Date: 04 December 2018
Category: Assistive Technology
It seems obvious that older people with long-term conditions could make greater use of assistive technology, which would help prevent crises and hospital admissions. The Health Foundation has just published a briefing showing 55% of hospital admissions and outpatient visits and 75% of primary care prescriptions are for people living with two or more long term conditions. Even in the least-deprived fifth of areas in the UK, people can expect to have two or more conditions by the time they are 71 years old.
So, why is assistive technology not playing a bigger role in preventing crises? There is no single answer. Reasons seem to include complexity or poor usability of the technology, excluding design processes, poor user testing, poor integration with other systems, cost, the wrong people (often engineers) deciding what is required and people not being taught how to use it. Many development projects seem to be led by the technology rather than the problem, with minimal engagement of the users, let alone co-production of the solution.
Assistive technology comprises a very wide range of equipment that meets someone’s daily needs, whether at home, in a care home, out in the community or at work. It is less about the technology and more about how people can enhance their lives by using it. This includes large items, like stair lifts, automatic (and in future, self-driving) cars and ‘automatic’ toilets, and small electronic devices like pills dispensers and sensors as well as mobile technology and communication aids.
Wifi and computerisation now enables 24/7 monitoring which enables rapid response should an event occur. An example is continuous glucose monitoring via a skin sensor for people with type 1 diabetes, helping them to avoid damaging glucose levels and long-term complications.
Many of the current products are still standalone and depend on the person at the centre being quite technologically literate. There is a need to bring together all the necessary technologies into a single package to warn the individual (or their carers) before a crisis happens. No one wants a proliferation of incompatible devices around their home that have different instructions.
The technology can be very complex. One problem is the ‘feature creep’ we see in many electronic devices for the home, like in washing machines with dozens of possible wash programmes, despite only three or four being used. Complexity stops many older people using technology that is not intuitive. Smart phones or tablet computers have improved a lot and are good for simple tasks, but usually only specialists (or grandchildren) can help if they go wrong.
Few systems enable the individual (or their carer) to define normality for themselves, when they are ‘feeling good’. Clinicians and A&E departments usually only see a person when they are in (or close to) a crisis and at their lowest ebb, so unsurprisingly they tend to underestimate what someone is normally capable of doing for themselves.
For example, a frail person who gets a virus may get temporarily confused and become dehydrated if they forget to drink, particularly if they are living alone. If that person is taken to hospital they often get ‘stuck‘ there, even though their confusion disappears when they rehydrate, as their home support may be considered inadequate by professionals.
A well designed alert system could recognise this problem and facilitate early intervention to avoid the crisis (and possible hospitalisation), and would reassure carers and friends that any deterioration would be identified early.
There is good evidence that ideas (and technology) spread much more easily where people want it because it works well (user pull) rather than where technology is pushed by suppliers. https://youngfoundation.org/publications/in-and-out-of-sync-the-challenge-of-growing-social-innovations/ Developers of innovative technology tend not to involve the users and carers as much as they should in co-designing, co-producing and field-testing their products. If they did, this would create more ‘pull’ for products and systems that are well designed and effective.
Thinking beyond technology in the home, we risk creating ghettoes of older people who are socially isolated and cannot help themselves, let alone help their neighbours. Old and young need to live side by side and build intergenerational communities that help one another. Younger people can benefit from the time-rich, wise elders (e.g. for childcare), who in turn can be helped by technologically savvy, energetic younger generations.
Housing design that increases shared space for socialising and practical aspects of living such as shared laundry rooms, kitchen and dining facilities, can help to facilitate this. An example is the Abbeyfield Society, in its communities for independent living and in co-housing projects across the country. (https://www.housinglin.org.uk/Topics/type/Innovative-Housing-Models-for-an-Ageing-Population/
What would I like from assistive technology? Looking at this from a personal point of view, my ideal would be an easy to use, reliable alert system that would understand when I was ‘normal’ and let me (or my carers) know when I am not doing so well so that I, or my carers, can act quickly to prevent me getting worse. It will ‘know‘ my normal condition and behaviours so that it can detect and tell me when things are not right. It will be continually record my ongoing health and daily activities, linking to information from my health monitoring devices, my mobile phone and importantly include insights from people in my circle of care. This will allow me or others to identify any changes which give an early indication that my condition(s) is getting worse or that I am generally not managing as well as I should. While I will still want to take decisions for myself if I can, this will form a background ‘automatic’ system that will provide a back up if I miss something or cannot act for myself!
We need to develop comprehensive integrated alert systems that support individuals to feel confident and remain independent, and provide a backstop that identifies problems early and initiates action to address them. These systems should learn what people can normally do for themselves, rather just addressing crises, and the systems always need to include carers, friends and families as well as professionals.
We need developers to recognise the need for better evidence about which technology works well, is safe and acceptable to the people who need to use it. We also need evidence about the accuracy of alerts and their impact on quality of life, hospital admissions etc.
The NIHR Dissemination Centre’s latest themed review on use of assistive technology, Help at Home, has been useful in highlighting where evidence is strong but also where research needs to go next.
The strength of the evidence needs to be appropriate; thoughtful piloting and testing which is well documented and published in such a way as to encourage people-powered demand for good quality systems. Organisations like the Consumers’ Association, Carers UK, AgeUK and the disease-focused medical charities have an important role here, but need to coordinate their work to avoid creating disease-specific devices or systems.
There is much work already under way to increase healthy ageing, which is one of the government’s grand challenges. The new Secretary of State for Health and Social Care has stated that the greater use of technology is one of his early priorities. But there needs to be combined approach which brings together people’s views with health, social care and environmental perspectives and encourages effective, integrated technology, rather than seeing these as different conversations happening in disparate places.
Older people with long-term conditions could make greater use of assistive technology, which would help prevent crises and hospital admissions. Assistive technology comprises a very wide range of equipment that meets someone’s daily needs, whether at home, in a care home, out in the community or at work.
Sylvia has a background in health systems, planning and social innovations and advised the Scottish Government on Shifting the Balance of Care and building social capital.