Old Habits Die Hard, by Emilie Roberts and Linda Seymour, shows that managers in NHS and social care organisations struggle to prevent discrimination on the grounds of age. It concludes that the government's objective of eradicating ageist practices from the NHS will not be achieved unless local managers are given more help to implement the policy.
The main barriers to tackling ageism are a lack of resources to implement the National Service Framework for Older People; widespread ageism in society as a whole; and a legacy of discrimination in the welfare state.
Janice Robinson, King's Fund director of health and social care, said: 'Combatting age discrimination is a complex and uncomfortable process for public service managers. Efforts to eradicate ageist practices must be backed up with funding for staff education and training; a clear definition of what constitutes unacceptable behaviour; and a new law to make discrimination on the basis of old age unlawful.
'Legislation by itself does not make discrimination go away. But it will at least give public service managers the incentive and the leverage to make meaningful changes in their organisations.'
Old Habits Die Hard: Tackling age discrimination in health and social care, by Emilie Roberts and Linda Seymour, is available from the King's Fund bookshop on 020 7307 2591 or online. Price£6.99.
An executive summary follows.
King's Fund summary: report findings
Old Habits Die Hard: Tackling age discrimination in health and social care
This report shows that managers in NHS and social care organisations struggle to prevent discrimination on the grounds of age. Based on a telephone survey of 75 senior managers in hospitals, primary care groups, community trusts and social services departments, it shows that, while the majority support moves to combat age discrimination, they lack practical tools for the job. They feel unsure about how to identify age discrimination in practice, and whether age-related policies and practices are ever justifiable. The report concludes that the government's stated objective of eradicating ageist practices from the NHS will not be achieved unless local managers are given more help to implement the policy, and suggests ways to do this.
In its National Service Framework (NSF) for Older People, published in March 2001, the government made clear its determination to 'root out age discrimination' in health and social care. The paper identified tasks and targets to be met by NHS organisations and local authorities, including better involvement of older people in developing local services, a review of age-related policies, auditing of service provision, and staff education.
Our research suggests that the direction and values expressed in the government's new framework have been welcomed by and found considerable support among managers in health and social care. All the managers interviewed in the King's Fund's telephone survey thought age discrimination was undesirable and said they would take action to remove it if identified locally.
But there was also a widespread perception that age discrimination remains endemic within health and the social services, and that implementing government policy on the ground will not be easy. Ageism was felt to be difficult to define, identify and relate to resource allocation, and therefore manage in practical ways. There was a daunting legacy of 'old habits' to tackle - custom and practice which had been evolved rather than planned, coupled with a legacy of ageism in society and welfare provision.
Government policy has undoubtedly provided an important stimulus and reinforcement to local action to combat unfair age discrimination in services. Most managers are working to meet the directives laid out in the NSF for Older People, including appointing older people's champions and undertaking audits of age-related policies.
But the reality is that the timeframe for meeting these requirements is tight, and support and resources lacking. Without practical tools, managers, however supportive and willing, will be limited in their ability to realise this complex and far-reaching policy consistently and at the depth required on the ground.
The report argues that motivation to tackle age discrimination would be strengthened by the establishment of a legal requirement for health and social care organisations to promote age equality in their services.
-- Between May and September 2001, the King's Fund carried out a voluntary telephone survey with a representative sample of senior managers working in health and social services in 25 local authority areas across England, responsible for implementing the government's National Service Framework (NSF) for Older People. The survey was designed to identify whether they believed that age discrimination affected services in their local area, and what if anything they were doing to combat it.
-- Initial invitations were sent to chief executives from primary care trusts and NHS community trusts, medical directors from acute and specialist trusts, and directors of social services. Confidential telephone interviews were conducted with a total of 75 managers, of whom half were the person first contacted and half were managers delegated by the initial contact. Four in five of the primary care group/trusts and social service departments approached took part, and just under half of the NHS hospitals.
-- The survey found that three out of four senior managers believed age discrimination existed in their local services, and many felt that ageism was endemic. The remainder believed there was little or no age discrimination, but many added that they were not sure how easy it would be to identify age discrimination if it were taking place.
-- There was widespread uncertainty about how to define age discrimination and identify it in practice, and whether in some cases it might be justified. These problems were especially marked in relation to specialist services for older people, and clinicians' predisposition to under-treat or over-treat people of very advanced age. Many senior managers seemed unsure what to look for in the task set them by government to 'root out age discrimination'.
-- About one in three managers volunteered examples from their experience of direct age discrimination - policies which restricted access to particular units, facilities and treatments by setting upper or lower age limits. Fewer examples of indirect discrimination - for example, lower funding for services disproportionately used by certain age groups - were offered. Those provided reflected concerns about limits in the availability of surgery, drugs and equipment for older people. Positive discrimination was also instanced - for example, community health services with minimum age criteria to ensure older people's access to services in high demand.
-- Most managers said that there were few written policies specifying age criteria, especially in the health care sector. Managers in community trusts were the most likely to identify age-related policies. Where explicit criteria existed, managers felt they had 'evolved' rather than been planned as part of a coherent wider strategy.
-- Social service provision is typically organised and funded by age groups. Some managers believed this led to lower levels of investment in older people's services, and felt that older people's needs were defined at a more basic level than those of younger people or children. Some suggested that older people were more likely to be placed in residential care and offered fewer care options than other clients. Others thought funding disparities across age groups reflected the higher market costs of services for younger people compared to older people.
-- Managers defined a range of barriers to implementing government policies on age discrimination. In management terms, this priority often came second to other, more urgent government imperatives. There was little public pressure, with few complaints from older people and their families about care and treatment, and modest expectations among older people themselves. Culturally, ageism was widespread in society and in traditional approaches to welfare. Finally, lack of resources - for example, funding for new initiatives or staff training - was seen as a major constraint.
-- A few managers suspected that GP hospital referrals might be biased towards younger patients, but in general the role of GPs as gatekeepers to hospital services was little discussed, despite recent publicity for age-discriminatory practices by GPs. Views on hospital care for older people were mixed. Some managers felt staff attitudes could be improved, others that medical interventions for older people at the end of their lives were sometimes too heroic. A lack of specialist palliative care was also identified.
-- There were mixed views about whether dedicated or integrated wards for the elderly were the best way to deliver hospital care, but on the whole the arbitrary nature of using age to define access was questioned more than specialisation of services. At the same time, managers observed that, in practice, many staff interpreted age cut-off points flexibly.
-- When asked whether they felt they personally would receive adequate support from health and social care services in their own old age, managers were on the whole confident they would, in part because, as part of the post-war generation, they felt they would be more demanding of better care.
-- In general, managers of community health and social services considered the involvement of older people in scrutinising policies and practices to be under-developed. Managers working in acute hospitals appeared less committed and involved with the public involvement agenda.
-- Most managers could point to some local initiatives to implement the government's National Service Framework for Older People, and there was considerable optimism and enthusiasm about these. But rates of progress were felt to vary widely. The time-scale for carrying out the expected audit of age-related policies - plus the lack of guidance from the Department of Health - were frequently criticised. It was felt that most service development initiatives underway were likely to have an indirect effect on age discrimination.
The King's Fund recommends that the government lead on taking forward the following:
-- Clarify the meaning and consequences of age discrimination. This will better equip managers and others in the health and social services sectors to identify age discrimination in their local services and determine whether or not a particular policy or practice is justifiable.
-- Develop clear benchmarking systems as a matter of urgency. This will help to detect hidden age discrimination, by enabling comparisons of patterns of referral, treatment, care and support achieved in one locality with those in comparable areas.
-- Invest in staff education and training. Awareness of ageing and ageism should be included in staff education programmes at all levels, and an investment made in developing appropriate course material and providing opportunities for staff to reflect on practice and ways of creating change.
-- Make a critical assessment of specialist services for older people. This will help eliminate policies that disadvantage older people by restricting access to quality care.
-- Implement new age-equality legislation. New legislation is needed to outlaw age discrimination in health and social care and to require local agencies to demonstrate that older people are not disadvantaged in terms of access to, or quality, of services provided.
-- Scrutinise national social policies. Age-related policies and policies that have a disproportionate effect on older people and may indirectly discriminate against them should be examined.
The full report, Old Habits Die Hard: Tackling age discrimination in health and social care, (£6.99) is available from King's Fund Bookshop, 11-13 Cavendish Square, London W1M 0AN, (tel: 020 7307 2591, fax: 020 7307 2801). Or order online at www.kingsfundbookshop.org.uk.
For further information about our work on age discrimination in health care, including related reports and work in progress, see www.kingsfund.org.uk/eHealthSocialCare/html/index.html.
The King's Fund is an independent charity working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through grants. We are a major resource to people working in health, offering leadership and education courses; seminars and workshops; publications; information and library services, a specialist bookshop; and conference and meeting facilities.