Battle in Print: Doddery but a little too dear? - a defence of improving care

Professor David Oliver, 19 October 2010

Fauja Singh Runs the London Marathon each year, wearing his ‘oldest runner’ vest. He’s 98, and clearly a ‘character’. Buster Collins (101) still works three days a week at Pimlico Plumbers. Sheila Hancock headlines a West End musical eight shows a week at 77. Yet at 61 years old, QC Ming Campbell becomes Lib Dem leader and is mercilessly lampooned as a doddering old fool, despite the razor sharp presence of Shirley Williams (77), Tony Benn (84) and Michael Heseltine (77). There’s a marked contrast in attitudes towards the active Singh and doddery Ming. And tellingly, these common one-dimensional stereotypes of older people mask a real discomfort with growing old.

Indeed, the Daily Mail runs a ‘dignity for the elderly’ campaign which presents a seemingly amorphous group of ‘older people’ as victims of neglect and abuse. Yet the same paper kicks up a stink about Manchester council wasting public money on a guide to enjoying sex in later life. Surely, pensioners don’t need that kind of thing! Older people also distance themselves from being old. ‘I am not doddery, doddery I am not’ says Sir Bruce (83) defiantly on Strictly each week. Go speak to any group of older people, as I often do. They’ll make it clear they‘re not frail or vulnerable ‘like your patients’. I sometimes think there’s nothing quite so ageist as an older person.

An unhelpful view of ageing


So, what’s going on? For a start, there’s a societal fetishisation of youth. To quote Julian Meyrowitz:

Older People are not generally appreciated as experienced elders, or possessors of special wisdom, but to the extent that they can behave like young people, ie, working, enjoying sex, exercising and taking care of themselves.

This is mirrored by a collective fear of ageing or its physical correlates. To show signs of ageing is somehow to be diminished. Myths abound, unsubstantiated by evidence, that older workers can’t learn new skills or their sickness rates will be higher. Older people’s often superior skills and shrewdness are ignored.

This isn’t helped by negative perceptions of ageing. A few years ago, Age Concern led the ‘Doddery but dear’ campaign. It implied older people may be sweet and benign but they’re also incapable. This reflects the ‘disengagement’ model of ageing, which holds there’s a specific time for younger generations to take the reins. Not all ageism or age discrimination is hostile or even conscious or intentional, but even when well meaning it can still be patronising.

The second problem is an unhelpful dialogue about ageing demography. In 1901, average life expectancy in England was 45 for males and 49 for females, with two million over 65s. These figures were 77, 82 and 8.1 million by 2001. In 2010, a female born in England has a one in two chance of living to 100. At the start of the NHS in 1948, only around one in two survived beyond state retirement age. Now it’s 18% - a figure static for the past two decades. Life expectancy at 60 in England is now a further 29 years (hence the debate on the sustainability of pensions). Within 20 years, one in five of the population will be over 65, and there will be an 80% increase in the number of over 85s.

Surely this represents a success story for our society? It means individuals have the chance to flourish. It represents a victory for better housing, sanitation, welfare, nutrition and working pay and conditions. Importantly, these social and cultural factors are responsible for this success, rather than healthcare specifically. Public health and disease prevention have played a major part. This includes battles against killer diseases such as cholera and TB, through mass vaccination and better preventative services, risk reduction and screening for killers such as stroke, heart disease and cancer. Better medical interventions have converted former mid-life killers, such as heart or respiratory disease, into conditions people can live with for many years. Do we celebrate these gains? Not nearly enough. Instead, we use apocalyptic language: ‘time bomb’, ‘crisis’, ‘tsunami’, ‘burden’, and foment intergenerational conflict with tales of baby boomers stealing generation Y’s inheritance.

This raises again the dichotomy of ‘Ming versus Singh’. Older people are represented either as vulnerable, marginalised victims and figures of ridicule or heart-warming stories of elite successful ageing. Where is the balance?  There’s a reality gap, not only in news values but in society – and consequently reflected in the health and social care professionals recruited from it.

A more balanced perspective


I will give you some balance. We know from sources like the census, the general household survey or the health survey for England that being old is not all doom and gloom. Even over 80, 60% of women and 70% of men report they don’t suffer from a longstanding illness which limits their lifestyle. Similar numbers report their health as being ‘good or very good’. These numbers haven’t changed for two decades. Neither has the number of people dependent for help in one or basic activities such as stair climbing, dressing or toenail cutting. In these terms, health is not simply the medical model of absence of disease but about wellbeing and independence – being able to do the things that matter to you. Only one in ten people over 65 are either in long-term care settings or dwelling in long-term residential or nursing care. Half the people over 90 are still in their own homes.

On the other hand, we can’t get avoid the fact that, short of revolutionary improvements in prevention and healthcare, if we live long enough a number of things are more than likely to happen. We may need to live with long-term medical conditions. Currently 40% of people over 65 have two or more such conditions. For example, around 800,000 people suffer dementia in England, with only one in three adequately diagnosed. This figure is set to double in the next two decades. There’s a projected increase of 50% in the next twenty years of over 65s dependent on help for two or more basic activities of living, such as washing, dressing and walking.

Although it’s misleading to suggest all older people suffer from such problems, population ageing is a game changer for health and social care services in developed nations. It’s now clear that ‘Older People R US’. For instance, the median age of hospital patients in England is 68 and people over 65 account for 60% of admissions and 70% of bed days. Sixty percent of social care spend is on people over 65, whilst 80% of GP activity and drug spend is on people with long-term conditions. As local government cuts loom and NHS spending flattens, it will become increasingly apparent we must focus more on older people.

Indeed, the NHS Constitution gives a universal right of care based on need alone. The 2010 Equality Act makes it a positive obligation to provide non-discriminatory services. Yet we have a long way to go before health and social care systems are ‘age proof and fit for purpose’. There’s much evidence from well-respected sources which suggests older people are still too often labelled as a problem. Frail older people are often seen to have ‘social admissions’ when they actually need the same diagnosis and management plan a younger person would expect. Common age related conditions are under recognised and under treated. There are numerous reports of older people being patronised, denied choice or information or the right to take risks - and sometimes by their own families. When vulnerable or dying, they can suffer needless indignities around feeding, toileting, privacy or control of distressing symptoms.

What’s so bad about preventative medicine?


But where are these realities represented in the media? In particular, where are the stories of older people who do live with medical conditions, or who have some disability and still live worthwhile, active lives?  In September, the Royal College of Physicians published the largest audit of continence care in the world. It revealed an appalling lack of investment, skills and training. It was barely picked up by the media. Even given the current pressure around better care for dementia, it’s usually younger people such as Sir Terry Pratchett who make the headlines. A well-known correspondent from a national newspaper told me a couple of years ago: ‘If you want publicity conditions like dementia, you’ll have to find a young person with it.’

In conclusion, the increase in longevity owes a large debt to social advances. Modern medicine has contributed, though many gains have been made by better preventative public health and primary care. Yes, heroic, high tech interventions have played their part. Conditions formerly fatal in midlife can now be cured or better managed. There may be a debate about the utility of expensive treatments such as chemotherapy, but in the UK this is a sideshow. Most people now expect to live a long life. Though many will have some medical problems, this doesn’t mean their lives are unhappy or unfulfilled.

Rather than project the value judgments of the young and fit onto older people, we should listen to what they say about their own health. In the main, older people want to be sufficiently active and independent, preserve control and do things they enjoy. But they don’t expect to be as active as in their youth. Yet,  it would be hard to justify not fixing someone’s broken hip or treating their pneumonia merely on the grounds of chronological age, so what should we stop doing? When it does come to more serious ‘do or die’ treatments, older people are generally the first to say what their quality of life warrants. The more pertinent debate is how we ensure older people using services are treated with dignity and respect. That’s what they’ve told us is important to them.

Finally, in the blurb for the debate at this year’s Battle of Ideas, I notice a favourite canard reappearing. To paraphrase, ‘do we want the nanny state spoiling our enjoyment of life with their endless lectures on eating, drinking and smoking?’  As a man of expanding girth who enjoys a pie, a pint and a bet, I’ve some sympathy with this. As a doctor, I should know better. However, adhering to advice on exercise, alcohol, smoking, diet or other lifestyle factors has never been compulsory. Being given useful information on what I can do now in mid-life to reduce my risk of a premature and unpleasant death from cancer or heart disease, or on measures around my lifestyle that can increase my odds of remaining active, independent and lucid well into old age can surely not be quite the awful finger wagging threat to my autonomy suggested.

Lifestyle factors have been critical in prolonging life expectancy. Older people themselves consistently ask for information to help them maintain well-being. It’s hard to see how helping people make choices which could protect them from harm deserves such ‘Aunt Sally’ status. I’d be far more exercised by the challenge of ensuring all older people are treated with respect and dignity.

Author

Professor David Oliver, national clinical director for older people, Department of Health; consultant physician, Royal Berkshire Hospital; visiting professor, medicine for older people, City University, London

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