Social Science & Medicine 72 (2011) 347e354

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Telecare and older people: Who cares where?

Christine Milligan a, *, Celia Roberts b, Maggie Mort c
a
Division of Health Research, Lancaster University, Lancaster LA1 4YT, United Kingdom
b
Department of Sociology, Lancaster University, Lancaster LA1 4YT, United Kingdom
c
Department of Sociology/Medicine, Lancaster University, Lancaster LA1 4YT, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: ‘Telecare solutions’ are seen as a potential means of addressing the future care needs of ageing societies
Available online 15 September 2010 in Western economies. The development of these remote care systems runs in parallel with policies
aimed at ‘ageing in place’; and is targeted at supporting the perceived care needs of frail older people
Keywords: within the home. Drawing on ethnographic and deliberative panel data from European Community
Older people funded research, we consider how these developments contribute to a reshaping of the place and
Telecare
experience of care for older people. We do so by addressing the ways in which remote care systems can,
Home
firstly, act to change the experience of home; and secondly, re-order the place of care-work and
Ageing in place
Work
responsibilities to care as new actors become enrolled within the care network and existing care-givers
Extitution take on differing roles and responsibilities. Finally, we consider how this paper contributes to conceptual
UK debates around institution and extitution e that is, the de-territorialisation of the physical structure of
Technology the institution and its re-manifestation through new spaces and times that seek to end interior and
exterior distinctions.
Ó 2010 Elsevier Ltd. All rights reserved.

Introduction
In the UK, as in Europe and much of the developed world, the
proportion of older people in the population is increasing. Projec-
tions indicate that this increase will continue for at least the next
two decades. This is reflected in rising aged dependency ratios e
the implications of which figure significantly in both national and
international policy agendas (Cmd 7655, 2009; Gianakouris, 2008).
Indeed, recent figures for the UK population reveal that for the first
time ever there are more people aged 65 and over than there are
under-16s (ONS, 2008). This demographic shift is likely to have
profound effects on the provision of care and support, particularly
for the frailest of our older people. Declining numbers of family
members willing and available to undertake informal care-giving,
combined with a projected decline in those available to undertake
paid care-work, raises a haunting spectre of future care for our
ageing population e one that foreshadows potential resource
problems both in the financial and human reserves needed to
provide these services (Milligan, 2009).
This care dilemma comes at a time when older people’s
expectations are also changing. They and their families are no
longer prepared to accept solutions offered on the grounds of
convenience or efficiency. Rather, they are pressing for improved
* Corresponding author. Tel.: þ44 1524 592401.
E-mail address: c.milligan@lancaster.ac.uk (C. Milligan).
standards of care and support and greater independence (Bowes &
McColgan, 2006). Care homes are increasingly seen as the ‘option of
last resort’ and the focus of community-based care has progres-
sively shifted towards supporting people to ‘age in place’. That is,
policy is now geared towards developing mechanisms that enable
older people to remain in their own homes for as long as possible.
As a result, many developed countries have begun to implement
a range of local and national initiatives designed to facilitate
a significant shift in the way that care services are provided and, in
particular, to try to bring care closer to the home.
It is little wonder, then, that the emergence of telecare, designed
to address and support the care needs (or perceived needs) of frail
older people living at home through remote monitoring, has
attracted considerable interest. For governments, telecare offers
a potential ‘solution’ through which to address the problems of
a diminishing workforce and increased demand for services, with all
its resource implications (Bowes & McColgan, 2006). Evidence of
this ‘turn’ towards remote care is prominent throughout the EU,
underpinned by the European Commission’s ‘communication on
telemedicine for the benefit of patients, healthcare systems and
society’ (European Commission, 2008). In England this has been
manifest through the Preventative Technology Grant, discrete
funding amounting to some £80 million made available by the
Department of Health (DoH) from April 2006e2008. The grant was
designed to ‘kick-start’ telecare provision with the expectation that
local authorities would mainstream these services from 2009
onwards. Similar enthusiasm for telecare initiatives is evident in

0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
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348 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
Spain (López & Sánchez-Criado, 2009) the Netherlands (Pols &
Moser, 2009) and Norway (Thygesen, 2009) amongst other coun-
tries. The English initiative is designed to increase the number of
people who can benefit from telecare services by initiating changes
in the design and delivery of housing, health and social care. Whilst
primarily aimed at older people, the DoH believe that these tech-
nologies hold the potential to enhance and maintain the well-being
and independence of a wide range of individuals who would,
arguably, be otherwise unable to live independently in the home. As
the title of the grant infers, these technologies are also figured as
preventing, or minimising, the effects of accidents in the home (e.g.
from falls, fire, flooding etc.). Promoting telecare has also been
viewed as part of a strategy to reduce the number of older people
entering residential care and hospitals (Bayer, Barlow, & Curry,
2007). Indeed, over the initial two year period of the grant, the
DoH stated its belief that telecare would contribute to a reduction in
older people’s residential and in-patient stays by around 160,000
(DoH, 2008).
These are fairly radical claims and while telecare technologies
may have much to offer, it is important that their development and
implementation are not accepted without critical examination.
Indeed, Chan, Campo, Estève, and Fourniols (2009) point out, that to
date we have a poor understanding of user needs e a fact that is
partly explained by an industry that tends to be dominated by
suppliers that are providing a technology-push rather than
a demand-pull approach. Other commentators have argued that
telecare could act to reinforce medical models of ageing (Sinha,
2000) and in doing so may fundamentally detract from progress
that has been made in promoting socially inclusive models of ageing.
Further critiques point to an over-emphasis on risk that could result
in remote care becoming seen as a new form of restraint e one that
could result in certain groups of older people (e.g. those with
dementia) being labelled as ‘personifications of risk’ that could
precipitate early entry to residential care (Manthorpe, 2004, p. 148).
The emphasis on surveillance technologies within and outside the
home (such as sensors, video monitoring or electronic tagging) has
also lead some commentators to claim that telecare runs the risk of
overriding basic human rights such as privacy and informed consent
(Fisk, 1998; Magnusson & Hanson, 2003). So whilst remote care
technologies may be seen as neutral by governments e in that they
have the potential to be used in a variety of ways that can be
considered as either ‘good’ or ‘bad’ e as Bowes and McColgan put it,
‘like all technological innovations, they cannot be considered as
“purely” technical, in that they occur within a social context and are
stimulated by issues perceived within that context’ (2006: 18). We
would go further and suggest, in line with a ‘science studies’
approach to technological artefacts, that the technologies them-
selves are social: that is, they are conceived, produced and marketed
within complex social arrangements and are materialisations of
these arrangements and practices. Analysing telecare technologies
thus requires a detailed examination of the technologies in practice,
how they are designed and made, and how they are implemented
and experienced by a range of users.
Geography and new care technologies
Critically for geographers, the implementation of telecare and
other remote care technologies facilitates a change in the organi-
sation and modes of delivery of care e in this case to frail older
people e and the places in and through which care occurs. Their
implementation allows for the folding or collapsing of the time-
space continuum (Couclelis, 2009) in ways that enable economies of
scale and the delivery of care at a distance. Proponents thus argue,
that they not only offer a ‘solution’ to concerns about a growing care
deficit, but hold the potential to reduce spatial inequities in access to
care. Telecare is thus inherently geographical e indeed even
a cursory glance through the Journal of Telemedicine and Telecare
reveals a concern to emphasise its geographical potential. Yet with
one or two notable exceptions, geographical work on the issue is
absent. Whilst recent papers by Andrews and Kitchin (2005) and
Cummins, Curtis, Diez-Roux, and Macintyre (2007) point to poten-
tial utility of a geographical perspective on telecare and tele-
medicine, it is perhaps Cutchin (2002) who makes the most notable
attempt to address this deficit. Focusing specifically on telemedicine
(interactive video-consultation between medical specialists and
local primary care providers) in the United States, he demonstrated
how technological networks create new geographies of care. Orga-
nized in a regional manner to deliver virtual services to a population,
they both interact with, and are largely reliant upon, the material
care system ‘on the ground’ to prosper. Cutchin further suggests that
these networks offer medical care organisations a way to define,
expand and defend their territorial control, requiring us to rethink
how technologies, organisations and places interact. Hence the
territorial power of a large telemedicine ‘hub’ can become both an
economic and a political issue (p. 22) e one that raises new ethical
questions about connectivity, access, power and control.
Sandelowski’s (2002) work on telehealthcare and its impact on
nursing practice, place and identity also presents a compelling case
for studying telehealth geographically. This challenge is taken up in
Andrews’s and Kitchin’s (2005) review of geographical and nursing
research around cyberspace in which they highlight the ways in
which cyberspace is ‘collapsing spatial and temporal boundaries,
leading to a radical space-time compression, which frees social
relations from the constraints of scale’ (p. 319). In doing so, they
maintain, it challenges the nature of those care-giving roles that
have traditionally been dependant on physical co-presence and
visibility. But, as Dodge and Kitchin (2001) also point out, while
cyberspace has the effect of disrupting the spatial logic of contem-
porary society, it does not render it obsolete. Indeed, they suggest
that in some ways it can become more important as different
activities become centralised and decentralised in different places.
New care technologies, then, can ‘affect the ongoing production of
space because they modulate the conditions through which space is
(re)created’ (Andrews & Kitchin, 2005, p. 320).
Hence, as Parr (2002) suggests, an approach that incorporates
new care technologies and cyberspace has the potential to broaden
current disciplinary perspectives on health, taking them beyond
traditional locally-rooted readings of place. These are issues we
take up in our own paper.
The research setting
To explore these issues, we draw upon European Community
funded research undertaken over the last four years (2006e2010)
that has used both ethnographic and deliberative methods to
explore the implications of the introduction of remote care tech-
nologies worn, installed or embedded in the homes of older people,
as well as the making of practice around telecare (see www.lancs.
ac.uk/efortt/). This work spans two consecutive European studies.
The first project (2006e2007) focussed on producing critical dia-
logue amongst a wide range of actors involved in telecare. As part of
this project, a two-day event was held in the Netherlands in
September 2007 that brought together around sixty practitioners,
policy-makers architects, researchers, designers and telecare
providers. Participants were drawn came from France, the
Netherlands, Norway, Portugal, Spain, Belgium, Ireland and the UK.
The event was based around a series of short position papers fol-
lowed by themed and recorded discussion groups (twelve in total).
The data were then transcribed, summarised and analysed
thematically. Prior to this event, we held two UK-based focus
 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
groups each consisting of with 6e8 frail older people who were
experienced users of telecare and/or their carers. Data collected in
these focus groups were presented at the Dutch event, forming
a basis for the discussions.
The second study (2008e2010) has involved a more in-depth
engagement with actors involved in the design, provision and
receipt of telecare across England, Spain, the Netherlands and
Norway. Here, our overall concern has been to explore the ethical
issues raised by the implementation of telecare with the aim of
developing a grounded evaluative and ethical framework to
enhance the legitimacy of European policymaking in this highly
sensitive area. This study collected data through ethnographic and
deliberative methods over a two year period, with comparable
data being gathered in each of the four participating countries.
After gaining ethical approval for this work from the Social Care
Ethical Review Board in the UK, we held a series of eight deliber-
ative panels (between 8 and 10 participants in each) with older
people; undertook ethnographic interviews in the homes of eight
older users of telecare (each lasting approximately 2 h); observa-
tions of telecare installations and the work of two monitoring
centres as well as of regional meetings of the social services tele-
care teams in our region of ‘Northshire’ and telecare promotional
events, hosted by technology providers and/or local authorities.
We also conducted interviews with 10 key actors from social care
services and telecare design companies. Older people participating
in the deliberative panels were all above retirement age and were
recruited through older people’s forums, older learners groups,
social care and third sector organisations. Most lived in their own
homes but in some instances ‘home’ referred to supported living
arrangements. Each deliberative panel involved a presentation on
existing and proposed telecare arrangements, with panel
members being asked to spend from 3 to 5 h discussing what they
perceived as the ethical issues arising from these technologies.
Whilst panel members drew on their personal experiences, they
also sought to reach a consensus about the ethical issues at stake
and discuss what they believed ‘good care’ to be. Panels and
interviews were recorded, and detailed field notes were made of
all observations. All recorded data were transcribed, analysed
thematically and refined in data workshops by the UK research
team. The emerging themes were further explored and refined in
a two-day data workshop involving the whole European team,
where differences and similarities across the four countries were
draw out.
In this paper we focus specifically on data pertaining to the UK
to explore two core themes: first, we focus on older people’s
perceptions of telecare and care interactions within the home; and
second, how new care technologies may contribute to a reshaping
of the nature and place of care and care-work. The ethical and
comparative findings of this work will be reported elsewhere
pending EU approval.
Conceptually, we draw on a comparison of institutional and
extitutional arrangements, considering the effect of telecare on
such arrangements in the UK. That is, the traditional arrangements
of attendance based on institutional structures and spaces are
replaced by what Domènech and Tirado (1997) call ‘extitutional
arrangements.’ Following Serres (1994), emerging entities are
identified that may resemble the old institutions with their estab-
lished arrangements for regulation, monitoring and surveillance,
but are virtual and apart from the building. In other words, the
extitution represents a de-territorialisation of the physical struc-
ture of the large-scale institution and its re-manifestation through
new spaces and times that, it is argued, create the potential to end
the interior/exterior distinction (Vitores, 2002). Before discussing
these issues, however, we give a brief overview of the technologies
constituting telecare.
349
The telecare domain
Whilst acknowledging that a wide spectrum of care technolo-
gies exists e including assistive devices such as hoists, canes and
rails e this paper focuses on new and emerging care technologies
designed by multinational and smaller companies specialising in
the development of information and communication technologies
and domotics (home automation technologies such as light and
climate control, control of doors and window blinds, security and
surveillance systems, multi-media home entertainment systems
etc.). These include remote care and diagnostic systems based on
sensors and/or webcam technologies; electronic pill dispensers
(designed to set off an alert call if medication is not accessed at
pre-set times); as well as wearable devices that monitor and
gather continuous data e all of which can be part of telecare
arrangements. Smart home devices may include motion detectors
(for monitoring inactivity, falls or usage of household appliances
and facilities such as fridges, food cupboards and toilets) and
intruder alarms. They can also incorporate environmental control
solutions such as wireless control of electronic equipment in the
home (e.g. television and video machines, hands-free telephones,
lighting and door systems). Others care technologies such as
‘smart clothing and fabrics’ contain inbuilt sensors that can
monitor an individual’s health status such as heart rate, abnormal
heart activity, pulse, temperature etc. In addition, we are also
seeing the emergence of smart care technologies designed to
counteract social isolation and address some of the emotional
needs of older people (for example, through the development of
robotic pets). Telecare, then, can be seen to cover a whole range of
technological ‘solutions’ designed to monitor the physical health
and activity of older people as well as to support both their
physical and emotional ability to ‘age in place’.
Telecare interactions within the home
Telecare affects the nature of care interactions within the home,
hence the widespread adoption of these technologies is likely to
have a significant impact on the broader landscape of care. In this
section we begin to unpack these issues by considering how they
affect those involved in their implementation and operation.
There is little doubt that, at their best, telecare technologies can
offer disabled or frail older people a level of empowerment in their
lives that they may not previously have enjoyed. As one older
service user put it:
‘It’s about being in control again and being able to achieve simple
tasks without frustrating a carer. To simply turn on the lights is
something that keeps people healthy and integrated e less
excluded and having more involvement in the world’ [‘Jean’].
Telecare can monitor for falls, movement, eating patterns,
irregular heart activity etc. providing support that can help to ensure
that lone dwellers or older households in which both partners
experience frailty maintain as healthy a lifestyle as possible,
enhancing their ability to remain in their own homes for as long as
possible. Proponents of telecare make significant claims about their
ability to increase independence (see for example Blythe, Monk, &
Doughty, 2005; Essén, 2008). Others, however, argue that
they simply create new or different forms of dependence e as one
telecare researcher from the Dutch discussion groups noted:
JP: you say telecare per se would support people to live indepen-
dently, but I have difficulty with this term independence because
what you’re doing is not making a person independent, but sup-
porting a person in all kinds of ways .. Is this, indeed, indepen-
dence? In our research we see different forms of dependence
350 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
appearing because people get more reliant on the healthcare
system e they know that they are checked, they know that they are
cared for e it’s a specific kind of independence which is actually
very much supported e in this case by technology.
So while new care technologies may enhance an older persons’
ability to ‘age in place’ this needs to be balanced against the cost of
increased dependence on new forms of care and how the benefits
of this new dependence relate to dependence on co-present care-
givers e and indeed whether this is a desirable outcome. This is
exemplified through this excerpt from a focus group with frail older
people using new care technologies and their carers:
MN: Technology can never replace human contact and carers.
Carers come to ‘[my wife] and I think apart from the practical
things that they do for her, I hear laughter going on all the time in
the social interaction. And the laughter e that’s so important and
cannot be replaced by technology.
JF: Technology has never replaced a light bulb! There are things
that just need doing on a regular basis.
FN: They can’t give you a bath can they?
MN: Yes, it has its part to play but it’s not a substitute.
[emphasis added]
[FG1]
Those using care technologies also express concerns that these
new forms of care could replace traditional face-to-face care
resulting in decreased social contact and increasing the potential
for frail older people to become isolated within their homes. When
asked what benefits and risks do you think telecare might pose for
older people, participants in one deliberative panel commented:
‘Edith’: I think this is one of the things that’s coming through over
telecare is the fact that people are feeling isolated and because
people think they’re safe they’re not going round to see them get in
touch with them or families are thinking oh, they’ve got that, we
can. there’s all sorts of implications really.
‘Brigit’: I couldn’t agree with you more on the human contact,
that’s what I said [when describing voluntary work] I like to hold
hands or do that to somebody’s arm, [touches the person beside
her] ..my generation still wants the hug and the touch. I don’t
think you will ever, ever. I mean, it’s said isn’t it? You can say so
much in a hug? You don’t have to say anything.
‘Irene’: and also what about one picture’s worth a thousand
words? If they just look at you they can tell very often, far better
than talking to you.
[DP1]
So on the one hand, care technologies are seen by older service
recipients as having a role to play in enhancing their ability to
manage their lives within their own homes, on the other, they point
to the potential to exclude and isolate. Understanding that telecare
should be considered as an aid and not a solution to growing
demands for care becomes increasingly important when we also
take into account the additional e and perhaps less overtly rec-
ognised e role that paid and unpaid carers play in the home. The
cleanliness of the house, the need for repairs, the state of the
garden and so forth, are all aspects of an older person’s ability to
deal with the general upkeep of their home that are often moni-
tored by paid and unpaid care-givers who are physically present
within the home, but which cannot be picked up by remote
monitoring.
This raises the issue of whether certain forms of telecare may be
seen as more acceptable by older people than other forms.
Respondents in our studies indicated that these fall largely into two
groups e those designed to enhance an older person’s ability to
manage their own daily lives and those designed to monitor health
and activity. For older people, systems that are designed to enable
them to make personal choices, to undertake more of the everyday
tasks of daily living or which enhance their sense of security within
their own homes may be seen as far more acceptable than those
which remotely monitor their health and activity patterns. Moni-
toring technologies such as sensors, webcams and smart clothing
that gather data on health, eating and levels of activity that is
remotely collated and analysed, raised significant concern:
Researcher: what about the sensors for when you get up and down
and go in and out?
CW: I wouldn’t like it if someone came in and put in this, that and
the other e I would feel a bit like ‘big brother’ was watching e like
it’s an invasion of your territory.
[FG1]
Monitoring technologies can be particularly disturbing for older
people with dementia. Indeed, one individual working for a major
Dutch company developing and producing telecare technologies
noted in relation to a pilot for people with dementia that:
‘After six months, they switched almost everything off, because a lot
of people were very afraid of a voice coming out of the wall, and
a camera that’s continually following you. So the people were
continuously very disturbed by all the technology that they saw.’
Questions have also been raised about who has access to this
remotely gathered data and the ethical implications attached to
this. Work by Tracy et al. (2004) in the Canadian context, for
example, has pointed to the potential for conflict where older
recipients of telecare objected to the disclosure of remotely gath-
ered data (such as the graphic representation of movement sensor
data gathered within the home) to family care-givers e despite the
view from health professionals that this may prove beneficial.
Even well-established technologies such as pendent alarms,
which are often routinely fitted in the homes of older people with
dementia, have limited use where that person is likely to either
forget to wear it unless prompted e either by a family carer or paid
care-worker e or, more significantly, forget to press the pendent
alarm if a fall occurs. This is demonstrated in our ethnographic data
which captured an exchange between ‘Peggy’, who has early stage
dementia and lives with her adult son ‘Fred’, and her two
daughters:
‘Peggy’: ‘You’ve just got to remember to use it [laughs] ‘cos the last
time, I.. I fell in the garden, I couldn’t get up e never thought of
pressing that to get help [touches the pendent alarm around her
neck]. I just .. sat there is in the grass e the wet grass e for a bit
until gradually I managed to get up in the end. They said ‘why
didn’t you press your button?’ and I said I never thought about it!
‘Sadie’: You slipped off the sofa as well didn’t you and ended up the
floor?
‘Peggy’: oh aye.
‘Helen’: ‘Fred’ was upstairs but he couldn’t hear her shouting, but
she forgot about her pendent.
‘Peggy’: I forgot about that.
‘Helen’: If you’d have pressed that, the alarm would have gone off
and ‘Fred’ would have known straight away.
‘Peggy’: Yeah, oh I forgot about that.
Furthermore, it is not enough to install these systems without
checking how they are being used e and critically, whether both the
older person and their care-givers understand both the purpose of
telecare devices and importantly, how they work. This is clearly
illustrated in the following exert from our observational field notes:
In the course of discussing the telecare that ‘Peggy’ has, ‘Fred’
mentions that she has a falls monitor that has never been used
since she got it e it lies under the bed unused. He rushes off
 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
upstairs to get it and show me.. Once back in the living room
we return to a discussion around the falls monitor. ‘Fred’ picks it
up to show me and it is clear he doesn’t know how it works e he
examines it and talks about it with his sisters asking whether it
is switched on or off. They look for an ‘on/off’ button but can’t
seem to find one. He then decides they might test it after they
have tested the pendent but his sisters suggest he just leave it.
He returns it to the stand and they forget about it. .. ‘Fred’
returns to the living room and tells me they have a gas detector
in the kitchen e he takes me through to the kitchen to show me.
It is supposed to be fixed high up on the wall but is lying on top
of a heap of books and other clutter on a kitchen worktop in the
corner behind the inside door. ‘Fred’ explains that the installers
stick them on the wall with adhesive pads rather than screwing
them in and eventually they just drop of the wall. It appears to
be lying in two separate pieces so I am doubtful that it works
properly. ‘Fred’ fiddles with it and can’t seem to fit the two
pieces together so sits them back down.
[Researcher 3]
Our participants also pointed to the need for those designing
and implementing new technologies to take seriously older
people’s ongoing and ever-changing needs for meaningful human
interactions. Whilst many of the systems can be cast as facilitating
older peoples’ ability to remain longer in their own homes, the
reduction in face-to-face care and concomitant increase in ‘distance
caring’ facilitated by telecare and webcam technologies raises
questions about those elements of care they are unable to address
(e.g. social isolation, identification of the poor state or repair or
cleanliness of the homes in which older people may be living,
whether the technology itself is being used effectively etc.). Morris,
Lundell, Dishman, and Needham (2003) for example, found that
older people with varying states of cognitive decline felt very
strongly about loneliness and the need to maintain social ties. They
argue that meeting these social needs is central to older people’s
health status. Given that technologies designed to support the
physical needs of older people in the home can also result in
a reduction in home visits from clinicians and carers, it is important
to consider the extent to which this might impact on older people’s
mental well-being. As one deliberative panel member commented:
. ‘I mean my next door neighbour this 95 year old, when some-
body goes in she’s also got dementia so she thinks she’s been alone
for a long time, she doesn’t realise that actually the last carer went
2 hours ago and you know another carer’s coming in another 2
hours, she’ll grab your hand and this physical contact, this
desperate need for physical company, just to feel somebody to love
them, that they matter etc. so you know, something on the ceiling
or the door so that somebody else can be reassured that person is
alright is no substitute for somebody going in.’
[DP4]
Interestingly, a few telecare designers are beginning to address
the importance of social and affective needs of older people (see for
example, Lundell & Morros, 2004; Morris et al., 2003; Pols & Moser,
2009). ‘Affective’ technologies, it is claimed, help older people to
monitor and broaden their social interactions, or express affection e
for example, through stroking or playing with a robotic pet. Studies
also show that new care technologies are often used by older people
in ways that blur the distinction between material/health needs and
social/affective needs. Pols and Moser (2009) are thus lead to suggest
that attempts to define technology as ‘cold care’ and human inter-
action as ‘warm care’ need to be more critically examined. Indeed,
they go so far as to claim that people can develop affective relations
with healthcare technologies meant for home use, in ways that may
in fact, help to develop rather than reduce social ties.
351
Resistance and subversion
Older people often resist or ‘misuse’ care technologies by
developing ways of using the provided technology to undertake
more social activities, or using it in other inventive and even
subversive ways. Yet despite this ‘adaptation’ it can still provide the
service or activity it was designed for, albeit in different ways (Wu
& Miller, 2005). Hence telecare users can exert their independence
through actively using the technology for alternate purposes such
as playing games, or ensuring they gain the personal attendance
they actually desire through purposely triggering telecare alarms.
In our own study area of ‘Northshire’, the extent of this ‘misuse’ of
the telecare system to gain social contact (by pressing the alarm
without a ‘real’ reason) has been such that at their regular regional
telecare meetings, social care personnel have discussed taking
technologies away from those they refer to as ‘persistent offenders’.
These acts of resistance were also raised by older participants in
our discussion groups, where participants highlighted the potential
problems of relying on remote care technologies over personal
attendance.
JF: Just before I retired, I was a nurse, and tablet dispensers were
the ones that bothered me, because I know that when I was going in
to elderly patients’ homes to remind them to take medication that
there was a lot of joking around this, and I had to cajole them into
taking it, “now come on, you’ll get me the sack if you don’t take it”
and all those kind of interactive things that no machine could
possibly do.
Researcher MM: Some papers describe how people open and shut
them to make it seem that they have taken them.
KW: That in itself is an assertion of your independence e to say I’m
going to shut it.
[FG1]
Similar issues were raised by practitioners as this excerpt
from an observational fieldnote of a regional telecare meeting
illustrates:
In the discussion about the ‘misuse’ of telecare, ‘M’ gave an
example of a pill dispenser that was not used by an older person
and which was later found in another site in the same building
but not linked to the response line [i.e. the older person had
passed it on to a neighbour].
[RESEARCHER 3]
Such actions demonstrate how older people are able to adapt
the technologies offered to them in ways that better meet their
needs, raising important questions about what we can learn from
this resistance and how this might be incorporated into further
developments. To do so, it is important to understand the envi-
ronment within which telecare is to be located and to recognise the
importance of addressing older people’s social and emotional
needs as well as their medical needs. It also highlights the social
nature of both technology design and use (i.e. designers have
particular users and uses in mind when they design, but struggle to
make these the sole potentialities of the objects they make) and
hence the importance of involving older people from the outset in
discussions around the forms of care systems that should be
developed. That is, the forms of care technology that older people
actually want to enhance their ability effectively to ‘age in place’,
where they should operate and whose needs they should serve.
Whilst older people would appreciate greater technological inter-
activity, especially in relation to entertainment and social aspects,
thus far telecare developments have tended to follow older medical
models e where the patient is the subject of observation rather
than an active participant in the formation of care (Wu & Miller,
2005).
352 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
Telecare and the changing place of care-work
With the exception of environmental control systems and
robotic pets, the vast majority of telecare technologies are focused
around monitoring older people’s activity or health status within
the home. They are designed to either send back health data or raise
an alarm where activity patterns diverge from the norm. They
cannot then prevent accidents or negative health events, but can
provide early signals that such an event has occurred, or indicate
a high risk or recurrence. This all relies on care taking place
somewhere remote from the home, resulting not only in changing
patterns of care-work, but also a shift in where that care takes
place. Commentators point out that these shifts can result in
a downward cascade of care-work and responsibilities: from
doctors to nurses (Engstromm, Ljunggren, Lindqvist, & Carlsson,
2005; Starren, Tsai, Bakken, Aid Ala, et al., 2005); from nurses to
monitoring-centre staff (Oudshoorn, 2006); and from nurses to
family carers or patients. For example, remotely located moni-
toring-centre staff have to make decisions about the responses of
older people to automated calls; patients have to decide when to
take medical readings in the home with the data being automati-
cally transmitted to remote care settings (Mort, May, & Williams
2003); nursing and other clinical staff have to learn to make
remote medical assessments via store and forward images (Mort
et al., 2006) or webcam (Laflamme, Wilcox, Sullivan, Shadow,
et al., 2005). Finally, technical staff charged with the installation
and maintenance of telecare are also drawn into the home, often
making important decisions about what and whether care tech-
nologies should be installed. Field notes from an observation of
a telecare installation indicates this seemingly common practice.
Here the installer tells a story about deciding not to install any
telecare (against the qualified social worker’s guidance) once he
had been to visit the client in her home.
In the car on the way to the client’s house, we talk about how he
makes decisions about what to install. I am struck by how much
power he has in this situation. He takes the social worker’s
recommendations [which he has printed out from the
computer] as a guide only. He takes the technologies he thinks
might also be needed and is give careful thought to what is
being recommended by the social worker and what he thinks
might be better. Sometimes he makes no installation at all. He
tells me a story about a woman with a friend of 50 years, who
lived nearby. When he went to do the installation, the friend
was there and said to the client, ‘But you wouldn’t ever press the
alarm, would you?’ The woman agreed. She also said ‘But you’ve
never worn anything around your neck, have you? So you
wouldn’t wear the pendant’. The installer also discovered on
talking with the client and her friend that the woman’s carers
come after she gets up in the morning and comes downstairs
(which is when the risk of falling was greatest) so there seemed
little point in giving her a falls monitor, as she would have
needed the carer to put it around her waist. So he ended up not
installing anything.
[RESEARCHER 2]
As suggested above, one site of care which is critical to the
functioning of telecare is the monitoring centre. Telecare moni-
toring requires mediation between clients (older people living at
home e mostly on their own), formal (paid) and informal (family)
carers, friends and neighbors as well as emergency services.
Monitoring-centre workers have to assess each situation arising
from a call from a user or an alarm and decide who needs to become
involved. Their first response is always to try to contact the client
directly (i.e. through the client’s telephone or, more usually,
through ‘the hub’: a white plastic box, installed next to their phone,
which should be audible in any room in the home). Often this fails
and operators must decide whether it is appropriate to go straight
to the emergency services or call those named contacts on the
client’s contact list (usually a family member, neighbour or friend or
who lives within a reasonable travel distance). In our region of
‘Northshire’ social care services stipulate a maximum response
time of 45 min. Where these ‘contacts’ are not available or able to
help, the operator then requests a visit from a paid carer working
for a contracted care agency. However, this also can also create
difficulties as such carers are usually busy undertaking other care-
work and must interrupt their routines to make these additional or
unscheduled visits. Hence, as this observational excerpt illustrates,
monitoring-centre operators have to work with uncertainty and
indeterminacy in monitoring telecare:
‘Jill’: You know a lot of the Alzheimer’s, things like that where their
memory’s going. I mean we’ve got gas detectors in and that and
you go through and you’re talking to them and you say ‘Can you
small any gas? Can you check your cooker for me?’ [They say] ‘I
haven’t got a gas cooker’ and they have, you know. So you just
have to get someone [to go out]. I’ve always said, telecare’s only
as good as the contacts we’ve got.
In making decisions they also have to work with incrementally
acquired personal knowledge e about the clients and their support
networks and their homes and wider social environments.
The changing place of care: institution and extitution?
Geographical research has drawn attention to the ways in which
‘ageing in place’ can both create changes in how people use their
homes and contribute to shifting power relationships within the
home e between service recipients, health professionals and family
carers (see for example, Dyck, Kontos, Angus, & McKeever, 2005;
Milligan, 2001, 2003; Twigg, 2000; Wiles, 2005; Wiles et al.,
2009; Williams, 2001, 2002). Twigg (2000) for example, pointed
to the way in which home-based care places more power in the
hands of care-recipients (e.g. the power to exclude) but as Milligan
(2001) noted, the extent of power to exclude shifts as dependency
on care services increases. For Willems (2006), some care tech-
nologies (for example, telehealth diagnostic equipment, oxygen
regulators, home dialysis machinery etc.) can change the nature of
home to the extent it becomes almost unrecognisable. This, then,
raises critical questions about whether telecare is able to make the
home a better place to live than alternative options, or whether the
spaces and functions of the home e and the power relationships
within it e change such that they may no longer be recognisable or
desirable places to live.
It has been suggested in earlier geographical work on care in the
home, that the introduction of non-ICT technologies such as
adaptive aids (hoists, commodes, support rails, lifts etc.) can affect
the nature and experience of home such that, as frailty increases, an
institutionalisation of the home begins to take place (Milligan,
2000). The furnishings, décor and layout that are key to individ-
uals’ expression of individuality and identity and that have histor-
ical meaning for the individual are moved, adapted or removed to
make way for care aids and the workspace around them. The
private space of the home thus becomes increasingly transformed
into a site of work, inhabited by both formal and informal carers
and the paraphernalia of care. In England, the notion of the home as
a site of care-work has been reinforced by recent smoking legisla-
tion introduced in 2006 (The Smoke-free (Premises and Enforce-
ment) Regulations Statutory Instrument 2006 No. 3368). Care
providers now have to ask care-recipients to refrain from smoking
in their own homes during those periods in which care-work takes
place. How enforceable this is has yet to be tested, but it does point
 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
to an ever increasing porosity of the boundaries between home and
work in the field of care.
In thinking about new care technologies, however, we have to
recognise that while, as with adaptive technologies, much of their
physical manifestation is writ within the home, telecare designers
make significant efforts to find ways to camouflage these devices in
order to encourage the older person to engage with what López and
Sánchez-Criado (2009, p. 345) refer to as the ‘“invisible” scaffolding of
telecare’. Home hubs for telecare are becoming more compact,
sensors are smaller, newer pendent alarms are more akin to a watch
or other piece of everyday jewellery and telecare via webcam tech-
nology employs the use of everyday computer- or television-based
technologies that have become increasingly normalised within the
home. Yet as the preceding sections of this paper have demonstrated,
despite this lack of physical intrusiveness these technologies still have
a significant impact on how older people feel about and relate to the
home. They also bring into play new sites of care that can be remote
from both the home and the institution. Teleconference and moni-
toring centres, for example, are all sites of care that are remote from
both the home and traditional institutional arrangements, yet they
are intimately linked to them. Our work has illustrated, for example,
the ways in which telecare becomes enrolled within the extitution as
much of the caring takes place through the virtual space of computer-
supported communication. The old institutional way of ensuring
a patient remains within the care-giving system based on monitoring
and attendance within a physical (institutional) structure, for
example, is thus replaced by a set of horizontal processes (networks)
that are dispersed across open space. Such places are seen to be
‘haunted’ rather than inhabited e there is no one building to inhabit,
but rather an interlinked network of care that is located in a series of
dispersed places (Serres, 1994). How this is played out in terms of the
home, telecare and its impact on where care takes place has been set
out in the preceding two sections. This, we suggest, takes us beyond
concerns about institutionalisation and deinstitutionalisation, to
think about spatial care arrangements that enable us to engage with
both the physical and virtual spaces that these new care technologies
inhabit.
Discussion
We set out in this paper to draw attention to the ways in which
governments across the developed world are turning to telecare as
a potential ‘solution’ to the projected rise in demand for care services
from an ageing population. In England this has been underpinned by
government policy directives and targeted and protected funding
designed to support ageing in place and reduce the number of resi-
dential care placements. But as Chan et al. (2009) point out, despite
governments’ enthusiasm, to date we have a poor understanding of
the needs and desires older people’s themselves in relation to tele-
care. We also have a poor understanding of how effectively these
telecare technologies are actually being used within the home. As our
work demonstrates, some of the targeted users of telecare may
struggle to understand and engage with these systems, and indeed
may experience them as intrusions or as providing less meaningful
forms of care. Furthermore, this extends to family care-givers, for
where they too lack a clear understanding of how telecare operates,
the technologies can lie unchecked and unused.
It is also clear that for older people, ageing in place successfully is
wrapped up in the ability to exert control over their own lives and
avoid social isolation. Human contact is seen a critical to this. So
while some telecare technologies are seen by older people as
holding the potential to enrich their lives e particularly as they
become physically less able to cope with daily life within the home e
this is viewed as a resource that should be in addition to and not at the
expense of human care and support. Environmental control and self-
353
activated alarm call systems seem particularly welcome: in other
words, it is those technologies that are seen by older people them-
selves as being enabling, and which place decision-making within
their own hands that are viewed favourably. This said, as our
research has also demonstrated, these systems are not yet
adequately designed to meet the needs of all frail older people e the
memory loss experienced by people with dementia, for example,
clearly affects how these technologies are used. But of course
memory loss in older age is not solely an attribute of dementia.
Similarly hearing loss will undermine the effectiveness of systems
reliant on telephone responses following a fall or other critical
incident. In addition, despite the claims of Essén and others, older
participants within our research had significant reservations about
telecare systems whose primary purpose is active monitoring or
surveillance and which does not rely on the older person to activate
them. This reflects an industry that has tended to be dominated by
a ‘technology-push’ rather than engaging with the needs and
experiences of older people themselves.
Our second broad theme involves the way in which the imple-
mentation of telecare may be changing the landscape of care away
from institutional and community-based arrangements to extitu-
tional ones in which new actors in places remote from traditional
care settings are drawn into the care network. Telecare providers,
monitoring-centre operators, installers, care professionals and
family carers are all drawn into new care relationships that operate
within the home and across both virtual and physical space. This
has implications not only for who cares but where that care takes
place. More specifically, telecare can be seen to be contributing to
increased porosity of boundaries between the home and the exti-
tution, manifest through surveillance and monitoring using web-
cam, sensors, automated alarms and so forth. Within the home the
increased porosity of the boundaries is also evident between public
and private space and between home and work. Such develop-
ments, we suggest provide clear indications of the ending of the
interior/exterior distinction symbolic of the old institutional
settings, but at the same time they bring with them some of the
regulation, practices and surveillance that typified the old institu-
tional regimes. So whilst the notion of the institutionalisation of the
home still holds validity e particularly for the most frail elderly e
this has to be set against these new arrangements for care that take
us beyond both the home and the institution.
Acknowledgements
The research upon which this paper draws was funded by the
European Commission under its FP6 and FP7 Capacities (Science in
Society) programmes, specifically MEDUSE and EFORTT projects.
We would like to thank Cathy Bailey and Megan Waugh for
contributions to our work.
References
Andrews, G., & Kitchin. (2005). Geography and nursing: convergence in cyberspace?
Nursing Inquiry, 12(4), 316e324.
Bayer, S., Barlow, J., & Curry, R. (2007). Assessing the impact of a care innovation:
telecare. Systems Dynamic Review, 23(1), 61e80.
Blythe, M. A., Monk, A. F., & Doughty, K. (2005). Socially dependable design: the
challenge of ageing populations for HCI. Interacting with Computers, 17, 689.
Bowes, A., & McColgan, G. (2006). Smart technology and community care for older
people: Innovation in West Lothian, Scotland. Scotland/Edinburgh: Age Concern.
Chan, M., Campo, E., Estève, D., & Fourniols, J.-Y. (2009). Smart homes e current
features and future perspectives. Maturitas, 64, 90e97.
Cmd 7655. (2009). Building a society for all ages. London: HSMO.
Couclelis, H. (2009). Rethinking time geography in the information age. Environ-
ment and Planning A, 41, 1556e1575.
Cummins, S., Curtis, S., Diez-Roux, A. V., & Macintyre, S. (2007). Understanding and
representing ‘place’ in health research: a relational approach. Social Science &
Medicine, 65, 1825e1838.
354 C. Milligan et al. / Social Science & Medicine 72 (2011) 347e354
Cutchin, M. P. (2002). Virtual medical geographies: conceptualizing telemedicine
and regionalization. Progress in Human Geography, 26(1), 19e39.
Department of Health. (2008). Carers at the heart of 21st-century families and
communities. London: HMSO.
Dodge, M., & Kitchin, R. (2001). Mapping cyberspace. London: Routledge.
Domènech, M. Y., & Tirado, F. J. (1997). Rethinking institutions in the societies of
control. International Journal of Transdisciplinary Studies, 1, 1.
Dyck, I., Kontos, P., Angus, J., & McKeever, P. (2005). The home as a site for long term
care: meanings and management of bodies and spaces. Health and Place, 11(2),
173e185.
Engstromm, M., Ljunggren, B., Lindqvist, R., & Carlsson, M. (2005). Staff perceptions
of job satisfaction and life situation before and 6 and 12 months after increased
information technology support in dementia care. Journal of Telemedicine and
Telecare, 11(6), 304e309.
Essén, A. (2008). The two facets of electronic care surveillance: an exploration of
the views of older people who live with monitoring devices. Social Science &
Medicine, 67, 128e136.
European Commission. (2008). Communication on telemedicine for the benefit of
patients, healthcare systems and society. COM (2008) 0689.
Fisk, M. J. (1998). Telecare at home: factors influencing technology choices and user
acceptance. Journal of Telemedicine and Telecare, 4, 80e83.
Gianakouris, K. (2008). Ageing characterises the demographic perspectives of the
European societies. Eurostat in Focus: Population and Social Conditions 72/2008.
European Commission.
Laflamme, M. R., Wilcox, D. C., Sullivan, J., Schadow, G., Lindberg, D., Warvel, J., et al.
(2005). A pilot study of usefulness of clinician-patient videoconferencing for
making routine medical decisions in the nursing home. Journal of the American
Geriatrics Society, 53(8), 1380.
López, D., & Sánchez-Criado, T. (2009). Dwelling the telecare home: place, location
and habitability. Space and Culture, 12(3), 343e358.
Lundell, J., & Morros, M. (2004). Tales, tours, tools, and troupes: a tiered research
method to inform ubiquitous designs for the elderly 18th Annual Conference of
the British-HCI-Group. Leeds Metropolitan Univ, Leeds.
Magnusson, L., & Hanson, E. J. (2003). Ethical issues arising from a research, tech-
nology and development project to support frail older people and their family
carers at home. Health and Social Care in the Community 431e439.
Manthorpe, J. (2004). Risk taking. In A. Innes, C. Archibald, & C. Murphy (Eds.),
Dementia and social inclusion: Marginalised groups and marginalised areas of
dementia research, care and practice (pp. 137e149). London: Jessica Kingsley.
Milligan, C. (2000). Bearing the burden: towards a restructured geography of caring.
Area, 32, 49e58.
Milligan, C. (2001). Geographies of care: Space, place and the voluntary sector.
Aldershot: Ashgate.
Milligan, C. (2003). Location or dis-location: from community to long term care e
the caring experience. Journal of Social and Cultural Geography, 4(4), 455e470.
Milligan, C. (2009). There’s no place like home: People, place and care in an ageing
society. In Ashgate geographies of health book series. Aldershot.
Morris, M., Lundell, J., Dishman, E., & Needham, B. (2003). New perspectives on
ubiquitous computing from ethnographic study of elders with cognitive
decline. UBICOMP LNCS, 2864, 227e242.
Mort, M., May, C., & Williams, T. (2003). Remote doctors and absent patients: acting at
a distance in telemedicine. Science, Technology & Human Values, 28(2), 274e295.
Mort, M., Finch, T. and May, C. (2009). Making and Unmaking Telepatients: Identity
& Governance in New Health Technologies. Science, Technology & Human Values,
34, No1, 9-33.
ONS. (2008). Ageing: More pensioners than under-16’s for first time ever. Office of
National Statistics website. http://www.statistics.gov.uk/cci/nugget.asp?
ID¼949 Accessed November 2009.
Oudshoorn, N. Exploring and rethinking invisibility in the context of telemedicine.
Paper presented at the workshop ‘Material Narratives of Technology in Society’.
University of Twente, Enschede, October 19e21, 2006.
Parr, H. (2002). New body-geographies: the embodied space of health and medical
information on the Internet. Environment and Planning D: Society and Space, 20, 73e95.
Pols, J., & Moser, I. (2009). Cold technologies versus warm care? On affective and
social relations with and through care technologies. ALTER e European Journal of
Disability Research, 3(2), 159e178.
Sandelowski, M. (2002). Visible humans, vanishing bodies and virtual nursing:
complications of life, presence, place and identity. Advances in Nursing Science,
24, 58e70.
Serres, M. (1994). Atlas. Madrid: Cátedra. 1995.
Sinha, A. (2000). An overview of telemedicine: the virtual gaze of health care in the
next century. Medical Anthropology Quarterly, 14(3), 291e309.
Starren, J., Tsai, C., Bakken, S., Aid Ala, A., Morrin, P., Philip, C., et al. (2005). The role of
nurses in installing telehealth technology in the home. Computer Information
Nursing, 23(4), 181e189.
Thygesen, H. (2009). Technology, and good dementia care: a study of technology
and ethics in everyday care practice. Unpublished PhD thesis available from the
Centre for Technology, Innovation and Culture (TIK) University of Oslo, Norway.
Tracy, C. S., Drummond, N., Ferris, L. E., Globerman, J., Hebert, P. C., Pringle, D. M.,
et al. (2004). To tell or not to tell? Professional and lay perspectives on the
disclosure of personal health information in community-based dementia care.
Revue Canadienne Du Vieillissement. [Canadian Journal on Ageing], 23, 203e215.
Twigg, J. (2000). Bathing e The body and community care. London: Routledge.
Vitores, A. (2002). From hospital to community: case management and the virtu-
alization of institutions. Athenea Digital, 1, 1e6. http://ddd.uab.es/pub/athdig/
15788946n1a13.pdf.
Wiles, J. (2005). Conceptualising the importance of place in the care of older
people: the role of geographical gerontology. International Journal of Nursing for
Older People, 14(8b), 100e108.
Wiles, J., Allen, R., Palmer, A., Hayman, K., Keeling, S., & Kerse, N. (2009). Older
people and their social spaces: a study of well-being and attachment to place in
Aotearoa New Zealand. Social Science & Medicine, 68(4), 664e671.
Willems, D. Moral machinery, medical high tech in the home. Paper presented at
Lancaster University seminar series: Perspectives in Science, Technology &
Medicine, 4 May 2006.
Williams, A. M. (2001). Home care restructuring at work: the impact of policy
transformation on women’s labour. In I. Dyck, N. Davis, Lewis., & S. McClafferty
(Eds.), Geographies of women’s health (pp. 107e126). London: Routledge.
Williams, A. M. (2002). Changing geographies of care: employing the concept of
therapeutic landscapes as a framework in examining home space. Social Science
& Medicine, 55(1), 141e154.
Wu, P., & Miller, C. (2005). Results from a field study: the need for an emotional
relationship between the elderly and their assistive technologies. Foundations of
Augmented Cognition, 11, 889e898.