Studies on ageing: ECA series in conjunction with the Sheffield Institute for Studies on Ageing

Doug Emery is a lecturer at the School of Nursing and Midwifery in the University of Sheffield with involvement in SISA. He is also a trustee at Sheffield Crossroads, an agency involved in providing respite care for the carers of older people. He addresses the importance of supporting older people with telecare.

Introduction and perspectives: The current limits of telecare and telemedicine

In this paper, the importance of focusing advice on the specific needs of the older person and their family are explored and discussed. In particular, carers and older people often have their own personal standards of care that might defy the usual criteria for minimum care standards. These criteria must be addressed if trust is to be maintained between all parties involved in providing assistance for older people.

One way in which support might be improved is through the inclusion of telecare systems in the home. This is complicated by contrasting viewpoints that either centre around the belief that such technology can be intrusive or that it can be supportive in the knowledge that assistance is never far away.

Advisers working with older people may be struck by the increasing rates of change within recent community-care policy, which has been the subject of major modification. Other initiatives did not receive the same attention. Telecare and telemedicine has been talked about for the last decade and yet, apart from personal-alarm systems, few ideas have been implemented and set up to facilitate independent living at home.

The need for perceptibly proper support at home

Within the areas of health, social services and housing, there has been a policy shift from hospital-centred care to an emphasis on care delivery at home. The rationale for this is straightforward: institutional care is expensive and most people would prefer to live under their own roof, managing their own affairs rather than handing control over to a designated professional. Many government documents and initiatives have been released, for example, the NHS Plan, the Supporting People arrangements and provision to sustain home ownership, all of which are designed to promote self reliance.

A central element of research at SISA attempts to understand the preferences and views of older people and their carers. This we believe is essential to determine the most effective and appropriate care and treatment for this client group. Our own work and that of others clearly demonstrates the desire among these recipients of service provision to maintain personal autonomy, but people can be daunted if support at home is not up to their own very high standards.

The work of Mike Nolan and Sue Davies at SISA has demonstrated that older people and particularly their carers often make subtle judgments about care based on their own perceptions of cost and benefits. It is important to take account of the individual’s perception of their needs in developing care packages so that they are able to play a realistic part in assessing the merits of any changes.

In today’s consumer-oriented society, the notion that doctor or legal adviser knows best is increasingly challenged. Satisfaction among clients is almost certainly driven by positive relationships as well as the quality of the advice. Relevant services may be rejected if they don’t regard the help offered as specifically relevant to their own requirements. These may involve unusual situations that include personal routine behaviour rather than logic.

What level of care is appropriate?

Within healthcare there has been a lot of emphasis on client-centred care but this is being enhanced by a wider focus that concentrates on the family unit being involved in determining the most appropriate care provision. Carers provide about 80 per cent of support for older people and it is appropriate to value each individual within the family framework when developing a set of services that will keep the whole group informed, prepared and functioning.

Home care may be preferential for most people, but often nursing and residential care is necessary to remedy deteriorating circumstances. There have been a number of high-profile cases in both nursing home and domestic-care environments that have resulted in the provision of inadequate care. This has been a factor in the implementation of the Care Standards Act (2000), which requires each organisation to meet specific criteria. Implementation of national care standards for both nursing and domestic-centred agencies has been ongoing over the last few years with the consequence of a more professional approach within voluntary and independent organisations. This, in turn, is raising prices for many organisations that consequently experience financial difficulties. The costs will inevitably impact on the funders of the service, with many older people providing a significant proportion of their own care costs.

Sometimes older people find themselves in a position through which they require direct care up to several times daily. This inevitably means a social care or health worker coming into the house regularly. The relationship between the care worker and the cared for is usually good, but it does allow workers to challenge rights being exercised by the occupier of the home. As long as continuity of staff is maintained and competent people assist the individual, trust between all parties is usually retained.

Although many older people are in a position whereby they require regular direct care, the numbers of older people needing occasional assistance is even higher. These people might only require visits for basic tasks to be carried out such as getting the shopping or cleaning the house. This may be of concern to families due to the lack of monitoring in relation to the high chance of falls, occasional episodes of forgetfulness or other medical problems that could lead to a crisis situation. To suggest that people who fit into this category require supervised care within an institutional care setting may not be desirable or acceptable to them. A more preferable outcome would allow them to remain within familiar surroundings but have the safeguards and features built into their home environment. This may also avoid anxieties often felt by carers who worry that their relative may be left for long periods in a dangerous situation or wander outside due to a mildly confused state.

“Smart homes” facilitating better care at home

The term “smart homes” and telecare relate to a system designed to facilitate the delivery of health and social-care assistance to people in their homes through the use of technological devices. It can be argued that early implementation of such systems came with the advent of the telephone, but it wasn’t until the introduction of alarm monitoring that this assistive technology moved into mainstream healthcare. The present systems usually incorporate radio-data communication and have a central unit that fixes into the telephone connection and a number of devices that can link wirelessly to it. The most basic systems have an alarm trigger that the person uses to summon help when they are in difficulty, while others include a visual and audio system for identifying callers and a remote method for unlocking the door. Alternatively, devices are able to detect natural gas, flooding, smoke, carbon monoxide and temperature. These can be linked to systems such as a flood detector that will automatically turn the water off while simultaneously alerting care workers to the problem.

Some telecare devices are more intrusive and include a bed-occupancy sensor that turns lights on when the person gets up. The monitoring station is warned if the individual is not in bed during times they would usually be asleep. Homes can also be set up with wandering detectors that trigger if the front door is opened during certain intervals, such as 11pm to 7am. Fall detectors are still in the process of being developed, some of which have the advantage that they use mobile-phone technology, but at the moment I regard these as unreliable. Medical-focused data can also be transmitted using telemetry, as in the case of electrocardiograph data or blood-sugar information. It cannot, however, be regarded as a mainstream NHS approach to healthcare at home although is commonly used in emergencies by paramedics.

The use of assistive devices as an alternative to closer personal supervision can be supported through lower costs and add a sense of security for vulnerable people and their families, while also maintaining choice and dignity regarding care provision. For many, the implementation of telecare monitoring incorporates automatic transmission of data when a crisis occurs and strengthens their ability to retain independence. For others, there is concern due to lack of trust or understanding in the systems and sometimes they perceive them as unreliable or over-intrusive.

As a co-ordinator of telematics projects I am rarely surprised by the reluctance of people to accept that data-security measures are adequately in place and systems are safe to use. Further concerns raised ensure the need for equipment to be aesthetic by fitting it in with the environment, be automatic whenever possible and allow the user to feel, and be in control. With modern electronics, there is no need for bulky, obtrusive, unsightly boxes cluttering up the home and the user has to be able to trust the system and possess the knowledge to operate and manage it.

One particular project in which I was involved included the use of videophones attached to the person’s TV. This could be regarded by some as particularly intrusive. However, some people found it to be a comfort as they were able to talk and see other people in similar situations to themselves. One of the intentions was to enable communication between health practitioners and people at home, but we found that the home users in the trial much preferred to talk with each other than with the professionals. This was a way in which older people were using the technology to avoid loneliness and over time built up an informal support group. The issue of intrusion became secondary and was not regarded as a problem by the users once they felt able to control the camera and associated equipment. A further example illustrating the lack of concern that many people have regarding intrusion is raised by the low level of anxiety people express in the knowledge that their movements can be traced when travelling with a mobile phone.

Many local authorities in the UK have been involved in different telecare trials with varying degrees of success and acceptance. In most locations it is the user who pays for the alarm system and monitoring service rather than the NHS or local authority. New construction of buildings is likely to include provision for broadband access, such as those funded through extra-care housing funds via the Department of Health and some complexes such as in West Lothian that use a telecare arrangement in individual residences. In addition, older properties have been wired up and the infrastructure developed to support a larger community of homes that have devices installed and working. With such initiatives, a package of care that includes telecare support is likely to be supported financially as the infrastructure will be fully in place.

It is hoped that advisers of the elderly will know about programmes that relate to care provision in their areas. There is a very clear structure within the NHS to determine practice that is evidence based, but at the moment it is difficult to provide enough evidence to support a large investment in a technological and human infrastructure for widespread telecare.

The UK government is not averse to investing in technological systems for care-related activity if they recognise a genuine need. NHS Direct is a good example and has been implemented over a short space of time. Locally focused telecare systems may also need a similar national directive to get them to encourage more activity, be more focused and more suited to individual need. Some areas are beginning to recognise that alarm and home monitoring can be cost effective and over time it is possible that keeping people in the comfort of their domestic environment with support using all the mechanisms available, is a better alternative to that of institutional care.

Doug Emery is a lecturer at the School of Nursing and Midwifery at the University of Sheffield. He can be contacted by e-mail at: d.emery@sheffield.ac.uk, or by telephone on:0114 2229861.