An exploratory study of creating dementia-friendly businesses in the visitor economy: evidence from the UK.

Many governments have promoted the development of a civil society to encourage citizen involvement in addressing many of the grand social challenges such as the growing prevalence of dementia, as ageing becomes a major trend in developed societies. One outcome has been the development of Dementia Friendly Communities, created via Dementia Action Alliances (DAAs) in England, to enhance awareness, care and the experience of people with dementia in accessing services and facilities. These initiatives are based on engaging the business community and yet no research studies have examined this theme to date. Given the growing significance of leisure and tourism activities that people with dementia and family members engage in, this study examines the experience of business engagement with DAAs in the visitor economy in England. The notion of shared value articulated by Porter and Kramer (2011) is used as a basis for understanding the type of business engagement.

Introduction

Dementia as a societal problem – a role for business?

Ageing and the growing prevalence of dementia in modern society presents a grand societal challenge, not least as dementia creates difficulties for people to participate in a civil society (Birks, 2016) due to the barriers associated with everyday activities, in accessing services provided by businesses. Some 46.8 million people are affected by dementia worldwide, a figure expected to double every 20 years reaching around 131.5 million by 2050 (World Health Organization, 2017). A wide-ranging political discourse exists on how to help people with dementia ‘live well’, premised on the principle of a participatory public able to engage in society (Coffe et al., 2013). Yet to date the contribution of businesses to living well with dementia remains largely neglected in the business and management literature, particularly in relation to consumer sectors associated with the visitor economy. As a global issue, dementia has seen many countries develop social policies to enhance service provision and dementia diagnosis. There have also been shifts in political thinking that reflect new theoretical approaches to social policy in which businesses have a role to play. In the UK, the Prime Minister's Dementia Challenge aspires to all businesses becoming dementia-friendly (DF) by 2020 (Department of Health, 2015). Such a Challenge reflects a significant focus on the DF theme, reflected in an international study that ranked the UK as the most dementia-ready country in 2017, because it is seen as a leader in innovative practice (Alzheimer's Disease International/Global Coalition on Ageing, 2017). Yet this dementia-readiness is not uniform across all areas of society and no studies have sought to understand the transformational journey businesses have embarked upon to help address this major societal challenge as part of a civil society paradigm. The route which most businesses have taken to date is associated with engaging in the development of Dementia Friendly Communities (DFCs)1. However, research on the degree of business engagement with this issue is largely located in grey literature and has been slow to evolve in the mainstream business literature.

Previous research on the business-society nexus has examined the values of businesses that affect the level of engagement with wider societal challenges (e.g. Weisskopf and Thain, 1960; Agle and Caldwell, 1999). The engagement has been framed through the development of studies that are informed by concepts such as corporate social responsibility, business ethics, philanthropy and community engagement as a number of notable examples (see Porter and Kramer, 2006 for a review of these concepts). One additional area of thought that has challenged our thinking around business and society is Porter and Kramer's (2011) notion of creating shared value. The shared value notion has particular salience for this study as a concept to illustrate some of the potential motives for business engagement with DF initiatives and the DFC values as set out by the Alzheimer's Society. This paper adds to existing knowledge moving the research agenda away from a focus on concepts and idealism, as highlighted by Dentchev (2009), to evidence and demonstrate the shift from theory to praxis in relation to business engagement with DF initiatives. To achieve this, the paper focuses on how businesses in the UK have engaged with DF initiatives within the context of DFCs.

This study examines one specific research question: How have local businesses in coastal environments engaged in their DAAs and what has been the contribution to the development of a dementia-friendly visitor economy? To address this question, the paper commences with a review of voluntarism and third sector grassroots associations to understand the theoretical basis to their development and rationale. It is followed by a discussion of DAAs as grassroots organisations and the significance of coastal environments and visitor economy for living well with dementia, with the diverse range of visitor economy business types. The methodology that was used to develop the study and the results are then examined. The paper concludes with an evaluation of the implications for business development.

Theory

Theoretical and conceptual issues in business engagement and Dementia Friendly Communities

DFCs seek to empower and enable people with dementia, and other citizens, to use knowledge and know how to overcome inherent barriers to participation. While the term civil society is a highly contested one, where the political and academic discourse is often tautological, one unifying feature exists - the desire to understand how individuals (often labelled citizens) seek to help others to achieve a better life or society which in this context is individual businesses. This has great salience for the analysis of dementia as part of social realities, particularly in how new actors adopt a strong advocacy role through grassroots level organisations to leverage the support from business and the community to improve people's lives (Popple and Redmond, 2000; Beito et al., 2002). Much of the recent development of grassroots organisations and the role of a civil society to lead a change agenda on dementia is rooted in an emergent academic discourse on social innovation with its focus on addressing social challenges such as dementia. A rich literature has emerged on social innovation alongside grassroots action at a community level (e.g. see Have and Rubalcaba, 2016; Pol and Ville, 2009; Geronmetta et al., 2005; Cajaiba-Santana, 2014) and this has a major bearing on how a civil society has been harnessed to address societal issues. Even so, the concept of social innovation is not new. As Schumpeter (1909) demonstrated, social value is created through altruistic means by groups and individuals in a capitalist society where a specific cause is championed (also see Moulaert et al, 2013). Thus, social value is based on 'mutual interaction and interdependence between individuals' (Schumpeter 1909: 214) where new social practices can meet social needs to further develop a civil society. Moving beyond this literature to understand how this can occur in practice requires additional building blocks and Porter and Kramer's (2011) notion of creating shared value helps to explain the theory to praxis nexus. Porter and Kramer argue that by bringing business and society together to create economic value can also create value for society. Porter and Kramer (2011: 4) argue that ‘businesses acting as businesses, not as charitable donors, are powerful for addressing pressing issues we face’ as part of advancing the vision of a civil society. The practical application of shared value as Porter and Kramer (2011: 5) argue can be achieved in three areas of business activity ‘by reconceiving products and markets; by redefining productivity in the value chain; by enabling local cluster developments’. Yet to do this, businesses would need to collaborate with DFCs and to share the values of DFCs, in part or fully which is embedded in the notion of a civil society.

Edwards (2013) traces the evolution of the term ‘civil society’ and the challenge of theorisation given the prevailing reductionist approaches and application by policy-makers to denote its value as a ‘big idea’ for the twenty-first century. Ehrenberg (2013) indicates that this is far from a new concept with roots in classical civilisation focusing on civility and the common good. Yet there has been little debate about how this ‘big idea’ has led to the creation of grassroots organisations that engage businesses to help people live well with dementia through the provision of DF infrastructure and services as a form of social innovation.

The research problem: business provision of DF infrastructure in the visitor economy

This paper addresses this lacuna in academic investigation through the analysis of one innovative grassroots organisational form – the Dementia Action Alliance (DAA) and business engagement with them. DAAs comprise an organisational vehicle for transforming local communities into places where the awareness, understanding and provision of services enable people to live well with dementia. In their most highly developed stage, DFC status is conferred.

The paper examines the experience of DAA development in coastal communities of England during the period 2012–2017, informed through an analysis of the business membership of DAAs. The Prime Ministers Challenge (Department of Health, 2015) ambition, as originally conceived in 2012, was for all businesses to become DF and to have 20 DFCs operational by 2015. By 2015, some 152 DFCs had been formed. Such a rapid growth in voluntary organisation development may not necessarily lead to all business sectors engaging with this innovation. We focus on the extent to which businesses in the visitor economy have engaged with DF initiatives as a basis to welcome both residents and visitors within their DFCs and local communities. This builds on the most recent study of dementia and the visitor economy (Connell et al., 2017)2, where the focus was on the concept of a visitor destination that comprises visitor attractions, accommodation, accessibility (i.e. transport) and ancillary infrastructure (i.e. visitor services), a widely used concept in tourism research. From a dementia perspective, the key challenge in the visitor experience at the destination is the large number of touchpoints a visitor may have with services and infrastructure in the locality. To help people with dementia overcome the social isolation associated with exclusion from daily activities (Genoe and Dupuis, 2014; Lokon et al., 2019; Eades et al., 2018), the destination must provide an accessible DF visitor experience. Fig. 1 illustrates the typical problems that people with dementia and their carers face in accessing businesses in the visitor economy.

Fig. 1

Problems facing visitors with dementia and their carers in accessing the visitor economy in destinations (Developed from Historic Royal Palaces 2017).

An important premise to this study, as Crampton et al. (2012) argue, is individuals are consumers prior to the onset of dementia and remain as consumers and users of businesses and services after diagnosis, particularly so in the early stages of the disease. Some of the typical symptoms reported include: memory loss; difficulty concentrating; finding it hard to carry out familiar daily tasks, such as getting confused over the correct change when shopping; struggling to follow a conversation or find the right word; being confused about time and place; mood changes (National Health Service, 2018).

In fact research by the Centre for Business and Economics Research (2014) identified the economic imperative of addressing dementia in a business setting was that dementia-related consumer spending was worth £11 billion in 2014 and is forecast to rise to £27.2 billion by 2030 (Centre for Economics and Business Research, 2014). This is particularly significant for the UK visitor economy because a significant proportion of visitor activity has a consumer spending element to it. In other words, the existing and future potential of dementia-related spending in the visitor economy is significant and set to grow through time.

Understanding voluntarism, grassroot associations and business engagement: theoretical constructs

There is a growing recognition that the massive growth in voluntarism that many industrial nations experienced can be traced to the nineteenth and early twentieth century, and this contributed to social policy development (Edwards, 2013). A key contribution of voluntarism was to the development of a civil society, where altruistic motives (among other motives) by businesses and individuals, were used to develop a wide range of grassroots organisations to address social challenges of the day. The history of community and grassroots organisations in bringing about social change is a well-established narrative in North America and Europe, but the wider engagement of businesses in these associations is less clear, beyond large business donations and financial support.

Kunreuther (2013, p. 55–56) defines the broad form of grassroots associations as a ‘subset of the associations universe and in many ways they capture the ideal of civil society. These are groups where people come together voluntarily to advance a concern or interest, solve a problem, take an action or connect with each other based on something they share in common …characterised by democratic and less hierarchical forms of governance’.

These associations have a specific purpose – to mobilise citizens within a community. Whilst there are power relationships within all organisations, one specific category of grassroots association that characterises the DAA is the social change organisation. A social change organisation seeks to increase the power and visibility of marginalised groups such as people with dementia and may include paid staff (e.g. DAA coordinators) and the primary goal is to address the root cause of a problem (Kunreuther, 2013). Such a route to voluntary citizen action reflects the response to the state pulling back from centralised management of social care issues and seeking partners and supporting third sector organisations to fill the void.

Theorising this transition has seen many analyses of the changing political ideologies that characterise the role of the state in individual's lives and interconnections with political support for the notion of the civil society to fill the space between the state and societal obligations towards the care of others. Influential studies such as Giddens (1998) The Third Way and other ideologies around compassionate conservatism and new public sector management (Lane, 2000; McLaughlin et al., 2002), have shifted the focus to local level accountability and citizen involvement. Giddens argued that the notion of citizenship was central to the development of a more active civil society to help with developing new local social policy responses. At the start of the new millennium, greater state resource was directed towards the third sector in the UK (Popple and Redmond, 2000; Carmel and Harlock, 2008) prior to the period of austerity, in pursuit of social policy objectives in poverty and social care. Critics have argued this represents a shift towards entrepreneurial solutions to harness the latent potential of business interests and skills in the third sector to address grand social challenges such as dementia. This is in juxtaposition to other sociological debates associated with the decline in social capital and voluntary associations in modern society (Putnam, 2000) that posit a decline in voluntarism and community orientation, albeit from a US perspective.

Etzioni (2000) used the concept of mutuality as an explanation for how people (and business leaders) develop an open ended moral commitment within their local community, expressed through a social obligation to the community. This, in part, explains why businesses engage with these grand societal issues, while Tonkiss et al. (2000) extend this explanation by pointing to some of the prerequisites for engagement such as creating a culture of trust, framed around shared values (also see Birchall, 2002; 2008 on trust). In more self-interested settings, businesses engage to gain local acceptance and to fulfil broader corporate social responsibility objectives. Austin's (2000) seminal study of non-profit-business collaboration endorsed the underpinning concept of mutuality of interests whilst other key explanations highlight building a common ground between business and the local community and recognising synergies, where collaboration can accomplish more together, embedded in the concept of interdependence (also see Austin and Seitanidi, 2012). Bowen, Newenham-Kahindi & Herreman's (2010) meta-analysis of the literature on business community engagement identified three distinctive strategies that businesses may pursue as part of a socially-responsible path (i.e. transactional, transitional and transformational). However, in the context of this study many of the businesses in the visitor economy are small to medium sized enterprises (SMEs) (see Thomas et al., 2011 for a review), not necessarily possessing the resources to make major donations that characterise charitable giving and corporate social responsibility. Instead, visitor economy SMEs report low profit margins so their approach to engagement is likely to be more transactional and focused on the customer experience (i.e. which is related to their day to day business). In the social innovation literature, explanations of such transactional engagement have been attributed to a bifocal approach (see Borzaga and Bodini, 2014). The bifocal approach relates to the precondition of fulfilling both a value creation role for the business in supporting the social innovation (i.e. becoming DF) so there is a payback.

Austin (2000) argued that developing a critical mass of businesses to engage with a grassroots non-profit organisation like a DAA will hinge upon the underlying principle of marketing - how value is created (see Anheier, 2000 for a discussion of how organisations are evolving systems in which they negotiate problems and opportunities). The bifocal approach recognises that business-grassroots association relationships will need to be based on a mutually shared objective that meets their business needs and only then will pro-community engagement occur. Consequently, before grassroots associations can align with national strategies, such as the National Dementia Declaration (NDD) (National Dementia Action Alliance, 2010), complex negotiations must occur with a diverse range of business and stakeholder interests.

The National Dementia Declaration

The NDD, launched in 2010 provided an important stimulus for social innovation which eventually resulted in the DFC concept embedded in the DAA model of delivery. However, explaining the complexities and power relationships among businesses that engage with grassroots organisations led Covey and Brown (2001) to develop theoretical explanations around how business engagement has reshaped mutual obligations in a civil society. This has been described as a more proactive citizenship ‘aligning business practices with societal expectations’ (Covey and Brown, 2001, p. 2) as new political ideologies foster the third sector as a way to embrace grand societal challenges. Covey and Brown (2001) proposed a useful theoretical construct – critical cooperation where the conflicting and converging interests of businesses operate. As Covey and Brown (2011) highlighted, four patterns of interaction may occur (Fig. 2). Covey and Brown (2001) indicate most cooperation occurs on the right of the diagram, but a growing interest is in the critical cooperation cell to expand the scope of business engagement, where differences, conflict and competing objectives need to be managed to create engagement and innovation.

Fig. 2

Covey and Brown’s model of business engagement.

In the case of DAAs, it is the capacity of the leadership and steering groups in each locale to harness converging and conflicting interests, especially where business objectives may not neatly dovetail to the organisational objectives. The management of DAAs needs to harness a loose pattern of co-existence between the flexibility for businesses to set their own objectives as members, through to parameters that harness any conflict (for example, a lack of resource or time to implement major changes) to seek creative solutions. Within any DAA, business skills can be harnessed through critical cooperation that involves negotiation, networking and balancing power relationships to develop DF outcomes. Achieving this may be through interest-based negotiation that addresses the needs, desires and fears of the various parties to create win-win situations as opposed to adversity, so mutually beneficial relationships and agreements create durable membership. Clearly the power relationships within voluntary organisations will be complex and challenging to manage, but Covey and Brown (2001) point to four key principles in establishing critical cooperation: balancing power asymmetries so not every party has to be equal in power but that their cooperation can make major contributions to the organisational goals; recognising critical rights and accepting these rights can harness mutual benefits so boundaries are not crossed (e.g. not expecting businesses to make major investments in resource for no payback in business growth); negotiating converging and conflicting interests, to maximise mutual gains while reducing losses; and managing relationships with key stakeholders, where prior history of conflict should not prevent achieving future goals.

Study area

Third sector organisations and dementia: Dementia Action Alliances as grassroots organisations

After the launch of the NDD, lead third sector organisations such as the Alzheimer's Society (AS) and the signatories of the NDD laid the groundwork for a community-based response to embedding the 7 pillars of the declaration:

I have personal choice and control or influence over decisions about me

I know that services are designed around me and my needs

I have support that helps me live my life

I have the knowledge and know-how to get what I need

I live in an enabling and supportive environment where I feel valued and understood

I have a sense of belonging and of being a valued part of family, community and civic life

I know there is research going on which delivers a better life for me now and hope for the future

Source: Alzheimer's Society (no date) National Dementia Declaration: Desired outcomes for people with dementia and their carers.

The Declaration embodies many of the principles of empowerment as a process of change whereby advocacy of the principles was designed to give people with dementia a voice, to address the social and disparities inherent in existing service provision for people with dementia and their carers.

The Declaration informed the subsequent development of the AS framework to create DFCs (Alzheimer's Society, 2013, p. 2), which defined a DFC as a city, town or village where people with dementia are understood, respected and supported, and confident they can contribute to community life. In a dementia-friendly community will be aware of and understand dementia, and people with dementia will feel included and involved and, have choice and control over their daily lives.

The emphasis on the local scale and community is implicit in this definition, and policy initiatives by government (e.g. the Prime Minister's Dementia Challenge in 2012) acted as a further catalyst to developing DFCs, via grassroots associations to embrace the third sector, voluntarism, businesses and service providers and mutuality at a local level. To become a DFC, one would need a DAA as a vehicle to drive the change as the AS indicated, and it would need to focus on 10 areas that one would expect to see in a DFC. These ten areas on becoming dementia-friendly means:

Empowering people with dementia and recognising their contribution

Businesses and services that respond to customers with dementia

Shaping communities around the views of people with dementia and their carers

Ensuring early diagnosis, personalised and integrated care is the norm

Maintaining independence by delivering community-based solutions

Appropriate transport

Challenging stigma and building awareness

Befrienders helping people with dementia engage in community life

Easy to navigate physical environments

Ensuring that activities include people with dementia

Source: Alzheimer's Society (2013) Guidance for Communities Registering for the Recognition Process for Dementia-Friendly Communities.

The ultimate aim is to enable the creation of an inclusive locale where people with dementia feel empowered and safe, with access to services, social networks and meaningful activities that requires the involvement of the business community3. The development of a DAA was expected to embrace the seven Foundation Criteria. The seven Foundation Criteria for establishing a DFC are:

Criteria 1: Make sure you have the right local structure in place to maintain a sustainable dementia friendly community (including a DAA or equivalent structure that is ‘a collection of stakeholders brought together to improve the lives of people with dementia in their area. They will usually include police forces, fire and rescue services, retailers, local authorities, local transport providers, charities, community groups, businesses, care providers, health trusts, and people living with dementia and their carers’ (Alzheimer's Society, 2014: 3).

Criteria 2: Identify a person or people to take responsibility for driving forward the work to support your community to become dementia friendly and ensure that individuals, organisations and businesses are meeting their stated commitments (i.e. a Local Leader)

Criteria 3: Have a plan to raise awareness about dementia in key organisations and businesses within the community that support people with dementia (including a list of individuals in local businesses, and organisations that are a priority to engage with to establish the focus and direction of the DAA and shape of the future DFC)

Criteria 4: Develop a strong voice for people with dementia living in your communities. This will give your plan credibility and will make sure it focuses on areas people with dementia feel are most important

Criteria 5: Raise the profile of your work to increase reach and awareness to different groups in the community

Criteria 6: Focus your plans on a number of key areas that have been identified locally (i.e. transport, health care or local businesses)

Criteria 7: Have in place a plan or system to update the progress of your community after six months and one year

Source: Alzheimer's Society (2014) Foundation criteria for the dementia-friendly communities recognition process.

What the DAA exemplifies is the organisational focus for local level advocacy (see Lishman, 2007 for more detail) of the NDD principles and their implementation at a local level, to seek to empower people with dementia and their carers to become more autonomous, involved in the community as active citizens, and for a lead body to be their voice to ensure they were heard and treated in a respectful manner. As Lishman (2007) demonstrates, advocacy requires a great deal of persistence in achieving long-term goals such as becoming DF. Attention now turns to why it is pertinent to examine DAAs within the context of coastal environments. One of the most obvious contributions to living well with dementia is through coastal tourism and recreation activities that may provide opportunities for spiritual refreshment, engagement with outdoor spaces, and memories of past family holidays, all of which may act as important cognitive stimuli.

Living well with dementia, the visitor economy and the coastal environment

Much of the existing debate on creating more age-friendly environments and services (e.g. see Fitzgerald and Caro, 2014) has led to a proliferation of research around adapting and designing environments that are more accessible for people with dementia, often premised on the spatial notion of wayfinding (see, for example, Fleming et al., 2017). A great deal of research on dementia has reported findings of case studies and projects from grey literature but a major debate overlaying this is how to transition to a society where dementia is treated as a normalised experience (World Health Organisation, 2012) by sectors of the economy such as the visitor economy. The visitor economy has a number of key roles to play in developing more DF approaches to local communities for their own residents and visitors, not least in engaging businesses and the supporting infrastructure to ensure all visitor touchpoints are DF. This is a major task for many localities where a great deal of DF action has been focused on local resident service needs in accessing early diagnosis, service design and basic service provision for health needs.

A synthesis of the extant literature on leisure and tourism (see Genoe and Dupuis, 2014; Page et al., 2015; Innes et al., 2016) demonstrates the therapeutic value of daily outdoor activity for people with dementia and their carers through to holiday-taking. Despite this proposition, subsequent research on the visitor economy (Connell et al., 2017) illustrated that this remains a largely neglected area in dementia research. The obvious role of outdoor activities such as walking, the use of hospitality services (e.g. visiting cafes), visiting visitor attractions (e.g. museums), using local transport and accommodation and support services in the visitor economy (e.g. Visitor Information Centres) all comprise forms of dementia-related leisure consumption. The visitor economy around England's coastline is an important setting in which to examine such consumption and service provision for several reasons given its potential to offer ‘blue water exercise’ opportunities for well-being (Page et al., 2017). First, the visitor economy is a dominant element of the physical infrastructure of many coastal towns (House of Lords, 2019). In terms of the employment structure, coastal towns account for £4.8bn in visitor spending and the UK visitor economy is worth 8.2% of GDP. In resorts, this figure rises to 12.8% of GDP in destinations such as Bournemouth where a specialised visitor economy exists (House of Commons Communities and Local Government Select Committee, 2007). Second, these environments perform a dual role for residents and visitors in terms of the opportunity to visit a memorable location, often the site for previous family holidays or experiences and so has a strong cognitive stimuli and coastal environments are accessible to much of the UK population within one to two hours driving time. Third, outside of the peak holiday season, when many resorts and coastal areas become extremely busy with visitors, these environments can provide relaxing spaces, sites and resources (e.g. promenades, parks) in a non-crowded setting for people with dementia and their carers to enjoy daily leisure and holidays. This is in stark contrast to the highly crowded mass tourism experience that can occur during peak resort visitation and in other tourism environments such as cities where congestion, noise, crowding and dense development can be disorientating and unappealing. Therefore, attention now turns to the research methodology developed for the study.

Methodology

This study aimed to examine the activities of local businesses in the development of a DF visitor economy. Beatty et al. (2008) identified 37 seaside towns with a population of over 10,000 although this increased to over 100 locations in England if the population threshold of 10,000 was removed. Therefore, we adopted the broader criteria of over 100 coastal locations. In England, there were 324 DAAs with 5850 members listing 20,579 actions in mid-2017. This study identified 48 coastal locations with active DAAs comprising visitor destinations, ports and other coastal areas with visitor economies with a combined resident population of 5.9 million. Therefore, almost half of the coastal locations in England are currently covered by a DAA.

The study examined the research question using a pragmatic research paradigm. It was decided to focus on one research method – a quantitative analysis of business engagement derived from their application to be part of the DAA. The quantitative research approach was selected because the National Dementia Declaration specified the 7 categories which businesses might align with in becoming DF as part of a DFC and many of the responses were capable of being coded for quantitative analysis. Whilst this may not be seen as a conventional form of content analysis that utilises a qualitative methodology to analyse texts and codes elements of a narrative, this was deemed to be a valid method for converting qualitative data into quantitative data (Neuendorf, 2017) to interrogate the responses. This was selected as a means by which the complete population of businesses who had joined the DAAs in the visitor economy responses could be coded in a consistent manner to enable a quantitative analysis to explore the broad themes on becoming DF, established in other studies (Connell et al., 2017). This involved coding the business responses to each of the three elements of the NDD and the 7 pillars of the declaration (see above) in their application to become DF. The development of an initial framework for coding was arrived at following an initial analysis of a sample of 20 business applications in which a common set of issues arose that permitted various aspects of the responses to be allocated to specific codes. This research approach was supplemented by an in-depth interview with a DAA regional coordinator which yielded useful contextual information on the formation and development of DAAs and their management to understand the way the DAA operated. The research team also recognised that whilst a business survey would have added further data on the motivation for engagement in the DAA, it was unlikely to yield results via a questionnaire survey or an in-depth interview technique given the recognition of the difficulty of gaining business engagement with social survey techniques. This is often attributed to over-surveying that is now occurring in business research (see Mellahi and Harris, 2016). The coding was further informed by the results from a study by Connell et al. (2017) in which business responses to becoming DF from in-depth interviews highlighted many of the likely barriers and obstacles that may arise in becoming DF.

As the visitor economy is a relatively novel issue within the well-established domain of dementia research, this approach allows sufficient flexibility to identify and explore in more depth what is happening at the current time (see Creswell, 2009) and how best to understand the challenges of dementia for service businesses in accommodating a more DF approach. In this respect it is an exploratory study that seeks to navigate and map out the landscape around becoming DF because DAAs have attracted no academic research studies to date despite their key role in promoting DF activity in their localities.

Each DAA located in an English coastal area entry on the Alzheimer's Society website (http://www.dementiaaction.org.uk/local_alliances) was examined and each DAA's entry was coded, with reference to specific attributes. These attributes were extracted and analysed to construct a number of alphanumeric variables, comprising qualitative and quantitative information. The variables included the location of the DAA, its population catchment4, whether it had achieved DFC status, when it was established, the number of businesses engaged with the DAA and the proportion of these which operated in the visitor economy. Each business in the visitor economy was examined in relation to two key themes associated with joining the DAA: its action plan to become DF and actions it was taking to enable it to become DF including the status of these actions, and any challenges the business faced. Both the survey results and the DAA website data were analysed using SPSS v.23 to create descriptive statistics to understand some of the common themes arising.

Results

The analysis of the DAA website data resulted in 1508 businesses being identified in 135 DAAs that covered the coastal areas. Of that total population of businesses, 111 were located in the visitor economy, comprising 7.3% of the total membership.

DAAs and business engagement: methods of developing shared value

The principal motivation in establishing DAAs is to empower local people. As Have and Rubalcaba's (2016) review indicates, these organisational structures are designed to empower citizens to create change for local people, around shared values on becoming a DFC. In terms of creating shared value, the DAA approach in most cases was to adopt a local clustering approach by recruiting businesses so as to mobilise the local business community to develop specific DF initiatives which would engage more businesses to accelerate the process. DFCs were all promoting, Dementia Friends5 sponsored by the AS which provided support and capacity building resources as a first step in businesses becoming DF. This was an important first step for businesses in recognising the need to understand more fully the challenge of dementia amongst consumers. As a new organisational structure for many localities, developing the knowledge base and understanding of dementia is central to establishing a DAA and the frequency with which they undertook training often via a local Dementia Champion6 in two cases. When asking about the provider of the training, a variety of sources were cited, typically a local Dementia Champion and AS ‘Dementia Friends as a means of enhancing awareness and understanding of dementia and the principles set out above in pursuit of building DFCs. Lishman (2007) highlighted the challenge of empowerment and advocacy without regular sources of funding and among the typical means of support for DAAs are the local authority recruiting a DAA coordinator; donations and fund raising; offers of in kind support (i.e. meeting venues and officer time).

DAA business membership

The population within each DAA was distributed across a range of settlement types and a total of 135 DAAs were identified from the web-based analysis. The coastal town/city and resort dominated, reflecting their well-developed visitor economy as illustrated in Table 1 represented by larger resorts such as Bournemouth, Blackpool and Scarborough as well as smaller localities. The sample was dominated by the South West of England with its coastal resorts and towns accounting for 60% of the total sample of 135 DAAs (n = 81), 22 in the East of England, 19 in the South East, 11 in the North West and one in the East Midlands. This pattern reflects the distribution of regional tourism visitation in England, where South West England is a major coastal tourism region. The majority of the DAAs had received DFC status. The year the DAAs were established varied, although only 29 DAAs listed their inception date, ranging from 2012 (five DAAs), 2013 (six DAAs), 2014 (five DAAs), 2015 (eight DAAs) and five were established in 2016. In terms of business engagement, DAAs listed members in business activities across the private, public and voluntary sector. Of the 1508 business members listed in the sample, nine DAAs recorded 1–5 members, five had 6-10 members, 17 had 11-20 members, nine DAAs had 21-50 members and three recorded 51–100 members. Only two recorded over 100 members (one of which was a County-based DAA). The largest DAA had 203 members.

Table 1

Population of DAAs by settlement type.

Population Size	Coastal town/city	Coastal village	Coastal resort	Port	Island	County	Total
Up to 10,000	2	4	1	0	0	0	7
10,001–25,000	6	1	3	1	0	0	11
25,001–100,000	5	0	4	0	1	0	10
100,001–500,000	3	0	9	4	1	1	18
Over 500,000	0	0	0	0	0	1	1
Total	16	5	17	5	2	2	47

Turning to the proportion of DAAs with businesses located in the visitor economy, as mentioned previously, DAAs recorded 111 businesses operating in the visitor economy from the total business population of 1508. Overall, relatively low numbers of visitor economy businesses were recorded in the DAAs. with one business being the most common occurrence in 14 DAAs followed by two businesses for four DAAs with one recording three business members and two recoding four businesses. One DAA contained nine visitor economy businesses and two possessed 11, while one outlier identified 47 visitor economy businesses. The majority of businesses were SMEs, and their activity and ownership structure is illustrated in Table 2, with 85 private sector businesses dominating, with smaller proportions from the third sector and public sector.

Table 2

DAA visitor economy business type by ownership structure.

Business type	Ownership type
	Public sector	Commercial	Third sector	Total
Accommodation	0	10	0	10
Food and beverage sector (e.g. cafes and restaurants)	0	43	2	45
Visitor attractions	5	1	6	12
Visitor Information Centres	2	0	0	2
Transport	0	23	1	24
Tourism support services (e.g. British Transport Police)	2	0	0	2
Leisure Centres	2	0	1	3
Arts venues	1	6	3	10
Other	0	1	0	1
Total	12	84	13	109

Number of missing cases: 2

One of the initial requests for any business joining the DAA is to create an Action Plan comprising three distinct parts:

The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation's role in delivering better outcomes for people with dementia and their carers?

What are the challenges to delivering these outcomes from the perspective of your organisation?

What actions are being undertaken and their status (e.g. planning or implementation)? (Source: Alzheimer's Society, no date).

In terms of the Porter and Kramer (2011) shared value notion, this provided an opportunity to assess the degree of reconceiving products and markets to accommodate DF consumers.

The Alzheimer Society (AS) advice to prospective members was to examine the NDD and to see what outcomes they may contribute to as part of their commitment to this shared value approach to developing DF business practices. This provides an opportunity to assess the level of cooperation (e.g. through to compliance with the NDD) and more critical cooperation ranging from establishing a different set of objectives to the NDD. Arguably, the tensions here relate to an organisation's desire to remain an independent partner, seeking to take a lead with developing other objectives through to partial compliance and a desire to also set other desired outcomes, recognising economic value alongside any societal value. Such a situation demonstrates the continuum along which business engagement with becoming DF is, with minimal engagement typified by undertaking a Dementia Friends event for its staff. Of the 96 businesses listing strategic outcomes, 29 (21.5%) businesses listed only one action, with 21 (15.6%) listing two, 25 (18.5%) listing three actions, 14 (11.9%) listing four actions, four listing five actions and one listing eight actions.

The areas businesses could contribute to to assist with living well with dementia in relation to the NDD are as follows, with businesses engagement with the National Dementia Declaration and specific outcomes outlined (with number of responses and percentage in brackets):

I have personal choice and control or influence over decisions about me (15, 10%)

I know that services are designed around me and my needs (51, 34%)

I have support that helps me live my life (24, 16%)

I have the knowledge and know-how to get what I need (19, 12.6%)

I live in an enabling and supportive environment where I feel valued and understood (37, 24.6%)

I have a sense of belonging and of being a valued part of family, community and civic life (3, 2%)

I know there is research going on which delivers a better life for me now and hope for the future (1. 0.6%)

These results illustrate that the businesses in the visitor economy listed 150 actions from 96 businesses with 15 businesses with no responses. What these results show is that the main focus is on service delivery to enhance the experience of a product or service, and in embedding an understanding and awareness of dementia within their organisation so people with dementia and their carers could visit their business. There are two important observations to be made at this point. First, the scope for reconceiving products and markets in relation to addressing some of the issues highlighted in Fig. 2 is clearly wide ranging and so allows a broad portfolio of options in the journey towards becoming a DF visitor economy business. Second, from a more theoretical perspective, it also represents the bifocal nature of business engagement through the creation of social value through supporting the DAA whilst simultaneously enhancing their business performance, a key strand of the creating shared value proposition. However, 41 of businesses were planning and implementing actions that were not part of the NDD pledging 92 specific additional outcomes, dominated by the private sector businesses and third sector. In some instances, innovative examples of best practice in the Museum sector involved outreach and training for other businesses.

Looking at the challenges which businesses identified in seeking to become more DF, 171 challenges were recorded for all businesses and the dominant issues were: staff and public limited awareness of dementia; limited time to commit to the DAA journey towards becoming DF; and, funding to implement changes. Therefore, whilst the Alzheimer's Society (ND, p. 14) Guide to Creating a Local Dementia Action Alliance clearly states ‘the very minimum requirement, to be a Member of a DAA, is to commit to providing a better understanding of dementia in their organisation’, which most businesses acknowledge, the wider objective that ‘recruiting members to the Alliance is about seeking a behavioural commitment not financial’, reflects organisational challenges. This epitomises the responses in the Covey and Brown (2001) model in terms of critical cooperation, given business owners and managers report a lack of funding and time stretch. The implications are a limited ability to accommodate DAA objectives in their business beyond the simple awareness raising. A small proportion of businesses were concerned about the limitations that existing buildings and infrastructure provided for less accessible visitors, and the issue of cost in making adaptations. Other key challenges were the turnover of staff and finding the time to train staff among 11% of businesses.

The last area which businesses were asked to focus on in their Action Plans was the range of DF actions they were committed to. An impressive 245 Actions were listed by 103 businesses. The main focus was on training, focusing on dementia awareness for staff, running events or providing activities for people with dementia (including an example of tailored events that are built around Cognitive Stimulation Therapy), largely by arts venues and visitor attractions. A wide range of adaptations or innovations to assist people with dementia and their carers ranged from spreading the word and use of window stickers to promote the DAA in business windows, auditing the premises or processes to identify how to be more DF, customer cards for bus travel, coin charts at cash tills to assist with the identification of money as people with memory difficulties can face problems in recognising money. Better menu design to aid readability and improved signage to aid wayfinding were also listed. Businesses also recorded the status of their actions and some 177 examples were observed which were either at: the planning stage (78); had been delivered or implemented (97); and one was at the scoping stage. A very encouraging finding is that at least 77 of all businesses recorded actions and the two lowest scoring types of business were in the food and beverage and the accommodation sector. Each sector noted restrictions which the infrastructure and layout of the premises posed for adaptations, especially in historic buildings.

Discussion

This study has significant implications for the transition of businesses towards becoming more DF, not least in establishing the shared value notion as a basis for engaging businesses in this course of action. More strategically, Fig. 3 presents a framework of the various challenges which a visitor destination may face in becoming DF in seeking to develop a cluster of businesses across the supply chain for the visitor experience. Fig. 3 is a useful framework in which to situate the findings where there is a low level of engagement between DAAs and visitor economy businesses. The visitor economy is a key feature of England's coastal towns, especially in the resorts of Bournemouth, Brighton, Blackpool and Worthing which generates over a half a million jobs. Indeed, ‘The share of jobs in distribution, hotels and restaurants is markedly higher in seaside towns (30 per cent compared to an English average of 24 per cent)…[and in]...smaller seaside towns, the share of employment in distribution, hotels and restaurants is at least 10 percentage points higher than the national average’ (Beatty et al., 2008, p. 20). But only 135 of 1508 of the total number of businesses engaged with DAAs were located in the visitor economy. As this is a key area for both resident leisure and visitor activity, strategically the sector needs to be included in any DFC if the DAA objectives on creating a DF locale are to be delivered.

Fig. 3

Challenges for developing a dementia-friendly destination. Source: Authors, developed from Crampton et al (2012).

The ‘people’ element of Fig. 3 is underpinned by the leadership role of the DAA in raising dementia awareness, brokering training and DF initiatives promoting collaboration and engagement with businesses through the shared value concept. However, the low level of engagement with visitor economy businesses should not be seen as a criticism of the DAAs achievements. Their recent formation as grassroots organisations, many of which receive no public sector funding, underlines the social innovations these organisations have achieved at a community-level in a short-time horizon. This reaffirms the arguments that DAAs fit the various models of social innovation, addressing a grand societal challenge and strengthening the civic contribution through voluntary action. It is natural for many DAAs to be orientated towards local health-care delivery issues in the early stages of their establishment. But building a much greater local engagement with the business community operating in the visitor economy may be the next step for many DAAs. As a grassroots voluntary organisation with minimal or no funding, it was not unsurprising that the visitor economy remains largely untapped in many localities given the challenges of coordinating and engaging with a plethora of SMEs. Evidence from the DAA websites highlighted that DAAs had well-developed networking with a wide range of dementia-related organisations and social care bodies to promote the improvement and understanding of dementia in society. The challenge they face with the visitor economy is in applying the principles of DF service design to the various touch points in the locality as indicated in Fig. 1 for both residents and visitors who use many common services. This is compounded by the potential adjustments required to make the touchpoints DF. The challenge evident from the visitor economy businesses is the concept of bifocal social innovation, where they were happy to make service design improvements largely around the visitor experience (i.e. how staff engaged with people with dementia) as predominantly private sector businesses. But beyond basic dementia awareness training, many private sector SMEs reported challenges around recruitment and retention of staff (i.e. due to the problems posed by seasonality and staff turnover) and time to commit to any more than this basic requirement. The result is that the ideology of shared value has its limits with businesses who engage, as a proportion of businesses reported cost concerns with making adjustments to make provision more DF. The same businesses had experience of compliance costs with the 1996 disability legislation on accessibility. The most innovative examples representing best practice emerged from third sector and public sector businesses with a requirement to engage a wider audience as well as larger tourism operators with a broader understanding of the touchpoints and service journey (e.g. as epitomised by an airport in the study). Ultimately the destination needs a joined-up approach to link the disparate businesses together to ensure a diversity of touchpoints that can provide a minimal provision that is DF, extending the cluster idea to the supply chain concept for the touchpoints visitors experience. Many businesses had plans to develop DF initiatives further but funding remained a challenge.

What the results of the businesses engaged with the DAA demonstrate is a four-fold grouping (see Fig. 4) of pioneers (largely from the public sector and larger organisations); followers of the pioneers, seeking to learn from the best practice and planning to transition towards a DF state; reluctant compliers who engage on the margins of the DF agenda and undertake the minimal changes needed to justify engagement; a large population of non-engaged businesses. The DAAs need to do more than scratch the surface of the visitor economy with small numbers of pioneers and followers, and increasing engagement requires a more detailed understanding of the bi-focal concept.

Fig. 4

Typology of businesses in the visitor economy and their degree of engagement with the dementia-friendly agenda.

As Connell et al. (2017) and Connell and Page (2019) suggest, the DAA may not necessarily be the right body to be taking forward the DF agenda alone within the visitor economy - a strong visitor economy business champion is needed. The leadership experience of the local destination management organisation (DMO) may assist in engaging a wider mix of businesses to provide a DF experience that encompasses all aspects of a destination (attractions, accommodation, transport, associated infrastructure and the food and beverage sector) (Connell and Page, 2019). The visitor experience is a complex construct and the results suggest the need for the development of a service blueprint for the DF visitor journey through a destination (Shostack, 1984). This would need to be informed by people with dementia, advising what visitor needs can be met through a realistic assessment of the changes that can be introduced. There is little difficulty with engaging public sector businesses in the visitor economy, many of whom have experience and examples of best practice of what works well as epitomised by Klug et al. (2017). Nonetheless, this is a long way apart from the resource constraints being noted by many private sector businesses.

Conclusion

To date, no visitor destination in the UK has decided to make the claim for being DF (although Brecon Beacon's National Park is working towards this ambition – see Brecon Beacons National Park Authority, 2014). If the results from this initial exploratory study are representative of the situation in the wider visitor economy, it is reasonable to posit that visitor destinations have a considerable journey to embark on before claiming to be DF. The results have to be viewed against the recent assessment that the UK is seen as one of the most dementia-ready countries globally (Alzheimer Disease International and Global Coalition on Ageing, 2017). However, in terms of the visitor economy, the results from this exploratory study of coastal destinations suggest it is at an embryonic stage in understanding what a DF visitor experience might look in terms of day visits and staying visitors. This indicates that the visitor economy has some way to go before the DF infrastructure needed to host visits in each locality is sufficiently embedded in a range of business types. The results illustrate that there are many problems which businesses report as obstacles in making only a limited number of changes to their practices to become DF, given the reliance upon SMEs and micro businesses which dominate the visitor economy. In contrast, the organisations such as museums, which have a public remit to widen participation among visitors often have access to funding or resources to help with these DF actions (see Klug et al., 2017 for a range of case studies of such actions). Currently progressing this agenda seems to fall between two stalls. The DAAs do not have the specific knowledge or influence over the visitor economy businesses to galvanise support across the spectrum of visitor economy businesses. Conversely, other studies of local DMOs, who have the influence over visitor economy businesses have not viewed this as a major priority, since the majority of DMOs have no mention of DF issues on their websites as current research indicates (Connell and Page, 2019).

From the exploratory nature of the results reported in this study, one might argue that the concept of shared value may be a useful way forward for DAAs and DMOs to progress the wider engagement of businesses to create more DF destinations around DF principles. But this notion is dependent upon businesses understanding the societal challenge that ageing and dementia poses for their current and future business model and the need for change. Getting businesses to understand the economic value of visitor-related dementia spending associated with a growing ageing visitor population in many developed countries might be more clearly articulated with case studies of how this helped the bottom line and improved consumer satisfaction among visitor economy businesses that have become DF. The limited findings in this study indicate that this subject is certainly a fruitful area for further collaborative working between the DAAs, DMOs and local businesses and researchers with a more holistic understanding of the issues in each locality. A next step may be to design a DF visitor experience which requires using the concept of service blueprinting to maximise the opportunities in a joined-up manner so a destination has a balanced portfolio of service delivery. Such experiences also need to be marketed to people with dementia to improve knowledge, awareness and understanding of how to provide an experience that creates value for businesses and the visitor alike.

Current debates around DF have largely ignored the visitor economy and the creation of visitor spaces that enable people to live well with dementia. Realism is needed to recognise business needs and expectations if wider engagement is to be achieved in DFCs. As Voorberg et al. (2015) suggest, citizens are an important part of the innovation process for destinations as they embark on the journey to where dementia is treated in a normalised manner rather than requiring adaptations. The awareness training and advocacy role of grassroots organisations like DAAs is fundamental to making dementia an accepted facet of modern society. But this needs to be backed up with the type of support that the results of this study illustrate and to be coordinated if DF destinations are to be created.

Although these is a lacuna of academic research on DAAs, the review of their progress outlined in the literature review in this paper demonstrate that they have made substantial progress as grassroots organisations to enhance the lives of people with dementia, typically with an emphasis on residents. Refocusing their emphasis in many coastal locations which function as visitor destinations means that DAAs and other stakeholders have the potential to help people to live well with dementia given their appeal as places for leisure consumption and pleasure. Moving these localities towards a DF visitor destination is a significant challenge, as reflected in elements of Fig. 1 for individual businesses and in Fig. 3 for the destination. At the destination level, some of these challenges have been observed in other studies of the built environment (see Mitchell et al., 2003). The exploratory results from this study point to the need for further in-depth qualitative and quantitative research to understand the experience of why businesses do not embrace the DF journey to understand how organisations like DAAs and DMOs might help with expanding DF business practices. Grassroots organisations do have an ability to stimulate social innovation, but engaging businesses in their pursuit of the values of a DF community will need to have a greater focus on action and outcomes (Have and Rubalcaba, 2016). The model of bringing together the community with public and private sector business interests to make society much fairer and inclusive, may begin to bridge some of the gaps that social theorists have pondered since the seminal study of Tönnies (1887) on the different types of social organisation in society (i.e. gemeinschaft with the focus on community where mutuality exists and gesellschaft, with the focus on a society where individual's goals and aims dominate). Seeking to bridge this divide and enable businesses to engage is a worthy objective given the forecasts of an ageing population for many developed countries and the prospects of increased prevalence of dementia.

Declarations

Author contribution statement

Joanne Connell, Stephen Page: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interest statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.