The Scottish Government

« Previous | Contents | Next »

Listen

HOW DOES THE COMMUNITY CARE? PUBLIC ATTITUDES TO COMMUNITY CARE IN SCOTLAND

CHAPTER ONE: AIMS AND METHODS

INTRODUCTION

Devolution has provided the impetus to improve the availability of data about Scotland in order to inform and evaluate policy. The Scottish Social Attitudes Survey started in 1999 with the Scottish Parliamentary Election Survey. In 2001, the third year of the survey, the Scottish Executive commissioned and funded a module of questions on attitudes to community care. This was the first time that the survey, or the long-established British Social Attitudes Survey on which it is based (Jowell et al, 1999), had included a large number of questions relevant to community care policy. The British Social Attitudes survey, which began in 1983, is the most comprehensive and authoritative source of data available about the ebb and flow of the public's values. Although, as a Britain-wide survey, it covers Scotland, its overall sample size of 3,600 respondents makes it impossible to examine in any detail the views of people in Scotland (because the sample is designed to be representative of the population of Britain, only around 360 people in Scotland are included in any single year). This limitation led to the design and implementation of an annual Scottish Social Attitudes survey. The 2001 community care module represents the first, national enquiry into the attitudes of people in Scotland across a wide range of community care issues. The questions were designed with current and future Scottish policy concerns in mind.

Community care services (with an annual spend in Scotland of 803 million (Scottish Community Care Statistics, 2001)) affect the lives of a large number of people - either as service users or as unpaid carers, relatives, friends or neighbours of someone receiving such services. Services are provided in a wide range of settings including people's own homes, day and resource centres, supported living projects and ordinary community settings. A person who needs support to carry out an everyday task, such as shopping, may increasingly find that support being offered to enable them to do it themselves in the community in which they live. A wide range of activities are covered by community care supports and services, ranging from the provision of equipment and adaptations and other services that help people to stay in their homes (such as shopping and repair services), to help with personal and nursing care needs. In order to facilitate the inclusion of people with support needs into the community there is also increasing attention to the links with housing, education, employment and leisure opportunities. It is to be expected that an increasingly wide range of people and mainstream services will become aware of the need to, and benefits of, adapting to people with a wide range of needs.

There is already a substantial framework of legislation and guidance in place to facilitate the implementation of modernised community care (The Scottish Office, 1998). This framework goes well beyond the support of individuals at home in place of long-stay settings. It includes: measures to encourage integrated and comprehensive approaches to the assessment and support of people with mental health problems (The Scottish Office, 1997), support for unpaid carers (Scottish Executive, 1999a), provisions designed to enable people to exercise more control over their own services, for example, direct payments under the Community Care Direct Payments (Scotland) Act 1996, a national strategy intended to ensure that people with learning disabilities enjoy the same opportunities as everyone else (Scottish Executive, 2000a) and funding for a wide range of measures to support older people at home (Scottish Executive, 2000b).

This programme of measures has a number of expected outcomes. These include: making a difference to the quality of life of some of Scotland's most vulnerable groups and their families; achieving value for money from public expenditure; making access to health and social care services equitable and transparent; and ensuring that agencies and professionals in different sectors work together to provide services that are timely, driven by the needs of the person (and not those of the service provider), and accessible through a clear entry point - the 'one-stop shop' (Scottish Executive, 2000c). Moreover, developments in community care are firmly placed within the Executive's social inclusion (The Scottish Office, 1999) and social justice strategies (Scottish Executive, 1999b).

Local authorities have the lead responsibility for community care planning but a wide range of agencies is involved in commissioning and providing services. These include social work departments, housing agencies, voluntary sector agencies and the private sector. Over the last ten years the work of these agencies has been marked by considerable change - in, for example, the range of home care services available and the provision of support in the community for people with very high levels of need (who would previously have only been offered institutional care). Underlying these changes have been less visible developments in the way care is funded, accessed and organised. These include the development of care management, the use of social care providers in the private and voluntary sector, and more joint planning and service provision. The Joint Future agenda will lead increasingly to joint management and resourcing of community care services, beginning with those for older people (Scottish Executive, 2000c). Other areas of development relate to the transition between hospital and community (for example, in intermediate care) and the increasing links being made with primary care settings (Scottish Executive, 2000d). The implementation of free personal care for older people represents a distinctively Scottish approach to community care policy funding and implementation.

AIMS

The aim of the survey module was to assess and explore public attitudes towards community care in Scotland.

It is important to monitor public attitudes to these issues for a number of reasons.

• Firstly, it is recognised that a change in public attitudes is necessary if the social inclusion of, for example, those with disabilities and mental health problems is to become reality. Discriminatory attitudes can restrict people's opportunities to find employment, to live in safety and to take part in ordinary community activities. Lack of awareness can also restrict access to services (Scottish Executive Central Research Unit, 1999). One example of the importance afforded to public attitudes can be found in the national strategy for people with learning disabilities which explicitly tasks the new Scottish Consortium for Learning Disability with a remit for public education as part of the implementation of the review (Scottish Executive, 2000a).
• Secondly, information about public attitudes and perceived priorities is needed for policy makers to assess the extent to which their proposals are supported by public opinion. There are a number of key policy areas (most obviously the funding of long-term care) whose success will in part depend on their public acceptability and the priority given to them by the tax-paying public.
• Thirdly, effective policy implementation requires information about how the general public is experiencing and responding to changes in community care services. What, for example, are the views of the public in Scotland about prioritising different types of needs? Are they aware of the service changes that have occurred? Do they perceive community care as having implications and responsibilities for everyone - or do they see them as only relevant to a discrete set of services for 'minority' groups? The answers to these questions are of general importance in understanding how people in Scotland view their rights and responsibilities in Scottish society.

THE SCOTTISH SOCIAL ATTITUDES SURVEY

This survey aims to fulfil for Scotland what the British Social Attitudes survey does for Britain as a whole - to provide a unique record of Scottish social and political history. Unlike Britain-wide surveys, which will always tend to focus on Britain-wide issues, it allows the examination of issues of special importance to, or relevance in, Scotland. The series does not aim to imitate what opinion polls do - to take, at frequent intervals, the political 'pulse' of the public about issues of the day. Rather, the emphasis is on tracking the presence (or absence) of any underlying changes in people's attitudes and values over time. In other words, while the polls chart changes in the immediate political weather, the task of this survey is to monitor and explain changes in the more general social and political climate.

The survey is conducted by the National Centre for Social Research Scotland. In 2001 the survey involved a face-to-face interview with 1605 respondents and a self-completion questionnaire completed by 1383 of these people. Copies of the questionnaires are available from the National Centre for Social Research. The dataset will be archived at the UK Data Archive in Essex on publication of the findings of the survey as a whole by the National Centre for Social Research.

Sample Design

The sample is a national probability sample of adults aged 18 and over living in private households in Scotland. People were eligible for the survey if they were aged 18 when the interviewer first made contact with them. The sampling frame for the survey was the Postcode Address File (PAF), a list of addresses (or postal delivery points) compiled by the Post Office.

For practical reasons, the sample was confined to those living in private households. People living in institutions (such as nursing homes or hospitals - though not in private households at such institutions) were excluded, as were households whose addresses were not on the Postcode Address File. The sampling method involved a multi-stage design, with three separate stages of selection: selection of sectors, addresses and individuals. Further details of the sampling procedure are given in the Annex.

Weighting

Data were weighted to take account of the fact that not all the units covered in the survey had the same probability of selection. The weighting reflected the relative selection probabilities of the individual at the three main stages of selection: address, household and individual. All the percentages presented in this report are based on weighted data. Further details of the weighting procedure are given in Annex.

Fieldwork

A full interview comprised a face-to-face interview using computer assisted personal interviewing techniques (CAPI) and a self-completion questionnaire. (Computer assisted interviewing involves the use of laptop computers during the interview, with questions appearing on the computer screen and interviewers entering responses directly into the computer.) Interviewers attended a one-day briefing conference to familiarise them with the questionnaires and procedures for selecting addresses and individuals to interview. Fieldwork started in June 2001. Three-quarters of the fieldwork was completed by the middle of August 2001, 95% by the third week of September and the rest by the end of November.

The average interview length was 60 minutes. Interviewers achieved an overall response rate of 60%. Details are shown in Table 1.1.

Table 1.1 2001 Scottish Social Attitudes Survey: sample and response

All respondents were asked to fill in the self-completion questionnaire which, whenever possible, was collected by the interviewer, but in some cases was posted to the National Centre. Up to three postal reminders were sent to obtain the maximum number of self-completion supplements. A total of 222 respondents (14 per cent of those interviewed) did not return their self-completion questionnaire. It was judged unnecessary to apply additional weights to correct for this non-response because the socio-economic characteristics (for example gender, age, highest educational qualification) of those who completed the self completion were sufficiently similar to those of the full sample that further weighting would have made little or no difference to the survey's estimates.

THE COMMUNITY CARE MODULE

Consultation

The Nuffield Centre for Community Care Studies at the University of Glasgow took responsibility for the design of the Community Care module questionnaire with the advice of the National Centre. Two consultation meetings were held to obtain the views of community care stakeholders in the voluntary and statutory sectors. Further views were sent in writing. The interests represented included health and social work, older people, people with mental health problems, private care homes and community care providers in the voluntary sector. Two individuals with learning disabilities took part in the consultation. A meeting was also held with members of the Scottish Executive. These consultation sessions were of considerable assistance, both for prioritising the limited number of items which could be covered by the survey and for advising on issues of language and approach. Inevitably there was not space within the survey for all the areas that individuals would have liked to be included.

Themes

Forty questions are available for a module and in order to tap the attitudes of people in Scotland to community care it was decided to concentrate on a number of key themes:

• Awareness of and attitudes to the changes that have occurred in the way services are delivered. Do people in Scotland agree that people with support needs should live in the community?
• Tolerance of people with support needs. Community care is about social inclusion; not just where support is offered. Do people in Scotland see individuals with particular types of need, such as being older and frail, as an accepted part of their community?
• Rights. Do people in Scotland accept that people who need support have the full rights and responsibilities of citizens?
• Responsibilities. Do people in Scotland see paying for different types of care as a public or a private responsibility?

In order to examine factors that might shape attitudes we also asked about perceived experience of receiving care by the respondent or someone close to them and of giving care. We wanted to know whether people identified with the need for support. Many demographic and other variable were available for analysis from the survey dataset including age, gender, education, income, social class, area (urban or rural) and party identification.

The vignettes

Most of the community care questions were asked in relation to stories (vignettes) of four different people who live in the community and need support. Vignettes were chosen because the language used to describe people with support needs has changed over time and respondents might not all have understood the same thing by language such as 'a person with a learning disability' or 'a person with a mental health problem.' It should also be noted that certain terms, for example 'elderly', were likewise selected on the grounds of familiarity and/or clarity. This was despite a recognition that certain terminology is no longer considered good practice.

The vignettes were intended to describe an older person with dementia, a person with a learning disability, a person with a severe or enduring mental health problem and a physically frail older person. There was only space for four vignettes; it was also clear from the piloting that to introduce more would fatigue respondents. Therefore plans to include a vignette of a younger person with physical disability were dropped. Each vignette first described the person, identifying why they had a need for support. Then one support need was mentioned for each person. This was clearly an over-simplification but it was done so that in some later questions differences in attitudes to who should provide and pay for nursing care, personal care, social support and domestic care could be detected. To avoid gender bias each story was described to half the respondents as if the person was female and to the other half as if the person was a man. The text of the vignettes is given below in full.

"John (Susan) is 87 and lives alone. He often forgets things like leaving the gas on and has been found in the street in his night clothes. John needs to be checked on several times a day and needs help with bathing. "

"Alice (David) is 44 and moved out of a long-stay hospital two years ago. She cannot read or write, has limited speech and is not very aware of danger on the roads. She has trouble making friends and needs someone to take her to a club once a week."

"Stuart (Pat) is 50. He has a mental illness and occasionally spends a few months in psychiatric hospitals. He often talks to himself in public. He takes medication that controls his illness but needs someone to check that he has taken it twice daily."

"Sarah (Paul) is 90 and has recently had some falls at home. Last time she was not found for twelve hours. She is very independent and does not want to leave the family home where she has lived for 40 years. Sarah needs help with shopping and cooking."

Thus the vignettes included an older person with dementia who had personal care needs, a person with a learning disability who had social care needs, a person with a mental illness who had a health need and a physically frail, older person with a need for domestic help.

The content of the interview

The first part of the survey interview was about the respondent themselves and their perceived identity. Then the respondent was asked the questions in the community care module. After some questions about their own needs and caring responsibilities, the first vignette was introduced. The vignette was shown to the respondent on a card and read out before a set of questions was asked about the person. Then the next vignette was introduced and the questions repeated. Interviewers for the pilot reported that many respondents engaged with the approach of asking about individuals, responding as if the vignettes were real people.

Questions asked of all vignettes were:

• How comfortable would you feel living next door?
• Who would be the best person to provide care?
• If someone outside the family had to provide care, who should pay?
• Where would it be best for them to live?

A question asked only of David and Pat was:

• Should the person be able to sit on a jury?

A question asked of all except John was:

• If you had a relative like this, who would you go to first to arrange care?

After the vignettes, respondents were asked about priorities for government spending for older people. In the self-completion questionnaire, they were also asked if they would like more or less government spending on a number of items which included care for older people and whether an older person in need of regular care should be cared for in their own home because they wanted it, even if this cost more than in a care home. Finally there was a question about equity - should older people be able to pay for higher quality help if they could afford it.

THE RESPONDENTS

There were 1605 respondents. Ten per cent felt that they themselves had needed regular care or support recently and just over 40% reported that someone close to them had done so. The proportions were not much different when the question was asked about need for care in the future. The questions were:

"At some point in their lives people can need regular help looking after themselves because of illness, disability or old age. Have either you or someone you are close to been in need of any regular help like this over the last ten years?"

" Now thinking of the next five years or so, are you concerned that you or someone you are close to might need any regular help like this because of illness, disability or old age?

Table 1.2 Perceived care needs in past ten years

Table 1.3 Perceived care needs in next five years

The third measure of perceived closeness to the issue was whether the respondent had ever provided unpaid regular help.

"And have you ever provided unpaid regular help for someone who needs help to look after themselves because of their illness, disability or old age?"

Under half of the respondents (36%) reported that they had, compared with 64% who had not. One in ten people in Scotland, therefore, identify with a need for support and under half with being an unpaid carer. This is a measure of perceived, rather than of actual, need.

The question in this survey asked about perceived need because it was concerned to identify how close people felt in their experience to the situation of needing care. Demographic data for Scotland is available from the Scottish Household Survey (Bulletin No. 7) which reports that 12% of households contain someone who needs care. Households in which the highest income earner is aged over 65 are the most likely to include someone who needs care. Women are more likely to need care than men (60:40%). The Scottish Household Survey also asks about disability and chronic illness. It finds that 6% of all household members are reported to have a disability, 7% to have a long-term limiting illness or health problem and 3% both. As for care-giving, 3% of all adults provide regular help or care for someone in the household and 10% for someone outside the household, such as parents. It is important to note that differences in question wording may affect the responses to the two surveys.

« Previous | Contents | Next »