Special report: Telecare: A waste of time or the future of health and social care?

This article explores how telecare devices have evolved and the growing evidence base that assistive technologies can help to deliver more efficient health and social care services

Telecare technologies are being increasingly adopted by health and social care authorities in order to support people to live in their own homes for longer, reducing costs associated with hospital and nursing home care and improving people\'s independence

In this special report, BBH explores the current market for telecare devices, including personal and environmental sensors and alarms that have the potential to support vulnerable people, particularly the elderly, to live independently in their own homes for longer

Telecare may be a relatively new buzzword, but the principles behind it have been around for decades.

In the 1970s it was relatively commonplace for people living in sheltered housing or care homes to have a pendant or chord via which they could summon help from a warden.

Fast forward more than 40 years and this technology is now known as telecare and has paved the way for similar, albeit more-advanced, systems that have the potential to support people to live independently in their own homes for longer.

We are living longer and that’s great, but with that comes other issues such as how do we support people as they get older and how do we do that cost effectively

This is particularly important as the NHS struggles to become more efficient and reduce reliance on acute hospital services.

“Telecare has been around for a lot longer than people imagine,” said Carl Atkey, head of CarelineUK, the UK’s largest provider of emergency alarm monitoring.

“It started as pendants for social housing so that residents could summon the warden and this evolved into a series of alarm systems. Later these were linked through telephone lines. It was not about an alternative to care, but to give peace of mind to residents and their families that they could summon support if they needed to.”

Under the radar

However, pretty much taken for granted in many social care settings, the future potential of these systems stayed pretty much under the radar until more recently.

“Telecare used to be all about the thing you plug into the telephone line – low-cost ‘button in a box’ technology,” says Atkey. “That is now slowly moving on.”

The major drive behind this relatively recent boost is the Department of Health’s Whole System Demonstrator (WSD) initiative, the largest randomised controlled trial of telecare and the more clinically-centred telehealth ever carried out anywhere in the world.

While the study team is yet to report full details of the results of telecare deployment and the impact they have on clients and the wider healthcare system, as a result of the trial the Government recently announced the launch of the 3millionlives programme. This will see three million people with long-term conditions or social care needs utilising telehealth and telecare devices.

Fiona Carmichael, sales manager at Buddi, manufacturer of mobile personal alarm systems, said: “Three years ago I had never heard of telecare and I had never thought about what vulnerable people, regardless of age, would do to remain at home.

Telecare is as much about the philosophy of dignity and independence as it is about equipment and services

“We are living longer and that’s great, but with that comes other issues such as how do we support people as they get older and how do we do that cost effectively. The vast majority of people want to stay in their own homes and therefore assistive technology can be an enabler.”

Having moved on from the ‘button in a box’ systems of the late 20th Century, telecare is now a huge market with new technologies regularly being launched. These can be grouped into two main categories – environmental sensors and personal sensors.

The first group of solutions monitor the environment in which a person lives, setting off alarms or summoning help should a threat arise. These technologies include sensors that can detect fire or smoke, carbon monoxide and other gases, water or flooding, and temperature changes. As well as calling for assistance, many of these technologies can also automatically shut off gas or water supplies, therefore minimising the potential impact.

With the increasing prevalence of dementia, there is also a growing market for systems that can detect when doors have been opened and when people may have wandered or someone is at the door, including bogus caller solutions, movement detectors and door entry and video security systems.

Peace of mind

Personal devices are much more user-centric. They include epilepsy sensors that know when a patient is having an attack; fall detectors; enuresis sensors; and personal location monitoring devices such as GPS technology.

One of the biggest changes in terms of the demand for new technologies has been for systems that can offer the same kind of support when people leave their homes

A spokesman for the the Telecare Services Association (TSA), the industry body for telecare and telehealth in Europe, said: “Telecare is as much about the philosophy of dignity and independence as it is about equipment and services. Equipment is provided to support the individual in their home and is tailored to meet their needs. It can be as simple as the basic community alarm service, able to respond in an emergency and provide regular contact by telephone, or it can include detectors or monitors such as motion or falls and fire and gas sensors that trigger a warning to a response centre staffed 24 hours a day, 365 days a year.”

Around 1.7 million people in the UK are already benefiting from some form of telecare or telehealth system, but it is still a relatively young industry and the advancement of technology has until now tended to happen at a faster rate than services have changed to accommodate it.

The iVi pendant from Tunstall detects when people have fallen and is one of a rapidly growing range of sensors aimed at helping people to live independently at home for longer

To address this problem the TSA has developed a Telecare Code of Practice1. This lays out stringent standards, not only for the individuals in receipt of services and their families and carers, but also for those who commission services, such as NHS trusts and local authorities.

The code is the result of the widest stakeholder consultation exercise ever undertaken by the TSA and involved ministers from government departments in England, Scotland, Wales and Northern Ireland together with TSA members.

The resulting document is structured into eight process modules dealing with the deployment of technologies as well as the systems themselves. They cover support and advice, referral, profiling, service set-up, monitoring, response and re-evaluation. There are also 12 standards modules including safeguarding, governance, partnership working, technology management, privacy and data protection and legislation. The TSA has also developed a range of challenging key performance indicators which telecare service providers must attain and retain in order to ensure the quality levels that users require.

It is not about removing the risk entirely, but much more in the future it will be about being able to better manage that risk, whether at home or outside

Members of the TSA can now apply for accreditation to the code and there is an audit scheme run by an independent body which undertakes site inspections to verify standards.

But, despite the good intentions of 3millionlives, the widespread deployment of telecare technologies will depend largely on how the market responds to the need for cost-effective, end-to-end solutions.

Carmichael said: “Traditional telecare tends to be home based, enabling people to summon help if something goes wrong inside the home. One of the biggest changes in terms of the demand for new technologies has been for systems that can offer the same kind of support when people leave their homes.

“Traditional sensors can help to build independence, but the minute a person steps outside that sense of security and confidence goes. People want solutions that are mobile. It is not about removing the risk entirely, but much more in the future it will be about being able to better manage that risk, whether at home or outside.”

Based on the findings of this particular trial alone, there is no convincing evidence to justify the public sector to invest in telecare from purely a cost saving perspective

Buddi is one of a new generation of mobile technologies that uses the latest GPS satellite and mobile phone systems to pinpoint the wearer’s location and alert carers and family members.

Carmichael explains: “It is basically a safer walking device so that people can leave their homes and family can see where they are and will be alerted if they leave the house or they go outside of a pre-determined location. Buddi is about helping people to retain their independence, which is what the health service is going to have to do in order to be cost effective in the future.”

CarelineUK, rather than creating the technology itself, is an organisation that delivers the connecting service, picking up and reporting alerts when they are triggered.

It is this end-to-end service, linking the technology itself to those who will monitor it, that the TSA’s Code of Practice aims to enhance. This may then enable the Government to realise its vision of deploying solutions on a much larger scale.

THE EVIDENCE

While the Government reports positive early results from its Whole System Demonstrator trial, particularly around the telehealth market, the true impact of telecare systems has not yet been fully reported.

And during the wait for formal results, while manufacturers are responding with innovative new solutions, there have been several high-profile reports that call into question the economic and social impact of the technologies.

The latest in a series of papers to look at the findings of the trial, published recently in the journal Age and Ageing2, found there was ‘no convincing evidence’ that telecare can reduce health or social care costs.

It claimed that those involved in the trial, who used 27 different devices while others continued with their usual care plans, saw no significant change to secondary care use or contact with their GPs or practice nurses. Of participants monitored using telecare, 46.8% were admitted to hospital within the 12 months of the trial, compared with 49.2% of the control group. The difference between the groups was not statistically significant, the report authors added.

Coupled with the considerably higher number of over-65s referred, it is clear that telecare has enabled adults and older people to remain living in their homes for longer

Similar proportions from the two groups were admitted to permanent residential and nursing care during the 12 months; 3.1 and 3.2%, respectively. GP contacts were 18% higher among the telecare group, compared with controls, but this was not significant when adjusted for prior differences in use.

The report concludes: “Though our analyses were limited, we were able to test the claim that telecare reduces admissions to hospitals or care homes. Based on the findings of this particular trial alone, there is no convincing evidence to justify the public sector to invest in telecare from purely a cost saving perspective.”

But these findings do not reflect the experiences of many telecare users and manufacturers themselves.

Speaking to BBH , Frances Thompson, assistive technology development manager at Wakefield Council, said its experience of deployment had led to financial savings as well as significant improvements in patient wellbeing.

The local authority conducted its own assessment of 135 participants of all ages and abilities using telecare and calculated net savings of £1,325,753 in one year based on the cost of the current care plans deducted from the allowable residential care admission costs.

Alongside the management of adults and older people, telecare also had a positive impact on the support of people with learning disabilities. An evaluation was carried out on a random selection of 68 people from adults, older people and learning disabilities services. The efficiency outcome was determined on the prevention of service users entering residential care and the resulting net cost saving was £863,371 per year, with an average saving per person amounting to £12,696 a year.

“Our evaluation has demonstrated that telecare can help people maintain independence and delay, or even eliminate, the need for residential care,” says Thompson.

I think there is more awareness of the technologies and what they can do, but the market would benefit from a standardised approach to deployment and commissioning

“In Wakefield, telecare enabled a reduction of more than 12,200 hours in deferred residential admissions. Coupled with the considerably higher number of over-65s referred, it is clear that telecare has enabled adults and older people to remain living in their homes for longer.”

But he added: “It is important to note that telecare is not a replacement for human care, rather, it should be regarded as a supplement to help restore independence and dignity that may otherwise be lost, while providing a great deal of support and reassurance for family and carers.”

Blackburn with Darwen Borough Council has also thrown its weight behind telecare as a means of improving quality of life and making financial efficiencies.

The 17th most-deprived local authority in England out of 354, it is expecting a 43% increase in the number of people aged 85 and over by 2028. The borough also has the highest rates of admission to residential care in the North West.

Working in partnership with telecare supplier, Tunstall, the council has deployed a number of devices in the homes of vulnerable people, with the result being an 18% reduction in residential care admissions, total net saving of £2.2m in one year and an increase in people signing up for services.

Sally McIvor, director of social care at the council, said: “The telecare service has made a huge difference. Without it we would simply not have been able to realise the savings. Over and above this, we have managed to keep people in their own homes, connected with their history, community and identity, and that’s something I’m really proud of.”

And the London Borough of Hillingdon is providing free telecare to over-85s, with savings of £4.7m generated in 12 months, a reduction in residential and nursing care placements from 8.08 per week to 3.57, and a 10% reduction in homecare hours purchased.

The council’s corporate director for social care, health and housing, Linda Sanders, said: “Technology like telecare can play a vital role in helping care for an ageing population and that’s why in Hillingdon we are offering it free to those aged over 85. By enabling them to stay in their own homes we can reduce the demand for residential or nursing care, which can in turn result in significant savings for the council.”

One user said of the systems: “The alarms make me feel much safer. I know if anything happens someone will come to help me, but in the meantime I get out and about and make the most of my life.”

So what needs to be done to ensure other local authorities and healthcare organisations realise the same results as these more successful schemes?

Telecare systems are evolving to be used outside the home

Key, according to industry insiders, is an improvement to the system for commissioning. Carmichael said: “The majority of customers currently are local authorities and every one does it differently. Some clients just want the technology and do not intend to charge clients. Others say that potential users have to meet certain criteria, and some people have individual health budgets and can make their own choices. It seems to be very mixed and everything is different from one authority to another, even neighbouring authorities are taking different approaches.

“I think there is more awareness of the technologies and what they can do, but the market would benefit from a standardised approach to deployment and commissioning.

“I believe the evidence for telecare is there and that in general it is very cost effective, but we need to create a better framework that means we are not just concentrating on smaller pilots and can instead see the potential benefits of more widespread deployment.”

Atkey agrees that a lack of continuity could scupper the Government’s aims. He said: “It is quite complex and it’s about breaking down the barriers and making telecare more mainstream.

“The problem with the Whole System Demonstrator was that it looked more at individual products rather than an overall service. Telecare moving forward has got to be about an end-to-end service.

“There is a strong evidence base, but this is mainly about demonstrating the technologies on offer when it should be about the impact on the wider system. What we need to consider now is how we deliver large-scale services that provide truly economical care.”

While the TSA Code of Practice and the 3millionlives campaign aim to drive adoption and ensure joined-up services, within the marketplace changes will also be occurring.

Atkey said: “There has been a growing demand for mobile telecare devices and the market will move in this direction in the coming years. At the moment all devices are analogue and another major development will be if BT moves over to digital, then there will need to be a complete redesign of telecare devices. This will also create massive potential for the future of telecare.”

To help drive this change CareLineUK is investing in education campaigns, creating a telecare forum that is looking to improve adoption.

“Rather than putting all our resources into small pilot schemes that have been going on for years, we are really looking to create a better environment for the widespread future adoption of telecare,” said Atkey.

References:

1 Telecare Code of Practice: Click here.

2 Click here

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