Look Homeward: Simon Brownsell

The Road to Home Telecare for the Elderly in the UK, and What Lies Beyond

By Dr. Kevin Doughty
e-mail: dr.k.doughty@btinternet.com

Background

During the 20 th Century, profound changes in lifestyle and life expectancy impacted the way that Western society dealt with disease, disability and healthcare. Hospitals changed from relatively small local institutions where people died, to enormous treatment centres where lives were saved by complex surgical interventions aided by new imaging and diagnostic technologies. Tertiary hospitals excelled in offering specialist treatments for people with serious or complicated conditions.

One consequence of these changes has been to increase the journey length of many people from their first GP appointment through to their treatment at a hospital that could be tens if not hundreds of miles away from their homes. Patients are more likely to be older, reflecting both an ageing population and the increased likelihood of older people suffering from many of the life-threatening conditions such as cancer and heart disease. Travelling is a major issue for them and for their families and friends.

Thus, using technology to bring treatment closer to the patient should be popular with the general population, as well as potentially reducing the effect of geography in enabling people in rural communities to access the very best of healthcare services. This is the attraction of telehealthcare which includes telemedicine between healthcare professionals in hospitals, clinics and GP surgeries, and telecare, which provides remote management, and/or delivery of healthcare services to the individual’s own home using information and telecommunications systems.

New and Emerging Technologies for Use with the Elderly at Home

The significance of Telehealthcare in the development of future models of care cannot be overstated but it must develop alongside two other technology streams that are also maturing due to developments in the electronics and information systems industries. They are Assistive Technologies and Smart Homes, which have emerged from their previous focus on either overcoming challenges of physical disability or of providing an entertainment centre (mainly through home theatre) into a mainstream where convenience, security and a compensation for some of the problems of old age.

Figure 1 shows a connection diagram for the full range of services that can exist in the home together with telemedicine and home designs and adaptations which are deliberately excluded from the telecare model. They are clearly converging and telecare would seem to be the logical banner under which they might all be discussed. However, it is apparent that telecare will continue to grow, as an agenda until all the technologies are mature and available and when services have been developed to exploit them in a complete and holistic manner.

Figure 1: The Convergence of Technologies That Are Embraced by Telecare

Telemonitoring

The need to supervise vulnerable people to ensure that they are supported quickly in the event of an accident or a bout of illness is a fundamental tool employed to control identified risk situations. This can be intrusive, especially if it involves the use of video surveillance techniques, and will ultimately be limited by the number of people available to monitor images. This leads to the use of “smart” sensors where smart is defined in Table 1. These are effectively alarm sensors because they transmit signals that are relayed as emergency situations that need to be responded to according to an arranged protocol and escalation procedure.

Table 1: Significance of SMART Sensors in Telecare Systems

Feature	Acronym Meaning	Consequence
Specific	Each sensor detects specific dangerous situations without ambiguity	Allows most appropriate response protocol to be followed
Modular	Individual sensors can be added or removed as a person’s needs change	Investment in hardware is minimised; less intrusion for service users
Automatic	Sensors are passive and need no action on behalf of the client,	Telecare system can be used by people who are unable to interact with technology
Rapid	Designed to produce alarm in the minimum possible time	Enables risks to be managed by ensuring that help is quickly at hand
Tested	Performance of sensor has been validated in independent pilot studies	Little chance of device failing to meet the desired requirements

The first smart sensors used in the UK were mainly environmental in nature-- i.e., they provided an alarm for situations that represented a risk to the fabric of the home, such as smoke, flood, the presence of combustible gases, and extremes of temperature. Whilst these sensors may be considered as protecting the housing stock (which implies that they might be installed as standard by builders and by landlords), they also have great potential for protecting lives. They are all relatively straightforward (and hence low price), as they have no user adjustable parameters to consider.

Safety Systems

Many people are moved into residential care because of the risk to their safety when they perform some of the activities of daily living, especially bathing and cooking, without help or supervision. Closed loop control of such situations using a sensor and an actuator is possible in many cases. The examples shown in Figure 2 can be used to prevent a flood, a fire on the hob, a fall, and a gas explosion. Others will switch off an electric cooker if it’s been on for too long without attention, or switch on the lights to the exit in the event of a fire alarm.

Figure 2: Examples of Closed Loop Control Systems Used in the Home

Communications Systems

The communication needs of future homes will be extensive, as the system must allow for a wide range of functions of the type shown in Table 2. The connection to the outside world must serve basic alarm needs but also new applications based on broad-band and video technologies. These will be necessary for virtual presence applications that will be required for overcoming social isolation and depression and also for accessing a range of information services.

Table 2: Telecare Applications for Communications Systems

Application	Examples
Interact	Digital TV enable viewers to provide opinion on specific issues
Vote	E-voting will support community development
Socialise	Virtual meetings and trips using video telephony
Discuss	On-line chat-rooms and debate forum
Educate	E-learning and virtual universities
Entertain	TV, radio and other broadcast media

At this time, it is unclear whether services to the home will be delivered through microwave transmissions, or through wired or cable services. Within the home there will be an increasing emphasis on wireless technology but the possibility of data collision will need to be addressed.

Response Services

Although telecare is a service that is primarily delivered at a distance, it nevertheless requires people to involved at all levels from assessment of unmet needs and risks to independence, through to the installation of technologies. Telecare does not remove the need for people to deliver hands-on care. Rather, it offers ways of using human resources more efficiently and more effectively. Support is always available but is offered on a Just in Time rather than a Just in Case basis; this minimises intrusion for the 90+% of people who want to be independent and who do not want strangers in their own homes unnecessarily.

The correct use of telecare enables providers of planned care services to be employed more purposefully, and their performance monitored through the measurement of outcomes. Thus, rehabilitation or reablement by therapists and other healthcare professionals can be assessed through automatic telecare services employing the 2 nd generation techniques such as Lifestyle Monitoring. However, it is unplanned needs-- i.e., emergencies, that are most difficult and costly to the NHS and to local authority services. They may occur at any time of day or night, during the week or at weekends. All require a rapid response though the level of training and expertise of that responder will vary greatly according to the nature of the problem. Whilst a person with a detached (or blocked) catheter will need trained medical support, someone who needs helps to mop up water following a domestic flood would gladly accept the intervention of a housing support officer. In each case, an ambulance to take the client to hospital would be inappropriate and unnecessary. This would be the only solution in the absence of a dedicated response team or if the telecare service was unable to identify the problem automatically.

Figure 3: An Emergency Response Tele-Ring of Care

Figure 3 shows the possible composition of an emergency response team, which can be called upon to deal with any foreseeable situation that might require telecare. It assumes coordination by a Telecare Service Centre where protocols are in place for each identified risk, and an escalation procedure that ensures that there is a contingency plan for every circumstance (especially when a named family responder is not available). The operation of such response services is not yet sufficiently mature to identify the responder who is most likely to be able to provide a service in the majority of situations. However, from an analysis of alerts from social alarm systems, it is likely that mobile wardens of home care staff could be fundamental to the successful implementation of a telecare service.

Overcoming Future Shortages of Carers

Telecare does not per se reduce the need for human intervention, and it most certainly does not attempt to take away from vulnerable people the important human contact provided by their carers. However, current projections show that the population continues to age while the birth rate declines – a phenomenon not confined to Western Europe and North America. If the care needs of older people are not significantly reduced by improvements in lifestyle, medication and surgery, then there will be an enormous mismatch between supply and demand. This will inevitably mean that many of the most vulnerable older people will be unable to access the care services that they will need and demand.

The previous sections have shown that technologies embraced by telecare can support a form of independence where help with personal care is replaced by machines, or by “electronic assistants”. Whilst it might currently be difficult to envisage the appearance of a device that helps a lady to pull on her stockings, there can be no doubt that such equipment could be made if there was sufficient demand, and constraints of cost and maintenance were removed. Making the device in a form that would be acceptable in the home is another matter, but one that is already taxing the creative skills of engineers.

Conclusions

By taking the first steps down the road to telecare, we have started a process that could transform the way that people maintain their independence when challenged by age, disability or loss of function or senses. Progress could be rapid if people share a vision and understand that the driving force is choice, dignity and independence rather than economic advantage. Extending telecare to the use of more personal and safety electronic devices and systems will have a major effect on service provision and could ease demands on domiciliary care services.