We must end ageism and age discrimination in health and social care

Age discrimination can take several forms: the failure to afford older people sufficient respect, choice and control – described in numerous reports, most recently by the Delivering Dignity Commission – or the attitudes towards, language about and labelling of older people, who are often written off as ‘acopic’ or ‘bed blocking’. Some services and system rules are skewed in favour of the young, with far worse access and quality for older people in services like mental health and psychological therapies. And some conditions largely affecting older people (eg, dementia, osteoarthritis, osteoporosis or incontinence) receive systematically worse attention and treatment than those equally common in mid-life.

A survey of more than 1,000 experts in ageing and ageing in health care from across Europe for the Economist showed that 80 per cent were concerned about the standard of their own care when older and 51 per cent felt that older people were far less likely than younger people to have adequate assessment and treatment in their countries.

Yet there is legal protection against age discrimination in the NHS. The NHS Constitution guarantees a ‘comprehensive service to all, irrespective of age, a duty to respect human rights, access based only on clinical need,’ and the Equality Act explicitly bans age-based discrimination, whereby ‘meeting individual’s needs should be based on individual circumstances and not arbitrary assumptions based on their age.’ 

As a doctor who looks after older people and fights ageism, my first reaction is ‘thank goodness’ – clarity from government about rights, expectations and responsibilities. But so far, there have been no test cases on age discrimination in health care and the impact of the Constitution is unproven.

It’s sad that older people should need any special legal protection. Even the minority who are frail, demented, dependent or dying are fully contributing citizens. They are not somehow ‘other’ and generally have the same expectations of wellbeing and health services as younger people. But in a youthfulness-obsessed society, ageist attitudes, language or representations are common. NHS staff – some with similar attitudes – are drawn from this society. In his recent report, Francis was emphatic that poor care for older people with complex needs was at the heart of what went wrong and should be a priority for change.

Older people (unlike minority groups at risk of discrimination – eg, people with learning disabilities) account for the most activity and expenditure in health services, and will continue to do so, as the recent Lords' report Ready for Ageing, made clear. They are in effect a ‘disadvantaged majority’. The care of older people – often with frailty, dementia and complex co-morbidities – is now ‘core business’ and a major part of the jobs of most staff working in health and care. It is key to transforming the way we deliver care, as the recent report on transforming the delivery of health and social care by The King’s Fund sets out.

I do want to acknowledge others’ concerns about the danger of fixating on avoiding accusations of discrimination. For some services it makes perfect sense to focus on a particular age group, because of needs and skills, though this should not be a rigid age-bar. There are also times when age is entirely relevant to decision-making (for instance in relation to the dose or side effects of drugs or survival chances from surgery). Considerations about treatment goals, in terms of length or quality of life are legitimate for both patients and practitioners. And some transparent objective decisions on rationing legitimately take age into account – in some instances (eg, NICE guidance on flu vaccination or osteoporotic fractures) favouring older patients. 

However, that doesn’t change the fact that organisations, professions and policy-makers can’t allow age discrimination to continue. And we mustn’t simply accept that ‘hospitals are bad places to care for older people’ as recently asserted by the Chief Executive of NHS England and the Chair of the Care Quality Commission. Let’s make hospitals (and the full range of services) good places to care for the older people who will continue to use them, rather than fancifully wishing them away. Legislation is only one of a range of solutions in the ‘revolution’ in care for old people, called for at last year’s Leeds Castle Summit. But unless our society changes its attitudes to older people, it will be an uphill battle to deliver results.

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Comments

#40485 Sheila Holmes
Chairman
Older Persons' Partnership Board for the Royal Borough of Windsor and Maidenhead

We agree with most of what Dr Oliver says and we are aware that whilst there may not be overt discrimination against the 'mature' there is covert discrimination, in health care, the well used 'pat on the shoulder, it is your age my dear' is still very common. Our difficulty is identifying a workable solution. Changing attitudes by legislation does not work and changing attitudes in the current frenetic NHS/Social Care agendas is very slow work. Any practical suggestions would be very welcomed.

#40488 david oliver
Kings Fund Fellow/Hospital Consultant
Kings Fund/Royal Berkshire Hospital

Dear Sheila
I don't pretend to have all the answers and we know that it has taken society a generation to change attitudes to sexual equality, tolerance of same sex relationships, race or disability. I grew up in the seventies and remember the kind of language and attitudes that no-one would find acceptable now. Legislation is but one part of the solution but if we think about the impact of making seatbelts compulsory or stricter laws on drink driving or banning smoking in pubs, it can help. But when it comes to attitudes and behaviours from health and social care professionals, i think we need to select for the right values, make sure that throughout their training, doctors, nurses, social workers and others are regularly working with older people, that we have older people and their carers helping this training by speaking from their experience (and also by providing examples of older people who are not ill or dependent to talk about their lives) . We also need to make sure that at both pre-registration training and ongoing higher training, what we teach people in those professions adequately reflects the fact that for most of them caring for very old people will be a key part of their job and so should have the right competencies to help the people they will actually be looking after. And we have to ensure that the things people or institutions are measured on delivering reflect adequately what matters to older people and their carers. Most of all though we need to remember at all times that older people - even those with severe dementia or disability are someone's friend or relative, with a lifestory, needs, likes, dislikes, wishes of their own and people who have contributed to society throughout their lives. And treat them with the same respect with which we would want to be treated in our own older age. I strongly recommend three documents on this. 1. The Kings Fund Document Care of Older People Leeds Castle Summit report (referenced in my blog). 2. The Age UK/NHS Confed "delivering dignity" commission 3. Win Tadd's excellent paper "dignity in practice". There is also a great paper from Age UK/Peninsula Medical School called "healthcare for healthy active ageing". I am off to the national pensioners' convention next week (my fourth trip) to speak about these issues at the Winter Gardens - always one of my favourite speaking engagements. Anyone who thinks of older people as passive, unopinionated, recipients of services, should go and meet them. One pitch i would make though - the media have a lot to answer for - constantly representing older people either as elite skydiving grannies or as victims of abuse and neglect with no balanced realistic representation, and use of phrases such as "the elderly" and a fixation with youth. All of this feeds into the negative stereotyping and condescending attitudes. I am 48 so i want it sorted before i am eligible to be a delegate in Blackpool myself. David

#543779 Sarah Lund

Hi. I don't even understand why ageism is encouraged. It's a form of discrimination. Why are members of authority allowed to get away with it? They wouldn't be racist, or sexist, so why is this any different? Nobody should tell me who I should be hanging around with. Why would I go looking for new friends, when I'm very happy with the ones I have? If I was given a choice, between them being killed, or me being killed, I know without question that I'd take a bullet for them. So what if all of my friends are older than me? Is it harming anyone? No. I do what feels right for me. If this stupid discrimination doesn't end, then idiots will stay idiots. Just because someone is "too unfit to work", it doesn't mean they're falling apart.

#544022 rose lewis

I have lived abroad and had no experience of NHS denying treatment to the elderly. My Mother became ill with diverticulitis and was admitted to hospital. I was denied access to the medical notes while she was in hospital so had no real idea what they were doing until now despite repeated complaints trying to get her put on a ward for internal medicine.
The admission says she should be urgently be put on gastro enterology.
She was put on a geriatric ward and left in agony begging for help for three months until she died of a ruptured colon. The doctor asked her what she wanted him to do.
I cannot begin to describe the effect on myself but I refuse to go into an NHS hospital ever. I will rather die at home.
My Mother was an otherwise healthy woman living alone and out every day enjoying life. Out shopping the day she entered the hospital with a temperature of 40.
No doctor should have the right to treat a human being in this way. I believe that Mother was about four stone when she died from not being able to eat. In agony her dignity was stripped from her in every way while they wrote on a wall chart how near to death she was.
There is much more but I am finding it very difficult to write.
Is this what she paid the NHS for her whole life?

#544392 Sarah Lund

One of my friends is starting to just feel fed up of being patronized. He doesn't want to do typical pensioner things that are stupidly expected. He is only in his fifties. Let's get real, who'd want to waste the rest of their life pleasing others when it's not making you any happier? If he doesn't want to do certain things, then that should be the end of it. I actually admire him for sticking to his guns.

#547782 Phillip Carless
Worker
Gloucestershire authority

Well done for highlighting a huge issue and addressing the problem of the general attitude of the populace to age within the UK. As we are now in a huge blame culture, I blame TV and the Government. Both institutions breed aggression from the youngsters. American gangster culture, Thatcherism, Attitude changes can only be nurtured through inclusion, not alienation. Largest percentage of the workforce, most experienced members of the workforce, just need a 3 day week so can have time to do the things that help the you guns, unpaid childminding,etc

#548064 Ruth hoyles
Retired

I am on of the poor old b...... being described above .....I read some of the contents with sheer horror.....what a world we are living in when age stands in our way of a decent life after all our efforts to improve matters! Ruth hoyles

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