Tackling age discrimination

Some services for older people have changed their referral criteria to emphasise clinically based parameters, to ensure that service delivery is best tailored to the patient's needs and least likely to be intrinsically ageist. However, the shape of an ideal service for older people is still open to debate. New service designs need further evaluation, but it is vital that they encourage and provide skills to treat functional and organic disorders in the presence of other illness and physical frailty. That breadth of approach has long been a valued characteristic of successful older people's services. Discarding what works well may also be ageist if it leaves a sector of the community without dedicated, needs-appropriate services.

Clinicians are not going to openly admit to ageism, but ageism, possibly unintentional, is deeply embedded in healthcare. A survey by the British Geriatrics Society and Age UK concluded that the National Health Service (NHS) is institutionally ageist. ³ Ageism includes underestimating older people's ability to benefit from interventions, for both mental and physical illness. The latter was highlighted in a recent report about under-treating older people with cancer on the basis of chronological age rather than according to their overall health and fitness and likelihood of benefiting from treatment. ⁴

The route to achieving non-discriminatory services is carefully outlined in the College statement. ¹ However, a number of pitfalls lie in our path and we must not be complacent.

Law might not be enough

Legislation alone does not guarantee enforcement. The NHS itself is enshrined in law by the National Health Service Act 1946. It was meant to be universal and provide for all age groups according to need. Laws to prevent discrimination on the grounds of disability, sexual orientation, gender, race and religion are still not fully implemented. Interpreting the law depends on the culture, expectations and understanding of society, not just legal matters. Society includes the medical profession, and politicians, policy makers and local healthcare commissioners designing services.

Arguments that higher numbers of older people relative to those of working age who support them will make social and welfare costs ‘so great as to result in a lowering of the national standard of living’ ^{Reference Rowntree5} have been reiterated over decades. It has not happened. Current commentators doubt whether it ever will. ^{Reference Spence6} There appears to be a fear of uncontrollable cost which has undermined levels of investment. An ‘invest to save’ model of older people's services has not been attempted. Rather than reducing initial costs, evidence has shown that investing in high-quality new services can ultimately result in lower healthcare costs for older people. The Rapid Assessment Interface and Discharge (RAID) model of acute liaison hospital services ^{Reference Parsonage and Fossey7} and the Gnosall project for dementia care ^{Reference Greaves and Greaves8} are good examples. However, attitudes may undermine true equity when planning services. Health service commissioners might have little clinical experience of working with older people, and might not listen to clinicians. If decisions about service development are based on poor understanding of the illnesses experienced, or unwarranted negative perceptions of the potential for health improvement in old age, that is discrimination.

We need to listen to the optimists about the ageing society. ⁹ Otherwise, debates about funding are likely to continue, at least partly because of ageism, and despite the Equality Act.

The ‘£2 billion gap’

The College's guidance on the Equality Act points to an incredible £2 billion gap in the funding of health services between older and younger adults. ¹ This has accumulated over many years.

Negative attitudes towards older people have contributed to relegating them to second place in healthcare provision. This preceded the NHS, but was explicit in the planning of the welfare state when Sir William Beveridge stated in 1942:

Fears at a time of high infant mortality and declining birth rate may have influenced that stance. But it also seems relevant to ongoing reluctance to provide age-appropriate services.

In 1947, the British Medical Association (BMA) committee on the care and treatment of the elderly and infirm commented about delays in the provision of services:

In 1956, a government-appointed committee reported on the cost of the NHS. It warned against under-resourcing older people's services:

Providing additional resources for old age was regarded as necessary, affordable and appropriate, but it was not forthcoming.

In the 1970s, health economist Nick Bosanquet reiterated the need to prioritise older people and prophesised:

The mental health charity Mind urged the government in 1979 ‘to introduce legislation compelling social services departments to provide an early assessment and intervention service’. ¹⁴ That never happened. It is, however, reminiscent, 30 years later, of the National Dementia Strategy which aimed to achieve ‘early diagnosis and intervention’. However, the Strategy unfortunately also stated that, ‘There is no expectation… that all areas will necessarily be able to implement the strategy within 5 years’. ¹⁵ Now, over 3 years into that 5-year period, despite improvements in some places, elsewhere little has been achieved. Clinically sound, well-intentioned objectives have been tempered by the laissez-faire acceptability of delays in implementation, as feared by Mind, and all too similar to the BMA statement in 1947.

Providing adequate mental health services for older people may need to be made obligatory; giving providers discretion has not worked in the past. The Commissioning for Quality and Innovation (CQUIN) payment framework giving financial rewards for implementing clinical innovations may have that effect; the national dementia CQUIN to identify dementia in older people admitted to general hospitals may be a step in the right direction. ^{Reference Burns16} However, the alarm has been raised by some geriatricians doubtful whether service capacity is sufficient for following up those identified. Nevertheless, the CQUIN is a welcome first step.

In 2009, there was a 24-fold variation in activity between the highest and lowest performing primary care trusts for provision of dementia services. ^{Reference Spence6} Age discrimination and the ‘postcode lottery’ both need to be addressed. The Faculty of the Psychiatry of Old Age and its predecessors have repeatedly tried to improve this state of affairs. Collaboration with other organisations such as Alzheimer's Society has helped, but old age service advocates are fighting widespread prejudices of society and have not yet achieved their goals. In March 2012, we heard the Prime Minister declare that dementia care is a ‘national crisis’; once more deficits are acknowledged, but will they be remedied? ¹⁷ Is this rhetoric, with action impeded by ageism?

Today, with the unfavourable economic climate, many might be tempted to reiterate the statement by the Ministry of Health in 1950 about proposals for better services for ‘mental infirmity’ in old age: ‘It is recognised that the present conditions of financial stringency limit opportunities for action’. ¹⁸ Repeatedly putting older people to the end of the queue is discriminatory and has not worked; the crisis remains. The Equality Act may provide opportunities to argue for and implement age-appropriate schemes on a par with those for younger people, and result in better health and cost savings.

We cannot afford complacency

We have a moral and ethical obligation to support people who are dependent because of age, illness or disability. The Equality Act should help us achieve that. It will be disastrous if the Act is allowed to join a catalogue of other ineffective legislation and powerless Department of Health proposals. The Act is well intentioned and idealistic with respect to older people. We need to grasp the opportunity it gives us and ensure it succeeds.