Research Policy and Planning: The journal of the Social Services Research Group – 2000
Services for the 21 st Century: meeting the needs of older people
Tessa Harding, Help the Aged
Services in the 21st Century – or at least at the beginning of it – are likely to be shaped by current trends. The most significant is demographic change and the ageing of the population. Being older will be ‘normal’ and services will be increasingly shaped by the voice of older people themselves. The Human Rights Act and government emphasis on ‘the civil society’ will over time change the balance of power between the individual and the state, and technology has all sorts of possibilities in store. However, it seems likely that there will be enduring problems – notably persistent poverty in old age, endemic ageism in our society and a legacy of paternalism in our services. If services are going to meet the needs of older people in the 21st Century, they are going to have to change radically. What older people want is ‘life, not a care plan’. The first priority will be to ensure that older people are able and encouraged to play a full part in society and in their own communities. The second priority is to have in place the right kind of help to ensure that people stay healthy and retain their independence. We are going to need older people in the 21st Century, because they will be a very significant proportion of our population. And they will be us – so it is up to us to make our own futures.
The new millennium presents an irresistible temptation to think big, think broad and speculate on the future. This is clearly always a risky thing to do. What happens in the future is always a surprise and those who attempt to predict are inevitably heading for a fall. Leon Kreitzman, whose job entails thinking about the unknowable, likes to tell the story of the US Academy of Sciences which in 1937 undertook a study for President Roosevelt to predict scientific breakthroughs. It came up with some good guesses about agriculture, synthetic gasoline and synthetic rubber. It totally missed nuclear energy, antibiotics, jet aircraft, space travel, computers and transistors, as well as lasers, fibre optics and transplants [Kreitzman, 1996]. So perhaps we should be a little humble and stick to current trends and extrapolate from those, rather than trying to think the unthinkable.
So what are the trends and influences we can see at present?
First, and most obviously, there is the impact of demographic change. Along with the rest of the world, we have an ageing population. I won’t repeat the figures here because I am sure you are familiar with them. But there are two significant features: firstly that older people will make up a much greater proportion of the population as a whole, and their role within society is likely to change as a result; and. secondly, that the steepest rise in numbers will be in those in the oldest age brackets, and these are the people most likely to need some form of support.
I hope that, with the help of the Royal Commission on Long Term Care, we have got over the moral panic that an ageing population will necessarily be a ‘burden’ and a drain on resources. As they have said, it is intolerable to describe older people as a problem. We should instead see it as an unprecedented opportunity, and a challenge to our capacity to change as a society:
There is now a clear opportunity to see old age for what it is, a stage of life where we have the gift of time to be able to acquire knowledge and experience for which there may not have been time during working lives. In this age of opportunity, while physical capabilities or mental faculties may change, people should not necessarily be assumed to be the passive recipients of the goodwill of others or inevitably incapacitated, befuddled or redundant. [Stationery Office, 1999: para 1 & 14]
Of course we know that to be the case – there are plenty of older people in their 80s and 90s who are active, healthy and still pursuing their interests with vigour and determination. We have invited a few of them to contribute to a book to be published shortly called ‘Getting a life – older people talking’. But we need a profound change of mindset to stop equating age with incapacity, frailty and lack of usefulness. However, we must also recognise the fact that increased numbers of older people will require us to ensure that we are geared up to provide the right level of support. What the demographic picture should do is alert us to the need to be prepared and to plan ahead – and to do that imaginatively and with the involvement of older people themselves.
A Growing Voice
The second major trend is the growing voice of older people. With the ageing of the population, older people are increasingly going to be the norm rather than the exception. As a group they are going to have ever greater voting power (and older people do tend to use their vote) and they are already beginning to be a major force as consumers. Products and services aimed at ‘the grey market’ are expanding. Both these factors are likely to become increasingly significant. But perhaps even more significant is the growing older people’s movement.
All over the country there are Senior Citizens’ Forums which bring older people together to tackle issues that are of concern to them. At Help the Aged, we know of some 450 such groups, and more are springing up all the time. They originate from a variety of sources -sometimes from the initiative of individuals, sometimes with help from local development workers attacked to voluntary organisations or local authorities, sometimes from trade union Retired Members’ Associations. We have a programme called Speaking Up for Our Age which aims to support the development of such groups with grants, information and opportunities for networking and for participating in regional and national conferences [Help the Aged, 2000]. In some areas, there are regional umbrella organisations such as the Greater London Forum for the Elderly or the Strathclyde Elderly Forum which foster new groups and co-ordinate activities between existing ones. In others, where Better Government for Older People has had twenty-eight pilots, new groups have developed as part of implementing local strategies for an ageing population. Those areas have had the advantage of backing from the Better Government core team, the commitment of their local authority and other local partners to the programme, and of the Steering Group which has crucially involved central government.
There are national organisations bringing Forums and other groups together – the National Pensioners’ Convention is by far the biggest and best known – and has a high political profile, particularly on the issue of pensions on which it has been battling for years. Other new national networks are developing, such as the Older Women’s Network UK, a potential network for ethnic minority elders and the Better Government for Older People Advisory Group which, with the backing of the programme, has developed a strong and cohesive voice of its own.
What is common to such groups is that they are independent and a platform for voicing older people’s own priorities. Their agendas are typically very wide: they encompass transport, the level of the pension, the closure of post offices, conditions in the local hospital, charges for community care, street safety and a future as well – for the world that their children and grandchildren will inherit. They are usually more than willing to work in partnership with local authorities and others – but they do expect to be heard and they do expect that the issues they identify as important will be given due consideration.
Do not underestimate the power of that voice – as older people become more organised and have a vehicle for their views, they will make themselves felt as a power in the land. Over the past ten or twenty years, the various disability movements have made their presence felt and have wholly changed the agenda for disabled people. They have created new concepts like the social model of disability, challenged preconceptions and prejudices, generated new legislation such as Direct Payments and wholly changed the quality of life of disabled people. Something similar is now happening for older people, and they themselves are becoming the agents of change in their own lives and our futures.
Citizenship and Rights
Another factor which is likely to influence the future is the Governments own agenda for a civil society, in which all citizens have responsibilities and a role to play within society, and in which all citizens also have rights. The implementation of the Human Rights Act in October 2000 has been called (by Jack Straw) ‘ the most significant constitutional change since 1688’. It will incorporate into UK law the European Convention on Human Rights and requires that all public bodies act in accordance with those rights. All new legislation now going through parliament has to conform to the Convention, and so will all local policies agreed by public bodies or those acting in their name, including private and voluntary service providers. It will also mean that it will be easier for individuals to challenge their treatment by such bodies if they feel that their human rights have been contravened.
It is difficult to know at this stage quite what impact the Act is likely to have in practice, but no one is doubting its significance. For the first time, our law will be framed not just in terms of the duties placed on public bodies but also in terms of the rights of the individual.
The final trend I want to mention is that of the growing potential of technology and its influence on our daily lives. it has already changed the way we communicate and greatly increased our access to information, and will no doubt continue to do so. it is beginning to influence the way we shop, the way we handle our finances, the way we work and the way we manage our home lives. We are only at the very beginning of recognising the potential of technology to make the lives of older people easier and more interesting, and the ways it could enhance independent living.
Along with Counsel and Care, Help the Aged has just established the Technology for living Forum. The aim of the Forum is to generate discussion between those who know what technology is capable of – the manufacturers and developers – and those who know what the problems are that it might help to alleviate -that is, older people themselves and the housing and care providers that are trying to cater for their needs. The list of the first round of seminars the Forum is holding reads like an agenda for change in its own right: mobility, communication, design, safety and so on – together with some of the ethical issues that arise from the application of new technology.
These, then, are likely to be significant drivers in shaping the future. What they will have to contend with are some of the enduring problems that we face – notably, persistent poverty in old age, endemic ageism in our society, and a legacy of paternalism in our services. These are major and long-term challenges for all of us.
The poverty issue shows few signs of being resolved -certainly for the current generation of older people. The minimum income guarantee is intended to ensure that the poverty of those reliant on the state pension is relieved, but we all know the problem of unclaimed benefit entitlements. And the issue of those whose small occupational pensions lifts them just above the income Support level remains unaddressed. While the government has made some welcome – and expensive – gestures towards the older population (such as free TV licenses for the over 75s and £150 annually for pensioner households for heating bills), most older people would have preferred an increase in the basic pension and the dignity of choice.
For future generations, the risk still is that, while some of us will be reasonably well provided for, many will not. Even the stakeholder pensioner for people on low incomes does not address the needs of those who are unable either to find or to take long-term employment. With work patterns changing, men in the future may find themselves in a similar position to that of many women today, with broken employment records and inadequate contributions.
Lack of a ready solution to poverty in old age has far-reaching implications – because the first priority for security in old age, and for having some choice and control in one’s life, is a sufficient income [Henwood and Waddington, 1998]. But we show no real signs of cracking this problem yet. If services are going to meet the needs of older people in the 21st Century they are going to have to change radically.
A Life, Not a Care Plan
What older people want first and foremost, confirmed again and again in consultation exercises in which older people set the agenda, is access to all those facilities and services that the rest of us take for granted. To put it in the words of one of the participants in some Kings Fund research: ‘I want a life, not a care plan’ [Easterbrook, 1999]. Older people want to be able to play a full part in society and in their own communities.
They want to be mobile, to be involved, to be able to pursue lifelong interests and to acquire new ones; to be able to participate in education and in leisure activities, in music and the arts, in sport and in community activities, and to have a social life, just like the rest of us. Of course many older people do just that. they are the backbone of many community groups and our society would fall apart without them. But there are also barriers in the way which make it very difficult, and indeed impossible, for some.
Such barriers include practical things like lack of money. We produced a video called ‘A Life worth living’ a couple of years back – one of the scenes that stays in my mind is of a very alert but disabled older woman in Glasgow, one of the founder members of the Strathclyde Elderly Forum, saying – ‘I used to like to go out for a drink, but I don’t go now; I can’t stand my round’ [Help the Aged, 1998]. Also a lack of safe, accessible, reliable and affordable transport. Many older people, especially older women, are dependent on public transport. lack of transport in rural areas, or bus routes which stop running at 5.30 in the evening, or routes where you may have to wait a long time in the cold because the buses are unreliable, are all major inhibitors of participation and confine older people to their own homes. So are unsafe streets and unfriendly public environments.
Other barriers are less tangible but equally off-putting – for example education policies and programmes which focus exclusively on vocational training and education and have nothing to offer most older people, or sports facilities which are too expensive or unfriendly to older people. Older people’s groups and Forums have campaigned on all these issues and many have achieved significant successes locally. Quite often, the problems that bar older people from a full life are quite easy to resolve – provided that those responsible are listening and willing to respond.
One of the most exciting things that has happened over the last two years has been the increasing recognition that older people have an interest in, and want to have a say in, the whole range of services and facilities that local authorities are responsible for; that they do not belong in a box labelled ‘Health and Care’ but have interests across the board.
The Better Government for Older People programme has led the way here. By encouraging local authorities to take a strategic approach to meeting the needs of the older population, by basing the pilot projects wherever possible under the aegis of the Chief Executive rather than the Director of Social Services, by seeking to involve the whole Council and its partners in the private and voluntary sectors and, crucially, by involving older people directly in shaping and progressing the agenda, many of the Better Government pilots have been tackling these barriers and making local communities much more inclusive of older people [Cabinet Office, forthcoming]. The Better Government for Older People programme will be coming to an end in its present form at the end of this year, but we are looking for ways of integrating this learning into the wider modernising agenda for local government.
Help to Stay Healthy and Active
The second priority from older people’s point of view is help to stay active and healthy. In an ageing population, helping older people stay healthy and independent makes economic as well as human sense. The Government agenda, which is about tackling the causes of ill health and putting greater emphasis on prevention and rehabilitation, is right in line with these problems.
This is a hugely wide agenda – from tackling poor housing conditions and cold homes, through the new emphasis on public health to primary care services which actively seek to ensure that illness and disabling conditions are caught and treated early, and better information about where to get help when you begin to need it. It will mean finding new ways of ensuring that older people can get help in the home for those jobs they can no longer manage, whether that is fitting door and window locks or insulation, or gardening, or changing lightbulbs and washing the curtains.
It is right in line with the strong emphasis on rehabilitation and the promotion of independence that have become part of the health and social services agenda in recent years. But with resources in social services already so stretched to provide essential care for those who are most dependent, it is going to need substantial new investment, as well as a concerted effort along with housing departments and the voluntary sector, to begin to make a real impact on preventative services.
The next round of Beacon Councils will include a theme on promoting the independence of older people that will provide an opportunity for further highlighting these needs and for looking for imaginative and creative solutions. My suggestions to those who want to bid for Beacon Council status is to start consulting older people locally – it is likely that some of the most economical and imaginative solutions will come from them and from some of the voluntary organisations that are already active in this field.
Creating a New Generation of Services
Finally to social services themselves. There can be no doubt that most services for older people Jag far behind the developments that we have seen in recent years in services for disabled people or people with learning difficulties. There are still far too many services – in residential care. in day care and in domiciliary care – where older people are expected to fit in with and put up with what they are offered, rather than being offered the kind of support that they want, tailored to their individual and specific needs and their priorities in life. And what they are offered can be very limiting and very narrow.
Support for older people, as for other groups, should be about maximising quality of life and promoting autonomy – irrespective of the state of health or degree of disability of the person concerned. You cannot very easily help someone achieve a decent quality of life by popping in for twenty minutes three times a day just to make sure they are cleaned and fed. And the size of your room in a residential home is no guarantee that you will not be slumped in the corner of the day room bored to tears and with nothing to do and no aim or purpose in life. There is ample research evidence that levels of depression amongst older people are very high, whether they are in their own homes or in residential care. Frankly, I do not think that is surprising when the quality of support we offer is often so limited and older people have so little control over their own lives.
It is really encouraging to see more imaginative forms of support developing, in which older people have a real role in shaping their own lives and taking decisions, and in which there is a variety of opportunities available to them to use their time constructively. I have seen housing with care initiatives that offer a whole new lease of life to very frail older people, and day services which offer a range of stimulating opportunities suited to a variety of tastes and in which older people themselves decide what they want to do – and often organise it for themselves. 1 hope and trust that these are the early signs of a new attitude to social services for older people, and of their emancipation from the burden of being labelled ‘dependent`.
Underlying the whole of this agenda is a changed attitude to older people. For any of us, living a full life means having a useful and purposeful role and the respect of others. But at a meeting I was at the other day, an older woman said: ‘Once your hair turns grey, you disappear into the wallpaper’. The comment drew nods from the ninety or so older people in the room. Older people are all too often overlooked, ignored and stereotyped. They are the losers – but so are we. With an ageing population we are not going to be able to do without their skills, experience and energy. To quote Margaret Simey, herself now in her nineties:
What we need is a new emancipation movement that will bring our elders out of the cold of dependency into the warmth of mainstream life in the community to our mutual benefit. [Simey, 1998]
We will all be the inheritors of the efforts older people are making now to make that vision come true.
Kreitzman, L. (1996) in Harding, Meredith and Wistow (eds), Options for Long Term Care, HMSO: London
Stationery Office (1999) Royal Commission on Long Term Care: With respect to old age, TSO Cm 4192-1
Help the Aged (2000) Speaking Up for Our Age, evaluation, Help the Aged: London
Technology for living Forum UK: leaflet, conference report and newsletter 1999-2000
Henwood, M. and Waddington, P. (1998) Expecting the worst – views on the hiture of long term care, Help the Aged and Nuffield Institute for Health: London
Easterbrook, L. (1999) When we are very old -reflections on treatment, care and support of older people, Kings Fund
Help the Aged (1988) Life worth living video, Help the Aged: London
Cabinet Office (forthcoming) Better Government for Older People Evaluation Report, The Cabinet Office: London
Simey, M. (1998) in Bernard and Phillips: The social policy of old age, Centre for Policy on Ageing: London