Memorandum by Age Concern England
RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES
(HSS 34)
9. BARRIERS/INCENTIVES
TO ENCOURAGE/DISCOURAGE
USE OF
PARTICULAR SERVICES
Age limits as a barrier
9.1.1 For older people, barriers to services
may exist solely because of their age. Age Concern is aware, on
an anecdotal basis, that the current divide of client groups employed
by many local authorities, hospitals and health authorities, can
mean that individuals whose need for services first arises after
the age of 65 are grouped together under a generic heading of
"older people", irrespective of what their individual
needs might be.
9.1.2 In social services departments, this
can create difficulties for those who are, by virtue of their
age, in the "older person" category yet, by virtue of
their need, require the expertise of specialist teams concerned
with younger adult age groups. For example, Age Concern England
is aware of older people who have been unable to access the specialist
drug and alcohol dependency team in social services departments,
solely because this service was only available to adults up to
the age of 65.
9.1.3 Similar problems arise in the NHS,
where the availability of some treatments or services seem to
be determined by age, rather than by clinical need. For example,
the Government's own review of kidney services shows that, whilst
the incidence of kidney failure rises steeply with age, two-thirds
of kidney patients aged 70-79, and seven-eighths of those aged
80 or more, are not accepted for life-saving dialysis or transplant.
This is despite evidence that rejection of transplanted kidneys
is less likely in older than younger patients.Twenty per cent
of coronary care units operate age-related admissions policies,
and 40 per cent restrict the giving of "clot busting"
drugs to older people (Healthcare rights for older people:
the ageism issue, Nursing Times/Age Concern, 1997).
9.1.4 In the case of mental health, it is
not an uncommon attitude for agencies to consider that the main
diagnosis for people over 65 is some form of dementia. Such an
approach can serve to effectively exclude older people who may
have other forms of mental health difficulties, such as schizophrenia,
or clinical depression.
9.1.5 This is not to suggest that expertise
in caring for older people has no value. However, it is to suggest
that rigid application of age limits can effectively deny older
people access to treatment, care and expertise from which they
could otherwise benefit.
9.1.6 Age Concern believes that:
— Central government and local government
must ensure that age limits are not used as a barrier to receiving
appropriate services by either health or local authorities.
9.2 Barriers to remaining at home
9.2.1 Many older people continue to see
an assessment of their care or health needs as a "test"
which they must pass in order to achieve their wish to remain
living at home (Hospital discharge: user, carer and professional
perspectives, Nuffield Institute for Health, 1996). It is
likely that the concept of passing some kind of test will continue,
particularly given the complexity and tightening of criteria for
some services. Individuals contacting Age Concern seek information
as to likely words or phrases they should use which may trigger
a response such as an assessment or service. By increasing the
technicalities for entry to services, or setting other limitations,
local and health authorities may be actively discouraging individuals
from contacting them for assistance. However, if entry into the
system is made too difficult, some older people who should be
able to access services may instead fall through the net. Moreover,
such an approach may not be consistent with local authority duties
towards individuals, both for care assessments and the provision
or arrangement of services.
9.2.2 The vast majority of older people,
their relatives, carers and friends, who contact Age Concern with
queries about care, wish to remain living at home for as long
as possible. However, in many areas, local authorities have set
"ceiling" or maximum amounts for the care which they
will provide or arrange for someone to remain at home. Once those
maximum amounts are exceeded, it is most likely that the individual
will meet criteria for some kind of residential care. These maximum
amounts are generally linked to the average net cost to the local
authority of arranging placements in independent sector residential
or nursing homes. Legal judgement has confirmed that if two service
options will meet an individual's assessed needs, then the authority
may legitimately choose to offer the option which is cheapest
for it to provide or arrange (R v Lancashire County Council
ex parte Ingham, 1996). There is some evidence that health
authorities are also beginning to set ceiling limits for continuing
health care services.
9.2.3 Yet such maximum amounts are often
based on the historic configuration of services. For example,
over the past two decades there has been a far greater expansion
in residential and nursing homes for older people than for any
other client group; generally, such care has tended to attract
lower levels of state funding even though dependency levels of
residents are increasing. Such factors mean that, in most cases,
the maximum amounts of care which will be provided for older people
who live at home are often significantly lower than maximum levels
for other, younger client groups. Equally, the exclusion of older
people from the Independent Living (1993) Fund, and the inability
for older people to access specific benefits to help with the
extra costs of mobility if such problems first arise after the
age of 65, has meant that older people generally have not had
access to the highest levels of support at home.
9.2.4 The impact of new legislation on the
type and level of care is a particular issue which needs addressing.
For example, the introduction of an European Union Directive on
risk assessment for handling, lifting and carrying individuals
in 1993 continues to have an impact on availability of services.
In situations where such an assessment identifies the need for
two carers where previously one had been provided, can effectively
halve the hours of care available to older people at home. In
addition, this change has led to a large increase in requests
for hoists and other lifting equipment, putting additional pressure
on the level of funding for Disabled Facilities Grants (Managing
adaptations, ADSS/Joseph Rowntree Foundation, 1996).
9.2.5 Age Concern believes that:
— the Government should acknowledge
that the community care promise was that older and disabled people
should be able to remain in their own homes for as long as possible.
It should ensure that there is sufficient funding for local and
health authorities to meet these needs in relation to changing
levels of dependency and legislative requirements.
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