Centre for Research in Public Health and Community Care, University of Hertfordshire – Written evidence (INQ0059)

Technologies that can enable independent living in old age. By Dr Jennifer Lynch, Prof. Frances Bunn and Prof. Claire Goodman. University of Hertfordshire, Centre for Research in Public Health and Community Care.

Dr Lynch is an NIHR Knowledge Mobilisation Research Fellow researching the implementation of assistive technology for older people living in the community. She also works on the Wellcome Trust and NIHR funded Studies in Co-creating Assisted Living Solutions (SCALS) programme (Greenhalgh et al. 2016). Professors Goodman and Bunn undertake research on the health and wellbeing of older people, including those with dementia, frailty and other complex needs.

In our submission we refer to the terms of reference, responding to questions 6 and 8. We include:

• What technologies will be needed to help people to live independently for longer, with better health and wellbeing
• The current state of readiness of these technologies
• What should be done to help older people to engage with technologies
• The barriers to the development and implementation of these technologies
• What is needed to help overcome these barriers

What can be done to improve the acceptability of technology to older people?

Acceptability of technology among older people is high if several factors are considered (Liu et al. 2016; Peek at al. 2016; Cook et al. 2016):

• Whether the technology meets a need that is recognised by the older person;
• Older people’s own perceptions of whether the technology will help them to remain at home;
• If the technology makes them feel less dependent or helpless
• Attitudes towards technology and awareness of options prior to receiving assistive technology;
• How easy the technology is to use;
• Whether others in their social network recommend and will support them using a technology;
• The influence of organisations such as domiciliary care providers e.g. if they use technology or are willing to help the people they work with to use it;
• How the technology fits into their home environment i.e. if it works with the physical and spatial aspects of the home and is not considered intrusive by the user.

From our own research (Lynch et al 2018; Lynch 2015) we know:

• That even when new technology is initially acceptable to the user they will often need ongoing monitoring and support to continue using devices over time. Few technologies can be used ‘off the shelf’ by older people without being adapted or tailored to the individual needs of the user.
• If human support has been reduced as a result of receiving technology but the older person stops using the device over time because it is not sufficiently tailored to their need, there may be unintended consequences such as an increase in the person’s isolation.

Maintaining independence in daily living—devices designed to help and current state of readiness

• Research findings don’t yet paint a clear picture of which technologies help people to live independently. Evaluating the effectiveness of a technology is complicated for many reasons. The speed of technology development means research findings may not reflect the most up-to-date version of the device.
• Technologies are used alongside other services so it can be difficult to disentangle the benefits of the technology from those of other service components (Knapp et al, 2016).
• Remote monitoring for older people. Many local authorities are investing in technologies that can remotely monitor older people’s health, wellbeing and safety at home (NIHR 2018). These include sensors and alarms around the home or worn by the person themselves. These are linked to a system that prompts a response when needed. They may require no or some interaction from the user and some collect data on people’s behaviour or health indicators.
• Despite the popularity and intuitive appeal of these technologies with social care commissioners few research studies have been conducted with older people using the technologies in their home setting (Lapierre et al. 2018; Liu et al. 2016) . Small studies involving people using remote monitoring technologies in their everyday lives have suggested a misplaced confidence in people’s willingness or ability to engage with the technology once they are left alone with it (Lynch 2015).
• Health and social care professionals are attracted to the potential of remote monitoring technologies to help prevent older people falling. When older people fall the consequence is often severely reduced independence because mobility and confidence both decline suddenly.
• Research evidence that technology can prevent falls is currently weak. This is because most studies look at the functionality of the devices and not how people use them. Where evaluations of technologies in use have been done, they show little impact on the prevention of falls, hospital admissions or improving quality of life (NIHR 2018; Liu et al. 2016; Hirani et al. 2014; Steventon et al. 2013).
• Research evidence about remote monitoring is strongest in relation to supporting older people to continue self-care activities, such as bathing and grooming (Liu et al. 2016).

Barriers to implementation

There are a number of well-documented barriers at system and individual level to successful technology implementation (Lynch et al. 2018; Greenhalgh et al. 2018; Knapp et al. 2016):

At a system level these are:

• The generally weak evidence base causing uncertainty for potential investors;
• Poor alignment between national and local policies about assistive technologies and the priorities of service users;
• The ability of commissioners to achieve economies of scale by balancing current and potential demand for new technologies; Lack of integration between new technologies and legacy systems and routines;
• The inability of small-scale implementation projects to be scaled up and sustained over the long term.

At an individual level:

• Poorly designed, developed and/or installed technology that does not allow for personalisation to the individual
• The skills, awareness and attitude of frontline care staff who support older people to accept and use technology;
• Difficulties in measuring the benefits of technology in a timely way for the older person and the system.

How can we overcome these barriers?

• Developing and implementing assistive technologies needs to start with the requirements and aspirations of older people rather than being led by what the technology industry wants to sell. This means taking a coproduction approach to designing services that include technologies so that older people and the professionals involved can equally express and exchange ideas. Where this has been done well older people have emphasised the importance of having more information available about different technologies; of making devices customisable; and of using technologies to build and sustain human relationships (Wherton et al. 2015).
• Our current research (see NIHR funded Knowledge Mobilisation Research Fellowship ref: KMRF-2017-06-ST2-006) is showing that local authority commissioners and frontline staff are struggling to synthesise information about new technologies and make evidence-based decisions. More needs to be done to establish what people do and do not know about the benefits of technology and improve the sharing of research knowledge.
• Social care assessments must include planned conversations about assistive technologies with potential service users to fully understand individual needs and tailor the technology to the person (Forsyth et al. 2019). Resources such as training materials and assessment tools are needed to help social care staff to support older people’s use of technology.
• Investing in robust, long-term relationships between local health and care organisations and industry partners to ensure the production of local technology that is responsive to the current and future needs of local populations.
• Less focus on short term results in the social care commissioning process and recognition of the need to set realistic goals to embed new technologies and reduce service costs. Our current research shows the long-term benefits of organisations spending time identifying and reducing potential challenges to successful implementation using tools developed through research before investing in the technology (see NIHR funded Knowledge Mobilisation Research Fellowship ref: KMRF-2017-06-ST2-006) (Greenhalgh et al. 2018, 2017).

Summation

Technology has the potential to support older people to live independently for longer but currently there is not enough research evidence to tell us which technologies can do this best. Research and social care practice must develop methods of working that start with what older people say they want help with and work with them to test new technologies. Social care professionals need more help to support older people to use technologies and to understand all the factors that might influence the success of a technology enabled service.

Glossary

Assistive technologies: Devices that help people with everyday tasks or make it easier for people to keep in contact with others or collect information about a person’s activities to support their care.

Older people: Adults aged 65 years and over.

Quality of life: Subjective assessment of a person’s ability to enjoy normal life activities taking into account the impact of illness and treatment. Measurement is usually carried out using a questionnaire before and after a person interacts with an intervention, like a new technology. It includes factors such as mobility, emotional state, social contact, fatigue and other disease specific symptoms.

Coproduction: A way of working whereby professionals and people who use services come together on an equal footing to find a shared solution, for example to plan and deliver a new service.

References

• Cook, E. J., G. Randhawa, C. Sharp, N. Ali, A. Guppy, G. Barton, A. Bateman, and J. Crawford-White. 2016. “Exploring the Factors That Influence the Decision to Adopt and Engage with an Integrated Assistive Telehealth and Telecare Service in Cambridgeshire, UK: A Nested Qualitative Study of Patient ‘Users’ and ‘Non-Users.’” BMC Health Services Research 16 (1): 137. https://doi.org/10.1186/s12913-016-1379-5.
• Forsyth, K., C. Henderson, L. Davis, A. Singh Roy, B. Dunk, E. Curnow, R. Gathercole, et al. 2019. “Assessment of Need and Practice for Assistive Technology and Telecare for People with Dementia-The ATTILA (Assistive Technology and Telecare to Maintain Independent Living At Home for People with Dementia) Trial.” https://doi.org/10.1016/j.trci.2019.07.010.
• Greenhalgh, T., S. Shaw, J. Wherton, G. Hughes, J. Lynch, C. A’Court, S. Hinder, et al. 2016. “SCALS: A Fourth-Generation Study of Assisted Living Technologies in Their Organisational, Social, Political and Policy Context.” BMJ Open 6 (2): e010208. https://doi.org/10.1136/bmjopen-2015-010208.
• Greenhalgh, T., J. Wherton, C. Papoutsi, J. Lynch, G. Hughes, C. A’Court, S. Hinder, R. Procter, and S. Shaw. 2018. “Analysing the Role of Complexity in Explaining the Fortunes of Technology Programmes: Empirical Application of the NASSS Framework.” BMC Medicine 16 (1): 66. https://doi.org/10.1186/s12916-018-1050-6.
• Greenhalgh, T., J. Wherton, C. Papoutsi, J. Lynch, G. Hughes, C. A’Court, S. Hinder, N. Fahy, R. Procter, and S. Shaw. 2017. “Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies.” Journal of Medical Internet Research 19 (11): e367. https://doi.org/10.2196/jmir.8775.
• Hirani, S. P., M. Beynon, M. Cartwright, L. Rixon, H. Doll, C. Henderson, M. Bardsley, et al. 2014. “The Effect of Telecare on the Quality of Life and Psychological Well-Being of Elderly Recipients of Social Care over a 12-Month Period: The Whole Systems Demonstrator Cluster Randomised Trial.” Age and Ageing 43 (3): 334–41. https://doi.org/10.1093/ageing/aft185.
• Knapp, M., J. Barlow, A. Comas-Herrera, J. Damant, P. Freddolino, K. Hamblin, B. Hu, et al. 2016. “The Case for Investment in Technology to Manage the Global Costs of Dementia PIRU Publication 2016-18.” www.piru.ac.uk.
• Lapierre, N., N. Neubauer, A. Miguel-Cruz, A. Rios Rincon, L. Liu, and J. Rousseau. 2018. “The State of Knowledge on Technologies and Their Use for Fall Detection: A Scoping Review.” International Journal of Medical Informatics 111 (March): 58–71. https://doi.org/10.1016/J.IJMEDINF.2017.12.015.
• Liu, L., E. Stroulia, I. Nikolaidis, A. Miguel-Cruz, and A. Rios Rincon. 2016. “Smart Homes and Home Health Monitoring Technologies for Older Adults: A Systematic Review.” International Journal of Medical Informatics 91 (July): 44–59. https://doi.org/10.1016/J.IJMEDINF.2016.04.007.
• Lynch, J. K. 2015. “Policy Aspirations and Practice in English Telecare: A Case Study of Story-Lines and Invisible Work.” PhD Thesis. University of Birmingham. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.675772.
• Lynch, J. K., J. Glasby, and S. Robinson. 2018. “If Telecare Is the Answer, What Was the Question? Storylines, Tensions and the Unintended Consequences of Technology-Supported Care.” Critical Social Policy, March, 026101831876273. https://doi.org/10.1177/0261018318762737.
• NIHR, Dissemination Centre. 2018. “Help at Home - Use of Assistive Technology for Older People.” https://doi.org/10.3310/themedreview-03345.
• Peek, S.T.M., K. G. Luijkx, M. D. Rijnaard, M. E. Nieboer, C. S. van der Voort, S. Aarts, J. van Hoof, H. J.M. Vrijhoef, and E. J.M. Wouters. 2016. “Older Adults’ Reasons for Using Technology While Aging in Place.” Gerontology 62 (2): 226–37. https://doi.org/10.1159/000430949.
• Steventon, A., M. Bardsley, J. Billings, J. Dixon, H. Doll, M. Beynon, S. Hirani, et al. 2013. “Effect of Telecare on Use of Health and Social Care Services: Findings from the Whole Systems Demonstrator Cluster Randomised Trial.” Age and Ageing 42 (4): 501–8. https://doi.org/10.1093/ageing/aft008.
• Wherton, J., P. Sugarhood, R. Procter, S. Hinder, and T. Greenhalgh. 2015. “Co-Production in Practice: How People with Assisted Living Needs Can Help Design and Evolve Technologies and Services.” Implementation Science 10 (75). https://doi.org/10.1186/s13012-015-0271-8.

20 September 2019