The National Service Framework for Older People
The United Kingdom is ageing fast. In common with much of the rest of the world the population of older people is increasing (HM Government (HMG), 2010; Nolan, 2001, Improvement and Development Agency (IDeA), 2009) and their prevalence in the population is predicted to rise to 29% by 2031 (Association of Director of Social Services (ADSS), 2003). For the first time, the number of pensioners will outweigh numbers of those under age sixteen. In 1980 it was suggested that men aged 65 could expect to reach 78, however, predicted life expectancy today would extend to 85 and by 2050 it is expected to stretch to around 89 years. This should no longer be looked upon as exceptional as older people can now expect to live over a third of their lives above pensionable age (HMG, 2009) and the advance in life expectancy can be seen as a major accomplishment for public health (Gillam et al, 2007) though it is also a major challenge.
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In 2001 the Department of Health (DH) launched an ambitious policy aiming to set standards for older people's care in all health and social care settings. The National Service Framework for Older People (NSFOP) was established to set national standards that would improve services, drive up quality and eradicate disparities in care. It was, state Williams and Webster (2002), a "key vehicle for ensuring that the needs of older people were at the heart of health and social services reform." This essay will discuss the development of the NSFOP, and it's progression since 2001, in a political context with particular reference to the inequalities experienced by older people associated with social exclusion.
Life expectancy in 1856 was only 40 years and early reports recognised how the inequality of socioeconomic conditions impacted hugely on health (DH, 2008). The historical association between age and ill health is widely acknowledged. Under the Elizabethan Poor Law of 1601 the elderly were cared for in poor houses, often referred to as the feared 'workhouses' (Donaldson and Scully, 2009). The responsibility of the Poor Law transferred to local government and was then replaced by the National Assistance Act in 1948, just as the National Health Service launched.
Recognising the link between poverty and inequalities The Black Report (1980), commissioned by the previous Labour government in late 1970's, saw social isolation coming under close scrutiny for the first time. It was published as the Conservatives claimed power in 1979 despite their attempts to restrain its completion, then not endorsing its findings as it disclosed a noticeable gradient between social class and disease prevalence implying the association between income and health (Lewis et al, 2008). Black et al (1980) also noted that any health improvements on the part of the impoverished could not match those experienced by the more affluent in society. On re-election of the Labour party in 1997, a further report reaffirmed the existence of the inequalities previously reported on by Black, adding that those gaps between the poor and the affluent had, if anything, widened (Acheson, 1998).
The fact that some individuals are more or less susceptible to poor health has notable ramifications for public health (Donaldson and Scally, 2009) and health inequalities experienced earlier in life have been found to continue in later life (Acheson, 1998). The term 'health inequality' refers to the difference in health experienced by one group above another due to one group's advantage of the other, with the difference being noted as avoidable and unfair (Flowers, 2006). Marmot notes that this reflects New Labour's ideology that any health inequalities which could be avoided are unjust (Marmot, 2010). Such differences may be economical, demographical (age, gender, ethnicity), social (class) or geographical (Acheson, 1998; Gillam et al, 2007; Lewis et al, 2008). Historically, older people experience more ill-health, relying on health and social care services more so than other groups in society yet often falling foul of 'The Inverse Care Law' which states that those in greatest need are least likely to receive support services (Tudor- Hart, 1971). This is generally due to factors such as pre-disposition to certain disease, poverty-related illness and death, the common treatment of older people and their social isolation (Lewis et al, 2008).
There is substantial evidence showing that social isolation and loneliness can be detrimental to older people's health, well-being and quality and life (Abbott and Freeth 2008) affecting one in seven people over age 65 (Greaves and Farbys, 2006). Social isolation (and exclusion) causes inequality since it prevents people from participating in
normal activities within their society as a result of factors outwith their control (Le Grand, 2003). Marmot (2010) declares that the social characteristics of a community and how healthy behaviours are promoted and facilitated habitually can contribute to social inequalities in health. He describes the link that connects and binds older people to each other, their families and friends within and outwith their communities, as having a major impact on the effects of such inequalities as "social capital". Muntaner et al (2000) describe social capital as "all types and levels of connections among individuals, within families, friendship networks, business and communities" and, since the 1990s, it has been widely considered to have an influence on health (Almedon, 2005; de Silva et al, 2005; Pearce and Davey Smith, 2003;Coulthard, Walker and Morgan, 2002 ). Thus, Wainwright (1996) promotes the possibilities that social capital may offer a public health policy alternative to "large scale government redistribution" such as diminishing the welfare state post World War 2. The social networks that build social capital create civic participation, trust and "reciprocity" (Gillam et al, 2007; Pearce and Davey Smith, 2003). These indicators of social capital have been strongly related to rates of mortality (Pearce and Davey Smith, 2003) as social networks are affected as people age. Losing spouses, partners and friends reduces social capital, leading to depression, loneliness and a loss of community participation (Office of the Deputy Prime Minister (ODPM), 2006). Putnam (1993) declared the following on his findings on social capital:-
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"Of all the domains in which I have traced the consequences of social
capital, in none is the importance of social connectedness so well
established as in the case of health and well-being." (Putnam, 1993)
The fact that health is generally dependent of factors such as diet and lifestyle make it somewhat beyond Government control. Increasing social capital to reduce inequalities such as social exclusion may, therefore, be an easier target for governments as they consider it to be something they can have greater control over. Hence, in 1989 Thatcher's Government published the White Paper 'Caring for People'. Deemed to be the starting point for considering the community care strand of policy around social exclusion it set principles to assist with social integration in later life. When New Labour came to power in 1997 with their 'Third Way' policies based on "rhetoric of community, partnership & strong government" (Klein, 2001) claiming they would look after the poorest first, Blair made tackling social exclusion one of his priorities (ODPM, 2004), recognising that older people sometimes get 'lost' between health and social care services.
The well-being of older people is not only attributable to income, but also involves housing, health, care, transport and social contacts. Recognising this the Local Government Centre directed the driver against social exclusion resulting by launching a two-year research programme, Better Government for Older People (1999), aimed at developing strategies to provide a seamless and more accessible service for older people. One result of this was the launch of the NSFOP (2001) that would set standards to reduce variations in care which result in equalities including exclusion. Blair's Secretary of State, Alan Milburn declared, in his forward, that Labour were "determined to deliver real improvements for older people" and their priorities lay with looking after the poorest in society. The NSFOP was expected to deliver improvements in both health and social care for all older people over a set timescale of ten years.
With older people's prevalence in the country rapidly increasing as discussed, and the subsequent costs rising substantially, the agenda was set for the development of the NSFOP. The policy making cycle continued with formulation of an External Reference Group of actors including the Professor of Health Care for Elderly People, the Chief Inspector of the Social Services Inspectorate, the Director of Social Services, and other practitioner and management groups working in the field of care for older people such as Help the Aged and the Carers National Association. Policy development also included those in Primary and Secondary Care with specific disease management knowledge and from Community Care including those forming the User Reference Group. Proposals were agreed based on evidence-based expert opinion and consideration of the values which underpin care services (NSFOP, 2001). Evidence included systematic reviews, individual intervention case studies and also fundamental experiences of older people themselves and their carers. Further input would be required across the implementation period of the policy from health and social care by forming Local Implementation Teams tasked with disseminating the policy's objectives.
Policy implementation would be continual over the 10 year period and was based around eight 'Standards' of care targeting progess towards improved service provision, One and Eight being most pertinent to reducing exclusion. Standard One (Rooting out age discrimination) fit neatly with New Labour's agenda to reduce age-related stigma and increase fair access to services based on need (Baldwin, 2003) so is perhaps predictable. It promised to audit all age-related policies, assessing service patterns across the country to establish examples of best practice with a view to setting benchmarks on which to measure future improvements arising from the NSFOP. Standard Eight (The promotion of health and active life in older age) aimed for a joint NHS/Council approach to increasing fair access to services to help people stay well and independent, hence discouraging exclusion. Health promotion initiatives for older people have been shown to provide early returns in improved health, independence and wellbeing making them economically sensible investments for any Government (DH, 2006a) particularly when promoting healthy ageing is central to the health inequalities agenda (DH, 2003).
Since the cycle of the NSFOP was set until 2011 the final stage of evaluation remains incomplete. However, several papers have been published analysing its progress and considering the next steps to be taken to meet its aims (Baldwin, 2003; DH, 2003; Commission for Healthcare Audit and Inspection (CHAI), 2006; DH, 2006b; Cornes et al, 2008; ODPM, 2006). Whilst noting that there was still a long way to go, each report agreed progress had occured and made reference to some significant development in Government policy as a result of the NSFOP including: Opportunity Age (HMG, 2005); Independence, wellbeing and choice (DH, 2005); and Our health, our care, our say (DH, 2006b). Such progress includes increased breast cancer surgery for the over 85s, 39% more hip replacement operations for the over 65s and an increased coronary artery bypass procedures for the over 65s. Although, an increasingly ageing population would logically result in increased necessity of these operations with or without the NSFOP. Other services have not faired so well. Older People's Mental Health initiatives have focused specifically around those who are still of working-age, irrationally since many older people suffer reduced mental health after retiring due to the loss of focus and a feeling of no longer being of worth, often resulting in depression and isolation from the rest of society (CHAI, 2006). The "deep-rooted attitude to ageing"(CHAI, 2006) is still evident in some services and only 15% of older people have been found to be in contact with health and social care services at any one time. Whilst the CHAI report that spend on these services for the over 65s has increased - 40% of the NHS budget in 2001 increased to 43% for 2003/2004 and £5.2 billion of social services budget increased to £7billion in the same period - it is unclear whether this increased service delivery results from the NSFOP framework or is simply due to the amplified demand of an increasingly ageing society. Many of the initiatives stemming from the NSFOP designed to improve older people's health and wellbeing whilst reducing social exclusion have been found to be inconsistently accessible to older people, resulting in continuance of the exact problem they aimed to remedy. Baldwin (2003) agrees, believing the NSFOP to be ideologically sound yet found it to ironically increase age-related exclusion in relation to some health services.
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Many initiatives aimed at improving older people's health and social care have their roots based predominantly in a top-down medical model in which the primary objective is to ensure that care is provided. Jack (1995) argues that it is vital to recognise the need for empowering older people since they are amongst the most disempowered in society, often being regarded as a problem by service providers due to their increasing numbers resulting in rising costs. Nusberg (1995) agrees and is quoted by Thompson and Thompson (2001) as stating:
"Older people are one of the last groups with which the notion of
empowerment has become associated. Yet the privilege it represents -
the ability to make informed choices, exercise influence, continue to make contributions in a variety of settings and take advantage of services - are
critically important to the well-being of elders."
Having choices and being able to maintain control over decisions about their own health is of great importance to older people and unless the medical model is challenged, older people will continue to be social excluded and considered a minority group, being treated by service providers and policy-makers as recipients of care, rather than simply as older adults with the same range of problems as younger ones. The NSF Next Steps (DH, 2006a) recognises the potential that older people can contribute to their local communities, in turn improving their own health, independence and well-being. Through consultation with older people, the Public Service Agreement 17 (HM, 2010) acknowledges their diverse needs and aspirations noting their contribution to society as "an important factor in well-being, independence and connectedness in later life". New Labour aimed to support older people to contribute more to society by taking forward their plans from the HM Treasury Final Report (2007) to promote and support best practice in volunteering and mentoring. Renewal of civil society formed a component part of Blair's ideology and many policies on health inequalities developed during New Labour's reign refer to the role of society, encouraging Wanless's statement that ultimately everyone is responsible for their own health and that of their families (Wanless, 2004). This ideal has been reflected in some of the NSFOP progress reports, almost using older people's lack of engagement in inequality-reducing initiatives as a 'get-out' clause for the timescales not having been reached. This swing towards passing the responsibility of reducing inequalities such as social exclusion over to society under the banner of 'civil participation' is set to continue through Cameron's ideology of 'The Big Society.'
In their 2010 manifesto, the Coalition announced that they would safeguard age-related entitlements, free travel and increased opportunities for work, all of which would move towards reduced inequalities for older people. The fact that reducing the current deficit displaces all other planned measures has quickly altered the Governments' promises. Already the swingeing public spending cuts are causing concern for older people. Age UK (London Evening Standard, 30/9/2010) suggest the poorest will be hardest hit losing an average income of between 29% and 33.7%, yet only 12 months ago in 'Building a society for all ages' (HMG, 2009), Gordon Brown stated pensioners were now less likely to be in poverty than other groups with benefit changes enabling the poorest households to be on average £2100 per year better off. Brown also boasted more employment opportunities for older people. However, unemployment rates for the 50-65 age group are higher than the rest of the working population (Audit Commission, 2008). The Coalition state one way they will tackle loneliness and encourage older people's social interaction is through promotion of digital technology. Many older people remain connected to friends, families and social sites through internet use in venues such as libraries yet the new Government plan to close many local libraries. They also plan to alter free bus pass privileges by increasing eligibility age to 65, yet a third of over 60s used a bus at least weekly as their only form of transport throughout 2007 (Audit Commission, 2008). Such changes inevitably exclude older people further and are only likely to increase isolation. The substantial demographic shift requires a radical change in the way the Coalition Government now proposes to support its older people. Attitudes and expectations need to change across society, stereotypes should be shed and the assumptions about what growing older means must be challenged to tackle the inequality of being older along with the social exclusion that often accompanies it.
The Centre for Policy on Ageing report (2010) cites approximately 75 policy documents developed with an aim to improve older people's services since March 2005. Even the very recent publication, 'Building a society for all ages' (HMG, 2009), starts by discussing the prevalence in ageing and proposing a programme to "end age discrimination and promote age equality". 'Equity and excellence' (DH, 2010a), aiming to liberate the NHS, claims it will create a service which will "eliminate discrimination and reduces inequalities in care". However, in a very unstable financial climate, NHS Primary Care Trusts (often the drivers behind the NSF's) will struggle to achieve the NSFOP 10 year targets. Facing the prospect of huge debt, job losses and imminent abolishment any aspirations of developing further initiatives needed to meet the NSFOP final objectives will inevitably be crushed. Marmot (2010) states: "Even backed by the best evidence and with the most carefully designed and well resourced interventions, national policies will not reduce inequalities if local delivery systems cannot deliver them". Evidence-based or not, in his 1997 manifesto TB said "What counts is what works" (Klein, 2001), however what 'counted' has not made any major improvements since the NSFOP launch according to the considerable body of evidence and consultation papers delivered subsequently which basically all make the same already recognised statements - that the population is ageing quickly and older people remain isolated from many essential health and social care services - yet not appearing to move forward in what is being done to address the situation.
Understanding how policy affects older people can be seen as challenging, particularly in view of the changing demographics. A key challenge in implementing policy is the need to engage older people in the process by putting their needs at the centre of policy development. Elbourne's 2008 report to Government advises that "policy makers and service providers will be better prepared to plan & deliver policies that really do meet the needs of older people when they begin to welcome the rich diversity of views and experience owned by this group". Likewise, Cattan et al (2005) advocate the importance to policy and practice of involving older people in planning, developing and delivering activities that prove most effective at reducing inequalities. Older people often believe their contributions are not valued and their voices go unheard only exacerbating the very problems of discrimination, poverty, isolation and social exclusion (ADSS, 2003) which the NSFOP aims to reduce. With 'fairness as its cornerstone', Equity and Excellence (DH, 2010b) promises to involve 'patients, service users and the public' in all service developments. Politicians often acknowledge the wealth of experience that older people have to offer within White Paper rhetoric - perhaps this is the time to actually listen and value that experience and then adhere to their promises and not use them simply for votes. After all, the new Coalition's mantra is "No decision about me, without me".
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