Introduction

The notion of Ageing in Place has become an important issue in redefining health and social care policy for older people in recent years. The basic premise of Ageing in Place is that helping older people to remain living at home fundamentally and positively contributes to an increase in well-being, independence, social participation and healthy ageing. Furthermore, care at home is often seen as a less expensive option than moving frail older people to supportive environments, such as nursing homes. However, there is little research or evidence that explores and evaluates both the positive and potential negative impacts of ageing in place at home. This paper addresses the issue of Ageing in Place from the perspective of the United Kingdom and has a number of objectives. Firstly, it discusses some of the issues around the concept of Ageing in Place and evaluates the implications of these for policy and practice. Secondly, data from research on a sample of people aged 80–89 in the UK are used to illustrate some of the challenges facing older people as they age-in-place at home. A concluding perspective looks at some of the emerging solutions for enabling Ageing in Place, specifically the use of new technologies to help older people live independently, and evaluates some of the potential benefits and disbenefits of these technologies.

Theoretical Aspects of Ageing-in-Place

Ageing in Place has been a major thrust of UK policy on older people and housing. The underlying assumption is that enabling people to ‘age in place’ at home will not only benefit the older person in terms of their quality of life, but will also be a cost effective solution to the problems of an expanding population of very old people (Tinker et al. 1999). Such assumptions have not yet adequately been investigated, especially in relation to the older old population. In particular, the psycho-social and environmental factors involved in living longer at home have yet to be fully understood in terms of mental health, quality of life, social isolation and exclusion. Aside from expensive medical aid, helping a person to stay in their own home should decrease the human and financial cost of placing an elderly person into residential or nursing care (Tinker 1997). In this respect, a healthy and independent older person is much more cost effective in terms of health and welfare services.

The economic arguments for remaining living in the community are important considerations in the UK where the population of very old people is growing (the number of people over 85 has grown from 0.2 million in 1951 to 1.1 million in 2001 to 1.9% of the population (Office for National Statistics). Life expectancy at birth in the UK in the year 2000 was 75.3 for males and 80.1 for females. Currently, at age 80 in the UK life expectancy is 7.0 years for men and 8.6 for women. The health and welfare services demands of an increasing aged population is a cause for both economic and humanistic concern since there are high levels of morbidity and disability associated with extreme old age. Sauvaget et al. (2001) assessed 1,557 people aged 75 years and above and found that active life expectancy at age 75 was 4.6 years for men and 3.1 years for women. Cognitive impairment-free life expectancy at age 75 was 8.4 years for men and 9.9 years for women (92.3% and 93.4% of remaining life). After the age of 87, the proportion of active life decreased dramatically with age in both sexes accompanied by some activity restriction. Providing adequate health and welfare services to cope with functional decline within the home environment is crucial to independent living and can improve an older person’s quality of life (Burnholt and Windle 2001).

Alongside economic and health status arguments, previous research has suggested that the majority of people over 75 prefer to stay at home living independently as long as possible, (Burnholt and Windle 2001). Most older people wish to stay in their own homes as long as possible (Tinker 1997; Gitlin 2003). Given that very old people do spend a considerable amount of time at home (Sixsmith 1990; Gitlin 2003), the home environment has the potential to play an extremely important part in health and well-being. However, little is currently known about this relationship, in particular, the home as a determinant for healthy ageing. Here, healthy ageing refers not just to biological and medical aspects of ageing, but adopts the more holistic perspective advocated by the World Health Organization to include functional definitions emphasizing autonomy, participation and well-being (Bryant et al. 2001). Understanding the ways in which Ageing in Place and the home environment supports or constrains healthy ageing may be of critical importance in maintaining and improving quality of life amongst very old people.

There are some indications that ‘staying put’ at home can benefit personal health either directly or indirectly. On the one hand, it has been demonstrated that good housing conditions can help to sustain good physical health and also good mental health (Altman et al. 1984; Burnholt and Windle 2001; Moore 2000). On the other hand, housing in poor condition can be detrimental to older people’s well-being and quality of life, for example as Tinker (1997) illustrates, a damp home environment is directly linked to poorer health, while the incidence of falls (the main cause of accidental death in the over 75’s) is related to housing conditions and hazards within the home. In terms of mental health, poor quality housing can contribute to psychological distress (Evans 2003) and psychologically, a home which lacks positive meaning “provides no sense of security, order, identity, connectedness, warmth, or suitability (Gifford 1996, p. 197). A good physical and social housing environment can positively influence health and wellbeing, but evidence based on research explicitly and comprehensively considering the socio-physical environment of very old people is still lacking. Understanding the relationship between home and healthy ageing needs to recognise that home is not simply a physical or spatial environment, but is an environment of experience and meaning in which person-place transactions are constructed (Sixsmith and Sixsmith 1991; Moore 2000). Research on the experience and meaning of home indicates that home is of central significance in the person’s life. It is a psychological space of privacy, comfort and safety, a space in which social relationships are negotiated (Depres 1991; Annison 2000). For older people in particular, home is of profound symbolic and personal significance (Tinker 1997) and is increasingly where events, internalised in memory over the life course, have taken place, connecting people as they age to their own past lives (Rubinstein et al. 1992).

Home is also recognised as a place which helps to maintain independence and autonomy (Sixsmith 1990; Moss 1997), especially important in Western cultures where “dependency” is seen in very negative terms. As Rubinstein et al. (1992, p. 4) say, “to have a home, to live in one’s own home, to be in the home are very much part of a sense of personal coherence and continuing physical viability”. However, the everyday lived experience of home is not always a highly positive one in later life. Home should, for instance, be understood in terms of what a person is trying to achieve in their lives, their life circumstances and their life transitions (Sixsmith and Sixsmith 1991). For some older people, home can become a virtual prison or a tremendous burden. As people age, often with attendant health and functional capacity declines, managing the home environment can be problematic. Self adaptations to the home environment are often accompanied by adaptations of the physical home with consequent psychological and social implications for the meaning of home. Moss (1997) very clearly shows such personal, psychological, physical and social changes in her study of the negotiation of space in home environments amongst older women living with arthritis. This work revealed how negotiation of home space was linked to the older women’s conceptions of ageing and arthritis. Moreover, the importance of the wider social political economy was highlighted in relation to the relative social positionings of older women to resources, income and access to power. Such instrumental aspects of everyday life underpinned the structural aspects of the home as well as the women’s experiences of them. Such work indicates the necessity of taking a holistic perspective and ‘context sensitive’ focus on the experience and use of home (see Moore 2000) in order to map out the ways in which person-home transactions function in regard to healthy ageing.

The nexus between financial considerations and humanitarian concerns has been at the heart of UK policy on long-term care for older people. For example, the Audit Commissions (1986) report “Making a Reality of Community Care” highlighted the high cost of institutional care (hospitals, nursing homes or residential homesFootnote 1) compared to care provided in people’s own homes. A landmark publication in 1989 was the Griffiths Report that criticized the “perverse” financial incentives that had resulted in a huge expansion of nursing and residential home during the 1980s to meet the growing needs of an ageing population. The Wagner (1988) Report emphasized that residential care for older people should be a “positive choice” and not something that older people are forced or channeled into because of a lack of viable options. More recent policy discussion papers and service frameworks (DH 2001; 2005) accept the fundamental idea of ageing-in-place and focus more on issues of quality of service. The thrust of this policy has been that strategies to help older people remain at home will have both societal benefits in terms of reduced costs and individual benefits for the health and quality of life of older adults. While these assumptions are at the heart of UK policy, the reality is not straightforward. In this paper, some of the results of qualitative research are presented to illustrate some of the benefits, problems and challenges that exist in relation to Ageing in Place in the United Kingdom.

Methodology

This study is based on qualitative data collected from 40 people age 80–89 in the north-west of England as part of the ENABLE-AGE Project (Iwarsson et al. 2007), conducted during the period 2002 to 2004 and financed by the European Commission and involving six partner universities in five countries: Sweden, Germany, the United Kingdom, Hungary, and Latvia. In this paper, only the results of the UK part of the research are summarized.

A grounded theory approach (Charmaz 2003) was deemed appropriate because of its data driven orientation, enabling the older people’s perspectives to be prioritised over researcher assumptions. Grounded theory constitutes a systematic and rigorous process of working with qualitative data in which the methodology focuses on the generation of theory from data (Strauss and Corbin 1997). Participants were drawn from a larger sample of older people interviewed during the survey phase of the Enable-Age project and chosen on the basis of the following diversity criteria: age, gender, type of dwelling, self-rated perceived health, ADL dependence, accessibility problems in the home and degree of social participation. Forty people were selected from the survey sample of which, 24 were women and 16 were men, reflecting both the male to female survival ratio and the greater reluctance of older men to participate in interview studies (Stratton and Moore 2002).

Pilot studies were conducted and from this an in-depth semi-structured interview schedule was developed based on five key topic areas: the meaning of home, autonomy, social and community participation, health and well-being, and societal supports for Ageing in Place. The interviews were carried out by multi-professional teams including psychologists, sociologists, occupational therapists, medics and gerontologists. All interviews were carried out at home visits and the time and date of the interviews were arranged in accordance with each participant’s preferences. This study focused on how the participants experienced home in relation to aspects of health.

All interviews were taped and transcribed verbatim. Immediately after each interview the interviewer took field notes. These were used to document the interviewer’s interpretations of the context of the interview, the key points revealed in relation to the research questions, initial ideas for analytical themes, relationships between themes, and the general tone of the interview. Constant comparative analysis according to grounded theory was conducted. The analysis initially focused on the identification of key themes using a line by line coding system, followed by focused coding (Charmaz 2003), which is a selective phase aiming at synthesizing data. Codes emerged, were compared and sorted into categories, exploring interconnections. Each of these categories was carefully examined to identify the properties that characterized the category, and subcategories were identified. Relationships between categories were sought. In reality, the different steps of analysis were not strictly sequential. Instead, the analysis was conducted by moving back and forth, constantly re-examining data, codes, categories and core variables. In this way, a close correspondence was maintained between the older person’s perspectives and the data analysis. Additional information generated in each interview was successively integrated into the developing analysis.

Research procedures were based on ethical protocol that provided guidance for all the researchers, with particular consideration given to written informed consent from each participant; protection of privacy and anonymity; and protection from risks such as fatigue and emotional distress. Participants were also aware they could withdraw from the research at any stage up to publication. Ethical approval was gained under the umbrella of the National Health Service’s research ethics service (http://www.nres.npsa.nhs.uk/).

Results

The research explored the meaning and experience of “home” and Ageing in Place for very old people, many of whom face the challenge of increasing frailty while living alone. The study highlighted the value of being able to remain living at home for the older people in the study. Firstly, the home provides the person with a sense of independence, security, privacy and comfort. The house confers considerable control over access into private domain of the individual and the ability to close the door on the outside world is central to retaining control over one’s life and maintaining a sense of identity. Secondly, the home is an important place socially, especially in terms of being able to socialize with family, friends and neighbours and to maintain these networks. Having one’s own home allowed the person to maintain these ties without becoming burdensome to family, allowing paid carers to deliver help and support into the intimacy of their home. Thirdly, the physical environment of the home can be seen as a material and symbolic medium for preserving independence. As health and mobility declines, the person can adapt the home to meet their needs. The demands of living at home can help to preserve abilities, while serving to demonstrate that ability to remain independent.

The research echoed findings of a growing body of research on ageing and home that has emphasized the positive benefits of Ageing in Place. For many participants, there was a deep sense of attachment to their home:

“…for me it’s(home) absolutely perfect, it couldn’t be better (Edmund, O-M) This bungalow is very very special to me… I fell in love with it because it had a big garden, and room to grow stuff… We did an awful lot, we’ve been doing it since,.. and now got it just lovely! I absolutely love it! I think its just heaven! And em I’d never want to go anywhere else, I just absolutely love it, I think its ideal. (Edith)

The study revealed many of the important dimensions of subjective home experience, such as privacy, control over personal space, memories and possessions that contribute to a strong bond between person and place. Moreover, most people were fearful of the alternative of moving to an institutional setting, such as a nursing home:

I mean, I do not want to go to a nursing home (…) I mean (.) nursing homes are very necessary, let me say that, I don’t know what we would have done with (Name of Sister) without the nursing home, they’re very necessary. But the idea that being, say with forty other patients all ill (.) no (.) it doesn’t appeal (.) (Ann: 1036–1040).

Even becoming housebound was seen as preferable in order to remain at home. Yet the older people have to weigh their ability to stay put against the practicalities and challenges they often face, for example:

“…years ago when I was young, don’t forget I’m eighty-five (.) years ago when I was young, if people married they all stayed in the same district close to mum and dad. So mum and dad were well looked after but this is a different age… they can’t get home and look after their mother (.) or they go down to London to work or they go everywhere but they don’t live like they did when I was young. (Ann)

It is in this context of the desire of older people to remain living, but often facing significant practical challenges, that Ageing in Place policy needs to be explored and evaluated. As well as the positive benefits of remaining at home, the ENABLE-AGE research uncovered negative aspects of remaining at home and highlighted the many practical challenges both to the older people themselves and to housing and service providers.

Barriers in the Home

As the ageing process decreases functionality and health status, the physical aspects of home such as steps and stairs can be transformed from unconscious presence to tangible barriers. While there are many recent initiatives in designing housing more appropriate to the needs and capabilities of older people, such as Universal Design, the fact remains that most housing in the UK contains barriers that may undermine the older dwellers’ ability to remain living in their homes (Iwarsson et al. 2007). In these circumstances, the current study data shows that housing adaptations are an appropriate but often inadequate solution:

Now here you can’t have a ramp or a rail on the patio because it would have to go down to the foundations. So we can go through the sitting room but even coming out of the sitting room there is the patio window. So you can fall if you can’t see that. If the lift is out of order you can’t go downstairs.” (Victoria)

As well as loss of independence, many older interviewees in this research were aware that inappropriate aspects of their living environment could lead to increasing social isolation, for example, if their ageing friends and family themselves can no longer manage stairs. It is important to consider that the personal experience of home is a transaction between person and place, whereby changes in personal circumstances or in the environment have the potential to transform this ecological relationship (Sixsmith and Sixsmith 1991). The ENABLE-AGE study has shown that frailty, loss of energy, decreased functionality and health problems all have the potential to transform a comfortable and manageable home environment into a place of social exclusion, isolation, fear and vulnerability.

The Symbolic Home

It is also important to consider the symbolic quality of the home. The qualitative data indicates that staying put is a personal and social symbol of one’s continued ability to be independent. Alternatively, many people resist home adaptations because they can signify the negative experiences of decline associated with later life, for example:

“I told her (nurse) about the difficulty I had in getting into the bath, and she said ‘Oh yes we can get you things that you get in’ but I don’t want it, because I’m hoping that in a couple of days time I’ll be able to go climb into the bath by myself, (unclear) so although I’m very grateful about the things that are being offered to me, you know I just don’t want them” (Dave).

This seemingly “irrational” response to instrumental supports may frustrate community equipment and adaptation schemes that are ostensibly set up to help people, but nonetheless should be taken seriously. This consideration of the symbolic dimension of the meaning of place is a component of the Universal Design movement that promotes accessible environments and social participation through inclusive design, rather than through exclusionary design that labels and stigmatizes disabled and older people. People also respond aesthetically to home adaptations. For example, if devices, equipment and modifications are intrusive (e.g. dissonant colours) then a dweller may refuse them, even though they may be functionally useful.

Hiding Increasing Frailty

While the home is almost invariably construed in positive terms by the older dweller in terms of privacy and control over one’s personal space, the “flip side” of this is that the very features of the house that bestow privacy and control over personal space can also serve to hide the growing vulnerabilities of the person. Indeed, many people choose to hide declining capacities within the home, invisible to the outside world:

“I do value independence, and I’m not very good at asking for help, and, people said to me ‘why didn’t you ask me? I would have taken you there’ or ‘why didn’t you ask me’ and it has never occurred to me so I suppose I really ought to have a little bit more sense and instead of being quite so independent now” (Edith).

The complex nature of the relationship between person and home was very much implicated in feelings of independence. Participants in the study had become aware of their former selves, their skills, activities and the condition of their home. Changes in their capabilities to care for self and home were felt very much as instances of dependence, just as continuing capabilities were signs of independence. Asking for help to maintain independence was difficult and technological aids were useful in this respect. However, the meaning and use of such aids sometimes contradicted the ways people wanted to live at home (their privacy, sense of safety and aesthetic homeliness) rendering them less effective. Where social support was essential, older people often preferred to pay for this in the form of services, linking their level of independence to the financial resources available to them. Interestingly, retaining psychological control over such services helped older people feel independent, even in the face of substantial domestic and personal care. Nevertheless, paying for help enabled the older person to avoid the feeling of becoming a burden to their family and friends. This was perhaps a consequence of avoiding strain on social relationships and helping them to retain a sense of continuity and remain the sort of person they had been throughout their lives.

Fearfulness

As people become older and frailer, many become very aware of their vulnerability. Often this fear exceeds the “reality” of the situation. For example many older people are fearful of becoming victims of crime. Even though they are unlikely to be victims and less likely than many other groups in society, older people often change their behavior in anticipation for negative experiences, often choosing not to go out at night. None of the research participants described events in which they had been attacked or had suffered from crime at night. Rather, it was the fear of what might happen that creates a self-perception of vulnerability and behavioural consequences such as curtailment of social life. The same principle can be seen in the following:

I used to go across the road. But I stopped going there because again, if I was crossing the road, I could fall down. I don’t need anything to fall over, I just fall down. And you know you couldn’t (unclear) a driver, who couldn’t stop in time to stop running over you. And I’ve got no intention of being run over. If I’m going to die I’m going to in bed in peace and quiet. (Ann)

The implication here is clear. Some people would rather restrict themselves rather than participate in activities that they see as “risky” This strategy may effectively constrain older people’s lives to their home environment, reducing activity and social participation possibilities.

Barriers Outside the Home

In the last quote fear was the main barrier to participation, rather than actual falls themselves. On the other hand, poorly designed environments and lack of facilities were seen by interviewees as fundamental and intractable barriers. One major issue in this respect concerned transportation. The ability to drive (and feel safe while driving) was crucial to social participation. However, for some, poor night vision and worries about accessible parking places could prevent personal car use. For others, having access to buses, nearby the home, bus stops with seats and buses with low steps and helpful drivers were essential. Moreover, low rates of pensions meant that cheap transport was required:

Transport does affect me very deeply, because for instance now on a nice sunny day like this I would like to get into a car and go around the markets of Wales and have a look around the scenery in the countryside, but economics deter me from that. So, transport is very important and I have to give up my bus pass because it’s impossible to climb on to a bus and take a journey by bus, so transport is (.) a very important factor in term in my life or lack of transport (Des).

Even if these conditions were satisfied, older people still had problems in using public transport because of the unpredictable running times. Waiting for a bus in cold or hot weather could cause severe problems for older people who might have strict needs of medication, toileting facilities and so on. In order to overcome public transportation problems, taxis were often used as a quick and efficient alternative. However, taxis were expensive and getting in and out of a car proved difficult for some people, and embarrassing in front of taxi drivers. Even when older people enjoyed a large network of family and friends, they often denied themselves social opportunities in order to avoid positioning other people as unwilling helpers.

Loneliness

The home could be experienced as a place of intense loneliness. When the door was closed, a sense of being alone without support or care could pervade the home for some people:

I could easily sit here all day and (Inaudible word) somedays, you know, especially if the weather’s bad and you can’t go out er (.) but it’s no good you’ve got to make an effort….I make myself go out to a certain extent… I’m not a loner really because I (.) I hate every minute I live on my own (Maude).

Common reasons amongst the participants for loneliness included a loss/death of family (spouse/sister/brother) or pets (or just not being able to have one). Loss/death of a spouse, or close companion was a major factor in loneliness for the older people. Also, loneliness is the result of the decrease in social networks, often due to the dying of friends:

I’ve had 18 of my friends all die and now there’s so few of us left and we’re all getting so old now we can’t get to see each other so good. When you’re old like me, you can’t be going visiting like you used to. (Pru)

Situational factors that were linked to isolation were health, moving (relocation), not knowing many people in the area (social networks), self image, transport and other services, weather, fear, as well as environmental and psychological barriers to going out. However, it should be noted that isolation does not inevitably equate to loneliness. Many participants appeared content with their situation, perhaps due to their personality or through a process of adaptation over the years.

Challenges to Services

The ENABLE-AGE research also highlighted weaknesses in the services that were available to support people in the community. Data from the qualitative interviews highlighted the following points:

  • Despite an abundance of policies, initiatives and agencies providing financial and instrumental support, many older people remain unaware of what is available, with awareness often based on chance information and word-of-mouth.

  • Even when people are aware of schemes, the problem of negotiating bureaucracy often discourages applicants, who may choose to “do without” or self-finance.

  • Many people mistrust outside help. While familiarity with local general practitioners helped to build up trust, there is often a lack of trust and confidence in unknown or remote help and support.

  • Many people live in towns and neighbourhood environments that are disabling (e.g. lack of toilet facilities, pubic seats, uneven pavements, transportation limitations etc.) rather than enabling, leading to restrictions on social and community participation, such as going to the shops.

  • Services are often insensitive to the routines and preferences of the individual and are often highly disruptive in their own right to the everyday lives of older clients and patients.

  • Many services are seen as stigmatizing, particularly social services that are often seen in terms of impoverishment, invasiveness and loss of capacity.

  • Issues of identity and personal choice are also important. Many people choose to forego help and support to which they are entitled, because they feel that asking for help simply does not represent ‘who they are’ as capable adults and do not want to feel that they are ‘scroungers’.

  • Many services are seen as age-discriminatory, with older people seeing the available services as second-rate care and support or are unavailable compared with younger adults.

  • Older people are often dependent on public transport, but the quality of service is highly variable. Many people complained that bus services were often unreliable and inconvenient and operated in a way that was age-discriminatory.

  • Most people in the Enable-Age project expressed satisfaction with the basic services and few people complained of poor treatment. However, many felt that much more could be done to support their participation within society. There may be a process of disempowerment of older people acting here, where the relative lack of power is expressed in terms of low expectations and acceptance of the status quo.

Discussion

The Enable-Age study documented people’s feelings of vulnerability and loneliness and many weaknesses in the everyday supports required for ageing-in-place. The older people were well aware that a fall or serious illness in the privacy of home might go undetected and cause serious health problems or even death. However, the attitudes of older people themselves are also a significant factor, one which is culturally bound. Secker et al. (2003) argue that the emphasis placed upon independence and personal autonomy is an outcome of cultural values in UK society. In this context, dependency is seen as weakness and something to be avoided, even when this clearly unviable: “the most important thing in the world is to remain independent. So old people live alone, perhaps on the verge of starvation, in time without friends but we are independent” (Mead 1971 in Secker et al. 2003, p. 379). Indeed, such an ideology is apparent in older people’s reluctance to consider alternatives to remaining within their own home, even where a person’s ability to live within their own home is severely restricted (Bland 1999). The many negative experiences of being “independent”, low expectations and the reluctance of many older people to accept help remain hidden in the privacy of the home. “Out of sight, out of mind” may not be an explicit dictum of the organizations charged with the care and support of older people, but it is a convenient reality in the context of limited budgets and organizational constraints.

Despite a long tradition of policy to support ageing-in-place in the UK, the issues raised in this paper represent very serious challenges to providing effective help and support to frail older people in the UK. It is clear, from the ENABLE-AGE data presented above, that even with the support they receive, general living circumstances are far from optimal often combining to create substantial barriers to continued ageing-in-place. In circumstances where people receive appropriate housing adaptations and support services, there are many more fundamental (and often psycho-social) aspects of living at home in old age that undermine quality of life. Sixsmith (2006), while agreeing with the principles of ageing-in-place, argues that reality is a long way from the ideology and rhetoric found in policy statements. He suggests that in practice the home care paradigm has fundamental weaknesses, pointing to a range of contributing factors, many of which are borne out from the current analysis of older people’s perspectives:

  • Demographic change: The ageing of the UK population is well-documented and increasing numbers of very old people, especially those living alone, within the population has increased demand for care and support within the community. Increased longevity and the ageing of the baby boom generation represent huge challenges to which society may be unwilling to respond.

  • Role of informal carers: Changing demographics and lifestyles are likely to mean that there are fewer informal carers around to provide help and support. Informal caregivers may have many other responsibilities, such as jobs and children, limiting their ability to provide help and support. Workforce mobility may result in caregivers living many miles from the frail parent. In this context, Ageing in Place policy needs to fully recognise the role of informal caregivers and provide them with the necessary support and incentives. Policy has to address employment and welfare benefits as well as the traditional health domain in order to achieve this. The role of policy champions to drive and coordinate cross-sectoral policy is essential here.

  • Neighbourhood and infrastructure: Changing patterns of living in the UK and other developed countries have seen very significant changes to services and amenities within urban environments. Increasing use of cars has meant that many essential shops are located away from local neighbourhoods. Changes in social structures may have seen a reduced role of institutions such as local churches, while “community spirit” or the social capital of a place may have decreased in many places. All these factors can have an impact on the ability of functionally impaired people to remain living at home

  • Limitations of formal sector support: The above factors represent huge challenges to the health and social care sectors and these are challenges which the formal sector has been unable to deal with. The main driver of the formal sector is cost-containment, with limited resources available to meet growing demand. In the face of this, social services for older adults have become increasingly targeted on the most needy, marginalising people with lower level needs. Care is largely reactive, responding only to “eligible” cases as they are presented. In terms of service quality, care is generally task-oriented, with little focus beyond instrumental support for everyday tasks of living, with problems such as poor continuity of care personnel. However, the most serious challenge is structural. There are fundamental restrictions on the ability of the formal sector to deliver care in the community. The simple logistical challenges of delivering services in the community undermine the delivery of high quality care and support to ever-increasing numbers of frail older people

Policy Responses in the UK—the Role of New Technology

The various challenges to the provision of effective ageing-in-place services discussed above require creative responses. One response that has become increasingly high profile in the UK is the development of telecare services, where information and communication technologies (ICTs) are used to help people to live more independently in their own homes (Fisk 2003). A first “generation” of telecare (Doughty et al. 1996; Sixsmith et al. 2007) refers to community alarm systems, where a person raises an alarm in a call centre by pushing a button (or pulling a cord) on a device in their home or on a pendant or wrist device worn on their person. The call centre then checks the person and arranges some kind of response if required. This could also include services where the call centre checks if the person is okay at regular intervals. These types of systems have been around since the 1960s, based on conventional telephone technology and are widely used. The UK market for this type of technology is perhaps the most well-developed worldwide (SOPRANO 2007) with approximately 1.5 million users. While there are countrywide monitoring centres, services are generally localised, with local authorities, housing organisations and community organisations providing a monitoring service for their locality. There are about 270 response centres across the UK. More recently, a second “generation” of telecare has emerged as a response to some of the challenges to ageing in place discussed above. Second generation telecare involves the use of more advanced ICTs, such as sensors and artificial intelligence for monitoring potential emergencies. First generation systems essentially involve the enhancement of conventional phones with an alarm push-button. This is very simple, understandable, affordable and easily installed, perhaps reasons for the wide usage in the UK and worldwide. However, a significant limitation of this technology is that it is dependent on the user initiating the emergency signal. It is possible to envisage a number of scenarios where first generation systems are inadequate: where the person is unable to press the alarm because they are incapacitated; where the person is cognitively impaired and unable to recognise a problem and/or initiate a response; where the person forgets to carry the call device; where the person may be unaware of a problem, such as fire, smoke, flood, gas escape, etc. Second generation telecare uses more recent, but well-established technologies to automatically detect the problem and raise an alarm in the call centre. Typically, such systems attempt to identify unusual or “abnormal” patterns of activity, for example if a person is motionless for an extended period of time. Fall detectors have been developed which detect sudden movements or changes in position that may indicate the person has fallen. Typically, second generation systems comprise:

  • Alarm button, telecommunications link, control centre, records system for monitoring alerts (the first generation functionality)

  • Sensors for passively monitoring the person’s movements (e.g. PIR, door opening, pressure sensors for bed or chair occupancy, or enuresis)

  • Environmental sensors for smoke, flood, temperature, gas etc.

  • Intelligent home base unit or hub to link in home sensors together

  • Advanced record system logging new data from sensors

These kinds of systems are now commercially available, although the market for second generation telecare remains immature. Almost all local councils now provide, or will shortly provide, telecare services at least as pilot schemes. The largest schemes (e.g. Newham in London and West Lothian in Scotland) now have in the order of 3,000 telecare clients). A third generation of telecare is also envisaged, where information and communication technologies, can play an important part in preventative care services and enhancing a person’s capacity to perform activities of daily living and social participation.

The picture in the UK is currently developing significantly as a result of recent government policy “Building Telecare in EnglandFootnote 2” in 2005 (DH 2005), which outlined the government’s expectations in relation to the Preventative Technology Grant (PTG). Under the PTG £80m ($160m US) was made available to local authorities (£30m in 2006/2007 and £50m in 2007/2008) to introduce and mainstream innovative telecare services into packages of home-based care (but not upgrades to existing community alarm systems). It was expected that up to 160,000 extra people would benefit, (at a cost of about £500 each). While the PTG is a fairly modest amount when spread across the whole of the UK, this small investment in technology was expected to lead to profound changes in the way social care is delivered within community settings. The “re-engineering of community services” would involve the integration of ICTs and human-based services leading to improved care and a more cost-efficient delivery of services.

It is possible to identify a number of benefits of telecare. First of all, the introduction of telecare can help improve the quality of care and support provided to older people in the community. In particular technology can extend the range of services offered to clients. For example, round the clock care in a person’s home is prohibitive and is a feature of residential or nursing home care and the use of first generation community alarms effectively delivers this component of residential care into their own homes. The additional functionality of second generation systems provides people with enhanced safety and security within the home. A second beneficial aspect of telecare is its potential for widening access to support in the community. The focus on the frailest people means that people with lower-level needs may be unable to access the help and support they need. The first generation alarm systems have been hugely successful in the UK and help to provide a measure of confidence to many older people who require only limited support. Finally, there is the potential of telecare to make care provision more cost efficient. This has been very difficult to demonstrate and indeed it could be argued that issues of cost run counter to some of the benefits described above. However, the use of ICTs in general, and telecare specifically, may be able to make the delivery of care more efficient in several ways. For example the use of electronic client records and systems for communication between care professionals may help to increase productivity. Moreover the potential of more preventative approaches to care may have long-term cost benefits, by keeping chronically ill older people at home and out of expensive acute care.

Despite the apparent benefits and the availability of appropriate technologies, the emergence of technologically-based initiatives, beyond the simple first generation systems, has been surprisingly limited. It is possible to identify a number of barriers to implementation, such as lack of awareness by users (clients/patients and service providers), availability of funding and fragmentation of the service delivery. Moreover, while the potential benefits of telecare have been assumed, there is as yet little empirical evidence to support its widespread adoption (Sixsmith 2003). The evaluation of the telecare initiatives under the PTG grant may be helpful in providing this evidence base.

Conclusion

With improved living conditions, hygiene and health care, increasing numbers of people in the UK are living into very old age such that present and future populations will live a great deal longer than any previous generation. This increase brings with it dilemmas in health and social care in terms of extending healthy ageing and providing very old people with a good quality of life and opportunities for enjoying a sense of well-being. In this respect, the notion of ‘Ageing in Place’ has become an important issue in redefining health and social care policy for older people in recent years, with some proponents suggesting that “staying put” at home fundamentally and positively contributes to an increase in well-being, independence, social participation and healthy ageing amongst older people. The research from the Enable-Age project presented in this paper suggests that while Ageing in Place may bring benefits to the older person, there can also be a significant down-side on an everyday level. Home in old age can be a place of intense emotional experiences, frustrations and negative experiences, such as loneliness. There may also be significant weaknesses in terms of informal support, physical environment of the home and neighbourhood and social network, which undermine the person’s ability to live independently. Moreover, the health and social care provided may be insufficient or inappropriate to supporting the needs of the person. In these kinds of situations, the person may experience long-term malaise and stress and the eventual traumatic breakdown of their ability to remain independent. At a service level, the emphasis on Ageing in Place may marginalize residential and nursing home care, leading to a second-rate service and reduced options for clients. The key message here is that policy and practice cannot assume that simply by supporting the basic needs of a person at home will inevitably lead to improved well-being.

The development of ICT-based telecare services for ageing-in-place can be seen as a potential solution to some of the issues and the UK Government expects that the PTG will lead to a sea change in the way that older people’s services are delivered in the community. However, there is only limited evidence at the present time about the impact of the PTG. Indeed, evaluation of local PTG initiatives has been approached in an ad hoc manner, which may further reduce the eventual impact. Woolham et al. (2007) suggest that the impact of PTG initiatives is likely to be undermined without significant structural changes. They argue that “savings” accrued from introducing telecare will be through improved efficiency, rather than real “cash savings” and that these are likely to be unevenly spread. Expenditure on telecare by social services departments will primarily benefit the national health service, for example by reducing demand for community health and hospital care and act as a disincentive without a more equitable way of apportioning budgets. This is a fundamentally problematic issue and, however strong the case for telecare, it is unlikely that major organisational changes will emerge from a relatively small-scale initiative. In this scenario, the key argument in favour of telecare will be its impact on quality of care and quality of life of service clients. The evidence for this will have to be extremely compelling without clear financial benefits accruing to the provider organisations.