures affecting wellbeing.

As previously expressed, although it was a trialparticipants had high expectations of the systemand there were some negative views, but thesecommonly centred around alerts that participantsfelt were not necessary. However, despite someresidents being unhappy with the sensitivity ofthe system the majority, around 76%, thought thesensitivity was 'just right'. Some commentsreceived were:

'It phoned up when I fell asleep on the settee,4.30 to 5.00p.m. I don't usually go to sleepat that time of day. I think it


Section Two

is a bit oversensitive. It doesn't botherme much... it's better than the button, ifI fall over and can't reach the button, Iwould be lying there.'

'The lady near me had so many falsecalls. The warden was called and had totravel in at odd hours of the night... Thelady felt that she was getting the blamefor that, for all the false calls, that shewas to blame for causing the alarms.'

Participants in the trial were asked if theythought the LMS was an improvement on thecommunity alarm system. This is a difficultquestion to answer as the two systems are reallycomplementary. Community alarms only work ifthe user activates them whilst the LMS works ifthe community alarm is not activated.Nevertheless, 67% thought that the LMS was animprovement with 28% preferring a communityalarm, primarily because of the immediateresponse.

Confidence in the system

If more technology is to be used in the future toassist older people then the systems employedmust be effective and users must haveconfidence in them. The system was developedand trialed on the same people but despite somepeople experiencing alerts they felt wereunnecessary, there was still a very highconfidence level in the system. Indeed, 58% feltthe system made them feel more secure in theirhomes and only 11 % felt that the systemprovided no added feelings of security.

‘It makes me feel safer. I am 90 and younever know when you are going to go. Inthe past I have had to use a pendant. Ihad a fall and once I went to bed andcouldn 't get up in the morning.'

It was recognised that in such circumstancesthe LMS would generate an alert call andassistance would be called for them. Table 6.3indicates through various questions theconfidence participants had in the system wasconsistently high.

The LMS has proved that monitoring of thisnature is possible and that participants had ahigh degree of confidence in the system.Approximately 70% thought that if they neededhelp then the system would detect this and theywould be given the assistance they required. Asa consequence the LMS gave people moreconfidence. This is an important benefit becauseif people lose confidence then it may result inrestricted activity and be a significant factor inthe person moving to a less independent, moresupervised environment, such as a residentialhome.1 Obviously any developments that canhelp reduce the possibility of this will bewelcomed by all.

Another key purpose of this system was tohelp users stay living at home.

‘I wouldn't like shelteredaccommodation. I am independent. Iwouldn't like one of those homes. I doall my own cooking. I am independent.This (Anchor Trust/BT system) helpsme to stay at home.'

In addition to enabling people to stay at home itwas also recognised that the system could enablepeople to be discharged from hospital earlierthan at present, for example one participantremarked:

‘I had to go into hospital recently andI didn't like it very much. I think thesystem could help me to spend moretime at home. The system is a goodthing for me'

I feel help will arrive ifsomething happens

I feel moreconfident

It helps me stayliving at home

Strongly agree 59% 47% 41%Agree slightly 12% 7% 6%Not sure 12% 13% 18%Disagree slightly 12% 13% 18%Strongly disagree 6% 20% 18%

Table 6.3 Participants' confidence in the system



I feel I am being watchedall the time

My home is lessprivate now

It is intrusive

Strongly agree 6% 12% -

Agree slightly 12% 12% 13%Not sure 6% 12% -Disagree slightly 17% 17% 31%

Strongly disagree 59% 47% 56%Table 6.4 How participants' felt about intrusion

As previously discussed the emphasis forsupporting older people (and other groups) hasmoved away from institutions to the communityand this is one of the reasons why technology isbeing investigated. Table 6.3 shows that whenparticipants were specifically asked if the LMShelped them to stay in their home, 47% indicatedthey thought it did. It should be remembered thatthe LMS was a trial system and not a finishedproduct and that it is only an element of a 2ndgeneration system. If biomedical monitoring andinformation sources (Phases 2 and 3) wereincluded a significantly higher figure would beanticipated.

Intrusion

Before the trial began potential users expressedconcern that they may find the system andtechnology intrusive. However, by the end of thetrial it would appear that these fears were notevident. Fisk2 has stated that if clear benefits can bederived from the technology then intrusion can bereduced. It would appear that this has happened inthis situation as indicated by Table 6.4.

When asked, is this intrusive? Only 13% ofparticipants thought it was, and these only slightly,with 87% stating that the system was not intrusiveto them. Unmistakably there is clear evidence thatthe system was not intrusive. Even so there weresome people who thought the system was intrusiveand this stems from alert calls they thought wereunnecessary. By way of illustration one participantsaid 'I have had quite a few calls. The last oneswere a nuisance. There's no privacy.' While thiswas a minority view the system was obviouslyintrusive to this person and if the system is to bebeneficial to everyone the level of intrusion mustbe acceptable to almost every user. This target

can be met by agreeing on which alertsituations should guarantee a call.

Who benefits?

As discussed, it would appear that the mainbenefactors of the system were the participantsin the trial since 72% thought the systemprovided added security and 46% deemed theLMS as either essential or very important.Before the field trial commenced it wasthought people living alone in the communitywould benefit the most from this system andafter the trial this was still the case with 62%indicating that they believed the mainbenefactors would be such people. However24% indicated all older people would benefit.Therefore, 86% of those involved in the trialthought that older people would benefit fromthe system. With the success of the trial andthe benefits derived from its use there is strongevidence to suggest that such a system shouldbe made available to many more users.

It is known that with the growing number ofolder people, services will increasingly bestretched to meet the required need. Whencommunity services are lacking this increasesthe stress on informal care givers and makes itmore likely that an older individual, dependenton care, will end up in residential care.3Evidence from the trial is that there is areduction in anxiety, both for the older personand for the family and social networks.Therefore, not only will the system provideassistance when needed but it also reducesstress and may help enable people to stay intheir own homes away from residential care.Table 6.5 presents the evidence for this.

In addition to the results of the qualitativeresearch, participants were aware of thecomfort the system afforded.


41

Section Two

The system gives peaceof mind to my family

Does the system help thefamilies of older people

Strongly agree 56% Yes, definitely 55%

Agree slightly 19% Yes, possibly 20%Not sure 6% Not sure 10%Disagree slightly 19% Possibly not 10%Strongly disagree - Definitely not 5%

'It is a wonderful idea. I live family is in Yorkshire. The feeand peace of mind it gives yoThe system went off when I was at the resource centre. They pfirst, but her boyfriend didn't kso then they phoned my son. warden to check if anything wasaid I was at the resource centrsense that they are on the ball getting to you. It gives you a wof being secure. Oh my son was was absolutely thrilled that it pi

Carers' experienceOlder people's experiences of thvery favourable and if such sysused widely it is important thatreceive a benefit. Generating aalert call is an improvement oncommunity alarm but it is the ralert that is of more significancCarers are major stakeholders similar systems as it is they whactually provide the necessary support. For the purposes of th'carer' refers to anyone giving cformal or informal means, for esocial services contact, friend omember. In total, over 20 carersin the project of which 14 partfollow-up questions.

From above, one of the beolder person's perspective is can reduce the anxiety of fami

42

Table 6.5 H
ow the Lifestyle Monitoring System helps families
on my own. Myling of securityu is wonderful.

out of the househoned my niecenow what to do,He phoned the

s wrong and shee. It gave me aand so quick inonderful feelingvery pleased. Hecked it up.'

se system weretems are to be carers alson appropriate the presentesponse to thise to the user.in this ando respond andcare andis analysisare, be that byxample ar family were involvedicipated in

nefits from thethat the systemly members and

it would appear that carers would agree with thisand many of the other themes expressed byparticipants.

A successful system

Carers were even more receptive to newtechnology than the older people with 93%believing that new technology was a good thing.This is an important result. As previouslydiscussed, one of the fears of both users andcarers was that technology would be used as atool to replace wardens and provide cheaperservices to people. It appears that these carersacknowledged that technology could be used tomonitor people and draw their attention todifficulties earlier than presently possible, while,most importantly, recognising that the purpose ofthe technology is not to replace them orminimise their role.

Carers were asked how important the systemwas to them and similar results were obtained tothose provided by the older people involved inthe trial. Only 7% of carers deemed the LMS tobe essential, but 36% thought it to be veryimportant. Similar figures were obtained fromthe participants with 46% viewing the system aseither essential or very important. However,while 23% of older people thought the systemwas fairly important, 50% of carers were of thisopinion. Thus 93% of carers gave positiveresponses, further demonstrating the success ofthe trial and indicating that there is a demand forlifestyle monitoring.

There were more than 60 alert calls in thecourse of the trial and the majority of residentsthought that the system sensitivity was at anoptimum level, yet it is the carers



who must respond to alert calls and thus theirrequirements may be different. There was someevidence to suggest that the system was too sensitivewith 18% of carers conveying this feeling, but themajority, 73%, indicated that the sensitivity was 'justright'. Since similar responses were obtained fromboth carers and participants it would appear that forapproximately 75% of all participants, the systemcould effectively generate alert calls. However, for25% the system was thought too sensitive. With sucha diverse range of people involved in the trial thesefigures are encouraging but the system needs to bedeveloped further so that all users and carers arecontent with the sensitivity of the monitoring.

Overall carers were very satisfied with the system,as expressed in Table 6.6, and when asked if theLMS was better than a community alarm, 64%believed that the LMS was in fact more effective. Asalready indicated, community alarms and the lifestylemonitoring system are really complementarysystems and harnessing the benefits of both systemswould seem to provide users and carers with thekind of system they are seeking.

Overall, howSatisfied are youWith the system?

Very satisfied 50%Fairly satisfied 36%Not very satisfied 7%No View 7%Table 6.6 Carer satisfaction with the LMS

Who benefits

In a similar fashion to older people, most carers -64% - also thought that those benefiting the mostfrom the LMS would be people living on their own.The remaining 36% thought all older people wouldbenefit. Carers were asked to nominate the group ofpeople who would benefit the most from the LMS,add a group of their own or indicate that no-onewould derive a benefit from it. It is particularlyinteresting that 100% chose older people and thiswould suggest that the carers believed the systemhad a very real positive benefit.

In terms of benefiting families and carers and thereduction in anxiety that may result, positiveresults were again obtained. Everyone commentedthat the system helped families and carers with64% indicating that this was definitely the case and36% saying they thought that this would possiblybe the result.


The evaluation of the Lifestyle Monitoring Systemhighlighted a number of actual and potential benefits,which make a strong case for the implementation oflifestyle monitoring and similar technologies withinthe range of community care services available toolder people. Generally the feedback from users waspositive:

• 80% were either very or fairly satisfiedwith the lifestyle monitoring system

• 70% thought that if they needed help thelifestyle monitoring system would detectthis and automatically call for help

• the system aids independence with oneuser commenting 'I wouldn't likesheltered accommodation. I amindependent. I wouldn't like one of thosehomes. I do all my own cooking. I amindependent. This (Anchor Trust/BTsystem) helps me to stay at home.'

• in addition to aiding independence it wasalso recognised that the system couldenable early discharge from hospital. 'Ihad to go into hospital recently and Ididn't like it very much. I think thesystem could help me to spend moretime at home. The system is a good thingfor me.'

• the system was generally not intrusivewith only 13% indicating they found it'slightly intrusive'.

The feedback from carers was also very positive:

• 86% were satisfied with the system• 93% thought new technology was a good• thing• 64% believed that the LMS was more• effective than present community alarms.


Section Two

References

1. Tinetti, M.E. & Powell, L. (1993). Fear offalling and low self-efficacy: a cause ofdependence in elderly persons. Journal ofGerontology 48 (special issue), pp. 35-38.

2. Fisk, M. (14/15 November 1996). Telecareequipment in the home: issue ofintrusiveness and control, Proc.TeleMed96. London.

3. Alber, J. (December 93). Health and SocialServices. Summarised from older people inEurope: social and economic polices. 1993report of the European Observatory. AgeingInternational. XX (4), pp. 15-19.

Overall the conclusions that can be drawnare:

• the system is generally acceptable. Itincreases the care choices available

• it enhances people's feelings of safetyand security in the home, reducing theirfears and apprehensions, eg of falling orbecoming ill

• it supports and enhances the carers role.

Taken together, these are important factorsthat are likely to stimulate independence andhelp older people to remain living in theirown homes.


Chapter 7

BiomedicalMonitoring

Unfortunately a full-scale field trial ofbiomedical monitoring was not possible.However, focus groups were undertaken togain an appreciation of the range of viewsolder people had on this kind of monitoring.

BackgroundOver recent years telemedicine hasincreasingly been investigated buttelemedicine is not a new phenomenon.Some people say that it came about with theintroduction of the telephone1 and it wascertainly practised by telegraph in the early1900s2 and by radio shortly afterwards.Offshore telemedicine started in the 1920swhen several countries offered medicaladvice from hospitals to their fleets of tradeships using Morse Code.1 Among the earlytelemedicine efforts was the research anddevelopment work into telemetryundertaken by the National Aeronautics andSpace Administration (NASA) in the USA.Scientists at NASA demonstratedsuccessfully that physicians on earth couldmonitor the physiological functions of anastronaut,1 whilst in 1957 Dr Cecil Wittsonestablished the first

interactive video link, between NebraskaPsychiatric Institute in Omaha and theNorfolk State Hospital, 112 miles away.3

There have been many examples ofsuccessful telemedicine projects throughoutmuch of the developed world4-6, whilst inthe UK the government is embracing newtechniques in the provision of medicalassistance. During 1998 the Department ofHealth began a trial of NHS Direct inwhich nurses provide 24-hour telephonehealth advice. The government aims toextend this service to cover the wholecountry by the end of 2000.7 User surveyshave shown a high level of satisfaction fromboth men and women and also with olderpeople who do not want to waste thedoctor's time unneccessarily.8 Makinnonsuggests that between 2003 and 2008 theaccelerating development of computing andbroadband networks will lead to a revolutionin the ways in which healthcare is delivered.One of the consequences of thesedevelopments will be the facilitation of thedelivery of a high standard of health care inthe community.9 As such it is important toinvestigate what older people think of suchinitiatives.


Section Two

MethodologyIn addition to evaluation of the lifestylemonitoring system, Dr Andrew Sixsmith of theInstitute of Human Ageing, Liverpool University,conducted the evaluation of the biomedicalmonitoring phase. In total there were three focusgroups, comprised of participants from AnchorTrust sheltered housing schemes. Participationwas open to anyone living in the Anchor Trustschemes in order to maximise the number ofpeople in each group and to get a wider sample ofusers including those who might be bothpositively and negatively disposed to suchtechnologies. The purpose of the focus groupswas to:

Investigate the attitudes of older peopleto new technology in general and theninvestigate attitudes with respect tobiomedical monitoring.

In order for those participating in the focusgroups to gain an appreciation of the kinds oftelemedicine equipment available, two systemswere described in some detail. It should be notedthat there is an ever-growing list ofmanufacturers and suppliers of telemedicineequipment but for the purposes of the focusgroups theWristCare system from InternationalSecurity Technology (IST) was made availableand a video of Instromedix equipment shown.

The IST system

Details of the International Security Technologysystem can be found at http://www.ist.cc/EN.Thissystem, developed in Finland, provides 24-hourmonitoring of a person's health status using aportable wrist communicator. The communicatoris worn on the wrist and looks similar to a wrist-operated pendant.

In addition to the panic button that a pendantconsists of, sensors for monitoring physiologicalsignals are also included. The WristCare containsa microprocessor that analyses its user's healthcondition and sends evaluation data as well asanalytical results to a base unit. If anything out ofthe ordinary occurs the base unit transmits a callfor help via the telephone network to a helper orcontrol centre. As such, a change in the user'shealth condition following a fall or even

unconsciousness during sleep will trigger analarm automatically whilst flu or a fever on theother hand will not usually trigger an alarm. TheWristCare system's primary role is to call forassistance when the user is unable to or is notable to identify changes in their conditionrequiring investigation.

The system comprises:

• WristCare unit - to measure physiologicalparameters, and a 'panic button'

• MultiLink base unit - continuously receivesdata about your health condition from theWristCare unit and transmits a call for helpvia the telephone network if necessary

• alarm receiving centre or control centre - torespond to the call for help.

The Instromedix system -

Instromedix is an American company fromPortland, Oregon, which specialises in cardiacevent recording and pacemaker follow-upsystems. Details of the company and products canbe found at http://www.instromedix.com. Thecompany specialises in the measurement of anelectrocardiogram or ECG. This measurement isthe most reliable method for diagnosing a cardiacarrhythmia and the single most usefulinvestigation in the management of patients withacute chest pain.10

The system and technology describedcomprises:

• sensors - to be placed on the body torecord blood pressure and ECG

• shuttle - to receive and store that datagathered from the sensors. It also promptsthe user to send the data when necessary

• communications - linked to the user'stelephone line to send data from the hometo the control centre

• control centre - receives the data fromusers homes and presents this for analysis.

The system has three key aims:

• enable early discharge from hospital - byproviding a high level of accuratemonitoring at home patients can bedischarged from hospital earlier in theknowledge that effective monitoring istaking place


Chapter 7. Biomedical Monitoring

• reduce the cost of care - by providing moreefficient home care after a shorter stay inhospital

• manage care more efficiently - computerisedaccess to patient profiles and recordsoptimises communication within the healthcare network.

Focus groupsIn total, 50 people aged from their mid 60s toearly 90s attended the focus groups with thesessions comprised of the following elements:

• attitudes to new technology in general• perceptions of the IST and Instromedix systems in terms of

- general feelings towards each system- potential benefits of the equipment and

system- potential problems associated with the

equipment and system- who the target users would be.

Results

Attitudes to new technology in general

In order to understand people's reactions tospecific technologies it is important to examinegeneral attitudes towards the actual and potentialrole of technology in providing care and supportto older people. Across the three focus groups awhole range of views were expressed,encompassing people who were negative andpositive to the future role of technology. Thegeneral trend to new technology in general couldbe summarised as a welcome one but with a noteof caution. Some of the reoccurring themes were:

• despite the limitations of the presentcommunity alarm system, users were verysatisfied with this system

• those welcoming the automatic generationof alert calls would still require a systemwhere they could call for assistance if theydeemed it as necessary

• if technology is to be used more then thetechnology must work in the way they wantit to work. Only if it meets their particularrequirements would it be welcomed.

Residents knew what they wanted and would notaccept anything less • cost - those who would welcome moretechnology were concerned that they would haveto pay for it and that costs were likely to be highwhilst other people and organisations would makethe savings. Those people unsure about whetheror not they would welcome more technology werealso concerned about the costs and this may haveinfluenced their thinking.

The IST system

The overriding trend was that this system couldplay a positive role in the future withapproximately two-thirds viewing this system in apositive light. Residents commented 'It sounds togood to be true', 'It's a good idea, it's infallible' or'It sounds like a wonderful idea'. Discussionswere often centred on operational issues reflectingthe fact that they saw themselves using thisequipment. Comments were made such as, 'woulda powered wheelchair affect the system'. Somepeople thought that the IST system 'did the samething as the Anchor Trust/BT system but withoutthe sensors'. Residents were aware of the AnchorTrust/BT system with some of the residentsinvolved in the trial. Since the Anchor Trust/BTequipment was already available some did notconsider the IST system as important.

It was generally felt that the system offered byIST was very comprehensive and would benefitmany older people, however there were someconcerns. For example, the comment was made'would it put people out of work?' It was apparentthat behind this was a concern that if theyaccepted this technology then eventually theycould be in a position where people were replacedwith technology, for example their warden.However, there was also a concern that theacceptance of technology could result in fewerjobs for younger people and as such they did notwant to add to the difficulties some young peoplehave in securing employment.

An interesting comment was made that the ISTsystem had the advantage of not having sensorsdistributed throughout the dwelling and therefore'you were not exposed to the public gaze of thesensors'. Obviously this relates to the issue ofintrusion with this


Section Two

resident preferring to wear a device that they couldhide under a jumper. However, the IST systemrequires the WristCare to be worn, which somemay regard as more intrusive than having sensorsdispersed throughout the dwelling.

In respect of who the intended users should bethe simple answer was 'us'. It was felt that 'everyolder person' or 'person needing a little extra help'would benefit. However, it was also discussed thatthose who could potentially gain the most were'people living on their own, without anybody tolook after them.'

The Instromedix system

The overriding theme was that the system was astep too far, it was seen as 'too complicated' and'just too much bother'. Some thought suchmonitoring would be welcome, but this was aminority view. The Instromedix system was seenas a replacement for human contact and residentstherefore opposed this. 'The introduction of thesekinds of system will eventually mean that they willdo away with wardens and district nurses. Thingswill just be manned by machines.' People wereaware that through systems like this dischargefrom hospital might be secured earlier and this waswelcomed as long as any additional communitycare requirements were available at the time ofdischarge.

It was thought that the main benefits from thissystem were not for older people. Comments weremade such as 'The main idea is to free up a hospitalbeds' or 'The doctor benefits most, not us.' Whilebeing discharged earlier from hospital was seen as abenefit there was a considerable amount of concernthat people could be sent home earlier than theyshould be. It was also thought that the system couldhelp keep you out of hospital and this may not beadvantageous.

'It might identify little problems, but not pickup on the big ones. They may not pick up onpossible problems you have if you are in yourown home. I fell over and pressed the alarmbutton and the ambulance came. At thehospital they went through everything andfound I had cancer of the kidney. I think thatwould only have been picked up in hospital'.

ConclusionsThe IST and Instromedix systems are not dissimilar.Both aim to provide medical attention to peoplewhen they require it and enable early discharge fromhospital yet the majority welcomed the IST systemand opposed the Instromedix system. It wouldappear that the IST system was seen as adevelopment of the present community alarm with apendant-like panic alarm and additional features thatcould raise an alarm if physiological signals changed.The Instromedix was portrayed as a more medicalsolution and words such as ECG were used. Inaddition this technology required the user to bemore involved with the placement of sensors orequipment on the body. People therefore becameanxious that they may get this wrong and theybecame sceptical.

Throughout the various discussions and focusgroups several issues were repeatedly raised.

• Cost implications.Few people said they would be willing/able to payfor telemedicine equipment. There was also afeeling that the NHS should fund telemedicineequipment and any money saved should bereallocated into improving services.• Loss of personal touch.Concern was raised at how new technology couldreduce the level of human contact in care andsupport services. In particular participants wereconcerned at the possibility of losing their warden.• Perception that technology was

complicated.In particular the Instromedix system was perceivedas being too complicated. While many were happy touse new technology, the level of user involvementwith the Instromedix system was felt to be too high.The IST system did not require the user to do anymore than wear the device and thus this waswelcomed.

The research indicates that people wouldwelcome some medical monitoring, but areoccurring theme throughout the project is thattechnology would only be accepted if it met theuser's requirements. In combination with theLifestyle Monitoring System, telemedicine couldbecome a key element of


Chapter 7. Biomedical Monitoring

the 2nd generation telecare system but there areobstacles that must be overcome. How thetechnology interacts with the user is critical and iftelemedicine is to have a positive impact there is arequirement for collaborative working. Althoughhousing has a key role to play, in as much as theequipment will be in the home, housingprofessionals must work with health and socialservices to provide the necessary support andinformation.

As sheltered housing is remodelled in the future,wardens could have a role to play in the facilitationof care with patients being discharged from hospitalwith telemedicine equipment. If the support of thewarden is to be utilised then collaboration betweenall service providers is required and it would appearthat this is not currently occurring. In a survey ofsheltered housing staff attending the 1997 CIHsheltered housing conference, less than 10% ofwardens indicated they were regularly informedabout hospital discharge arrangements.11 Iftelemedicine is to be successful in the futurecollaboration is a prerequisite.

References

1. Wright, D. (1998).Telemedicine anddeveloping countries. Journal ofTelemedicine and Telecare, 4 (Supplement2) p. 5.

2. Anonymous. (1997). Classic episodes intelemedicine. Journal of Telemedicine andTelecare 3, p. 233.

3. Bashshur, R. & Lovett J. (1977).Assessment of telemedicine: results of theinitial experience. Aviation, Space andEnvironmental Medicine 48, pp. 65-70.

4. Burton, D.C. & Huston, J. (1998). Use ofvideo in the informed consent process.Journal of Telemedicine and Telecare, 4(Supplement 1) p. 38.

5. Ball, C. & Puffett, A. (1998). Theassessment of cognitive function in theelderly using videoconferencing. Journalof Telemedicine and Telecare, 4(Supplement 1) pp. 36-37.

6. Whitten, P. & Collins, B. (1998). Nursereactions to a prototype hometelemedicine system. Journal ofTelemedicine and Telecare, 4 (Supplement1) pp. 50-52.

7. CallCentre Europe. (1998). NHS Directmeans health advice is just a phone callaway. Issue 17, p. 20.

8. Channel 4. 2 July 1998 8pm. No WaitingRoom.

9. Makinnon, M. (1998). Broadbandmultimedia for education. Journal ofTelemedicine and Telecare, 4 (Supplement1) p. 48.

10. Freedman, S. (1999). Direct transmissionof electrocardiograms to a mobile phonefor management of a patient with acutemyocardial infraction. Journal ofTelemedicine and Telecare, 5 (Supplement1) p. 67-69.

11. Thompson, L. & Page D. (1999).Effective Sheltered Housing: A GoodPractice Guide, p. 93. London: CharteredInstitute of Housing.


Biomedical monitoring or telemedicine is atechnology that can be used to monitor people'shealth at home. If deviations occur then medicalattention can be provided earlier than at present.Two systems were shown to perspective usersand the general response to biomedicalmonitoring was a welcome one but with a note ofcaution - participants welcomed one system andopposed another.

Participants commented that the systemdeveloped by IST was 'too good to be true'. Thistechnology was familiar to residents as it acted asa pendant with some added features for healthmonitoring. The Instromedix system had a moremedical focus and participants rejected this asthey felt there was a choice between technologyand human contact. There was a concern that thecontinued development of technology couldreduce their interaction with people and thiswould be opposed. Nevertheless, if medicalattention can be provided at an earlier juncturewith new technology then this was generallywelcomed.


H'wefTmopiiAciA

e

50

Section Thre
Chapter 8
Frameworkfor customerapplication

What are the implications ofintroducing telecare

ousing has long been considered thefoundation of community care', a notion

hich is entirely compatible with agendas tompower older people and which break awayrom ageist frameworks of service provision.echnologies within the home can play aajor part in achieving community care

bjectives and in helping to ensure that oldereople have greater control.1 The researchdentified that housing and care providers,ncluding Registered Social Landlords such asnchor Trust, must develop cost-effective and

oherent strategies for designing andmplementing telecare systems and services.s such a number of key issues have emerged.

Access to information

It is important that information on LMS ortelecare services is available to all. Informationmust be accessible to people with sensoryimpairments and available for those who do notspeak/read English. It must also explain clearlywhat the telecare service is and what potentialcustomers can expect. For example, when is analert detected and a call generated to anominated carer?

Key pointsTelecare service providers should have a policyon access to information, and how users of theservice can access this information, includingits availability:

• in accessible formats such as large print,Braille or tape

• in other languages.


Chapter 8. Framework for customer application

Promoting/marketing telecare

With the expected increasing demand for LMStype services as the number of frail older peopleincreases and the resultant attempts to maintainindependence, the promotion and marketing ofLMS or telecare services will become increasinglyrefined. It will therefore be necessary for telecareagencies to produce a marketing or promotionalstrategy to ensure awareness of and access to itsservices.

A

I

types of referrals include self referral; by aneighbour, relative or friend; housingauthority or landlord (such as an RSL); healthand social services; non-statutory agencies(such as advice centres, Age Concern or otherbenevolent/charitable organisations); thecommercial telecom and home security/safetysector. It is vital that by whichever routeprospective customers access telecare services,it is easily understood and accessed. Toachieve this there must be close co-operationbetween agencies on how and in whatcircumstances a referral should be made.

During the course of the research project, itwas identified that there could be two distinctreferral procedures subject to whether theprospective customer is a 'self payer' or likelyto be in receipt of state support. The potentialroutes are illustrated in Figure 8.1 below.

Personal telecare plan (PTP)

Telecare systems must reflect the needs andpreferences of users by way of carefulassessment, ie personal telecare plans.Telecare systems of the future could include

Key pointsThe promoting/marketing strategy shouldinclude:

• how the service is provided• who it is for• the type of service to be provided• how this will be customer orientated.

The strategy should also identify targetaudiences including customer groups egolder people, referral sources, otheragencies and professionals.

ccess to the service

t is evident from the research undertaken thatere is potentially a wide referral network. (This

hould be identified in your marketing andromotional strategy). The

many features: the lifestyle monitoring system,community alarm panic buttons,telemedicine. Internet services etc. What oneindividual assesses as beneficial another maynot. Providing the systems required to meetan individuals needs and circumstances isdifficult but very important.

thsp


Section Three

Assistive technologies could help inensuring that the correct resources areprovided to the people who require them. Oneof the difficulties of assessments are that theyare 'snap shots' of that particular time. Peoplehave good and bad days and depending onwhen the assessment occurs the servicesrequired are accordingly provided. Throughthe use of telecare services more detailedinformation can be provided which is based ona longer time frame. Therefore if over time adecrease in the amount of movement isapparent then this information, aided by anassessment, may assist the assessor inproviding the correct aids.

Irrespective of whether the customer is aself payer or requiring financial assistance orstate benefits to meet costs, it is therefore offundamental importance that acomprehensive Personal Telecare Plan (PTP)is completed. This will not only assess anindividual's personal need for a LMS but alsoaid future installation and monitoring.

Maintaining user confidentiality

User confidentiality has to be maintained at allstages of the process, from assessment toapplication, in order to maximise control and choiceof services. The system has demonstrated that it canprovide feelings of security and safety and giveusers a new confidence. As a result there is a greaterchoice available to users, both in terms of whattechnology elements to include in their personalsystem, and in terms of staying in their own home ormoving into more institutional care.

The Lifestyle Monitoring System and telecaresystems in general will give people a choice theypresently do not have. There are clearly people whorequire some assistance and who choose to go intoresidential care, perhaps because they feel at risk andthe level of safety they seek cannot be secured intheir homes. Through the use of systems, such asthat developed by Anchor Trust and BT, these peopleare given a choice. The monitoring many may seekcan be provided in their own homes and thereforethere is a real alternative to moving up the 'careladder'. It should also be noted that for lessdependent people the system provides considerablelevels of comfort and security. Removing fear is anessential foundation to enabling people to remain intheir own homes, stimulating independence andassisting in preventive measures affecting well being.However, due to the complexity and multiplicity ofrelationships between a customer and other partiesin an LMS system, it is essential that there areeffective policies, practices and procedures onconfidentiality.

• professional carer. Give name, address,telephone number and details if a keyholder)

• medical practitioner and social carepractitioner details (eg GP, hospital,social services, other)

• income details (eg employment,benefits, savings and financialcommitments)

• customer technological preferences (egtype of LMS, other smart technologiesetc).

Key pointsThe checklist below gives a useful outline ofwhat should be contained in a PTP. The keydata requirements include:

• customer details (eg name, address andtelephone number)

• customer profile (eg age,wellbeing/impairments, lifestyle andhousehold composition)

• housing situation (eg dwelling and/orstock type, local authority area and sitedetails)

• dwelling specifications (eg size,conditions, accessibility, other facilitiesincluding telephone)

• tenure type (plus name, address andcontact of landlord where relevant)

• housing, care and support needs (egdwelling related, age, health orimpairment related, other circumstances)

• existing levels of care or support (egmeals, domestic help, personal care,nursing care)

• other options (eg warden, alarm,equipment or adaptation, move to otheraccommodation)

• carer details (both informal and formaleg relative, family, friend, neighbour or



Assessing eligibility for telecare

The value of a PTP is that it provides a template forassessing an individual's needs and their LMSpreferences. The detailed information collated willenable customers, both self-payers and those inreceipt of state support, and relevant agencies todecide who would most benefit from an LMS. Wherepossible, assessments should be joint assessmentsbetween health, housing and social services.

Eligibility criteria in connection to LMS are stillembryonic. However, PTPs play an important role inidentifying those in greatest need and, in particular,in ensuring that statutory agencies across health,housing and care provision can plan, pool,commission and/or target their available resources. Itis likely that eligibility criteria will draw on housingand community care assessment practice. This couldresult in the following scenarios.

PRIORITY SCENARIO

Urgent Prevents admission torequirement hospital, or enables early

discharge from hospital ora move to more supportivecare environment

Priority Maintains or promotesrequirement independence in the home

as part of an overall carepackage

Moderate Compliments existing carepriority and support service

Low priority Offers 'peace of mind'to the customer (mostlikely to be taken up byfee payers)

Whichever scenario is followed, it is alsocrucial that when making an assessment, theagreement of both formal and informal carersis obtained. While the PTP should be tailoredto the individual's requirements, the nature ofthese other relationships can introduceunforeseen problems, such as the ability of thenominated carer to provide assistance 24hours a day or the distance between theindividual and the carer who may live out ofthe area. Nevertheless, the plan should offerother practical and realistic solutions toovercome these difficulties, and provide anaction plan for meeting the individual'srequirements. This is illustrated in Figure 8.2.

Key pointsThe confidentiality procedures shouldclearly state:• that the customer has the right to any

information held and access to records• that the information is fair and accurate• what information can and cannot be

passed on to other parties• the procedures for customer redress.


Section Three

Installing telecare systems

Incorporating LMS systems in the design ofnew dwellings can enhance future care andsupport needs of residents. It will also bringdown the cost of retrospective installation. As aresult. The Housing Corporation should reflectthis in its Scheme Development Standards forfuture new build programmes. In particularallowance should be made for the installationcosts including:

• the infrastructure and cabling• hardware and software equipment costs.

These costs should be included in the capitalor remodelling cost and incorporated inapplications for Social Housing Grant.

In addition, RSLs and other housing providersshould incorporate into their design specificationfeatures specific to LMS. For example, thepositioning of sensors, sockets, additional cablingfor telecommunication purposes.

Similarly, in all remodelled housing orretrospective installations of individual customerdwellings, there is a need for detailed specificationand minimum requirements for systeminstallation. In particular, causing as littleintrusion for customers as is possible. Figure 8.3highlights these requirements in relation toconducting a site visit, following a successfulcompletion of the PTP.

The site survey must produce accuratespecifications. As previously explained, the sitingof the sensors is of critical importance. To ensureaccurate data the correct type, number andplacement of sensors must be defined. It mustalso be remembered that the LMS will be installedin a wide variety of dwelling types and sizes andthis will result in a plethora of specificationsagainst customer characteristics. Over time, thiswill make installation more effective and efficient,thereby reducing installation costs and the need torevisit sites to reposition sensors or modifysoftware.

Installation must be undertaken by an approvedcontractor (use Housing Corporation, Care &Repair guidelines as appropriate). HomeImprovement Agencies should be able to includeLifestyle Monitoring Systems within their work.These

5

Key pointsIn following assessment procedures, thesubsequent points should be adhered to:

• no equipment should be installed unlessan assessment of a prospectivecustomer's needs and the appropriatenessof the LMS has been carried out

• the assessments must be customerfocused and 'signed off' by the customer

• consent must also be obtained fromcarers

• where an assessment results inineligibility for LMS, reasons why mustbe given in writing

• customers should be advised of anycomplaint procedures if they areunhappy with the decision.



schemes are ideally placed to monitorinstallation contracts in people's own homes.Consent must be obtained and the customerfully informed of date of installation, possibledisruption and what is being done to avoidany misunderstanding. The latter should alsoinclude any 'making good' such as minorredecoration. Once the system is installed thecustomer and other parties must be notifiedwhen it is going 'live' for data retrieval andsubsequent alert monitoring.

Trouble-free system integration

The telecare system should allow for further systemintegration to enable the take up of additionalservices, when users require or wish them, ie adviceand information, security, energy efficiency andentertainment systems. What is required is a numberof services that can be prescribed when needed. Forexample, some telemedicine equipment may beprovided upon discharge from hospital and thenwithdrawn at a later date. A modular approach istherefore suggested where elements can be addedand removed with ease, utilising 'plug and play'technologies. These should be identified through thePTP process and any further review or reassessment,or ongoing maintenance procedures.

System management andmaintenance

It is essential to ensure easy system management innew or existing dwellings, ie the installation andmaintenance of the sensors, control units, telephonesand software. The introduction of telecare systemsalmost inevitably requires some technology to

be present in every room in the home. Currentlyradio activated systems can be used so noadditional cabling is required, however the lifeexpectancy of batteries is a limitation on thesystem. The life expectancy of batteries isconstantly increasing and more work needs to bedone to find the correct battery technology so thedisturbance of changing batteries can beminimised. It may also be beneficial to investigateother technologies.

Key pointsWhen installing LMS, there should be:

• a client-centred approach, respectingthe individual's needs and property

• an approved contractors list ofagencies with relevant skills

• a complete record maintained of workundertaken against the specification,LMS equipment installed and siting

• notification of the customercomplaints procedure if a customer isunhappy with the installation.

Key pointsAgencies involved in the management andmaintenance of telecare systems must:

• have effective maintenance and repairingpolicies, practice and procedures

• arrange for annual review (or morefrequently) subject to assessmentrequirements

• have the ability to repair, replace orremove telecare components within 24hours (maximum)

• ensure that customers are advised of anycomplaints procedure if they areunhappy with the maintenance service

• ensure that where lines of responsibilityare divided between a variety ofagencies, customers are notified of keypoints of contact and protocolestablished between the agencies toclarify lead responsibilities.

Promoting independence

The independence of users must be promoted byminimising the risks of living at home orpreventing and/or delaying the need to move on tomore costly housing, care and support. Theresearch conducted has proved that telecaresystems could enable people to live at home in amore secure and safer environment with manyresidents believing such systems could delay orprevent a move up the 'care ladder'. However,more detailed work is required to understand theimpact of assistive technologies on older people.

There is a risk that technology can do too muchand may in fact advance a move up the 'careladder'. Smart home technology in particularcould lead to such a possibility where curtainsand doors are opened and closed by remotecontrol or automatically. Users could be in theposition where they can


Section Three

run their home from an armchair. However,although some of these tasks may be difficultthe exercise and movement involved incarrying them out could be helping them tomaintain their independence. Providing thetechnology required is critical and furtherwork is required.

Promoting partnership

Telecare is clearly a housing and care initiativeto promote independence. For the concept tomove from research and development and intoa robust product, housing providers and socialservices will need to collaborate. Throughsocial services, health providers need to makea contribution as benefits such as preventivemeasures and early discharge are derived fromthe use of telecare. Social servicescommissioners will need increasingly tospecify that a telecare environment is to beprovided when tendering for care contractsfor older people.

As previously stated, telecare needs to beseen as an essential part of a care plan, andfor this to happen care and housing providerswill need to co-operate. The introduction oftelecare as part of the care package could helpsocial services to deliver a cost-effectivedomiciliary care service, where older peoplefeel more secure and independent andtherefore need less formal care.

This partnership approach between housingand social services to introduce telecare couldhelp in the current debate to refocus shelteredhousing. The residents of sheltered housingcould be supported, through telecare anddomiciliary care, to remain in their ownhomes longer and not move to more expensiveforms of care.

System usability

Providers must ensure that the system is easilyunderstood by users and carers alike, and easyto use in terms of functionality of theoperating systems and its accessibility to users,ie frailer older people or people withdisabilities. The level of acceptance betweenthe IST and Instromedix systems clearlydemonstrates this point. Both systems couldbe used in similar ways but because onesystem required the user to be quite heavilyinvolved in its use this system was rejected

whilst the more automated system waswelcomed. The research has concluded thatusers are quite willing to be monitored and forthe data to be subsequently analysed andstored but there is a point where users nolonger wish to be monitored if they are tooheavily involved in gathering the data.

The design and operation of the userinterface is perhaps the primary way ofensuring that the user keeps control of thetechnology and their surroundings. Speech andvision are the most natural forms ofcommunication and therefore are obvioustargets for a user interface. Other forms ofinterface include Braille systems, push buttons,physical and optical pointers and joysticks.Whatever form of interface is chosen, it mustbe suited to the needs of the particularindividual for which it is intended, and thesocial and psychological aspects associatedwith its use must not be overlooked.2

Reassurance of the technology rote

Users need to be reassured of the role ofexisting staff, ie the wardens, and thereliability of back-up services such ascommunity alarm systems. Throughout thetrial it was evident that many saw the greateruse of technology as a way of reducing oreliminating the role of wardens and otherprofessionals. One of the purposes of the trialwas to investigate if technology could be usedto enable care and support to be providedearlier than presently possible. The purpose ofthe technology is to draw professionals'attention to situations that require furtherinvestigation, not to replace them.

The introduction of household burglaralarms into the mass market was not used as ameans to reduce staffing levels within thepolice service; in a similar way telecare shouldnever be positioned as a method of reducingthe physical presence of staff. Telecare willenable a better, more informed care service, butit should not be used as a replacement for it.

Ensure the professionals role

Efforts need to be made to ensure thattechnology does not try to replace staff. Anyfreeing up of staff's time should result inadditional housing management and support



tasks in a move to prevention. It is clear that technologycannot provide the support that people give buttechnology can indicate who perhaps requires a littlemore support, and assistance can then be targeted tothese people.

The identity and role of sheltered housing is beingredefined, and therefore the role of the warden alsoneeds attention. As telecare becomes more widespreadin sheltered housing the warden will need to be able torespond to alert situations and provide immediateassistance. Many older people value the traditionalmorning call of the warden either by a physicalpresence or by the community alarm voice system.Telecare should not be seen as a replacement for thispersonal contact, but rather an extension of it.

The telecare system itself will need checking andsimple adjustment from time to time. The warden orcare worker could, with training, perform many of thesetasks. Consequently the updating of the skills andknowledge of new and existing staff must take intoaccount the applicability of telecare systems.

The future role of carers

It is clear from what has been said previously thatformal carers will not be replaced by telecare. At itsbest telecare will restore

confidence to older people and stimulate themto do things for themselves. This may thereforeslow down the need for additional care as timegoes on. Carers will need to understand thepotential and the limitation of telecare, and becomfortable to work alongside it.

All too frequently when an older personbegins to receive formal care, eg domiciliarycare, the informal care of family and friendsrecedes. With the demographic changes leadingto an increase in the older population a waymust be found of continuing to utilise theinformal care system. Telecare can offer tofriends, relatives and neighbours a cost-effectiveway of being alerted when the lifestyle patternchanges. This may encourage informal carers tocontinue in their role and work in partnershipwith more formal care.

Who should pay for the system

More evidence needs to be gathered todemonstrate the feasibility and affordability ofthe system and services, in particular, to thoseliving on low incomes. The Lifestyle MonitoringSystem trialed has proved successful in manyrespects but the question of who should pay forsuch technologies remains unanswered. Suchsystems have the potential to save lives andincrease security and independence, but thequestion of who should pay for these benefits isa difficult one.

It can be argued that the older person shouldpay as they are enabled to stay in their ownhomes, which many of them want. Equally, itcould be argued that the NHS should paybecause such technologies are used in apreventive way, enabling people to bemaintained in the community instead of morecostly hospital beds. It could be argued thatsocial services should pay because it is their roleto help people in the community, and if theyshould pay should the funding come fromwithin the Supporting People proposals?

Finally, it can be argued that housingproviders should fund the provision andinstallation of such systems as it could beviewed as an accommodation issue, especiallyfor those who require additional help. UnderThe Housing Corporation's schemedevelopment standards, in particular for

Key pointsTo manage change, agencies must beginplanning for the necessary skills needed todeliver effective services which may rely ontelecare or similar applications. To achieve this,agencies must:

• take into account the numbers, posts, andquality of staff to deliver services

• set out the training required to meet theneeds of the service

• identify any gaps in provision• consult with staff about the role of new

technology and personal development• ensure staff receive training on age,

cultural diversity and disabilityawareness

• provide customers with a basicunderstanding of how the telecaresystem works and how they can control it.


Section Three

sheltered housing, telecare systems could beconsidered as an equally essential element asother services such as electricity, heating anda telephone point. The debate on who shouldpay is still to be resolved.

References

1. Fisk, M. (1999). Our Future Home:Housing and the Inclusion of OlderPeople in 2025, pp. 26. London: Help theAged.

2. Brownsell, S., Williams, G., Bradley, D.A.,Bragg, R., Catlin, P. & Carlier J. (1999).Future systems for remote health care.Journal of Telemedicine and Telecare, 5,pp. 141-152.


Chapter 9

Conclusions &Recommendations

The Anchor Trust/BT project sought toinvestigate the feasibility of using technology toaid the independence of older people and togive them more choice. The recent RoyalCommission on Long Term Care states:1

"The thrust of the Commission'srecommendations call for improvements inhousing to make staying put a morepractical option and for changes infinancing to tilt where possible towards theindividual in their own home rather thantowards residential forms of care."

To enable people to have the security, safetyand independence the Royal Commissionsuggests there is a requirement to have someform of monitoring in the home. Technology isone way in which this could be done but thereare a number of other factors drivingdevelopments.

• Older people are increasingly usingtechnology and benefiting from its use.They are therefore starting to demand newtechnologies and push for developments.

• The emphasis for supporting older people(and other groups) has moved away frominstitutions to the community and

technology enables a level of monitoringpreviously only possible in institutions.

• Technology can improve the user's lifestyleas recognised by the recent RoyalCommission into long term care.

• Demographic change is resulting in anageing society. The European Commissionhas predicted that between 1995 and 2025the UK will see a 44% rise in the 60 andover age range.2

• Older people absorb the greatest finance.Those aged 85 and over are the heaviestconsumers of all. The average per capitaspending on services for this group is fivetimes that of the whole of the 50-64 agegroup3 whilst the number of people aged85 and over is the fastest growing cohort.

Against this backdrop technology isincreasingly being investigated and used toassist older people in their own homes. Thepresent technology, community alarms, hasproved successful but it suffers from a majorlimitation - the user must initiate the call forassistance. Until the user activates the alarmcall no assistance can be provided and a usermay not activate their alarm because they areunable to, or they may be unaware that theyneed assistance. The Anchor Trust/BT project


59

Section Three

sought to investigate the possibility of usingtechnology to aid the independence of olderpeople and to remove the limitation of thecommunity alarm system. As stated the primaryaim of the project was to:

Harness the application of new technologyin a non-intrusive way to service the needsand wishes of older or vulnerable people,central to which is that of maintainingindependence and choice.

Were the project objectives met?Objective Comment1. Develop and implement new technology to find out if such technology can reliably and

automatically call for assistance if theuser is unable to activate an alarm callthemselves

The project has successfully demonstrated that technologycan realiably detect situations that require furtherinvestigation and automatically call for assistance

2. Test and evaluate the benefits/disadvantages of new technology insupporting older or vulnerable people intheir own homes.

The evaluation of the project indicates that users gainedconfidence from the system and consequently enabled themto be supported at home. The only disadvantages discoveredcentered on the possibility that technology could ultimatelyreduce or remove human contact. This was a major concernand is likely to impact upon the take-up of such systems. Ifpotential users feel the system will replace human contactthen the system or technology is likely to be rejected.

3. Explore, consider and assess the issuesconnected or resulting from its use witholder people themselves. In particularto investigate how intrusive suchtechnologies are and whether or notusers want them.

There is clear evidence that the users in this trial werecomfortable with the technology and intrusion was perceivedto be very low. It is also very clear that the system has manypositive aspects with 46% of participants deeming the systemas either essential (32%) or very important (14%) with 23%suggesting the system was fairly important.Unmistakably there is clear demand for such technologies.

4. Explore the formal and informalnetworks of carers who support olderpeople, so that services of this kind canmeet the needs and wishes of both usersand carers.

The Lifestyle Monitoring System met the wishes of users andcarers. Carers were even more receptive than the olderpeople with 93% of carers believing that new technology wasa good thing and 93% of carers having positive feelingsconnected with the system trialed.

5. Investigate the hypothesis that greateruse of technology can enable olderpeople to stay in their own homes forlonger in a cost effective manner.

As previously stated 47% of participants though the systemcould enable them to stay living at home. In addition it wasalso thought that early discharge from hospital could beachieved as a result of the Life Monitoring System with oneparticipant commenting ‘I had to go into hospital recentlyand I didn’t like it very much. I think the system could helpme to spend more time at home.’ As a result it would seemthat telecare systems could be cost-effective, but morelongitudinal research is required to clarify the situation.


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At the end of the project this target has beenmet. The project has developed a system andproven that lifestyle monitoring is an effective toolin automatically recognising alert conditions.Potentially life-threatening situations, whichpreviously could go undetected, can now berecognised and assistance provided.

Before the field trial began the system andtechnology were perceived to be intrusive bypotential users and providers. However, when thetrial concluded it was evident that intrusion wasnot as significant as initially believed. Thoseinvolved in the trial were asked 'is the systemintrusive?' Only 13% agreed slightly with thisquestion, while 87% stated the system was notintrusive to them. Other less direct questionsaimed at this subject matter also revealed that thesystem was not intrusive with only 18% feelingthey were being watched.

The Lifestyle Monitoring System aidsindependence with one user commenting:

‘ I wouldn’t like sheltered accommodation.I am independent. I wouldn't like one ofthose homes. I do all my own cooking. Iam independent. This (Anchor Trust/BTsystem) helps me to stay at home.'

In addition 47% of participants in the trialthought the system could enable them to stayliving at home. The system therefore provides agreater degree of flexibility and choice. Theparticipants believed that by having the systemthey could be enabled to stay in their own homesrather than move on to other care arrangements,therefore empowering the older person andproviding greater choice.

The results of this trial suggest that lifestylemonitoring would be a welcome component in thefuture. People are enabled to stay in their ownhomes with greater independence, security andchoice. It would also appear that similar resultscould be obtained with more dependent people.For people who require high levels of care andsupport, residential care is usually cheaper than aflexible domiciliary care package allowing them tostay at home. Most local authority social servicedepartments have well-defined guidelines forprioritising clients and assigning a maximumspending limit on each case4 and

a domiciliary-based care package is only a realoption under public funding as long as costs donot exceed the equivalent residential or nursinghome costs. Where the dependency of the clientis high, requiring intensive levels of care, thenthey are likely to be admitted to residential care.The 'dependency threshold', or the point whereinstitutionalisation becomes necessary for theindividual, is therefore not determined byconsiderations of care, but primarily byeconomic considerations. The use of newtechnology could play an important role movingthis dependency threshold towards a higher levelof need, extending the options available topeople in these categories.

The capacity of telecare to proactively raisealarms, even when the person is unable to do so,will mean that living at home will become a safeand secure option for higher dependency clients.This is very much in line with currentphilosophies of long-term care of the elderly anddisabled and provides a win-win situation. Olderpeople gain as many of them choose to stay intheir own homes and the technology can helpfacilitate this, whilst overall funding organisationsgain, as providing people with what they wantand preventing an unnecessary move would alsoappear to be financially the most cost-effectiveapproach.

Cost-effectivenessTo prove the cost-effectiveness of this and othertelecare systems more longitudinal research isrequired. However drawing on research lead byProfessor David Bradley and conducted by theUniversity of Abertay, Dundee, in associationwith Birmingham City Council HousingDepartment, there is evidence to suggest suchsystems can be provided in a cost-effectivemanner. This work compared a 2nd generationtelecare system incorporating lifestylemonitoring and telemedicine with the presentcommunity alarm system and for 10,000 olderpeople a saving of £5m over 10 years, wassuggested.5 Even on a simplified example theeconomic benefits are evident. Approximately 5%of the older population live in some form ofinstitutional care6, representing about 450,000people in the UK. As a result of the LifestyleMonitoring System 47% of participants


Section Three

thought the system would enable them to stayliving at home. Nevertheless, if it is assumed thatonly 5% are enabled to stay at home rather thanenter institutions then 22,500 people can stay inthe community instead of entering institutions.

In monetary terms if the cost of residential careis used, then at a cost of £2657 a week, for 22,500people almost £6m a week is saved. This,however, does not represent an accurate figure.People in the position of possibly going intoinstitutional care or being enabled to live at homewith new technology must pay for the equipmentthey require and any additional community carethey may require. Taking a conservative analysis,assuming an additional carer visit per day at £108

and 3 nurse visits a week at £14 each, additionalcare costs equate to £112. Therefore, the actualsaving is £153 per person per week or £3.5m forall 22,500 people on a weekly basis. Translatingthis to an annual sum reveals a saving of £179mwith the only costs not included being related tothe equipment.

In financial terms, the 22,500 people representthe people where the greatest monetary savings areobserved. However, as demonstrated by this trial,telecare systems have the potential to benefit manypeople and in particular community alarm users.The results from the University of Abertay takeinto consideration many more of the operatingcosts and compare costs with all community alarmusers having a telecare system. Expressing theseresults as representative of all community alarmusers in the country reveals a potential saving of£58m a year.

RecommendationsThe Lifestyle Monitoring System has clearly beenshown to be a successful and welcome componentof a new generation of community alarm systems.It is hoped that the growing evidence from varioussources and the foundation laid by this trial can befurther built upon to offer older people the choice,safety and independence so many of them areseeking. In order to achieve successful telecaresystems various organisations must take a positiverole in developing what older people

and service providers require. Therecommendations that follow provide aframework for what could be done to build uponthe work already carried out in this field.

• Government - needs to take a lead inbringing together health, housing and socialservices to deliver a holistic service aimed atincreasing independence and choice for olderpeople. Existing vertical funding systems are ablockage to joint working and to a user-focused service that uses a new technologyplatform to support people in the community.

• Health Service - could be a majorbenefactor. The growth in the number of olderpeople means real savings are unlikely, but newtechnology can play a significant role inreducing demand for primary health care.Early discharge from hospital and preventionare key positive areas for further work. Lifestylemonitoring offers considerable potential.

• Social services - need to understand thevalue of new technology and value itspreventive and 'peace of mind' contribution.Social services will need to take on board anassessment role if the equipment and itsrunning costs are to be publicly funded.

• Housing service providers - newtechnology can benefit the delivery of housingmanagement and support services to older peoplein their own home. It can also aid older people togain access to repairs and maintenance servicesand to broader services such as advice andinformation about their housing and care choices.

• Housing design - there is a need toincorporate new technology into designspecifications. New and refurbished orremodelled housing should be more flexible andable to accommodate new technology withoutcausing major disruption to the dwelling. Thisshould be reflected in The Housing Corporation'sScheme Development Standards and thegovernment's modernisation programme.

• Housing revenue - it is essential that capitaland revenue funding decisions arecomplementary in the light of thegovernment's review of housing benefit and thefunding of supported accommodation.


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• Housing investment funding - shouldrecognise the important role of newtechnology and provide capital funding forsuitable equipment and its installation. Thisshould be taken into account in The HousingCorporation's future investment strategies anduse of its Approved Development Plan tofund new build and refurbishment.

• Home improvement agencies - shouldbe able to include lifestyle monitoring systemswithin their work. These schemes are ideallyplaced to monitor installation contracts andensure people who wish to remain in theirown home have the technology infrastructureto be able to do so.

• Technology providers - need to formconsortia to take forward the research ideasfrom this and other projects. Much of thebasic equipment exists, but it is not broughttogether into affordable, practical productssuitable for a wide market. Future systemsneed to be flexible, upgradable, reliable andcustomer friendly.

Older people themselves have clearlyindicated, in this and other related work, thatthey want a fully integrated system. Thereforelifestyle monitoring, and other telecareinitiatives, need to be integrated with thepresent community alarm technologies. This isnot an unreasonable request and technologyproviders need to form consortia to bringsuitable, affordable products to market.

• Community alarm centres - need tomove away from their traditional role and bewilling to provide a 'call centre' type service,more integrated with social services andhealth, and be able to respond to lifestylemonitoring systems.

• Older people - many are already usingtechnology and increasingly wish to do so tomaintain their independence and feeling ofsecurity. Older people need to be assisted tofeel comfortable with new technology and beprovided with the training and skills to makemaximum use of it, which would be beneficialto them and to public finances.

References

1. Royal Commission (1998). With Respectto Old Age: A Report by the RoyalCommission on Long Term Care, p 88.London: The Stationery Office.

2. The Guardian 5 March 1996.3. Glending, C. & Mcloughlin, E. (1993).

Paying for care: lessons from Europe.Social Security Advisory Committee,research paper 5, pp. 14-27.

4. Audit Commission. (1996). Balancing theCare Equation: Progress with CommunityCare. Community Care Bulletin Number3. London: HMSO.

5. Brownsell, S., Williams, G., Bradley, D.A.,Bragg, R., Catlin, P. & Carlier J. (1999).Future systems for remote health care.Journal of Telemedicine and Telecare, 5,pp. 141-152.

6. Tinker, A. (1997). Older People inModern Society, p 110. Harlow: Longman.

7. Government Statistical Service (1996).Key Indicators of Local Authority SocialServices, Section 5. London: Departmentof Health.

8. Audit Commission (1998). Home Alone:The Role of Housing in Community Care,p. 32. London: Audit Commission.


Section Three

European research anddevelopment programmesA considerable amount of time and money hasbeen invested, by both private and public sectors,in developing a range of telecare and relatedtechnologies. In recent years the majority of thelarge-scale projects have originated from theEuropean Commission, in particular under the IVFramework programme and the TechnologyInitiative for Disabled and Elderly people (TIDE)programme. The scope of this latter programmeincluded research and development into productsand services targeted to the general marketwhich can assist older people and people withdisabilities to fulfil their needs and maintain theirindependence.1 The TIDE programme started in1991 with a pilot phase of 21 technologydevelopment projects and a major study ofrehabilitation technology in Europe. In 1993 anadditional phase of TIDE2 was introduced toprovide a bridge between the pilot phase and theIV Framework programme. This had a budget of42 MECU1 (£29m).

The IV Framework programme operated from 1994to 1998 and in total funded research anddevelopment across all its themes to a total of13,215 MECU (£9,170m). Details of the IVFramework and its programmes can be found athttp://www.cordis.lu/src/i_006_en.htm. Funding wasprovided for a range of themes includingInformation and Communication Technologies, LifeSciences and Technologies and Transport. Ofparticular interest to Anchor Trust and thedevelopment of services for older people was theTelematics for Disabled and Elderly People themeunder the Telematics Applications Programme(TAP). For research and development in this area atotal of 69 MECU (£48m) was made available withthe purpose of developing applications whichprovide support for independent living, autonomyand social integration opportunities.3 It is not thepurpose of this document to provide details of all thetelecare and related projects, however projectsfunded by the EU in this area can be found at

http://www2.echo.lu/telematics/disabl/disabl-proj.html.

Appendix 1


Appendix 1

As the IV Framework programme ended, the VFramework programme began and it will end in2002. The total budget for V Frameworkprogrammes has increased to 13,700 MECU4

(£9,507m), of which 483 MECU (£335m) hasbeen made available through the The AgeingPopulation and Disabilities section of Improvingthe Quality of Life and Management of LivingResources.5

United Kingdom research anddevelopment

Appendix References

1. http://www2.echo.lu/telematics/disabl/backgr-1.html#over

2. European Council decision on acommunity technology initiative fordisabled and elderly people (TIDE) 1993-1994. OJL240/42 of 25.9.1993.

2. http://www2.echo.lu/telematics/disabl/obj-dis.html

3. http://www.cordis.lu/fp5/src/budget.htm4. http://www. cordis.lu/fp5/src/budget1.htm

Collaboration between academic institutions andcommercial enterprises has been facilitated in recentyears by the Technology Foresight programme of theUK Office of Science and Technology. The healthand life sciences panel of the Office of Science andTechnology has funded the AgeNet projecthttp://www.agenet.ac.uk with the aim of stimulatingmultidisciplinary and multisector researchpartnerships relevant to academia, industry and theNational Health Service.

The Engineering and Physical Sciences ResearchCouncil (EPSRC) (http://www.epsrc.ac.uk) has beenparticularly concerned with developing newtechnologies to help disadvantaged groups such asfrail older people and disabled people. In 1997, theEQUAL (Extending Quality of Life in the BuiltEnvironment) programme was launched to helppeople remain independent and active for as long aspossible. This clearly recognises the significance ofpopulation ageing. In 1998, EPSRC launched asecond call for proposals under the HealthInformatics programme. Of particular relevance toolder people were two information technologythemes to support patient care, and technologies tosupport rehabilitation and enablement.

In respect of projects and developments in the UK,the Research and Development Division of theDepartment of Health has commissioned a databaseto be compiled providing a list of current researchand suppliers of telemedicine equipment in the UK.Details of projects including the Anchor Trust/BTtrial and a list of suppliers can be found athttp://www.dis.port.ac.uk/ndtm.


a report on the anchor trust/bt telecare research project · acknowledgements during the course of...

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