Consultation event on age equality in health and social care

1. Ageism and Age Discrimination Consultation event on age equality in health and social care Leeds Feb 8 2010 David Oliver Source: www.southwest.nhs.uk/age-equality.html

2. First, a heartfelt “thankyou”... • To Richard Gleave • Jan Ormondroyd and Sir Ian Carruthers • John Dixon • And their teams.... • The Centre for Policy on Ageing • Individuals & organisations involved in the reports, reviews of evidence, consultations • A great resource for all involved in older peoples services • Well beyond the Equality Bill Itself..... Source: www.southwest.nhs.uk/age-equality.html

3. And thank you.. • To all those who have helped us at these consultation events • It is taken on board • It isn’t just for show • And things you have said do influence the implementation strategy Source: www.southwest.nhs.uk/age-equality.html

4. NSF 2001 • Standard 1: ‘Rooting out age discrimination’ to counter infringement of dignity and unfair discrimination in older people’s access to care” • “NHS services will be provided, regardless of age, on the basis of clinical need alone.” • “Social care services will not use age in their eligibility criteria or policies, to restrict access to available services.” • Also standards re: • General hospital care • Training and skills of staff • Single Assessment Source: www.southwest.nhs.uk/age-equality.html

5. “Living well in late life” report 2006 • Progress in eradicating discriminatory policies • Still issues around user experience, dignity, person-centred services, staff attitude/training • Still issues around provision of services to meet common conditions of ageing • “We need to make services age proof and fit for purpose” • A New Ambition for Old Age, 2007 Source: www.southwest.nhs.uk/age-equality.html

6. Four principles in report “Achieving equality in health and social care” • “unjustifiable age discrimination and unfair treatment based on age have no place in a fair society, which values all its members” • “personalisation means that meeting individuals’ needs for health and social care should be based on their individual condition and circumstances, not assumptions about their age” • “services should be differentiated by age only where this is beneficial and therefore objectively justifiable” • “services should demonstrate value and beneficial outcomes for all people in the use of public funds.” Source: www.southwest.nhs.uk/age-equality.html

7. Recent Reviews of Evidence (how and where age discrimination is apparent? ) • Centre for Policy on Ageing (2009) (all on CPA site) • Primary Care • Secondary Care • Social Care • Mental Health • National Review for Equality Bill • Services • Systems • Incentives/Funding/Levers • Attitudes/Skills/Knowledge/Behaviours Source: www.southwest.nhs.uk/age-equality.html

8. The report “Achieving equality in health and social care” makes 35 specific recommendations around implementation and preparedness • For national bodies and organisations • Local organisations • Including educators and regulators • To move from describing the problem.. • To intention. • To action. • To tangible gains. • These actions will be key.. • Toolkit .... Source: www.southwest.nhs.uk/age-equality.html

9. Hands up who thinks...that in general the Equality Bill is a good thing for public services and their users? Source: www.southwest.nhs.uk/age-equality.html

10. Hands up, who is pleased with the detailed set of recommendations/toolkit in the report? Source: www.southwest.nhs.uk/age-equality.html

11. Hands up, who has serious concerns about feasibility, costs, threats to services? Source: www.southwest.nhs.uk/age-equality.html

12. Implementation: Risks/Threats/Unintended Consequences • Excess cost of providing non discriminatory services • Where to take the money from • Cost of change • Opportunity costs of focus on • Preparedness • Risk management • Re-writing policies • Changing services • At expense of getting on with improving quality, access and efficiency • “throwing the baby out with the bathwater” • i.e. Stopping age-differentiated services, policies or practices • which provide good, personalised and age appropriate care • Cost of dealing with vexatious legal challenges? Source: www.southwest.nhs.uk/age-equality.html

13. Challenges to health and social care s • £15-20 bn efficiency savings.. • Demographic Shift • Advancing technology • Information revolution • More informed service users • Squaring • Cost/efficiency • Quality • Access • Personalisation • Equity and Fairness • Local commissioning priorities versus national “must dos” Source: www.southwest.nhs.uk/age-equality.html

14. Other Levers • Human Rights? • Judicial review of national guidelines? • Role of Regulators? • National quality standards? • PBR? • Education and Training? • “High quality care for all”? • “Putting people first” • “Carers strategy”? • “World class commissioning” and quality assurance? Inc LAAs/JSNAs? • Dementia Strategy? • End of Life Care Strategy? • Prevention/Integration? Source: www.southwest.nhs.uk/age-equality.html

15. Ageism v Age Discrimination v Age-Based Differentiation Source: www.southwest.nhs.uk/age-equality.html

16. Ageism – Butler 1996 • ‘Prejudicial attitudes towards older people, old age and the ageing process, which includes attitudes held by older adults themselves” • ‘Discriminatory practices against older people by individuals’ • ‘Institutional practices and policies that perpetuate stereotypes about older adults, reduce their opportunity for life satisfaction and undermine their personal dignity’ Source: www.southwest.nhs.uk/age-equality.html

17. Levenson 2003 • Many factors that make it difficult to identify discrimination: • The subtle nature of discrimination • Difficulty of assessing whether a decision is evidence based or innate ageism of practitioners • Older people themselves accepting discriminatory practices as the ‘norm’ • Shortcomings in services that may not be related to age discrimination but are an issue of quality for all groups. Source: www.southwest.nhs.uk/age-equality.html

18. Differentiation (Hagestad, 2005) • ‘Ageist behaviour grows out of stereotypes, prejudices and stigmatization” • ‘Age-differentiated behaviours can, however, be an appropriate function of the age of the target person, based on an understanding of development and thoughtful recognition of age differences” Source: www.southwest.nhs.uk/age-equality.html

19. Hands up who thinks the Bill alone will solve the problem of ageism and age discrimination in services? Or will be the most important lever? Source: www.southwest.nhs.uk/age-equality.html

20. The Equality Bill is about service users: better and fairer services for them • Older people are by far the biggest user group • And will continue to be so • “The disadvantaged majority”? • Whilst the financial climate risks organisations retreating into silos and desperate efficiency drives • Opportunity:. • Getting the care of older people right is key to the whole health and social care system • Better and more personalised care is often more efficient care Source: www.southwest.nhs.uk/age-equality.html

21. People over 65 • 60-70% total spend • 60% hospital admissions • 65% hospital bed days • 5 times as likely to see GP as working age adults • Main users of home care services (c 1.2 M in England) • And residential care (nearly 300,000 in England) Source: www.southwest.nhs.uk/age-equality.html

22. Source: D Wanless Report. Kings Fund 2006 Source: www.southwest.nhs.uk/age-equality.html

23. From Wanless D Report 2006 Kings Fund Source: www.southwest.nhs.uk/age-equality.html

24. Long term conditions (UK) account for… • 80% hospital days • 70% admissions • 70% health spending • 95% spending on 65+ population • 15% of people with 3 or more problems account for 30% inpatient bed days • 10% of inpatients account for 55% bed days and 5% account for 40% of bed days) Source: www.southwest.nhs.uk/age-equality.html

25. Systems which meet their needs of their biggest group of clients? • “If we design services for people with one thing wrong at once but people with more than thing once turn up, the fault lies not with the users but with the system, but all too often these people are labelled as “inappropriate” • Rockwood K 2006 Source: www.southwest.nhs.uk/age-equality.html

26. The language we use doesn’t help.. • “Bed Blocker” • “Social Admission” • “Acopia” • “Gomer” • “Inappropriate admission” • “Delayed transfer” • “Demographic time bomb” • “Pensions Crisis” • i.e. Older People as a Problem or Threat Source: www.southwest.nhs.uk/age-equality.html

27. Hands up who thinks.... That societal and media values/stereotypes aren’t always helpful to the cause of older people.. (Even when well-meaning).. Source: www.southwest.nhs.uk/age-equality.html

28. Facts and Figures • 1 in 3 people over 65 fall each year • 7% of each over 65 pop over 65 come through A&E with a fall • 1 in 3 women over 65 sustain a fracture (300,000 pa) • c. 700,000 people with dementia • (Around 40% of all admissions hospital admissions) • 1 in 3 over 65 with some degree of incontinence • 50% of people over 65 have two or more long term conditions...and are on 4 or more medications • Over 300,000 in England in Long Term Care • C 1 M in receipt of home care services Source: www.southwest.nhs.uk/age-equality.html

29. Google Fight... • Baby P • 434,000,000 results • Elder Abuse and Neglect • 596,000 • Action on Elder Abuse • 279,000 • Dignity for Older People/The Elderly • 368,000 Source: www.southwest.nhs.uk/age-equality.html

30. Meyrowitz J “no sense of place” • ‘Old people today are generally not appreciated as experienced elders or possessors of special wisdom but to the extent that they can behave like young people. that is the extent that they remain capable of behaving like young people. i.e. working, enjoying sex, exercising and taking care of themselves’. Source: www.southwest.nhs.uk/age-equality.html

31. Ming v Singh – the false dichotomy? Reality gap? • “Successful Ageing” V “Victimhood” or “Pointlessness” • In REALITY.. • Consequences of ageing can only partially be modified... • Many older people... • Are in good mental/physical health and neither lonely, vulnerable nor unhappy BUT Will • Suffer some illness, frailty or disability at some point • Or change of life role/income/circumstances • Most will need to use one or more services... • Sometimes, those services need to be tailored to their needs Source: www.southwest.nhs.uk/age-equality.html

32. Hands up who thinks that there is still plenty of ageism/age discrimination reflecting these attitudes in.. Professionals themselves Older People Their relatives and carers Source: www.southwest.nhs.uk/age-equality.html

33. Evidence from the CPA 2009 reviews • Attitudes, skills, knowledge and behaviour • Values and priorities • Services • Treatments/referrals/investigation for older people • Incentives and levers • Funding and Priorities Source: www.southwest.nhs.uk/age-equality.html

34. From national report • 1.Despite recent progress, and the good service received by many people of all ages, age discrimination remains an issue for the health and social care system which all organisations need to address. • 2.Many of the examples of age discrimination that have been shared with us are of indirect discrimination but these have just as detrimental an impact on patients, service users and carers and on public confidence in the system as direct discrimination. Source: www.southwest.nhs.uk/age-equality.html

35. National Report.. • 3. Pressing ahead with a number of existing commitments (including the personalisation agenda, High Quality Care for All and Putting People First), will do a great deal to advance age equality and tackle discrimination. • 4.A specific focus on age at local level is required: local audit and planning processes should include an age dimension, and clear action to advance age equality and tackle discrimination needs to be identified and followed through locally. A number of resources have been developed alongside the review to support local organisations to make rapid, substantial and demonstrable progress. Source: www.southwest.nhs.uk/age-equality.html

36. In conclusion • Progress since 2001 • Still a long way to go • This work provides one key tool for change • Alongside many others.. • But change is iterative • And in context of wider economic, health and social care policy agenda • And very real problems for service providers and commissioners Source: www.southwest.nhs.uk/age-equality.html

37. To finish with a smile.. • George Carlin • On ageing Source: www.southwest.nhs.uk/age-equality.html