Doctor in the house

Mr Brown is recovering from a heart bypass operation he had in 2021. In the past, he would have rested in a rehabilitation centre for many weeks. These days he can go home to get well and benefit from much faster recovery. He wears a special watch which monitors his vital signs and keeps track of any unusual changes. A doctor will arrive at his home at the first sign of a problem.

This fictional scenario is likely to become fact, if the government achieves its goal of putting telecare at the heart of the UK’s NHS. Telecare is the remote provision of care and medical services to people in their homes, using digital information and communication systems. The type of activities that telecare can support include routine diagnostics, monitoring, screening, basic counselling and advice.

The aim of this technical wizardry is to enable older, disabled or vulnerable people to remain independent for as long as possible – and the government is taking its potential very seriously. The key driver for this is the UK’s aging population. According to the World Health Organisation, within next 30 years the over-60s will form the largest group in society, costing the health service more every year. In 2000, the Audit Commission estimated that 50% of hospital beds were taken by people over the age of 75, who could be better cared for in their own homes with use of telecare.

The 2005-08 Spending Review introduced a preventative technology grant, providing local councils with £80m over two years to equip 160,000 vulnerable older people with alarm technology to keep them safe – and out of hospital. New pilot projects will also be funded to encourage innovative services across the NHS and in social care.

Professor James Barlow, who holds the chair in technology and innovation management at Imperial College London, describes what has happened so far. “This funding was announced last year,” he says. “Since then government has been putting together a framework for guiding local social services departments on what they can do and how to spend the money. From this autumn, those departments will be coordinating telecare projects.”

Another incentive to the growth of telecare is the greater availability of smart homes, houses that are pre-wired for a range of services such as heating, lighting, audio and video distribution, security and alarm systems. They also come with computer networks and telecommunications. The services are routed through a central processor and simple user interfaces such as remote controls or wall-mounted keypads in each room. Occupants can then control anything from anywhere in the house.

However, Barlow emphasises that telecare is not necessarily a high-tech option. “There’s no rocket science about this,” he explains. “The sensors themselves are small, lightweight, unobtrusive and battery powered. They are controlled by radio frequency, and can be stuck on the wall with Velcro and removed when the person no longer needs them. Occupancy sensors can be slipped under a mattress, or there are wearable heart monitoring devices. There is no need for cabling around the home.”

The only major piece of technology that is required is an information gateway, in the form of a smart phone. “This is really just an extension of the existing community alarm system. There are 1.5 million people using this sort of alarm system already,” says Barlow. Installation in older homes is relatively straightforward and different levels and types of services can be offered, depending on patient needs.

On a macro scale, it is currently difficult to predict what the impact of telecare on healthcare construction could be. Broadband connections make communication between a house and, for example, a local health centre much easier, so relaying health information and advice between patient and advisor is faster. For the construction industry, the growth of telecare is likely to create less demand for large-scale hospitals, and more emphasis on smaller intermediary contact centres linked to care providers – nurses, doctors or community carers. “Even within hospitals, the sensors are being used to enable patients to spend less time on intensive care wards,” says Barlow. “Monitoring allows patients to be moved out of these expensive beds and into a less costly hospital ward.”

While current technology is relatively straightforward, Barlow believes that telecare services will gradually become more advanced. “We are only at the emergency response stage. The next generation of telecare is just over the horizon and includes preventative monitoring of vital life signs, with tracking of movement in the home. It doesn’t require a massive technological development. After that you are looking at full-blown lifestyle monitoring, looking at diet for example. And beyond that you have the world of implantable devices that can monitor constantly, and even deliver medication without any human interaction at the right time and in the right dose.” (See panel below)

But the development of telecare doesn’t rest on IT alone – the organisation of the health service and its funding is crucial, particularly as telecare becomes more complex. “As you move away from safety monitoring into vital sign monitoring, then you bring the Primary Care Trusts into the picture,” says Barlow. “By and large, social services pays for monitoring at the moment, but what happens if an elderly person receives telecare services which could include call outs from social services or ambulance or doctors? Who pays for what?”

The current healthcare infrastructure is not set up to deal with a move towards telecare. It is centred on large hospitals, and more of these buildings are on the government’s agenda for UK health services. However, it seems likely that the reduction in NHS costs that telecare could provide will make it attractive for politicians. And with a public that is currently very wary of going into hospital or care homes as a result of the MRSA bug and questions about the quality of care delivered, healthcare at home starts to sound like an even more attractive option.

More importantly, the increasing ease of access to information on health issues – from the internet for example – has made us much more aware and capable of asking for treatments, meaning that power no longer rests entirely with the healthcare professionals. And individuals are increasingly being encouraged to take care of their own health – a preventative approach to illness. In the end, it is individuals’ demands for better healthcare, and the best available treatments, that will increase the speed at which telecare is introduced.

Telecare on trial: While it is not yet widely used anywhere in the world, telecare is starting to work its way into several countries’ consciousness – including the UK, USA and Japan

Telecare is not yet widely used in any country. The main issue is not technology, but infrastructure and organisation of delivery of the care services. A Europe-wide system is almost impossible, given the diverse health service networks in each member state. However, a number of trials have been carried out in the UK and around the world. Further UK government funding will progress such trials further, giving a clearer view of how telecare might be sensibly introduced. Imperial College’s Professor James Barlow believes it is likely that certain diseases, such as diabetes, will be targeted first, with those individuals asked to trial telecare services thereby reducing their burden on the existing health infrastructure.

USA … A pager known as HealthBuddy allows chronically ill patients in California to communicate with a doctor over the internet. The device connects to a telephone socket in the patient’s home. A daily list of questions from the clinic appears on a display – “Did you have trouble breathing last night?”. If patients respond with a “high-risk” answer, the clinic contacts them. This kind of patient finds it hard to visit the doctor regularly, and early identification of problems can make the difference between a $10,000 hospitalisation and a $100 visit by the doctor.

UK … The Anchor Trust/BT telecare project is trialling telecare to assess its effectiveness in supporting independent living by older people. The test involves lifestyle monitoring of 20 volunteers living in Anchor Trust housing, and 20 living in their own homes. Various sensors were installed to monitor activities such as an in/out switch on the front door; ambient room temperature; and use of the fridge. Alarms were triggered by a drop in temperature, or behaviour outside the normal patterns, such as late night exits from the house.

UK … Tameside council bought 30 telecare systems for £600 each (totalling £18,000) and spent £4000 on capital equipment (mainly PCs) for the project. Installation was carried out by wardens from a housing association as part of their duties. Batteries (£8 per system per year) were replaced by the two project staff. There was no other maintenance cost. The service saved £152,000 in its first 11 months by reducing the incidence of falls, evenly split between health and social services.

UK … Scientists at Imperial College London have developed a computer chip that can be implanted into patients to enable doctors to monitor them minute-by-minute. The sensor, which includes a 2 mm2 microprocessor, will initially be implanted into diabetics. The implant will send a text message in an emergency via a mobile phone to alert medical staff of changes in blood sugar level. Using a phone means that if the problem is serious, patients can be given emergency advice. In the future, it is hoped the sensor will be linked to an insulin pump that can be remotely operated by a doctor. The aim is to develop the system so people with other chronic diseases can use it over the next few years. Trials are due to begin later this year.

Japan … Not only is Japan’s population ageing rapidly, the Japanese have the longest life expectancy in the world. There are about 20 million people in the country who suffer from chronic disabilities. Japan has a readily available ISDN network which could easily carry telecare services. However, the growth of telecare was hindered by Japanese law, banning the treatment or prescription of medication without face-to-face diagnosis. Now this barrier has been removed there are trials being run by commercial alarm system companies, which have plans to widen the services they offer.