Introduction
Statutory day centres in the United Kingdom (UK) developed with little direction in either policy or funding structure (Kaye and Kirwin, Reference Kaye and Kirwin1990). Instead they have been regarded as ‘almost invisible’ and ‘under-researched’ (Tester, Reference Tester and Clark2001: 40). The variability of what is provided in day centres makes the service difficult to evaluate as a whole (Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014), though one commonality in many centres is that there are no time limits for those attending. This results in an ongoing involvement that can stretch for years (Burch and Borland, Reference Burch and Borland2001; Zank and Schaeke, Reference Zank and Schaeke2002; McCann et al., Reference McCann, Herbert, Li, Wolinsky, Gilley, Aggarwal, Miller and Evans2005; PricewaterhouseCoopers, 2007), with attendance most likely to conclude due to participants moving to a nursing home or dying (Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014). It is feared open-ended programming may create dependency as well as potential social exclusion (Catty et al., 2005). As such, time-limited approaches have been introduced as an alternative. In this study, participants attending short-term day centre programmes in Northern Ireland are surveyed regarding their experiences of the service and their reflections upon what it is like when they end. The findings are then discussed in line with potential future directions for day centres in the UK, a matter of some importance given increasing concerns about the value of the service.
Day centres in the UK were part of a wider welfare system that emerged due to a spirit of universalism, and therefore care for others, during the Second World War (Fraser, Reference Fraser2009), and as a pre-emptive model of care in the community as an alternative to institutional care. An initial aim was to provide services to manage medical conditions in the community rather than take up vital bed space in hospitals (Martin, Reference Martin1995). Some of this delivery was via day hospitals, which developed in the post-war period under the auspices of Joshua Bierer and Lionel Cosin (Rowntree, Reference Rowntree1947; Arie, Reference Arie1979; Fraser, Reference Fraser2009). Cosin, an orthopaedic surgeon, was inspired by a community-based day service in Brooklyn, New York (Beisgen and Kraitchman, Reference Beisgen and Kraitchman2003). This social centre's aims were to address older residents’ isolation and loneliness, and to promote nurturing relationships and a sense of belonging (Wills, Reference Wills2012), an idea in line with a prevailing view that precipitating risk factors for older people included loneliness and neglect (Martin, Reference Martin1995). As such, from the beginning, social and health factors have always aligned as correlations in day centre programming.
Day centre development in the mid-20th century was also strongly influenced by voluntary and charitable organisations, which had a keen focus on social needs (Tester, Reference Tester1989; Nies et al., Reference Nies, Tester and Nuijens1991; Henwood, Reference Henwood1993). Responding to grassroots concerns, groups such as the Women's Voluntary Service and the National OId People's Welfare Committee took the lead in providing clubs and activities to promote older people's socialisation (Keeling, Reference Keeling1961; Crossman, Reference Crossman1987). By 1953, there were 3,500 such clubs in Britain (Shenfield, Reference Shenfield1957), with approximately 10 per cent of older people attending some kind of day club by the 1960s (Richardson, Reference Richardson1964; Tunstall, Reference Tunstall1966). These increasingly came to be delivered by statutory providers, as services run more informally began to wane (Townsend, Reference Townsend1964), and by the end of the 1960s the clientele recommended for attending day centres was being narrowed to those at risk of inactivity or unable to leave their homes independently (Summer and Smith, Reference Sumner and Smith1969). This may explain why some anecdotal reports from older people at the time were already beginning to view the service negatively and as being restrictive (Tunstall, Reference Tunstall1966). Support for formal provision of day centres in the UK was urged through the Health Services and Public Health Act 1968, which encouraged local authorities to develop their own services (Brown, Reference Brown1969).
By the 1970s, two distinct models of day service for older people, the day hospital and the social day centre, were in operation but were often indistinguishable in terms of their programme provision (Summer and Smith, Reference Sumner and Smith1969; Morley, Reference Morley1974; Weissert, Reference Weissert1976). However, day centres may have been considered the ‘poor relation’ where there was more likely to be a lack of training and supervision, and where it was uncommon for social workers or any social care professionals to be employed (Younghusband, Reference Younghusband1978). Despite this, the sector experienced considerable growth. For example, in Northern Ireland there were only five full-time social day centres in 1973 but this had expanded to 32 within a decade (McCoy et al., Reference McCoy, Townsend and Fitzpatrick1982). By the 1980s, in the UK, despite the earlier lead by voluntary groups, the perceived benefits of day centres with a social focus meant that statutory agencies were now more likely to run these (Bacon and Lambkin, Reference Bacon and Lambkin1997). The potential benefits of day centres were formally recognised in the 1983 Griffiths Report when they were recommended as part of older people's care packages (Tester, Reference Tester1989). Objectives for the service at this time related to helping older people maintain independence, have access to rehabilitative or treatment services, access socialisation and gain support for carers (Tester, Reference Tester1989). Despite this, a study from the 1990s reported a lack of clarity over the purpose of day centres:
Is day care provision the ‘black box’ of welfare, where no one quite knows what goes in or comes out, or whether its purpose is to keep people at home or prepare them for residential life? (Salter, Reference Salter1992: 20)
Following a 1994 Audit Commission report, which had called for day centre providers to define their role (Powell et al., Reference Powell, Bray, Roberts, Goddard and Smith2000), by the beginning of the 21st century, statutory day centres were coming under increased scrutiny and criticism. Although day centres had been formally constituted for more than 50 years, there was little evidence of any formal evaluation (Morley, Reference Morley1974; PricewaterhouseCoopers, 2007) and no national standards had been developed (Reilly et al., Reference Reilly, Venables, Hughes, Challis and Abendstern2006). The emergence of day centres without specific guidance was not surprising given the burst of activity in terms of welfare services in the Attlee government of the late 1940s (Johns, Reference Johns2011), but a set of minimum standards in Northern Ireland were finally drafted in 2012 (Department of Health, Social Services and Public Safety Northern Ireland (DHSSPSNI), 2012).
Criticisms of day centres are rife in the literature, with their being described as being poorly co-ordinated and unprofessional (Nies et al., Reference Nies, Tester and Nuijens1991; Reilly et al., Reference Reilly, Venables, Hughes, Challis and Abendstern2006), segregating (PricewatershouseCoopers, 2007; Karpf, Reference Karpf2014), inaccessible (Clark, Reference Clark and Clark2001; McLeod et al., Reference McLeod, Bywater, Tanner and Hirsch2008), paternalistic (Roulstone and Morgan, Reference Roulstone and Morgan2009; Duffy, Reference Duffy2010; Age UK, Reference Age2011), infantilising (Ritchie, Reference Ritchie2003; Tse and Howie, Reference Tse and Howie2005), unstimulating (Manthorpe and Moriarty, Reference Manthorpe and Moriarty2014) and undesirable (Weeks and Roberto, Reference Weeks and Roberto2002; Heenan, Reference Heenan2006). Older people are conscious of these concerns and have reported hesitation about attending, though often feel happy with the service and how they are treated after a few visits (Powell et al., Reference Powell, Bray, Roberts, Goddard and Smith2000; Ritchie, Reference Ritchie2003; Lund and Engelsrud, Reference Lund and Engelsrud2008; Caiels et al., Reference Caiels, Forder, Malley, Netten and Windle2010). With the rise of personalisation, day centre provision in the last decade has reduced dramatically, with closures throughout the UK (Pitt, Reference Pitt2010).
Day centres have resisted a clear definition and purpose partly because they are peculiarly defined by their location rather than their aims (Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Broadly speaking, day centres provide health, social and related support services to adults for part of the day but not the whole day (Conrad et al., Reference Conrad, Hanrahan and Hughes1990; Vargese et al., Reference Vargese, Kurian, Mathew, Idiculla, Mathew, Cherian and John2019; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Most centres focus on therapeutic input and assisting with activities of daily living (Diaz Moore et al., Reference Diaz Moore, Geboy and Weisman2006). Centres may provide meals, social and craft activities, and respite for carers (O'Hagan, Reference O'Hagan2012). Programmes at centres promote personal growth, social engagement, and emotional and physical wellbeing (Mutchler et al., Reference Mutchler, Steinman, Gleason and Coyle2014). Meaningful activities with a focus are important, particularly for male participants, but attendees enjoy informal moments too as opportunities to catch up with friends and local news (Richie, Reference Ritchie2003). Beyond the provision of respite for carers, two service priorities exist for those attending. The first appears to reflect priorities that emerged from the day hospital model, the second from the social centre model.
Supporting independence/delaying institutionalism
Managing increasing impairment in the community continues to be a primary goal (Fawcett, Reference Fawcett2014; Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014) as early interventions with older people may reduce costly intensive services later in life (Curry, Reference Curry2006). However, the service acting as a delaying mechanism may be accurate as attendees often eventually progress to nursing home care (Gaugler and Zarit, Reference Gaugler and Zarit2001; Richie, Reference Ritchie2003; Cohen-Mansfield and Wirtz, Reference Cohen-Mansfield and Wirtz2007).
Socialisation
Socialisation, making friends and combating loneliness are regarded as primary functions of day centres (Kaye and Kirwin, Reference Kaye and Kirwin1990; Wenger et al., Reference Wenger, Davies, Shahtahmasebi and Scott1996; Morley, Reference Morley1974; Powell et al., Reference Powell, Bray, Roberts, Goddard and Smith2000; Aday et al., Reference Aday, Kehoe and Farney2006). One survey in England found that social contact was overwhelmingly the main reason for attending (Caiels et al., Reference Caiels, Forder, Malley, Netten and Windle2010). Day centres may allow new friendships to develop (Aday et al., Reference Aday, Kehoe and Farney2006) and, in one study, two-thirds of those attending stated they did not usually have any other social contact during the day (Whisnant Turner, Reference Whisnant Turner2004). However, one criticism is that, whilst day services may rescue an older person from social isolation, they may inadvertently add to social exclusion (Clark, Reference Clark and Clark2001).
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Studies have identified general characteristics of day centre attendees. They are likely to be in their late seventies, unmarried, female, widowed or living alone, with a lower income and level of education, have functional difficulties that require greater assistance with activities of daily living and receive care from an adult child (Dabelko and Balaswamy, Reference Dabelko and Balaswamy2000; Gaugler and Zarit, Reference Gaugler and Zarit2001; McCann et al., Reference McCann, Herbert, Li, Wolinsky, Gilley, Aggarwal, Miller and Evans2005; Jellinek et al., Reference Jellinek, Paradsani and Sackman2010; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Males are under-represented in day centre services (Moriarty, Reference Moriarty and Clark2001) and some surveys relay that females make up more than three-quarters of centre membership (Gaugler et al., Reference Gaugler, Jarrott, Zarit, Parris Stephens, Townsend and Greene2003; Skarupski and Pelkowski, Reference Skarupski and Pelkowski2003; Iecovich and Biderman, Reference Iecovich and Biderman2012; Fawcett, Reference Fawcett2014). ‘Age creep’ is visible in day centres, with the median age of participants rising over the last few decades (Whisnant Turner, Reference Whisnant Turner2004; Mutchler et al., Reference Mutchler, Steinman, Gleason and Coyle2014), though simultaneously participation may wane due to increasing frailty (Bulsara et al., Reference Bulsara, Etherton-Beer and Saunders2016).
The focus of this study is on time-limited programming in day centres. Specifically, one health and social care trust in Northern Ireland has developed these programmes, with a view to limiting open-ended participation and dependency. The trust has built these services around the theme of reablement.
Reablement is a well-regarded goal-oriented model of care in the UK, promoting recovery, rehabilitation, confidence and independence, particularly in relation to activities of daily living (Resnick et al., Reference Resnick, Gruber-Baldini, Galik, Pretzer-Aboff, Russ, Hebel and Zimmerman2009; Ryburn et al., Reference Ryburn, Wells and Foreman2009; Pitts et al., Reference Pitts, Sanderson, Webster and Skelhorn2011; Aspinal et al., Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016). The approach is time-limited, often 6–12 weeks in length, usually provided by home care workers in a service user's home, e.g. when an older person returns from hospital and requires short-term help in aspects such as dressing, bathing and other activities (Glendinning et al., Reference Glendinning, Jones, Baxter, Rabiee, Curtis, Wilde, Arskey and Forder2010; Tessier et al., Reference Tessier, Beaulieu, McGinn and Latulippe2016). The approach is attractive to older adults as it helps them remain in their own homes longer (Hjelle et al., Reference Hjelle, Tuntland, Forland and Alvavag2017; Doh et al., Reference Doh, Smith and Gevers2020), an ‘ageing in place’ goal (Aspinal et al., Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016) similar to the ethos envisioned early on for day centres.
Rehabilitation programmes have not been prioritised in day services (Metlife Mature Market Institute, 2010) and, whilst social connectivity is a desired outcome for reablement services (Francis et al., Reference Francis, Fisher and Rutter2011; Aspinall et al., Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016; Doh et al., Reference Doh, Smith and Gevers2020), social participation is rarely addressed (Ryburn et al., Reference Ryburn, Wells and Foreman2009). Day centre programming may provide an approach to answer this concern. In this study, seven statutory day centres in Northern Ireland provided reablement themed groups that ran one day a week for between 12 and 16 weeks in total. These were established in response to strategic views within the trust recommending that new approaches in day centres, with particular reference to rehabilitation, needed consideration (Northern Health and Social Care Trust, 2006). Four different programmes focus upon physical health and wellbeing, mental health, mobility recovery and early stages of dementia. Access to these programmes was through referrals from medical staff, social workers and other professionals. Programmes contained a mix of PowerPoint presentations on educational topics, group activities, discussion and, in some cases, physical exercises. Participants attending these programmes were invited to contribute to this study, which examined their thoughts and feelings about these time-limited services.
Aim
This study does not propose to evaluate the effectiveness of a reablement approach in day centres. Rather, participants were engaged to comment upon a time-limited programme within the service and its impact upon them. The aim of the study, then, is to analyse this experience and discuss whether this could be a viable and desirable model for future day centre provision.
Methodology
This study took place in one of the five integrated health and social care trusts that exist in Northern Ireland. Any new attendee over the age of 60 and commencing a new day centre reablement programme with the trust was invited to participate. The researchers initially approached the trust overseeing the day centres to gain access, then met with all day centre managers, to whom participant information sheets were given for distribution to individuals being approached to attend. Typically on the first day of day centre attendance, the researcher met with new group members to explain the purpose of the study and then asked for volunteers who felt comfortable recording their thoughts. Participants were asked to keep a diary recording their thoughts about their weekly attendance at their group, as well as reflecting on their daily social lives outside this. Initially, sampling was purposive as only those who felt able to complete diaries were asked to contribute. All participants were white and aged between 66 and 89. Participants reflected a diverse social class, including those who had been teachers, farmers, factory workers, sales people and full-time carers.
The use of diaries is a relatively unobtrusive research method (Furness and Garrud, Reference Furness and Garrud2010), allowing those participating to prioritise what they wish to write and to reflect on what is most important and valuable (Bartlett, Reference Bartlett2011). The approach used in this study is developed from the diary/diary-interview model, pioneered by Zimmerman and Wieder (Reference Zimmerman and Wieder1977) in 1970s counter-culture America. Diaries provide a snapshot into the participant's world and this can then be supplemented by follow-up interviews that help clarify and highlight forgotten events and significant moments (Bartlett, Reference Bartlett2011; Latham, Reference Latham2003; Milligan et al., Reference Milligan, Bingley and Gatrell2005).
Diarists were given a hard-back A5 notebook at the commencement of their group attendance and asked to keep a record throughout. An instruction page was inserted within this, which the researcher talked through with each diarist. Diarists were specifically asked to consider their weekly experience of the day centre and anything they had learned there, as well as any general reflections on their social lives. However, respondents were encouraged to diverge from what was requested, should they so wish (Mackrill, Reference Mackrill2007). The researcher revisited the day centres at programme end to collect the diaries and to arrange interviews. These usually took place in participants’ homes, though day centres were also willing to facilitate interviews at the request of participants. A semi-structured interview approach was taken, which involved an interview schedule, though the researcher willingly deviated from this both in response to the interviewee's lead in terms of what they wished to discuss and also as a result of seeking clarification on what had been recorded in individuals’ diaries. The interviews included enquiries about participants’ experiences on the programmes, their views on day centres and their social lives outside the centre. Specific questions focused on what was valued about the centre and those who attended, what was learned during the programmes, and what limitations may have been experienced.
Details of the 17 participants are noted in Table 1. Two-thirds of the respondents were female, which appropriately reflects day centre participation. Five participants fully completed diaries for the duration of the programme, whilst a further six returned incomplete entries. Ten interviews were completed in all and this included four participants who had not kept or completed diaries. Supplementing the diarists with others both extended participation to those who lacked confidence about diary keeping as well as allowing greater chance of data saturation. In terms of outlining findings from the diaries, the original intention was to use material from the incomplete, as well as complete, diaries. However, after reading through the incomplete diaries, it was decided not to include entries from these as there was minimal material to draw upon, which focused on basic, factual information.
Table 1. Study participants
Notes: NR: not recorded. 1. One diary was completed by a day centre worker on behalf of these three participants.
As diaries and subsequent interviews are subjective accounts and interpretations of events (Jones, Reference Jones2000), an Heideggerian phenomenological approach was used, promoting the view that participants’ individual interpretation was both valid and valuable. Both diaries and interviews were surveyed line by line and coded. Comparisons were made across all transcripts and codes were then merged and developed into themes presented in the Findings section.
This study gained ethical approval from the Northern Ireland Office for Research Ethics Committees (reference 12/NI/0194). Each participant was given detailed instructions of the research via an information sheet and gave written consent to their involvement. Participants were able to cease involvement at any time, and this freedom was evidenced partially through the incomplete diaries.
Note on the text
All diary entries in the text below are reproduced as written with spelling and grammatical errors uncorrected. Ellipses are used in both diary entries and interview transcripts to indicate a gap inserted by the researcher. Northern Irish vernacular and phrasing is apparent in some quotations, and this has been reproduced as stated as it helps represent the participant voice. Text omitted includes pauses, non-words and text that either seemed extraneous or required to protect identity. Any name cited is a pseudonym.
Findings
Preconceptions of day centres
Background literature has already indicated that day centre programming may be perceived as stigmatisting and segregating, and potential attendees were not ignorant of such views:
Day Centre – Who Me? – not on your life was my initial reaction when asked by my social worker if I would like to participate in a 16 week programme at [day centre]. I visualised me basket-weaving or rug-making – No appeal whatsoever. (Courtney, diary)
I wanted to meet people but I didn't want to go out among a lot of strangers, you know, but I had to overcome that or else turn into a recluse or something like that. But, no, I really appreciated being able to come here. (Alyssa, interview)
At the same time, there was a sense that initial views of the service were easily broken down in the first few weeks of attending:
I thought it was a waste of time … [but] I got quite a lot out of it … I thought it would be … company with other has-beens like myself which wasn't going to cheer me up no end. That turned out differently. And I miss some very nice people. I had a good social life there. (Kurt, interview)
I didn't like it to begin with, I have to say, but I got to like it very much … Before I had to leave I was enjoying it no end. (Megan, interview)
Informal engagement and benefits
Initial anxieties like those indicated by Kurt and Megan were apparent in other respondents, who nevertheless found the company experienced in the day centres lessened their concerns.
Both attendees and staff were valued:
I've found the people here are very friendly. The staff are always willing to help you in any way they can. (Keisha, interview)
I was actually blessed with the group that I did have because they were all so different and yet, all so together. (Rochelle, interview)
There was evidence of reciprocal relationships being developed, yielding benefits for individual roles in assisting others:
I sat beside another lady in a wheelchair who appeared quite sullen and told me she wasn't enjoying the day at all. The more I chatted to her the more pleasant she became. (Courtney, diary)
There were opportunities to mix with friends old and new:
Well, I'm settling in nicely – sometimes I lunch with three ladies – other times with the gents – I feel at ease with them all. (Dylan, diary)
The members are all very friendly and someone's always telling a story about their life. You learn different things about other people. (Keisha, interview)
I met several [town] people whom I got to know as I was born and bred there and we had a lot in common. I love to chat so it was great to meet everyone. (Courtney, diary)
There was a traveller there. Ah, salesman shall we say. Sold quite a bit to the streets going back. He was quite interesting. Quite an intelligent critter, too. And, ah, I think there were people worse off than myself there. (Kurt, interview)
Some attendees found that day centres were valuable both for getting away from the four walls of one's own home and also in terms of respite for what might be occurring there:
People will say, you know, ‘Well, we have people who will come and talk with you.’ And I said, ‘No. I need to get out. I need to get out of the house and out of the atmosphere of the house and in among people, you know’ so it was good to get to the day centre. (Alyssa, interview)
Cannot wait to get back to the day centre. It take all my worries away for a while. (Amber, diary)
Programmed activities
Concerns about day centres have focused on the service's potential purposelessness. In attending reablement programmes, participants had specific group work activities with which they were obliged to engage. Respondents reflected upon a wide range of topics presented during their stays:
M, one of the nurses, gives a talk on ‘Healthy bowel and bladder’. It's easy to follow as she has it on a screen. She involves everyone and we are all free to voice our opinions at any time. (Dylan, diary)
They chose a different topic every week. One week it may have been sunshine, vitamin D; another week, smoking, alcohol; another week, socialisation, you know, interaction with other people. Another week, what your [inaudible] food was like. (Courtney, interview)
Some participants, especially those on the programme that focused on mobility, had ‘homework’ to complete outside the centre:
I quite honestly think if you didn't do these exercises, if I didn't do them, I should say, I think I probably wouldn't be as well as I am now. (Zachary, interview)
Formal group presentations were complemented by art classes, games promoting gentle physical activity and videos:
After lunch, we assembled for a game of skittles (I think). It reminded me of the Scottish game of curling – but it was an enjoyable interlude. Although I can't say I shone as a star – but this day was enjoyable. (Dylan, diary)
After dinner we play Boccia, very enjoyable as even I can participate. (Courtney, diary)
We're doing an art class at the minute and it's really good. It's fun. It's something you can get … if you've never done it before, it's hard learning it, but if you get taught to do it, you can be very good. (Keisha, interview)
[We watched] a travelogue about [town] and districts. This was tastefully presented and includes shots of old [town] – as well as the modern, up-to-date shopping metropolis and outlying villages were also shown – in lovely colour – with haunting background music. (Dylan, diary)
Impositions
Whilst respondents were able to reflect on many positive aspects of attending, these were tempered by frustrations and limitations. These included some members feeling they did not always have choice and control over what they did:
At 1 pm after coffee everyone either goes outside or watches the news on TV [television]. This is one great change I would make. One should [not] feel obliged to watch news. In future, I'll go elsewhere for 20 mins [minutes]. (Dylan, diary)
One thing I didn't like was that between … after dinner, between half one and two o'clock, we were all brought down to watch the lunchtime news and I definitely didn't like that but what some of us did… now I don't smoke now, but people who do smoke went out into the garden and the summer having been so good, I always went out and joined them in the garden. (Courtney, interview)
The activities are very good except the afternoons are a bit prolonged … You watch television for about half an hour after lunch and then they play these wee games or have quizzes or something, which are quite boring. (Kurt, interview)
Certain activities that individuals wished to partake in were actively discouraged:
Two ladies want to get up and dance but this is forbidden as it breaches health and safety rules. (Dylan, diary)
[Reflecting on not being able to return his finished dinner plate to the kitchen] I suppose I don't like being obliged to other people, you know, people helping you all the time or trying to help you. If you ask for anything they'll do their best to get it for you. Which was never my cup of tea at all. If I wanted something I went and did it myself. (Kurt, interview)
Health and safety concerns also led to the exclusion of one former participant, whose mobility led to a risk from her accessing the bus from her front door:
Then they decided that they couldn't come for me anymore unless I would get a back road for them to come in and me come out the back door and get in the bus or whatever it is that collected me. And there was no way I could get that done. (Megan, interview)
One further inevitable imposition from a time-limited service engagement is a sense of regret at the ending of the service. A number of participants commented upon this and had asked service providers if they could remain or attend a new group at their centre:
I enjoy my day at the Day Centre but unfortunately it will come to an end when this session ends and I'll have to find somewhere else to go. (Alyssa, diary)
[Friendships made at the centre] seem … to terminate … unless you meet them again and then, depending on what was wrong with them, they might not remember you, I don't know … I'm asking for another [programme] but I'm sort of fobbed off a wee bit now. There's … the plea was that they were hard up, their finance was rough there. (Dylan, interview)
I think that was one of the things why I was so keen to go and keen to get back again because they were all very nice to me, staff and all the members of the group and I got on well with them all. (Zachary, interview)
Believe me – I shall miss the company on these sessions. (Dylan, diary)
Not every participant finished involvement due to the programme ending:
I was discharged whenever I was moved out of the area. I was very lonely. I missed the company of the day centre. (Keisha, interview)
Discussion
This study has reported upon the views of individuals participating in a time-limited day centre programme. Benefits have been highlighted in terms of social interactions, friendships and learning from what was presented in group activities. These findings reflect both a purposeful and meaningful experience for those attending and also indicate that the inherent social relations are particularly valued. For frailer older adults, network shrinkage, especially in relation to peers, is often apparent as health and social care needs grow (Keating et al., Reference Keating, Otfinowski, Wenger, Fast and Derksen2003), yet here the centre helps maintain levels of much needed social contact. Day centres with a ‘relationship-centred’ approach (Bulsara et al., Reference Bulsara, Etherton-Beer and Saunders2016) recognise the importance in venues facilitating social interaction between attendees. Examples cited in the findings reveal not only benefits from contact but also the value of being able to help one another, which demonstrates the setting provides opportunities for reciprocity, integral for lifting morale and feeling integrated (Schnittker, Reference Schnittker2007; McLeod et al., Reference McLeod, Bywater, Tanner and Hirsch2008; Stephens et al., Reference Stephens, Alpass, Towers and Stevenson2011).
That there are social benefits from the service is not surprising. As noted earlier, socialisation has been a core goal for day centre provision since its inception. However, even though the social aspects of attending provide a buffer for participants’ physical and mental wellbeing (Valadez et al., Reference Valadez, Lumadue, Gutierrez and de Vries-Kell2006), this alone may now be inadequate for a service referral (Needham, Reference Needham2014). Additionally, positive findings about social relationships must be contextualised against the time-limited nature of the programme, where friendships are often linked to the service and, for frailer older adults, unlikely to extend beyond this (Baumeister and Leary, Reference Baumeister and Leary1995). One review reported that significant declines in self-esteem and perceived physical health correlate with the cessation of day centre programming (Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014). This appeared to be the case in this study, with participants feeling that friendships made or rekindled during their attendance were unlikely to be maintained. The regrets and anxieties raised when participants’ programmes come to an end does highlight the need to have active, sufficient follow-on plans to ensure this much-valued social interaction does not suddenly just disappear. In this study, anecdotally, several participants, their confidence restored, did go on to engage themselves in other social outlets, such as the Men's Sheds movement, following their day centre attendance. Others re-engaged in other programmes the day centre offered, e.g. either one of the other reablement programmes or therapeutic art classes. However, findings illustrate that not everyone was successful in re-entering the service and the ‘step down’ element of the service for every attendee therefore must be scrutinised.
What was also striking in participants’ responses was the impositions described, reflecting a paternalistic or welfarism model of service provision, where older people are regarded as vulnerable recipients of care who need to be looked after, where their lack of ability is exaggerated (Thompson and Thompson, Reference Thompson and Thompson2001), and where there is a need to control and supervise (Biggs and Powell, Reference Biggs and Powell2001). Day centres have been criticised as a service that ‘does’ things for its members, rather than allowing its members to take control of activities (Davidson et al., Reference Davidson, Daly and Arber2003). Paternalistic care appears benevolent but may actually be overprotective (Fernández-Ballesteros et al., Reference Fernández-Ballesteros, Sánchez-Izquierdo, Olmos, Huici, Ribera Casado and Cruz Jentoft2019). Concern about conflicts between paternalism and autonomy for older adults is not new (e.g. Cohen, Reference Cohen1985), and its influence on social and health-care structures such as day centres continues to be debated today (Fernández-Ballesteros et al., Reference Fernández-Ballesteros, Sánchez-Izquierdo, Olmos, Huici, Ribera Casado and Cruz Jentoft2019), yet it is apparent in the narratives in this study that, despite numerous reported benefits, opportunities for unfettered movement and free choice are compromised in the service provision. Frustrations, such as that expressed by Kurt above, have been reported elsewhere in projects investigating the enablement and empowerment of older people in community services. Andrews et al. report on one respondent who reflects Kurt's concerns:
If people help the staff, they are told that it is not your job … for example, if I was to take a cup of tea to this lady and I was to spill it, who would be responsible? (Andrews et al., Reference Andrews, Gabbay, le May, Miller, O'Neill and Petch2015: 15)
The authors go on to note that fears of litigation and reputation become serious concerns for organisations involved in work with frail older adults (see also Carr, Reference Carr2011). In the example cited, this extends to older people's freedom to pour tea for each other. The increasing impact of age creep and concerns about physical health and wellbeing, as noted earlier both indicative of contemporary day service users, aligns with organisational pressures to provide a protective environment for those who attend. Risk management then trumps autonomy in these settings due to the perceived vulnerabilities of those in attendance and the notion that such restrictions promote the welfare of those receiving the service (Fernández-Ballesteros et al., Reference Fernández-Ballesteros, Sánchez-Izquierdo, Olmos, Huici, Ribera Casado and Cruz Jentoft2019). However, service users themselves may not view their choices to, for example, return a dinner plate or dance, as risky and therefore the need for agencies to listen to concerns and respond appropriately is recommended (Carr, Reference Carr2011). In Northern Ireland, day care standards outline that service users’ views must be listened to and consulted about the running of the service (DHSSPSNI, 2012).
When surveying other authors who have reported on the origins of day centres, it seems significant now that the emphasis has been on how social centres emerged from day hospitals, and not from the less-medicalised day clubs and other voluntary services (Gustafson, Reference Gustafson1974; Weissert, Reference Weissert1976; Arie, Reference Arie1979; Kaye and Kirwin, Reference Kaye and Kirwin1990), even though, as noted earlier, Lionel Cosin himself championed the inspiration of the latter. What the respondents in this survey have demonstrated is that there remains a strong pull from service providers to skew towards a medicalised or paternalistic gaze overseeing service provision (Biggs and Powell, Reference Biggs and Powell2001), not to deliberately diminish older people's autonomy but on the basis of minimising risk, potential harm and therefore liability; what has been described, partially due to resource limitations, as a model of playing safe (Community Care, 2005). Northern Ireland day centres could be particularly vulnerable to this approach, given the nature of integrated health and social care systems. This may result then in a sterilised, unattractive and institutionalised service (Miner Solar and Rich, Reference Miner Solar and Rich2001; Mutchler et al., Reference Mutchler, Steinman, Gleason and Coyle2014) that is perceived to be less person centred and undesirable to anyone contemplating such provision. In summary, the increasing frailty of day centre attendees not only heightens paternalism but also, on the other hand, demonstrates how the service is not a universal one for all older adults.
Study participants, here, generally report positive and enjoyable experiences of attending their programmes, with some able to pinpoint specific learning accrued from groupwork sessions. This is in contrast with wider views that are more disparaging about the service, as highlighted earlier in this article. One ongoing concern amongst gerontological scholars, then, is whether day centres are desired by those who attend. There is a strange dichotomy with day centres. They have been described simultaneously as innocuous and divisive (Community Care, 2005). Commissioners and other commentators may view them as outdated, whilst simultaneously day centre attendees value the service (Needham, Reference Needham2014; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Day centre closures have been ‘triggered by local authority decommissioning rather than being a response to new commissioning choices by individuals’ (Needham, Reference Needham2013: 8). Older adults should be consulted regarding future adult social care service provision but there is little evidence of their being directly involved in which resources are invested in (Miller et al., Reference Miller, Williams, Allen and Glasby2014). However, it has also been reported that participants in research on day centres may give socially desirable responses to questions (Dabelko-Schoney and King, Reference Dabelko-Schoney and King2010) and proffered positive responses to services may be due to feelings in attendees that, in terms of opportunities for social interaction, the centre may be the option of last resort (Unruh, Reference Unruh1983; Community Care, 2005). For older men, it has been argued that attendance at day centres is relevant only if they felt too old or sick to go elsewhere (Davidson et al., Reference Davidson, Daly and Arber2003). As such, it remains uncertain how to interpret individual responses: if other options were available, might these be more amenable to respondents? Yet the significant physical and mental health concerns that led to referrals to the programmes at least highlight that the service appears relevant to attendees’ needs.
Finally, the reablement programme reflects a desire to make an innovative response to perceived criticisms about the day centre's relevance in the 21st century. This article began with a survey of how day centres have risen and declined in the UK since the end of the Second World War. How, then, do they remain relevant as we move into the 2020s? The first thing to note is that, from the 1960s onwards, what day centres do is, by necessity, restrictive. In other words, only those who require the service should attend: it is not universal provision for all older people and the programmes described here were accessed via professional referrals.
Certain groups may require targeting. Making best use of scarce resources has an impact on whether any programme continue to be funded (Aspinal et al., Reference Aspinal, Glasby, Rostgaard, Tuntland and Westendorp2016) and, as such, day centres must justify the value of what is being offered. In line with observations on age creep, day centres are increasingly catering for a frailer, more vulnerable service user group with high levels of physical and cognitive disability, and who may require personal care services (Community Care, 2005; Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014). Day centre programmes evaluated as being successful include those that address mental, physical and emotional health concerns and improve quality of life (Schmitt et al., Reference Schmitt, Sands, Weiss, Dowling and Covinsky2010; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Those reported as being most likely to benefit from attendance include those who live alone, are on a low income, have physical and/or mental health problems, have mobility difficulties and require assistance in self-care (Vargese et al., Reference Vargese, Kurian, Mathew, Idiculla, Mathew, Cherian and John2019; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). In contrast with US day centres, which are often privately funded, UK day centres, operating with a deliberate function to target those who are disadvantaged and in greater social need (Rill, Reference Rill2011), are more likely to attract populations from lower socio-economic strata with higher rates of benefits dependency (Oliver et al., Reference Oliver, Blythe and Roe2018). In this study, a social mix of participants included those from professional careers as well as those much less well off, particularly in the case of some of the female respondents.
This speaks to an equitable function to ensure that those at risk of social exclusion are those who should be prioritised by the service, but a further challenge to this is the rise of personalisation and direct payments (Orellana et al., Reference Orellana, Manthorpe and Tinker2020). For day centres to be successful in an era of personalisation, there is a requirement for budgets to be pooled for relevant services to enable their continuation (Pitt, Reference Pitt2010; McNeil and Hunter, Reference McNeil and Hunter2014). However, one person's choice may impact the choices of others inasmuch as there may be reduced collective options available to consumers due to only the most popular options, which may not provide for those with a higher level of distinct needs, being economically viable (Daly, Reference Daly2012; Orellana et al., Reference Orellana, Manthorpe and Tinker2020). At its best the day centre has the potential to provide a location where multiple specific personal and social care services can be easily supplied for a larger number (Diaz Moore et al., Reference Diaz Moore, Geboy and Weisman2006; MacRae-Krisa and Paetsch, Reference MacRae-Krisa and Paetsch2013). Despite day centre provision being described elsewhere as a feasible, cost-effective approach to institutionalisation (Vargese et al., Reference Vargese, Kurian, Mathew, Idiculla, Mathew, Cherian and John2019) and a ‘bargain’ (Weissert et al, Reference Weissert, Elston, Bolda, Cready, Zelman, Sloane, Kalsbeek, Mutran, Rice and Koch1989: 649; Haight and Kittredge Duchesnau, Reference Haight, Kittredge Duchesnau, Haight and Gibson2005: 289), these venues are already being lost (Needham, Reference Needham2014). At the same time, there is still uncertainty about what a day centre ‘intervention’ actually entails and, as a result, the effectiveness of the service remains in question (Fields et al., Reference Fields, Anderson and Dabelko-Schoeny2014). This may need better articulation at a policy level.
Limitations
This has been a small-scale study seeking the views of 17 participants of time-limited day centre programming in Northern Ireland. Additionally, the participants were attending seven different centres and, whilst the programmes broadly followed the same script across the centres, there were variables relating to staff delivery. By using purposive sampling, it is possible that the frailest participants were excluded, though some attempt at diversity had been undertaken by including the voices of those who felt unable to complete diaries.
Conclusion
This study helps address a gap in the research literature regarding there being little known about how those attending day centres feel about the service (Orellana et al., Reference Orellana, Manthorpe and Tinker2020). Historically, day centres have been associated with a ‘social orientation’ as opposed to the physical health focus of day hospitals (Bulsara et al., Reference Bulsara, Etherton-Beer and Saunders2016). However, this may have led to a misperception of the service as one which is universally open to all older people, which may both stigmatise the service and undermine its mission, which is often and increasingly required to be more specialised. Additionally, the paternalistic models of care reported reflect the notion that day centres are not generalist facilities with services that can be universally accessed by all older people, nor should they be understood to be so. However, that does not mean that some reflection by agencies who provide such services should not be undertaken to review what participants can and cannot do during their time in attendance. Personalisation has, at least, encouraged service providers to think more creatively about their service and ways forward must actively include what is relevant, meaningful and inclusive of older people's views and active participation. The time-limited service provision here could be considered partially successful. There is a strong emphasis on ensuring a specific, educative focus, with a desire to limit dependency. However, what is striking in the views of participants is how they regret the ending of the service, maybe indicating a lack of alternative provision for this particularly frail population. Service providers, then, must be conscious of the adequacy of follow-on strategies when adopting such a model, as well as ensuring that the experience at the day centre remains as inclusive and involving as possible for those attending.
Conflict of interest
There are no financial benefits to the authors as a result of the research.
Ethical standards
This study gained ethical approval from the Northern Ireland Office for Research Ethics Committees (ORECNI; reference 12/NI/0194).
