JULY 1998 - Ref 768
The importance of 'low level' preventive services to older people

A new study suggests that 'low level' services, like help with housework, gardening, laundry, and home maintenance and repairs, both enhance quality of life for older people and help them maintain their independence. It found that keeping a well-maintained house was central to many older people's sense of well-being and of being part of society, as well as to their confidence about coping at home. The research found:

• The fundamental concern of the older people interviewed was to stay in their own homes where they could exercise choice and control.
• Their home's appearance was particularly important to older women. Their public and private identities as competent adults were closely linked to it. Help with housework and related activities was seen as central to their ability to retain their independence, preventing or delaying the need for residential care.
• Women viewed housework as skilled work in contrast to the low status often accorded it by social services departments and other professionals.
• The relationships older people developed with home carers could be as important as practical assistance and could make it easier for them to accept help. This may have not been recognised by the purchasers of services who tended to discourage personal attachments.
• Older people defined personal and domestic assistance as help, not care. They wanted services which supported them to care for themselves. Being looked after meant loss of independence.
• What older people saw as important to their independence shifted in line with changing capacities and other circumstances. They would accept help but only for things they could no longer manage themselves. Service provision was not always sufficiently responsive to such changes.
• Having access to help from reputable organisations was important to older people's sense of security and safety, particularly for those requiring help with home maintenance and repairs.
• Older people valued having alternatives to always having to ask the family, which could undermine their sense of independence.

Background

There is increasing recognition among policy-makers and practitioners of the value of low level preventive services in promoting quality of life and social engagement, and enabling older people to care for themselves and to maintain their homes, delaying any need for more intensive and costly services. Yet social services departments may be reluctant or unable to divert resources to promote quality of life and social engagement as ends in themselves without clear evidence of cost-effectiveness.

Pressure of resources means that social services departments prioritise 'personal care' over domestic help. Help with housework is not seen as life-threatening nor as being a deciding factor as to whether or not people stay at home or go into residential care. Since the 1980s, the trend has been for social services departments to gradually reduce or withdraw the home help service which provided a large number of older people with domestic help, replacing it with a more intensive home care service providing primarily 'personal care', but for fewer people.

Home care in effect came to be seen as an alternative to residential care and in this sense may be perceived as preventive. Yet this left a vacuum in terms of those older people who had lower levels of need and who could not meet the new eligibility criteria for social services support. At the same time, older people with higher levels of need and who met eligibility criteria could only get minimal help with their housework despite the difficulties they faced. This was because the 'personal care' element of their care package used up the resources allocated to them.

The reforms to community care laid out in the White Paper, Caring for People, and the subsequent guidance documents did little to reverse these trends. Although they emphasised independence, choice and dignity, the focus on those with greatest needs meant that they failed to set a preventive agenda to address lower level needs. The new Government has clearly placed issues of social exclusion and quality of life on the policy agenda, and has emphasised the need for co-ordinated, multi-agency working. However, to date there has been no attempt to issue national strategic planning or policy directives on low level preventive services.

Staying at home

The fundamental concern of the older participants in the study was to remain in their own homes. They made a clear distinction between being at home and being in a home. Being at home meant they could exercise choice and control over what they did, when they did it and with whom. Being in a home would mean following a regime set down by the institution.

The research confirmed the findings of previous studies in recognising that home has a range of meanings for older people, extending beyond being a physical environment. It is the place where they conduct the majority of their social lives and it gives them a social identity. The cumulative effects of ageing, together with environmental barriers, can mean that older people spend increasing amounts of time within their own homes.

The importance of housework

The research showed how the appearance of their home can impact upon older people's comfort, sense of well-being and social participation. Having a clean and tidy home meant that older people felt more confident in inviting people in. At the same time, it was very important to present an image to the outside world of the home 'sailing along' as it always had done. The public identities of older people, and in particular women, were very tied up with the presentation of their homes to the outside world. Their home became a demonstration of their competence as adult members of the community and therefore its appearance was an important factor in feeling included in society.

Older women's perceptions

The older women interviewed saw the withdrawal of help with housework and related activities as a failure by social services to understand what was important to them. In their view, getting such help stood between staying in their own homes and going into residential care. Keeping the house up was akin to keeping themselves up. At the same time, diminishing energy levels and difficulties in managing heavy or physical tasks created concern that they could no longer cope in their own homes. Seeing the dust pile up or no longer being able to reach the top shelf was a constant reminder of what they could no longer do. This could have a negative impact upon both mental health and motivation to manage.

Many older women were concerned and often distressed about the appearance of their net curtains and the difficulties they experienced in changing them. Having clean 'nets' was an outward sign of respectability, having 'mucky nets' was evidence of not having 'troubled to wash them'. They were, however, unable to get formal help to change their net curtains and some risked falling as they struggled to manage for themselves.

Home carers, where involved, often acted outside of their official remit and safety regulations and did little extras for their clients, including changing and washing net curtains. Others within social services departments, however, regarded such activities, along with relationships formed between older people and home carers, as crossing professional boundaries and questioned the 'expert' status of home care. It was generally apparent too that other professional groups did not regard housework as a professional occupation and this was further reflected in the low priority accorded the service. In contrast, the older women viewed housework in terms of skills and competencies and often described home helps and home carers as 'experts'. For them, the 'work' of housework was as important as the 'care' of personal care. They accorded it very high value in terms of helping them remain in their own homes and retain their public and private identities.

The men interviewed tended to hold a more functional view of housework and appeared generally less concerned about the appearance of their homes. However, widows reported that their late husbands had increasingly taken on more housework tasks to help them maintain the home's appearance. The grief experienced by these women was exacerbated by the loss of this help and they became increasingly concerned about 'keeping up standards'.

Relationships with front-line providers

The relationships older people had with front-line providers were as important for many of the participants as the task itself. They often described their home helps or home carers as 'like a daughter' or 'a friend'. Home helps and home carers provided emotional as well as practical support for some older people, making them feel cared about and consequently better able to cope. Social services purchasers didn't always recognise this and discouraged the development of close relationships. They saw such relationships as unprofessional and potentially problematic for both older person and provider.

When the service in one study area was transferred to another provider, older people expressed considerable distress over the loss of these valued relationships. It seems that it was simply easier for older people to have somebody coming into their homes and providing help if they could develop a relationship with that person. Moreover, the front-line provider was sometimes their sole or most significant social contact, mitigating feelings of isolation.

Help not care

Older people preferred to care for themselves rather than being cared for. 'Care' implied being looked after and consequently having less independence. They consistently described the services they got as help rather than care and saw them as supporting their own ability to care for themselves. This was irrespective of the type of service they got and their assumed level of need. Along with staying in their own homes where they could exercise choice and control, they stated that doing as much as they could for themselves was central to their independence. In order to protect that, they were prepared, though sometimes reluctantly, to accept 'that bit of help'.

Professional definitions of independence, however, were shaped more by notions of function and deficit rather than choice and control. Where statutory services concentrated upon care provision, this was often at the expense of the help older people saw as necessary to their ability to cope whilst still retaining their independence.

Shifting boundaries of independence

Older people's perceptions of their independence shifted in line with changing capacities and other social and environmental circumstances. This was not necessarily a one-way process - capacities could increase as well as decrease. Older people did not equate their needs for assistance with loss of independence. Tasks which could no longer be managed alone could be given up without feeling that independence had been forfeited as long as provision did not supplant what they could still do for themselves. Many stressed the importance of will-power in sustaining their own boundaries, whatever these may have been. For some it was doing their own shopping, for some it was cooking for themselves, for others it was housework. There were some concerns that other demands upon their energies might have undermined their capacities to sustain these boundaries. Therefore, some wanted help to be there 'just in case' so they didn't have to worry now about what they might not be able to manage in the future.

Home and security

The condition and security of their homes was important to older people, and some participants expressed concerns about having unknown men undertaking house maintenance and repair work. Sometimes this was linked to feelings of personal safety and sometimes to fears of being overcharged and 'taken advantage of because you're old'. The services provided by Care and Repair organisations were highly valued because people felt they could trust the workers involved.

Alternatives to asking the family

The older people generally found it difficult to ask for help. This was particularly the case when it came to family support. Older people who got such support were appreciative of it but at the same time, always having to rely upon the family could undermine their feelings of independence. Older people sometimes had to walk a fine line, particularly where families had expressed concern about their ability to cope - asking for help then was tantamount to an admission that they indeed couldn't cope. They also didn't want to be perceived as a burden which would have undermined their families' independence. Having to repeatedly ask could be perceived as a rejection and reinforce feelings of dependency. Access to alternative forms of help overcame these problems and gave older people increased choice and control.

Conclusions

The research suggests the need for a national strategy for the development of low level preventive services which takes on board the voices of older people themselves. The researchers conclude that services which enhance quality of life and social engagement have a central role in helping older people to remain in their own homes with dignity and independence.

About the study

The research was undertaken in three local authority areas in the south of England. In-depth and loosely structured interviews were conducted with 51 older people in their own homes. One-third of these were interviewed on 2 or 3 separate occasions in order to incorporate the impact of changing circumstances on their perceptions and experiences. Group discussions with members of luncheon clubs and a pensioners' pressure group also contributed to the findings. Professionals from the statutory and independent sectors were interviewed and these interviews, along with reference to local and national policy, were used to balance the findings. The research focused on the stated priorities of the older participants.

How to get further information

For further information, contact Dr Heather Clark, Senior Lecturer, Chichester Institute of Higher Education, College Lane, Chichester. PO19 4PE. Tel: 01243 816000; Fax: 01243 816080; e-mail: H.Clark@CHIHE.ac.uk; or Sue Dyer, Principle Lecturer, Institute of Nursing and Midwifery, University of Brighton, Ashdown House, University of Sussex Campus, Falmer, Brighton, BN1 9RT. Tel: 01273 570038; Fax: 01273 670960; E mail: S.Dyer@bton.ac.uk.

The full report: 'That bit of help': The high value of low level preventative services for older people by Heather Clark, Sue Dyer and Jo Horwood is published by The Policy Press in association with Community Care magazine and the Foundation (price £13.95, ISBN 1 86134 118 0).

This title is now out of print.