The changing communications landscape of technology-enabled care

This is the 3rd article in a series that examines the impact of technology on the care and support sector. 

Technology enabled care services are currently going through a significant period of change due to  the digital switchover of telecommunications networks in the UK. This has major implications for  alarm-based telecare, as existing analogue products and platforms are not optimised for use with  these new fully digital (IP-based) networks.

As legacy analogue telecare products are upgraded to  digital equivalents and new data monitoring products become increasingly both the norm and the  expectation, the well-established technologies used to allow devices to talk to each other are changing. This affects how devices communicate both within the home and with related monitoring  services and telecare response services where they exist.

This article discusses these changes and their impact on the sector, including how they will accelerate the adoption of new technology enabled care and support service models and applications. 

First and Second Generation TEC and the Digital Switchover 

The digital switch-over process of the UK’s telecommunications infrastructure, initially announced in  2017 is now well underway and is due to be completed by December 2025. By then, the long established analogue telephone service (the Public Switched Telephone Service or PSTN) will be  decommissioned, as will ISDN services. These changes have significant implications for alarm-based  telecare technology within the home, and for monitoring services more generally. Simultaneously,  Fibre to the Premises (FTTP) is being rolled out across the country, linking homes to the core network using fibre-optic cable (‘full-fibre’ broadband), to replace copper wiring with a more resilient medium  that enables data to flow at much faster speeds. To complicate matters further, the UK’s mobile  network providers are in the process of retiring their 3G networks over the next year or two to focus  on improvements in their 4G and 5G networks; these new networks also provide better, faster, and  more reliable services with extremely low latency that enables real-time interactions to take place. 

The telecare sector has responded to these challenges by investing in the development of digital  alarm hubs which essentially replicate the key features of the analogue units they are replacing. They  are designed primarily to manage the transition period as service users are switched over to new  digital services. The shift to a digital network has significant implications for how voice-based  telephone services are provided and for services such as telecare, that currently rely on the use of  the legacy analogue phone network (PSTN); namely: 

• The phone connection will fail in the event of a power-cut as an independent power supply  is no longer available as it was with the PSTN. Digital voice-based services will be provided  through a broadband hub, which is mains-powered. This has implications for both telecare  alarm equipment connected using the hub and for the ability to contact the emergency services using the 999 service. In addition, properties with a FTTP ‘full fibre’ broadband  connection, will also lose power to the Optical Network Terminal (ONT) that is required  between the fibre optic cable to the home and the connection to the hub.
• Analogue alarm equipment, such as telecare alarm hubs, may not operate reliably over the  new digital network because they use analogue alarm protocols based on DTMF ‘tone based’ signalling. These tones are not always reliably transmitted over digital networks,  resulting in alarm call failures due to handshaking errors between alarm hubs and the  monitoring centre. This leads to a need for multiple call attempts, and a delay, before a  successful alarm call is received at the monitoring centre. 
• Most modern analogue alarm hubs (newer than about ten years old) should work over  digital networks using the Analogue Terminal Adapter of the broadband router, but some  older equipment will not work at all; and will need to be discarded and upgraded. It is  expected that as the digitisation of the network is extended across the UK, the rate of  analogue alarm call failures will increase. 
• Existing wired phone extensions in the home will not work, although most people now use  wireless DECT handsets to support multiple phones in their home (these will also fail in the  event of a power-cut). 

The impact of the changes described above for dispersed telecare are being addressed with the  following approaches: 

• The use of a battery backup solution to provide power in the event of a power cut for a brief  period (usually about an hour). This would need to power the broadband router (if in use)  and the optical network terminal used with a full-fibre connection. If a DECT base station is  used for supporting legacy phone handsets throughout the home (connected via the  Analogue Terminal Adaptor (ATA) of the broadband router), then this would also need to be  powered to allow these to be used. Telecare alarm equipment will have its own internal  backup battery (EU/UK social alarm standards currently require 24-hour continued operation  in the event of local power failure) and should also have an alternative communications  route either with a dual SIM approach, or by using a broadband landline connection. Of  course, if a power-cut covers an extended area, it might also impact the local cabinet,  exchange, and mobile masts. Whilst exchanges will have access to a backup power supply,  mobile masts have mixed access, with variable up-times. Ofcom are in the process of  reviewing their guidance on this issue with a view to improving the resilience of telecom  networks. 
• New digital telecare hubs are now available that support digital IP-based alarm protocols  that are designed to work over IP-based networks. However, these can be twice as expensive  as their analogue counterparts, offer little additional functionality (other than remote  programming and device management) and are not always fully interoperable with all alarm  monitoring platforms, even when the suppliers of the system claim to support a particular  alarm protocol. Digital grouped living platforms are also available that support IP-based  alarm protocols and networks. Furthermore, there are cloud-based services which function  as a bridge between the analogue and digital/IP worlds. These work by receiving analogue  alarm protocols and converting them to IP-based alarm protocols for onward transmission to  the monitoring service of choice. 
• DECT handsets are still supported by connecting the DECT base station to the Analogue  Terminal Adapter (ATA) of the broadband router. There are also Digital Voice handsets that  link to a DECT base station built into broadband routers that support digital voice services. 

Some providers also support the use of a digital voice app that can be used by several users,  which also allows its use outside of the home. 

There has recently been some negative press for both the telecom and telecare sectors concerning  the switchover process because of example situations which have not been well managed.  Consequently, Telecoms providers have signed a new Charter committing to “concrete measures to  protect vulnerable households”, with the following key commitments: 

• All providers have agreed to not forcibly move customers onto the new network unless they  are fully confident, they will be protected. 
• Providers will conduct additional checks on customers who have already been forcibly  migrated to ensure they do not have telecare devices that the provider was not aware of,  and if they do, to ensure suitable support is provided. 
• No telecare users will be migrated to digital landline services without the provider, customer,  and telecare company confirming they have a compatible and functioning telecare solution  in place. 
• Providers will be required to work to provide back-up solutions (battery systems) that go  beyond regulator Ofcom’s minimum of one hour of continued, uninterrupted access to  emergency services in the event of a power outage. 
• They will collectively work with Ofcom and the UK government to agree a shared definition  of ‘vulnerable people’ for this transition, so it is no longer dependent on the company and  establishes an industry wide standard. 
• Government will also continue to work with the telecare sector to reduce risk for users  during the digital transition. 

However, all alarm users do not automatically qualify as being vulnerable; users need to register as  such with their communication provider. In response to situations where vulnerable people and other  edge use cases where the transition to digital voice may not be straightforward by 2025, BT and  Openreach are developing an additional phone line product called ‘SOTAP for Analogue’. This will not require a broadband connection and will also provide remote power (removing the need for battery  backup). However, it is likely that the alarm transmission issues described above with analogue  (DTMF) telecare hubs will remain. 

ISDN services are also being decommissioned with implications for both grouped housing schemes  and monitoring centres. Schemes typically use ISDN to provide shared connectivity for multiple  dwellings with the monitoring centre. Likewise, many monitoring centres use ISDN to provide  analogue alarm and voice telephony services. Monitoring centres will need to upgrade their analogue  telephony with suitable digital broadband connectivity and support for IP-based digital voice services (using SIP) and associated IT support without further delay. They will also need to ensure that their  alarm monitoring platform can handle the new digital alarm protocols and IP-based voice/telephony  services. Many of the smaller centres have closed during the past few years as the cost of upgrading  escalates. 

3G+ TEC Applications 

Third, fourth and fifth generation telecare services have moved the focus from alarms and voice based interaction to continuous monitoring of activities and health parameters, with timely alerts  replacing emergency alarms. Data-led applications depend on reliable wireless connectivity within the home, and then onward transmission using a wireless or landline broadband connection to cloud based services and/or a monitoring service. Worn devices that support continuous operation will also  make use of wireless connectivity to provide on-going support when out and about. Following data  analysis or call handling, a tailored response will be provided by a blend of people-based support and  digital applications, as appropriate. Figure 1 shows an overview of the key wireless technologies of  relevance for use both within and outside the home. 

   

Figure 1: Wireless communications inside and outside the home. 

Within the home, individual devices typically connect wirelessly to a local hub. This provides  connectivity out of the home using either an integrated 4G+ mobile data connection or a landline  broadband connection, or both to provide redundant capacity if one channel should fail. The digital  hub itself could be a smartphone or a tablet computer but is usually a bespoke product with varying  degrees of interaction possible with the end-user. Peripherals can be connected to a hub using wired  connections, including powerline network adapters, although by far the most common method is wireless radio. Whilst traditional telecare devices use licensed radio channels specifically for alarm  use, new hub designs, such as the ones shown in Figure 2, are more likely to support newer consumer  wireless technologies that have their roots in smart home and Internet of Things (IoT) applications. 

Figure 2: Example hubs. 

They each have slightly different characteristics; a summary of some of the key technologies is  provided below:

• NFC – Near Field Communication is used over very short distances, typically a few  centimetres, to securely transfer small amounts of data. It is the technology used with  contactless payments and can be used to log visits to a home by professional carers or to  provide access to a property. Information is usually transferred in one direction only. 
• Bluetooth/Bluetooth LE – Bluetooth is commonly used for streaming audio over a relatively  short distance (it has a typical working range of about 10m, depending on local conditions). Bluetooth Low Energy (LE) is used for transmitting small packets of data between devices.  Examples include transmitting data between a medical device or fitness tracker and a  smartphone app or to control devices such as a smart light bulb.  
• ZigBee/Z-Wave/Thread – these are low-power technologies that allow devices to  communicate with each other using mesh networking to help extend coverage across the  home. They are commonly used in smart home and IoT applications They are used to  transmit data or commands between devices e.g., room temperature data from a sensor to  the main thermostat controller; or an instruction to turn on the light in the hallway following  a command received from a sensor or a voice instruction through a smart speaker such as an  Amazon Echo device. Significantly, Thread, the newest technology, is based on the Internet  Protocol (IP) so that it can connect directly to other IP-enabled devices throughout the home  without a bridge device (reducing costs). It is the radio protocol that the new smart home  connectivity standard – Matter – is based on. Matter has been conceived to standardise  wireless connectivity in smart homes and is likely to become the leading technology, but as it  is still relatively new it will take time for supported devices to become widely available.  
• Wi-Fi – Wi-Fi is a ubiquitous wireless communication technology that allows devices to  connect to the internet and communicate with each other wirelessly. It enables devices such  as smartphones, tablets, laptops, smart TVs, and smart home devices to establish a wireless  connection to a local area network (LAN) or the Internet. It provides high-speed data  transmission and allows users to access online services, browse the web, stream media, and  transfer files without the need for physical cables. It is relatively power-hungry and so is not  generally suitable for battery-powered devices.  

The key lesson is that new-generation (4G+) systems use commercially available ‘commodity’ products resulting in lower cost and more aesthetically pleasing devices. There are many suppliers of  sensors and peripherals that use smart home wireless technology to communicate with a hub. So, there is no reliance on a single supplier, and it opens the possibility of in-home interoperability  between products of different manufacturers. The widespread adoption of Matter as a smart home  connectivity standard might go some way to achieve in-home interoperability between devices. 

Low Power Wide Area Networks (LPWANs) 

LPWANs are an interesting ‘third way’ of linking sensors to cloud-based services. Significantly, they  do not require a hub in the home to link sensors to the cloud, rather sensors link directly to the cloud  via a Low Power Wide Area Network (LPWAN). They are intended for applications with small messages  only a few times per hour rather than data-heavy applications like streaming, and hence they are  ideal for event-based and low data rate sensor-based applications. They make use of gateways that  provide a wireless connection between devices and cloud-based services over the Internet. The  operating range of a LPWAN gateway varies from a few kilometres in urban areas to over 10 km in  rural settings. There are two groups of technologies – ones built around specific gateway  infrastructure and those built on existing cellular (mobile) networks. Significantly, there is no need for a hub in the home for LPWAN enabled devices providing it is within range of an existing gateway/cell.  There are again several competing technologies, examples include: 

• LoRaWAN – this uses open-source technology and can transmit over unlicensed frequency  bands. Designed for the Internet of Things (IoT), it works well indoors, is ultra-low power – supporting a battery life of up to 10 years – and is especially valuable for applications in remote  areas where cellular networks have poor coverage. The gateways, with receiving antenna, can  be situated on the roofs of municipal or community buildings that can provide both power  and connectivity to the Internet. 
• NBIoT/LTE-M – these are based on existing mobile phone technologies and networks, though  availability around the country remains patchy. Narrow Band IoT (NBIoT) is a standards based LPWAN technology that supports very low data rates and is ideal for use with static sensors.  It is low power and supports a battery life of up to 10 years. It has excellent indoor coverage  and is scalable, supporting many device connections per cell. It also benefits from all the  security and privacy features of mobile networks, such as support for user identity  confidentiality, entity authentication and data integrity. LTE-M offers higher data rates, voice  capabilities, SMS messaging, improved security and supports more simultaneous connections  than NBIoT. Individual sensors require their own SIM card and data plan to connect to the  network. 

LoRaWAN has been around for longer than NBIoT, consequently it is more mature and has a greater  choice of devices which are generally lower cost than NBIoT due to its wider adoption, although this  may level out as NBIoT becomes more established. The range of LPWANs means that a single gateway  or cell can monitor thousands of devices. Potentially, all properties in an entire county could be  monitored through a relatively small number of gateways or cells. The result is that these solutions  are readily scalable, offering opportunities to provide services to entire communities, thus enhancing  the opportunities for the early detection of issues. Forward-looking local authorities and housing  associations are already using these networks for monitoring homes both in urban areas and in rural  environments. 

Benefits of LPWAN for Smart Cities and Communities 

Both activity and remote vital signs monitoring systems will increasingly employ lower-cost, generic  sensors that meet relevant industry standards for connectivity, data-sharing, and security. They are  usually provided only when they are required (preferably after a needs assessment). Installation is  then organised, often leading to a delay in hospital discharge. Procedures for the maintenance, testing  and withdrawal of the sensor devices will also have to be arranged.  

For grouped housing that is managed by a social landlord, an alternative approach might involve the  installation of devices in all properties so that all households can be monitored if necessary. Following appropriate assessment and consent, the relevant sensors could be enabled to allow monitoring to  be switched on, remotely, only when needed (and switched off when no longer required). LoRaWAN  systems can provide the most cost-effective approach, especially where mobile coverage is poor and  when monitoring is in one direction only. 

As an example of wide-scale adoption, in France, smart metering for energy and water use is available  through three competing long range, low power systems – LoRaWAN, NBIoT and Wize. The former  has become the market leader with over 3.5 million systems deployed. This includes 350,000 in the Lyon district alone where the municipality has control of the system and the data. This is in line with  a common theme where customers may prefer to use a private rather than a public network where  management is performed by a local organisation or delegated to a third party on a contract basis.  This approach enables that control remains local beyond the contract period. 

Mobile Communications 

About once a decade, a new generation of mobile network technology is introduced that is faster and  has less lag than the previous generation (see Figure 3). 4G mobile technologies and above enable more applications to be offered without the need for a fixed line broadband connection to the home,  whilst also supporting the use of more data intensive applications when out and about. The earlier  generations were used for basic telecare services but could not offer the speeds needed for two-way  video calls, including the rapidly expanding market of remote patient monitoring. 

Figure 3: The five generations of mobile telecommunications. 

In terms of speed, 4G and 5G mobile technologies are beginning to rival basic fixed-line broadband and, where available, can be provided quickly so that telecare services can be deployed as soon as a  person is assessed as needing such support, e.g., following discharge from hospital. But there remain  significant differences in the running costs – fixed line broadband is a much lower-cost option for on 

going applications including the streaming of films and other video content. More generally, the  situation may be complicated by the range of schemes available for fixed line broadband; homes  where copper has been replaced by fibre offer the fastest speeds but at a higher cost. There are social  tariffs available that enable people in receipt of certain eligible benefits such as income support,  universal or pension credits to take advantage of Internet access using fixed-line or mobile  connections.  

The benefits of 5G will initially be seen in applications outside the home, especially in transport,  where autonomous vehicles will be dependent on rapid communication for safe motoring.  Ambulances and rapid response paramedics will be able to provide real-time ECG and other vital signs  information for immediate and on-going analysis by doctors in the hospital. 

Figure 4: Tytocare and Medwand home health monitoring kits. 

More generally, the implications for social care and for community support will also be significant: 

• Remote monitoring from the home using ‘tricorder’ devices that can be loaned to families  could be useful in both paediatric and geriatric applications. Both Tytocare and Mediwand  (see Figure 4) offer an integrated device that links to a physician, a paramedic or a hospital’s  emergency department for triage or for follow-up assessment to avoid hospitalisation.  Cameras within the devices enable real-time viewing of ear, nose and throat, for example. 
• Physiotherapy/occupational therapy – a single professional may monitor multiple patients  simultaneously for group exercises, increasing staff productivity and avoiding the need for  travel by staff and patients. Similar sessions for social care applications are also enabled. 
• Medication adherence – systems such as Paman, enable trained pharmacy staff to offer advice  and monitor medication administration, thus improving outcomes. 
• Automatic responses to emergencies can be initiated – smart home devices (see above) can  make situations safe, while interface devices, such as Care Messenger can be used for triage. • Control of robotic devices – future aids in the home will be capable of autonomously  performing most domestic tasks but will need connectivity to cloud-based services to ensure  that they can operate safely and deal successfully with changing circumstances. 

In each of the above cases, communication needs to be fast and bi-directional using either a fixed line broadband or 4G+ mobile connection to be successful. 

Conclusions 

The changes described in this article are technology-focussed but have significant consequences for  how technology-enabled care services are currently implemented and how new applications can be  delivered going forward. These are summarised below: 

• The shift to fully digital (IP) telecommunications networks means that elements of analogue  infrastructure, including older dispersed alarm units, may not work reliably. The adoption of  digital hubs and monitoring platforms will solve alarm transmission issues but will also  introduce new challenges. 
• Both digital telephony and alarm services are reliant on a functioning internet connection. If  this fails, then so does the ability to communicate with a monitoring or a response service.  For landline connections, internet access can fail due to a local issue such as a power cut or  some technical problem elsewhere across the network. The former can be successfully  mitigated by using devices that can switch automatically to battery operation in the event of a local power failure. The latter requires an alternative communications path, such as a built in mobile data connection.
• The uncertainty surrounding fixed-line broadband connections has led to the use of hubs  that rely primarily on their own mobile data connection. They also have a battery backup  capability, making them self-sufficient and easier to deploy – with no requirement for an  existing landline connection. This is also true of 3G+ (non-alarm) data monitoring hubs. 
• Some products circumvent the need for a local hub entirely by using sensors that can  connect directly to low power wide area networks. This approach is sensible for providers of  social housing and to local authorities who may wish to monitor both general needs housing  and schemes designed primarily for older and more vulnerable tenants.  
• The move to digital platforms has driven the development and adoption of industry standard  digital alarm protocols which will help improve interoperability issues between home hubs  and alarm monitoring centres. Whilst proprietary alarm protocols are still preferred by some  manufacturers, the sector must move to commissioning systems that have been validated  against the latest industry standards. This will ensure that products and systems from  different manufacturers can work seamlessly together, thus reducing supplier tie-in. It will  also enable replacement service providers to take over monitoring responsibilities more  easily in the event of a business failure. 
• This is not the case for 3G+ data monitoring products as there is currently no agreed coding  standard for environmental and activity monitoring across the sector.  
• In alarm-based telecare, the move to IP technology has not been extended to devices in the  home, so interoperability between sensors and peripherals may still be some way off.  However, in 3G+ data applications, the increasing use of off-the-shelf consumer IoT devices means that there is increased potential for interoperability to exist between devices. 
• Emerging smart home standards like Matter will support improved interoperability between  devices both at the radio and data description level, which will help open the in-home  sensor/device market. This will lead to the ability to commission best-of-breed devices to  work with any compatible hub. 
• Home hubs are likely to become generic – providing basic access to the internet together  with home networking and battery backup capabilities – with data analytics applied in the  cloud. Product differentiation may include expanded user interface capabilities such as  touchscreens or voice UI, supported with a bespoke or consumer-based intelligent agent. 
• Future systems may use fixed line broadband or 5G wireless networks to provide the fast  connection that will be necessary for virtual presence applications as well as HD video  discussions, digital therapeutics and social/care robotics. 
• In the meantime, commissioning bodies need to consider how the range of digital care and  support applications that they use connect to the cloud and to other linked services. 

The technological landscape of technology-enabled care, which has been stable for decades, is  currently undergoing a seismic shift. This can be unsettling for service providers and commissioners  who must manage the changeover process and its associated risks. It involves porting legacy systems  over to the digital world but also keeping one eye to the future. Key to all of this is how these systems  can be made to work together – preferably through an integrated platform – and thus enabling a truly  data-driven service. Their ability to respond to alerts generated by the individual, their family and  carers, or by smart equipment will also be critical to success. 

Article written by T-Cubed