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THE IMPENDING CRISIS OF OLD AGE: A CHALLENGE TO INGENUITY
592
of technology has had the effect of depriving the skills of the
Care of the
THE IMPENDING CRISIS OF OLD AGE: A CHALLENGE TO INGENUITY*
E. D. ACHESON M.R.C. Environmental Epidemiology Unit, Southampton General Hospital, Southampton S09 4XY WHAT CRISIS IS IMPENDING?
IN THE next 30 years we shall witness the culmination of a tide of increase in the elderly that began many years ago. If formoment we define old age in terms of the usual age of compulsory retirement, a superficial analysis suggests that. the tide is at full height and the ebb is about to begin. Thus, the number of people aged 65 and over in England and Wales grew from a figure ofl’77 million in 1901 to about 8 million in 1981. There will be only a marginal increase in this figure by 1991 and it will have fallen back to the current number by the end of the century. These figures conceal, however, more subtle changes. During the next two decades, the number of the oldest and most frail will increase dramatically, while the pool of younger retired people, many of whom have the time and the energy to help support the very old, will shrink. In simple numerical terms, by the year 2000, we can expect an increase of approximately 250 000 in each of the age groups 75-84 and 85 + while at the same time there will be a slightly greater reduction in the number of generally fitter men and women aged 65-74. The increase in the number of those over 75will be equivalent to the number of people it would take to fill Wembley Stadium five times over. Mental and physical disability, and the corresponding consumption of public resources, increases steeply with age. If current rates of disability and dependency were to continue to prevail, by the end of the century at least half of the additional elderly over 85 might need help in taking a bath, one fifth of those living in their homes might be bed-fast or home-bound, and a substantial proportion would be suffering from troublesome incontinence. Unfortunately, while the numbers of the very elderly increase, other social trends are taking place which have the effect of diminishing family support for them. The increasing mobility of younger families and other changes in family composition, including increasing rates of marital breakdown, led to a doubling of the number of persons of pensionable age living alone from 17% to 3407o between 1961 and 1971, and a substantial proportion of these people never had children. In the older group with whom we are principally concerned, the proportion living alone may well be much higher. Another relevant trend is the increasing proportion of married women in paid employment. It has been suggested that by 1986, 70% of married women aged 45-59 (that is, the age group most likely to be called upon to help elderly relatives) will be in paid employment outside the home. There are differences of opinion concerning the extent to which there has been a deterioration in society’s attitude towards the aged. In former times, many elders were revered as repositories of experience, but now the rapid development *Excerpts from the 6th Christie Gordon Birmingham on June 22, 1982.
lecture
given
at
and elderly of much of their relevance. The retirement age accentuates a sharp line of demarcation between those considered to be independent and productive and the rest. Only artists, politicians and, according to their own account, general practitioners are considered, like great claret, to improve indefinitely with age. In the past, the rarity of survival to old age itself contributed to the veneration of the elder. Simone de Beauvoir has pointed outl that the poverty of the elderly also diminishes them in our eyes. My view is perhaps deeply coloured by my medical experience and I find that the term "geriatric" has become derogatory and belittling to both patients and staff. It makes me reflect that in some ways our attitude to the elderly is now not unlike that of our great-grandparents to the institutionalised poor.
middle-aged compulsory
Elderly
the
University of
ARE WE PREPARED FOR THE CRISIS?
Government decisions over the last 40 years have led to divisions of responsibility between contrasting systems. State pensions and age-related financial help are a function of the Department of Health and Social Security; personal social services and old people’s homes are administered by Local Authorities; and the provision of hospital and domiciliary health services for the elderly are functions of the National Health Service. The most significant development which has occurred in the last 20 years has been the link between the Department of the Environment and district housing authorities, in the form of sheltered housing schemes. In 1963, it was estimated that approximately 36 000 elderly people lived in sheltered housing schemes; today the figure is nearly 500 000. It is a bizarre consequence of what can otherwise be described as a runaway success that the housing authorities, through their warden-assisted schemes (the housing authorities employ the wardens), now find that they are undertaking the provision of personal caring services side by side and sometimes in direct competition with social and health services workers. In some areas there are growing problems of coordination which may be manifested as overlap, gaps, tension, or even conflict between wardens, home-helps, social workers, community nurses, and health visitors. In Britain, a coordinated central policy for the elderly which embraces social and health care and accommodation has never existed and, except at Cabinet level, there is no forum for the development of such a policy. This is not a new situation. In 1975, a proposal2 was published to provide a means for the development of social policies where the matter fell within the scope of two or more Departments, but it met the usual fate of ideas which threaten the independence of the mandarins: oblivion. PENSIONS AND BENEFITS
The lack of a coordinated policy for the care of the elderly and the disjointed way in which the various services are provided are also reflected in the provision of pensions and benefits. As it stands, the system has a number of major shortcomings: it is illogical because it shapes and distorts demands for certain services in ways that were never intended; it is inequitable because it discriminates against those of modest means and against those undergoing longterm care in the N.H.S.; it discourages initiative and diminishes freedom of choice; it is too complex for anyone but the expert professional to understand; and it is wasteful to run.
593
the logic (or lack of it), we find that in (part III accommodation), local authorities out a means test so that an elderly person may be carry a week. However, a person with a similar to ;[60 charged up degree ofincapacity may receive long-term care in the N.H.S. without any direct charge. This often leads to resistance from relatives to transfer of a patient from hospital to residential care and has the effect of expanding unnecessarily the provision of expensive long-term facilities in hospitals. The system is also blind to equity and does little to foster independence and freedom of choice. It is frankly iniquitous that long-term elderly patients in the N.H.S. must surrender most of their pensions not only because of the principle involved but also because of the practical consequences of the reduction of income not least, and this is often forgotten, upon dependants of the elderly person at home. The only possible justification for this would be if the equivalent sum were applied to improving the living conditions of the patient. If we believe that activity, social contact, and cash may sustain the independence of the elderly how can we justify the earnings rule which discourages old people from taking up part-time employment? (These are the people who suffered greatly from unemployment in the ’30s.) Retired people with moderate means just above the supplementary benefit level, and a recent survey suggests that this is a substantial proportion, are faced with a bewildering array of benefits each with a different means test. Such people, if they lack persistence or help, end up worse off than those with lower incomes and fall into a poverty trap all the deeper because they are likely to get less than their share of social services.
Looking
first
residential
care
at
HOUSING THE
ELDERLY
Little is known for certain about the factors determining the rate at which the health of old people declines. There seems to be some agreement, however, that breaking social contacts and removal from familiar surroundings, as occurs when an elderly person moves from home to sheltered or residential care or to hospital, may be deeply disturbing and damaging and hasten decline. For this reason, although one removal might in many cases be beneficial, policies3 should minimise the need for repeated moves. The ideal should be a flexible and, if necessary, increasing amount of support from health and social services in the chosen accommodation. Except during the crises of major illnesses or where extreme mental or physical disability has supervened, help should be taken to the elderly not the elderly to help. If this view is accepted, the location of the elderly in relation to the services and the degree to which their segregation into groups is compatible with maintaining their individuality and sense of identity, become crucial. We were struck with the high levels of infirmity encountered in old people’s homes (where the average age on admission in many places is over 80) and warden-assisted schemes. The dividing line between these and nursing homes becomes increasingly thin and difficult to maintain as the age and frailty of the residents increase. I have already referred to the growth of warden-assisted accommodation provided by district housing authorities. We singled out for special attention the increasingly difficult situation in which many wardens now find themselves. Due to the increasing age of the residents, more is now expected of wardens than a good neighbour relationship. Residents in sheltered accommodation often need 24-hour cover, which requires the employment of relief wardens. Modern alarm and communications equipment may help, but becomes
when the client is too forgetful or understand its use. Frequently, general practitioners now expect wardens to provide meals and even nursing care. The respective roles of the warden, the staff of the social services, and the domiciliary nursing services are far from clear and the client sometimes suffers as a result. The housing departments are understandably reluctant to extend their caring roles by increasing levels and respond by fitter for tenancies. This the candidates vacant selecting only places increasing pressure on the dwindlingnumber of vacancies in old people’s homes. Surely these points make the need for a comprehensive coordinated housing strategy in each district obvious. Such a strategy must take into account not only the needs for sheltered accommodation and places in old people’s homes but also the requirements of the seriously demented and disturbed, of whom there will be an increasing number as the demographic trends work themselves out.
counterproductive
confused
to
staffing
HOSPITAL SERVICES
It is inescapable that the incidence of many types of incapacitating illness, both mental and physical, and their duration, increases steeply with age. As substantial proportions of the very old are found not only in the medical specialties but also in the surgical, orthopaedic, and psychiatric departments of hospitals, it follows that most doctors who work in hospitals share in their care and will feel the effects of the increase in numbers. It is, however, the provision and organisation of the non-surgical care of the very old in hospital that attracts most controversy. A system is required which ensures swift admission to deal with crises of illness, effective rehabilitation, and smooth return to the preferred place of residence. Unless skilled inpatient care is available immediately it is required, deterioration rapidly takes place in the very old and complications supervene. Not only does this add unnecessarily to the burden of chronic dependency but it overloads and leads to breakdown in other sectors, such as the domiciliary support services, and sometimes to loss of mutual
confidence. The most important between the role of the
question concerns the demarcation specialist geriatrician and the other physicians. Historically, geriatrics was associated with the custodial care of the elderly, chronic sick, usually in isolated out-dated hospitals difficult to staff and founded on the old Poor Law Institutions. The geriatrician would be summoned to the scene to remove from a "blocked bed" the patient who had failed to recover in the acute ward. Today, at its best, geriatric medicine brings special skills to the care of the elderly which minimise chronic dependency and hasten rehabilitation, but geriatricians thereby come into direct competition for resources with other physicians. We found it impossible to find out how many Health Districts have at least one specialist geriatrician. In a substantial proportion of districts, perhaps as many as 1 in 8, the geriatricians have no access to laboratory or radiographic facilities for their patients and no resident medical staff to support them. Quite apart from any effect the discontinuity of acute and continuing care may have on the individual patient, it has negative effects on the system as a whole. A geriatric physician without access to the acute facilities of the district hospital cannot offer an adequate service to colleagues within or outside the hospital and this will affect other services in the district. Deprived of support from junior staff and isolated from the stimulus of teaching, the geriatrician
594
may lose heart. When he or she leaves it will be no one comes forward as a replacement.
no
surprise if
WHAT SHOULD WE DO?
Our recommendations were shaped by two overriding considerations: a policy of least removal and the importance of choice and privacy. A single judiciously timed move with a degree of protection and with flexible and increasing support (if necessary) in health care and daily living should be encouraged. I believe that all ofus3 accepted that some degree of grouping of the elderly frail was desirable in the interests of economy, and that provided such units were kept small the unfavourable features of segregation could be kept to a minimum. Many people suffer a decline in reasoning power and initiative in their later years. Nevertheless, within the limits set by the mental and physical condition of the individual, it was felt that every means should be used to encourage freedom of choice. Some people like self-catering, some prefer hotels; some like a quiet life, others like to be gregarious. We hope that encouraging freedom of choice will retain a sense of personal identity and self-respect and so diminish dependency. The shaping of a financial strategy in accord with this principle is one of the most important conclusions. Privacy (where desired) and the retention of personal belongings should be assured for the elderly in institutional care. The presence of a few cherished and familiar belongings are necessary for a sense of identity. Our inability to find any data about the numbers of single as compared with shared bedrooms in old people’s homes suggests that the high priority we place upon privacy may not be shared by those in
authority. A CENTRAL POLICY
I hope it has become clear that the provision of suitable accommodation for the elderly is the keystone of an effective policy. The scale of provision of sheltered accommodation must be linked with the provision of residential accommodation, and each planned with the available resources of supporting manpower in mind. The necessary central coordination of policy could be attained by an interdepartmental committee, but these are rarely effective. One solution might remove the provision of special accommodation for the elderly from the jurisdiction of the Department of the Environment and including it within the scope of the D.H.S.S. This move would make the provision of both residential and sheltered accommodation come under a single Department of State, there would be a better chance of coordinated planning, and many of the current problems of providing support services would fall away. It would be essential, however, to secure within the new system the rights of tenancy which are so highly valued by people in sheltered accommodation and which residents in old people’s homes do not share. It would be logical for a Minister to have responsibility for the coordination of services for the elderly with a remit wide enough to match the scope of the problem. Our second recommendation is a review of the whole system of cash benefits and subsidies for the elderly and especially the working of the means test. The underlying principles of the system should be equity, simplicity, and the promotion of independence. The earnings rule discourages the elderly from activity and social contact, and pensioners (and, indirectly, their dependants) are singled out to pay hotel charges as long-stay patients in the N.H.S. Many people of
modest means are disqualified by means tests from a package of benefits. We would favour the widening of special income supplements for disability so as to enable more people to make arrangements for help in their own homes or in a voluntary or private nursing home. We consider that more can be done to develop schemes whereby the pensioner using his own capital can be helped to buy sheltered accommodation. Existing machinery of coordination at district level, the Joint Consultative Committees, is generally ineffective, but a model partnership agreement will depend on effective provision of acute hospital services. We recommend that in each district a physician is nominated as coordinator of inpatient services for the very elderly frail. The essential element for success, in our view, is not whether he or she is deemed a geriatrician or a physician with an interest in geriatrics, but that the practitioner should be interested and informed and have, in addition to modern rehabilitation and day hospital services, a major presence in the District General Hospital. Special provision will have to be made in each district, using an approach based on partnership, for the elderly mentally infirm. Given a cohesive policy from the centre, a rational and simplified system of benefits and joint planning, and ’
teams in each district, new opportunities will arise for the various authorities to work in partnership. In order to preserve an element of choice, a range offacilities will be necessary and a single blueprint has not been proposed. However, we draw attention to recent developments in the concept of sheltered housing such as those in Stockport, at Kinloss Court in Southampton, and in other areas.While continuing to be assured of the privacy and freedom from intrusion which is the right of any council tenant, the client has help available which goes far beyond what can be provided by a warden. It includes support from social services, community nursing services, and from the general practitioner, and, where necessary, includes an immediate response from the hospital geriatric services. Other such schemes include complexes incorporating both sheltered housing and accommodation nearby with dining facilities, or with round the clock custodial or sick-bay care. These may be financed through joint funding or by partnership with the voluntary or private sectors, and caring staff are also provided jointly by the health, social service, and voluntary sectors. Evidence is beginning to come in that these developments are certainly no more expensive than orthodox institutional care and may help preserve independence.
operational
CODA
The object of the strategy outlined above is to maximise the quality of life of our elders and minimise dependancy. I am convinced that it is within our means to do this and thereby meet the challenge to our ingenuity presented by the impending crisis. If we fail, I believe we shall not be able to blame lack of resources. Our failure will be that we did not take a broad enough view; that instead of coordinating our efforts we allowed ourselves to be ruled by the vested interests and demarcation lines of individual departments and professions and that we sacificed to them the prior interests of our elders. REFERENCES 1. de Beauvoir S. Old age. Harmondsworth, Middx: Penguin Books, 1977.. 2. A Joint Framework for Social Policies. Central Policy Review Staff report, 1975.
3. This article
of the findings ofa study group set up by the Nuffield Hospitals Trust in 1979. These are reported in full in Shegog RFA ed. The impending crisis of old age: a challenge to ingenuity. London: Nuffield Provincial Hospitals Trust, 1979. summarises some
Provincial
of technology has had the effect of depriving the skills of the
Care of the
THE IMPENDING CRISIS OF OLD AGE: A CHALLENGE TO INGENUITY*
E. D. ACHESON M.R.C. Environmental Epidemiology Unit, Southampton General Hospital, Southampton S09 4XY WHAT CRISIS IS IMPENDING?
IN THE next 30 years we shall witness the culmination of a tide of increase in the elderly that began many years ago. If formoment we define old age in terms of the usual age of compulsory retirement, a superficial analysis suggests that. the tide is at full height and the ebb is about to begin. Thus, the number of people aged 65 and over in England and Wales grew from a figure ofl’77 million in 1901 to about 8 million in 1981. There will be only a marginal increase in this figure by 1991 and it will have fallen back to the current number by the end of the century. These figures conceal, however, more subtle changes. During the next two decades, the number of the oldest and most frail will increase dramatically, while the pool of younger retired people, many of whom have the time and the energy to help support the very old, will shrink. In simple numerical terms, by the year 2000, we can expect an increase of approximately 250 000 in each of the age groups 75-84 and 85 + while at the same time there will be a slightly greater reduction in the number of generally fitter men and women aged 65-74. The increase in the number of those over 75will be equivalent to the number of people it would take to fill Wembley Stadium five times over. Mental and physical disability, and the corresponding consumption of public resources, increases steeply with age. If current rates of disability and dependency were to continue to prevail, by the end of the century at least half of the additional elderly over 85 might need help in taking a bath, one fifth of those living in their homes might be bed-fast or home-bound, and a substantial proportion would be suffering from troublesome incontinence. Unfortunately, while the numbers of the very elderly increase, other social trends are taking place which have the effect of diminishing family support for them. The increasing mobility of younger families and other changes in family composition, including increasing rates of marital breakdown, led to a doubling of the number of persons of pensionable age living alone from 17% to 3407o between 1961 and 1971, and a substantial proportion of these people never had children. In the older group with whom we are principally concerned, the proportion living alone may well be much higher. Another relevant trend is the increasing proportion of married women in paid employment. It has been suggested that by 1986, 70% of married women aged 45-59 (that is, the age group most likely to be called upon to help elderly relatives) will be in paid employment outside the home. There are differences of opinion concerning the extent to which there has been a deterioration in society’s attitude towards the aged. In former times, many elders were revered as repositories of experience, but now the rapid development *Excerpts from the 6th Christie Gordon Birmingham on June 22, 1982.
lecture
given
at
and elderly of much of their relevance. The retirement age accentuates a sharp line of demarcation between those considered to be independent and productive and the rest. Only artists, politicians and, according to their own account, general practitioners are considered, like great claret, to improve indefinitely with age. In the past, the rarity of survival to old age itself contributed to the veneration of the elder. Simone de Beauvoir has pointed outl that the poverty of the elderly also diminishes them in our eyes. My view is perhaps deeply coloured by my medical experience and I find that the term "geriatric" has become derogatory and belittling to both patients and staff. It makes me reflect that in some ways our attitude to the elderly is now not unlike that of our great-grandparents to the institutionalised poor.
middle-aged compulsory
Elderly
the
University of
ARE WE PREPARED FOR THE CRISIS?
Government decisions over the last 40 years have led to divisions of responsibility between contrasting systems. State pensions and age-related financial help are a function of the Department of Health and Social Security; personal social services and old people’s homes are administered by Local Authorities; and the provision of hospital and domiciliary health services for the elderly are functions of the National Health Service. The most significant development which has occurred in the last 20 years has been the link between the Department of the Environment and district housing authorities, in the form of sheltered housing schemes. In 1963, it was estimated that approximately 36 000 elderly people lived in sheltered housing schemes; today the figure is nearly 500 000. It is a bizarre consequence of what can otherwise be described as a runaway success that the housing authorities, through their warden-assisted schemes (the housing authorities employ the wardens), now find that they are undertaking the provision of personal caring services side by side and sometimes in direct competition with social and health services workers. In some areas there are growing problems of coordination which may be manifested as overlap, gaps, tension, or even conflict between wardens, home-helps, social workers, community nurses, and health visitors. In Britain, a coordinated central policy for the elderly which embraces social and health care and accommodation has never existed and, except at Cabinet level, there is no forum for the development of such a policy. This is not a new situation. In 1975, a proposal2 was published to provide a means for the development of social policies where the matter fell within the scope of two or more Departments, but it met the usual fate of ideas which threaten the independence of the mandarins: oblivion. PENSIONS AND BENEFITS
The lack of a coordinated policy for the care of the elderly and the disjointed way in which the various services are provided are also reflected in the provision of pensions and benefits. As it stands, the system has a number of major shortcomings: it is illogical because it shapes and distorts demands for certain services in ways that were never intended; it is inequitable because it discriminates against those of modest means and against those undergoing longterm care in the N.H.S.; it discourages initiative and diminishes freedom of choice; it is too complex for anyone but the expert professional to understand; and it is wasteful to run.
593
the logic (or lack of it), we find that in (part III accommodation), local authorities out a means test so that an elderly person may be carry a week. However, a person with a similar to ;[60 charged up degree ofincapacity may receive long-term care in the N.H.S. without any direct charge. This often leads to resistance from relatives to transfer of a patient from hospital to residential care and has the effect of expanding unnecessarily the provision of expensive long-term facilities in hospitals. The system is also blind to equity and does little to foster independence and freedom of choice. It is frankly iniquitous that long-term elderly patients in the N.H.S. must surrender most of their pensions not only because of the principle involved but also because of the practical consequences of the reduction of income not least, and this is often forgotten, upon dependants of the elderly person at home. The only possible justification for this would be if the equivalent sum were applied to improving the living conditions of the patient. If we believe that activity, social contact, and cash may sustain the independence of the elderly how can we justify the earnings rule which discourages old people from taking up part-time employment? (These are the people who suffered greatly from unemployment in the ’30s.) Retired people with moderate means just above the supplementary benefit level, and a recent survey suggests that this is a substantial proportion, are faced with a bewildering array of benefits each with a different means test. Such people, if they lack persistence or help, end up worse off than those with lower incomes and fall into a poverty trap all the deeper because they are likely to get less than their share of social services.
Looking
first
residential
care
at
HOUSING THE
ELDERLY
Little is known for certain about the factors determining the rate at which the health of old people declines. There seems to be some agreement, however, that breaking social contacts and removal from familiar surroundings, as occurs when an elderly person moves from home to sheltered or residential care or to hospital, may be deeply disturbing and damaging and hasten decline. For this reason, although one removal might in many cases be beneficial, policies3 should minimise the need for repeated moves. The ideal should be a flexible and, if necessary, increasing amount of support from health and social services in the chosen accommodation. Except during the crises of major illnesses or where extreme mental or physical disability has supervened, help should be taken to the elderly not the elderly to help. If this view is accepted, the location of the elderly in relation to the services and the degree to which their segregation into groups is compatible with maintaining their individuality and sense of identity, become crucial. We were struck with the high levels of infirmity encountered in old people’s homes (where the average age on admission in many places is over 80) and warden-assisted schemes. The dividing line between these and nursing homes becomes increasingly thin and difficult to maintain as the age and frailty of the residents increase. I have already referred to the growth of warden-assisted accommodation provided by district housing authorities. We singled out for special attention the increasingly difficult situation in which many wardens now find themselves. Due to the increasing age of the residents, more is now expected of wardens than a good neighbour relationship. Residents in sheltered accommodation often need 24-hour cover, which requires the employment of relief wardens. Modern alarm and communications equipment may help, but becomes
when the client is too forgetful or understand its use. Frequently, general practitioners now expect wardens to provide meals and even nursing care. The respective roles of the warden, the staff of the social services, and the domiciliary nursing services are far from clear and the client sometimes suffers as a result. The housing departments are understandably reluctant to extend their caring roles by increasing levels and respond by fitter for tenancies. This the candidates vacant selecting only places increasing pressure on the dwindlingnumber of vacancies in old people’s homes. Surely these points make the need for a comprehensive coordinated housing strategy in each district obvious. Such a strategy must take into account not only the needs for sheltered accommodation and places in old people’s homes but also the requirements of the seriously demented and disturbed, of whom there will be an increasing number as the demographic trends work themselves out.
counterproductive
confused
to
staffing
HOSPITAL SERVICES
It is inescapable that the incidence of many types of incapacitating illness, both mental and physical, and their duration, increases steeply with age. As substantial proportions of the very old are found not only in the medical specialties but also in the surgical, orthopaedic, and psychiatric departments of hospitals, it follows that most doctors who work in hospitals share in their care and will feel the effects of the increase in numbers. It is, however, the provision and organisation of the non-surgical care of the very old in hospital that attracts most controversy. A system is required which ensures swift admission to deal with crises of illness, effective rehabilitation, and smooth return to the preferred place of residence. Unless skilled inpatient care is available immediately it is required, deterioration rapidly takes place in the very old and complications supervene. Not only does this add unnecessarily to the burden of chronic dependency but it overloads and leads to breakdown in other sectors, such as the domiciliary support services, and sometimes to loss of mutual
confidence. The most important between the role of the
question concerns the demarcation specialist geriatrician and the other physicians. Historically, geriatrics was associated with the custodial care of the elderly, chronic sick, usually in isolated out-dated hospitals difficult to staff and founded on the old Poor Law Institutions. The geriatrician would be summoned to the scene to remove from a "blocked bed" the patient who had failed to recover in the acute ward. Today, at its best, geriatric medicine brings special skills to the care of the elderly which minimise chronic dependency and hasten rehabilitation, but geriatricians thereby come into direct competition for resources with other physicians. We found it impossible to find out how many Health Districts have at least one specialist geriatrician. In a substantial proportion of districts, perhaps as many as 1 in 8, the geriatricians have no access to laboratory or radiographic facilities for their patients and no resident medical staff to support them. Quite apart from any effect the discontinuity of acute and continuing care may have on the individual patient, it has negative effects on the system as a whole. A geriatric physician without access to the acute facilities of the district hospital cannot offer an adequate service to colleagues within or outside the hospital and this will affect other services in the district. Deprived of support from junior staff and isolated from the stimulus of teaching, the geriatrician
594
may lose heart. When he or she leaves it will be no one comes forward as a replacement.
no
surprise if
WHAT SHOULD WE DO?
Our recommendations were shaped by two overriding considerations: a policy of least removal and the importance of choice and privacy. A single judiciously timed move with a degree of protection and with flexible and increasing support (if necessary) in health care and daily living should be encouraged. I believe that all ofus3 accepted that some degree of grouping of the elderly frail was desirable in the interests of economy, and that provided such units were kept small the unfavourable features of segregation could be kept to a minimum. Many people suffer a decline in reasoning power and initiative in their later years. Nevertheless, within the limits set by the mental and physical condition of the individual, it was felt that every means should be used to encourage freedom of choice. Some people like self-catering, some prefer hotels; some like a quiet life, others like to be gregarious. We hope that encouraging freedom of choice will retain a sense of personal identity and self-respect and so diminish dependency. The shaping of a financial strategy in accord with this principle is one of the most important conclusions. Privacy (where desired) and the retention of personal belongings should be assured for the elderly in institutional care. The presence of a few cherished and familiar belongings are necessary for a sense of identity. Our inability to find any data about the numbers of single as compared with shared bedrooms in old people’s homes suggests that the high priority we place upon privacy may not be shared by those in
authority. A CENTRAL POLICY
I hope it has become clear that the provision of suitable accommodation for the elderly is the keystone of an effective policy. The scale of provision of sheltered accommodation must be linked with the provision of residential accommodation, and each planned with the available resources of supporting manpower in mind. The necessary central coordination of policy could be attained by an interdepartmental committee, but these are rarely effective. One solution might remove the provision of special accommodation for the elderly from the jurisdiction of the Department of the Environment and including it within the scope of the D.H.S.S. This move would make the provision of both residential and sheltered accommodation come under a single Department of State, there would be a better chance of coordinated planning, and many of the current problems of providing support services would fall away. It would be essential, however, to secure within the new system the rights of tenancy which are so highly valued by people in sheltered accommodation and which residents in old people’s homes do not share. It would be logical for a Minister to have responsibility for the coordination of services for the elderly with a remit wide enough to match the scope of the problem. Our second recommendation is a review of the whole system of cash benefits and subsidies for the elderly and especially the working of the means test. The underlying principles of the system should be equity, simplicity, and the promotion of independence. The earnings rule discourages the elderly from activity and social contact, and pensioners (and, indirectly, their dependants) are singled out to pay hotel charges as long-stay patients in the N.H.S. Many people of
modest means are disqualified by means tests from a package of benefits. We would favour the widening of special income supplements for disability so as to enable more people to make arrangements for help in their own homes or in a voluntary or private nursing home. We consider that more can be done to develop schemes whereby the pensioner using his own capital can be helped to buy sheltered accommodation. Existing machinery of coordination at district level, the Joint Consultative Committees, is generally ineffective, but a model partnership agreement will depend on effective provision of acute hospital services. We recommend that in each district a physician is nominated as coordinator of inpatient services for the very elderly frail. The essential element for success, in our view, is not whether he or she is deemed a geriatrician or a physician with an interest in geriatrics, but that the practitioner should be interested and informed and have, in addition to modern rehabilitation and day hospital services, a major presence in the District General Hospital. Special provision will have to be made in each district, using an approach based on partnership, for the elderly mentally infirm. Given a cohesive policy from the centre, a rational and simplified system of benefits and joint planning, and ’
teams in each district, new opportunities will arise for the various authorities to work in partnership. In order to preserve an element of choice, a range offacilities will be necessary and a single blueprint has not been proposed. However, we draw attention to recent developments in the concept of sheltered housing such as those in Stockport, at Kinloss Court in Southampton, and in other areas.While continuing to be assured of the privacy and freedom from intrusion which is the right of any council tenant, the client has help available which goes far beyond what can be provided by a warden. It includes support from social services, community nursing services, and from the general practitioner, and, where necessary, includes an immediate response from the hospital geriatric services. Other such schemes include complexes incorporating both sheltered housing and accommodation nearby with dining facilities, or with round the clock custodial or sick-bay care. These may be financed through joint funding or by partnership with the voluntary or private sectors, and caring staff are also provided jointly by the health, social service, and voluntary sectors. Evidence is beginning to come in that these developments are certainly no more expensive than orthodox institutional care and may help preserve independence.
operational
CODA
The object of the strategy outlined above is to maximise the quality of life of our elders and minimise dependancy. I am convinced that it is within our means to do this and thereby meet the challenge to our ingenuity presented by the impending crisis. If we fail, I believe we shall not be able to blame lack of resources. Our failure will be that we did not take a broad enough view; that instead of coordinating our efforts we allowed ourselves to be ruled by the vested interests and demarcation lines of individual departments and professions and that we sacificed to them the prior interests of our elders. REFERENCES 1. de Beauvoir S. Old age. Harmondsworth, Middx: Penguin Books, 1977.. 2. A Joint Framework for Social Policies. Central Policy Review Staff report, 1975.
3. This article
of the findings ofa study group set up by the Nuffield Hospitals Trust in 1979. These are reported in full in Shegog RFA ed. The impending crisis of old age: a challenge to ingenuity. London: Nuffield Provincial Hospitals Trust, 1979. summarises some
Provincial