Scottish Government

SCOPING STUDY OF OLDER PEOPLE IN RURAL SCOTLAND

CHAPTER 6: HEALTH AND SOCIAL CARE

Introduction

6.1 Most older people are healthy and can enjoy active lives well into their 70s. Some are less fortunate, suffering from illnesses developed in middle age or illness associated with ageing, such as arthritis, deafness, heart disease, diabetes and the dementing disorders of old age. Increasing frailty, generally associated with advancing years, can bring a greater risk of falls and other accidents and brings greater vulnerability to infection. The time taken to recover from an illness also increases with age and frailty.

6.2 The Report of the Expert Group on Healthcare of Older People Adding Life to Years (Scottish Executive, 2002, p5) notes that " As a nation, we should be planning now for increasing numbers of older people in the future". MORI Scotland (2001) found that only 4% of the over 60s in Scotland have private medical insurance. Almost all older people, therefore, rely upon the NHS. How do older people use health services? Adding Life to Years notes that each year NHS Scotland provides the following for older people:

• 3,769,000 GP consultations
• 287,000 new outpatient referrals
• 206,000 day cases and elective inpatient admissions
• 185,000 emergency inpatient admissions

Fewer older people now reside in institutional care than in previous decades. Around 95% of the over 65s live at home, many of whom make no greater demands on health and social care services than do younger members of the community. However, the likelihood of care being required increases significantly with age, particularly in the over 80s age group. As the absolute number within this age group is growing and will continue to grow in coming decades there will be increased pressure placed on health and social care services.

6.3 This chapter reviews issues associated with the provision of health and social care. It does not consider specific clinical needs as these are considered to be outwith the scope of this report. A number of health related services, projects and initiatives associated with older people in rural Scotland are described. The chapter is structured around five themes; the statutory provision of health and community care, involving older people in community care decision making, physical activity in old age, care giving and mental health.

The provision of health and social care services in the UK and the Nordic countries

6.4 The National Health Service is the principal provider of primary and acute health care in the UK. Care is organised at a sub-national level by Health Boards, regional units who oversee the delivery of services in their local area. Acute services cover, for example, surgery and specialist medical care such as cancer treatment. In rural Scotland, most Health Boards have a single acute hospital in their region whereas those serving a metropolitan area, such as Lothian, contain more than one. The rural Health Boards will also send patients from their region to specialist centres e.g. the Beatson cancer centre in Glasgow and the stroke centre at the Western General Hospital in Edinburgh. Primary and Community Care incorporates the GP service, most mental health services, rehabilitation, most non-acute geriatric services and the community nursing service.

6.5 In effect, a three tier hospital structure operates in Scotland. This is not dissimilar to the structure in the Nordic countries. For example, in Norway each of the five health regions has three types of hospital: district, central and regional hospitals. In Iceland, a three tier hospital structure is also in place, with specialised teaching, general and community hospitals. The need to react to an ageing population and the demands this places upon health services is evident in the Norwegian Quality Action plan for care of the elderly 1998-2001 and the Finnish National Framework for high-quality care and services for older people (2001).

6.6 In the UK, support with the tasks of daily living, as opposed to clinical needs, are delivered via Community Care through a partnership between Local Government Social Work Departments and the Health Service and other agencies as appropriate. Community Care, as outlined in the White Paper Caring for People (Secretaries of State for Health, Social Security, Scotland and Wales 1989) and The National Health Service and Community Care Act, 1990, means:

"providing the services and support which people who are affected by problems of ageing, mental illness, learning, physical or sensory disability need, to be able to live as independently as possible in their own homes, or in 'homely' setting in the community" (Dumfries and Galloway Community Care Plan 1997-2000).

The overarching goal of community care is, where possible, to enable people to live in their own homes.

6.7 The key agencies involved in delivering Community Care across Scotland are Health, Housing and Social Services. These public bodies initiate, deliver, and co-ordinate a range of services that enable the priorities identified in local care plans to be achieved. Some services, such as residential homes and some home-help services are contracted out to the private and voluntary / not-for-profit sectors. Running in tandem to this formal care are services and activities run by many voluntary organisations. Some are associated with national bodies and delivered through local branches with support available from paid employees of the organisation, for example the British Red Cross and the Women's Royal Volunteer Service have branches across rural Scotland. Other activities are run by local groups, in the main relying solely upon volunteer efforts. Community care also involves close contact with the large numbers of unpaid carers, usually a relative of the individual in need of support.

6.8 The structure of social care in the Nordic countries has some differences to the service in the UK. The Scandinavian solution to long-term care, in terms of organisation, financing and functioning, is typically tax-financed formal care (Romoren, 1996). The responsibility for care is generally decentralised, being organised at the local level and is usually run directly by the state. In Norway the social welfare service is a responsibility of the municipal authorities and in rural areas the provision of high quality services for the elderly is regarded as one of the most important tasks of local government ( personal communication Oyvind Glosvik, 2002). Previously the responsibility of regional authorities, in recent years social care services have been decentralised to a more local level. The municipalities cater for the requirements of the physically and mentally disabled, those who have been discharged from hospital but still require treatment and rehabilitation, and the elderly. About a quarter of the municipality budgets are allocated to the social care services required by these four groups. In Denmark, levels of institutional long-term care of the elderly are the lowest among the Scandinavian countries (Romoren, 1996). Elderly people are instead most likely to be cared for in sheltered housing (i.e. older people live in independent housing units and thus maintain autonomy) with intensive community care support. Institutions providing long term care in Denmark are legally social institutions: the private sector is not involved as a service provider.

6.9 The private, profit making sector is almost non-existent as a provider of long-term care of the elderly in Norway (Romoren, 1996). In Sweden the private and voluntary sectors play little part in the delivery of health and social care services (Baldock and Evers, 1992), and although informal support provided by relatives, friends and neighbours is important, even when formal care is provided, it has received relatively little acknowledgement. The voluntary sector plays a part in public health care in Norway, but their services are almost entirely financed by the public sector (Romoren, 1996). This contrasts with the UK where the private and voluntary / not-for-profit sectors are closely involved with the provision of social care for the elderly but do not necessarily receive state payments for services they provide.

The state of older people's health

6.10 Older people, especially those over the age of 75, are major users of health and community care services. Health and social work are two of the four largest areas of public expenditure in the UK (the remaining two being education and policing). Adding Life to Years (p12) observed that " the care of older people is the principal task for NHS Scotland in the 21 ^st century". It is no surprise then that the literature contains many items about the health and social care of older people and that so many policies, projects and initiatives targeted at older people in rural Scotland have a health and social care slant.

6.11 How do the Scottish population view their own health? The Scottish Household Survey included a random adult question about self-perceptions of health over the past 12 months. The results are presented in Table 6.1

Table 6.1 State of respondents health over the past 12 months

Available observations: 28321
Source: Scottish Household Survey

6.12 As can be expected, Table 6.1 shows that a lower proportion of the older age bands than younger age bands reported good health. Overall, for each age band, a greater proportion of those living in rural areas reported good health than those living in non-rural areas. Conversely, for each age band, a greater proportion of those living in non-rural areas reported that their health had not been good. A similar question was included in the British Household Panel Survey. It showed that, for all age groups, those living in Scotland were more likely to report excellent health than those from the UK as a whole. The over 75s in Scotland were less likely to report fair or poor health than were the over 75s across the UK. The better perception of health in rural areas is perhaps related to a higher quality of life in rural areas, in particular better environmental quality.

6.13 These findings may suggest that there is a difference between rural and non-rural demands for health care services amongst the older population. However, the possible influence of geographical variations in health status within non-rural and rural areas should not be overlooked. It is well known that the poor health status of west central Scotland residents has a significant influence upon overall Scottish health statistics. If this region was removed from the sample the difference between urban and rural areas may not be so great. It should also be borne in mind that the table reports self-assessment, rather than an objective assessment of health status by a clinician. An objective assessment of health status may have produced different findings.

Statutory providers of health and community care: the National Health Service and local government departments

6.14 The health and social care of elderly people across Scotland follows a fairly standard plan. The first point of contact is usually the General Practitioner who will then refer an individual to an appropriate support service. In the case of an individual being admitted to hospital for emergency treatment, the hospital, working in collaboration with Social Work Departments, Occupational Health and the local GP, will then determine the care plan for that individual. Small 'cottage' hospitals are utilised for elderly care when a patient will require a long time to recover from an operation and need some further respite care but not a large amount of medical care. Acute hospitals serve large geographical areas, therefore small local hospitals allow elderly people to recuperate within or near to their home community. Social isolation is minimised by a transfer to a local hospital as they tend to be much easier places for family and friends to visit.

6.15 The most difficult rural areas to deliver health and social care services to are remote rural areas. The IMPRESS project - Improving the Elder Care Policies in Sparsely Populated Areas, is a collaborative venture between the Nordic Regions of Finland, Russia, Sweden and Norway. Research is currently underway on this project and findings from the research, when they are published, may include recommendations transferable to a Scottish context.

Where are health services located?

6.16 In rural Scotland accessing most health services, particularly specialist services, involves patients travelling considerable distances. An overarching problem is how to deliver quality acute and primary health services to small numbers of people dispersed across large geographical areas. The Arbuthnott report (1999), Fair Shares For All, presented recommendations that have gone some way to ensuring that the additional costs involved in providing health care to rural populations are accounted for in the resource allocation process (a remoteness weighting was recommended in the Arbuthnott report in addition to a demographic weighting that accounts for the fact that children and older people consume a greater proportion of health services than other age groups). There is a growing trend across rural Scotland to deliver visiting health care services from buildings such as Village Halls and community centres. Such innovative methods of service delivery help to overcome accessibility problems and sometimes are the result of older people themselves placing direct requests to service providers that a mobile and thus more local service is developed. For example, in the Lochaber area the membership of a senior citizen's lunch club have submitted an application requesting that the chiropody service comes to their village hall rather than them travelling 16 miles each way to access the service in its current location. Nevertheless, the barriers of distance, difficulties in filling specialist professional positions in remote rural areas, and deciding where to base services remain significant challenges for the NHS in Scotland.

The need for health-related transport

6.17 A number of patient transport schemes across rural Scotland make it easier for older people to attend in-patient and out-patient hospital appointments. For example, in Dumfries and Galloway, a community transport scheme takes patients from the Stranraer area to Edinburgh to receive chemotherapy. The service received financial support from Stranraer and District Lions Club. Older patients from the Northern Isles often have to travel to Aberdeen for specialist hospital treatment. The Women's Royal Voluntary Service (WRVS) is currently raising funds to provide a private waiting area at Aberdeen airport where those returning home from hospital can have privacy and be separated from the bustle of the terminal. Schemes such as these, while not bringing treatment closer to patients, make accessing necessary medical treatment more comfortable.

Networks between statutory providers and the voluntary sector

6.18 NHS services only deal with specific problems that can be overcome by the provision of equipment or professional health care. Very often the voluntary sector is involved in health and social care as an extension to NHS provision. For example, the British Red Cross, thorough its network of local branches, runs a Medical Loan Scheme, used predominantly by elderly people. This scheme is used in cases where elderly patients are awaiting assessments from Occupational Health Departments and require equipment quickly, or as a means of easing people into their own homes after surgery or illness. Equipment, such as wheelchairs, backrests, commodes, bath seats and walking aides can also be provided as portable equipment, allowing people to go, for example, on holiday. The British Red Cross also operates a Home from Hospital service, providing practical help and emotional support for people leaving hospital. Services offered under this initiative include collecting prescriptions, small shopping trips, both of particular benefit to older people living in the more remote rural areas where the distance between home and pharmacies and shops may be considerable, and supporting the social services medical care team.

6.19 The WRVS also operate Home from Hospital Support services. For example, in Fife the WRVS are contracted by the Social Services Department to provide an extension to the service delivered by the Social Work Department Rapid Response Teams. The Home from Hospital Support is a concentrated version of the WRVS' Good Neighbours Project ( see Chapter 5) where volunteers encourage independence and an interest in activities outwith the home, building confidence and slowly edging elderly people back into the community. The project can intervene to curb depression and isolation in elderly people leaving hospital. Whilst Social Work services concentrate on ensuring that medical requirements are met, this service provides social and humane care, considered to be particularly important for elderly people who live in the more remote rural areas of Fife. The WRVS service is contracted for 12 weeks in the first instance and the client's needs are reviewed monthly thereafter.

Community care: social work services for older people

6.20 Social Work Departments play an important role in non-clinical elderly care. They assess individual care in the home needs and prepare individual care plans. Help with dressing, toileting, feeding and small essential domestic chores, such as lighting coal fires, can be provided and meals may be delivered or cooked in the client's home. These are tasks that assist older people to remain in their own homes and can delay, or even prevent, the need for an elderly person to move into supported accommodation. (further details are presented in Chapter 4). In some areas these home care services are provided directly by the local authority. In others they are contracted out to private, not-for-profit or voluntary sector organisations. For example, in the Lochaber area the Women's Royal Volunteer Service are contracted to provide a meals on wheels service by the local authority. It is not uncommon for services contracted out to the voluntary sector to involve older volunteers providing a service for other older people.

Involving older people in the decision making process

6.21 Recent reviews of NHS services and the delivery of community care have highlighted the need to involve older people in the decision making process (for example, the reports Better Government for Older People, Scottish Executive, 2001c and Adding Life to Years, Scottish Executive, 2002). A recent review of initiatives to involve older people in community care planning found few examples of the involvement of frail older people as opposed to active older people who were participants in pensioner's action groups and elderly forums (Thornton and Tozer, 1994). An innovative project, initiated by Age Concern Scotland, has encouraged the involvement of frail older people in the decision making process. Age Concern Scotland Fife User Panels were intended to " enable older people who were unable to leave their homes without assistance to meet together to develop a collective voice expressing the needs and experiences of older service users" (Barnes and Bennett, 1998, p102).

6.22 The User Panels were evaluated by Barnes and Bennett (1998). They considered the model to " demonstrate benefits both for the older people who became involved and for officials seeking to improve the sensitivity of services to the needs of older people" (p102). There is a need to ensure that services for older people strike a balance between what professionals think older people should receive, and what older people themselves think that they need to help them remain independent (see, for example, Tanner, 2001) and the User Panels are one means of achieving such a balance.

6.23 In Finland a large number of municipalities have established senior citizen's councils in recent years. The objectives of these councils are " to increase co-operation between the elderly and people working with old age issues" ( http://www.jyu.fi/liikunta/tervtiede/SGT/research). Research investigating how these councils operate, and how the viewpoints of older people influence the decision making processes is currently underway. Extending the concept of senior citizen's councils to rural Scotland would be a useful means of ensuring that the opinions of older people are regularly fed into the policy and service delivery process.

Health promotion and older people

6.24 Maintaining physical fitness helps to keep the mind alert and the body supple. Participating in physical activities is important in old age, especially load bearing exercise. Many older people across rural Scotland are physically active. Cycling and walking are common day-to-day physical activities in rural communities, fulfilling a functional rather than recreational need. Sports such as golf, bowls, rambling and swimming are popular activities for men and women in urban and rural communities. Village and community halls as well as specialist sports facilities are the venues for activities such as aerobics classes, line dancing sessions and other recreational activities that require physical exertion.

6.25 The National Service Framework for Older People was launched by the government in 2001. It introduced formalised standards of care that older people can expect to receive from the National Health Service, regardless of where they live in the UK. Standard 8 promotes an active, healthy life in older age. This Standard is reflected in the long-term targets of the Scottish Executive's social justice agenda which wishes to ensure that older people can enjoy active, independent and healthy lives - or what is termed 'active ageing'. The Movin Aboot project tries to do just that, and has been active in the North of Scotland since 1996. The project is particularly beneficial to older people with limited mobility who would not be able to participate in more strenuous forms of exercise.

6.26 Preventative health care, including encouraging middle aged people to participate in regular physical exercise, is an important facet of encouraging active living amongst older people. If people get into the habit of taking regular exercise before retirement they are more likely to remain active as they get older. The General Practitioners Exercise Referral Scheme is an innovative scheme to encourage people in the Borders to become active for life. It is a good example of a multi-agency local partnership for health improvement.

A similar GP 'prescription' for a physical exercise programme, specifically targeting older people, received funding from the Scottish Executive under the Better Neighbourhood Fund at the beginning of 2002. Up to 100 older people will be encouraged to remain active in Nithsdale and Annandale and Eskdale. The aim of the project is to promote physical activity to improve health and reduce falls through trained staff providing suitable exercise programmes (Galloway Gazette, 4 ^th January 2002).

6.27 An area of preventative health care that appears to overlook older people is sexual health. For example, information on the Health Education Board for Scotland's web page about STDs and HIV/AIDS is targeted at young adults. It should not be assumed that older people, in particular the young-old, are sexually inactive and are thus not in need of sexual health education, advice and support services.

6.28 The 2002 research programme of the Kuntokallio Foundation's Center for Gerontological Training and Research in Finland includes the theme of Functional capacity, Health Promotion and the Elderly. One ongoing project whose findings may be relevant to health promotion for the rural elderly in Scotland is entitled Promoting the Functional Capacity of Rural Elderly.

Care giving

6.29 Older people requiring care include the frail elderly, those who have suffered physical impairments following a stroke and those suffering from a dementing disorder of old age (Alzheimer's Disease, Multi-infarct Dementia and Senile Dementia). Strokes and dementia come under two of the three illness groups which are declared priorities of the Scottish Health Service (cardio-vascular disease and mental health respectively, the third priority being cancer, refer to C ancer in Scotland - Action for Change, Scottish Executive, 2001d, the Coronary Heart Disease / Stroke Task Force Report 2001 Scottish Executive, 2001e and A Framework for Mental Health in Scotland, Scottish Office, 1997).

6.30 An unpaid volunteer army of carers provide help and support to thousands of elderly people across rural Scotland.

"It has been estimated that 13% of the adult population in Scotland are carers and that to replace [unpaid] care given by carers through paid care would cost an estimated 3.4 billion a year" (Borders Joint Community Care Plan 2000 - 2004, p86).

While the quote presents the market value of all caring, more than half of Scottish carers are providing support to older people. Approximately 7.5% of the adult population in Scotland are thought to be involved in the provision of informal care for the elderly (Leontaridi and Bell, 2001). To pay for their services would involve considerable public expenditure.

6.31 Since the trend to de-institutionalise care in the UK began, c.1979, service provision by the NHS for older people, convalescence, rehabilitation and mental illness has decreased from more than 80% to about 25% of all care beds (Pollock, 2001). The concurrent trend of increasing care in the community has lead to an increasing need for paid and voluntary carers for the elderly across the UK, with rural areas being no exception to the general trend.

Who are 'carers'?

6.32 In the UK unpaid, freely given care of elderly people most commonly comes from spouses and adult children. Jones and Vetter (1984) identified that the family is the main source of assistance to dependent elderly people and that female family members were the most likely to be carers. Wenger et al (2001) noted that carers for people with dementia are typically female and older than other carers. They also noted that elderly husbands are amongst the oldest carers of elderly people with dementia. There are also a sizeable number of elderly carers of adult children with some form of long term illness or physical / mental disability. Informal care and support provided by friends and neighbours is also an important element of caring for older people. Leontaridi and Bell (2001) found that 75% of all carers are in full-time, part-time or self employment but that there is evidence to suggest that those caring for elderly relatives are moving from full- to part-time employment to accommodate their caring role. They also established that income status has no bearing on the likelihood of an individual becoming a carer.

6.33 Keeping older people out of institutional care and in their own homes for as long as possible may run into difficulties in the future as " the supply of those people conventionally seen as carers [e.g. women aged 50-69] for the frail elderly will not grow as fast as the numbers needing help" (Baldock and Evers, 1992). Given the demographic trends evident across rural Scotland, where the numbers in the older age bands are expected to increase and numbers in younger age band decrease, there is a risk that there will not be enough voluntary carers available in rural communities to look after older people in coming decades.

Care provided by the voluntary sector

6.34 The voluntary sector plays an important role in providing support for carers in rural areas. For example, the British Red Cross operate an Emergency Care scheme, offering short-term support when a domestic crisis has arisen. If someone's regular carer falls ill, has to go away suddenly, or simply cannot cope, a suitable person is matched with the client to provide as much of the care as possible, continuing their usual routine. The WRVS in Fife offer a Carer Relief scheme as part of their Home from Hospital package.

Voluntary carer relief services are particularly important in rural areas where existing local authority care staff attend clients over a large geographical area and may find it difficult to build emergency respite care into their work schedule.

Care provided by relatives

6.35 In Sweden, adult children or other family members are under no legal obligation to care for their elderly relatives. Taken together with Sweden's high female participation rates in the labour market and the fact that few elderly people live with their children, an extensive public care system is a prerequisite (Johansson, 1991). State services are being put under increasing pressure as the numbers of old-old rise and Johansson predicts that the informal care sector, mainly through relatives, will be put under pressure to take on caring responsibilities. In rural Scotland, where the families of many elderly people live far away from them (and because the out-migration of young people from rural areas of Scotland shows no sign of abating it is likely that this situation will continue in the medium to long term) and where female participation rates in the paid labour market have increased considerably in the last few decades, a similar situation to that in Sweden is emerging. The state cannot assume that, in rural areas, family members are on hand to provide care and support to their elderly relatives. However, when social care budgets are tight the question of how to provide care and support to elderly rural people poses many problems.

Caring and communicating

6.36 Until the last quarter of the twentieth century, Doric (North-East Scots), Lallans (Lowland Scots) and Gaelic were widely spoken across rural Scotland and many elderly people still retain these minority languages as their mother tongue. In the elderly, including the demented elderly, memory for long-distant events is retained when that for recent events can be lost. Older people are often fluent in the minority language of their earlier years and may not express themselves clearly in standard English. This can create problems for care givers because they may not understand the elderly person they look after and their clients may not understand them. Similar problems may be experienced by the smaller number of elderly people in rural Scotland of Continental European and Asian origin. As well as retaining cultural aspects of rural Scottish life, encouraging younger people to communicate in Doric, Lallans or Gaelic could help to ensure that elderly people do not become excluded from those around them on language grounds.

Providing support to carers

6.37 As noted by the Social Services Inspectorate (1998), carers remain dependent upon the range and the quality of support services offered to the person they look after. Rarely are specific services designed to meet the needs of carers themselves. Jones and Vetter (1985, p643) observed that " carers support elderly dependents at great cost to themselves and with inadequate support from community services". Many carers suffer from stress and related physical ill-health as a direct result of caring for another person and many give up some social activities when they start caring. Wenger et al's study of carers of people with dementia found that in the 12 months prior to interview, 23% of carers received no specialised formal service for the person with dementia. They observed that "the contribution that carers make to care in the community for the most dependent people who remain at home, therefore, should not be underestimated" (p36).

6.38 The needs of carers are diverse, but across Scotland many voluntary groups provide support at a distance and practical help to those who care for elderly people and to elderly people who themselves are caring for a dependent. National organisations such as the Alzheimer's Society ( http://www.alzheimers.org.uk) and The Stroke Association ( http://www.stroke.org.uk) produce information sheets for carers. The former has a network of branches, carers support groups and carers' contacts (although none are based in Scotland). The Alzheimer's Society also offers support to those whose role as a carer has ended, helping them to rebuild their own lives after spending time caring for someone else. The After Dementia Millennium Awards can help carers rebuild their lives through grants to help develop the skills and interests of the former carer. Practical help for carers is also available. Emergency / crisis care is offered by a variety of voluntary groups, ensuring that short-term care is provided at times when the regular carer cannot fulfil their caring role. Other forms of support are also available, for example, in Dumfries and Galloway the British Red Cross' Transport and Escort service is running a pilot project transporting carers of housebound and/or isolated people:

Mental Health

6.39 " Rural elders are one of the greatest at-risk groups for experiencing mental health problems" (Kaufman et al, 2000 p462). Depression and dementia are the most common mental health problems experienced by older people. Mental health still carries a stigma for many people, and, coupled with the unevenness of mental health service provision across Scotland and a lack of awareness and training about mental health issues amongst professionals in daily contact with older people, many mental health problems pass undiagnosed (see, for example, Vetter et al, 1986). Organic mental illnesses, such as dementia, are largely untreatable. Psychiatric disorders such as depression and anxiety are treatable, and the service offered to older people is no different to that offered to the community as a whole.

6.40 The Framework for Mental Health Services in Scotland is concerned with the implementation of improvements to mental health services across Scotland. Improvements to mental health services are also underway in the Nordic countries. For example, in Norway the government instigated a plan for mandatory state investment in improvements to mental health services in 1998. The aims of the plan include improving municipal services with a particular emphasis on preventative care and early help and expanding provincial psychiatric centres and polyclincs to improve psychiatric services for adults. Expanding services at the local level will be of particular benefit to rural municipalities and will mean that older people requiring mental health services will have easier access to the services they require.

Factual information about depression and dementia amongst the older population

6.41 Adding Life to Years, (Scottish Executive, 2002 p40), makes the following observations about depression amongst the older population in Scotland:

• Affects 3 -5% of the over 65s at any point in time;
• Milder forms of mood disorder are present in another 10-15% of the over 65s at any given point in time;
• 40% of people who have suffered a stroke become depressed;
• Rates of depression are particularly high in long-term care settings.

6.42 The following observations about dementia are drawn from factual information provided by the Alzheimer's Society (2001) and the Adding Life to Years report.

• c750, 000 people in the UK suffer from dementia (97.5% of whom are over the age of 65);
• c5% of people aged 65+ suffer from some form of dementia;
• c25% of those aged 85+ suffer from some form of dementia;
• 60% of dementia patients live at home;
• Alzheimer's disease is the most common form of dementia, multi-infarct dementia is the next most common.

6.43 Research in the UK and North America (Vetter et al, 1986, Kaufman et al, 2000) suggests that the prevalence of mental illness, depression in particular, amongst the older rural population has been underestimated. Vetter et al (1986, p127) observed that " health and social services personnel are poor at detecting psychological abnormalities, particularly in the elderly, and at differentiating symptoms due to anxiety and depression on the one hand and organic brain failure on the other". Training care staff to identify mental health problems could help detect more cases of treatable, non-organic mental health conditions.

6.44 As is the case with physical health care, providing appropriate psychological and psychiatric care to the elderly rural population poses more logistical problems than does providing such services within densely populated urban areas. The national trend in recent years has been to decentralise mental health services, to the benefit of rural communities. Community based psychiatric teams now deliver a locally based service to rural communities, but this does not mean that all rural centres are the foci of community psychiatric teams. Some assessment and treatment may be made within a patient's home. Other evaluation and treatment may require an out-patients appointment, often delivered in community health centres and GP premises. Some services may involve the use of video-conferencing. As noted by Sumner (2001, p370) " Telepsychiatry presents an innovative and cost-effective strategy for the provision of improved local access to quality mental health services for the underserved elderly". Basing his observations on the psychiatric health service needs of older rural Americans he suggested that advances in tele-medicine technology will make it possible for a core mental health team, located at a geographical distance from their clients, to deliver timely, quality psychiatric care that would not be possible under traditional methods of practice. Mobile clinics may be used to bring psychiatric services to local communities or may provide day-care facilities. For example, in the Highland Health Board Area, a trial project has run whereby a mobile psychiatric day hospital has taken mental health services into the community.

6.45 There are obvious advantages to rural communities in the delivery of mental health services within the community, notably the reduced need to travel to appointments. On the other hand, the anonymity of patients may be diminished by attending a local service, but older people are no more affected by this than any other member of the community requiring treatment for mental illness.

6.46 Providing high quality mental health services to rural communities relies on the service being staffed by good quality personnel. Although the shortage of qualified professionals in gerontological psychiatry, geriatric nursing and gerontological social work is nowhere near as acute in rural Scotland as it is in, for example, across rural communities in the United States, it can be difficult to attract suitably qualified professionals to take up positions in remote rural areas.

Paying for health and social care

6.47 Across Europe, welfare systems have been restructured in the last 20 years. The main focus of policy activity has been in the areas of pensions, unemployment benefits, parental leave and payments for the care of the ill, elderly and incapacitated people (Daly, 1997). These welfare reforms have taken place at the same time as the numbers of older people, and in particular the old-old, have increased throughout Europe. As the numbers of older people increases, increasing demands are made for state pensions and welfare services such as health and social care. All the Nordic countries have restructured their welfare systems in recent years. In general, Finland and Sweden have implemented more cut-backs to their welfare programmes than Denmark and Norway (Kvist, 1999).

6.48 In Denmark, where services for elderly people are managed by the local authorities, 65% of local authority expenditure in the social sector is consumed by services for elderly people (Petersen, 1992). The Danish government has made increasing demands on local authorities to limit spending and therefore increased demands for public services by older people have had to be accommodated without an increase in public funding. However, although costly at the outset, restructuring long-term care of the elderly by implementing integrated systems for home and community-based services appears to have resulted in the cost of caring for the over 80s dropping as a percentage of GDP (Stuart, 2001). The lesson to be drawn from the Danish experience is, therefore, that setting up quality elder-care systems, although costly in the short term, may lead to longer term savings in public expenditure

Conclusions

6.49 There is no firm evidence to suggest that the health and social care needs of elderly people in rural areas are any different to those required by those living in non-rural areas. The rural dimension to health and social care is expressed primarily in terms of service delivery challenges. Demographic trends noted in this report also indicate that an increasing demand for health and social care services will result as the total number of those aged 75 and over increases. As rural areas contain a higher proportion of older people than non-rural areas of Scotland, it is likely that increasing numbers of over 75s and, in particular, over 85s, will have the greatest effect in rural areas of Scotland. The Arbuthnott report recommendation of incorporating a remoteness weighting into the resource allocation formula will benefit rural areas and should accommodate the increase in service demand caused by the growing elderly population. However, it cannot ensure that the delivery of health and related social care services to older people in rural areas will be problem-free in the future.

6.50 The implications of bed-blocking, the closure of private sector residential homes and increasing use of voluntary organisations to deliver statutory services require detailed consideration if the delivery of high quality health and social care services are to continue across Scotland. It is clear from the material presented in this chapter that health and social care needs have strong relationships with accessibility and housing issues. It is impossible to consider one theme without bearing in mind possible knock-on effects from other themes. The need for integrated service planning and delivery is recognised, but closer liaison between professionals representing these areas is still required.

Key Issue 1

6.51 In the past, frail elderly people have been much less likely to be involved in the community care decision making process than their more active counterparts. There is thus a need to ensure that all elderly people have opportunities to voice their opinion to decision makers. The Finnish model described above may be transferable to Scotland for this purpose and the Fife User Panel model could be extended to other parts of the country.

Key Issue 2

6.52 There is a need for employers to consider the elder care responsibilities of their employees (see Gilhooly and Redpath, 1997). Family-friendly policies, however, appear solely concerned with a child-centred approach. We recommend that 'family-friendly' policy is extended to incorporate the needs of the carers of elderly relatives.

Key Issue 3

6.53 Adults who leave the labour market to care for elderly relatives may endanger their own financial status in old age as they reduce the number of years in which they make National Insurance and pension contributions. It is worth considering whether such adults could receive National Insurance credits for the time they spend as carers so that they are not penalised financially in later life.

Key Issue 4

6.54 The provision of unpaid care, usually within the family unit, cannot be assumed to be as readily available in the future as it is now. Neither can it be assumed that the level of voluntary activity will remain the same (volunteer fatigue is already an issue in rural areas). It will therefore be necessary to consider scenarios where fewer elderly people in need of care and support are assisted by unpaid labour when planning for the delivery and resourcing of care and support services in the future.