The UK has a rapidly ageing population with increased healthcare needs. Yet social isolation and exclusion resulting from stigma and age discrimination means that many older people are confronted with inequalities in access to and quality of health care. These inequalities are particularly prevalent among older people with mental health issues and older people from black and ethnic minority groups. There are a number of steps nurses can take to increase the inclusion of older people in health promotion and community-based healthcare services. Nurses are exemplars for public health service delivery and are aptly placed to demonstrate the importance of healthcare services free from ageist and discriminatory attitudes.
The UK comprises an ageing population. Over the last 25-years the percentage of the population aged 65-years and over increased from 15% in 1984 to 16% in 2009, an increase of 1.7 million people (ONS, 2010). Over the same period, the percentage of the population aged under 16-years decreased from 21% to 19%. This trend is anticipated to continue and it is projected that by 2034, 23% of the population will be aged 65-years and over. The fastest population increase has been in the number of people aged 85-years and over; by 2034 the number of people in this category is expected to be 5% of the total population.
The increase in quantity of life is often not accompanied by increases in health-related quality of life (QoL) (ONS, 2010). The English Longitudinal Study of Ageing (ELSA) found that for both men and women, overall QoL decreases from state pension age onwards, with the fastest decline occurring after 70-years of age (Hyde et al., 2003). In both men and women aged 65-84-years, circulatory diseases were the leading cause of death. Rates of respiratory and infectious diseases, cancers, injury, and poisoning were also higher in this age group compared to younger groups. The highest mortality rates were in people aged 85-years and over, with circulatory diseases having the highest rates, followed by respiratory diseases and cancers (ONS, 2006).
Thus, despite individuals aged 65-years and over accounting for just 16% of the population, they represent 40% of all those who are not in good health and are likely to have specific healthcare needs (ONS, 2001). Indeed, it has been reported that the number of years of life spent in poor general health between 1981 and 2006 rose from 6.4-8.7 years for males and from 10.1-11.0 years for females (ONS, 2010). This is, in part, due to an increase in unhealthy lifestyle practices. For example, in England, the percentage of people aged 45-64 and 65-74 who were obese increased by 10% to about 30% between 1995 and 2007 (ONS, 2009). This is largely due to increasingly unhealthy diets accompanied by reduced physical activity. It is thus not surprising that, in 2007, approximately two-thirds of both men and women aged 75-years and over in Great Britain reported having a long-term chronic illness or disability.
Despite a greater need for interaction with healthcare services, older people can become socially detached and unable to access support from healthcare professionals. This is not always the result of restricted mobility or individual choice, but social exclusion is strongly associated with increasing age. Regardless of the reason for social isolation, it ultimately leads to huge inequalities in the provision of health services across age groups. Indeed, additional findings from the ELSA study show that in 2006 approximately one in ten people aged 50-years and over in England did not have anyone strongly supporting them when in need (Hyde et al., 2003). This includes friends and family, as well as healthcare professionals. Many older people are widowed and thus also lose out on the additional health benefits of social support. Furthermore, since older people’s travelling patterns are often dependent on their health, without access to transport for GP, hospital, and other healthcare appointments, special efforts to prevent inequalities in access to healthcare are paramount.
Excluded older people can be found across all geographical regions of England. However, there are some areas which are found to have a higher extent of exclusion amongst their older population than other areas. Older people living in London have been found to be more multiply excluded compared with older people living in other regions in England. The south east and east of England are found to have the least risk of exclusion amongst older people. The north east and west, Yorkshire/Humber, east and west Midlands and south west all have higher rates of exclusion for older people.
Social isolation through exclusion is a particular risk factor for older people from minority ethnic groups, those in rural areas, and for people older than 75-years who are widowed or living alone (Office of the Deputy Prime Minister, 2006). It is a common risk factor for a range of health problems and thus prioritising prevention of health problems by tackling social isolation is being encouraged (DH, 2010). Focusing on prevention requires taking action to: 1) delay or reverse older people’s deterioration (i.e. promote their independence and well-being); 2) reduce the risk of crises and the harm arising from them; 3) maximise people’s functioning (i.e. re-enablement); and, 4) provide care closer to home (i.e. arrange for he least institutional or intensive intervention that is able to appropriately meet people’s needs). It has been stated that commissioning should address all four aspects of prevention in order to fully optimise the local system. Special efforts to prevent inequalities in access to healthcare are paramount if the tenet of the NHS, that everyone has a right to health care on the basis of need and clinical ability, is to be maintained.
Age discrimination, one of the Standards outlined in the NSFOP, is a form of prejudice that exacerbates the problem of social exclusion. It can be defined as treating someone unfairly because of their age, for example, by providing them with a lower quality of care. This is surprisingly rife within the NHS. In a survey of 200 doctors, conducted by the British Geriatric Society (BGS), over half expressed that they would be worried about how the NHS would treat them in old age (Clark, 2009).
Age discrimination can have dramatic and detrimental effects on older people and the care they receive. For example, in the survey conducted by the BGS, 72% of the doctors said that older people were less likely to be considered for and referred on for essential treatments or specialist care.
The introduction of the Equality Act 2010, which replaces the existing duties on the public sector to promote race, disability and gender equality, now comprises a single duty to promote equality across eight ‘protected’ characteristics (Box 2).
The Act also includes provisions allowing the government to make age discrimination in service planning and delivery unlawful. This is likely to be implemented in 2012 and thus it is crucial that nurses make themselves aware of what age discrimination is, the different types of age discrimination, and how it can be prevented (Box 3). Age discrimination is not necessarily a conscious act and thus healthcare professionals are likely to be questioned on actions and clinical choices that would previously have been acceptable. Examples of age discrimination are presented in Box 4.
It is anticipated that the Equality Act 2010 will eliminate the stereotypes underlying age discrimination, such as that older people will be confronted with declining health and should thus adapt to symptoms. In reality, the majority of older people describe themselves as being in good health and less than 1% of the older population is in hospital at any one time (Roberts, 2009). There needs to be a move away from viewing older people as an homogenous group characterised by passivity, failing health, and dependency.
It is important to note that discrimination is not always negative. Indeed, positive discrimination is often used for addressing inequalities in health. For example, people who are over 60-years of age are entitled to free prescriptions and eyesight tests, and all registered patients over 75-years of age are offered an annual primary care health check.
There are also instances where discrimination through the rationing of services is viewed as justified. For example, it has been argued that the setting of explicit age limits for routine screening for certain diseases, such as where there is no evidence for an overall benefit in the older population, is justified. Nevertheless, age discrimination can come from the unintended consequences on attitude towards risk of disease where age limits have been set. Age limits for routine breast screening might be justifiable, but lack of awareness of the availability of screening on request as well as lack of information on individual risk and self-care is not.
A wide range of mental health problems can be experienced in later life, including depression, anxiety, delirium, dementia, schizophrenia, and alcohol and drug misuse. Undiagnosed depression is a particular problem, with a quarter of people aged 65-years and over living in the community having symptoms of depression, only half of whom are diagnosed. Another study estimates that depression affects 40% of older people in care homes. Furthermore, there were 790 suicides amongst people aged 65-years and above in the UK in 2006. Up to 60% of older people in hospital have mental health problems or develop them during their stay.
Despite these overwhelming statistics, the Royal College of Psychiatrists estimates that 85% of older people with depression receive no help at all from the NHS. Mental health services for older people are poorly developed in many areas of the country and staff in mainstream services can lack the necessary knowledge and training to deal with people with mental health problems. Community nurses can play a major role in detection and prevention of mental health issues among the older population. It is crucial that nurses are trained in how to distinguish age-related cognitive and mental decline from symptoms of depression and other mental health disorders.
It is no longer acceptable to see declining mental health as an inevitable part of ageing, and fortunately, greater efforts are underway in terms of improving the mental health of older people (NICE, 2008). For example, since regular exercise has beneficial effects on general health, mobility and independence, as well as reduced risk of depression and improved mental well-being and self-esteem, recommendations have been made to promote physical activity in older people via tailored exercise programmes in the community (DH, 2005).
Traditionally, older people with mental illness have been excluded from intermediate care, which was introduced in 2000 via the National Beds Enquiry in an attempt to meet the demands for acute patient care resulting from an ageing population. The NSFOP (2001) defined the objectives for intermediate care services as being to promote independence by providing enhanced services from the NHS and councils to prevent unnecessary hospital admissions and develop effective rehabilitation services to enable early discharge from hospital, as well as to prevent premature or unnecessary admission to long-term residential care. As a result of exclusion from such services, in 2005 the Care Services Improvement Partnership (2005) emphasised that mental illness should be an integral part of service provision. Thus, nurses can play an important role in signposting older patients with mental health issues to intermediate or rehabilitative services.
Box 6 highlights the five main areas of action identified within the UK Inquiry into Mental Health and Well-Being in Later Life. After reading about these five areas, complete Time out 4.
Box 6: The UK Inquiry into Mental Health and Well-Being in Later Life – five areas for action
Ending discrimination: discrimination includes direct age discrimination, ageist attitudes and stigma. Key actions outlined include removing age barriers to services, tackling stigma associated with mental health problems and paying more attention to ‘invisible’ groups such as older people with alcohol and drug misuse problems.
Prioritising prevention: social isolation is a common risk factor for a range of problems. This indicates that nurses have a key role in health promotion among older people. The report recommends challenging the ‘widespread defeatism’ that leads to the assumption that mental health problems are an inevitable part of growing older. Reducing isolation, improving social support, and focusing on preventing depression and delirium are outlined as key actions.
Enabling older people: only a small percentage of older people with mental health problems receive help through formal services, so support for self-help and peer support is necessary. Key actions focus on community development initiatives, promoting peer support and support for unpaid carers of older people.
When considering inequalities in healthcare experienced by older people, it is important to remember that older people are not a homogeneous group. The proportion of older people from black and minority ethnic communities is small but growing. One study examining the future ageing of the ethnic minority population in England and Wales, reported a projection of 2.4 million black and ethnic minority people aged 50-years and over in 2016, rising to 3.8 million by 2026 and 7.4 million by 2051 (Lievesley, 2010). Over the same time spans, there will be just over half a million black and minority ethnic people aged 70-years and over by 2016, more than 800,000 by 2026 and as many as 2.8 million by 2051.
In the main, older people from black and minority ethnic groups tend to report poorer health than their white counterparts (Bajekal et al., 2004). Some also report that they experience age-related changes at an earlier age (Ebrahim et al., 1991). Indeed, it has been suggested that health differences by ethnicity are actually greatest among older people (POST, 2007).
Key messages within the Better Health Briefing conducted by the Race Equality Foundation (Moriarty, 2008) were that older people from black and minority ethnic groups continue to receive poorer treatment from health and social care services; they are also often under-represented among those using services. Barriers to accessing services include lack of information, language difficulties, and differing expectations about how services can help. Stereotyped assumptions on the part of professionals may also act as a barrier to service use.
Older people from minority ethnic groups share views similar to their white counterparts in terms of their ideas about what constitutes a good quality service (e.g. reliability and treating people as individuals), but they may have additional concerns, such as being able to share the same language. They also place particular importance on linking the quality of health and social care services with other factors impacting on health, such as poverty, housing, crime and racism (Butt and O’Neil, 2004; Chahal and Temple, 2005; Manthorpe et al., in press).
All services should reflect the diversity of this growing population. This is, however, rarely the case. For example, in a survey commissioned by Better Government for Older People (2003), it was identified that a third of local authorities who responded had approaches underway, another third were considering or initiating responses, but approximately one third of local authorities had no plans to produce a strategic document for meeting the needs of their black and minority ethnic older communities.
Some health service providers continue to see older people in a stereotyped way, where cognitive decline, decreasing mental well-being, and deteriorating physical health are characterised as being part of the ageing process. There is a clear need for a greater awareness of the role of health and well-being in the ageing process, via professional education, national policy directives, and modelling of best practice. Nurses are at the forefront of public health delivery and are aptly placed to demonstrate the importance of healthcare services free from ageist and discriminatory attitudes.
There is a clear need for a more concerted policy focus on physical and mental health in later life, including the maintenance and promotion of well-being as well as support for people with significant mental illness or cognitive impairment. There also needs to be more attention to the changing long-term support needs of older people and those with complex or comorbid conditions, as well as more emphasis on integrated support for people towards the end of life. Social exclusion drives inequalities in healthcare and older people, especially those of ethnic minority, are more vulnerable to this. Therefore, there needs to be more work on the prevention of social exclusion within the community and within the healthcare setting.