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In recent years images of independence, active ageing and staying at home have come to characterise a successful old age in western societies. 'Telecare' technologies are heavily promoted to assist ageing-in-place and a nexus of demographic ageing, shrinking healthcare and social care budgets and technological ambition has come to promote the 'telehome' as the solution to the problem of the 'age dependency ratio'. Through the adoption of a range of monitoring and telecare devices, it seems that the normative vision of independence will also be achieved. But with falling incomes and pressure for economies of scale, what kind of independence is experienced in the telehome? In this article we engage with the concepts of 'technogenarians' and 'shared work' to illuminate our analysis of telecare in use. Drawing on European-funded research we argue that home-monitoring based telecare has the potential to coerce older people unless we are able to recognise and respect a range of responses including non-use and 'misuse' in daily practice. We propose that re-imagining the aims of telecare and redesigning systems to allow for creative engagement with technologies and the co-production of care relations would help to avoid the application of coercive forms of care technology in times of austerity.

Seventy six senior academics from 11 countries invite The BMJ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Two settings are used to illustrate this approach: genetic counselling and primary care consultations in multilingual areas. In genetic counselling, interactions are organised around the tension between the risks of knowing and the risks of occurrence. This can lead to a 'rhetorical duel' between health professionals and patients and their families. In intercultural primary care settings, talk itself may be the problem when interpretive processes cannot be taken for granted. Even widely held models of good practice can lead to misunderstandings under these conditions. CONCLUSION; Through discourse analysis, the talk under scrutiny can be slowed down to show the interpretive processes and overall patterns of an activity. Discourse analysts and health professionals, working together, can look at problems in new ways and develop interventions and tools for a better understanding of communication in medical life.

Objective To assess the effect of ethnicity on student performance in stations assessing communication skills within an objective structured clinical examination. Design Quantitative and qualitative study. Setting A final UK clinical examination consisting of a two day objective structured clinical examination with 22 stations. Participants 82 students from ethnic minorities and 97 white students. Main outcome measures Mean scores for stations (quantitative) and observations made using discourse analysis on selected communication stations (qualitative).Results Mean performance of students from ethnic minorities was significantly lower than that of white students for stations assessing communication skills on days 1

1 The details of EFORTT investigators are in 'Acknowledgement' section. AbstractContext Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny.Objective To develop an ethical framework for telecare systems based on analysis of observations of telecare-in-use and citizens' panel deliberations.Design Ethnographic study (observation, work shadowing), interviews, older citizens' panels and a participative conference.Setting Participants' homes, workplaces and familiar community venues in England, Spain, the Netherlands and Norway 2008-2011.Results Older respondents expressed concerns that telecare might be used to replace face-to-face/hands-on care to cut costs. Citizens' panels strongly advocated ethical and social questions being considered in tandem with technical and policy developments. Older people are too often excluded from telecare system design, and installation is often wrongly seen as a one-off event. Some systems enhance selfcare by increasing self-awareness, while others shift agency away from the older person, introducing new forms of dependency.Conclusions Telecare has care limitations; it is not a solution, but a shift in networks of relations and responsibilities. Telecare cannot be meaningfully evaluated as an entity, but rather in the situated relations people and technologies create together. Characteristics of ethical telecare include on-going user/carer engagement in decision making about systems: in-home system evolution with feedback opportunities built into implementation. System design should be horizontal, 'two-way'/interactive rather 438 ª

ObjectiveTo investigate how electronic templates shape, enable and constrain consultations about chronic diseases.DesignEthnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry—an approach called linguistic ethnography.SettingTwo general practices in England.Participants and methodsEthnographic observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory.ResultsConsultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients’ stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient—as ‘individual’ or as ‘one of a population’. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient's narrative.ConclusionsDespite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of ‘quality’ care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging ‘institution-centred’ care over patient-centred care.

The provision of 'distant' care to older people living at home through telecare technologies is often contrasted negatively to hands-on, face-to-face care: telecare is seen as a loss of care, a dehumanization. Here we challenge this view, arguing that teleoperators in telecare services do provide care to older people, often at significant emotional cost to themselves. Based on a European Commission-funded ethnographic study of two English telecare monitoring centres, we argue that telecare is not 'disembodied' work, but a form of care performed through the use of voice, knowledge sharing and emotional labour or self-management. We also show, in distinction to discourses promoting telecare in the UK, that successful telecare relies on the existence of social networks and the availability of hands-on care. Telecare is not a substitute for, or the opposite of, hands-on care but is at its best interwoven with it.