Service Framework For Older People Research Articles

Falls prevention: let's put an end to startling statistics

Nursing and Residential CareVol. 18, No. 5 EditorialFalls prevention: let's put an end to startling statisticsLinda NazarkoLinda NazarkoSearch for more papers by this authorLinda NazarkoPublished Online:20 Apr 2016https://doi.org/10.12968/nrec.2016.18.5.248AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Age Concern & Help the Aged (2011) Stop Falling: Start Saving Lives and Money. Age Concern, London. http://bit.ly/1Un55A0 (accessed 18 March 2016) Google ScholarBritish Orthopaedic Association (2007) The care of patients with fragility fractures. British Orthopaedic Association, London. http://bit.ly/1VkaiZ5 (accessed 18 March 2016) Google ScholarDepartment of Health (2001) National Service Framework for Older People. Department of Health, London. http://bit.ly/1pyRBoC (accessed 18 March 2016) Google ScholarDepartment of Health (2009) Falls and fractures: effective interventions in health and social care, Department of Health,London. http://bit.ly/1nCtOlf (accessed 18 March 2016) Google ScholarGiannoulis D, Calori GM, Giannoudis PV (2016). Thirty-day mortality after hip fractures: has anything changed? Eur J Orthop Surg Traumatol [Epub ahead of print] Crossref, Google ScholarGillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE (2012). Interventions for preventing falls in older people living in the community (Review). Cochrane Database Syst Rev 9: CD007146. Google ScholarHealth and Social Care Information Centre (2104) Monthly hospital episode statistics for admitted patient care, outpatients and accident and emergency data - April 2012 to February 2013. http://bit.ly/14cU6Sw (accessed 18 March 2016) Google ScholarHelp the Aged (2004) Managing the Risk and Effect of Falls Among Older People in Care Homes. Help the Aged, London. Google ScholarNHS England (2016) NHS Chief announces plan to support ten healthy new towns. NHS England, London. http://bit.ly/1oLb8RK (accessed 18 March 2016) Google ScholarNational Institute for Health and Care Excellence (2012) Osteoporosis: assessing the risk of fragility fracture. NICE guidelines [CG146]. http://bit.ly/1TYqG23 (accessed 18 March 2016) Google ScholarOffice for National Statistics (2015) Death Registrations Summary Statistics, England and Wales in 2014, Table 2. http://bit.ly/1pCgDTR (accessed 18 March 2016) Google ScholarRoyal College of Physicans (2016) Falls and Fragility Fracture Audit Programme (FFFAP). National Hip Fracture Database (NHFD). An analysis of 30-day mortality in 2014. National Hip Fracture Database mortality supplement. http://bit.ly/1PkjxRJ (accessed 18 March 2016) Google ScholarPatient's Association (2009) Breaking Point. Patient's Association, London. http://bit.ly/1pUvmcH (accessed 18 March 2016) Google ScholarStevens JA, Olson S (2000) Reducing falls and resulting hip fractures among older women. MMWR Recomm Rep 49 (RR-2): 3–12 Google ScholarWoolf AD, Akersson (2003) Preventing fractures in elderly people. BMJ 327(7406): 89–95 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 May 2016Volume 18Issue 5ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 20 April 2016 Published in print 2 May 2016 Information© MA Healthcare LimitedPDF download

A SYSTEMATIC REVIEW OF LITERATURE ON THE CARE OF OLDER PEOPLE WHO FALL AND USE OUT-OF-HOSPITAL EMERGENCY SERVICES

BackgroundOlder people who fall have been a priority area for the NHS since the publication of the National Service Framework for Older People. Evidence suggests falls prevention can reduce further...

“You don't know what you are saying ‘Yes’ and what you are saying ‘No’ to”: hospital experiences of older people from minority ethnic communities

ABSTRACTImproving responsiveness to the needs of older people from minority ethnic communities has been emphasised as a goal in England since the publication of the National Service Framework for Older People in 2001. Despite this, people from minority ethnic groups consistently give poorer ratings of their health services than ‘majority’ populations, both in England and across many other health-care systems. Language barriers have been shown to play a particularly important role, and appear to be a stronger predictor of perceived quality of care than ethnic origin per se. This paper reports findings from a larger study exploring older people's experiences of care transitions, focusing on the findings from one case study area which explored the hospital and discharge experiences of older people from minority ethnic communities. A participatory approach was adopted, with older people from the local area collaborating in the design, delivery and analysis of the research as ‘co-researchers’. Twenty-four in-depth narrative interviews were carried out with people who had experienced a recent hospital stay as a patient or a family member providing care and support. Our findings show that many aspects of the hospital experience, including the desire for personalised and humanistic approaches to care, are important to older people irrespective of ethnic background. However, older people from minority ethnic communities can also face language and cultural barriers which negatively affect the quality and experience of care. People who had limited English proficiency struggled to understand, communicate and participate in their care. Where professional services were not available or requested, interpreting was provided informally by other patients, family members, hospital staff in clinical and domestic roles, or not at all. We conclude that targeted strategies are required to ensure appropriate and effective hospital services for a multicultural population.

Loneliness, isolation and the health of older adults: do we need a new research agenda?

From Greek mythology and the Bible to modern critiques of the digital age, loneliness has been portrayed as part of the human condition. Recognition of the significant adverse consequences for health has come more recently, with much of the interest triggered by a rise in the death rate in Europe in 2003. Unusually high temperatures in the summer of that year were linked with the deaths of more than 40,000 mainly elderly people throughout mainland Europe. Proportionately fewer deaths were recorded among frail and sick older people living in institutions, compared with more able, but less well-supported people living in the community. These deaths stimulated much discussion and reflection on the treatment of elders in society. In France, and later the UK, non-governmental organizations instigated campaigns to address loneliness and isolation among the aged. Such campaigns, along with research from different disciplines linking loneliness and isolation with adverse health outcomes and premature mortality, have focused attention on the problems. But despite acknowledgement of isolation in the UK National Service Framework for Older People in relation to falls and depression,1 concern among care providers and commissioners has never matched the breadth and severity of the consequences of isolation and loneliness. In this article, we present an overview of current evidence and suggest that a renewed research agenda is required for a growing older population.

Designing and implementing healthy ageing policies

Dr Gareth Morgan from NHS Wales looks at how healthy ageing policies need to be implemented to ensure a success healthy ageing programme What is 'evidence'? The traditional hierarchy of 'evidence', ranging from metaanalysis of randomised controlled trials (RCTs) to expert opinion has limitations. For example, some situations may not be amenable to RCTs1 and furthermore, evidence may be open to interpretation and the application influenced by the specific context. 'Evidence-informed policy', at least in part, reflects the concept of the complex journey from evidence to implementation.2 Good evidence is not always effectively implemented. For example, there is good evidence, underpinned by meta-analysis of RCTs, that aspirin prophylaxis has a favourable benefit versus risk balance in the secondary prophylaxis of vascular events.3 Yet, there is evidence of an under-use of the medicine for this indication. 4 Does this represent a policy failure? Perhaps there may be underpinning issues at a primary care level? It might be individual choice, linked to the broader consideration of medicines management within the healthy ageing agenda? Or perhaps the under-use might be anticipated, indeed even accepted as inevitable, during the journey of evidence to implementation? Indeed, whilst acknowledging that the increased use of aspirin alongside other measures, such as smoking cessation, might help deliver substantial benefits,5 there are policy challenges. In terms of a theoretical conceptual framework, based on a review of the literature, six policy factors have been identified6 as important in underpinning 'evidence based health policy': (i) support by the national Government; (ii) the need for policy implementation to be locally sensitive; (iii) the need to have a broad evidence base to draw upon; (iv) the circular relationship between research and policy; (v) the importance and value of having multi-disciplinary teams and; (vi) the benefit of stakeholder involvement. A casestudy from Wales, 7 on the National Service Framework for Older People has found that these factors had been satisfied. Two independent studies in Wales have suggested variation in the provision of healthy ageing initiatives.8-9 In theory at least, this variation might be beneficial by developing locally sensitive approaches to healthy ageing. Such variation might also have disadvantages as well, however, such as inconsistency of initiative delivery and also difficulties in measuring impact. Indeed, Wales does contribute to the research 'evidence' on healthy ageing, for example, the 'Age Well Feel Good'10 programme is a prospective cohort study of older people in Wales. It has been established to collect information on factors pertinent to healthy ageing and also to explore the use of information technology in such studies. …

Health promotion for older people in Wales: preliminary evaluation of the National Service Framework for Older People

Aim. In this preliminary study, the health promotion activities for older people in Wales were evaluated with a view to form initial conclusions and research areas. The study drew on a dataset that is collated on an all-Wales basis. Background. The National Service Framework for Older People is a 10-year strategy concerned with the effective delivery of health and social care for individuals over the age of 50 years. It has 10 standards and number 3 of these relates to health promotion. The health promotion standard covers a wide range of issues, including alcohol, smoking, exercise, diet and vaccination. Methods. Information was extracted from an all-Wales Self-Assessment Audit Tool. A ‘realist review’ methodology was used to further extract information, using a combination of note taking and a questionnaire protocol. A further analysis was undertaken using a theoretical framework of six policy factors. Results. Health promotion in Wales is being implemented in locally sensitive ways and this has strengths. Weaknesses include measurement and comparison. Conclusions. This study illustrates that the health promotion agenda has a considerable amount of activity in Wales. Future research might include detailed evaluations of some areas, perhaps with health economic analysis included.

Rapid assessment of the impact of the National Service Framework for Older People in Wales

PurposeThis rapid assessment aims to focus on the perceptions of healthcare staff from Welsh Health Boards on the National Service Framework (NSF) for Older People.Design/methodology/approachA questionnaire was sent by email to key colleagues in each of the seven Health Boards. This was crucial for this rapid assessment and conferred the additional advantage of also allowing for correspondence to be undertaken. Anonymity was crucial to allow colleagues to score their returns honestly.FindingsOverall, the position was equivocal and the impact of the NSF was perceived as too difficult to assess. The most promising element of the NSF appeared to be a perception on the impact on joint health and social care working.Research limitations/implicationsA rapid assessment exercise, using existing networks that are built on trust, can yield valid and useful information which can help policy development.Practical implicationsThe NSF urgently needs to provide evidence of positive impact. The next stage, based on a focussed approach, offers an opportunity to progress this.Originality/valueFor the first time, a rapid assessment has been undertaken on the Welsh NSF. This inexpensive and readily achievable approach has advantages.

An initial analysis on the variation in health service provision for older people in Wales

To consider the provision of services to older people in Wales and to undertake an initial analysis, without judgement, of the variation that might exist. Wales has a National Service Framework for Older People which presents evidence-based standards for service provision. Analysis of one of these standards has suggested that there is variation in practice within Wales. A ‘realist review’ was undertaken using the search engine ‘Pubmed’. The method has been used in other situations and the ‘realist reviewer’ makes annotated comments on documents and extracts a summary of messages. Certain broad themes emerge from the studies included. Primarily, there is an observed variation in the provision of a number of services in Wales. Variations appear in the provision of health services to older people in Wales. Establishing a research, policy and practice interface arrangement which includes researchers, providers and policy makers may be helpful.

Use of the internet in assessing service provision for older people

Purpose – The evaluation of primary and other care services for older people remains difficult due to the challenges of cost‐effective sampling and assessment of older people's views. The internet is an increasingly attractive option for evaluation due to its low cost and flexibility of use. The purpose of this paper is to report on a pilot study into the use of a web‐platform with older people.Design/methodology/approach – A sample of 552 community dwelling men and women, aged at least 50 years, participated in an epidemiologic study conducted entirely remotely which included questions on the provision of services for older people.Findings – The sample was heterogeneous being 52 per cent male, an age range of 50‐95 years (x¯=64 years) and with 13 per cent being in the two most deprived categories of social deprivation. Awareness of the National Service Framework for older people was low (14 per cent). For areas covered by the policy satisfaction with the availability of services was generally high (>70 p...

Nurse champions of older people: a national audit and critical review

This paper aims to equip nurses working with older people with an understanding of the roles and activities of Champions for Older People. The position of Older People's Champion was established in England to help implement the National Service Framework for Older People at local level. This paper reports on the findings of a national survey of older people's Champions. It sets this in the context of developments around health polices for older people. Forty-three of the 209 Champions who participated in this study were nurses. Nurses were the most commonly appointed clinical Champions in National Health Service Trusts responding to the survey; they used this position to promote changes within their organisation and locality. While focusing on the implementation of National Service Framework for Older People targets and requirements, some used their position to work with organisations of local older people and advocated for older patients' interests. Nurses conceived their position as clinical Champions broadly and reported that they used this role to promote service improvements for older people. Those who established networks with other Champions and older people's groups found this useful. Their role as Champions appeared to encourage a proactive and outward-looking perspective and provides evidence of the workings of one model of Championship. Embedding championing roles within organisations may be one way of bringing about change in the way that services to older people are developed.

National pilot audit of intermediate care

The National Service Framework for Older People resulted in the widespread introduction of intermediate care (IC) services. However, although these services have shared common aims, there has been considerable diversity in their staffing, organisation and delivery. Concerns have been raised regarding the clinical governance of IC with a paucity of data to evaluate the effectiveness, quality and safety of these services. This paper presents the results of a national pilot audit of IC services focusing particularly on clinical governance issues. The results confirm these concerns and provide support for a larger scale national audit of IC services to monitor and improve care quality.

An age-old problem: care of older people undergoing surgery

The National Confidential Enquiry into Patient Outcome and Death last specifically reported on the provision of care for older patients having surgery 11 years ago (National Confidential Enquiry into Patient Outcome and Death, 1999). This was followed by the first National Service Framework for Older People (Department of Health, 2001).

A critical analysis of the NSF for Older People standard 6: falls

As practitioners, we need to have an awareness and recognition of how policy affects our professional practice. The NHS has undergone major policy changes in recent years, many of them affecting older people. These include national policies and guidance intended to prevent and reduce falls in the older adult. The prevention and management of falls among older people is a priority in the Government's public health strategy, which aims to reduce falls by at least one fifth by the year 2010. Standard 6 of the National Service Framework for Older People was developed to reduce the number of falls in older adults and to ensure effective treatment and rehabilitation of those who have fallen. However, a recent national audit has highlighted inadequacies and deficiencies in fall prevention services. Falls in older adults have a significant impact not only on the individual but also on the NHS. Nurses have an active role to play in assessing older people who have fallen. They are also pivotal in implementing falls-prevention programmes and in influencing policy that will change practice. If falls prevention policies are to be effective, it is imperative that effective training systems are in place and healthcare professionals are trained and equipped to deliver the quality of care needed to help reduce falls in the older adult.

Reflective practice and self-awareness

Gareth Morgan, Project Manager of the National Service Framework for Older People for the Welsh Assembly, suggests that self-reflection may be key to developing the public health workforce Workforce development is matter of considerable importance to ensure the effective and sustainable delivery of local and national public health policy. Given the diversity and challenges of public health roles, workforce development requires multiplicity of approaches, and reflective practice could be considered, perhaps with increasing prominence, as part of this. It has been suggested that the benefits of reflective practice are threefold.1 The first is to re-define the understanding of professional knowledge; the second to develop personal knowledge or self-awareness: and the third is to evaluate the appropriateness of actions. This piece presents summary of some of the underpinning theories of reflective practice along with examples of how these may be applied. The literature on reflective practice is extensive and includes contributions from Boud, Schon and others. A critical review of this literature has identified three key stages that appear to underpin the process of reflective practice.2 Stage 1 is triggered by an awareness of uncomfortable feelings or thoughts; stage 2 involves constructive analysis of the situation, examining feelings and knowledge; while stage 3 involves the development of new perspective on the situation. Prerequisites to reflection appear to include having an open mind and being self-aware.2 One limitation to this three-stage model might be that it does not recognize the potential for positive feelings or thoughts to be trigger for reflection. Despite this limitation, the suggested prerequisites to reflection are interesting and have been explored in other contexts. For example, in clinical medicine, lifelong learning and improving performance may not occur if mistakes are reviewed alone.3 Furthermore, it has been suggested that the achievement of expert levels of practice requires guided feedback.3 Perhaps the journey towards expert practice therefore requires an open-minded approach to learning from experience supported by guided feedback from professional mentor. Meditation can be helpful in developing self -awareness, and theoretical models may also provide useful frameworks with practical application. The Johari Window model, for example, presents domains that relate to the level of self-awareness; this includes reference to a spot.5 In nursing practice, it has been suggested that portfolios provide the opportunity to document personal and professional growth, which in turn may help to minimize the blind spots that compromise self-awareness. The Hawthorne effect is management principle that suggests that individuals tend to improve their performance when they are under observation. So perhaps another potential route to reflection is to ask colleagues to observe and provide feedback on performance. Some have questioned the Hawthorne effect,6 yet being under observation from colleagues could trigger reflection and iead to some of the benefits described previously. The potential exploitation of the Hawthorne effect might be best undertaken as complement to line manager feedback and continuing professional development opportunities. Another approach to reflection might be through the keeping of personal journal. Moon has suggested number of possible questions for prompting reflective writing and critical thinking/ Starting with pure description of an event that sets the scene, questions to facilitate reflection might include: How do you feel about the situation? How do your feelings relate to any action? If you step back from this, does it look different? Are there ethical, moral or social issues that might be explored? The 360-degree feedback of professional skills offers structured method to facilitate reflection and selfawareness, and can provide valuable information to promote reflection on range of matters including interpersonal skills and thinking styles. …

Older people’s views of dignity and how it can be promoted in a hospital environment

The study investigated the lived experiences of older patients who had been in hospital, to explore their views on dignity and the factors which promote dignity. The UK government's new ambition for old age (New Ambition for Old Age: Next Steps in implementing the National Service Framework for Older People: A Report from Professor Ian Philip, DH) states that older people should be treated with dignity. The dignity in Care Campaign ('Dignity in Care'Public Survey, October 2006: Report of the Survey, DH) highlighted the need to raise staff's awareness and understanding of dignity. A purposive sample of older people took part in semi- structured interviews which focussed on their recent experiences of hospital admission. Qualitative data analysis was used. Ten participants aged 73-83 were interviewed by a nurse researcher at home. All of the participants had an unplanned admission and were discharged home. The participants although generally satisfied with their care had strong views on dignity. The following factors had the potential to promote dignity; privacy for the body, cleanliness, independence and being able to exert control, sufficient time from staff, attitudes to older people and communication. This study suggests that independence and effective communication are of central importance in maintaining dignity through achieving control of their situation. The participants observed that factors such as speaking inappropriately and waiting for personal care undermined older people's perceptions of dignity. Several participants feared for their own dignity should they have cognitive problems later in their lives. Staff need to be aware that communicating in a way that conveys empathy and responds to the individual as a valued person is an important factor in maintaining dignity. Nurses on hospital wards particularly need to take measures to safeguard the dignity of older people with cognitive problems who have difficulty in making their needs known.

The availability and use of allied health care in care homes in the Midlands, UK

Aims A review by an international charity for older people, Help the Aged, suggested that older people living in care homes in the UK do not receive the appropriate levels of access to health professionals. The authors aimed to establish the access to and use of services provided by allied health professions to care homes in Oxfordshire and Warwickshire. Methods A postal survey with telephone follow up of the use of and access to allied health-care services in 121 Oxfordshire and Warwickshire care homes was conducted using an established questionnaire. Findings The majority of homes reported using a chiropodist (91%), an optician (86%), hearing services (63%) and a physiotherapist (65%). Less than half of the homes reported using an occupational therapist (41%), a dietician (44%) or a speech and language therapist (39%). A third used an alternative therapist (35%) and a similar number (35%) a social activities organizer. There was inconsistency in the sources of funding and the reasons for referral, particularly regarding occupational therapy and the provision of aids and adaptations. Conclusions The expertise of allied health-care professions available in UK hospital and domiciliary National Health Service (NHS) settings is not evident or accessible in the care home setting unless funded privately. When taking into account the high levels of impairments in these settings, access would appear to be contrary to the UK National Service Framework for Older People, which suggests that the NHS will provide a universal service for all based on clinical need, not ability to pay.

‘We are not blaming anyone, but if we don't know about amenities, we cannot seek them out’: black and minority older people's views on the quality of local health and personal social services in England

ABSTRACTImproving access to culturally-appropriate services and enhancing responses to the needs of older people from black and minority ethnic backgrounds were among the aims of theNational Service Framework for Older People(NSFOP) that was introduced in England in 2001. Progress in meeting the aims of the NSFOP was evaluated by a mid-term independent review led by the Healthcare Commission, the body responsible for regulating health-care services in England. This paper reports the consultation with older people that underpinned the evaluation. It focuses on the views and experiences of older people from black and minority ethnic (BME) groups and of the staff that work in BME voluntary organisations. A rapid appraisal approach was used in 10 purposively selected local councils, and plural methods were used, including public listening events, nominal groups and individual interviews. In total 1,839 older people participated in the consultations and 1,280 (70%) completed a monitoring form. Some 30 per cent defined themselves as of a minority ethnic background. The concerns were more about the low recognition of culturally-specific and language needs than for the development of services exclusively for BME older people.

Can clinicians benefit from patient satisfaction surveys? Evaluating the NSF for Older People, 2005–2006

A transformation of healthcare is underway, from a sellers' market to a consumers' market, where the satisfaction of the patient's needs is part of the definition of quality. Patient satisfaction surveys are widely used to judge service quality, but clinicians are sceptical about them because they are too often poorly designed measures that do not lead to improvements in the quality of care. To explore the use of patient satisfaction survey data in identifying problems with the provision of inpatient care for older people. A case study using secondary analysis of postal survey data about older people's experiences of health and social care services, obtained during the evaluation of the National Service Framework for Older People in 2005-2006. The survey asked about experiences of inpatient care and of discharge from hospital, and sought perceptions of the avoidability of the admission. A total of 4170 people aged 50 years and over returned a postal questionnaire in six local authority areas of England. Responses from 584 who had experienced a recent overnight stay in hospital are reported and discussed. The response rate was 35%, ranging from 26% to 44% in the six areas surveyed. The great majority of those who had recent direct experience of inpatient care reported that they had been engaged in decision-making, that staff promoted their independence and maintained their dignity. There were widespread examples, however, of the opposite experiences. Discharge from hospital was problematic for about one-third of survey respondents with this experience, and there were different accounts of poorly managed discharges from all areas. Case studies using local survey data can be used as formative assessments of services. The response rate to the survey and the likelihood of responder bias mean that patient satisfaction survey data of this sort cannot be used to judge or compare services in a summative way, but can highlight areas where remedial action is needed. Small-scale local surveys may seem to lack the robustness of larger studies, but do identify similar areas of concern. Commissioners and clinicians could use the findings of such surveys to inform dialogues about the quality of hospital care for older people.

Wise owls and professors: the role of older researchers in the review of the National Service Framework for Older People

This article explores the involvement of older people in research and inspection, reflecting on the learning from the recent 'joint review' of the National Service Framework for Older People in England. Working in 10 different localities, the 'joint review' comprised a formal inspection of health and local council services (carried out by the Healthcare Commission, Commission for Social Care Inspection and the Audit Commission) and an externally commissioned university-led research project designed to ascertain the views and experiences of older people living in the 10 inspection sites. In total, 1839 older people were interviewed individually and through focus groups and an additional 4200 older people completed questionnaires. A distinctive feature of the research was the inclusion of a team of older researchers who had undertaken training in research methods in later life. Reflections of the older researchers and other members of the research team on undertaking this large-scale user involvement project were ascertained via a day-long seminar which was tape recorded and transcribed. While many espouse the principle of 'service user involvement' in research, there is a need to move beyond the rhetoric of participation and any blanket assumptions about what it means to be an 'older researcher', a 'service user researcher' or indeed, a 'professional researcher'. This means ensuring that within any given team (user-controlled or collaborative) there are clear lines of accountability and equal opportunities for individual appraisal, support, and personal or professional development. Such considerations are key to working with 'older researchers' and encouraging diversity in the research workforce more generally.

Beyond the NSF: Continuing Older People's Involvement and Engagement

In this article we report findings from a small scale user‐controlled study which explores involvement and engagement in terms of the legacy of the National Service Framework for Older People (NSFOP) and the new opportunities that are opening up around community well‐being and active citizenship. A key finding of the study is that, when participating in implementation of a major policy initiative, older people's reference groups and forums require good support: practical help with administrative tasks and more professionalised support to help develop members' skills as activists and campaigners. We distill what this means for practice in a commissioning framework which can be used to specify support services that may be provided to older people's groups by external organisations such as the voluntary and community sector. Here, involvement and engagement are understood as a dynamic relationship between three stakeholder groups (older people, the statutory sector, and the voluntary and community sector). We pinpoint likely tensions in these relationships and how they might be addressed.