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Research on Aging

Telecare for Older 35(1) 32­–49

© The Author(s) 2013
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DOI: 10.1177/0164027511427546
Independence, http://roa.sagepub.com

Participation, and Identity

Alison Bowes1 and Gillian McColgan1

Abstract
Drawing on interviews with 76 older people (aged 60 years and older)
receiving telecare services at home and in housing with care and 16 family
caregivers in West Lothian, Scotland, the authors consider how far telecare
can support older people’s citizenship goals of independence, participation,
and identity. They conclude that although these goals are to some extent
supported by telecare, they are also supported by the model of care being
applied and limited by aspects of the wider environment, such as ageism. The
authors argue that in every case, contextual factors beyond the intrinsic
capacities of a technological system and beyond the models of care devel-
oped and promoted by a service delivery organization must be explored
if the impact of telecare is to be fully understood. Thus, the human use of
technology and its moral context are critical to its success or limitation.

Keywords
technology, community care, citizenship, user perspectives, telecare

In this article, we report and discuss the findings of an evaluation of telecare

in West Lothian, Scotland. We present a reanalysis of findings exploring the
1
University of Stirling, Stirling, UK

Corresponding Author:
Alison Bowes, School of Applied Social Science, University of Stirling,
Stirling FK9 4LA, UK
Email: a.m.bowes@stir.ac.uk
Bowes and McColgan 33

extent to which telecare can support older people’s independence, participa-

tion, and identity. The discussion identifies both possibilities and limitations
of telecare and suggests that some of the enthusiasm for telecare in policy
debates may need to be tempered.

Description of the Problem

Much research on telecare has considered older people primarily as users of
care services (Barlow, Singh, Bayer, & Curry, 2007; Fisk, 2003), thus repro-
ducing a “service users” orientation that, through starting from a service
provider perspective, tends not to consider the whole person, issues of rights,
or issues of social inclusion (Rummery, 2006). Furthermore, evaluation of
telemedicine and telecare innovations has commonly reflected competitive
attempts by deliverers of services to promote the legitimacy of their preferred
models of service delivery (May, Mort, Williams, Mair, & Gask, 2003).
Thus, researchers and evaluators have privileged the service providers’
points of view.

Policy Context of Telecare

in the United Kingdom
Service ideologies across the United Kingdom are increasingly emphasizing
individuals’ taking responsibility for and choosing their own care and sup-
port through the government-led self-care agenda (e.g., Kerr, 2005) and, in
social care services, “personalization” (Department of Health, 2010). Such
developments are linked with individual responsibility for the management
of care through personal budgets (England) or self-directed support (Scotland)
(Homer & Gilder, 2008).
Technological methods of delivering this policy agenda of choice are rela-
tively recently developed. A typical definition of telecare states,

Telecare is the remote or enhanced delivery of health and social services

to people in their own home by means of telecommunications and
computerized systems. Telecare usually refers to equipment and detec-
tors that provide continuous, automatic and remote monitoring of care
needs emergencies and lifestyle changes, using information and com-
munication technology . . . to trigger human responses, or shut down
equipment to prevent hazards. (Scottish Government, 2009)

The “human responses” can of course be varied and may include remote
consultation as well as delivery of care. As Demiris and Hensel (2008) noted,
34 Research on Aging 35(1)

there is a view that telecare may have the potential greatly to increase inde-
pendence for older people, support the delivery of more efficient and effec-
tive services (Bowes & McColgan, 2006; Fisk, 2003; Joint Improvement
Team, 2008) and control expenditure on care, projected to increase massively
in coming decades (Wanless, 2006). UK government, among others, has
invested significantly in telecare development and delivery, perceiving its
significant potential (Barlow & Hendy, 2009). For example, the Department
of Health (2005) asserted that telecare could support older people to remain
at home, reduce hospital admissions, improve quality of life, address work-
force issues, cope with increasing demand, and save money, and the Scottish
Government has argued similarly (Joint Improvement Team, 2008). These
developments have proceeded on the basis of a limited evidence base (Barlow
et al., 2007; Demiris & Hensel, 2008; Martin, Kelly, Kernohan, McCreight,
& Nugent, 2008; Poole, 2006; Rojas & Gagnon, 2008).
Although government appears supportive of telecare, others have ques-
tioned its purported potential. For example, Percival and Hanson (2006),
drawing on a series of focus groups involving service providers, older people
and family caregivers, identified concerns about the possibility for telecare to
reduce human contact and thus increase isolation. Manthorpe (2004) argued
that older people are often seen as especially risky, inclining social care sys-
tems toward monitoring and surveillance. Magnusson and Hanson (2003)
additionally identified complex ethical issues regarding telecare use, includ-
ing its impact on complex family relationships, such as care partnerships in
which care is coproduced (Phillips, 2007, reviewed the nature and complex-
ity of such relationships in detail). Similarly, Fisk (2003) identified that some
aspects of telecare are more focused on surveillance and monitoring than on
promoting independence and choice, raising important ethical issues. Sävenstedt,
Sandman, and Zingmark (2006) argued that when telecare is contemplated,
professionals need to be aware of possible concerns by clients that their ser-
vice may become less humane.
These debates about telecare reflect wider debates about technology and
society. Dant (2006) argued that technological developments (which would
include telecare) are socially embedded and may have contradictory conse-
quences. On one hand, they may promote Elias’s (2000) “civilizing” process
of increasing interdependencies between myriad people involved in their
production, maintenance, and consumption. On the other hand, telecare may
reduce interdependency, by decreasing reliance on others and potentially
increasing isolation.
Research findings to date, policy debates about telecare, and the theoretical
debates about the potentially conflicting outcomes of technological inno-
vation all imply a need for more nuanced understanding of telecare as
Bowes and McColgan 35

experienced by those on the receiving end, in the case of this article, older
people. The debates noted here raise questions about the benefits and limita-
tions of telecare for service recipients.
Because so much previous debate has been driven by policy or service
provider concerns, in this article, we revisit our evaluation of telecare in West
Lothian to consider the extent to which telecare can support the citizenship
goals of older people themselves. Our discussion is framed by Craig’s (2004)
work on older people’s citizenship goals. He noted that concepts of citizenship
have historically focused on nationality and particularly on workforce status.
Craig argued that older people’s citizenship also requires reconsideration,
because many are not part of the paid workforce. His research involves empir-
ical exploration of older people’s own citizenship goals and identifies three:
first, a desire to maximize independence, in the sense of physical indepen-
dence, autonomy, and choice and control (Nordenfelt, 2009); second, valuing
social participation and inclusion in social relations and social interaction; and
third, maintaining a sense of identity, as one’s own person rather than as an
anonymous, ignored, and excluded older person. These three goals, defined by
older people themselves, will frame our discussion of research findings.

Telecare in West Lothian

Telecare implementation in West Lothian focused on supporting older people
to remain in their own homes as long as possible. The service aimed to pro-
mote choice and independence for older people and to prevent unnecessary
admissions to hospital or long-term residential care homes.
The telecare equipment consisted of a home alert console linked to a tele-
phone landline (a “plain old telephone system”), with a basic package of
devices attached, namely, two passive infrared detectors, which can detect
movement or the lack of it; two flood detectors; one heat-extreme sensor (hot
and cold); and one smoke detector. Depending on requirements, and follow-
ing an individual assessment, other devices, such as pendant alarms, door
entry systems, and sensors and monitors of many types could also be attached,
and some packages included Internet access. All the sensors and alarms were
linked, via the console, to a call center holding an individual protocol for each
person specifying what assistance should be called if needed. The first step in
most cases was to call the older person himself or herself to check what had
happened.
Initially, telecare was available for people assessed as having care needs,
either in their own homes (the large majority) or in newly built “housing
with care” developments, in which people were tenants of a small flat or
bungalow, with care available on site as needed. However, an early decision
36 Research on Aging 35(1)

was taken to make the system available to every household in West Lothian
including a person aged 60 years or older (i.e., to “mainstream” the service).
This was seen as ensuring that everyone, should they need further care as
they aged, would have the basic equipment to which additions could be made
if necessary. Mainstreaming was also seen as removing some of the stigma
attached to receiving services. By the end of the evaluation, 3,200 households
had telecare packages: the total number installed over the period, however,
was larger, as some people had ceased to use the service because of admis-
sion to care homes or death.
The West Lothian approach to telecare included, first, the particular use of
the technology, involving the standard package, the additions according to
individual need, and the call center protocol-driven responses; second, the
capacity-building and support-oriented service model, in which staff mem-
bers were specifically trained not to “care for” people and do things for them
but to support them to do things for themselves; and third, the whole-system
change that accompanied the introduction of telecare. Disciplinary boundar-
ies were specifically challenged in the approach, with the service delivery
team having a wide range of care backgrounds and able to deliver general
support and personal and nursing care. In addition, West Lothian was distinc-
tive because it was not a pilot, in a field of multiple pilots (Poole, 2006), and
telecare continues at the time of writing to be integral to local services.
In terms of a wider policy goal (i.e., delivering effective services for an
aging society at reasonable cost) during the development and rollout of tele­
care (from 2000 onward), West Lothian showed exceptional and sustained
improvement in several key indicators, including budgetary control, delivery
of free personal care, and a significant reduction in delayed discharges (i.e.,
people waiting for discharge from hospital into other care settings), from 48
in April 2001 to 3 in April 2006 (a saving of approximately £85,000). In
relation to performance indicators (Audit Scotland, 2010), service quality was
high (e.g., high levels of weekend and overnight care suggested that people
with complex needs were being supported in the community). Furthermore,
the authority’s financial performance was one of the best in Scotland (Bell,
Bowes, & Dawson, 2007). In these respects, therefore, the West Lothian
approach appeared to have succeeded in delivering high-quality services at
relatively low cost.

Purpose of the Study

The aim of this study was to foreground the perspectives of older people them-
selves, using their own citizenship goals as a frame to explore the benefits and
limits of telecare. We began by exploring the policy context of care for older
Bowes and McColgan 37

people in the United Kingdom, and the role of telecare within this. We describe
the telecare development in West Lothian, Scotland, and the methods used
in our evaluation of it. We then discuss findings regarding the potentiality
and limits of telecare for supporting older people’s citizenship goals of inde-
pendence, participation and identity (Craig, 2004).

Methods
The full evaluation (Bowes & McColgan, 2006) lasted more than 3 years
(2001 to 2005). The evaluation team and funding were independent of West
Lothian Council. Ethical approval for the research was given by the University
of Stirling. The evaluation had a formative element, in that interim reports
were regularly produced and used to support the further development of the
program (Kelly, 2005).
The full evaluation aimed to explore the experiences and views of stake-
holders of the telecare program, to examine the implications of telecare for
older people’s quality of life, to explore value for money, to compare the
telecare provision with support in a comparator local authority area without
telecare, to consider the implications of the initiative for all stakeholders, and
to identify best practice for dissemination nationally.
Table 1 lists the various data sets that were collected. Full results are
reported elsewhere (Bowes & McColgan, 2006).
The older people were recruited by seeking volunteers from four succes-
sive cohorts receiving services over a period of 19 months, using age and
gender quotas to ensure that participants reasonably represented the popula-
tion of those receiving services. Of the older people, 32 were interviewed
once, 27 twice, and 17 three times, at intervals of 3 months. Our possibilities
of repeat interviews were influenced by the condition of some respondents
and also by the fact that beyond a certain point, no new findings were emerg-
ing, despite our having followed up a variety of respondents. Respondents
ranged in age from their late 50s to their late 90s. Forty-four lived in their own
homes in the community and 32 in new housing with care developments with
telecare installed. Fifty-four were women and 22 men. Ten family caregivers
were women and six were men. Levels of impairment varied from little
impairment to people assessed as needing full-time care, including people
with dementia. The semistructured qualitative interviews focused on experi-
ences of and reactions to telecare in the context of people’s daily lives and
lasted between 20 minutes and 1.5 hours. Interviews were fully transcribed
and analyzed using initial open coding to identify key themes, drawing on
a grounded theory approach, followed by grouping of topics to develop a
38 Research on Aging 35(1)

Table 1. Data Collected for the Full Evaluation

Data Collected Number of Participants

Semistructured qualitative interviews with older people 44
receiving telecare services in their own homes
Semistructured qualitative interviews with older people 29
receiving telecare services in housing with care
Questionnaire survey of people receiving the 89
mainstreamed telecare service
Semistructured qualitative interviews with family 11
caregivers
Semistructured qualitative interviews with staff members 79
(managerial and frontline care staff members, call center
staff members, health care professionals, social workers,
housing staff members, occupational therapists)
Data from a comparator local authority not delivering 9 staff members, 7
telecare, including scrutiny of local statistics and a small clients, 6 family
interview study caregivers
A value-for-money study exploring the costs of providing Not applicable
care and support for older people in West Lothian and
comparing these with other Scottish local authorities

coherent account of experiences of and reactions to telecare in relation to the

questions guiding the evaluation. Data were managed using NUD*IST 6 and
NVivo 8, which facilitated, respectively, the original analysis and the
reanalysis.
For the purposes of this article, we returned to the interviews with the
older people and family caregivers and reanalyzed the coded data by identify-
ing and reviewing material relating to the themes of independence, participa-
tion, and identity outlined above (Craig, 2004). Our aim was to consider how
far these goals, as Craig’s (2004) study described them, could be supported
through telecare situated within the West Lothian service model and what
were the limits of this. In establishing validity, we used techniques of verifi-
cation in qualitative research as described by Morse, Barrett, Olson, and
Spiers (2002) as follows. These included, first, checking back and forth
through the iterative processes of data collection and analysis using initially
open coding and then building structured themes, and second, the researcher’s
use of open-ended questioning, checking back with respondents and repeat
interviewing. The sampling process involved checking that participants were
representative of those receiving support services in West Lothian and that
Bowes and McColgan 39

where there were gaps (as there were at one stage in terms of those receiving
care at home), measures were taken to remedy this. We continued interview-
ing until the point of theoretical saturation (i.e., when no new themes were
emerging). We developed theory through the process of the research: the
focus on independence, participation, and identity very much emerged from
the ongoing process of scrutinizing and coding the data and represented an
additional level of analysis. The process at this stage used adaptive theory
(Layder, 1998), in that it was driven by the theoretical concepts supplied by
Craig’s (2004) work. In proceeding with the data analysis at all stages, we
cross-checked repeatedly, seeking negative examples. Coding was compared
at several stages across the research team, and interpretations of findings were
reviewed. During the process of evaluation, findings were discussed with a
wide range of stakeholders via the presentation of a series of interim reports,
but most thoroughly with an advisory group that met regularly.
In presenting the findings, we use illustrative, typical quotations from par-
ticipants, identifying each one with a code number. It should be noted that the
responses to telecare among the study participants were generally positive
(Bowes & McColgan, 2006) and that we did not identify systematic variation
according to age, gender, or levels of impairment. We note some differences
between people living in the community and those in housing with care as the
discussion proceeds. We consider each dimension of citizenship and its limits
in turn.

Findings
Independence

It was clear that their independence, especially in the sense of choice and
control, was of great importance to the older people in the study. Despite feel-
ing their increasing age and limitations of disability, participants made par-
ticular efforts to retain their independence. For example, some of those
receiving traditional care at home services made a point of “getting ready” to
see care workers who visited in the morning, ensuring that they were dressed
and breakfasted and that the house was tidy, despite the fact that the care
workers could help with all these tasks. Participants were keen to show that
they could manage for themselves:

As long as I can do without that [care], I would prefer to do so.

(CHB16i)
40 Research on Aging 35(1)

Can I make that clear right away, that that would be my aim—to be as
independent as I could. (CHB2i)

In housing with care, similarly, people valued their independence, their

freedom to come and go as they pleased, and to call on help if and when they
needed it. Explicit contrasts were drawn with the perceived regimented
regimes of care homes and their predetermined daily timetables. One woman
described how she liked to take a nap after lunch in the privacy of her flat:

I just go to my bed and close everything out. (CLTA5ii)

She liked the time and space to think that this gave her: Worried about her
future, she described a need to “clear my mind of things that’s in it.” This sort
of freedom came at least partly from the fact that those in housing with care
were tenants, with tenants’ rights, not “residents,” as care home clients are
generally described.
Several people who moved into housing with care regained some lost
abilities. Having previously lived in a care home that had closed down, they
had opted to move to housing with care rather than another care home. For
example, they reported making themselves cups of tea when they wanted,
rather than having to wait for staff members to provide them. In another case,
a woman regained the confidence to use the shower alone, knowing that help
would come quickly if needed.

Limits to Independence
Although people highly valued their independence and worked hard to
retain it, their ability to do so clearly depended on the particular service
model. The West Lothian approach explicitly set out to promote indepen-
dence and saw supporting and maintaining people’s capacity to do things
as essential. The telecare program, as suggested above, provided the means
to support this approach in the form of, for example, flexibility and choice
about daily life and the ready availability of help if and when needed. These
provided people with confidence, feelings of safety, and freedom to choose
their activities.
However, a more risk averse service model would be unlikely to support
independence in this way (Manthorpe, 2004): Social care systems can pro-
mote dependency by avoidance of risk, such as by constant visiting of people
in their homes “just in case.” Our findings suggest that people prefer to limit
Bowes and McColgan 41

the degree of intervention by services in their lives, particularly the disruption

to daily life produced by the constant expectation of a care worker “just call-
ing in,” which can be significant: people say that they “never know when the
care worker is coming” and feel the need to be constantly prepared for a visit.
Our respondents explicitly contrasted telecare with such arrangements.
A further limitation on independence can be seen among older people who
stayed in their own homes. Previously, they had either left their front doors
open or arranged for care workers to let themselves into the house. Once the
telecare was installed, door entry systems enabled people to see who was at
the door and to let them in as appropriate. They welcomed these devices, as
conferring “control over one’s own front door,” something presented as fun-
damental to being independent and in control of one’s own environment.
However, many people agreed to have telecare installed because of fear, most
commonly of young people hanging about and creating various kinds of nui-
sance, but also in some cases behavior such as drug dealing and even drug-
related deaths in the neighborhood. These security aspects of the telecare
system were attractive to older people without assessed “care needs,” provid-
ing protection against a world perceived as hostile:

I can see them even when they’ve not pressed the [door] bell. You can’t
hear anything and they can’t hear anything, but you can have a look
outside, yes. . . . It’s brilliant. It really is. (CLTB6i)

Telecare could support fearful older people, but the causes of their fear
persisted. The local council was involved in initiatives to reduce so-called
antisocial behavior, but until these succeeded, there remained a sense in which
telecare was addressing a symptom and not a cause, helping people remain in
their own homes but not necessarily in welcome surroundings. Furthermore,
one reason for people’s deciding to move into housing with care was per-
ceived antisocial behavior in their old neighborhoods.

Social Participation
People with telecare at home continued to live within their accustomed com-
munities, often after many years. As an area including mining villages and
the new town of Livingston, founded in the 1960s to take in “overspill”
population from cleared housing in Glasgow, in which older cohorts were
only now emerging, West Lothian included many long-standing communi-
ties in which people had lived all their lives:
42 Research on Aging 35(1)

Oh I like living here. I’ve come back to my roots and I’ve got every-
thing arranged for my funeral to happen. I’ve got all the arrangements
made. . . . So I’m just waiting on. (CLTB8i)

Linked with their desire for independence, participants spoke of their

wishes to continue involvement in their community lives, retaining contacts
and relationships with locally based families and friends. Telecare at home
could enable people to stay close by their long-standing social networks, par-
ticipating as they wished:

When it’s nice, I like to be outside and I just potter about in the garden.
. . . And I’ve lived here so long, everybody knows me, so of course
when they’re passing by, they’re shouting to you, speaking to you. And
I like that. (HS23)

Many respondents had family caregivers, either coresident spouses or

children living nearby. Telecare was especially supportive for family care-
givers living locally; for many, it had changed their whole experience of car-
ing, through providing, as many of them commented, “peace of mind.” They
described how, without the telecare and the secure knowledge that help
would come if needed, they had been constantly afraid that their relative
(usually parents) might fall, or start a fire, or go out in the night. A particular
issue had been the use of gas stoves:

But she still thinks that she should cook. Then she leaves the gas on.
There’s a buildup of gas, so she’s now got . . . a gas detector, and that
goes through to the Call Centre, and they either get in touch with her
next door neighbor or with me. (CARB2i)

Provision of the detector had been a considerable relief.

Family caregivers explained that they now enjoyed improved relation-
ships with their relatives, calling in for a cup of tea and a chat, rather than visit-
ing to assuage anxiety about them. Thus, telecare provided improved social
participation not only for older people but also for family caregivers.

Limits to Social Participation

One factor commonly cited as a consequence of telecare is that it may become
a substitute for human contact, thus diminishing people’s lives (e.g., Sävenstedt
et al., 2006). Interestingly, this outcome was neither observed nor regretted
Bowes and McColgan 43

by our participants. This is most likely linked to their views about having
care workers visit them at home identified above; regular visits by care work-
ers could be a burden and a worry and additionally carried the negative con-
notation of being in need, dependent, and not “in control of one’s own front
door.” Our study, then, does not confirm the view that telecare reduces social
participation in this way.
However, limits to participation did emerge. Like all older people, those in
our study were experiencing the narrowing of their social networks and restric-
tions on participation in activities formerly enjoyed. Their own accounts of
these changes referred to declining health and greater difficulties in getting
about. Although people worked hard at maintaining their activities, some-
times, they said “it just got too much.” Others had lost interest in former activ-
ities, sometimes as a result of bereavement—activities were not enjoyable
alone—or did not want to “hold their families back” as they struggled to keep
up with family outings or holidays:

I feel I’m at the stage where they like walking and I’m not able to walk,
and I feel if I go I’m keeping them back. (HS15)

Some of these restrictions were linked with aging and the kinds of choices
that people made for themselves, appropriate to their own circumstances and
feelings. Others related to wider issues of exclusion, such as difficulties travel-
ing about, or access to public spaces, which could be difficult if they were very
crowded, or if there were people “hanging around,” perceived as threatening.
One woman explained that she preferred not to go out on her electric scooter
when children were coming out of school, seeing this as a general issue for
older people:

You’ve no idea the abuse I get when I’m [out] on that scooter . . . espe-
cially when the school comes out and they’re all together. Verbal abuse
and oh, terrible it is—I mean not just me, all the old ones. (HS25)

Thus, Although telecare could support and promote social participation in

some respects, in others, wider forces were restricting people’s opportunities,
as they lived in a disabling society and felt they did not “fit in” to certain
aspects of the environment.

Identity
Identity relates to a sense of belonging, appreciation by others, and a positive
construction of the self. The telecare system, insofar as it permitted people
44 Research on Aging 35(1)

to retain their independence and to enjoy positive social participation, also

supported a positive sense of identity. Where people felt local connection and
involvement that telecare enabled them to maintain, it supported their senses
of identity. Many respondents were actively maintaining senses of positive
identity, and telecare was one factor supporting this. For example, people
spoke of their attachments to their homes and possessions, and the deep value
that these had, especially in terms of links with loved ones:

My husband and I had so many happy years in here and I don’t want
to go. (CLTB12i)

A particular aspect of the West Lothian approach was the mainstreaming

strategy, which blurred some of the distinctions between older people assessed
as having “care needs” and those without, and thus had potential to reduce
stigma attached to receiving services. Our participants resisted receiving ser-
vices and fought against “giving in” to their impairments; for many of them,
becoming a service user was in some senses an admission of failure. Thus, the
mainstreamed telecare could in this sense permit people to maintain their pre-
ferred identities and to avoid taking on the identity of a “failed” service user.

Limits to Identity
However, questions remain as to why people felt so negatively about accept-
ing help that they needed and to which they were entitled. Their views reflect
wider attitudes toward the receipt of services in older age, linked with historic
constructions of the care system as directed toward people defined as socially
problematic (Bland, 1999). In recent years, these perceptions have been over-
laid by the “positive aging” agenda (Katz, 2005, offered a comprehensive
critique), which urges older people to stay active, maintain their own health,
and avoid succumbing to the trials and tribulations of old age and infirmity.
Older people are presented as responsible for their own problems and as hav-
ing the means to address them, if only they would make the effort.
Thus, wider social pressures encourage older people to take responsibility
for their own lives (which they want to do). Yet older people inevitably feel
difficulties of advancing age, for which they need help and support. There is
useful insight here from work on disability, which highlights that a society
that is organized and equipped for able-bodied people can exclude and dis-
able people with impairments (Thomas, 1999). Older people also face impair-
ments, and social arrangements can promote their disabilities. Staying at home
and “getting ready” for a care worker who “pops in” at unexpected times is
disabling because it restricts people’s freedoms to choose what they do
Bowes and McColgan 45

throughout the day. Telecare can help alleviate that disability, but it cannot
deal with many other disabling factors, such as transport difficulties, the
“ownership” of public spaces, fear of crime, and so on. This quotation illustrates
some of the ambivalence that people could face in terms of maintaining self-
image, when accepting support:

I didn’t really want it, and my daughters said we would feel better if you
had it. . . . I thought folk who had them were really poorly. . . . And I
was trying to get away from that image. . . . When they said it would
give them peace of mind, it wouldn’t have been fair if I hadn’t taken it,
so I took it. But you see I worked, and I had a superannuation. (HS23)

Notably, this respondent asserted features of her past that were clearly
important to her sense of self-worth.
Ageism was a further contextual factor limiting people’s preferred identi-
ties. Many reported direct experiences of being stereotyped and treated badly
simply because of being an older person. One woman commented,

Maybe at seventy-six you’re not supposed to have your marbles—I

have been treated with ageism for some considerable time. I tell [my
husband] “another one, another one who does not think you can use
your brain.” . . . I was hearing on the television the other day that ageism
has become common. Did you know that? (HS24)

Respondents also commented on the complexity of the care and benefits

systems, explaining that these had a disabling effect, producing a self-fulfilling
impression of stupidity on the part of anyone attempting to get care services
or claim benefits. Thus, stereotyping interacted with disabling practices to
produce “spoiled” identities, and telecare could do little to alleviate this.

Discussion and Conclusion

Against the background of policy that claims to promote independence and
choice for older people, and suggestions that telecare may deliver these, we
set out to consider how far telecare might deliver older people’s own citizen-
ship goals of independence, social participation, and identity.
In some respects, telecare supported older people to realize their own
goals. Independence was supported, as telecare facilitated people’s control
over how they spent their time and their own determined efforts to retain
independence. In terms of social participation, support to remain in one’s
46 Research on Aging 35(1)

own home provided opportunities to enjoy social interactions of people’s

own choosing. Identity, we suggested, is related to aspects of choice and
control, as well as sociable links with others, and our analysis indicated that
telecare enabled people to realize their identity goals, in particular to
avoid the imposed identity of a dependent older person. Furthermore, the
mainstreaming strategy explicitly challenged the stigma of dependence in
older age.
However, Although it can be argued that telecare can deliver the policy
goal of increased independence and choice, in terms of older people’s own
goals of independence, social participation and identity, there are some limits,
and perhaps some of the optimism of policy makers needs to be tempered.
Those aspects of the West Lothian approach that succeeded in moving toward
a positive citizenship agenda, such as the mainstreaming strategy and the
emphasis on capacity building, were indeed facilitated by telecare. However,
these did not derive entirely from telecare but from the service model.
Furthermore, service provision still occurred within an ageist society, the
older people still faced issues of ageism in their daily lives, and social prob-
lems remained in many of the communities in which they lived. Telecare
provided people with some protection from these but did not address them.
The limits on citizenship thus came from the context of telecare delivery. We
suggest therefore that contextual factors beyond the intrinsic capacities of a
technological system and beyond local service models must be explored if
the potential and limits of telecare are to be fully understood. As Dant (2006)
and May et al. (2003) suggested, the interactions of technical innovations
with human relations must be a central concern for future evaluations of
telecare. The use of the citizenship lens in evaluating telecare is important
for focusing attention on the wishes of older people themselves and draws
attention away from the service-led assessment of effectiveness.
Our contribution to the limited evidence base on telecare has not consid-
ered a number of outstanding questions relating to the potential of telecare
to support policy goals relating to current promotion of self-care and person-
alization. These include the balance of face-to-face support and remote tech-
nological support; the inherent surveillance properties of the telecare devices;
the extent to which telecare can be user led within a personalization agenda;
and, as thresholds for receipt of services rise seemingly inexorably, whether
mass service providers will invest in telecare. Against these continuing con-
cerns, West Lothian’s pioneering work as one of the first large-scale telecare
implementations provides some instructive insights regarding the potentiali-
ties and limitations of telecare but, we suggest, leaves some persistent ques-
tions outstanding.
Bowes and McColgan 47

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: We are grateful to the Nuffield Foundation
(Project SGS/00644/G) and the Health Foundation (Project 512/1139) for research
funding.

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Bios
Alison Bowes is a professor of sociology at the University of Stirling. Her research
interests focus on care of older people, including those with dementia and those from
minority ethnic groups. She has published widely in these areas.

Gillian McColgan acted as a research fellow in the projects reported in this article.
Her research focuses on people with dementia, and she is especially committed to
ensuring that the perspectives of people with dementia are included in research.