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Emerald Group Publishing Limited
How can we assess the value of support for older people?
Article Type: Editorial From: Quality in Ageing and Older Adults, Volume 15, Issue 3
Balancing costs with the value of providing different types and sources of support for older people is ever more heatedly debated as providers and policymakers consider who should provide and who needs to receive such support. Well-conceptualised and evidenced research makes it increasingly possible to address this balance in planning such support as the papers in this issue demonstrate in UK and international contexts.
What we see as the value of home-based care work may be obscured by assumptions that popularly-perceived lack of quality in delivering such work, simply reflect a lack of skill inherent in the nature of the work itself and the capabilities of the workforce delivering it. Underlining how any such problems are likely to be heightened by the extent to which this work is performed under pressure, such assumptions are challenged by Briar, Liddell and Tolich in the findings of their focus group and interview study with this group of workers in Australia. They first document the extent and nature of pressures in the employment, then detail from those workers' perspectives the range of considerable skills they use in home-based work. They go on to examine a range of reasons, including those relating to the gender, class and ethnicity of home-based care workers which may work to minimise both the acknowledged value and the sense of fair reward for this work. They suggest that emotional labour may need to be made more visible for such support skills to properly appreciated and compensated.
Providing appropriate support for people with young-onset dementia may raise particularly complex problems if the role of existing family support is not taken into account when their needs are being assessed. The interview study with five clinical staff by Roach et al. and the co-production, use and refinement of a Family Assessment Device (FAD) with five families and a multidisciplinary advisory group suggests that in these circumstances, systematically examining the needs of families as whole can contribute importantly to connecting and contextualising the changing life circumstances and biographical history of the person with dementia. Their findings suggest ways in which the "relational" gap in care, by enabling family-centred care to underpin person-centred care. They suggest that integrating such wider awareness into a new model of provision for this group to predict both health and social needs may help ensure the provision of support can be more timely as well as better-tailored to the complexities of care.
The value of supporting and sharing self-understandings of ageing through life stories has become well recognised in older peoples' research. How to enable this in ways that can actively involve people living with dementia is still rather less certain. The review of life story resources offered by Kindell et al. explores a diversity of ways in which life stories can be reconnected and used to affirm the continuing identities and personhood of people with dementia. These are less concerned with truth finding or with specifying precise times and events and more with identifying what the person themselves may see as important. These authors show how this raises some serious questions about how far formality and carer control are central requirements for building life story activities. Instead they suggest (as indicated in Godwin's paper) that more flexible, nuanced and multi-modal communication skills will be needed by those aiming for life story-building partnerships which can be enabling for people with dementia themselves. Addressing such considerations, therefore, may help people with dementia to continue to build new interactive, practical and emotional connections with others.
The challenge of complexity in meeting the needs of people with dementia is addressed further by Meijboom, Van den Bosch and Schalk as they argue for the value of an operational management (OM) approach to appropriately combine the components of person-centred care required by any one person. The several phases of dementia as a condition, means care provision needs to be both collaborative and increasingly sensitised to the needs of that person rather than the priorities of the provider. These authors propose a model for case management in dementia care which combines two concepts from OM, configuring "front/back office configuration" and modularity to provide flexible responses to changing needs. They show how this may offer "coupled" processes as a means of resolving some of the conflicts which can arise in complex multidisciplinary and multiagency support packages, to increase their coherence in the interests of client centredness.
The positive impact of support on the health of older people is detailed in its examination by Al-Kandari and Crews from a comprehensive survey of specific health effects of social support for older people in Kuwait, where life expectancy and the proportion of older people in the population has been rising steadily alongside changing family structures. They contextualise their findings of persisting strong links between social support and health in the context of the Islamic traditions may continue to help sustain social solidarity through both extended family and religious-based networking, but is perhaps likely to decline if the current trends in family employment patterns, smaller family sizes and dispersal continues.
The context and basis of social and provider support for older people, can therefore be seen to be changing rapidly, with important consequences for our need for evidence and understanding of how to ensure we can continue to co-create responses which place older people at the centre of responses to such changes.