Select Committee on Science and Technology Written Evidence

Memorandum by Dr Frank Miskelly


  Developments in all areas of life usually entail embracing technology. The Zimmer Frame was arguably the greatest advance in elderly care in the 20th century. It is also a good example of an assistive technology. Electronic assistive technologies will identify the 21st century.

  Recent developments in electronic and telecommunication technology are destined to make a significant contribution to elderly care both in institutions and in the community. Numerous electronic aids and devices have become available which improve patients' safety, security and ability to cope. Systems using advanced technology to support people at home could benefit both the patient and the care providers as it is generally accepted that care in the community is preferable to patients and usually less expensive than in institutions. Technological innovations working in partnership with the existing care system will change the future face of community care


  The successful introduction of a New Technology aid or device requires the following:

  1.  A device which successfully detects or prevents the clinical problem. The main clinical problems in older people are:

    (a)  Falls.

    (b)  Wandering.

    (c)  Failure to Cope.

  Numerous devices claim to alleviate these problems and our research is focussed on evaluating the benefits of the equipment in clinical practice. Many devices are designed for other purposes and then adapted to healthcare eg, prisoner tagging systems adapted to patients with dementia. Our experience is that the device does not always reliably perform what it claims.

  2.  An available infrastructure: Equipment will fail if it's usage requires the development of an infrastructure. The most successful method to introduce equipment systems is on an existing platform such as the Community Alarm System. The Community Alarm Service provides the monitoring and response arm of the system. It has developed an infra-structure of communications, data-bases, control centres and response networks which is well established in the United Kingdom and which has gained the confidence and trust of older people and professionals alike. The community alarm system provides an ideal framework for bolting on recent developments in electronic and telecommunication technology so future generations of the Community Alarm System are likely to form part of an integrated telecare system

  3.  Ethical Acceptability: In our research on Electronic Tracking and Tagging of older people with dementia a considerable barrier has been ethical or moral objections by patient interest groups to the use of equipment. These groups see the increasing use of technology as a substitute to high quality personal care. Our view is that technology is an additional safety feature which is utilised alongside the normal care package

  4.  Cost-effectiveness. Virtually no group is investigating this issue in the introduction and implementation of new technologies. There are several reasons for this. Firstly few groups are conducting proper systematic evaluations when equipment is introduced. Secondly, health economists are not always available.


  This Project is described briefly as it illustrates the type of equipment under development. The aim of this Project is to evaluate the benefits of modern aids and devices for older people living in institutions and the community. We focus on preventing or detecting:

    (a)  Falls.

    (b)  Wandering.

    (c)  Failure to Cope.

  in frail elderly living in hospitals, residential and nursing homes or their own homes.

  The equipment is individually tailored to the needs of patients in their own home depending on the results of a "needs assessment." The Project is a joint venture between London Borough of Ealing, London Borough of Hammersmith & Fulham, Ealing Family Housing Association and Imperial College.

  The aids and devices we have been evaluating include:

  1.  Video-monitoring system. This system allows people to see each other on their television at the same time as they speak on the telephone. It is useful where parents and offspring live some distance apart. For example, it allows a daughter in Kent to make a "virtual home visit" each day to her mother in Fulham which would be impossible by commuting

  2.  Electronic tagging. Alerts a carer when a person with dementia wanders outside a pre-defined area eg, a house. They can wander freely within the area. It allows the carer to perform the housework and only if the person tries to leave the house are they alerted.

  3.  Electronic tracking. Locates a person with dementia who has wandered off provided the person is carrying a GPS enabled mobile phone. This system can locate people anywhere in the country with an accuracy of five metres. It allows people with dementia to go out shopping and if they have not returned within an expected period we can locate them.

  4.  Computerised Fall Detection Systems. A camera attached to a computer continuously monitors the older person's living area. The computer uses pattern recognition analysis software to detect events such as falls and intruders. Any untoward event generates an alert at the Community Alarm Centre.

  5.  Bed monitors. Electronic devices which fit under the mattress and alert a carer or nurse when a patient vacates their bed. These devices prevent falls and accidents at night.

  6.  Chair monitors. Electronic devices which fit under the cushion and alert a carer or nurse when a patient vacates their chair. These devices prevent falls and accidents during the day.

  7.  Health monitors. Electronic devices which are worn on the wrist and alert a carer when the wearer has a fall, collapse or faint.

  8.  Fall detectors. Small bleep sized devices that fit to the belt and contain a mixture of accelerometers, impact meters or tilt meters to detect falls.

  Some devices has shown substantial benefits in the care of older people while others have been less successful. Further evaluation is ongoing and new devices and technologies are being investigated.



Why Is There A Need For Technology?

  1.  Demographics. The Western World is ageing, family sizes are smaller and the number of younger people to provide care is reducing. In future, some care functions will be automated using equipment rather than carers.

  2.  Healthcare costs. It can be more cost-effective to provide routine care for a client at home than in an institutional setting. Maintaining some people at home with care will only be possible with the assistance of technology

  3.  Quality of Life. People prefer to live at home close to their family and friends. Many people who may have entered a residential or nursing home following an accident or a bout of illness might be able to live independently in the comfort of their own homes if they were provided with a suitable level of technology support.

  4.  Telecare and Telemedicine can provide long-term monitoring of older people living in the community. Developing the use of technology in the community allows people to be treated and cared for at home rather than in hospital. The quality of care received at home is often better than in hospital. This isn't because hospital staff are less skilled or professional; rather, it is because the home environment is more conducive to good personal care.

Memorandum by The Queen Mother Research Centre for Information Technology to Support Older People

  Although all technologies can impact on older people, this evidence will concentrate on Communications and Information Technology (C & IT).


  The applications of research in technology and design to improve the quality of life of older people

  Information technology appears to have made an enormous impact on every aspect of society in the developed world. A more detailed examination of statistics, however, indicates that some groups are not benefiting from these advances. This situation has been referred to as the Digital Divide—the divide between those groups of people who benefit from Information Technology and those who do not or cannot access it. The Digital Divide has many causes, including economic disadvantage, but inappropriate software and human factors engineering has also played a major part in exacerbating the gap between those people who benefit greatly from computer technology and those who are excluded. It is this aspect of the application of the applications of research on which this submission will focus.


  Much current information technology appears to have been designed by and for young men who are besotted by technology, and are more interested in playing with it, and exploring what the software can do, rather than achieving a particular goal.

  Many older people and people and people with disabilities, however, lack the visual acuity, manual dexterity, and cognitive ability successfully to operate much modern technology. Many find the Windows environment, and the software associated with it, very confusing and difficult or impossible to use. Most mobile telephones require good vision and a high level of dexterity and video tape recorders are well known for providing many usability problems for older people.

  In addition to the requirement for standard information technology products to be more usable by older people, the needs and wants of people who are in the "autumn" of their lives are not necessarily the same as those of younger people for whom these products have traditionally been designed, Specialised products are also needed which are designed to enhance independence and quality of life for older and disabled people.

  Many people have developed very low expectations of older and disabled people's interest in and ability to use information technology products. A major cause of this, however, is government's and industry's lack of sensitivity to the particular needs and wants of older people and hence the inappropriate nature and poor usability of most products for older people. In general, the problem is not that older people are unwilling to use "new technology." The problem is that they are overwhelmed and frightened by the manifestations of technology which have been designed by people who do not understood the needs and abilities of older people.


  3.1  Technology can make essential and non-essential services more accessible to disabled and elderly people who traditionally receive a poorer than average level of service, or may be excluded altogether from receiving these services due, for example to mobility visual or hearing problems. The services which are particularly relevant to older and disabled people include:

    (a)  Social communication—many older people suffer from social isolation , and appropriate electronic communication methods—mobile phones, email, chat rooms could provide substantial social and psychological support to isolated older people

    (b)  e-government—technology is increasingly being seen as a way of reducing costs and increasing efficiency of government, and at the same time a way of increasing participation in democracy by excluded or disaffected groups. On-line public information and electronic voting systems are examples of technologies that can enhance social inclusion.

    (c)  Support for the older workforce—there are good economic reasons for expanding the older workforce, but this can only be achieved if the workplace is appropriate for the older person.

    (d)  Healthcare—e-health applications can facilitate remote care and monitoring for disabled and elderly people, who may in any case need a higher than average level of care. At the same time, enhanced accessibility to on-line quality health information and decision support tools can lead to a more informed patient, who can as a result play an increasingly active role in their own care.

    (e)  Banking—on-line banking facilities can allow people to manage finances from home, reducing the need for a potentially difficult journey to a bank. Automatic teller machines (ATMs) allow direct and independent access at any time of the day to account information and cash, and increasingly offer additional banking-related facilities.

    (f)  Education—at a basic level, the Internet allows independent access to an enormous amount of information on a myriad of topics. Through e-learning applications, formal education, whether primary, secondary or tertiary may be made accessible to a wider section of society, and delivered in a way best suited to a learner with specific access needs.

    (g)  Commerce—through e-commerce web sites, independent access can be gained to on-line grocery stores, bookshops, clothing retailers; tickets for rail, bus, air or sea travel can be bought in advance. On-line auction services allow for an almost unimaginable variety of real—and virtual—products to be bought or sold.

    (h)  Dementia—although in its infancy research in the UK and the USA is beginning to show that information technology can provide support for people with dementia.

    (i)  Interactive television—this could provide a method for many older people to access services and information such as those listed above.

  Other examples of applications of information technology for older people can be found in the Appendix.

  3.2  It should be noted that a major user of government and e-health services are older and disabled people, and if the software provided for e-government is not usable by this group of people, it will have a very low up-take, and alternative manual systems will have to be in place, which will be expensive and inefficient. In addition lack of mobility and/or social isolation can mean that the introduction of usable web-based Banking Education and Commerce can make a much greater difference to the lives of older and disabled people than the rest of the population.

  3.3  In addition usable web-based services could substantially reduce the social isolation of older people. This could be achieved, for example, by providing appropriate entertainment, by such technologies as mobile phones, interactive television, on-line chat rooms, and multi-user gaming environments. Currently, however, such technology is almost exclusively aimed at the younger age groups and able-bodied people. This results in increased exclusion of the people who who would most benefit most from improved access to web based services.

  3.4  There is very little business software which takes into account the needs of older people, and the provision for disabled people is often less than adequate. This impacts negatively on the older worker, and the possibilities of extending active working life.


4.1  Foresight Exercise—December 2000.

  In December 2000, the Ageing Panel of the DTI's Foresight programme reported to government. Appendix I contains extracts from their report (The Age Shift—Priorities for Action, DTI December 2000). This report calls for research programmes to be expanded, including the EPSRC EQUAL (extending the quality of active life) programme, and that "there should be manadory inclusivity during periods of rapid technological development (eg e-commerce)", and that "Government has a role to play as a promoter and exemplar of good practice."

  It is not clear to this author that very much has changed since that document was produced. Unfortunately, unlike other Foresight Panels, the Ageing Population Panel was discontinued. The author has no evidence that the expertise on the Communications and Information Technology from the Ageing Population Panel has subsequently been used in the other Foresight panels which were continued.

  The EQUAL project has continued, as recommended, and an EQUAL network has been formed of interested researchers. It is gratifying to note that there is to be an expansion of the EQUAL initiative involving other research councils. The percentage of the EPSRC and other research councils' budgets devoted to the C & IT needs of older people, however, is still miniscule compared with the percentage of the population who may benefit from such research. The vast majority of the research funding into ageing is focussed on drug and other medical interventions to alleviate the effects of old age.

4.2  e-Government

  The current guidelines for UK Government Web sites published by the Office of the e-Envoy state the Government's policy as being that Web sites should be as accessible as possible.( Office of the e-Envoy "Guidelines for UK Government Web sites"). In the 2004 survey into the accessibility of UK web sites by the Disability Rights Commission (DRC), however, it was found that:

  "81 per cent of web sites evaluated failed to satisfy even the most basic Web Accessibility Initiative Category": (DRC 2004, p37).

4.3  Ofcom and Digital Television

  A major way in which C & IT will be provided to the public in the future is via digital television, and the access to programmes, will be via Electronic Programme Guides. It is satisfying to note that Ofcom has produced a Statement on Code on Electronic Programme Guides—26 July 2004, and a Code of Practice on Electronic Programme Guides. However this guide focuses only on certain groups of disabled people. Its General Principles refer to—"people with disabilities effecting their sight and hearing or both" —The main report has no mention whatsoever of older people, nor people with motoric and/or cognitive impairments which also effect significant numbers of older people. Indeed in the response to consultation comments (33) Ofcom states that it "sympathises with Age concerns view that EPG code should be extended to cover accessibility by people with dexterity and cognitive impairments, but this goes beyond the remit set by the Communications Act. By the same token we are not able to prescribe standards for remote controls". Both of these caveats provide a major shortfall in the requirements for many older people to successfully access and enjoy television—a situation which, if it continues, will severely compromise the possibilities of switching off analogue television (to which government is committed) exacerbated by older people being a major group not wishing to change to digital television.

  In addition although the Independent Television Commission was for many years committed to and financially supported external long term research into the needs of older people, it is not clear that Ofcom intends to continue such long term research in the area of accessibility and usability of digital television for older viewers.


  For the reasons adduced above, there needs to be substantially increased priority for information technology to be developed which is usable by and appropriate for older people and will extend the quality of their lives.

  5.1  The key challenges for research in this area indicated by the foresight report were:

    —  To be customer led not technology driven.

    —  To design for inclusion taking into account the full range of user's needs and perceptions.

    —  To produce simple reliable systems.

    —  To design systems where the use of advanced technology is invisible in terms of both operation and cost.

  5.2  The Disability Discrimination act tends to focus on young disabled people—whereas older people who are not "disabled" also require "reasonable adjustments if they are to be able to fully realise the benefits of information technology.

  5.3  Similarly there is a major concentration on health care rather than social care, and this again is less appropriate for older people.

  5.4  Old age is not a "health problem" which can be "cured". Barring sudden unexpected death, old people are likely to go through a period where they need support rather than aggressive medical interventions, and thus more emphasis needs to be placed on non-medical ways of improving quality of life—an area where information (and other) technologies can play a major part.

  5.5  These are not trivial challenges, and major long term research is required to address these issues, as well as a commitment to apply the lessons learnt in research into government and industrial products and services. There are some isolated examples of good examples and practice, both in software and websites, but this is not widespread, and there is clear evidence of a lack of awareness in the need to develop accessible technology. At the same time levels of knowledge in effective inclusive design techniques are also disappointingly low. The constant appearance of new technologies also can increase the barriers to uptake by older and disabled people. [The most striking example from the history of computing is that before the windows environment was introduced many blind people were able to use computers both for work and leisure using speech synthesizers. The introduction of Windows, with at that stage no consideration of the needs of blind people, led to numbers of blind people being sacked because they could no longer use the companies computer systems. It was many years before Windows became accessible to blind people].

  5.6  The major characteristics of older people in relation to their use of technology needs to be carefully mapped and subject to longitudinal studies which consider:

    —  The individual variability of physical, sensory, and cognitive functionality of people increases with increasing age.

    —  The rate of decline in that functionality (that begins to occur at a surprising early age) can increase significantly as people move into the "older" category.

    —  The more widely appearing problems with cognition, eg, dementia, memory dysfunction, the ability to learn new techniques.

    —  The effects of multiple minor (and sometimes major) impairments which can interact, at a human computer interaction level to produce a handicap that is greater than the effects of the individual impairments [Research into accessibility focused on single impairments will not always provide appropriate solutions].

    —  The significantly different needs and wants of older people due to the stage of their lives they have reached.

    —  How the environments in which older people live and work change their usable functionality—eg the need to use a walking frame, to avoid long periods of standing, or the need to wear warm gloves.

  5.7  Long term studies are needed of how older people use technology and the relationship between their abilities and the requirements of new technology, including sensory motoric and cognitive performance and, importantly, combinations of these. These should include longitudinal studies about how older people's use of technology changes, for example with early introduction of support for dementia.


  6.1  Research capability must be increased and this will only happen if more funds are focussed on it. In comparison with the resources available for medical and biochemical research, the funding available from governmental and charitable sources for technology to support older people is derisory, and relatively low compared to other technological strands, and there is little or no promise of long-term funding. There is also a lack of industrial support because, with one or two major exceptions, researching into the needs of older people is not seen as in the commercial interest of the company (despite all the publicity) and/or too expensive and/or they do not understand the needs of this group of consumers.

  This means that "high flying" researchers are not attracted to the field. Researchers need to be encouraged to see the excitement of working in this field, and to be assured of the long term benefit of working in this important field.

  Thus an EQUAL type initiative should be a permanent and expanding funding as part of EPSRC remit.

  6.2  Centres of Excellence need to be set up with core funding to enable them to conduct innovative research without the constraints of constantly having to obtain funding for specific projects. Biochemical research has shown the effects of such core funding can have both on increasing the recruitment to the field but also to the innovations which are made, and similar initiatives are needed in research into technological support for older people.


  There is some co-ordination of the research, such as the equal network, which could be built on, but the major challenge is increasing the quality and quantity of the research being done.


  The appendix contains an overview of research at Dundee University and describes the UTOPIA project funded by the Scottish Higher Education Funding Council. UTOPIA is an acronym for "Usable Technology for older people: inclusive and appropriate". The search for this "utopia" would make a major contribution to improving older people's active life.

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