By Catherine Henderson
In these times of budgetary constraints and demographic change, we need to find new ways of supporting people to live longer in their own homes. Telecare has been suggested as a useful way forward. Some examples of this technology, such as pull-cord or pendant alarms, have been around for years, but these ‘first-generation’ products have given way to more extensive and sophisticated systems. ‘Second-generation’ products literally have more bells and whistles – for instance, alarms for carbon monoxide and floods, and sensors that can detect movement in and out of bed. These sensors send alerts to a call-centre operator who can organise a response, perhaps call out a designated key-holder, organise a visit to see if there is a problem, or ring the emergency services. There are even more elaborate systems that continuously monitor a person’s activity using sensors and analyse these ‘lifestyle’ data to identify changes in usual activity patterns, but these systems are not in mainstream use. In contrast to telehealth – where the recipient is actively involved in transmitting and in many cases receiving information – the sensors in telecare do not require the active engagement of participants to transmit data, as this is done automatically in the background.
Take-up of telecare remains below its potential in England. One recent study estimated that some 4.17 million over-50 year olds could potentially use telecare, while only about a quarter of that figure were actually using personal alarms or alerting devices. The Department of Health has similarly suggested that millions of people with social care needs and long term conditions could benefit from telecare and telehealth. To help meet this need, it launched the 3-Million Lives campaign in partnership with industry to promote the scaling-up of telehealth and telecare.
The hope held by government and commissioners in the NHS and local authorities is that these new assistive technologies not only promote independence and improve care quality but also reduce the use of health and social care services. To decide how much funding to allocate to these promising new services, these commissioners need a solid evidence base. In 2008, the Department of Health launched the Whole Systems Demonstrator (WSD) programme in three local authority areas in England engaged in whole-systems redesign to test the impacts of telecare (for people with social care needs) and telehealth (for people with long-term conditions).
The research that accompanied the WSD programme was extensive. It included quantitative studies investigating health and social care service use, mortality, costs, and the effectiveness of these technologies. Parallel qualitative studies explored the experiences of people using telecare and telehealth and their carers. The research also examined the ways in which local managers and frontline professionals were introducing the new technologies.
Some results from these streams of research have been published with more to come. From the quantitative research, three articles were published in Age and Ageing over the past year. Steventon and colleagues report on the use of hospital, primary care and social services, and mortality for all participants in the trial – around 2,600 people – based on routinely collected data. Two papers report the results of the WSD telecare questionnaire study (Hirani, Beynon et al. 2013; Henderson, Knapp et al. 2014). The questionnaire study included participants from the main trial who filled out questionnaires about their psychological outcomes, their quality of life, and their use of health and social care services.
The most recent paper to be published in Age and Ageing is the cost-effectiveness analysis of WSD telecare. Participants used a second-generation package of sensors and alarms that was passively and remotely monitored. On average, about five items of telecare equipment were provided to people in the ‘intervention’ group. The whole telecare package accounted for just under 10% of the estimated total yearly health and social care costs of £8,625 (adjusting for case mix) for these people. This was more costly than the care packages of people in the ‘usual care’ group (£7,610 per year) although the difference was not statistically significant. The extra cost of gaining a quality-adjusted life year (QALY) associated with the telecare intervention was £297,000. This is much higher than the threshold range – £20,000 to£30,000 per QALY – used by the National Institute for Health and Care Excellence (NICE) when judging whether an intervention should be used in the NHS (National Institute for Health and Clinical Excellence 2008). Given these results, we would, therefore, caution against thinking that second-generation telecare is the cure-all solution for providing good quality care to increasing numbers of people with social care needs while containng costs.
As with any research, it is important to understand how to best use the findings. The telecare tested during the pilot period was ‘second generation’, so conclusions from this research cannot be applied, for instance, to existing pendant alarm systems currently in widespread use. And telecare systems have continued to evolve since this research started. Moreover, while the results summarised here relate to the telecare participants and do not cover any potential impacts on family carers, there is some evidence that telecare alleviates carer strain.
These findings inevitably raise further questions. What are the broader experiences of those using telecare? What makes a telecare experience positive? And what detracts from the experience? Who can benefit most from telecare? Some answers will emerge as we look across all the findings from the WSD research programme. We also need to look forward to findings from new research, such as the current trial of telecare for people with dementia and their carers (Leroi, Woolham et al. 2013). The ‘big’ question is not whether we should implement a ‘one-size fits all’ solution to meet the increasing demands on social care but for whom do these new assistive technologies work best and for whom are they most cost-effective response.
Catherine Henderson is a researcher at the London School of Economics. She is one of the authors of the paper ‘Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial’, which is published in the journal Age and Ageing.
Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.