Implications of an Ageing Population – the view from 1982

Judith Davey

11/08/2017

In another of my nostalgic moments, trying to winnow down my mountain of paper, I came across notes from a seminar in 1982.  This was a report-back by the New Zealand delegates from the World Assembly in Ageing, held in Vienna. They included the well-known names of Margaret Bazley and Margaret Guthrie.

The audience of about 70, including me (in the early stages of my interest in ageing) broke up into discussion groups, after material from the World Assembly had been presented. The groups reported some far-sighted conclusions. In some areas we have seen action in over 30 years, but others still need attention. Here is a summary, with my comments.

Could there be investigation of postponing receipt of universal superannuation (New Zealand Superannuation) beyond age 60, with increased increments at a later stage?

 The age of eligibility increased from 60 to 65 in the early nineties. Now a further increase from 65 to 67 has been announced, but only in increments from 2037 (20 years and almost 7 parliamentary terms away). Deferring receipt for a higher pension has been periodically suggested, but there are questions about fairness. Managerial and professional people would find it easier to defer and would end up with higher retirement incomes. Those not in a position to work longer would have a lower NZS and possibly hardship.

The well elderly need stimulation, recreation and education and places to socialise. NGOs could be funded to facilitate schemes using both voluntary and professional workers.

 The “young-old” are well represented as volunteers, but staying in paid work longer may limit this activity. There is little to encourage voluntary work and tighter regulations, such as police checks, may put some people off. In parts of the USA volunteers are rewarded by discounts on property taxes (rates) or given vouchers for education which can be transferred to other family members.

There is very little in the way of lifelong learning, re-training and re-skilling for older people.

We need flexibility in the mandatory age for retirement, because “people vary in their ability and interest in work”. What about flexible working hours and job-sharing?

 There is no more compulsory retirement here. The Human Rights Act came into effect in 1999. Section 22 forbids employers from discriminating against suitably qualified job applicants on the grounds of age and outlaws compulsory retirement. So it annoys me when people, often the media, talk about “the age of retirement”. I want to shout to them that there is no such thing. They usually mean age of eligibility for NZS.

 The Employment Relations (Flexible Working Arrangements) Amendment Act 2007 came into force in July 2008. This provided employees responsible for the care of any person with the right to request flexible working arrangements (variation to their hours, days, or place of work). The amendment was later reviewed, and the provisions extended to all employees. Of course, it still depends on the employer’s agreement.

Women over 50 need better financial support when they are often looking after their families and elderly parents or relatives.

 The treatment of working carers is an emerging labour force issue. Many people in their fifties and sixties still have parents alive, many of whom need care and support. In some countries family carers receive payments through the benefits system. But although it has been raised here, it has not become policy. There is no change in the fact that more women than men take on (or are expected to take on) eldercare responsibilities and this may affect their earning ability.

In an ageing population, we need to avoid stereotypes and accommodate differences in expectations of roles and accommodation standards. There is still a negative attitude towards ageing, so there should be lifelong preparation for the later period of life.

 The Human Rights Act may officially ban age discrimination, but it remains widespread through stereotypes and expectations that older people will lose their mental and physical capacity and become dependent. The Positive Ageing strategy and the Healthy Ageing Strategy contain exhortations about giving older people respect and dignity, but you only have to look at the birthday card selection for people 60 plus to see that negative attitudes are alive and well.

“The elderly” should have increased participation in their own decisions (I think we know what they mean). One group appealed for full integration of older people, regardless of disability or special needs, in all parts of life, with community support.

We have seen some progress in this area, with the setting up of Elders’ Councils and advisory committees of older people in many local authorities. The movement towards “age-friendly cities and communities”, if the WHO vision is adopted, should improve urban environments for older people, and for everybody. Again the Positive Ageing and Heathy Ageing Strategies call for greater participation for elders. After all, the “giving back” of wisdom is one of the psychological “tasks” of later life.

The seminar passed a unanimous recommendation to the Prime Minister asking government  to set up a Commission of Inquiry into the implications of an ageing population and to develop integrated policies concerning: income maintenance; housing; health, employment; social services; education and any other relevant matters.

In closing, the chair, Professor McCreary, noted similarities between these recommendations and the findings of the 1955 Conference on “the Ageing”. Some things do not seem to change, but we can hope!

Posted in Attitudes and values (culture, sexuality and spirituality) | 1 Comment

Older People and Alcohol in New Zealand

Judith Davey

What do we know about alcohol drinking among older New Zealanders?

Very little, according to the Health Promotion Association (HPA).[1]

The 2012/13 New Zealand Health Survey showed that around 82% of 55 to 64-year-olds, 79% of 65 to 74-year olds and 66% of people 75+ drink alcohol.[2] The highest rates are for Europeans/Pākehā – 77%, followed by 58% of Māori, 21% of Pacific peoples and 52% of ‘other’ ethnic groups.[3]

Wine is the most popular tipple among older people, followed a distant second by beer and spirits. Port or sherry drinking is now comparatively rare. When asked, older people say they drink to be social, to enhance social situations or special occasions, or to relax or unwind. Most link alcohol with food, many drinking around meal times. Older people mainly drink at home or when visiting friends or family. As they move into their sixties and seventies, older people tend to drink less alcohol than before. For some, especially older men, their drinking evolves into a pattern of daily, or near daily alcohol use, but at relatively low levels of consumption per drinking occasion – ‘a little but often’.

What are the reasons for these changes?

They may include reduced social activity, lower incomes, the onset of health problems, or a combination of factors. Alcohol aggravates health conditions such as liver problems, high blood pressure, diabetes and depression. People with these conditions may be advised by their doctor to reduce their drinking.

Health problems may disrupt usual patterns of socialising, making it harder to go out or limiting energy. Some older people also tone down their drinking in response to physiological changes that increase their sensitivity to alcohol’s effects. Of course some maintain or even increase their alcohol consumption as they age. They may have more opportunities to socialise and fewer family and work responsibilities.

What are the effects of drinking for older people?

While many continue to drink in old age, some older people drink in ways that are potentially unsafe. Apart from obvious effects such as intoxication, alcohol dependence or abuse, a wide range of health conditions have been linked to drinking, including liver disease, pancreatitis, cancer, stroke and high blood pressure. Some of these may result from the cumulative effects of a lifetime of alcohol use.

Also, many older people take medicines that are incompatible with alcohol, such as antihistamines, sedatives and antidepressants. Drinking alcohol may exaggerate the effects of drugs, increasing the risk of injury from falls or other mishaps.

Alcohol itself may be the cause of accidents suffered by older people, which often occur at home. Falls are a particular risk and may have long-term consequences.

Because of decreased tolerance, older people show certain effects of alcohol at lower doses than younger people. This is why older people can have the same drinking pattern for many years and only have alcohol problems when they are older.

On the other hand, a number of studies identify associations between low alcohol use and reduced risks for a few health conditions, such as coronary artery disease. Do the negative effects of alcohol outweigh the positive effects? The experts are still not sure.

How many older people drink hazardously or harmfully?

The majority of older men and women drink safely. The Health Survey found that only 11% of 55 to 64-year-old drinkers, 7% of 65 to 74-year-old drinkers and 3% of 75+ year-olds drinkers drank hazardously or harmfully. But, given older people’s greater vulnerability to the physical effects of alcohol, their greater risk of chronic medical conditions and use of medicines incompatible with alcohol, perhaps hazardous drinking thresholds should be lower for older people.

Categories of older problem drinkers

‘Early-onset’ problem drinkers are those who have been drinking harmfully for much of their adult lives, and continue to do so.

‘Late-onset’ problem drinkers may have used alcohol at mild or moderate levels when younger, but, as they age they may start to drink much more heavily, for reasons often associated with grief and loss, anxiety, depression, boredom, isolation, loneliness and chronic pain.  Sometimes they are advised to have a “nightcap” to help with sleeping difficulties, which can lead on to dependency.

Future challenges

Would it be useful to stipulate age-specific safe drinking guidelines for older people? How can we identify and help older people who may be drinking hazardously or harmfully? And how can we help people cope with bereavement, retirement, loss of independence and physical and cognitive impairments?

Alcohol abuse and dependency may remain undetected in older people because many are socially isolated.  They are less likely to get in trouble with the law and less likely to be noticeably drunk in public. Older people with alcohol problems are often wary of accessing treatment because of associated stigma and shame.  It is important that these people have regular social contact, and receive non-judgemental and unconditional treatment.

 

[1] Ian Hodges and Caroline Maskill (October 2014) Alcohol and Older Adults in New Zealand. Health Promotion Agency, Wellington.

[2] New Zealand Health Survey 2012-2013, Ministry of Health, Wellington.

[3] Percentage of people 64 plus who had consumed alcohol in the previous 12 months.

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The Case for Life-long Education

Judith A. Davey

Interest in lifelong education, which was the culminating point of my last blog, is not new. It developed through the 1960s and 1970s with the increasing pace of economic, social and technological change, and the perception that existing education, training practices and provisions were inadequate to cope.

Writers at the time, such as Freire and Illich, saw lifelong education not only as a mechanism for adapting the individual to change but also for transforming society. The concept of a “Learning Society” was defined as one in which citizens could continue to participate in education and training throughout their lives. This would not only improve the quality of life and wellbeing for the whole community, but would promote better health in its most holistic form, and social integration, as well as economic success.

Promoting lifelong learning and a learning society- but how?

Assuming that the state should be involved, there are three options:

A market model – education as a commodity subject to the forces of supply and demand. Education would be closely aligned to the needs of the economy. This could exacerbate inequalities in access and lead to the exclusion of non-vocational education.

A welfare model – where the state would intervene to target underprivileged and vulnerable groups such as long-term unemployed and welfare beneficiaries as well as special groups, such as Maori and Pacifica.

Progressive-liberal models aim to promote active citizenship and equal opportunities for all. Education to enrich individual lives and for self-improvement would be encouraged and supported.

There was early support for lifelong learning in New Zealand. It was emphasised by the National Council of Adult Education Working Party on Ageing and Education in 1989:

New Zealanders must go on learning. It is crucial for the individual and the country that we have a qualification subsystem which encourages people to gain further skills and knowledge….. people may have to change their jobs and learn new skills several times in a lifetime.

Lifelong education has a vital role to play, but on the way to the vision of a Learning Society there are both opportunities and challenges.

Opportunities

• We need a flexible and skilled workforce, capable of learning and adapting as knowledge rapidly becomes obsolete.

• High unemployment resulting from de-skilling is a waste of human resources.

• The declining proportion of young people in the population means there may be surplus capacity in the education system, which could expand facilities for adults.

• For people who are not in paid work, education offers the potential to gain knowledge and acquire skills in finding productive and meaningful roles outside the market place. The largest and most important of these groups is older people.

• New social movements – asserting human rights in all their forms (consumers, patients, indigenous rights) call for more informed and creative participation. This could include resistance to ageism.

• Educational programmes can help support community development. Older people often take the lead in these developments, such as in the Age-Friendly Communities movement and response to natural disasters.

But there are also Challenges

• It may be difficult to challenge the “education-work-retirement” life course model and the view that education is something only for the under 25s.

• People may be unwilling to shift away from long-term specialisation even if it opens up new employment opportunities.

• There may be institutional barriers that prevent adults from realising their wish to participate in education – entry requirements, timing of courses, financial support.

• Credentialism is a danger. Is a workforce with qualifications the same as one with skills?

• Existing patterns of participation in adult education are strongly related to high levels of initial schooling and higher socio-economic status. Will encouraging life-long education simply reinforce educational inequalities?

• Employers may react to the need for upskilling by substituting younger employees, limiting the opportunities for less-qualified older workers to retrain.

These are all background considerations when talking a closer look at older people and education.

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Education in an ageing society – why is it important?

Judith A. Davey

Looking through my list of blog topics, I notice the absence of education. Yes, there
is such a subject as educational gerontology. I was into this a good few years ago now
when I co-edited and contributed to a book called Living and Learning . This drew on
the findings of research among older students at Victoria University. Before going
into the findings I want to set out why education is important to everyone in our
changing world.

The ageing trend is important but is only one of many major changes and these require people to have more information and skills – more education. And older people should be part of this; their lives are changing too.

Health technology has revolutionised everyday life. It contributes to increased life expectancy – not only high-tech surgery and medicine – but also better preventive and diagnostic measures, including vaccination and body scans. Better water supplies and food hygiene also play their part.

Communication – an explosion of global communication through the internet, satellite telephone and television links. So information travels fast and social media is often first in spreading the news.

Computers have transformed our personal lives, by producing labour-saving devices at home, cost-saving processes in offices and factories, not to mention new forms of entertainment and recreation, from virtual reality interactive games to 3D printers and new materials for golf clubs and skate boards.

Technological change is speedy, with rapid obsolescence of goods, services and the skills to develop and deliver them. “De-skilling” is a consequence for many workers, but at the same time these changes create complex and difficult tasks requiring different, and higher levels of skill.

The labour market – technological development has produced economic changes and brought about greater flexibility in work processes and work locations. Swiss companies are using Singaporean finance to produce computer mice in Shanghai for the Chinese market; cars designed in Italy are built in Japan with components from all around the Pacific Rim. In a word, we have the globalisation of production and distribution.

Financial transactions have also been globalised. Financial markets have been called the “gaming tables of a world casino”. Venture capital is footloose and will shift to where conditions are favourable, where cost structures and labour supply are attractive. Countries must compete for the attentions of entrepreneurs and investors.

All these changes have destabilised labour markets around the world. Many jobs can no longer guarantee long-term occupational stability. A “dual labour market” has developed with a smaller highly qualified workforce with stable work prospects alongside a larger marginal workforce that experiences more and more short-term employment and uncertain work prospects – the so-called “precariat.” This pattern inevitably leads to a widening of income disparities.

Political change: we are all aware of shifts in superpower strengths and hegemony. The status of the nation state has been challenged by political alliances, economic trading blocs, even multi-national corporations and interest groups. Economic rationalism and “free market “policies have undermined the traditional welfare state. These policies have exacerbated labour market instability and produced uncertainties in many areas of life.

Social change – new social movements have developed, working against sexism, racism and other forms of discrimination, championing human rights and freedom of expression. Society is becoming more diverse and more accepting of a variety of value systems, although we still have a way to go. Traditional sex roles have been challenged, breaking down the stereotypical male breadwinner role. Greater instability in sexual partnerships and other economic imperatives have seen most women moving into paid employment.

Life course change– traditionally, people moved through stages of development in a fixed order and at relatively fixed times – education-work-retirement – or Shakespeare’s”seven ages of man” (As you like it, Act 2). But this analysis of human development is too rigid and deterministic. We now talk about “destandardisation of the life course” and “cyclical patterns” in which people move in and out of education, work, family responsibilities, retirement and other roles over their lifespan. Fewer and fewer people will follow the life patterns of earlier generations. Cohabitation is almost the norm for young and not-so-young couples. We have “blended” or reconstituted families. Children may have an array of parents, step-parents and de facto parents, not to mention the same variety of grandparents.

Peter Jarvis sums up the implications of these changes and makes the link with life-long education:

The traditional division of life into separate periods – childhood and youth devoted to schooling, adulthood and working life, and retirement – no longer corresponds to things as they are today and corresponds still less with the demands of the future. Today, no one can hope to amass during his or her youth an initial fund of knowledge which will serve for a lifetime. The swift changes taking place in the world call for knowledge to be continuously updated…..

  1. Davey, J., Neale, J. and Morris Matthews, K. (Eds.) (2003) Living and Learning: Experiences of University after Age 40. Wellington, Victoria University Press.

2. Peter Jarvis (1997) Ethics and education for adults in a late modern society.      Leicester, National Institute of Adult Continuing Education.

 

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Frailty – what does it mean and how could it be measured?

     Judith Davey

16/06/2017 

“Frail” and “frailty” are words often used in relation to very old people. Looking them up in the Shorter Oxford Dictionary gives us “likely to be broken, perishable’ when applied to objects and “weak, liable to err or yield to temptation” when applied to people. Probably not too helpful! Are these concepts which can be useful in examining the situation and wellbeing of older people? Or is “frail” just another stereotype, often association with “elderly” – another term with connotations of inevitable decline? So I looked around for current definitions.

Biomedical definitions

There is a growing consensus among experts that frailty does exist as a distinct syndrome in a subset of older people who are at increased risk of hospitalisation, dependency and whose life expectancy is reduced.  But there is no overall agreement on indicators of frailty or how it should be defined. A common measurement is based on five specific criteria indicating adverse functioning, which include both self-reported and performance-based elements. Those who meet at least three of the criteria below are defined as “frail”, while those not matching any of the five criteria are defined as “robust”.

  • Low physical activity
  • Muscle weakness
  • Slowed performance
  • Fatigue or poor endurance
  • Unintentional weight loss

It seems more helpful to clinicians to identify frailty on the basis of physical rather than psychosocial factors as these are more tangible, more objectively confirmed and are more likely to be treatable by medical means. This approach is intended to help “the development of screening tools for health workers to identify vulnerable older people and inform interventions and preventive strategies.”

But what about psycho-social factors?

Should frailty be defined purely in terms of biomedical factors? Go to:

Psychological, social and environmental factors may be important contributors to frailty and very influential in terms of care policies and service provision.

In the Survey of Older People in New Zealand (SOP) in 2000 the authors defined frailty as “a complex syndrome of underlying problems” resulting in “vulnerability to environmental challenge”.  Put another way – medical, physical or mental health problems could compromise the ability to carry out key activities – washing, dressing, getting about, housework, keeping records, etc. In this concept frailty resulted from the interaction between bodily conditions and functioning.

Prevalence of frailty by personal characteristics

The findings of SOP, not unexpectedly, were that frailty increased with age, especially after 85 years. Prevalence was slightly higher for females than males and increased sharply for women from age 87.

The prevalence of frailty among Maori was higher than for New Zealand European and Pacific Island people. There was the same prevalence of frailty among Maori aged 65-70 as there is among non-Maori aged 81-84 years. This suggests a 10 to 15 year difference in the onset of frailty.

Marriage appeared to have a protective effect, with higher frailty figures for the widowed, divorced or separated. This illustrated the influence of the social environment on an older person’s ability to continue to maintain activities and functions associated with independent living. Complementary roles and coping patterns between partners develop over long periods of time together. This fits with the finding that there was a greater prevalence of frailty among older people living alone.

An interesting finding was the clear association between income and frailty– those with lower incomes had a higher prevalence of frailty – another link between health status and socioeconomic status. This highlights the cumulative effect of life events. Older people who are frail are more likely to be those with histories of lower incomes, less secure housing and social isolation. Does this suggest that home ownership has an important protective effect? “Addressing declining rates of home ownership for all groups throughout the lifespan can also be seen as contributing to housing security and wellbeing in later life, with associated health benefits.” This conclusion was arrived at getting on for 20 years ago!

 Intervention

Most studies on preventing frailty have been conducted after acute events such as strokes or fractures. Relatively few studies have been undertaken on intervention once frailty has developed. But these show that it is possible to prevent further functional decline.

The beneficial effects of exercise in the older population have been widely publicised. Given that inactivity and muscle weakness are major determinants of frailty, it is not difficult to imagine a simple and cost‐effective exercise‐intervention measure that may slow or reverse the process.

Positive psychological states may also be beneficial in the prevention of frailty. It has been suggested that the concept of positive health is more than simply the absence of disability or disease. Thus, approaches aimed at the production of a positive psychological state in those at risk of frailty may strengthen other interventions aimed at stopping functional decline.

Clearly, the definition and measurement of frailty cannot rely solely on bio-medical factors. The life history and environment of very old people are equally important, if not more so.

 

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What does Wales have which we do not have? Its initiatives for the wellbeing of older people

Judith Davey 

02/06/2017

The population of Wales, at 3.2 million is smaller than NZ’s, but it has a slightly higher proportion of its population aged 65 plus (18% at present), and it has some very interesting initiatives which promote the wellbeing of its older people.

We heard about them recently during a visit by Professor Judith Phillips, currently at the University of Stirling in Scotland, but formerly at Swansea and, significantly, the chair of the Expert Group on Housing an Ageing Population in Wales. But this is only one of the interesting initiatives to come from this small country, better known for leeks and daffodils.

The Older People’s Commissioner for Wales is an independent voice and champion for older people across Wales. Her work is driven by what older people say matters most to them and their voices are central to her initiatives. Her aim is “to make Wales a good place to grow older – not just for some, but for everyone.” The Commissioner’s office works in partnership with the Children’s Commissioner to promote the benefits of intergenerational projects and activities. It all sounds great – should we have such a position?

 What is more, Wales also has Future Generations Commissioner, whose role is to act as a guardian for the interests of future generations. This has come about under the Well-being of Future Generations (Wales) Act 2015, which also establishes Public Services Boards (PSBs) for each local authority area in Wales. Each PSB must improve the economic, social, environmental and cultural well-being of its area by working to achieve wellbeing goals through Wellbeing Plans[1]. In these plans the Older People’s Commissioner has set out objectives relating to older people, with clear targets. These include reductions in the number of older people –

  • falling
  • affected by domestic abuse
  • affected by loneliness and isolation
  • living in poverty
  • affected by fuel poverty.

And increases in the number of older people –

  • with dementia supported to live well in their communities
  • who are and feel safe in their local communities and are actively able to do the things that matter to them
  • who return to employment after the age of 50
  • take up of financial entitlements.

The Commissioner is clear that it is not a case of prioritising older people when developing Local Wellbeing Plans, but rather ensuring that older people receive equal visibility and attention and are considered by public services equally to other groups. The Act will make public bodies focus more on the long term, work better with people and communities and each other, and do what they do in a sustainable way.[2]

The Older People’s Commissioner for Wales hosts and chairs a partnership of individuals, community groups, national and local government and major public and third sector agencies. Its programme – Ageing Well in Wales – is first of its kind in the UK and complements the Welsh Government’s Strategy for Older People.

To get back to Judith Phillip’s group – The report of the Expert Group on housing an ageing population in Wales[3] has five key themes:

  1. Understanding the housing requirements of older people – assessing housing needs and aspirations as part of the wellbeing plan, including the need for specialist housing.
  1. Supporting the right choices – to “stay put” or “move on.” This includes expanding organisations which provide aids and adaptations which enable people to “ “stay put” or move to a safer, more energy efficient, affordable and connected environment.”
  1. Living with confidence in older age – taking a person-centred approach, ensuring that new homes are designed to accommodate the projected health needs and diversity of the ageing population.
  1. A planning system which reflects the needs of the ageing population – encouraging local planning authorities to create mixed age friendly/lifetime neighbourhoods; encouraging “the development of a range of innovative and healthy housing solutions, (including private sector initiatives) that meet the housing demands and needs of an ageing population and bring wider social, economic and environmental benefits.”
  1. Making housing more affordable and incentivising change. Ensuring that there are affordable homes available for sale and rent and increasing diversity of tenures. Looking for opportunities to make the best use of capital and revenue resources across the housing, health and social care portfolios

It is important to remember that housing, social care and health are all devolved to local authorities in Britain, rather than being under centralised ministries as in New Zealand. The new legislation in Wales emphasises that these three services should be integrated, recognising how they rely on each other to provide wellbeing in the real world, as opposed to being in bureaucratic “silos”. This seems like a laudable aim which I would like to see pursued here as well.

[1] http://gov.wales/topics/people-and-communities/people/future-generations-act/?lang=en

[2] Interestingly enough, in March I attended a symposium in the Beehive which considered these very issues. It was called Intergenerational Governance and was sponsored by the Institute for Governance and Policy Studies at Victoria University.

[3] http://gov.wales/topics/housing-and-regeneration/housing-supply/expert-group-on-housing-an-ageing-population/?lang=en

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Aged care services – future demand and other conundrums

Judith Davey 19/5/17

 

What affects the demand for aged care services?

  • Population Trends: The 85 plus age group is growing rapidly. This is where the proportion in residential care is highest and most people living in the community need some level of support. Trends in mortality rates are crucial; the lower the rate, the higher the growth in the older age groups. Migration rates are less important, certainly in the short to medium term.
  • Disability trends: The incidence of disability increases with age. Assuming the prevalence of disability continues as at present, it is estimated that the number of people 85 plus with high support needs will increase by 225% between 2006 and 2036.

Estimates of population and disability trends are available and are likely to be reliable. But these are not the only factors influencing demand. Others are less predictable:

  • Social change – will informal care givers be available? Paid workforce participation by the “young-old” is increasing and being encouraged. Can paid work and eldercare be compatible? Residential mobility means that potential family carers could be scattered through the country and around the world.
  • Public policies on the provision and funding of care services are important and can change, along with the relative focus on institutional and home care; and the monitoring and regulation of care services. Immigration policy, which is currently being debated, will influence the availability of care workers.
  • Funding of services and fiscal constraints depend on the overall economic situation, especially in a context of rising demand and rising expectations.
  • Advances in health practices and technology. What changes will there be in the prevention and treatment of dementia? Tele-monitoring may allow more self-management at home. Strategies aimed at preventive initiatives and healthier ageing could reduce levels of impairment and hence the demand for care. And I have written earlier on assistive technology.
  • Business and management practices can also change and will influence privatised and contracted services. These include, for example, consolidation of facilities and economies of scale, improved processes and working practice, but also whether aged care is seen as a profitable investment.

Several exercises by public, private and voluntary agencies have attempted to project the future demand for aged care services and aged care workers in New Zealand. All this work points to an increasing demand for aged care services, both at home and in institutions, and signals a likely shortfall in supply, especially in the available workforce. A Department of Labour report suggested that the number of care workers needed will rise to 48,200 in 2036. Current growth trends produce a total of 21,400, clearly not enough.

Health Workforce New Zealand estimate that from 2011 to 2026 the numbers of people receiving home support and residential care will increase by 61% and 54%, respectively. A significant shortfall in funds is predicted. Not enough money; not enough workers. This is before we even think about workforce development and training.

As well as the supply-demand conundrum, what are some of the other issues for the future?

  • Finding a “client-centre” focus, giving a voice to older people’s needs and wishes.

The 2016 Health Strategy talks about “people-powered” services – enabling individuals to make choices about the care or support they receive; understanding people’s needs and preferences.  How practical is it and can we afford to take into account all the preferences of older people requiring care, assuming that subsidies will remain?

  • Balance of home and institutional care –response to cost or wishes of older people?

Where should the balance be? There is a growing concern about an increasing focus on people with higher level care needs and the withdrawal of services from those receiving low-level home care. How compatible is this with a preventive approach?  The ASPIRE trials suggested more intensive home care, giving more responsibility to “unregulated” care workers. Is this realistic? Will upskilling come along with higher pay?

  • Management and regulation

How do we reach an effective balance between “light touch” and heavy-handed regulation? Which will deliver better quality and better protection from abuse? Is there a trade-off between efficiency and choice?  How can innovation be promoted in a climate of claims and counter claims about funding in the sector?

  • Sharing responsibility

Who should be expected to provide and fund care for dependent older people in the future and how should responsibility be shared between individuals, families, communities, the voluntary sector, private sector and government agencies? How should the costs be shared? How do we identify and build on the strengths of the different sectors in the aged care field?

Clearly complexity and pluralism is operating in the provision of care for older people. Most research demonstrates that family and formal care are more effective when they complement each other. But, responsibility must be clearly defined –how? Issues of unmet needs, poor quality, abuse, “buck passing” and gate-keeping arise where responsibility becomes contested or where shared responsibility is difficult to negotiate.  Can multi-disciplinary case conferences and planning support person-centred care, and incorporate the perspectives of carers and other family members?

A lot of questions – calling for realistic discussion if older people are to receive the care they deserve.

 


[1] Based on notes for a workshop at the NZCCSS Conference in Wellington in 2012, led by Judith Davey.

 

 

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