RPP 18 1 Charles Patmore Consulting older community care clients about their services: some lessons for researchers and service managers

Research Policy and Planning: The journal of the Social Services Research Group – Vol 18 (1) 2000

Consulting older community care clients about their services: some lessons for researchers and service managers

Charles Patmore, Research Fellow, Social Policy Research Unit, University of York

Hazel Qureshi, Assistant Director, Social Policy Research Unit, University of York

Elinor Nicholas, Research Fellow, Social Policy Research Unit, University of York

Abstract

For purposes like Best Value reviews, Social Services need methods for consulting frail older people. This paper presents the results of research with 88 older users of Social Services community care, who were interviewed in groups, individually, or through a telephone conference about how they would like to be consulted about their services. They expressed a clear overall preference for individual interviews at home, which proved clearly more suitable than focus groups for people aged over 80. Written questionnaires were consistently criticised. Opinions varied about individual telephone interviews. Senior service managers were favoured as interviewers.

Introduction

Frail older people have been relatively neglected in the growth of consultation and user-involvement among community care clients (Barnes and Bennett, 1998). An obvious hurdle has been the relative difficulty of involving frail people, many of whom may not venture readily from home, in service users’ groups or public meetings commonly used to consult with other sectors of the community care clientele or active older people. Social Services Departments, however, must now obtain service users’ views as a core element of the Best Value Review (Department of the Environment, Transport and the Regions, 1999). Frail older people, major users of Social Services home care, must be included in such consultations. Indeed, the DETR guidance stresses that hard-to-reach groups should be included. Additionally, Modernising Social Services (Department of Health, 1998) now requires Social Services to conduct satisfaction surveys in which frail older people must likewise be included. Alongside statutory requirements, there are other good reasons for seeking the views of frail older people. Valuable practical guidance has been obtained from research interviews with older users of community care (Henwood et al, 1998, Clark et al, 1998). At a time when Home Care services are changing substantially, studies like these have helpfully highlighted the aspects of care which particularly matter to older people. Moreover, there is an increasing acceptance that community care services should, by right, be guided by feedback from their users.

It is important therefore to investigate which methods are effective in consulting older community care clients about their services. For example, what are older people’s preferences in relation to the questionnaires, group meetings, panels or telephone methods employed to consult users of rather different public services (Seargeant and Steele, 1998)? Methods used productively to gather older people’s views have included individual interviews (Saunders et al, 1992), group interviews (Henwood et al, 1998), telephone conferences (Thornton and Lloyd, 1995) and on-going user panels (Barnes and Bennett, 1998). But do older people find some methods more attractive or accessible than others? In particular, which methods are accessible to people with pronounced physical or mental frailties, whose views may be particularly important because they make much use of Social Services? Similarly it is important to establish which methods suit people aged over 85, who may comprise a large proportion of some social care case lists and whose outlook and accessibility for consultation may be very different from, say, people in their late sixties.

There are other aspects of consulting frail older people which merit investigation, for example, participant selection. How far, for instance, is it possible to systematically represent particular sub-groups among older community care clients by using computerised service records to identify people with the relevant characteristics? A common recruitment method is for researchers to ask service staff to invite older people whom they know, recommend as suitable and can persuade to volunteer. This approach was used in the last three studies cited. Such dependence on a third party’s contact networks, however, often means very specific groups of service users cannot be targeted – for instance, a particular age group or people receiving a particular weekly amount of Home Care. Furthermore, such an ad hoc method may lead to bias and does not conform to any of the established sampling frames (c.f. Morse, 1998:73). Thus it is useful to know if older people, identified from a database, can be persuaded to participate in a consultation in the absence of a recommendation from someone whom they know and trust. The study described here addresses all these issues.

Background to the study

A number of groups and individuals were interviewed in a Northern city as part of a research project, financed by the Department of Health, into how Social Services Departments could routinely utilise information about the outcomes of social care for older people living in their own homes (Patmore et al, 1998). The interviews sought to identify the views of different stakeholder groups on two broad questions. What were important outcomes from social care? What were appropriate methods for gathering the views of older service users about outcomes achieved through their own services?

These questions were put to a wide variety of older service users, family carers, and Social Services staff. Care was taken to include service users receiving high and low levels of home care, people who did not leave their homes, people who attended day care and people from minority ethnic groups. Steps were also taken to ensure that people with physical and mental infirmities were consulted. In these respects, the sampling frame conformed to Patton’s (1990) criteria that those chosen should be in a position to supply data which is ‘information rich’ and to Morse’s (1998) strategy of ‘maximum variety sampling’ which ensures that the sample is heterogeneous with core observable commonalities of experience. Table 1 shows the variety of interviewees and interview procedures among the 88 older service users involved. In addition, three sets of family carers and eight different sets of staff across Home Care, Day Care and Care Management, at a range of levels, were interviewed. This paper, however, focuses largely on the interviews with the 88 older people.

A key source of information about how older people would like to be consulted was the explicit response to this question during group discussions or individual interviews. Another source was the experience of the research team in recruiting and running the different types of interviews. Here older people could show their preferences through the form of participation they accepted.

Preferences about consultation methods stated during group and individual discussions with older people

At some stage during each of the nine sets of interviews listed in Table 1, explicit questions addressed methods for consulting older people about their own services. These covered a wider range of consultation methods than were actually employed.

Table 1: All sets of interviews with older people

 Interview set N. of part’s Method Recruitment
Home Care Clients (< 7 hrs service pw) 8 3 group meetings Names from database
Home Care Clients (< 7 hrs service pw) 8 1 individual interviewat home Names from database
Home Care Clients (> 7 hrs service pw) 6 3 phone conference sessions Names from database
Social Day Centre users 10 1 group meeting Intro by service staff
Mental Health Day Programme (functional) 8 1 group meeting Intro by service staff
Asian Older Men 9 – 15 3 group meetings Existing group at community centre
Asian Older Women 6 – 7 3 group meetings Existing group at community centre
Polish Older People 12 2 group meetings Intro by vol sector centre staff
Dementia services users 14 group & individual Intro by service staff
Total interviewees 88

There was a clear consensus that individual home interviews were generally the most preferred method. It was notable that group consultations, which participants seemed to enjoy, nevertheless also produced a recommendation that home interviews were more appropriate. These were praised because they could reach a wider range of people with health, mobility or vision difficulties than could other methods. They would also give an older person ample time and space to communicate their viewpoint – something which might be lacking in group discussions, some feared. Moreover, unlike many written questionnaires, they would allow people to communicate in their own words.

An unexpected finding, suggested spontaneously by most sets of interviewees, was that a senior Social Services manager should conduct the home interview. For four sets of participants this was the most broadly favoured among all possible consultation methods. It had strongly attractive features for three further sets who did not rank their preferences so clearly. Thus, phrases like “the men at the top” were often used for senior managers with interviewees being unclear about Social Services job titles. The reasons behind the appeal of this approach are described below.

People wanted to be interviewed by someone sufficiently senior to ensure that something was actually done as a result of the consultation. They worried that findings would otherwise not reach senior staff or be acted on. They believed that conducting this interview at home would add meaning to the interviewee’s words because the manager would be able to see their problems and living circumstances directly. Again and again, home interviews were envisaged as a means for educating managers who were so senior that they did not often see the realities of older people’s lives. Another recurrent theme was that senior managers had a moral obligation to witness first hand the results of the services for which they were responsible. Such visits, it was felt, would encourage older people by demonstrating that senior managers cared enough about them to investigate their services’ end results. Furthermore, if a senior manager would visibly invest time in asking the questions, then it was worth older people investing their own time in answering them. This contrasted with postal questionnaires which older people took much trouble to complete but could easily be ignored.

Older service users’ preference for interview by a service manager contrasted with expectations expressed by Social Services managers themselves, who often believed that consultation through an independent agency would be preferred. This preference for service manager as interviewer was found only among older people – not among their family carers, nor among Social Services clients aged under 65 in a parallel study (Bamford et al, 1998).

Other features of home interviews identified as desirable were:

  • plenty of notice should be given to allow interviewees an opportunity to prepare their thoughts;
  • if possible, an outline of the questions should be sent in advance;
  • some women would appreciate the offer of a female interviewer;
  • interviewees should be informed at the outset that they can decline to answer any question;
  • no probing should be attempted if the interviewee does not answer directly;
  • feedback should be given on the consequences of information collected through the interviews, for example, any action taken.

Figure 1 shows some interviewees’ suggestions for appropriate questions. These are noticeably few and simple. A common sentiment was that interviewers should focus on providing space to deliver a message which the older person had been able to prepare to some extent. The interviewer should not, it was felt, impose their own agenda. Participants did not wish to feel “interrogated”, as one person put it, by lengthy imposed questioning. These sentiments echoed other researchers’ findings that the older people are, the more likely they are to feel hostile or distressed by interviewer probing in sensitive areas (Wallace et al, 1992). Fisk (1997) recommends a loose, conversational approach to interviewing very old people.

Figure 1: Suggestions from older people for questions at a home interview

Some older people suggested the following should always be raised at some point in an interview, though without pressing for answers.

  • Are you managing?
  • Have you got enough money?
  • Have you got enough care or help in the home?
  • Can you get out of your house?
  • Can you make yourself a hot drink?
  • Do you get a diet which suits you?
  • Can you choose your own shopping?
  • Can you get a bath when you want to?
  • How satisfied are you with: your health? your services? your level of happiness?
  • Is there any type of help you want but which you’re not getting?

Other forms of consultation

Although group discussions received a fair degree of approval, this was modest compared to individual interview at home. The most positive comments about group consultations came from an animated focus group at a day unit for older people recovering from functional mental disorders, where there was a very successful group work culture. Even here, however, group consultation was ranked equal rather than above home interview.

There were nuances to these preferences. Asian older people attending a community centre for regular day care felt group discussions would be helpful in eliciting their views of that care. But, they felt, individual interviews would be best for understanding their individual needs and the overall adequacy of their services.

Postal questionnaires were widely criticised, with many participants highlighting that problems with vision and the manual aspects of writing made this approach very exclusive. The closed question style of many questionnaires, their impersonality, the sheer volume of questions and the ease with which answers could be ignored, were also identified by many as shortcomings.

Individual telephone interviews were liked by some and disliked by others. There were certainly older people who would be wholly content with these – and one person actually asked to participate in that way. Some members of the telephone conference, listed in Table 1, felt the phone aided frankness. Common concerns, however, were around hearing difficulties and distance, in that a telephone conversation could not show practical problems at home. Some people seemed to have an intrinsic dislike of phones or to have manual difficulties in using them. Others did not like being phoned unprepared – a barrier avoidable through the advanced written notice used in this study. Opposition to telephone interviews was too widespread for them to be the sole method in a consultation. But they were favoured by enough people to suggest that they might be usefully offered as an option alongside other approaches. Our actual use of a telephone conference is discussed later.

Interviewees were asked what they thought about maintaining a diary of their service experiences, which could be periodically borrowed for analysis for senior managers. While some thought this a good idea, more were opposed, as with postal questionnaires, on the basis of many service users’ problems with writing. Similarly some older people liked the idea of managers making eye-witness assessments of the service, for example, by visiting to watch home care staff in action. Again, however, more were opposed. Some doubted that a typical service would be in evidence on such occasions. Others felt angry that their own home might be used to subject hard-working, well-liked home care staff to a distressing experience of scrutiny. Neither of these methods should be contemplated for widespread application.

A common sentiment was that different forms of consultation might suit different people. Any procedure which offered choice would be appreciated by older people. Members of minority ethnic groups broadly reflected the views of other participating groups, but additionally stressed the importance of interviewing in the language of the interviewee’s choice. As a group they also particularly disliked the idea of written questionnaires, even with translations. Consultation with dementia sufferers is discussed elsewhere (Bamford, 1998).

Recruitment from a computerised database: influence of age and consultation method on older people’s willingness to participate

The research team wished to hear separately the views of people who received contrasting amounts of home care, as shown in Table 1. It therefore used a Social Services computerised database to randomly generate names of people receiving different amounts of home care per week. People on these lists were then invited to participate.

It was decided to use a telephone conference to consult people receiving more than seven hours per week of home care, bearing in mind their potential difficulties in travelling to group meetings. This method had been successfully utilised by colleagues (Thornton and Lloyd, 1995). Other home care clients would be consulted mainly through face-to-face focus groups. As described below there were notable difficulties in recruiting people aged over 80 for anything other than individual home interviews.

Recruiting for face-to-face focus groups

It was intended to set up two face-to-face focus groups, each with eight members, to access the views of people aged over 65 years receiving regular home care but for less than seven hours per week. Sixty names were drawn at random from the computerised register for calculating home care charges, which covered all service users. However, as Tables 2 and 3 show, only seven of these initial 60 people could be recruited. As a result it was decided that only one eight-member group would be used and eight individual interviewees would be sought from people who declined groups. Additional names needed to be drawn from the database for full recruitment of both these sets of interviewees, set out in Table 4.

This difficulty in recruiting older people for groups occurred despite substantial preparation and resources. A part time research assistant, based locally and with effective Social Services links, was appointed to visit prospective interviewees. A six member Older People’s Advisory Group was set up to provide peer guidance on initial communications, focus group venues and transport arrangements, an approach developed earlier by colleagues (Tozer and Thornton 1995, Thornton and Lloyd 1995).

Table 2: Reasons for Home Care Organisers excluding clients from group interview: initial lists of older people receiving no more than 7 hours per week

Low hours (Not more than 2 pw) Medium hrs (>2-7 pw) Total
Housebound owing to mobility problems 3 5 8
Cancelled service / Case closed 5 5
Dementia or confusional state 1 3 4
Other mental disorder 1 1 2
Hearing or speech impairments 2 4 6
Difficulties with English language 1 1
Resistant to participating 1 1
Ill / in hospital / under stress / away from home 1 3 4
Moved to residential or nursing home / died 1 1 2
Total excluded (% of sample) 14 (47%) 19 (63%) 33 (55%)
Approved for request for interview 16 11 27
Total names checked 30 30 60

Local Home Care Organisers (HCOs) were asked to screen the lists of names and recommend the exclusion of anyone who met certain criteria for unsuitability for a group discussion, as shown in Table 2. Some of the excluded categories were accessed through specialised interview groups elsewhere in the study, as shown in Table 1. For housebound people, for example, there was the telephone conference and for those with difficulties speaking English, there were groups in Polish and Asian languages. Similarly there were groups for both people with dementia and others with functional mental health problems. There were no grounds for thinking that HCOs excluded clients unnecessarily.

However, among people approved by HCOs, the researchers later excluded one as unsuitable and several others excluded themselves on the grounds of infirmity. Remaining clients were initially written to, then phoned by the Research Assistant to ask whether she could visit to elaborate what participation would mean. Participation was requested in three group meetings, a fortnight apart, with free taxis organised by the researchers and payment to participants of £15 per meeting.

Table 3 Results of focus group recruitment from sample of 60 older Home Care clients: recipients of not more than 7 hours per week

Excluded by Home Care staff screening 33 (55%)
Contact could not be achieved 2 (3%)
On holiday on relevant dates 1 (2%)
Relatives resisted participation 2 (3%)
Client declined to participate 8 (13%)
Client declined group but agreed to home interview 5 (8%)
Client declined group, agreed to home interview, then later withdrew owing to health problems 1 (2%)
Client volunteered for group, but SPRU excluded re communication problems, then included in home interviews 1 (2%)
Client volunteered to join group and SPRU accepted 7 (12%)
Total names from database 60 (100%)

Effects of age and the interview method offered

A key factor in the recruitment problems was a reluctance among people aged over 80 to participate in a group interview, preferring to be individually interviewed at home. As Table 5 shows, only two of the 20 people aged over 80 approved by HCOs agreed to join a group, compared to five of the seven people aged between 65 and 79. Table 5 also shows how some people aged over 80, while declining to join groups, chose individual interviews in their own homes without payment. Of ten people aged over 85 none joined the group, although three were interviewed individually.

Table 4: Interview sets recruited from lists from database

Interview method Focus group (3 sessions) Individual home interview Phone conference (3 sessions)
HC hoursselection criterion < 7 hours per week >7 hours per week
% HC caselist rec. this level of service 85% 15%
Estimated % of total HC hrs given to people rec. this level of service 60% 40%
N of participants 8 8 6
Mean age 75.5 years 85 years 77 years
Age range 65-84 years 75-90 years 69-94 years
Gender ratio 5F: 3M 5F: 3M 3F: 3M
Mean HC hours 2.8 hrs pw 2.6 hrs pw 12 hrs pw
Range HC hours pw 0.25 – 5.75 hrs 0.5 – 6 hrs 7.5 – 18.5 hrs

Table 5 Age and response to invitation to group or individual interview: people approved for interview by HCOs from initial sample of 60 recipients of not more than 7 hours pw.

Aged 65 – 79 Aged 80 – 92 Total
Joined group 5 2 7
Joined individual interviews 6 6
Declined to participate 1 8 9
Unavailable 1 4 5
Total approved for invitation 7 20 27

On the question of why the group was being declined, only one person cited specific dislike of groups. Health or mobility problems and plain lack of interest were more typical reasons. Half mentioned health problems, most of whom were willing, some indeed keen, for home interviews. Others felt they could not commit themselves to group meetings because of periodic “off days” when they felt ill. Despite transport being provided, groups were perceived as arduous. “I’m too old for that sort of thing” was an illustrative comment. The Research Assistant commented that people had often made their decision by the time she followed up the initial letter with the phone call. Neither payment nor the number of group sessions seemed an influence.

Refusal by the oldest people did not reflect higher needs for care. Those who joined the group actually received a higher number of mean hours of home care than the appreciably older people who opted for home interviews or who declined altogether. This higher average reflected that the two youngest, aged 65 and 70 years, experienced long-standing physical disabilities which entailed more than five hours home care weekly. Nor was refusal to participate associated with receiving so little home care that a person did not feel interested in commenting on it. A similar proportion received an hour or less home care among those who joined the group, those who chose home interviews, and those who declined both.

Whatever their reasons, group interviews were unattractive to many people aged over 80. Although groups could be recruited from this age group simply by using much larger initial samples, such a strategy would exclude many, such as those who were individually interviewed, who feel too frail to travel from home but would happily be interviewed there.

At least 13 of the initial 60 contacts would have agreed to a home interview – the six who agreed to these plus the seven volunteers for groups. Table 2 shows that eight people had initially been excluded from groups because of mobility problems, some of whom might also have been candidates for home interview. Thus home interviews would draw a substantially greater response and redress the group’s serious failure to represent the large proportion (62%) aged over 80 in the original sample.

In contrast, the acceptability of the group to people in their sixties and seventies was notable. Once established, the group thrived. Possibly because of regular phone contacts by the Research Assistant, there were no unplanned absences across the three group meetings. When re-contacted a year later to feed back on the research findings and Social Services’ consequent decisions, group members expressed satisfaction about their experience.

It is important to note that our group recruitment problems with people aged over 80 concerned people approached after identification through a database. We could recruit people in this cohort quite easily if the group was held at a day centre with centre workers asking people already present to join in. Among those groups listed in Table 1, for example, the mean age at the Social Day Centre was 81 years and for the dementia group participants, also recruited this way, it was 84. Groups recruited at day centres, however, did not represent the views of home care clients, 80% of whom did not use such services. Thus our critique of groups as a means for consulting people aged over 80 does not necessarily conflict with findings elsewhere that they can be recruited to and productively participate in focus groups (Quine and Cameron, 1995; Quine, 1998).

Recruiting a telephone conference for intensive users of home care

Phone conference participants are described in Table 4. There were some signs that recruitment may also have been biased towards the 65-79 year age range. An optimal six participants were sought, by a consultant who had previously run telephone conferences for older people, from a sample of 31 people receiving more than seven hours of home care a week. Home Care Organisers approved 13, but only three could be recruited and these included the only two people aged under 80. The three remaining members had to be drawn from a second sample, half of whom were aged under 80, thus producing a similar age combination. It should be noted that recruitment problems to the telephone conference did not necessarily mean explicit refusal by the home care client. The researcher needs to assess via preliminary telephone conversations whether a prospective participant can sustain the significant physical and cognitive demands of three one hour-long telephone discussions with several new people. Some people were not recruited because of a mixture of low enthusiasm and researcher doubts about their ability to participate.

A strength of the telephone conference was that it enabled participation from people receiving high levels of home care, as shown in Table 4. Only one participant appeared to have been likely to attend a face-to-face group. Screening by Home Care Organisers excluded no greater proportion of higher than lower level service recipients since telephone methods allowed people with mobility difficulties, a key reason for exclusion from face-to-face groups, to participate. The novelty of telephone conferencing does not seem a major barrier – when recontacted a year later, one group member praised this method, while others readily accepted it.

However, although people aged under 80 were fairly easily recruited for the telephone conference, there were grounds for questioning whether it is a method of choice for very old people. There are certainly reasons to suppose that face-to-face interview might be more attractive based on an analysis of studies of individual telephone interviews (Herzog et al., 1983). This research found that people aged over 65 years were more likely to refuse telephone than face-to-face interviews, whereas younger people showed the reverse. If older people experienced health problems, they were even more likely to resist telephone interviews. Older people who participated also seemed to experience the telephone as more burdensome than the face-to-face interviews. Very old people can experience even the latter as difficult (Wallace et al., 1992). Thus there are grounds for thinking that very old people, with sufficient health problems for high levels of Home Care, might prefer face-to-face rather than telephone interviews.

Discussion and conclusion

One consultation method – individual interview at home – was clearly preferred by older service users. Importantly, home interviews proved far more effective than focus groups for obtaining the views of people aged over 80 years, who were the clear majority in large sectors of the services studied. There is a case for testing any consultative method for how well it suits people aged over 80 or 85, noting their very large growth in numbers (Audit Commission, 1997). Our interviews suggested that postal questionnaires would engage few very old people, although we did not actually test this. However, studies of postal surveys in the general population show a decline in response rate with age (Kaldenberg et al., 1994). Other studies note an age-related decline in response rate for a variety of survey methods (Herzog and Rodgers, 1988). It seems that a study to compare responses to postal questionnaires and home interviews among older Social Services clients might be worthwhile. This could inform Local Authorities in choosing methods for their Best Value consultations with service users and the satisfaction surveys required by Modernising Social Services. Our own study, while limited in perspective, suggests that home interviews are, for all their time costs, the most reliable route to effective consultation. We would recommend the use of this method in consulting the oldest service users, with the option of an individual telephone interview if preferred. At the risk of stating the obvious, we recommend that consultations are planned from a demographic profile of the population to be consulted and that strategies are used to recruit interviewees who reflect this profile. Where home interviews were concerned, we found it perfectly feasible to recruit very old interviewees by simply writing, then phoning, people who had been selected randomly from an administrative database and screened by service staff. Individual home interviews should generally make it easier to include people with mobility, sensory or cognitive difficulties than any other method.

Our critique of groups is certainly not aimed at those established to facilitate older people’s influencing of local service decision-making, for example, the on-going forums in Fife (Barnes and Bennett, 1998). A collective approach is necessary for such purposes and, incidentally, participants in the pioneering Fife project had a mean age of 82 years. Our focus is solely on the methods by which service managers can best obtain the views of purposive samples of service users, including those who rarely or never leave their homes.

Did any other advantages emerge for either individual interviews and group discussions? Certainly individual interviews sometimes revealed important information which did not emerge from groups, such as pronounced individual differences in what were regarded as key quality issues for participants’ own home care. Groups, however, sometimes highlighted service user concerns more effectively than individual interviews. Thus without our groups, older service users’ preference for interview by a senior Social Services manager would have been defined neither as rapidly nor in as much detail. Within a group discussion it was immediately evident that this idea appealed to many participants who might not have raised it in an individual interview. Generalisations cannot be made in terms of comparative costs. For example, approaching individual group members and providing transport may incur significant costs whilst recruiting and conducting a day centre based group is relatively inexpensive.

Our study also identified certain ways in which home interviews can be made especially attractive to older people. One example, just mentioned, was that they be conducted by senior managers. We have since conducted a trial of 30 interviews using Social Services managers in the same authority. These interviews are intended to provide decision-makers with both eye-witness contact of typical situations among service users and of examples of outcomes of current local policies. These interviews’ usefulness will be evaluated on the basis of resulting changes in how services are provided.

Acknowledgements

This work was undertaken by the Social Policy Research Unit which receives support from the Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health. The authors would like to thank the older people who took part in this research. We also wish to thank Catherine Thompson for her work in recruiting and supporting the face-to-face focus group and Barbara Lloyd for recruiting and conducting the telephone conference.

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