Chapter 3: Older people
As with other segments of the population - young people, middle aged people - older people vary greatly, and have different needs. There are the:
- "Younger" older people, who tend to be fit, economically active and healthy or relatively healthy.
- "Older" people, who are still fit but not economically active, and may have regular but low-level calls on the health service to see, for example, a GP or pharmacist and will not need social care services unless they are carers looking after older family members.
- Frail older people, of whom there are:
- those who manage to get by largely on their own, perhaps with support from family and with regular visits to the GP and sometimes low level support services.
- people with high dependency needs who need specialist services and intensive support including personal care.
Getting older, feeling young
The definition of "older people" is fraught with difficulty, and changes with the generations. The age of an older person in 1900, when grandparents were the exception, was much lower than in 2000, when grandparents were quite normal. It also changes with the views of the individual - according to How Ageist is Britain?, a research report commissioned by Age Concern (September 2005) a 24 year old believes old age begins at about 55, while a 62 year old thinks youth does not end until 57.
As people get older they delay the age which they think of as getting old and the Report noted "Subjectively we tend to think we are still young".
How Ageist is Britain? records views from 1,843 adults and found very different views on the ages at which youth ends and old age starts. The average across those interviewed was that youth ends at 49 and old age begins at 65.
Trends seen already in the UK include that older people act and feel young, and that lifestyles traditionally associated with different age categories are being blurred. SAGA has built a large and successful business on providing holidays (including to destinations such as Vietnam) and other services such as insurance, to those over 50.
Research announced at the British Association Festival of Science in September 2005 stated that increasing life expectancy and better knowledge of ways of slowing the effects of ageing on the brain were leading to a growing gulf between biological and chronological age - "our bodies are getting healthier and we are living longer. The main threat to being able to function effectively in old age is the functioning of our brains".
This research noted strong evidence that for those over 50, the degree to which someone retains their functions is down to just a handful of factors - diet, exercise, mental stimulation, mental training and stress (moderate levels of stress can be stimulating, but very high levels are deleterious to health). It found that volunteers aged 65 and over who did 10 hours of training sessions to improve their memory, problem-solving and reaction times had mental abilities equivalent to people between 7 and 14 years younger than those who did not.
There is clear encouragement here for the aim of all health improvement work, which is that people reach older age as healthy as they can be. Those who are mentally and physically fit are much less likely to become dependent on others.
Health inequalities
Health inequalities are an important issue. The British Medical Journal (30th April 2005) suggested that inequalities in life expectancy between rich and poor areas of the UK continued to widen in the first few years of the 21st Century, alongside widening inequalities in wealth, suggesting that more potent and redistributive policies are needed. The levels of social security benefit for those out of work are relatively low compared to EU poverty standards and too low to maintain good health. When 50% of the Glasgow population is in the most socio-economically deprived decile of the Scottish population, the extent of the issue is clear. Income inequalities also affect quality of life and ability to purchase services.
Health inequalities are dealt with in Building a Health Service Fit for the Future (Volume 2 chapter 6). The Executive has responded with the Prevention 2010 programme in Glasgow. This will proactively seek out people at particular risk of preventable ill-health, and provide access to services. It is a preventative medicine approach to deliver services to those at greatest risk in deprived communities.
Ageism
There is an issue about ageism in the way in which social care and health policy is implemented locally in Scotland, perhaps largely related to the rationing of scarce resources. We note later in this Report examples of different approaches to the nature and standard and financing of social care provided to those under 60 and to those who are older.
Ageism can be very subtle, and the way the service is delivered is also important. Even when services for older people are tailored to their needs, services can nevertheless still make value judgements and pin-hole older people. Older people can also be very vulnerable, on their own, without close family advocates and may be less demanding of their entitlements than others. The result can be that services may not help older people as much as they could.
Changing perceptions and higher expectations
Finally, we also note that future generations of older people will not be like those of today. Today's older people have known rationing during the war years 1939-45, running on subsequently into the 1950s. The next generation of older people have been used to services available instantly, a wide variety of choice, and diversity of supply. They will have different aspirations and a higher expectation of services than previous generations. This has clear implications for the vision for care we develop later, which needs to be flexible to meet expectations.
Input from service users in workshops run for Personalisation and Participation: The Future of Social Care in Scotland (final report November 2005) confirm that people:
- see care as a right rather than a privilege.
- do not want to feel they have lost control, because their lives are being run by other people, no matter how well meaning.
- feel entitled to a say in shaping services to suit their needs.
People will want services that give them a sense of dignity, confidence and control.
Personalised services
The trend of the 21st century is towards greater individuality, choice and mobility. One response from the market place is towards personalised marketing, and personalised customer service. Further, people expect service to be available consistently - where, when and how people want it. This impacts on social care and health care, particularly when tomorrow's users are used to choice and service.
The call for services that meet people's needs is not new, and in recent years the emphasis has been on designing and delivering public services around the needs of individuals and, indeed, communities. Lately the term personalisation has been coined.
Personalisation
This has come to the fore through publication of Personalisation through participation (Demos, 2005). Personalisation of public services has the aim of meeting better the needs and aspirations of service users, and it underpins much of current and developing public services policy. The distinctive thing about personalisation is that it is not just about the use of services.
Personalisation builds on the capacity of individuals and communities to find their own solutions and to self-care, rather than creating dependence on services. It puts the person at the centre as a participant in shaping the services they get, and allows them to work with professionals and their carers to manage risk and resources. It leads to collaborative forms of provision which are person centred, flexible, adaptive and supportive, and yet which are also affordable.
This requires services to develop greater diversity and flexibility of provision, re-focus the roles and skills of workers, and develop the expertise of the individuals and families who need help.
The Report of the 21 st Century Social Work Review noted that personalisation means:
- more involvement of people who use services and their carers in designing and developing services;
- increased choice and flexibility in service delivery;
- increased recognition of the role of unpaid carers;
- a far greater emphasis on self assessment and self managed care;
- mobilisation of community resources; and
- the efforts of skilled professionals being increasingly focused on supporting those people who are unable to exercise choice.
Delivering for Health addresses similar themes, such as the development of informed service users, the importance of unpaid carers, the need to develop anticipatory care services and the need to streamline access to services.
The Care 21 Unit commissioned work from Demos Personalisation and Participation: The Future of Social Care in Scotland (final report November 2005). This found that people want a sense of dignity, and that they count as a person. Consequently services should be done with them, rather than to them: people do not want to lose control of what happens to them. They want a sense of dignity, to know they are listened to, and that their views count.
Participation of users is not an add on - they have much to give in developing, designing, providing in some cases, and monitoring services - so their participation is essential. An informed user of a service is an empowered one, and some of the decisions that person takes may be personal ones that contribute to health - stopping smoking, eating healthier food or taking more exercise. In this way people become participants and investors in their own care.
These are areas where people can make informed choices. Health care and community care services are dealing with quality of life, and only the person getting the service (and their family or carer) knows whether they are getting the quality of service they need.