Data and methodology

This analysis uses data from the 2023-24 Health and Care Experience survey. We selected all respondents aged 65 or older.

In 2023-24, HACE received 107,538 total responses - a 20% response rate. 48,876 responses were from people aged 65+ - a 42% response rate. Of these, 10,385 reported some kind of need for care, support and help with everyday living. Response rates to individual questions in the survey varied, as did response rates between different groups of respondents, as detailed in the HACE 2023-24 Technical Report. The total number of responses included at each stage of the analysis is included in the supplementary tables.

HACE was designed to measure patient and client experiences of a range of health and care services. Originally, the survey only measured experience of GP services. However beginning in 2013 a range of other services were added to the survey. This analysis substantially expands on the initial purpose of the survey, but can still provide some meaningful insights on reported need and unmet need for care, help and support with everyday living. We have outlined both the strengths and the limitations of this analysis below.

Definitions of need and unmet need

This report identifies four groups of adults aged 65+ living in Scotland:

1. No need for care, support and help with everyday living. The first group are those who selected  “No, I didn’t need any help” when asked whether they had had any care, help or support  with everyday living over the past 12 months.
2. Did not receive any help despite needing it. This is made up of those older adults who said “no, not had any help but I feel that I needed it” when asked about any care, support and help with everyday living that they had received in the past 12 months.
3. Received support, unmet need reported. The third group is made up of those who told us that they did receive some care, support and help with everyday living in the past twelve months, but went on to indicate an unmet need when asked to select all options that applied to them if they were “not receiving all the help and care services” they felt they needed. For example, somebody told us that they had received help with personal tasks in the past 12 months , and then went on to select the option “my current care service is not enough” in a following question, would be classed as receiving support but reporting an unmet need.
4. Received support, no unmet need reported. The fourth group is made up of those who told us that they did receive some care, support and help with everyday living in the past 12 months, but did not go on to indicate an unmet need. We consider people who selected “not applicable” or didn’t select any options at question 32 (“If you are not receiving all the care, support and help with everyday living that you feel you need, which options describe your situation?”) as not having indicated an unmet need.  

We identified the groups using their answers to the survey questions:

• 27 (“In the last 12 months, have you had any help or support with everyday living?”)
• and 32 (“If you are not receiving all the care, support and help with everyday living that you feel you need, which options describe your situation?”)

Question 32 also gave the option for respondents to leave a comment if they selected the response option “Other” to the latter question We analysed the comments to identify those which referred to an unmet need. People whose comments indicated they had an unmet need were counted as having an unmet need. This approach is consistent with our previous publication on further analysis of care experience.

The survey questionnaire is available online.

Strengths

1. This analysis of HACE data is the first of its kind, and provides our best estimate of the current rate of reported unmet need for care, support and help with everyday living, amongst the older adult population, at a national level.

There are limited data available to understand reported unmet need for care in Scotland. There are some datasets that provide additional evidence on this area (outlined in Annex B). This analysis of a recent, large sample survey is the best available assessment of older adults’ current self-reported care needs and unmet needs, and adds significantly to the evidence base.

2. This analysis takes a holistic approach to defining care, help and support with everyday living.

The HACE 2023-24 survey does not take a prescriptive approach to defining  what “care, help and support with everyday living” is, and it encourages respondents to include help that they get from “organisations, friends or family”. This is a very holistic approach to defining need. The benefit of this approach is that we are not asking respondents to interpret their own need through predefined service categories – categories which may not be suitable for them or they may not be familiar with. The downside is that this leaves some uncertainty around what kind of service provision is needed to address self-reported unmet need.

3. This analysis recognises that unmet need can still occur even where some support has been provided. 

Existing literature (as summarised by this literature review from Glasgow University) has highlighted that unmet need can still occur even where some support has been provided, and that, especially where this support is not of the right kind, frequency or duration, its presence may not meaningfully improve outcomes for the supported person. This analysis recognises this possibility by including two unmet need groups: those who receive no support and those who do receive some support but still reported an unmet need.

Limitations

1. This analysis does not provide insights on the needs or unmet needs of people aged under 65.

Adults under 65 have been excluded from this analysis because response rates among younger adults were lower, and there were higher than average reports of limiting long term conditions amongst those that did respond when we compared these estimates with other national datasets. As such, estimates for those under 65 may misrepresent the level of self-reported need and unmet need in the wider population.

Younger adults made up a minority of HACE respondents. Around 18% of total HACE respondents were aged between 17-44 whereas 36% of the Scottish population were aged 17-44 at mid-year 2022, as estimated by the National Records of Scotland. In contrast, adults aged 65+ made up more than 40% of HACE respondents.

As we well as having a high response rate, the 65+ age group showed prevalence and severity of limiting long term conditions, including those limited to old age, that were very similar to population figures from Scotland's Census, and the Scottish Health Survey, whereas they were not similar for adults aged 17-64 responding to HACE. We have assed that this gives a good level of confidence that information from the HACE survey provides reasonable estimates of self-reported need and unmet need for the wider population aged 65+.

2. This analysis uses the existing survey weights for HACE which may not be optimally designed for measuring need and unmet need.

Since the survey’s intended purpose is to measure care experience amongst service users, the survey weights may not be optimally designed to estimate the level of need in the Scottish population. The presence and severity of limiting longterm conditions is strongly linked to the need for care, support and help with everyday living.

As mentioned above, we believe that the 65+ age group were sufficiently representative to be satisfied that meaningful insights can be drawn for this group.

3. There is a risk that non-response to the survey is affecting our understanding of need and unmet need.

Not everyone who was sent the HACE survey responded to it. When the people that do not respond to the survey all share a characteristic that relates to the subject of the survey – for example, if they all had a very high need for support - this can bias the results. This is known as “non-response bias”. As far as possible, the survey weights seek to adjust for these general risks, but we have noted that we did not use custom weights for this analysis. (Please see the part on Survey Weights in this section, for more information on survey weighting).

4. We cannot tell from HACE what kind of care, support and help with everyday living people with unmet need require.

The HACE survey asks people to select from a list of reasons why they feel they haven’t received all the help and care services that they feel they need. However, it does not ask them what kind of help and care services they need. For example, it does not ask them if they need personal care.

We cannot meaningfully estimate what kind of care, support and help with everyday living people need from the data available in HACE. We can produce an estimate of how many people who received help with personal tasks in the past 12 months reported an unmet need. However, we can not tell if the unmet need they reported was for more help with personal tasks, or for another kind of help and support.

5. Our estimate of unmet need does not include all of those who had received help or support services, but expressed dissatisfaction with what they received.

Our measures of unmet need are those in which respondents directly indicated that they had no help but needed it or were not receiving all the help and care services they felt they needed.

This does not include others who may have indicated they had the care they needed, but answered in Q30 that they were dissatisfied with services (e.g., they disagreed with the statements “people took account of the things that mattered to me”, or “my health, support and care services seemed to be well coordinated”).

This analysis then potentially under-represents some aspects of the broader experience of help or support services that could be classified as unmet care needs. Dissatisfaction with care services amongst HACE respondents has been reported on in the HACE national report and also in the further analysis of care experience.

6. Certain groups of people are likely to be missing from the HACE sample, or under-represented.

We know that some groups of people who live in Scotland are less likely to receive the HACE survey questionnaire than others. The HACE survey is sent to a sample of people aged 17 and over who are registered with a GP practice in Scotland. You can read more about how the sample for the 2023-24 survey was selected in the sample design chapter of the HACE 2023-24 technical report. If a person’s address with their GP practice is out of date, or they are not registered with a GP, they will not have received the survey.

Most importantly for this analysis, which looks specifically at people aged 65+, this could mean that some individuals who have recently moved into care homes may be missing from the survey. It is also possible that individuals who live in care homes may require more support to complete a survey, and so may be less likely to respond. It is therefore possible that individuals aged 65+ who are living in care homes may be under-represented in this analysis.

Several other groups are also likely to be missing from the HACE survey and therefore also missing from this analysis of unmet need. This includes undocumented migrants and incarcerated people. We know that undocumented migrants are more likely to be under 65+ and so would have been excluded from this analysis. In the case of incarcerated people, the Scottish Government conducted an analysis of the need for social care in prisons in 2021. That study suggests that the support needs of incarcerated people are substantively different from the general population, and that the mechanisms through which they receive support are also different. As such, a study of their needs and unmet need would be best understood by a dedicated analysis, and would not be appropriate for inclusion in this general population study.

Weightings

As with the main HACE 2023-24 publication, throughout this report the survey results are presented as weighted percentages. Different proportions of people were selected from each General Practice in Scotland to receive the survey, and the response rate varied by age and sex. Weighting is used to produce results which are more representative of the population eligible to complete the survey.

The details of how the weights for the main HACE 2023-24 analysis were calculated can be found in the technical report of the 2023-24 survey.

Confidence intervals

Confidence intervals provide a way of quantifying uncertainty in the survey results. A 95% confidence interval means that, over many repeats of a survey under the same conditions, one would expect that the confidence interval would contain the true population value 95 times out of 100.

For example, given a result of 80% and a confidence interval of +/-3%, there is 95% confidence that the true result is between 77% and 83%.

There is more information on confidence intervals (including how they are calculated) in the HACE 2023-24 technical report.

The confidence intervals associated with the results presented for this analysis are available in the supplementary tables.

Where confidence intervals overlap differences observed between point estimates may not be statistically significant.

Rounding

The estimates we have presented in this report are rounded to the nearest whole number. The results to two decimal places are available in the supplementary tables, along with the 95% confidence intervals for each percentage estimate.

We have calculated percentages that describe the sum of two or more categories from the original (unrounded) estimates and then rounded them to the nearest whole number for this text. This means that percentages in this text that refer to a total across two or more categories may differ from what you would calculate by adding together the individual rounded estimates from each category.

For example, we would present a result of 2.80% as 3% (rounded), and a result of 5.60% as 6% (rounded). However, we would calculate the total (sum) of the two numbers as 8.40%, which we would present as 8% when rounded to the nearest whole number.

Significance testing

All comparisons which are reported as “higher” or “lower” that are discussed in the report are statistically significant at the 95% level.

Where results for different groups are described as “similar”, differences are not statistically significant at the 95% level.

The approach to significance testing in this report remains consistent with the main HACE publication. Details of this can be found in the HACE 2023-24 technical report.