people lives communities

1. Achieving Age Equality in Health & Social Care Equality Commission for Northern Ireland 25 September 2012 Helen Bowers – Head of Policy & Research, NDTi www.ndti.org.uk people lives communities

2. The National Review Sir Ian Carruthers Chief Executive South West SHA Jan Ormondroyd Chief Executive Bristol City Council Terms of Reference of the review • The national review of age discrimination made recommendations on the following areas: • the timetable for implementation of the ban on age discrimination; • where it is objectively justifiable to retain age-based differentiation in services; • how to support the health and social care system to implement the public sector equality duty in respect of all age groups; • which key actions health and social care bodies should take to make demonstrable progress in meeting their obligations as quickly as possible. 2 2

3. Contexts & outcomes of the review • Supported proposal in the (then) Bill to ban age discrimination against adults in provision of services & exercise of public functions • Supported proposal to create a public sector equality duty covering all protected characteristics • Made specific recommendations to make this happen in health and social care • Took account of key contexts and realities: • Personalisation • Financial crisis • Whole system approach • What currently exists to address inequality and discrimination • Multiple discrimination and inequality

4. Different treatment by age is not always discrimination It can be “good” It can be “neutral” It can be “bad” Age appropriate services where these meet people’s needs Positive action - to redress unfairness Reflect physiological characteristics in the population rather than individuals Differences in treatment may reflect natural variation rather than be the result of specific decisions Direct discrimination is treating someone less favourably because of their age Indirect discrimination is when an apparently neutral criterion places people of a particular age at a disadvantage compared to others unless the less favourable treatment is justified

5. The key test is, what does this mean for Joseph and Alice? Joseph is 77 years old. He went to the GP because he was having problems with walking to the shops. The doctor said that if he had been younger, then he would have referred him for an operation on his knee, but at his age, what did he expect? His daughter was present and she intervened and so the doctor agree to refer and Joseph successfully had the operation. Alice is 85 and lived in her own home with support from her daughter. When the daughter became ill, the social worker and GP were concerned about the level of support she would need to remain at home, even though she strongly wanted to remain there. She was not offered the option of direct payments. Alice was re-housed into residential care, where she died six months later.

6. There is clear evidence of age discrimination In the care of individuals and carers In the organisation of services for communities • In the organisation & delivery of acute care, mental health services and community health & social care services • Not including older people in medical research (thus insufficient evidence for some public health programmes) • Ageist attitudes and comments • Poorer access to investigations and treatments • Less comprehensive assessment of individual and carer needs • Lower expenditure on packages of care See the person not the age - personal care that has dignity and respect at its heart Be explicit about the effect of policies on different age groups http://age-equality.southwest.nhs.uk/definitions-legal-framework-and-implementation.php 6

7. A decade of progress but there is more to be done 2011- 2012 Implementation 2010 2009 2006 2001 Equality Act A resource pack to support local implementation “a reduction in explicit age discrimination … except for mental health needs… (and) poor treatment that indicated ageist attitudes or practice” “truly eliminate age discrimination … and ensure care is personal and meets the needs of each individual” “root out age discrimination” 7 7

8. The solutions are to be found in existing policies BUT with an explicit focus on age discrimination and age equality 1. Engaging with the public and partners 2. Focusing on personalisation and patient centred care 3. Delivering improvement in key services Dementia Falls Involvement Putting People First A focus on age High Quality Care for All Prevention Cancer

9. Recommendation on timing Recommendation: set the same commencement date as in other sectors October 2010: consolidation of existing equalities legislation covering race, gender, disability etc. April 2011: implementation of the new public sector duty to have due regard to the need to advance equality 2012: implementation of the ban on age discrimination in the provision of services and exercise of public functions

10. Recommendation on “objective justification” Recommendation – no wholesale exception but government should explore targeted exceptions Approach A Approach B Age differentiation must be “objectively justified” (i.e. a proportionate means of achieving a legitimate aim). Members of the public can challenge health and social care professionals and organisations where they feel they have been discriminated against. Professionals and organisations will need to show that their decision can be objectively justified Create one or two specific exceptions where age differences are demonstrably of general benefit. Age differentiation in all other areas must be objectively justified Professionals and organisations will need to show the difference can be objectively justified or it meets the criteria in the exemption. Members of the public can challenge if they feel that the exception is not applicable.

11. Recommendations on resources and commissioning • The allocation process • funding formulae for • PCTs and local authorities Cost effectiveness and prioritisation of decisions Commissioning services for populations Charging for social care Commissioning care for individuals

12. Recommendations on behaviours and culture “Seeing the person, not the age” Shaping norms – the role of the professional regulators Being seen, Being heard – involvement and feedback Education and training Leadership and organisational culture

13. Recommendations on local implementation • A local implementation process (recommendation 19): • Joint audit of services, systems and processes across health and social care • Joint action planning • Work with NHS, LA, third and independent sector providers • Involve members of the public; • Use local scrutiny processes; • Agreement about local resource consequences • Build on existing approaches and policies but recognise that the age provisions in the Act are a new requirement • A pack of resources, including good practice material, and whether there should be designated national centres of expertise (recommendation 20) • Developing a joint assurance process for social care and health to demonstrate progress, including links to the Equality and Diversity Council (recommendation 22)

14. Addressing age discrimination in health and social care Age discrimination has no place in a fair society, which values all its members and the principles and values which drive the NHS and social care require us to treat everyone fairly based on their needs, whatever their age. What should local authorities & NHS organisations do to end age discrimination and promote age equality? • Equality Act 2010 • In 2011 introduces a new duty to promote equality, including age equality • In 2012 bans age discrimination in the provision of services

15. A resource pack to support local implementation Age Equality Audit Tool Enables partners to do a joint self-assessment and create a gapanalysis to highlight priorities for action and inform localdecisions and investments Sector-specific practice guides, with information about how and why age discrimination occurs and examples of good practice to help address identified gaps and priorities NHS practice guide Social care practice guide Available from mid May

16. The Achieving Age Equality Toolkit http://age-equality.southwest.nhs.uk/ Agencies and communities work together to review current services using evidence based criteria to determine whether services are ‘age discriminatory’ or ‘age equal’

17. Getting Started & an “ideal process” • Assess your “readiness” for working together, and with local communities, to review the current situation and agree local priorities • Engage partners & stakeholders in an “Area Audit Group” • Agree your local, tailored approach • Use the “ideal process” as a starter for 10

18. Four sets of “AAE Criteria” • Organisational and system readiness • Acute care and treatment • Mental health & mental health services • Primary and community based health & social care

19. http://age-equality.southwest.nhs.uk/ Age Equality Audit Tool

20. Implementation issues • Always intended to be a “must do”; never enforced • Scepticism and lack of engagement at strategic, leadership levels – how best to tackle deep rooted ‘institutional ageism’? • Lack of a strong voice among older people using health & social care services – how best to increase, locally & nationally? • Need to build into existing (ever changing!) systems for quality, improvement, performance, regulation – which ones? • Is there a place for a toolkit / learning network across all public services?

21. Drivers for implementation.....do these have traction locally for health and social care leaders? The law is coming into effect at the same time as unprecedented pressures on health and social care budgets, so what are the local drivers for implementation? The quality imperative – general work on quality improvement and transformation will push organisations to take ending age discrimination seriously The legal imperative – the Equality Act adds a new dimension to implementation as organisations will be motivated to comply with the law and regulators will have powers to enforce the law The public imperative – patients, service users, carers and members of the public will push for organisations to end age discrimination and individuals may take out legal cases in the courts Local Action to end age discrimination and promote equality The moral imperative - there is a strong commitment to quality among health and social care staff which leads organisations to be motivated to ending age discrimination

22. Thank you & contacts • www.ndti.org.uk • Caroline.Bernard@ndti.org.uk @ndtihelen / @ndticaroline ndti.org.uk