Non-delivery of Homecare for Older People in Scotland: A multi-method study

Background: A large homecare service provider for older people in one region in Scotland reported concerns of an increasing incidence of non-delivery of homecare for older people. Non-delivery denotes planned care that care workers attempted to deliver but, for whatever reason, were not able to gain access to the service user to provide care. Concerns exist that, if not addressed, incidences will continue to increase, with negative implications for the wellbeing of older people and for service provision. This thesis presents an account of the research performed to address these concerns. Aims: To identify the extent of non-delivery of homecare for older people, to establish the characteristics of those most likely to refuse or avoid homecare, and to explore the reasons why, for some older people, care was more likely to be refused or avoided. Methods: Using a multi-method approach, and in two studies this doctoral thesis was designed to answer the research question: ‘What is known about non-delivery of homecare for older people in Scotland?’ The first study adopted a quantitative approach, linking data from a large homecare service provider in one region in Scotland, to individual-level hospital in-patient data (SMR01) to help establish the extent of non-delivery of homecare and to characterise those most likely to refuse or avoid care delivery within a discrete three-month time-period. The second study employed a qualitative design, drawing on individual interviews and a focus group discussion with older people receiving homecare, to explore in depth the reasons why, for some older people, care might be refused or avoided. Findings: This is the first study to explore the patterns and reasons for non-delivery of planned homecare. This research established that non-delivery of homecare was a problem for a few older people only. Using framework analysis, the findings revealed an unexpected propensity to accept rather than refuse homecare. Moreover, the presiding values of older people are to live at home, to be independent and to remain connected, and homecare was viewed as a means to protect these values. However, homecare did not always meet these expectations, and the findings revealed that older people would accept the compromises involved in being a homecare recipient in order to live at home rather than relinquish this independence. Three key findings, which presented as paradoxes are: i) older people would refuse homecare if it was unsatisfactory, yet, despite having this experience, very few actually refused; ii) older people valued their independence above staying at home, yet they would inadvertently relinquish their independence to the care service to stay at home; and iii) whilst non-delivery of homecare places older people at risk, these same assumed risks are those associated with the provision of poor quality care. Ultimately, although independence was considered important, living at home was crucial and the presiding motivating factor to accept homecare. The findings of this study are timely and relevant as they link into current governmental initiatives to keep people at home for as long as possible with appropriate and sustainable homecare at the core of national outcomes. Recommendations: Based on these findings, the study will inform future research, practice and policy, and all those interested in improving homecare for older people, notably: homecare service providers, local authorities, and government bodies. This study is particularly relevant considering the effects of COVID-19, the impact of which has affected the way in which care is delivered. As for now, living at home is the most effective way of shielding vulnerable people