Help the Aged wants a world where older people are free from the disadvantages of poverty, neglect and isolation, so they can live with dignity as valued, respected and involved members of society

1.  INTRODUCTION

  1.1  Help the Aged welcomes the opportunity to respond to the Health Select Committee's inquiry on health inequalities.

  1.2  Help the Aged is a charity fighting to free disadvantaged older people in the UK and overseas from poverty, isolation and neglect. It campaigns to raise public awareness of the issues affecting older people and to bring about policy change. The Charity delivers a range of services: information and advice, home support and community living, including international development work. These are supported by its fundraising activities and paid for services. Help the Aged also funds vital research into the health issues and experiences of older people to improve the quality of later life.

  1.3  In preparing this response, Help the Aged has drawn on our extensive research and experience of working with and talking to older people. Through the Charity's engagement strategy, Vocal Point, all issues older people raise with the Charity are logged and monitored to feed into the work of the organisation. We also proactively seek older people's opinions through focus groups and listening events, as well as liaising with members of Speaking Up For Our Age, a programme which facilitates and supports hundreds of local older people's forums.

  1.4  Health inequalities amongst older people are a serious concern. The starkest demonstration of the gap between rich and poor can be seen in the gulf in life expectancy between different social groups. Despite the Government's commitment that no-one should be disadvantaged by where they live, the reality is that people who are poor, or who live in poor communities die earlier.

  1.5  Health inequalities have wide ranging implications: Unless health inequalities can be addressed the raising of the State Pension Age between now and 2050 will have a disproportionate negative effect on people from lower socio economic groups. The pensions debate has focussed on the fact that, on average, the number of years people spend in retirement is increasing. However, the reality is that for some men in areas of Glasgow the average life expectancy is below the state pension age. This picture is replicated in other deprived areas of the country where many people will only live for a few years after they start receiving a pension, whilst in affluent areas people look forward to 30 years of retirement. Without action to tackle health inequalities the Government's entire ageing strategy will be in jeopardy.

  1.6  Tackling health inequalities is not just a job for the Department of Health: The whole Government must continue to tackle poverty across all ages, and must work to support the development of communities which work for all their residents, in order to reduce the isolation and deprivation which leads to poor health.

  1.7  Help the Aged understands that health inequalities are determined by a range of factors and this is reflected in our broad programme of policy work on issues that affect disadvantaged older people. This includes tackling fuel poverty, encouraging sustainable communities, combating social and financial exclusion, as well as promoting health and wellbeing.

  1.8  Help the Aged is committed to supporting preventative health interventions. We are the leading voluntary sector agency in the field of falls prevention, linking with academics, clinicians and practitioners. We have a long-standing programme in this area which includes an annual Falls Awareness Day, resource production and commissioning original research. We supported Department of Health in the early development of the mid-life health check, and are linked in with its health trainer programme.

2.  EVIDENCE

Poverty and health inequalities in the older population

  2.1  In his analysis of the English Longitudinal Study of Ageing (Wave 2), Sir Michael Marmot demonstrates that income is a major factor in health deprivation and poor mobility for older people.[260] More widely, ELSA documents how the risk of a wide range of conditions such as cardiovascular disease, arthritis, respiratory and psychological illness increases not only with age but also for manual workers (and retired manual workers), for those living in the North East and North West of England and for those with the lowest income.[261] There are significantly higher rates of early deaths from cancer, circulatory disease and smoking-related deaths in the north of England.[262]

Life expectancy

  2.2  Life expectancies, both at birth and at age 65, also show a large gap between the richest and the poorest parts of the country—someone aged 65 living in Kensington and Chelsea can expect to live on average 8 years longer than a 65-year-old in Glasgow City[263].

  2.3  On average, men in the UK can expect to live their last 6.9 years with a disability. For women, the figure is 8.7 years.[264] Healthy life expectancy is shorter for those in lower socio-economic groups, both in Great Britain and most of the rest of the EU.[265]

Future health projections

  2.4  In the next ten years in the UK, it is estimated that there will be[266]:

—  Nearly seven million older people who cannot walk up one flight of stairs without resting

—  One-and-a-half million older people who cannot see well enough to recognise a friend across a road

—  Over a third of a million with major speech problems

—  Over 4 million with major hearing problems

—  Up to a third of a million people aged 75+ with dual sensory loss

—  Over a million people aged 75+ who find it very difficult to get to their local hospital

—  A third of a million who have difficulty bathing

—  Nearly a million with dementia

—  Between 4-7 million with urinary incontinence

—  One-and-a-half million suffering from depression

—  Five per cent of men and six percent of women with three or more of the functional limitations listed above

  2.5  These statistics demonstrate the importance of reaching the older population with public health initiatives. To do this, we believe it is vital that targeted initiatives are developed. Whilst we are supportive of a broad public health agenda, we believe that, in designing and implementing public health programmes, we must differentiate between the needs of different populations. The needs of older people, and the ways in which they can be engaged with public health initiatives, will differ from other populations such as children and families.

  2.6  Below we offer some comments on the Committee's specific areas of inquiry.

3.   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government

  3.1  The NHS has a key contribution to make to the work to address health inequalities faced by older people.

  3.2  Whilst it is true that health inequalities persist amongst groups who are in poverty, or who live in poor communities, too often it is the failure of the NHS to adequately fulfil their obligations to these communities which is the problem—not their poverty in itself.

  3.3  A key example of this can be seen in the area of foot care. The failure of NHS trusts to prioritise foot care has resulted in a severe lack of podiatrists at the local level to meet the needs of older people[267]. A study for Help the Aged estimated that 25% of people over the age of 65 who need professional foot care were not receiving it and that to provide this level of services would require nearly doubling the size of the podiatry service. Clearly those worst affected are those on the lowest income, with the poorest health outcomes, because they cannot afford to buy podiatry services privately. The implications of untreated foot problems are serious. Older people suffering from foot problems are likely to suffer unnecessary pain, are less likely to be physically active and are at greater risk of falls. In this way gaps in NHS provision have a direct impact on health inequalities.

  3.4  Similarly the patchy provision of quality continence care contributes to unequal health outcomes. Help the Aged's research[268] suggests that incontinence has the potential to contribute to social isolation. Incontinence is not an inevitable part of ageing but the condition is more common in older age. 15 % of older men and women over 65 living at home have faecal incontinence. The condition is not well assessed and treated: many people report they have been given a pad to stop leakage and full assessments are not made. A recent continence audit found services across the country were patchy and many continence adviser posts and budgets for incontinence products are subject to cuts. The NHS could play a key role in tackling incontinence earlier and more effectively, and thereby address a much broader range of issues in older people's health.

  3.5  The NHS can also play a vital role in ensuring more people understand how to look after their own health, for example through the promotion of the physical exercise—ensuring that the gym is not seen as the preserve of the middle classes. Rates of physical activity decline with age, as identified in the recent Sport England survey[269], but international evidence suggests that this is not inevitable. We believe the NHS could do more to encourage physical activity as a way of preventing ill health, promoting good health and maintaining independence. Although not exclusively a health issue, as barriers to participation may be the result of poor provision locally, lack of transport links, perceived risk of crime, nevertheless the NHS has an important public health role in working with local authorities to promote the benefits of and opportunities for getting active. Some communities have successfully piloted the idea of "exercise on prescription" but this is not universally available, and inevitably it tends to be those who are more articulate and assertive, in more affluent communities who are better able to access these options (the inverse care law).

  3.6  In sum, whilst it is important not to over-estimate the role of the NHS in tackling health inequalities, if the NHS focussed more attention on those medical conditions which impact older people's broader quality of life, it is likely there would be a real impact on health inequalities.

  3.7  Ultimately, however, a multi-pronged strategy will be needed to tackle health inequalities.

  3.8  Poverty is clearly a central consideration. It remains the case that those who are wealthier can afford to stay active and healthy, those in poverty cannot. This is not just about the ability to buy into private solutions to health problems, where the NHS fails, but also about the wider impact of a life in poverty. The 2 million older people living in poverty in the UK often face harsh choices when budgeting on very low incomes. Research carried out by Help the Aged has shown that people are unlikely to go into debt or arrears with bills but instead cut back on basics such as fuel and heating. This can have serious implications for health, especially in winter where not heating the home properly can put people at increased risk of death from cold related illnesses. In addition, poverty can be extremely isolating as people cannot afford to be involved in leisure activities, due to the cost of the activity or itself or due to the cost of transport (a particular issue for those with mobility impairment or disabilities who cannot use buses and therefore do not benefit from a free pass.) In addition, communities which are lacking in facilities and services also exacerbate isolation.

  3.9  In a Help the Aged survey of older people's views on public toilet provision in their local area[270] 52% of respondents agreed that the lack of public toilets in their area stopped them going out as often as they would like. Large numbers of people who are tethered by an invisible "bladder leash" which restricts their movements to within easy reach of toilets, thus contributing to social isolation and the resulting health impacts.

  3.10  A further Help the Aged survey[271] suggested that 2.5 million older people have fallen on pavements and 13% of those people reported that the episode had left them afraid to leave home.

  3.11  All too often, poorly served communities are poorer communities—leading to a cycle of disadvantage and poor health.

  3.12  Another key issue is access to skills training and learning opportunities. Learning activity not only brings benefits in itself, through helping to keep the mind active, but can also give people the knowledge and tools they need to maintain healthy lives. Unfortunately recent cuts in adult education budgets have led to concessionary rates for older learners being withdrawn—as a result adult education now remains the preserve of the more affluent older person.

4.   The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities

  4.1  It is important that GPs are accessible to older people and physical access is therefore a key consideration. However geographical location need not be a major concern if appropriate transport is made available. All too often, though, older people find it difficult to make appointments to correspond with off-peak periods when bus passes can be used. But accessibility means more than just location, and ensuring a GP is approachable and helpful is also important. Older men's reluctance to approach GPs is well documented and therefore outreach programmes will be needed to reach some of those most at risk. There can also be issues for some older people, with the length of time allocated for GP appointments—which may not be sufficient for them to feel they can discuss their health concerns in full.

  4.2  There are particular concerns around access to primary care for people in care homes. Many older people are deregistered by their GP when they go into a home, and allocated to the home's chosen GP. Some homes struggle to secure GP services, with some doctors asking for retainers to work in care homes. Help the Aged has investigated this issue as part of My Home Life programme (www.myhomelife.org.uk).

  4.3  Other older people fall victim to age discrimination in health care. Help the Aged recently supported 500 older people to respond to the Government's consultation on discrimination law. Many responded with personal stories of age discrimination at the hands of medical professionals.

  4.4  One woman reported:

"My mother saw her GP for years complaining of back pain. He never examined her and told her it was old age. When she moved . . . the new GP sent her for a scan and found she had a tumor the size of a football in her back"[272]

  4.5  Help the Aged believes the Quality and Outcomes Framework could be used to improve older people's access to key health interventions—particularly in the area of falls and bone health. Osteoporosis is a serious problem amongst older people, and has an enormous impact on quality of life, yet access to bone density screening remains patchy.

  4.6  Falls represent the most frequent and serious type of accident in the over-65s and are a serious cause of morbidity and mortality. 30% of community dwelling people over 65 and 50% of those over 80 years will fall in 12 months with 60% of those who fall once, falling again within the same year. A proportion of these will fracture. Half of those who suffer a hip fracture never regain their former level of function.

  4.7  The recent Royal College of Physicians clinical audit of falls services found that quality was inconsistent across the country and bone health services lagged behind in many areas. Inequality of access to assessment and high quality treatment may contribute to inequalities in health outcomes.

  4.8  Involving GPs in the identification and treatment of those at risk of falls and with poor bone health would be a key way of tackling this issue, but unless falls and bone health are included within the QOF it is unlikely that progress will be made. Unfortunately, the ongoing debate over the new GP contract, which many organisations including Help the Aged argued should include falls and osteoporosis assessment and treatment, has reached an impasse.

  4.9  In terms of the role of Practice Based Commissioning, it is not clear whether, at the moment, GPs have the information they need to effectively target health inequalities affecting their localities, nor is it clear they have the expertise required to determine how to address them. If GPs are to undertake this role at all effectively they will certainly need to engage with the local Strategic Needs Assessment, undertaken by the PCT and local authority.

5.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective

  5.1  Clearly smoking and obesity are serious health concerns and need to be tackled as part of the onslaught on health inequalities. However too often the marketing of initiatives in these areas does not reach out specifically to older people, and as a result older people fail to benefit. Furthermore, Help the Aged is concerned that the heavy emphasis on these high profile issues may lead to the neglect of the particular issues faced by older people.

  5.2  It is right that the current obesity epidemic is a focus of Government thinking; however the coverage of this matter can crowd the public health space, so that the complex nutritional needs of vulnerable older people are not addressed. Many vulnerable older people need support with healthy eating, but may not be reached by broad brush messages around obesity. Indeed recent studies have highlighted the vulnerability of older people to malnutrition (particularly those in care settings). It is vital that this problem is identified and addressed, through both targeted public health messages to older people about eating well, and support from healthcare professionals such as nutritionists.

  5.3  Similarly, generalised messages and initiatives about increasing levels of physical activity are unlikely to reach older people. Targeted programmes will be needed to ensure older people are not excluded from the opportunity to maintain their health through physical exercise.

  5.4  Help the Aged's experience of running falls prevention initiatives demonstrates the importance of ensuring careful targeting of initiatives designed to improve health. In response to concerns about the failure of some BME groups to access mainstream falls prevention provision, Help the Aged established a Minority Ethnic Elders Falls Prevention Programme. The scheme piloted exercise classes and other initiatives aimed at minority communities within certain localities. The pilots demonstrated the importance of taking into account factors such as language, culture, and requirements around time of day, food etc, in order to ensure the needs of all communities are met.

6.   Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective

  6.1  Help the Aged does not have specific experience of Sure Start or Health Action Zones.

  6.2  However, anecdotal evidence from public health professionals at the local level suggests that initiatives such as health trainers have been extremely helpful in improving the outreach of PCTs to disadvantaged sections of the community. Evidence of impact on health outcomes is much more difficult to obtain. Further anecdotal evidence, however, suggests that older people have been responsive to targeted interventions and support from health trainers, for example a health trainer in one local area supported walking groups amongst older people to promote health, by going into a care home to explain benefits of physical activity, and how activity can be taken in small chunks.

  6.3  It is essential that health trainers reach out to older people in their local community and where possible, older people are recruited as health trainers themselves.

  6.4  We have also been impressed by the work undertaken as part of the Partnerships for Older People Projects (POPPs) pilots, and the Link Age Plus pilots, both of which have focussed on early intervention to reach disadvantaged older people and improve health and well-being outcomes. Initiatives undertaken as part of these schemes have included promoting physical activity, smoking cessation and access to nutrition information and advice. It is important to note that both these schemes specifically target older people through outreach in the community. Both projects are ongoing, so evaluations are not yet complete, however we believe it is likely that evaluation will show the importance of targeting and outreach in accessing the most disadvantaged older people.

7.   The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

  7.1  As discussed above, health inequalities amongst older people are the result of multiple factors. Multi-pronged approaches will be vital if we are to tackle health inequalities and reduce morbidity and mortality amongst older people. Unfortunately, we know that joining-up has proved a challenge in public health initiatives.

  7.2  However, there have been some successes at the local level, particularly where partnerships have been brought together through initiatives such as POPPs and Link Age Plus (as described above).

  7.3  Unfortunately budgetary pressures on the part of all agencies tend to militate against joint working outside pilot areas. The new framework of Public Service Agreements, indicators and Local Area Agreements may prove more conducive to budget pooling and joint activity to tackle health inequalities—but this remains to be seen.

8.   The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meets its Public Service Agreement targets for reducing inequalities

  8.1  The Department of Health continues to face challenges in securing cross-Governmental buy-in to reducing health inequalities.

  8.2  Cold-related mortality remains a serious problem in the UK with the level of excess winter deaths amongst older people averaging around 20,000 per year. Whilst these deaths are attributable to multiple health conditions, many of which could be impacted by health interventions, there are also links to fuel poverty, non-decent homes and lack of income. However, so far the Government has struggled to take a fully joined up approach to tackling this problem. Department of Health initiatives have focused on advice to older people, whilst DWP initiatives have focussed on the provision of benefits such as the winter fuel payment, Defra has provided Warm Front to try to improve heating and insulation in homes, and the DCLG has sought to tackle inadequate housing through the Decent Homes initiative. Whilst there are many departments involved in activity which might impact the problem of cold-related death, we struggle to describe this as a truly joined up initiative, as coordination across these initiatives is limited and each department chalks up its contribution in relation to its own internal objectives, rather than any broader Governmental aspiration.

  8.3  In some localities, enthusiastic and committed individuals have brought together initiatives on winter cold with positive results, but this has not been replicated nationally.

  8.4  The new framework of Public Service Agreements, and particularly PSA 17 which makes improving older people's well-being a cross Governmental aim, may herald a new dawn in joining up across Government, but as noted above this remains to be seen.

9.   Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

  9.1  Clearly if the Government does not reach the over 50s with its public health messages and initiatives it will fail to reach its targets. At present, however, public health work tends to exclude older people because of its generalised nature.

  9.2  As we have argued above, whilst a broader public health approach is laudable, reaching older people (and particularly more disadvantaged and excluded older people) requires specific targeted initiatives.

January 2008

261   English Longitudinal Study of Ageing, Wave 2, 2006. Back

262   Health Profile of England 2007. Back

263   "Inequalities in life expectancy at 65", Office for National Statistics, 2007. Back

264   Estimate based on Disability Free Life Expectancy for 2004 from Health Statistics Quarterly 33, Spring 2007, ONS and Period Life Expectancy for 2004, Government Actuary Department website. Back

265   Health Inequalities: Europe in Profile, European Union 2005. Back

266   Help the Aged estimate from Health Survey for England 2005, Research into Ageing factsheets, Dementia UK (Alzheimer's Society et al) 2007, SENSE factsheet 11, Wanless Review 2006 and Survey of English Housing 2006, calculated for the UK on a projected 24.5% rise in the 65+ population by 2017. Back

267   Best Foot Forward, 2005 (Help the Aged). Back

268   Incontinence and older people: is there a link to social isolation (http://policy.helptheaged.org.uk/healthyageing). Back

269   Active People Survey results, 2006 (Sport England). Back

270   Nowhere to go: public toilet provision in the UK, 2007 (Help the Aged). Back

271   Spotlight report, 2007 (Help the Aged). Back

272   Less Equal than Others: Older People's Responses to the Discrimination Law Review, Help the Aged 2007. Back