Real terms growth in older people’s needs

Following the intense interest in the Comprehensive Spending Review, we can be forgiven for thinking that the only figures that matter are the ones with pound signs in front of them. However, the Hospital Episode Statistics (HES) released last week come as a timely reminder of how important the NHS is for many older people.

The headline figures showed that average hospital stays for people over 75 years have grown by 66% since 1999. For people between 60 and 74 years, this number has grown by 48%. By comparison, people between 15 and 59 years saw growth in hospital says of 28% in the same period.

Further detail reveals how much longer older people need to stay in hospital compared with other groups. Observing average length of stay, we can see that people over 75 years are in hospital for almost three times as long as people between 15 and 59. However, people over 75 years have also seen the biggest drop in average length of stay since 1999, a decrease of almost four and a half days.

So apart from reflecting the growing numbers of our older population, what do these figures tell us? The growth in NHS funding since 1999 could explain the extra numbers of people being treated – we are spending around three times as much today then we were in 1999. People are also living longer and therefore could return to hospital on more occasions later on in their lives.

What of the decrease in the days spent in hospital? Reducing bed days has been a significant focus of the NHS for the past ten years and this clearly shows it has paid off. Certainly, getting people home, in appropriate circumstances and with the right level of support, should always be a priority. Advances in medical practice and the opportunity to treat more people as day cases have also paid dividends.

However, the numbers presented in the statistics relate to episodes of care, not individuals. We also know that emergency readmissions have gone up significantly since 1999. It could be that as the number of bed days go down, people have become more likely to return to hospital, thus generating a new episode of care. The Nuffield Trust recently made an assessment of rises in emergency admissions and highlighted the need for better care outside of hospital and prevention services. Whatever the figures show, it is important to remember that achieving more episodes of care is only one part of the picture.

The figures need further analysis to draw any firm conclusions, though it is immediately welcome that more older people are receiving care (though obviously less welcome that they need it in the first place). As we concentrate on the figures in the CSR going down, we must not forget those critical figures that continue to go up.

Progress on personalisation?

Last week’s Audit Commission publication of Financial management of personal budgets: challenges and opportunities for councils shows that there is still progress to be made in rolling out personal budgets across the board, and especially amongst older people. Only six councils have met the target of 30% of those eligible for social care to receive a personal budget (and a smaller proportion still receive this money as a cash payment). There is huge progress to be made before April 2011.

The report makes the valid point that personal budgets are not cost-saving in comparison to traditional services, and luckily councils involved in the research seem to have taken on the message.

There are some challenges for councils, not least to ensure their internal procedures and processes are capable of dealing with the requirements of a person-centred approach to care. The report also highlights that councils should be prepared to be flexible in the use of their Resource Allocation Systems which work out how much money can be used to meet someone’s needs. Councils should be prepared to increase the budget, using the Resource Allocation System suggested figure as a good initial ball-park. Coventry’s outcomes-based model of assessing what support someone needs is the way forward, but I wonder whether many other councils will take this on? It involves a reversal of the traditional ways of assessing someone.

However, what the report doesn’t mention is what councils have been doing to persuade those who need care and support that these budgets are a good idea. Mention is made of the attitude of staff being paramount, but this idea is not explored to see whether this might be the root of the lack of take up.

There is also very little mention of people’s rights and entitlements in social care. Unfashionable in today’s choice-and-DIY-social-care landscape, but nonetheless, a statutory responsibility that can’t be wriggled out of if councils provide services. The report talks about brokerage and care management as though the two are the same. This is a fundamental distinction, as care management is part of the statutory duty of the council, brokerage could be a charged-for service. It makes you wonder whether people are being charged incorrectly for care management?

Back to the 30% target. A bit of me can’t help wonder if personal budgets are not the rip-roaring success for older people that they were branded to be simply because for many people they do not work? There’s a world of difference between a younger physically disabled person using a personal budget for their stable and predictable needs and an older person learning to cope with a new disability which they’re not used to. It’s not impossible for this to be achieved by older people, but it needs careful thought and a great deal of support from the council providing the budget or the care and support to the budget holder.

We expect the coalition government will push personal budgets even harder. Some councils are clearly well on the way to broad provision of care in this way but they are few and far between, the majority need to up their game.

Introducing ELSA for the 4th time

As the dust was settling from the Spending Review, the world of UK ageing research gathered at the Royal Society last Thursday for the launch of the fourth wave of the English Longitudinal Study of Ageing. ELSA, as it ubiquitously known, is the single best source of data on experiences of later life in England. It tracks a group of people aged over 50 every two years, returning each time with detailed questionnaires and medical tests. After a day of presentations from researchers, focusing on everything from energy prices to sleep patterns, I joined a panel, chaired by Sir Michael Marmot, tasked with summing-up and reacting to the findings. So what were my first impressions?

Royal Society, London
Royal Society: Flickr user SBishop

Drawing some of the bits of the jigsaw together, first of all, the report shatters a few myths about getting older: people have better experiences of sleep as they get older; the number of people in later life who are underweight is very low; withdrawal from organised social activity in late old age is far less common than you might think; and caring for your partner is a greater burden than caring for your parents.

These snapshot findings are startling enough, but the real strength of ELSA is the portrait it can paint of change over time. With data now available from 2002 to 2008 a picture of the last decade is starting to emerge.  We know that on average older people now have higher incomes, driven by wealthier groups reaching old age with a higher share of non-state income than previous generations; spending on energy has risen significantly, as had spending on essentials overall, for poorer households; the credit crunch led to a noticeable decline in average personal wealth between 2006/07 and 2008/09; and over a longer period there was also a concerning decline in satisfaction with life and an increase in loneliness.

The single most positive change over the decade I picked up was the population-wide decline in cholesterol levels, evidence of the impact statin prescriptions have been having.  But the news on health in general is far more concerning: within each age group there is no clear evidence that health has been improving over the course of the last decade. Given that life expectancy has been rising fast, this implies people are living for more years with ill-health and disability – so called, extension of morbidity. The researchers were careful to say these were early findings; but if they’re backed up by other sources, this is a very serious trend, both for personal wellbeing and the national finances.

Finally, ELSA wave 4 paints a new portrait of inequality in later life. In some areas the evidence suggests that inequality is entrenched, but not growing worse – examples include quality of life, loneliness and many measures of health. But on other measures inequality in later life increased. Income inequalities widened over the period, and there is also evidence that opportunities for older workers are becoming polarised, with poorly educated people being much less likely to benefit for the general rise in 50+ employment.

These are just a few minutes’ reflection on a few hours of presentation; they merely scratch the surface. The latest ELSA report, like its predecessors, will be worth returning to for years to come.

Cuts to Local Authority funding – opportunity for a fresh approach?

The 26% cuts over 4 years to the grants from central to local government announced in last week’s CSR will burn a significant hole in the local public purse, and challenge even the most innovative and well-prepared local authorities to look again at how they can provide consistently ‘more for less’ between now and 2015.

The removal of ringfencing, the development of community budgets and the reduction of targets will be welcomed by many councils, as this will offer the freedom and flexibility they need to bring agendas together internally and externally to produce improved outcomes while reducing spend.

But will they take advantage of these new opportunities?

Age UK has recently been calling for a new cross-council approach to ageing, building the needs of older people into all departmental plans and factoring demographic change into all council budgets.

Too often ageing as an issue gets passed to the adult social care department. However, an Audit Commission report revealed that 85% of people over 65 don’t use council care services, but they do use – and often rely on – the majority of general council services and many use other services such as transport, leisure, and housing.

With growing numbers of older people in all but four of the local authorities in England, surely now is the right time to take a fresh look at ageing as a cross-cutting priority and bring together strategic thinking and budgetary planning at the highest levels to ensure reform of any or all public services has our ageing population in mind.

The fiscal clouds and the long-term vision

Pound coins - Photo: Flickr user hitthatswitchOver the last few days and weeks economists and analysts have speculated about the comprehensive spending review. In the build-up, endless rumours and ‘leaks’ and even snapshots of confidential papers inundated the media and kept almost everyone busy – and worried.

After the announcements, some breathed a deep sigh of relief, many felt disappointed while others felt outraged. However important it may be, the CSR only presents a set of fiscal measures to tackle the short term – until 2014 at the most – or, as the Chancellor put it in his speech, measures that ensure “that what we buy, we can afford; that the bills we incur, we have the income to meet; and that we do not saddle our children with the interest on the interest on the interest of the debts we were not ourselves prepared to pay.”

The Chancellor also announced that “a stronger Britain starts here”. Perhaps, but it will take a lot more than fiscal restraint for this attempt not to become a false start.

Fortunately, economics has developed the life-cycle approach, but unfortunately it is taught solely as a way to study consumption and saving decisions. There’s more to it than this.

Let’s consider the Marmot Review on health inequalities, for example. It lists a number of key policies over the life course. When it comes to ‘adults of retirement age’, one of the policy objectives was to increase access to apprenticeships. Certainly most apprentices are young adults – so, how come this is an appropriate objective for people past state pension age? It is, if we look far at the horizon where these young people get to retirement age.

Around 21 per cent of all economically active adults in England have qualifications below Level 2. Students who leave our schools with no or very low qualifications are twice as likely to claim job-related benefits before they are 25 as those with better qualifications. And it is also much more likely that it will be them who may have to struggle most to keep warm in winter and who may have to get by on very low incomes when they get to retirement age, and it is them who are more likely to endure worse health earlier in life and even more likely not to make it to retirement age.

A life-cycle or life-course approach helps dispel the short-term fiscal clouds and focus our effort on the long term vision more clearly. In our submission to the Comprehensive Spending Review, we highlighted 12 key long-term challenges we face as an ageing society. That is, even though we discussed and proposed measures related to public spending over the next four years, we refused to be locked in the short-term fog and never lost our vision.

The best thing about the CSR announcements – if there is such a thing as a ‘best thing’ about it – is that now the focus of the economic discourse may concentrate on the bigger, more meaningful and crucial picture, that of raising productivity and employability, and reducing inequalities, on behalf of everyone – including the people currently in older age and the future older people. This is the real challenge facing us in the longer term and Age UK will be seeking to ensure that it is not forgotten.

Spending Review – state pensions and welfare

The welfare budget has again been targeted for savings. In the Emergency Budget in June £11 billion of savings were announced and, in the recent Spending Review, George Osborne set out a further £7 billion of savings to be made by 2014-15. In the context of such major cuts it will be somewhat of a relief to many older people that cold weather payments will remain at £25 for each week of very cold winter weather and that despite rumours that the universal winter fuel payments could be restricted or means-tested they will not be changed.

Other much valued universal support such as bus passes and free prescriptions are also unscathed.  People aged 65 and over receiving the savings credit as part of their Pension Credit will be worse off as the maximum payment will be frozen for 4 years, although many of the other welfare savings will have limited impact on people under state pension age.

For those of working age, in the longer term the Work and Pensions Secretary Iain Duncan Smith has been given the green light to take forward his plans for major reforms to combine a range of benefits and tax credits into a single Universal Credit.

There is considerable support behind the principle of a simpler system with better incentives to save, but these are radical changes which  bring about major challenges. In the meantime, the contributory element of employment and support allowance will be restricted to one year from 2012-13 onwards. This will save £2 billion by 2014-15, but will mean that people unable to work due to disability and ill-health, who are not entitled to means-tested benefits, will get far less return from what may have been 30 or 40 years of working and paying  national insurance.

And the news isn’t good for some 5 million people in their 50s expecting to draw their state pension at 65 or earlier. Under current rules state pension age would have gradually increased to 65 for women by 2020 and then to 66 for both men and women between 2024 and 2026. The Coalition Government had already signalled their intention to speed up this increase and the Chancellor announced that equalisation will now take place in November 2018 and state pension age will rise to 66 for both men and women by April 2020.

This will be a particular blow to some women who face much steeper rises than expected and breaks the Coalition Agreement which says that any rise to 66 will no t start sooner than 2020 for women.   At Age UK we acknowledge that on average people are living longer but are concerned that disadvantaged groups who are most reliant on state pensions and have lower life expectancies  will be hit hardest. Proposals for further increase in state pension age in the future are also expected. We will be working hard to ensure that further reforms only go ahead if health inequalities are reducing, people have the ability and opportunity  to work longer,  disadvantaged groups are protected and everyone is entitled to a decent state pension.

Changing one thing in Rochdale

It takes just 2 hours to get to Manchester from London and only another 20 minutes to get to Rochdale by train. But when we arrive at the small cul-de-sac of bungalows, it feels a long way from Westminster and the Comprehensive Spending Review. But it is in places like this that the impact will be felt.

Welcome to RochdaleMy colleague and I are in Rochdale to meet with a group of older people. The driving force behind the group – I’ll call him Mr Jones – contacted Age UK because he was concerned about the state of the little cul-de-sac where he and his neighbours live.

I’m hoping that the group will take up our new Change One Thing campaign. We’re going to be supporting local groups of people in later life to campaign to make their neighbourhoods better.

We know from a wealth of research that the things older people say they need in their areas are often very practical – public transport to get around, benches and seats, accessible public toilets, and so on. We want to help groups identify the one thing which would make the most difference and run a local campaign to change it. (Hence the name!)

We’ve arranged to meet at the house of Mr Jones’ next-door-neighbour. While she makes us a cup of tea, Mr Jones pops across the cul-de-sac to gather the others. In the end we have a group of four.

We start to explore the problems that they face. Graffiti, litter and poor service from council and housing association contractors are all mentioned.

Two themes emerge from what they say. One is the degree to which they depend on ‘the powers that be’ (mostly the council and the housing association) for things like household repairs and maintenance, and the constant battle they feel they are waging to be heard by those powers.

The other is the support they give each other, and the sense of community they obviously have. I’m interested to see what the Big Society might look like here.

After quite some discussion, and with our encouragement, they settle on one issue to tackle: the poor state of the pavements in the cul-de-sac. Then we go on to think about who could deliver this, and how they can go about organising a campaign to persuade them.

If they can organise themselves, and stay focused, I think they have a reasonable chance of success. After all, in many ways, it’s a no brainer – the cost of repairing a few pavements is trivial compared to the cost of treating a hip fracture, or of providing home care to someone who is unable to get out and about after a fall.

But with cuts to council budgets inevitable, I have a nasty feeling that pavement repairs is exactly the kind of thing which may just not happen in the future. Let’s hope that councils will take the challenge of seeing the big picture.