From Welfare To Well-being – Planning For An Ageing Society
The Task Group was convened to examine key issues on the future role and potential of specialist housing and care options, in order to meet the aspirations of older people, and how these options could be funded and paid for both by public and private funding, and by older people themselves.
Taking account of the fact that most older people live in ordinary, rather than specialist, housing and the growing aspirations of older people to retain independence, choice and control in older age, the brief was broadened to address the wider challenges of planning for an ageing society.
In the UK, older people’s issues are still addressed on a fragmented rather than whole-person basis. The Way Ahead manifesto from the Newcastle Elders Council (Newcastle Elders Council, 2003) highlights the principles and issues which are important to older people.
Through initiatives which directly engage older people, such as the Better Government for Older People (BGOP) programme (Hayden & Boaz, 2000), the Joseph Rowntree Foundation’s Older People’s Programme, and thinking around addressing health inequalities (Wanless, 2002; Murtagh et al., 2003; Department of Health, 2003), the policy debate is beginning to broaden from the traditional focus on ill health and frail older people. It is starting to encompass an agenda which is about promoting quality of life and well-being, addressing ageism, recognising older people as equal citizens in society, and valuing the contribution older people make in their communities in all sorts of ways. The debate addresses issues which mitigate against older people being able to enjoy quality of life and independence in older age, whether these are legal barriers, attitudinal barriers, adequate income, or a range of often small but critical matters, which can make the difference between feeling ‘in control’ or not.
The Association of Directors of Social Services and Local Government Association have picked up the theme around prevention in a recent discussion paper (ADSS & LGA, 2003) and argued for a shifting of the balance away from a focus only on acute care and the most frail older people. ADSS, LGA, the Audit Commission, the Better Government for Older People programme, and the Nuffield Institute for Health are coming together to promote this broader approach. They are focusing on developing thinking around the meaning of prevention (Wistow et al., 2003) and the changes needed if public services are going to meet the needs of tomorrow’s older citizens (Carrier et al., 2004). A recent discussion paper states:
“A radical change of perspective is needed if public services are to meet the challenges of our ageing society. This approach may not cost more; it involves a better use of resources and more effective ways of public services working together in the interests of citizens.”
(ADSS, LGA, BGOP, Audit Commission, Nuffield Institute for Health, 2004)
There have been some incremental developments in government policy towards older people. However, we are still in a situation where:
- Wales is the only UK country which has an overall vision and policy framework for an ageing society (Welsh Assembly, 2003) – there is no overall government policy framework in England to take account of the demographic, social and economic change the rest of the UK is experiencing as a society in relation to the older population.
- Public services still, by and large, focus on the most vulnerable older people at times of crisis (some fifteen per cent of the older population) rather than an approach which enables the wider older population (the other eighty-five per cent) to remain independent for as long as possible and live their lives to the full.
- The current welfare-rationing approach for people on low incomes gets in the way of adopting a broader approach that applies to older people of all economic groups as citizens and consumers, and which draws in a wider set of partners, including the private sector.
- Older people do not have an equal place in Britain today. Ageism, discrimination and social exclusion are built into the fabric and culture of British society. Many older people are still excluded from universal services because of age discrimination.
Eight building blocks for change
The Task Group identified eight building blocks which need to be addressed if the UK is to make the radical changes necessary to successfully address the demographic and societal challenges that the ageing of the population presents.
A key part of changing the mindset from the current narrow focus on dependency and illness to a more inclusive approach for the wider older population is to adopt an older people-centred vision and culture which promotes quality of life and choice.
To enable older people to live well into later life, the Task Group believes that a vision should:
- promote social inclusion by acknowledging all older people as equal citizens with other groups of the population;
- celebrate diversity in the older population;
- address ageism and age discrimination;
- recognise each older person as a unique individual, rather than viewing older people as an homogeneous group;
- value older people as a resource to society, and as contributors to the daily lives of other people in all sorts of ways;
- promote the health and well-being of older people at all stages of older age, and an approach to information, income and mainstream services which supports that aspiration;
- recognise that adequate pensions and incomes are needed to retain control, choice and independence;
- ensure that service culture balances rights and risks, and recognises the desire of individual older people to maintain choice and control of decision-making; and
- enable older people, both as individuals and collectively, to be directly engaged as equal partners in decision-making and planning services that affect their lives.
A number of areas have now adopted a local vision. For example, The Quality of Life Strategy for Camden’s older citizens (Camden LBC, 2002) and the Darlington Strategy (Darlington Borough Council, 2000) are both good examples which set out a clear vision based on the above principles.
A key element of any vision is to ensure a culture which reflects how older people themselves want to be treated, and through this to challenge service providers as to desired behaviour. The Darlington Strategy, for example, specifically addresses this.
Older people being assessed for and receiving health, care and other services talk about being faced with a culture that is over-protective and ‘risk averse’. They highlight the need for a culture change which enables them to retain their sense of freedom through balancing choice, risk and safety in a way that does not over-protect and over-control.
For the Task Group, therefore, having a clear older person-centred vision and culture is central to underpinning the changes in thinking and action proposed in this discussion paper.
Respondents to the discussion paper published by the Task Group in October 2003 (Quality of Life for Older People: from welfare to well-being) reinforced the importance of following an age equality approach. One respondent said:
“Every time a bus route is changed or adult education classes are programmed without consideration for the impact on older people and how they might want to live their lives, there is a potential for indirect age discrimination. The exclusion from so many ordinary things in life that everybody values puts older people in an overlooked category. No wonder well-being suffers.
In addition, the fifteen per cent of older people with significant health and care needs do not get treated on the same basis as younger people. Disability benefits discriminate on age grounds – there is no mobility component to Attendance Allowance (unlike Disability Living Allowance), which means that disabled older people do not have the opportunity to be active and lead their own lives that younger disabled people have. Cost ceilings on care packages are lower than for younger people, so that older people get only safety net services at home and are forced into residential care earlier. There are different mental health services, with massive under-diagnosis and under-treatment of older people.”
The Race Relations (Amendment) Act 2000 requires all public bodies to promote race equality. There is a process laid down by which they should do this, and legislation is planned to promote equality in relation to disability. There is no good reason why local authorities and other public bodies should not promote equality on other grounds, such as age. The devolved administrations already have a duty to promote equality (or equal opportunities, in the case of Scotland). Northern Ireland has already started implementing this, which is beginning to make a difference.
As the new equalities framework is developed in England through the proposed Commission for Equality and Human Rights (CEHR), there is a need to ensure that age discrimination is treated in the same way, and with the same priority, as race discrimination. It should not be limited to age discrimination in employment, as at present.
It is self-evident that older people who have sufficient independent resources of their own are in a much better position to make decisions and choices about care on a 24-hour basis, or move to sheltered housing because they cannot get their grass cut or their house cleaned. They can pay to get services into their home.
The Economic and Social Research Council Growing Older programme highlights the importance of addressing not just ageism and inequality but also poverty as prerequisites to promoting quality of life in older age, and to ensure the right climate in which older people can lead their lives. Two million pensioners still live below the poverty line.
The remit of the Task Group did not extend to cover in depth the broader debate on pensions and income in retirement. However, the group would emphasise the fundamental importance of increasing pension levels to achieve what Age Concern, in its recent research carried out by the Family Budget Unit at York University (Parker, 2002) refers to as ‘Modest but adequate – a reasonable living standard for households aged 65-74 years’. The group believes that increasing pension levels to achieve the income levels set out in that report would enable many more older people to retain control of their decision-making and their lives, and have a substantial impact on reducing pressure on the formal welfare service sector. Furthermore, because older people would be determining what they wanted, not what the State thought was good for them, or that they needed, more purchasing directly by older people would make a substantial impact on the future pattern of services available over the years.
Although there is an emerging consensus with government about much of the policy direction, this has not applied to pensions and income. Here the government has taken small incremental steps around fuel poverty, the Minimum Income Guarantee, Pensions Credit and raising pension levels above the rate of inflation. It has not restored the link between pensions and earnings, or addressed the issue of income in retirement in the round.
The current framework is fragmented. A more root and branch programme of reform is needed, covering a comprehensive view of income in retirement. The three main components should be:
- a new coherent architecture around income in retirement, which would last for the 30-40 years of a person’s likely retirement, with a level of basic state pension to enable older people to stay out of poverty;
- financial advice to enable older people to take decisions in later life (see next section); and
- a long-term plan to raise pension income which might initially seek to raise the pensions to the level of the Minimum Income Guarantee, and then gradually raise the basic level over time to re-establish the link to income levels – a similar approach has been taken to children’s poverty.
The Task Group believes that to put older people in control there needs to be:
- access to information, advice and advocacy, from which decisions and choices can be made; and
- initiatives now, in the absence of a new architecture for income in retirement, to maximise the income that older people are entitled to, and to enhance the direct purchasing power of older people.
Information, advice and advocacy are central to shifting the current emphasis from one of rationing welfare services to one of promoting well-being, based around a citizen-led rather than client-focused approach. This was reinforced by the responses received in the Task Group’s discussion paper.
The Task Group has identified that a key dimension for older people themselves (and other people who may advise them, such as family, friends, and advice agencies) is the pattern of transitions in people’s lives and circumstances, and their implications for information, income, housing and service choices. Society needs to develop a much better understanding of these transitions, and how older people can access the information, advice and support to handle them. Pre-retirement planning includes providing information to older people about key transition areas, so that they can anticipate the potential impact of some of the transitions. The group recommends this as a key area for research.
The group believes that one of the major ways of driving change from a ‘service-led’ to ‘consumer-led’ approach is to put as much purchasing power as possible directly in the hands of older people themselves. It would like to see progress on two fronts.
1. Increasing the level of direct purchasing by older people themselves
For example, through better take-up of direct payments from social services. Economic and Social Research Council research shows significantly higher levels of take-up in other countries (Ungerson & Yeandle, 2002). Several responses to the discussion paper promoted the idea of extending direct payments to areas such as Disabled Facilities Grants, or even to replace Direct Payments with a nationally-funded award similar to the transition to mobility allowance, based on assessed need.
2. Addressing under-claiming of income to which older people are entitled
There is still significant under-claiming of benefits such as Attendance Allowance and other allowances that might be triggered alongside (Help the Aged, 2003). There is also under-claiming of benefits that are available to those who support older people, in particular family carers.
Research for the National Audit Office (Craig et al., 2003) shows the benefits of additional benefit income and the impacts of under-claiming.
Many of the things that older people want cannot be met by local or national government or the health service. Older people are consumers out in the market place, along with all other groups of the population. In some areas, and for some groups of older people, the market works well, with products and services Age Concern.
However, in many other areas the market has up till now failed to provide the types of products and services that older people look for. Examples are the shortage of extra care sheltered housing for sale and the high cost of single-room holiday accommodation.
This also applies to the range of financial products that older people want. Up till now, older people have shown little interest in various market mechanisms, such as long-term care insurance, to fund their own care, or to save and prepare for advanced older age with care or support and various accommodation options in mind. These aspects need considering. Perhaps older people’s views are changing and the market could respond differently.
However, stimulating the private market is about much more than paying for care. For example, the government has been trying to encourage the use of equity release to enable older people to fund adaptations to the home, personal care (via insurance plans or through paying directly) or to secure more disposable income.
There is uncertainty whether the current slow take-up relates to a lack of interest by older people, or, as the Task Group suspects, is more to do with current products not being attractive enough for older people to purchase. There is also concern about equity release possibly negating means-tested benefits. The question is whether the issue is still about making the right products available, or about promoting the concepts of insurance, pensions, savings products and equity release schemes to improve take-up.
Further product development is required to meet the priorities which older people have identified; for example:
- A simple equity release product is needed to enable older people on low to medium incomes to pay for low-level domiciliary care and to purchase other services to support quality of life and well-being.
- Equity release products are needed for lower value properties than are currently available.
- Long-term insurance products are needed which encourage older people to regain daily living skills so that they no longer need the product on a long-term basis, for example, through financial incentives such as premium holidays (where a premium is waived for a period because the customer has not claimed on the insurance, or claimed and then did not need it any more because of successful rehabilitation).
Currently, there appears to be a lack of confidence about some products. In addition, there is a lack of confidence about products for people on lower incomes, and for people with lower value homes.
Several initiatives seek to bridge the welfare and market models. One example is Houseproud.
In the absence of large-scale increases in the basic pension, the Task Group has identified the need to make paramount further progress on insurance and equity release mechanisms to assist in paying for housing, care and support. Alongside this, there is a need for initiatives to open up different methods and routes for take-up, such as local authority guarantees and tax incentives.
More widely, there is a need to educate the private sector about the older people’s market and about the type and cost of products and services that older people want to purchase, both as necessities and by choice, to improve quality of life in older age.
The Task Group believes that a key priority for change is to shift the focus from crisis support for vulnerable older people to a much more pro-active approach to support the wider older population to live full, active and independent lives for as long as possible.
A radical rethink is needed to move the current approach from one of managing dependence for a small part of the older population, to promoting independence and well-being for the older population as a whole.
The Task Group proposes three areas of action:
1. Refocusing prevention as mainstream through developing Quality of Life Strategies and partnerships with older people at local authority level
There are good reasons for taking this broader, more inclusive approach:
- It is what older people want.
- It is central to addressing the current health inequalities in the older population; they cover social and economic factors, access and power (Murtagh et al., 2003).
- There is growing evidence of the cost-effectiveness of an active ageing and preventative approach. For example, older people who undertake gentle exercise as part of a falls prevention programme have fewer falls.
A growing number of local authorities are now promoting an active ageing approach through developing Quality of Life Strategies for an ageing society.
The main issues raised by older people are: recognition, ownership, information, contact, and having an active role in the community.
2. Rethinking approaches to service delivery
Despite growing evidence from research reports referred to in this paper and others (Nuffield Institute for Health, 2003; Wistow et al., 1997; Lewis et al., 1999) as to the value which older people place on preventative services, they are still under-developed and under-funded across the country. The balance of services on the ground does not match the rhetoric, despite the fact that older people consistently say that a ‘little bit of help’ is central to quality of life and well-being in older age (Clark et al., 1998).
Some areas are now beginning to rethink the approach to service development, and are looking to develop a more mixed economy of services. These comprise:
- self-help initiatives led by older people themselves, such as social clubs, leisure, education and social support initiatives: in some of these initiatives, older people trade between themselves or with other groups of the population, for example through ‘time banks’ (older people and others give services free in return for other services given free by another person – the payment or swap is in time, not money);
- Social enterprise initiatives to bring young people into work or older people back to work, using a mixture of training, funding and charging for the services which are provided; and
- Fully charged-for services, with possible subsidies for older people who do not have the ability to pay.
We see the evolution of new models of service development, which get away from traditional welfare approaches, as key to putting a quality of life approach for older people into practice.
3. Developing a neighbourhood approach
Older people are increasingly being recognised and valued as a positive resource in society today, as the social capital with which society sustains and rebuilds communities. The Better Government for Older People (BGOP) programme identified numerous examples of older people as contributors, for example:
- inter-generational work in schools – as tutors, mentors, or volunteers;
- as neighbours and befrienders of other people in the area; and
- as providers of practical help to other older people or other groups needing support, such as drivers taking people to hospital, or preparing meals on wheels.
Yet research for the Housing Corporation (Fletcher, 2000) and Age Concern England (Riseborough, 2000; Riseborough & Jenkins, 2004) has shown that, at neighbourhood level, older people have often been marginalised from the regeneration process. This is despite the fact that they are normally the most stable population group because they have lived in a community for longer, move less often, and have more time on their hands.
In addition, services are still generally planned in isolation rather than on a geographical or neighbourhood basis.
The Task Group found, however, that some areas are working on a neighbourhood basis to bring together older people and agencies as partners in planning for older age, based on a positive view of ageing. This is based on the recognition that older people identify with the natural community where they live. If the home and environment are enabling and supportive, then older people are much more likely to maintain independence and a good quality of life than if this were not the case.
Focusing on a community or neighbourhood level also offers the potential to link into the often well-established community development approaches used in regeneration or neighbourhood renewal initiatives, and to ensure that prevention is not just driven by or seen as the responsibility of health and social services.
It also fits in with the community support networks which still exist in many smaller (sometimes more rural) communities, where professional services are more dispersed and self-help and mutual support are the order of the day. For example, some parish councils preparing their parish plan explicitly look at the needs of their older population and stimulate a range of initiatives to address social isolation or provide practical services. Slaley Parish Council in Northumberland, for example, following the preparation of its parish plan, has linked up with Age Concern to provide a rural shopping service, using Age Concern staff and local volunteers.
Benefits reported by areas adopting this type of approach are listed below:
- Engaging older people as partners and givers directly brings with it increased self-esteem and worth to older people, whom society seem to have written off as retired and no longer having a valued role to play (this includes people with health conditions and disabilities).
- Staff from different agencies reconsider their roles from being service-led to how they can support older people to deliver their agenda.
- Agencies work less in a box and more on a collaborative basis.
- The focus is more around the issues that the majority of older people identify as priorities, and on practical outcomes around promoting well-being, rather than a narrow and traditional health and social care agenda for the few.
- It is easier for older people to access services because often the stigma and red tape of becoming a ‘client’, or having to demonstrate need is ‘fudged’. People become givers as well as takers.
- Local co-ordinators and others find it easier to work across different organisational and professional boundaries to provide information, negotiate, find common ground, and cultivate reciprocity and collaborative effort. These are tasks that are not often included in the commissioning package and go further than just housing support.
It is therefore important that this active ageing and prevention approach, in partnership with older people, is promoted and embedded in regeneration and Housing Market Renewal areas.
One of the starting points for the Task Group has been to address the role of housing and housing-related services as a key dimension of living well into older age. Much of the attention around housing for older people has focused on specialist services for the minority of older people who live in sheltered-type housing. The group believes that this needs to be matched by an equal focus on the ninety per cent of older people – owners and renters – who live in ordinary housing. In addition, a growing number of older people are home owners, and a significant proportion of them are income-poor, even though they have a capital asset in the form of equity in their home. The place of older people in the housing market is an important dimension to address.
Supporting older people in ordinary housing settings
Housing-related services provide a key dimension of a preventative approach. Issues to address include:
- housing design that supports independence, together with access to adaptations and assistive technology to support ageing in place;
- getting flexible support into the home; and
- joining up housing services with health and care to create integrated teams on a neighbourhood basis.
The Task Group’s October 2003 discussion paper provides examples of such services and illustrates the value that housing-related preventative approaches, such as appropriate design, availability of adaptations, handyperson services, and flexible support services, can have in helping to shift the balance of services for older people away from the dependency approach for the few to the enabling approach for the many. However, they are still often developed on a one-off or fragmented basis. The Housing Options for Older People (HOOP) tool, developed by the Elderly Accommodation Counsel, identified several topics (domains) which can impact on whether or not someone’s home, and the environment and services linked to the home, are meeting their needs in older age. They cover:
- size of the dwelling
- how well someone can manage in the home
- quality of life.
There is a need to develop a more coherent approach which ensures that a range of initiatives is in place to address all the domains covered in the HOOP tool. This would enable older people to make more informed decisions about whether to stay put or move, and how to ensure that their housing choice, together with other aspects, such as environment and services, can meet their needs and aspirations.
Housing-based models of care
A key aim of the Task Group has been to develop a better understanding of the current development of housing-based models of care and the future role they can play to promote choice and quality of life in older age. Historically, there has been limited choice between ordinary housing and institutional care, apart from sheltered or retirement housing for rent and sale, which has played a broad but rather ill-defined role.
A shift away from nursing and residential care towards housing-based models of care has started. However, the Task Group was concerned to ensure that these models reflected a real cultural change away from a ‘dependency’ to a ‘promoting independence’ approach built around quality of life principles.
The group believes that it is essential for providers and commissioners to implement a quality of life assessment system and has commissioned the development of a toolkit for this purpose. This will be published in due course.
So what should the specialist accommodation system look like? There are increasingly expressed views that the role of traditional residential care will be replaced by more specialist nursing home care at one end of the spectrum, with the development of more flexible and joined-up service models for older people in ordinary housing at the other.
What role will be left for traditional sheltered housing? And what role will there be for the newer range of housing-based models of care that are emerging? Many areas are looking at developing extra care housing, but is the current interest a transitional phase that will last for 10-20 years and then become outdated, as further accessible models of ordinary housing are developed alongside a range of care and support services?
Consumer feedback from people living in housing-based models of care is generally positive, citing design features, the service model, and the philosophy of promoting independence and ‘help to help oneself’ (Fletcher et al., 1999; Helen Ogilvy Associates, 1999; Croucher et al., 2003). However, some people, who have moved into these schemes, have expressed reservations about perceived loss of freedom, whilst a small number have wanted to be looked after in a traditional care setting.
The evidence so far indicates that those housing and service models that are based on ‘quality of life’ principles can have a valuable role to play:
- as alternatives to residential care and residential-based intermediate care;
- by broadening choices to meet the growing diversity of the older population;
- by supporting people with dementia; and
- by playing a community regeneration and support role on both urban and rural areas.
However, they should not be seen as the solution at the expense of supporting older people in ordinary housing where that is their choice.
Breaking tenure divides
The Task Group has identified the need to overcome the current polarisation of specialist housing provision. Registered Social Landlords (RSLs) and local authorities develop social rented provision largely for low-income older people, and the private sector develops extra care type housing for sale for more wealthy people. This contrasts with the general housing market, where there is a growing trend to create mixed-tenure communities. The group believes that there needs to be a much greater flexibility of tenure and housing options, in order to break down the current polarisation and barriers between welfare and private provision.
There has also only been limited interest so far in developing private sector housing-based models of care. Most private leasehold housing is still firmly decoupled from care and support services, with the individual or their family being expected to purchase their own care and support services. The private market for assisted living has not taken off. Some twenty per cent of McCarthy and Stone developments are now assisted-living schemes, and some residential and nursing home providers have developed small housing-based schemes (sometimes known as close care) alongside their care homes. A significant expansion of specialist providers of very sheltered housing for sale has not developed, as might have been expected.
In addition to developing capital and revenue models that will appeal to the range of financial circumstances of older people, there is also a need for a much more pro-active approach from local authorities and their partners to stimulate and promote the development of the private and mixed tenure markets in their area. Although the housing and regeneration arms of local authorities actively work with private housebuilders, this does not seem to apply so much to the private retirement housing market. How many local authorities, for example, in planning to shift the balance of provision from residential care to housing-based models of care, such as extra care housing, explicitly include housing for sale as part of their plans. And how many approach private sector players as potential partners?
Responses received to the Task Group’s discussion paper show that current planning arrangements appear to inhibit private sector developments of extra care-type housing.
With the growing number of older home owners, and increasing equity values, there is a major onus on local authorities, including planning departments, to stimulate the private market and encourage mixed tenure for low equity value home owners.
Central government actions
Four main actions are needed from central government to create the climate for change that this paper is proposing.
1. A broad-based national strategy for an ageing society
The Task Group is aware that the Department of Work and Pensions (DWP) is co-ordinating work on a forthcoming national strategy on older people, but the scope of the strategy is not yet clear. A broad-based national strategy is needed that runs across the whole of central government (as is the case with the Wales Strategy), and is built around independence, citizenship and well-being. A national lead is needed, with appropriate funding to ensure value for money and no escalation of costs.
2. Local strategies for an ageing population
All local authority areas should be required to develop a Quality of Life Strategy for an ageing society. Only a few authorities have developed strategies for the older population as a whole. Government should require this as the norm rather than the exception.
3. Leverage for change – a suitable performance framework
Suitable levers are needed to ensure that the strategy is translated on the ground. The national strategy would need to be backed up by a new Comprehensive Performance Assessment (CPA) framework for older people for local authorities. Levers should address the well-being agenda for the wider population, not just health and social care performance for vulnerable older people. They need to be backed by carrots, such as financial incentives.
4. Creating an equitable approach
Although the government has taken a number of initiatives to create a more equitable approach for older people in relation to access to and paying for services, such as the Fair Access to Care initiative on charging policies, there are other areas where equal treatment about paying for different types of services does not exist.
One example highlighted in research (Oldman, 2000) is the difference between registered care homes and other forms of supported housing for older people, such as sheltered housing and extra care. In the former, older people pay a blanket fee to cover all their costs and do not receive housing and other benefits. Once their costs are paid, they are left with only £15 or so pocket money a week, not much with which to exercise choice and control. In contrast, people in supported housing schemes have housing rights, are eligible for housing and other benefits, and pay separately for accommodation, support and care costs. This allows for more disposable income and choice in how people spend their money to meet their individual needs.
A second highlighted example is the postcode lottery as to eligibility for adaptations and Disabled Facilities Grants (DFGs). For example, some local authorities will not let housing associations apply for DFGs on behalf of their tenants.
Action by government is needed to address key areas of inequality and develop a more equitable approach.
Local level actions
The Task Group has identified three areas for change.
1. Turning the planning system from managing dependency to promoting active ageing
In most areas, whole-systems planning around older people’s issues is still relatively narrow in concept, focused around health and social care for people in acute need. This approach needs to be turned on its head, with the focus starting with the wider citizenship and active ageing agenda for the older population as a whole, as a key dimension of the local Community Strategy.
Some new planning models are emerging. For example, the government guidance Preparing older people’s strategies (ODPM, DoH, and Housing Corporation, 2003) includes a broad-based, whole-systems planning framework based on five levels, ranging from citizenship and active ageing (level 1) to hospital and long-stay residential and nursing home care (level 5). The framework allows for the full range of current services to be mapped – from leisure and learning at one end to nursing homes at the other – for each level.
It can be applied at both local authority and neighbourhood levels. The framework can be used as a planning tool to change the future balance of services upstream. The goal should be to shift the balance of services and resources from the more dependent levels 4 and 5 into levels 1, 2, and 3. This is in line with the priorities set by older people about living well into later life (mainly levels 1 and 2).
The group believes that local authorities and their partners need to adopt a mapping and planning tool such as this to ensure that their strategies address the extension of universal services for the older population as a whole, as well as specialist services for more vulnerable older people.
2. Local and regional strategy, and commissioning structures with older people as partners
It is no longer adequate for local authorities and Local Strategic Partnerships(LSPs) to focus strategic planning and commissioning for older people around health and social services. There needs to be a recognition of the centrality of strategic planning through the LSPs and the Community Plan, as representing the vehicles that have the best potential to address all the facets of older people’s lives.
This approach can lead to the development of an overarching strategic approach for the ageing population. This is particularly important for both social services and Primary Care Trusts (PCTs), since it:
- offers a way of addressing the broader health and well-being agenda – for example the role of leisure in health promotion;
- opens up the potential for a broader set of partnerships, from regeneration to community safety to life-long learning;
- opens up the ability for partnerships and commissioning services on a locality basis;
- provides a vehicle to engage older people as citizens and partners rather than clients; and
- opens up the potential to put together a much wider range of funding sources to address initiatives across all five levels, rather than only levels 3, 4 and 5, which are the normal province of health and social services funding.
An approach based around the LSP and Community Plan can set the culture and strategic direction within which to address some of these very different requirements for commissioning, if it is to move from a service-led to an older people empowerment model.
A growing number of LSPs are setting up Partnership or Commissioning Boards which go beyond health and social care and link in with the wider LSP agenda – areas such as transport, leisure and education. The Task Group believes that all areas should adopt such broad-based partnership structures. As regional strategy and commissioning structures evolve, the same principles need to be adopted at regional level.
In addition, older people need to be given the opportunity to be engaged as partners in planning through forums such as Elders’ Councils and Senior Voice Forums, and to engage directly as members of LSPs and Partnership Board structures.
Older people also want to play a part in directly commissioning initiatives which will address their priorities, as they see them, rather than the normal pattern of professionals interpreting what older people want, and commissioning on that basis.
3. Rethinking resource use and priorities – a whole-system financial framework
How resources relating to the older population are currently spent, and the relative benefits of different spending and resource decisions, also need rethinking. For example, in relation to Direct Payments:
- What is the relative benefit to older people of a pound spent on residential care, extra care housing, home care, supporting a carer, an adaptation or piece of equipment to aid mobility in the home, making aDirect Payment, or not imposing a charge on the user of such a service?
- What are the implications of the fact that the estimated value of ‘informal’ care for older people (about £40 billion a year) is five times the total annual social services budget for older people?
- How does Britain shift from a welfare approach to spending on publicly purchased services, to a more rights-based approach where older people have direct purchasing power, and the market is challenged to provide what older people want?
The country needs to develop a much better understanding about the range of resources – both capital and revenue – which impact on the older population. Major issues are the:
- relative cost of different services (capital as well as revenue, in the case of housing);
- relative benefits of different types of services; and the
- flexibility (or lack) of being able to mix different sources of income and capital to the individual and to the State (for example, social services).
Yet society is still caught up in traditional welfare thinking about cash-limited budgets and rationed services. Thinking about all the resources potentially available if used creatively together to put the older person in control will require a major cultural shift away from service and resource rationing towards service and resource choice – within the financial limit that the local authority is able to commit. Local authorities and health purchasers need to broaden their approach from thinking it is their role to manage the market, to one of enabling older people to increase their direct purchasing power as a way of developing the market and making it more efficient.
This discussion raises the further issue of how one jointly commissions in a way that can put different sources of funding and income together flexibly.
Evidence needs to be collated to demonstrate the mutual benefits of jointly commissioning resources across a much wider framework than at present – beyond health and social care and into housing, social regeneration, leisure, learning and transport.
There needs to be common agreement and a common approach between commissioners about how they move towards an older people-led approach in resource terms. This means:
- understanding the whole-system financial framework alongside the whole-system planning framework referred to;
- funding effective information, advice and advocacy services, and community development and capacity building with older people, so that they can feel more in control of purchasing services directly themselves; and
- promoting initiatives to stimulate a much wider range of funding and delivery mechanisms, including the private, voluntary and community sectors.
Association of Directors of Social Services, Local Government Association, BGOP, Audit Commission and Nuffield Institute for Health (2004), Public services for tomorrow’s older citizens: Changing attitudes to ageing. ADSS and LGA.
Association of Directors of Social Services and Local Government Association (ADSS & LGA) (2003), All our tomorrows: Inverting the triangle of care. ADSS and LGA.
Carrier J et al. (2004), Older people – a changing approach. Audit Commission/BGOP.
Camden London Borough Council (2002), The quality of life strategy for Camden’s older citizens. Camden LBC.
Clark H, Dyer S, Horwood J (1998), That bit of help: The high value of low level preventative services for older people. Joseph Rowntree Foundation. Findings No. 768.
Craig G, Dornan P, Bradshaw J, Garbutt R, Mumtaz S, Syed A, and Ward A (2003), Underwriting citizenship for older people: The impact of additional benefit income for older people. University of Hull/University of York.
Croucher K et al. (2003), Living at Hartrigg Oaks: Residents’ views of the first continuing care retirement community. Joseph Rowntree Foundation. Findings No. 913.
Darlington Borough Council (2000), Growing older in Darlington: Integrated strategy for older people. Darlington BC.
Dean M (2004), Growing older in the 21st century. ESRC Growing Older (GO) Programme.
Department of Health (2003), Tackling health inequalities: A programme for action. Department of Health.
Fletcher P (2000), Social inclusion for vulnerable people: Linking regeneration and community care – the housing, care and support dimensions. Pavilion Publishing, for the Nuffield Institute for Health and the Housing Corporation.
Fletcher P, Riseborough M, Humphries J, Jenkins C, and Whittingham P (1999), Citizenship and services in older age: The strategic role of very sheltered housing. Housing 21.
Hayden C and Boaz A (2000), Making a difference, BGOP programme evaluation report. University of Warwick.
Helen Ogilvy Associates (1999), Evaluation of Fairfield Court, Anchor Trust.
Help the Aged (2003), Income index for older people in England and Wales.
Lewis H, Fletcher P, Hardy B, Milne A, and Waddington E (1999), Promoting well-being: Developing a preventative approach with older people. NuffieldInstitute for Health/Anchor Trust.
Murtagh M, Cresswell T, and Bailey K (2003), Ageing and inequalities: Tackling inequalities in older people’s health in the North East of England. Northern & Yorkshire Public Health Observatory.
Newcastle Elders Council (2003), The way ahead. Newcastle City Council.
Nuffield Institute for Health, University of Leeds (2003), Healthy ageing in healthy communities, Papers from Expert Seminar. 27 January 2003.
Office of the Deputy Prime Minister, Department of Health and the Housing Corporation (2003), Preparing older people’s strategies – linking housing to health, social care and other strategies. ODPM.
Oldman C (2000), Blurring the boundaries: a fresh look at housing and care provision for older people. Pavilion/Joseph Rowntree Foundation. Findings No. D40.
Parker H (2002), Modest but adequate: a reasonable living standard for households aged 65-74 years. Age Concern England.
Riseborough M (2000), Overlooked and excluded. Age Concern England.
Riseborough M and Jenkins C (2004), Now you see me… now you don’t: How are older citizens being included in regeneration? Age Concern England.
Ungerson C and Yeandle S (2002), Shifting boundaries of paid and unpaid work. Economic and Social Research Council.
Wanless D (2002), Securing our future health: Taking a long-term view. HM Treasury.
Welsh Assembly Government (2003), The strategy for older people in Wales.
Wistow G and Lewis H (1997), Preventative services for older people: Current approaches and future opportunities. Anchor Trust.
Wistow G, Waddington E, and Godfrey M (2003), Living well into later life: from prevention to promotion. Nuffield Institute for Health.
Members of the Task Group
Sir William Utting (Chair) Trustee, Joseph Rowntree Foundation
Peter Fletcher (Secretary) Peter Fletcher Associates
Don Brand Consultant to the Social Care Institute for Excellence (SCIE)
Bob Towner Housing consultant
Martin Shreeve Better Government for Older People, Independent consultant
Melinda Phillips Housing 21
John Graham Extra Care Charitable Trust
Gerald Wistow Nuffield Institute for Health
Veronica Jackson Oldham Metropolitan Borough Council
Janet Lewis formerly Joseph Rowntree Foundation
John Kennedy Joseph Rowntree Housing Trust
Sue Collins Joseph Rowntree Foundation
Pat Kneen Joseph Rowntree Foundation
Robin Means University of West of England
Paul Davison Darlington Primary Care Trust
Robert Bessell Retirement Security Ltd.
Bert Provan Office of the Deputy Prime Minister
Jane Minter Housing 21
Des le Grys Continuing Care Conference
William Laing Laing & Buisson Ltd.
Helena Herklots Age Concern England
Sylvia Cox University of Stirling
David Gardiner Older People’s Advisory Group/Better Government for Older People
Mollie Christ Newcastle Elders Council (till 2003)
Tracey Roose Department of Health (till July 2003)
Moyra Riseborough University of Birmingham