Newcastle Symposium on the Goals of Ageing Research
24th-25th April 2001 International Centre for Life Times Square, Newcastle
Session 4: The Social Policy Context
Session 4.1
Session 4.2 Discussion Points
Contents of Session 4
Chair: Professor John Bond

Paper 4.1: The Time of Our Lives - Kate Davidson

Paper 4.2: Sociology, Health Services Research and Changing Patterns of Health Care for
Older People - Carl May

Points from Discussions
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Session 4: The Social Policy Context
Paper 4.1
The Time of Our Lives
Kate Davidson
We have known since the middle of the last century that future generations were going to live
longer, so how can we denounce the greying population as a demographic and welfare crisis?
It is paradoxical that on the one hand, we congratulate ourselves on having established, through
social, environmental and public health measures as well as cutting edge medical advances, the
ability to stay alive longer, but then we penalise those who are the principal beneficiaries: people
who live into old age. It is not intended here to revisit the doom and gloom scenario on
population ageing – I think we have been inundated with sufficient rhetoric on the demographic
time bomb and its consequences for modern society. Rather, I am going to discuss some of the
policy implications for the 21st century and the importance of research in identifying priorities in
adding life to the extra years we now enjoy.
The principal areas of social research include: health, pensions and changing patterns of work
and social inclusion and exclusion.
Health
Implications for healthcare have already been discussed so I shall say very little about this area,
but I would like to add a social scientific dimension. More than two decades ago, Fries identified
the ‘compression of morbidity’, whereby, most of us are in good health, or at least have fully
treatable/preventable conditions, for most of our lives. This means that terminal illness tends to
be compressed into our period of old age. There are gender differences in morbidity patterns with
men suffering from more catastrophic illness and women from more chronic diseases but most
people need the greatest amount of healthcare in the last 12 months of life. However, primary
health promotion still lags behind secondary intervention procedures when it comes to budget
allocation.
The National Service Framework for Older People launched at last, a few weeks ago, was
wonderfully refreshing to read, inasmuch as the issue of discrimination and rationing on the
grounds of age has at last been admitted, with an imperative to address and rectify.
Probably for me, as a researcher, the most important aspect of the report is that older people
themselves were asked. Interestingly, most of the older people I have interviewed about NHS
health care have nothing but good to say about their actual medical treatment. But they do
complain about long waiting times to see a doctor (this includes appointments with their GP, a
referral to a Consultant as well as experiences in A&E) but more importantly, the say that they
think some of the attitudes of the staff could be improved. It is this ‘institutional ageism’ demonstrated by the inappropriate language used (infantilisation), the often rough handling and
insensitivity (privacy, for example) - that distresses older people and their carers. Some are afraid
to complain in case they make things worse. This element in discrimination will be very much
more difficult to eradicate than offering more medical procedures. There are training and
awareness implications for all NHS staff. In fact, this is an important issue for all people
involved with the care of disempowered frail, older people.
Pensions and changing patterns of work
In 1908 when old age pensions were first introduced for those with an annual income of less than
£31, there were concerns about cost implications. The original Old Age Pension started at the
age of 70 - a last minute change from the planned 65 - and were means tested on a sliding scale
(5/- a week for those with less than £21 pa sliding down to 1/- a week for those with £31 pa). The
benefit was non-contributory, paid through the Post Office, without stigma, and married women
received the same pension as men and unmarried women. The benefit represented a considerable
advance at that time. However, not only was the pension means tested, there were also ‘moral’
tests applied. For example, it was not given to people who were habitually drunken, had served a
prison sentence in the previous ten years and people who were in receipt of "indoor" Poor Law
relief. Interestingly, in the last scenario, a similar rule applies today inasmuch as older people,
who are in-patients in hospital and in long term care nursing homes, also have their pensions
dramatically reduced.
Almost a hundred years later, retirement income and patterns have changed, but not the concerns
with cost. Early retirement has increased dramatically for both men and women and a person can
spend a similar number of years retired as when they were employed. The Stakeholders Pensions
started at this financial year, and over the next 20 years, there will be equalisation of the age of
retirement.
However, beyond the economic anxieties, there lie other factors which impact on the
employment choices and constraints of older people: ageist attitudes to older workers as
‘inflexible’ or ‘not worth training’ and that they should ‘make way for younger workers’.
Motivation and ability to continue in employment after the statutory retirement age(s) are not
taken into consideration. How do retired people view their ‘lives after work’, and what if any,
has been the policy response?
Social inclusion and exclusion
Present government policy initiatives to combat social exclusion hinge on getting "socially
excluded" people into employment, thus stressing the importance of access to financial
resources. Social scientists have broadened the conception of social inclusion by examining the
connections between social inclusion and kith, kin and community networks. Particularly
interesting is the overlap between individual and state responsibilities, and social policy
implications for the care of an ageing population.
We have competing visions of the state as a manipulator of social division (statutory pension
age, health rationing, residential care) or as an institution that is engaged in offloading
responsibilities to family and neighbourhood networks (through care in the community). Is there
a real choice between community care which has been described as a humane form of house
arrest, and residential care which can all too often mean acute isolation or incarceration in a
group which provides the most minimal form of general social contact?
People’s potential to mobilise social networks and to participate in them varies enormously in
ways that are often socially determined. There have been concerted efforts to investigate to what
extent age, gender, class, marital status, ethnicity, disability, and the significance of national,
regional and local variation, impact on social networking and concomitant inclusion in modern
society. The Economic and Social Research Council (ESRC) for example has commissioned the
Growing Older Programme to look at issues of quality of life for older people, and in association
with the Institute for Public Policy Research (IPPR), the ESRC has run seminars entitled "Public
policy and social networks; promoting social inclusion" which addressed these issues.
Conclusion
There is no doubt that most research on older people has highlighted the importance of health in
old age. Indeed, people who are over the age of 65 are much more likely to perceive themselves
as ‘old’ if they have health problems. Research also reveals that access to financial security in
old age, mediated by gender, class and ethnicity, impacts on differences in health status among
this population. By taking a more holistic approach to the investigation of old age, we gain a
better understanding of the social processes of ageing and age-related experiences. Thus has
social scientific research been recognised as offering a major contribution to policy initiatives.
Reference
1. Fries. J (1980) "Aging Natural Death and the Compression of Morbidity." New England
Journal of Medicine 303 (3): 130-135.
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Session 4: The Social Policy Context
Paper 4.2
Sociology, Health Services Research and Changing Patterns
of Health Care for Older People
Carl May
My purpose in this short paper is to suggest some of the ways that health services research might
contribute to developments in the field of ageing research. The background to this is my longstanding interest in the sociology of the health professions, their knowledge, and practice – and
increasingly, the ways that new assistive technologies impact upon these. I want to begin by
drawing out the implications of the National Service Framework for Older People (NSF)(1),
which – despite its singularly low key launch – promises a policy commitment towards
attempting to solve some key structural problems in the provision of health and social care for
older people.
It has been well known for a long time that health and social care for older people is fragmented
and highly variable in quality. This has been exacerbated by policy interventions that have
attempted to shift the provision of social care out of the statutory sector. It is also been well
established for some time that one of the key factors that impedes good clinical care for older
people is their age. This has been manifest in the age-related rationing of some services and
procedures and in other kinds of implicit or explicit discrimination, as well as in wider patterns
of insensitive (and sometimes abusive) professional practice(2). Underpinning all of this is the
way that older people are sometimes conceptualised by health and social care professionals: as a
group that suffer mainly from clinically unrewarding longstanding chronic and inevitably
degenerative health problems that are highly resource-intensive. The latter are interwoven with
complex (and equally resource-intensive) social problems related to structural social inequalities
like poverty. These structural inequalities are important, for they bring in their wake lack of
access to the material and social resources that are needed to change the content and quality of
care. These have proved the vital lever in the kinds of interest group politics that have had such a
significant effect, for example, on the organisation and delivery of ante-natal and maternity care,
and which have led to major changes in service delivery to younger, more articulate and
powerful groups of health care consumers.
The NSF is part of an attempt to put in place a more integrated body of services that provide
better quality care, and in which older people are identified as a group who want to make active
choices about the kinds of care that they receive, and who are well able to adjudicate on its
quality. In addition to its focus on specific clinical problems, its broad objectives are: to end age
related discrimination; to provide person-centred care; and to develop a new level of
intermediate care. Despite its low-key launch, the NSF is widely regarded as a ‘good thing’ –
although there have been a number of critical commentaries that have pointedly observed that it
is not clear how service developments arising from it will be funded or their achievements
assessed. It is by no means clear that the policy objectives set out in the NSF can be achieved. In
this short paper I will signal some of the research issues that are brought into the foreground by
the NSF.
(a) Person-centred care is to be given priority, but needs to be evaluated. Beginning with the
notion of person-centred care, it should be noted that this is as much an ideological notion as a
practical issue in professional practice. There are long standing political and cultural shifts in this
direction in the provision of health care, and these derive from two sources. First, service users
themselves have over the past thirty years insisted that health services respond to them as
experiencing individuals with wants and needs, and who wish to be informed and to make
choices about their care. The shift here is away from seeing them than as passive recipients of
services and as impersonal objects of clinical practice and procedures. It has also meant that
service users’ ‘satisfaction’ with their care has become an important focus of interest, even
though what ‘satisfaction’ actually means is understood only in quite crude ways. This is a
general feature of health and social care, and forms the subtext of policy interventions since
Working for Patients(3). Health professions, especially in nursing and primary care, have – in
parallel – also developed highly worked out notions of the patient-as-person that have taken as
their focus the psychosocial problems of service users(4). Older people have not figured
prominently in these notions as they have been worked out across professional theory and
practice; they seem often to have been regarded as passive, rather than active, players in the
drama of care provision.
Person-centredness is going to become a more complex phenomenon in the environment
suggested by the NSF. If we are to take the notion seriously, then it means that we must better
understand how care can be delivered in ways that give older people real influence over the type
and quality of care available to them; and also how care can be organised in ways that undercut
the bitter contests over resource allocation that already mark the services available to them.
Research in this area will need to explore how individuals and groups are accommodated, or not,
in new institutional arrangements. For example, we know very little about how the viability of
older people for treatment is established implicitly in practice, and about how ideas about
‘appropriateness’ of treatment are organised into services for older people: so establishing a
strong knowledge base in this area is vital. The issues here are not simply about the organisation
and structure of care, but also relate to its ethical base and to the need to empower older people
and present them with positive choices about services that are humane.
(b) Person-centred care will be mediated through structured assessments, and interdisciplinary
teams. The blurring of institutional boundaries (between social and health care, and between
different ‘levels’ of health care) suggested by the NSF presents a second important research
agenda. This relates to the professional organisation of care itself, for against the background of
person-centredness as a moral imperative underpinning care, the instrumental capacity of
professionals to make important decisions about the lives of older people is extended by the shift
towards protocol driven assessments which apply quantifiable values to their health and social
status. Research on the provision of care for older people needs to rigorously interrogate the
effects of these instruments of assessment, the knowledge that underpins them and the practices
that stem from them. This is important because health care is knowledge-based, even when it is
at its most basic level of application. Qualitative research on nursing and primary care, for
example, emphasises that ‘knowing the patient’ is understood by practitioners to be a crucial part
of their work as individuals and in teams. In fact, we know very little about how good multidisciplinary teams work, and about the factors that promote or inhibit the provision of high
quality care. It is clear that at a macro-level, resource allocation and the division of labour
between different professional groups (and increasingly, the delegation of routine care to staff at
the most basic grades) have important consequences. But we also know little about what kinds of
knowledge about patient care multi-disciplinary groups deploy, how they build this and share it,
and how they adjudicate on the quality of care that they provide through this knowledge. To
understand how personal care develops within the NSF, we need to know more about the
dynamics of professional work across disciplinary boundaries, as well as focusing on the needs
and wants articulated by service users. This is will be crucial in understanding how
individualised needs assessments are conducted and employed to focus the work of health
professionals at a micro-level of activity, and how attempts to promote more integrated care
cohere (or come apart) around specific groups of service users.
Research aimed at understanding the knowledge-base and organisation of care for older people
ought to be a priority, then, for health services research. The situation here is dynamic, for new
technologies are becoming available that will change the delivery of care as well as professional
practice. Remote monitoring and home telecare systems are part of a range of assistive
technologies that have been established as effective and reliable ways of mediating between
service users and professionals. These are now coming into service in a range of settings, but
while the technologies have been evaluated, their effects on the organisation and delivery of care
have not(5). Health services research will need to focus on the impact of new technologies on the
delivery of care, and develop a stronger understanding of the ways that they change the conduct
of professional practice.
Perhaps all this signals not so much of a Health Services Research agenda, but an explicitly
sociological one. There is a substantial literature already on the distribution of service types and
on their evaluation. It is also well established that these do not always meet the needs of older
people, and that they sometimes actively discriminate against them(6). Research on the provision
of care for older people needs to draw on the lessons of social gerontology (on older people’s
experiences of health care provision, and how these are formed around their access to material
and social resources), and on those of medical sociology (on the ways that professional
knowledge and practice are produced and organised). This approach focuses on the organisation
of health care of older people as a dynamic system, and places the knowledge and practice that
different constituencies bring to it at centre stage. This will be important for two reasons: we
need to understand variations in the quality and provision of care for older people as more than a
technical problem of resource allocation. High quality care comes about as result of people in
post, rather than those who are not: understanding how professional knowledge is translated into
good practice, and how that practice is formed up to meet and accommodate the needs to older
people must be crucial objective of research in the field.
References
1. Department of Health. National Service Framework for Older People. 2001. London,
Department of Health.
2. Topic Working Group. NHS R&D Strategic Review: Ageing and age-associated
disease and disability. 1999. London, NHSE.
3. Department of Health. Working for Patients. White Paper, Cmd 555. 1989. London,
HMSO.
4. May C, Fleming C. The professional imagination: narrative and the symbolic
boundaries between medicine and nursing. J Adv Nurs 1997;25:1094-100.
5. May C, Mort M, Mair F, Ellis NT, Gask L. Evaluation of new technologies in health
care systems: what's the context? Health Informatics Journal 2000;6:67-70.
6. Age Concern. Turning your back on us: Older people and the NHS. 1999. London,
AgeConcern.
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Session 4: The Social Policy Context
Discussion Points from Session 4

Older people perceive that others do better than they do and that their needs are not a
priority. They need to be listened to and they need to receive explanations. But social
inequalities are not natural. They are the products of social organisation and the result of
political decisions. The organisation of professional knowledge and practice also leads to
social inequalities. For instance, there is a national shortage of nurses because of poor pay
and bad conditions, but that is a choice which has been made by society.

One of the problems for health care is the sheer volume of people to be seen. In medical
schools students are taught ethics and communication, but in the hectic years after
qualification the opportunities to foster person-centred practices can be rare because of
the pressure. Problems are caused by inadequate training and supervision of junior
doctors. This is seen, for instance, in casualty departments where junior doctors might be
inclined to over-order, over-test and over-admit patients. This is an area where education
could lead to health promotion.

The interface between medical and social care remains a problem. For instance, the report
into long-term care in the UK suggested that health and social care should be paid for by
the State, but instead the Government has made a distinction between health care and
social care, whereas in fact it is difficult to separate the two. Although a seamless
provision of care is recommended throughout health and social care, in practice it
remains difficult to provide this, although the World Health Organisation’s broad
definition of health encourages the broad view which would bring together every aspect
of health, whether it be physical or social. Indeed, providing seamless care should save
money because it would avoid the duplication inevitable when two services have to be
provided. It is for this reason that the single assessment, recommended in the National
Service Framework for Older People, makes consummate sense. What is required is not
professional rivalry, but a properly integrated health and welfare service.

It might be true that we have moved away from seeing ageing as a disease, but it is still
seen as almost entirely negative. This is despite the fact that older people provide a
tremendous resource and can make a positive contribution to society, as many do through
volunteer work.

Older people have fewer financial resources, but they also have fewer outgoings and they
have more control over their spending. They may be quantitatively poorer, but
qualitatively less poorly off. We should not pathologise everything to do with old age, but
should instead listen to older people. So, for example, older people have said that they
require better transport, good chiropody services and subsidised taxis. For many older
people these would be more important that home helps.

There is a mismatch between the current care which older people receive and the
advances of cutting-edge science. This stresses the importance of multidisciplinary
research, which is not adopted in many UK research groups to the detriment of agerelated research.

There is a danger that older people will have lower expectations. So, for example, they
might expect their eyesight to be poorer and to have less mobility etc. But it doesn’t have
to be like this. There may be a cohort effect and it might be that in the future older people
will expect and demand better services. There is also a change of attitudes needed, as
shown by the anecdote concerning the lady with a bad knee whose doctor blamed her
age, to which she retorted that her other knee was just as old!

There is a complex relationship between research and practice. This is another reason
why qualitative methods are required and relevant time frames must be used. The nature
of the research questions asked is crucial. This frames the problem and it should not be
that older people are themselves constituted as a particular kind of problem.

If health promotion gives better value for money, why does hi-tech medicine receive
more resources? Is this to do with careers or profits?

Much health education does not actually work. Health education and health promotion
seem to work when people believe in them, but there are often conflicts over the
scientific data. An example is the debate over whether or not red wine is good for people.
But then, people tend to have a contingent and situated view of risk.

Part of the problem is the high expectations which are placed on the health and social
services. These societal attitudes mean that the solution is not simply a financial one.

The mixture of poverty plus poor access plus low influence means that older people often
have no voice. This is a structural and political inequality.
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Ageing pages constructed by Andrew J. Palmer Jan 2002