Select Committee on Science and Technology Written Evidence

Memorandum by Dr S Brownsell and Professor M S Hawley


  Assistive technology (AT) has the potential to play a vital role in helping older people to stay living at home in a more secure, safe and independent manner; which may reduce the speed of decline and need for future care and support. However, the evidence to support the widespread deployment of AT, and examples of research and development projects leading to service delivery changes is thin. Over many years Barnsley District General Hospital has been both supplying AT services to patients through its clinical engineering service, and also researching and developing the field.

  It would appear that while the Government have been pro-active in developing policy (at least in some degree) to support AT, the evidence to support its widespread deployment can be sparse. There are also numerous examples of projects repeating previous work and being conducted without due attention to robust evaluation, if any evaluation has been conducted at all. Over recent years we have sought to contribute to a reliable evidence base and welcome this Committee on the scientific aspects of ageing.


  This section summarises the results of an ongoing investigation into the role of AT in addressing the needs of older people both now and in the future. A formal literature review was conducted, seeking to identify the reasons why older people need increasing levels of care and support or move to more supportive environment, such as sheltered housing or residential care. A total of 2,037 papers were reviewed and 102 trigger factors or reasons identified.

  While many trigger factors were evident in the literature, there appeared to be no ordering or ranking in terms of priority. In some ways this is perhaps surprising, as it would be assumed that planners and policy makers would require this information in order to target resources where the greatest returns may be observed. However, comparing one trigger factor against another is complex for three main reasons:

    1.  Trigger factors are often inter-related and it can be difficult to treat them in isolation;

    2.  Most of the trigger factors have been determined by qualitative investigations;

    3.  Studies vary in quality in terms of their approach, research rigour, and sample sizes.

  In an attempt to prioritise the trigger factors local experts from housing, health, social care, voluntary services and carers representatives were invited to a stakeholder event. All of the trigger factors were randomly ordered and presented to participants who were asked to prioritise the trigger factors relative to how many older people require a change in the amount of care and support they receive as a consequence of that specific trigger factor. Group consensus for each individual trigger factor on a scale of one to five was required, with one indicating a very important trigger factor and five the least important. A total of 36 trigger factors were identified as being in the top three bands of importance and these are listed in Table 1 (in alphabetical order).

Table 1


NoTrigger factor
Trigger factor
Trigger factor

1A fear of falling.
Difficulty toileting/continence management.
Needs assistance with personal care, hygiene needs, bathing, washing, dressing.
2A major health event—such as support following a stroke or hip replacement.
Family, friends or neighbours can no longer provide support to maintain the person at home.
Occurrence of falls.
3A perceived decline and concern for own health.
Family/caregiver stress.
Person feels isolated.
4A person feeling lonely.
Housework problematic (not including vacuuming).
Poor nutritional/dietary intake.
5Abuse (physical or mental).
Inability to care for self at home.
Poorly maintained housing.
6Bereavement, of a family member or friend.
Inability to cope with Independent Activities of Daily Living[2].
Presence of chronic disease (such as Parkinsons, heart problems).
7Cognition impairment (such as dementia, confusion or memory loss).
Inadequate home care provision.
Recent onset of visual impairment.
8Consequences of admission to hospital.
Managing pressure sores.
Requiring regular trips to hospital.
9Depression, mental breakdown or deterioration.
Medication management—such as compliance problems.
Self perceived inability to manage alone or care for oneself.
10Deteriorating physical functioning.
Mobility problems, getting around the house.
Self-management of health conditions (regulating insulin, dealing with the pain of arthritis).
11Difficulty cooking for themselves.
Moving to be near relatives (on the advice of, or choosing to be nearer to relatives or friends).
Unsuitable accommodation.
12Difficulty in managing stairs or steps.
Multiple minor longstanding illnesses.
Wound care—such as dressings, care of ulcers.

The role of AT

  Having identified the trigger factors resulting in additional care and support the role AT can play in assisting, preventing, or minimising additional care and support were investigated under three headings, namely:

    —  Formal care services: Regular and ongoing intervention by care and support services, such as a carer, occupational therapist and so forth, not including training of AT;

    —  Current AT provision: Technologies that do not necessarily function without formal care services, but the main support is through technology. Such technology can assist, minimise or prevent a certain trigger factor and are commonly used by formal care and support services;

    —  Emerging AT: Technology to assist, prevent, or minimise the impact of a certain trigger factor. It is assumed that such technology could become part of current AT provision within five years.

  Fig 1 presents each of the trigger factors of Table 1 using these three groupings above. Using this pictorial representation a number of findings are suggested.


Formal care services and AT interaction

  AT, when used appropriately, is a tool to assist the user, it is not necessarily the answer to all situations and neither should it be used as a last resort or in isolation of formal care services, but rather careful user centred assessment is important. Indeed Fig 2 suggests that 29 (81 per cent) of the trigger factors fall within the formal care services domain. Therefore, both now and in the future, at least to some extent, formal services are still likely to play a significant role in care provision. Fig 2 also indicates that 21 (58 per cent) of the trigger factors are in the central element consisting of all three domains. This suggests that AT has a role to play today, but that a greater role may be played in the future, but in all these situations the support of formal care services is required in combination with assistive technology. There is therefore a necessity to work with formal care services to ensure that the emerging technologies are appropriate not only to the older person, but to the professional user also.

AT cannot meet all of the trigger factors

  Fig 1 suggests that 23 (64 per cent) of the trigger factors fall within the current AT provision domain, and an additional eight (22 per cent) in the emerging AT domain. In under five years AT may therefore be able to assist, prevent or minimise the impact of 86 per cent of the major trigger factors identified as resulting in more care and support for older people. However, AT is not the answer in isolation of formal care services nor can it assist in all of the trigger factors.

Emerging AT

For eight (22 per cent) of the trigger factors there is no current AT provision, but it is suggested that within five years AT could be deployed, where appropriate, as part of standard care provision. With five of these factors there is no current AT provision, but through formal care services in combination with emerging AT it is suggested that the impact of these factors can also be minimised. For example, the "Perceived decline and concern for own health", "Consequences of admission to hospital" and "Multiple minor longstanding illnesses" could be minimised by remote health monitoring where the technology monitors the health of the user and only calls for medical assistance when necessary, which should also reduce the likelihood of hospital admission.

The role of AT

Of the 36 most important trigger factors resulting in older people needing greater amounts of care and support AT can assist, prevent, or minimise the impact of 64 per cent of these trigger factors. Indeed, if the emerging AT proves successful and is in common use then AT can be utilised against 86 per cent of the trigger factors. It may be that if AT could be targeted specifically at the trigger factors as to why older people need increasing levels of care and support then this may "free up" staff time to be utilised effectively elsewhere. For example, by providing more personal services, or more one to two hours of home care services per week, and so forth. Analysis of Table 1 suggests that 69 per cent of the trigger factors are included within health and physical aspects. This suggests that perhaps by focusing efforts on these areas we would be able to meet user needs better, help more people to stay living independently, while simultaneously reducing the demand for care and support needs.


  We have enclosed a book, published in 2003 which is very relevant to this call. However we have attempted to provide a summary of the main points. Prof R Wootton, editor of the international journal of telemedicine and telecare commented that "this book draws together the evidence for the benefits of telecare systems and makes a powerful case for their introduction on a wide scale . . . as a source of information for healthcare planners and policy makers it will be invaluable." It covers three main areas, of which the later two will be highlighted here:

    (a)  The need for AT and telecare.

    (b)  The evidence.

    (c)  Implications and recommendations.

User views

  The evidence section commences by focusing on the views of community alarm users towards AT. A face-to-face questionnaire was conducted with 176 community alarm users in the age range 56 to 91 with an average age of 76, living on a sheltered housing scheme in Birmingham. This represented an 89 per cent response rate and includes those both favouring and opposed to the introduction of advanced assistive technologies. The main findings were that:

    —  77 per cent welcomed the prospect of automatic fall detection;

    —  68 per cent welcomed lifestyle monitoring;

    —  57 per cent welcomed medical monitoring; and

    —  44 per cent welcome video conferencing.

  In total 57 per cent of those interviewed were interested in at least three of the four, and 25 per cent interested in all four. Only 11 per cent of those interviewed were not interested in any.


  The section continues by defining future systems that would be beneficial to users in the immediate (2nd generation system) or more long term. Based on this 2nd generation system a financial model was developed that adheres to the principles of health economics and compares the present system with the suggested 2nd generation system in the City of Birmingham with 11,500 users. In so doing it suggests the outcomes necessary by future systems if they are to be cost-effective.

  Technically, the 2nd generation system is more advanced and consequently will be more expensive than the 1st generation system currently in place. The model suggests that at the start of the first year there would be £6.4 million outstanding. However, there are considerable operational savings compared to the present system and break-even is achieved during the 5th year of operation with a positive cash flow secured thereafter. Using a conservative approach, it is assumed that no interest is gained on finance after the initial loan has been repaid in which case, by the end of the system life cycle (year 10) the scenario suggests a return of the order of £8.3 million.

  Sensitivity analysis reveals that the key areas are savings in the average duration of a hospital stay and the percentage of people in residential care. Changing these parameters by 50%, the best and worse case scenarios, suggests that the proposed 2nd generation system remains cost-effective (£0.5-£15 million).

  One of the main findings was that to fully realise the benefits, a holistic approach involving collaboration across all imposed service boundaries is essential. The results of the analysis suggest that the savings appointed to the main providers are 4 per cent to housing, 47 per cent to the NHS and 49 per cent to residential care. It would seem appropriate that since the savings are appointed this way that the system is funded similarly.

Implications and recommendations

  The impact of advanced telecare systems on human resources is a fundamental question which to date has been somewhat overlooked. The greater use of information and communications suggests an increased workload at the community alarm control centre for example. Modelling work suggests that at the control centre the proposed 2nd generation system actually reduces the number of calls by 57 per cent and the amount of time control centre operators are required to speak with callers by 55 per cent.

  It is difficult to foresee the kind and extent of changes that could result if telecare were implemented on a large scale. AT and information and communication technologies clearly have considerable potential across many different aspects of social care. The implications for organisations and personnel are considerable. The divide between health, housing and social care will have to close for telecare to succeed and personnel will need to learn new skills and new ways of working.

  It is evident that a greater degree of resources will be necessary in primary and social care and that a great reliance will be placed on computing and information access. However, perhaps the greatest implication is that, if successful, AT could assist many older and disabled people to live safely and independently in their own homes for longer. If this can be achieved, and there is evidence that such a system is wanted by users, is cost-effective and is deliverable, then the implications for service providers should be outweighed by the benefits that could be derived by introducing such systems.

  The book concludes by making a number of recommendations that need to be addressed if AT is to flourish and provide users with greater levels of choice and the ability to improve their quality of life.


  The book provides a vision for future technologies based on the views of users and practitioners, technological developments, government direction, and the likely speed of organisational change. It also indicates the current level of progress/research being undertaken to meet these objectives. As such it provides an indication of where beneficial technologies should be developed over the next 15 years. A summary is provided here, but more in-depth detail can be found on pages 39-49.

2nd generation telecare systems(2003-05)

  Overall, the 2nd generation telecare system provides greater support and monitoring than the present telecare equipment and removes the constraint of the user having to initiate a call for assistance. Automatic call generation and monitoring is provided through a number of new or emerging technologies, such as drug dispensers, automatic fall detection, or lifestyle monitoring. Each of the technologies included in the 2nd generation system can be provided on an individual basis so that a user may have a fall detection unit without a drug dispenser or lifestyle monitoring. The system is therefore truly plug-and-play or modular and able to address the particular "risks" of individual users. The intended users are the present community alarm users, while modules of the system may also benefit people in residential care or nursing homes. Details of the main components of this system are provided in the Appendix.

3rd generation telecare systems (2005-10)

  It is envisaged that the elements in the previous generation will become more refined with time. The 3rd generation system is enhanced and made more flexible and responsive. Tasks that were previously carried out by staff but did not require contact with users are taken over by the system. This therefore enables staff to spend more time with users and provide a more caring environment. Details of the main components of this system are provided in the Appendix.

4th generation telecare systems (2010-20)

  The focus of the previous generations was to monitor users and detect emergency situations. Attention was also given to prevention in respect to medical parameters, while the introduction of expert systems enabled the system to ensure that medication was prescribed correctly. The 4th generation system builds upon these previous generations by developing the system for both the user and provider.

  For the user, intrusion is reduced with implanted sensors under the skin so the user no longer has to wear a pendant or similar device when in the home. When outside of this environment, the implanted sensors work in the same manner as the medical band module, communicating with the distance support module. Assistance with tasks of daily living enable users to stay independent in their own homes for longer, automatic robots conducting tasks such as cleaning. Medical professionals received support from expert systems in the 3rd generation system and developments in artificial intelligence will enable remote assessment. The Activities of Daily Living (ADL) has conventionally been used by social services in assessing older peoples need for long-term care, however this often annual "snap shot in time" assessment has often failed to assess the user as their needs change, especially relevant after hospital discharge. The 4th generation system addresses this deficiency by monitoring the user on a daily basis and automating the assessment (this could also be true for the single assessment process). Users can then be formally assessed after the system has indicated that intervention would be beneficial. This allows resources to be effectively targeted and truly allows for a preventative system, both in terms of the users health and their daily living. Details of the main components of this system are provided in the Appendix.


  Please note that the responses to the following sections are in relation to research and technology development in assistive technology and telecare for older people

4.1  How effectively is research co-ordinated in the public, private and charitable sectors (including internationally)?

  There are bodies aimed at co-ordinating ageing-related research (the National Collaboration on Ageing Research—NCAR, and the Funders' Forum) but to date these appear to have had little impact on co-ordination in the field of assistive technology.

  The New Dynamics of Ageing programme (led by Prof Alan Walker, University of Sheffield), has assistive technology as one of its priorities and is expected to lead to greater co-ordination of research in this field.

  There is some current co-ordination in the public sector as a result of the existence of a small number of research funding programmes. An example of this is the Extending Quality Life (EQUAL) programme within the Engineering and Physical Sciences Research Council, where meetings have been held between some of the leading research groups in this field to decide upon priorities. As a result, a number of large multi-centre projects have been funded (see

  The European Union has no specific programme addressing older people's technology within Framework 6. There is, however, an e-inclusion sector within the IST (Information Society Technologies) programme, which may be funding current research on assistive technology. I am unaware of any means for co-ordination between this programme and UK programmes. It will be important to lobby for specific research into assistive technology for older and disabled people to be included within the EU Framework 7.

4.2  Have the correct priorities been identified? Are there any gaps in research?

  Research into assistive and telecare technologies is still at a relatively low level and there are a great many gaps. Research and development is required across the board.

—  Development of new assistive and telecare technologies

  There is huge potential to apply existing and emerging technologies to the benefit of older people, especially information and communication technologies (ICTs), sensor technologies and signal and information processing technologies (eg speech recognition). Research is needed to analyse the needs of older people and to apply technologies to address these needs. Thus, research should be user- or application-led, as opposed to technology-led. Fig 2 shows the research process.


—  Human factors involved in telecare design.

  One of the main barriers to the effective utilization of assistive technologies and telecare is the interface, currently efforts have cantered around developing the basic technology rather than ensuring the appropriate interaction with the end users.

—  User perspectives in telecare (eg acceptability, ethics etc)

  There is little real understanding of user perspectives in relation to assistive technologies and telecare. Although studies have suggested that AT and telecare would be accepted by users, the acceptability of these types of technologies in general needs further research. One crucial factor in emerging concepts of monitoring technologies is its acceptability and ethical position. A consistent refrain in discussions with users over the deployment of monitoring technologies is that of "Big Brother", meaning the intrusive observation of people's everyday lives. Whilst it is anecdotally observed that people are willing to accept monitoring if they can see benefits to themselves, much more in depth study of the ethical aspects of monitoring is needed.

—  Development of the most effective means of assessment for telecare

  Within the field of telehealth there is an emerging robust evidence base for specific applications, such as tele-dermatology, but within AT and telecare such evidence is sparse. The recent Audit Commission report 2004, sought to add to the evidence but it may have over emphasised the case. Companies are also often heavily involved in the evaluation of their own products and this has, on occasion, resulted in the press publishing misleading articles of the benefits of interventions. This raises serious issues, for example care packages could be modified and a reduced number of support hours given in combination with the technology intervention. Based on the "evidence" from the manufacturers this may seem appropriate and is an appealing proposition, but if that evidence is fundamentally flawed and the technology does not work as well as suggested then this puts people at an increased level of risk. This is currently happening and it is suggested that only by external parties conducing robust research will this be addressed.

  Current studies also tend to have questionable evaluations using questionnaires developed in house, which may have biased the result to be more positive than they actually are, rarely utilise control groups, and often allow recruits to self-select (thus only involving those people who are positive to the intervention). Large scale robust trials are therefore required, by independent organisations, that use accepted methodologies and research tools to learn the correct value of the emerging devices and seek to understand how different organisations and departments are required to work together. While a randomised control trial may not be the most appropriate method in all cases, research of a high standard is required. Such trials are desperately needed, and there are institutions in the UK that have the required AT and research knowledge but finance to conduct them is difficult to acquire.

—  Assessment of efficacy, effectiveness and cost-effectiveness of telecare interventions

  Evidence of the effectiveness of assistive technologies and telecare is sparse. There have been a large number of pilot projects in this field but little definitive evidence, largely because the pilots have been set up as service developments rather than research projects. Several cost models have been developed suggesting financial savings but these are based on assumptions of the performance of the intervention technology and there is limited support from trials that these assumptions are accurate. Research is needed to provide evidence to underpin the further deployment of these technologies. This can be seen as equivalent to the evidence that is crucial before the widespread introduction of new drugs and techniques into health care. The Health Technology Assessment programme and NICE should be more engaged with these technologies.

—  Service delivery and organisation related to assistive technology and telecare services

  There is little knowledge concerning the best way to organise and deliver services to support the effective deployment of assistive technologies and telecare. This evidence needs to be collected and information disseminated to service delivers. Specific attention needs to be given to how and who purchases assistive technology and telecare, who monitors the alert calls, what are the response protocols to respond to alert situations, who responds, and who pays for ongoing monitoring and call out costs. Many of these issues cross departments and the "glue" fitting the system together just isn't there.

4.3  Is there sufficient research capability in the UK?

  Research into AT and telecare needs to span a wide range of disciplines, including:

    —  Engineering.

    —  Clinical disciplines.

    —  Social science.

    —  Information science.

    —  Cognitive science.

  Research projects in this field, in the majority of cases, require multi-disciplinary input. This is a factor that has been recognized by EPSRC in the funding of EQUAL projects. Whilst there appears to be sufficient research capability within most of these disciplines to apply to the area, there are some gaps.

  The expertise that is in short supply is at the interface between engineering and clinical/sociological disciplines. This can be illustrated with reference to Fig 2, showing the research process necessary to develop new technologies. Social/clinical researchers have the expertise to elicit user needs and user views (using largely qualitative but also quantitative research techniques). However, user views in relation to technology are often best researched by those who have knowledge and training in technology/engineering as well as training in social/clinical disciplines. This becomes even more apparent in the translation of user views into engineering requirements, where an in-depth understanding of the user is required alongside an in-depth understanding of the technology potential and limitations. This is also true at the other end of the process, where trials of the technology are carried out and user experiences and views here are invaluable in improving the usability and usefulness of technologies.

  There is a need to train more people jointly in the engineering and clinical/social disciplines (this happens currently in Medical Physics/Clinical engineering/Bioengineering) and to support centres that are developing multi-disciplinary expertise combining these areas of expertise and developing methodologies for technology-related research across the disciplinary divide.

  The commercial sector in AT and telecare is dominated by small companies, whose resources to deploy in R&D are very limited. As a result, there appears to be a low level of research and innovation in these companies in the UK. It is essential to encourage (through grants and other financial incentives) the AT and telecare commercial sector to work more closely with research centres in Universities and the NHS.

4.4  Translating research into practice

  For AT and telecare to flourish it is vitally important for research to impact on policy and for service providers to embrace change. The lessons from other areas should be applied and these show success and speed of the adoption/diffusion process depends on ( doc_id=233248):

    1.  the roles of senior management and clinical leadership;

    2.  the generation of credible supportive data;

    3.  an infrastructure dedicated to translating the innovation from research into practice;

    4.  the extent to which changes in organizational culture are required;

    5.  and the amount of coordination needed across departments or disciplines.

  The translation process also depends on the characteristics and resources of the adopting organisation, and on the degree to which people believe that the innovation responds to immediate and significant pressures in their environment.

  The challenge is therefore to acquire the appropriate evidence base to provide credible supportive data which engages both senior management and providers at all levels so that change is driven from the top and truly embraced at a service level for the benefit of the people we are all trying to serve.


Main features

  Fall detection: A worn device to detect the presence of a fall and automatically instigate a call for assistance.

  Fire detection: Detect the presence of fire, inform the user and if necessary to contact the control centre.

  Gas detection: Gas levels should be monitored and the gas supply terminated if appropriate.

  Temperature analysis: Analysis of room temperature and if necessary inform the user of a risk of hypothermia.

  Water detection: Suspend the water supply if the bath, shower or sink overflows.

  Incontinence monitoring: To indicate when incontinence pads need replacing.

  Security: To provide a "panic button" at the front door and the other functions of a standard burglar alarm.

Provide a record of when carers arrive and leave the residence. Allow authorised access to the users EPR[3] (Electronic Patient Record) and information services.

  Drug dispenser: Dispenses the required drugs when required and reminds the user to take their medication if they forget.

  Lifestyle monitoring: To detect changes in the lifestyle of the occupants(s) that may indicate assistance is required.

  Medical monitoring: Stand alone equipment to measure the medical characteristics of users and facilitate a call for assistance if outside of allowable parameters.

  Virtual consultations: Remote medical consultations with video conferencing technology, integrated with the medical monitoring stations.

  Intelligent Home Alarm System (IHAS): This is the hub of the home based equipment and provides control to the various components of the home based technology; communicating with the user(s) and external organisations.

  Electronic Patient Record (EPR): Contains all of the appropriate information regarding a particular user.

  GP surgery: Provide medical assistance and video consultations.

  Control centre: Provide support and act as a first point of call to users.

  Hospital health services: Facilitate medical assistance and suspend and reinstate home care as necessary (information provided by updating the EPR)


Main features

  Components of 2nd generation system: the previous modules are available in the 3rd generation system.

  Lifestyle monitoring: identify the movements of users without having to use tagging, also measure the users gait and how often they climb stairs (if present).

  Security: more developed burglar alarm and automatic recognition of user. Access to EPR for all professionals.

  Weight detection: measures the users weight.

  Drug dispenser: enable repeat prescription reminders and analysis of the medication held within the dispenser.

  Medical band: provide 24-hour continuous medical monitoring for users wearing a medical bracelet or vest.

  Distance support: communicate with the medical band and allow the user to call for assistance when away from the home.

  Intelligent Home Alarm System (IHAS): the ability to track the user if they fail to return home at a specified time.

  User control: provide verbal communication with the home based system.

  Virtual GP/neighbourhood: provide remote physiotherapy and exercise schemes.

  GP surgery: expert system to suggest to the GP what medication they should prescribe.

  Pharmacist: enable paperless prescription.

  EPR: store the users data.

  Control centre: support for foreign languages and analysis of users EPR's to ensure that correct medication is being used.

  Hospital Health Services: no change when compared to the role undertaken in the 2nd generation system.


Main features

  Components of 2nd and 3rd generation system: the previous modules are available in the 4th generation system.

  Water detection: monitor the washing habits of the user.

  Incontinence detection: detect the onset of incontinence.

  Robotic assistance: provide mechanical assistance with vacuum cleaning, retrieving items from the floor and dressing.

  Virtual GP/neighbourhood: the scanning of letters and forms that cause distress. Assistance being provided from friends or relatives, and ultimately the control centre or social services.

  Implanted medical monitoring: implanted sensors measuring vital signs 24-hours a day.

  Intelligent Home Alarm System (IHAS): route emergency fire calls directly to the fire brigade.

  User control: the use of the mind to control electronic devices around the home.

  Control centre: through an expert system, each users EPR is analysed under the automatic ADL assessment.

2   These relate to domestic tasks such as shopping, vacuuming, handling personal affairs. Back

3   Further information on EPR's can be found at Back

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