This article is the first in a series focussing on the changes and challenges facing the UK’s technology-enabled care (TEC) sector. The series will explore how commissioners and service providers must rethink how they design and deliver services that use technology to help people live independently and on their own terms. We begin with a brief history of TEC in the UK – from its origins in community/social alarms to today’s more contemporary telecare services. This is to understand why telecare services look the way they do and how their centralised service model must evolve to take advantage of the opportunities provided by the sector’s digital transformation.
Social and community alarm systems
In the decade following World War 2, we saw the formation of the NHS and increased attention to the welfare of millions of people who had lost their homes, their loved ones, or their livelihoods. Local authorities were responsible for rehousing the nation’s heroes and its older people; they built sheltered housing apartments and bungalows. These were often serviced by scheme wardens who lived on-site and could provide support using ‘call-bell’ arrangements when needed.
The early systems were basic – tenants had hard-wired pull-cords to the warden’s office (or bedroom), located in their bathroom and beside their bed, Figure 1. These could be used to summon the warden in an emergency at any time of the day or night, seven days a week. They initially featured a simple bell or buzzer, but alarm panels were eventually introduced. Over time, more sophisticated arrangements with intercoms enabled tenants to speak with their warden or visitors who needed to be admitted to a scheme. The limitation was the availability of the warden who could only attend one alarm at a time with no mechanism for prioritisation. Wardens also needed holidays and might be off sick; the quality of provision varied considerably.
However, these systems were popular because, at that time, few older people had easy access to a landline telephone. Alarm systems offered them a convenient way of contacting their GP, the emergency services, or their family through their warden. Over time, the residential warden role became redundant; posts became challenging to fund, leading to a need for visiting services from mobile wardens, often restricted to weekdays and office hours. However, many emergencies happen during ‘out-of-hours’ when housing support services are not available, leading to a gap in coverage.
Meanwhile, an increasing number of older people lived in dispersed housing and did not wish to relocate when they had more significant needs. Many had telephones, which became their means of communicating directly with friends, families and GP surgeries. In 1974, Andrew Dibner, a U.S. psychologist and academic, and his sociologist wife, Susan, invented the Lifeline medical alert system. It was based on a unit with a radio receiver that could be activated by pressing a wireless pendant radio transmitter worn as a lanyard around the neck. In a hospital or nursing home, this would be linked to the nurse’s station, but a version that could be used with the telephone network was subsequently developed, allowing people in their homes to connect remotely to a 24/7 call centre, Figure 2.
The first such centre in the UK opened in Stockport in 1979; others followed rapidly, usually run by local councils or their successor housing associations. Within 20 years, they could be found across the UK and Ireland, with nearly all district councils in England and local authorities in Scotland and Wales having a centre. Those that didn’t usually commissioned a neighbouring authority to manage their connections.
It remained a relatively simple system but offered more options for actively raising the alarm and having a timely and appropriate response as decision-making and response coordination moved from the schemes to the monitoring centre. Each centre could manage thousands of connections fielded by a team of call handlers. We consider the above arrangement the first generation (1G) of telecare.
Care in the community
The number of older people in the UK increased rapidly during the second half of the 20th Century. In particular, the number of “old, old” i.e. those aged 80 or over (and deemed most likely to be at risk of ill health and accidents) increased by over 30% each decade from 1951, Figure 3.
Many of these people, especially those who lived alone, ended up in residential care homes funded by the Department of Health and Social Security (DHSS). When funding was transferred to local authorities as part of the Care in the Community changes in the 1990s, there was a new focus to help keep older people in their homes for longer. This led to a rapid expansion of homecare services and the realisation that community alarm services could play an essential role in avoiding long-term care, especially for people who lived alone or had no close relatives who could look in on them every day.
Technologies matured with a new focus on improving the quality of services at all levels, but especially for those who didn’t live in sheltered housing schemes and for whom there was no warden service to identify issues that could quickly be resolved. Key safes were introduced, with a code for entry held by the monitoring centre, so that responders and emergency services could quickly gain entry without a need to summon the police to knock down the door.
Local authority assessments of need often resulted in some home help being provided to assist with domestic tasks such as light cleaning, laundry services and collecting groceries. It was often accompanied by a referral to a community alarm (1G telecare) service. The areas of most significant concern were the possibility of someone falling and having a long lie on the ground, security issues (often related to bogus callers or the failure to keep the door locked), and forgetfulness, which could lead to flooding, cooking appliances being left on, or someone leaving home during the night and failing to return home. For various reasons, e.g. a reluctance to always wear or use a pendant, these incidents were generally not reported until it was too late. This led to the idea of passive monitoring using smart sensors – and the creation of a second generation (2G) of telecare.
Wireless alarm pendants were used with an extended range of smart sensors, such as the prototypes shown in Figure 4, to detect many different environmental and social/personal ‘emergencies’. These devices were introduced during the first few years of the 21st Century and commercialised mainly through Tunstall, the market leader, following their acquisition in 2001 of Technology in Healthcare (TiH). TiH had developed a range of innovative smart telecare sensors with funding from the then Welsh Office through a SMART award. Their EXTRA (EXtended Telephone Response Alarm) sensors were awarded ‘Millenium Product Status’ from the Design Council and won a major European Innovation in Housing prize.
The prototype devices were used in pilot projects in West Lothian, where telecare was deployed across the county in the most extensive application of care technology anywhere in the world. Other systems were deployed in Northern Ireland by the Fold Housing Association (now part of the Radius Group) and by County Durham and Cheshire district councils. They included a worn fall detector, a bed occupancy sensor, a property exit sensor, an enuresis sensor, a flood detector and a temperature extremes detector. The commercial versions of these devices became the backbone of the products often funded through the Preventative Technology Grant and its equivalent in the devolved nations between 2006 and 2008.
These second-generation telecare systems ‘piggy-backed’ on the established platforms shown in Figure 2 but supported enhanced decoding at the monitoring centre to identify the device and the alarm type/reason. Some devices could signal different alarms or states, enabling the most appropriate response to be initiated. This approach flourished for over ten years during which time the assessments and the support available matured. Services were able to establish protocols around the process shown in Figure 5. This worked well to manage the risks associated with many common emergencies, from environmental concerns such as fire, flood, and gas to more social issues such as falls, medication mismanagement, security, bogus callers, and people with forgetfulness due to cognitive impairments.
This approach was based on the need for effective assessment of risks which could then be managed through rapid detection and response. In most cases, sensors were provided only for those who had already experienced an accident and those who were housebound. Service quality improved significantly but failed to prevent the incidents that led to A&E admissions and the need for long-term care. As charges to service users were increased to cover the cost of providing services (coinciding with the removal of subsidies from schemes such as Supporting People), many users failed to perceive the value in their ‘just in case’ alarm service, especially if they hadn’t had any cause to use it.
The large-scale adoption of smartphones and the introduction of specialist mobile alarm devices that extended the ‘safety net’ outside the home also highlighted the limitations of home-based solutions. Home-based telecare moved into a new phase where data was used to detect abnormal situations and predict future decline using sophisticated algorithms. Their use would enable measures to be implemented that could prevent falls and other accidents from occurring or allow interventions to reduce the damage caused, i.e. a third generation (3G) of telecare.
3G systems have been available from multiple suppliers for several years, with some success, but they have struggled to displace the incumbent alarm-based model as the primary approach to providing technology-enabled care for most people.
The digital age
It may be apparent that the fundamental technologies used within technology-enabled care services haven’t changed that much until very recently. The pace of innovation has begun to accelerate, starting with the introduction of smart sensors at the turn of the century (and the shift from social/community alarms to telecare). More recently, there have been major technology developments in:
- smartphones, apps and the usability of technology
- home broadband, mobile connectivity and low power wide area networks (LP-WANs)
- mainstream consumer smart home devices and in-home wireless connectivity
- sensors and devices such as wearables and the Internet of Things
- battery technology
- voice-based user interfaces and intelligent assistants using ‘AI’ (e.g. Alexa, Siri)
- cloud computing and ‘software-as-a-service’
- data analytics, visualisation, algorithms, and machine learning
Figure 6 summarises the timeline of how technology has changed within technology-enabled care services.
The story of telecare has been one where services have been built around the user’s needs but constrained by the capabilities of the available technology. This has resulted in the dominance of a reactive service model that helps individuals if they, or smart devices, raise an alarm following an adverse incident.
As digital technologies become more mainstream, the range of needs that can be supported using technology will increase, and the nature of that support will also move away from solely focussing on alarms. To maximise the impact of these technological improvements, the services built around them must also be re-designed to reflect this. Significantly, the monitoring service (or control centre) role will change as services move away from a solely reactive alarm-based ‘just-in-case’ approach to a more versatile and preventative data-rich ‘just-enough-support’ approach. The focus on specialist alarm products will also be challenged with greater adoption of consumer devices that are often cheaper and more aesthetically appealing, removing the ‘badge of dependence’ that has plagued the take-up of some devices. The future promises a technology layer in the home and the person that will support ambient assisted living (AAL).
These changes will present numerous challenges to the sector. These will primarily revolve around the shift from an alarm-based service to a data-monitoring service. At a high level, once useful information and knowledge are available, the need to be able to share this across relevant health, care and housing organisations will grow. This will require a level of interoperability not previously seen across the sector – from the development of common data standards on how activities of daily living are recorded to the recording of outcomes. This will be required to support integrating data from products produced by different vendors. It should also be the case that individuals will maintain the right to choose which data are shared and who they are shared with.
Other challenges will be the mix of specialist vs consumer technologies, how people are made aware of and supported by these new digital products, and ensuring data protection and security across the platform. There will also be a significant change in the role of staff, including in the monitoring service. This will require further training and software tools to provide them with the knowledge and skills needed. Access to information resources from the Internet could result in potential service users knowing more about the available equipment than the service officer trying to ‘sell’ them a telecare package. The need for more and independently provided awareness training across professional and consumer sectors is apparent.
The future of technology-enabled care is promising, but these challenges will need to be addressed if it is to thrive and enable a better future in which more people are supported with hybrid care arrangements using an optimised mix of people-based services and technology.
The topics presented here will be discussed further in subsequent articles in this series, which continues with a snapshot of the care technology landscape in the UK.