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HAPPY 85TH BIRTHDAY Powered By Docstoc

Siobhan McClelland Jeremy Felvus Robert Taylor

The Authors
Professor Siobhan McClelland is an expert in Welsh Health Policy. Following graduation from Oxford University Siobhan joined NHS Wales as a general management trainee and worked in the NHS in a variety of management positions. She then moved to academic work with positions in Newport, Swansea and UWCM and is currently a Visiting Professor in Health Policy and Economics in the Health Economics Research Unit, School of Care Sciences at the University of Glamorgan. Jeremy Felvus has worked in the pharmaceutical industry for almost 6 years, most recently as a member of Pfizer's Government Relations Team based in Wales. Policy around Healthy Ageing is a key area of interest. Previously he spent more than 20 years in the public sector, first in local government, but majorly in the NHS in Wales. He has experienced most parts of the service including hospital management, commissioning and strategic planning roles. Robert Taylor has a background that includes social work and work with disaffected youth. In 1982 he took the post of director of Cardiff Council for the Elderly where he established a number of innovatory services for older people. In 1989 he moved to Age Concern Cymru and since 1991 has held the post of Director. He regularly represents the views of older people at Wales, UK and European levels and has a long-standing interest and commitment to the field of healthy ageing.

This initiative would not have been possible without the financial and technical support provided by Pfizer plc. GJW Cymru Wales provided invaluable logistical support and advice. The success of this project is entirely due to all those whose time, energy and willingness to contribute fully at the discussion dinners, enabled the authors to produce this challenging and timely work.

The views and opinions expressed in this analysis are not necessarily those of the authors or their employing bodies.

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Page Number 1. Introduction 2. The Dinners 3. What Will You Be Doing On Your 85 th Birthday? 4. Predicting The Future 5. Society, Politics and Democracy 6. Expectations 7. What Is Ageing? 8. The Health Class Divide 9. Responsibility 10. Health and Social Care 11. Health Promotion 12. Carers 13. Homes and Institutions 14. Technology 15. Finance 16. Retirement and Work 17. Unthinkables 18. Death 19. Conclusions Appendix. List of Participants 40 41 34 36 38 39 30 32 8 9 10 14 16 19 21 24 26 29 4 6

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The first part of the 21st century is likely to see a growing proportion of older people. The statistics suggest that in the UK generally:  By 2020 28% of the population will be over retirement age  By 2020 the number of people aged 85 or over will increase by a third  By 2041 50% of the population will be over 50 And:  By 2050 60% of the European population will be over 65 In Wales:     Currently 17.5% of the population are over 64 compared to a UK average of 16.6 This will increase to 25% by 2030 Rural areas will have the highest population of older people – currently 20% There will be a 17% increase in those of retirement age with a 60% increase in those aged 85 or over in the next 20 years  The number of those aged 75 or over will show an increase from 8.5% of the population to 11.5% by 2026 Good health is one of the top issues for older people, allowing them to fulfil other ambitions. Wales has a new Older People’s Strategy that will occupy much attention in its implementation, particularly over the first three years. We have, however, yet to become fully aware of what society is likely to look like in the more distant future and what implications this may have. There is a need for politicians, policy makers and society at large to consider the future of healthy ageing and provide imaginative solutions to the issues it presents. Age Concern and Pfizer wanted to provide an opportunity for key stakeholders in Wales to think ‘outside the box’ about the future for healthy ageing in Wales and beyond. A series of four “discussion dinners” were held, under the Chatham House Rule, in South, East, West and North Wales to try and do just that. This analysis formed the basis of “Happy 85 th Birthday?” which was released as a report on the 28th April 2004 and which is available from Robert Taylor at Age Concern Cymru or Jeremy Felvus at Pfizer Ltd. This analysis provides detailed description and comment on the main themes to emerge across the four discussion dinners. The shorter “Happy 85 th Birthday?” takes these themes and poses a series
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of challenging questions for policy makers and society alike. Overall the project, as encapsulated in both documents, is intended to stimulate debate in Wales on the future of healthy ageing and to identify areas for future research and discussion.

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The Dinners

Participants were drawn from a range of backgrounds including politicians, policy advisors, patient advocacy groups, civil service, NHS, consumers, professional bodies and clinicians. The dinners were intended to provide a relaxed and convivial environment in which they could take ‘time out’ to reflect on current practice and how this might change in the future. They would also reflect on new issues which were likely to have future importance and how this would feed into the policy process. The dinners also offered participants the opportunity to extend their own personal networks to facilitate future joint working. A full list of the participants is provided as Appendix 1. The dinner was preceded by two short presentations on the theme of healthy ageing from Age Concern and Pfizer. The Pfizer presentation was on a study of public perception across Europe of the challenge facing governments with an ageing population. The conclusions were that effective responses will require a wide range of skills and expertise, and a spirit of cooperation and solidarity. The Age Concern Cymru presentation focussed down on the current situation in Wales as described in the Older People’s Strategy. Each course of the dinner then coincided with three general questions for participants to consider and discuss and this discussion was facilitated by Professor Siobhan McClelland. The questions for consideration were: Question 1: The Starter Imagine that rather that today is your 85 th birthday … what are you doing? This was intended as a fun way of approaching individual perceptions of healthy ageing. As individuals shared their ideas of how they will be experiencing that birthday common themes emerged about expectations of what their lives will be and what they will need in order to live these lives and link these to a healthy ageing process. This question also intended to give everyone a chance to speak from an individual rather than stakeholder perspective recognising the importance of personal understandings and feelings about healthy ageing. Question 2: The Main Course Having transported you to your 85 th birthday we now want to take you to Wales in the year 2050 where the majority of the population are over the age of sixty. What does this society look like and what are the major challenges that face it?

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This question sought to move the participants from discussing individual perceptions to exploring the societal implications of an ageing population. By going so far into the future we wished to move away from current preconceptions and encourage some real ‘blue sky’ thinking. Question 3: The Desert We’ve had our 85th birthday and gone forward to the year 2050. Now we are coming back to the present and ask what policy solutions and measures should we be putting in place to meet individual and societal expectations of healthy ageing. This was intended to be a practical question asking participants to consider what needs to be done now by policy makers, practitioners and society to anticipate the needs of the future and the old age of our children. Each of the dinners was tape recorded (with the permission of those present and a guarantee of anonymity and confidentiality) and the tapes were subsequently fully transcribed. Whilst this was not intended to be a robust research exercise good practice in qualitative research was adopted and we each read through the transcripts independently and drew out key themes. On meeting together these themes were agreed and the transcripts coded against each of the themes by one of the authors and checked by the other two for shared understandings before finally being written up as the full analysis. The themes within are those which emerged from the dinners and the words are those of participants demonstrated by extensive use of non attributable quotations from the dinners themselves. Participants were also invited after the dinners to provide feedback and to offer any comments on the healthy ageing issue they felt they had not been able to make on the night. The analysis of the dinners, which follows, is divided into sixteen sections each reflecting a major theme to emerge from all of the discussions.

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What Will You Be Doing on Your 85 th Birthday? … a trip in a tank?

Participants allowed their imaginations to run freely in thinking about what their 85th birthday would be like. For some this would, as it currently did, still involve work “I think when I get up, I’ll be going to work when I’m 85” although for some a nightmare scenario was “getting up and going to work”. Being physically active was also considered to be important in the celebrations “I’ll be dancing .. I’m going to keep myself physically fit” and another participant thought she would be skiing. Being sexually active was important for some “when the party’s over and

everybody goes home me and my husband will rush upstairs and make mad passionate love”. Undertaking activities that the individual currently enjoyed, discussed that when we got older then whether we were in wheelchairs or zimmer frames or not we would have a rock band”.

including horse-riding and shopping, were part of the birthday plans for some with another reflecting a pact she had already made with her friends “we always

For some individuals travel was a potential birthday activity “I see myself in a little café in Brittany eating my moules and frites”. For others acquiring a new skill, such as playing the guitar, would be something they could demonstrate on their birthday. Some others had an even more adventurous spirit “the first deep sea

diver at 85 or something or maybe a trip in a hot air balloon or something fairly extraordinary or perceived as fairly extraordinary for an 85 year old to do” . One
participant had a friend who had done the Cresta Run in his 80s and the mother in law of another “on her 90th birthday we managed to have a trip in a helicopter but

she told me she doesn’t want anything special until her 100 th when she wants a trip in a tank”. For most participants having a party involving eating and drinking and most importantly surrounded by family was their ideal 85 th birthday “more family, maybe grandchildren, maybe great grandchildren” and “friends, family and drink”.
One participant summed up the day’s activities:

“When I come home from work to an excellent meal, engage in a passionate debate and then chase my second or third wife round the landing and catch her”.
Whilst participants were eager to share optimistic views of their birthday there was an understanding expressed that their 85 th could be very different. This was very much the converse of what has been expressed above with issues of poor health being seen to impede older age “in poor health. They may not have anything

to sustain their lifestyle at 85 and they may not have family support and a lot of illness”. As importantly was the fear of being alone with a “lack of independence and being isolated”.
4. Predicting the Future … we have seen tremendous changes haven’t we?

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Participants were asked to look into the future of healthy ageing. This was not considered to be easy although we sought to explore this using a number of different scenarios:

“we think about what we’re going to be like in 30,40,50 years time in the current mental framework we have where everything operates today”.
Those who had sought to predict the future had often been proven wrong:

“I remember a Professor saying that ‘there are two constants in international politics, firstly ‘the cold war will last at least another two generations’ – well it lasted eight years, and secondly ‘the European Community will remain stagnated and will never develop into a vibrant union’ and that lasted about four years”.
A number of participants felt that we could not have predicted the society we lived in now 30,40 or 50 years ago:

“If we look 50 years back, we have seen tremendous changes haven’t we? Technological, socio economic, medical science and all the rest of it, we have seen tremendous change and I think it is probably picking up pace, accelerating, so we are going to see similar greater change in the next 50 years”.
Technology was particularly cited as a rapidly growing area: “go back fifteen years and think about computers, think about mobile phones”. For one participant there was a notion of stability in human nature:

“I am not quite convinced that human nature of any generation is transformed. I think there are pretty clear constancies as far as what human designs are concerned and wants”
and for another a view that human beings could cope with future change:

“human kind seems to have an ability to cope with these challenges through progress in all the various fields that are relevant”.

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Society, politics and democracy … complete social breakdown?

Much discussion focused around an exploration of the way in which future society would be structured, the nature of politics and economics and how this would impact on the healthy ageing of the members of society.

Demographics … demographic time bomb?

Given the nature of healthy ageing it was unsurprising that some attention was focused on the implications for society of a population that was weighted heavily in favour of older people “what you have got is a lot less younger people and as a result of people living longer there is going to be that population swing” although there was some debate about the extent to whether this equalled a dramatic change in population structure or a gradual increase which the infrastructure was more than able to cope with “if you are going up from 20 -24% (of the population) then actually the service infrastructure is kind of going to be there”. Nor did the concept of a growing older population necessarily result in the well used notion of a ‘demographic time bomb’ “it is an interesting phrase, people are going to live a lot

longer and they are going to be a lot healthier we hope and most people expect and this is seen you know as a huge problem”. There was a view however that the
growth of people over the age of 80, which was the fastest growing age group, was seen to be particularly challenging although, as will be seen, caution had to be exercised to necessarily correlating this with frailty.

Politics … the democratic deficit is very serious

Some views were expressed that the growth in the proportion of the population who were older could have an impact on political processes and that this would particularly be the case if the older part of the population were economically inactive “If you have got one tenth of the population supporting the other nine

tenths are they going to be content with a situation that still allows the other nine tenth to dictate the agenda?”. There was not however agreement that this would prove problematic “The thirty-five year old who is working approaching the most productive part of their lives perhaps from income and knowledge base will have a father, mother and grandmother and a grandfather, uncles and aunts. I don’t think that they will suddenly say oh why am I in one tenth or whatever one fifth that’s supporting all these economically”. Whilst some concerns were expressed about
how far older people would be fully integrated into and valued within society there was some optimism about their future role and the respect that would be paid to them.

There was a view that the future political challenges “are going to be huge” partly because of the expectations of younger people “they will say this is not good
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enough and if you can’t provide Government then we will look to another Government to provide for us. You Government will have to make choices between roads, education, war whatever it might be to enable you to provide the services that we will expect and demand. I think that’s going to be a very tough decision for government whoever they are” . This was compounded by a concern that there was a growing loss of faith in democratic processes “the democratic deficit is very serious. The inability of politicians on the whole to convince us that what they are doing is more than having fun and playing nasty games”. This was not supported by all participants some of whom had a greater faith in the future of democracy “I’m fairly optimistic that democracy will survive in some fashion and it will be mediated by institutions and political parties”. There was some concern about the
short term vision of politicians which was seen by some to span little more than the four or five years between elections “One of the things about conventional agendas

from a government’s point of view, governments get re-elected every four or five years. This is a kind of a long game” although a view was expressed that in Wales this might be different where “Labour has a reasonable expectation of having long term political power” which could lead to a longer-term perspective. It was felt important that politicians engaged with people of all ages “The best thing is to actually engage in the debate in a public way” and that through this create a social agenda “because that actually shapes the political behaviour”. Family… the bamboo tree family
The issue of family structure received some attention. There was a general perception that there had been significant changes in the demographics of families with more divorces, people having fewer children, families no longer living proximately and more people living alone. This led to what one participant termed the “bamboo tree family because it’s like one parent and one child rather than two parents, grand parents and six children” and one where the concept of a close knit family was disintegrating. There was some discussion about whether ultimately this could lead to a very lonely and isolated older population and one which was more or less dependent on others. For some it was felt that this would make it less likely that children would be prepared to support their parents in older age and indeed whether their parents would want it “Parents themselves won’t want to put

their children in that position”.

There was however some dissent on the view of this increasingly fragmented society. For one participant the change in family demographics was not particularly marked “Some things remain remarkable constant. There may be lots

more divorces, there are also lots of marriages and if you actually look at the average length of a marriage, there is a lot less difference between this generation and previous generations. Previous generations died earlier, that’s what used to
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break marriages”. Nor did all participants support the view that family members

would no longer support older family members. Moreover the view was expressed that changes in family demographics could lead to positive changes in society where individuals developed a wider network of friends “Actually the family is a bad thing. All it does is reinforce social constraints” which might ultimately make an individual less dependent, particularly following the death of a partner.

Rurality … I don’t think I want to live in a rural area when I’m 85

It was felt by participants, particularly at the North Wales dinner, that rural issues in Wales offered some particular challenges for society now and in the future. Accessing services was seen as particularly problematic and something that got more difficult as the individual aged and was less mobile. For some of those who currently lived in rural areas this led to the conclusion that older people would be better off not living in rural areas “I don’t think I want to live in a rural area when I’m 85” and that living in an urban area “will afford me access to, even if it was by

taxi, but affordable access to the shops, to the theatres, to the symphony hall and whatever else I wanted to do … In my present dwelling, a farm in the middle of a field in the countryside I am going to be absolutely stuck if I don’t have mobility of some sort”. This was of some surprise to urban dwellers who might have hoped to move to the countryside in their older age “I mean my assumption is that I am actually the opposite, I would very much like to move to a rural area when I retire” and that this was the reality of “a high percentage of retired people coming out to live in Wales or Devon or wherever … they forget about the fact that they have chosen a detached house with a large garden that they now can’t dig etc you know the expense of decorating and maintenance are so horrendous that they have got no money to live on”. Social Fabric… no longer do you know Mrs Jones three doors down
Changes in the structure of society led some participants to express concerns about how this would impact on what was termed the social fabric and on state infrastructure. “Social disintegration and the inability to fund rising expectations of public services is serious” and for one participant this was related to a particular community “I have been watching the valleys, where I live, change so dramatically from very strong communities to complete social breakdown”. Some participants felt that individuals had become very isolated from the notion of community “we no

longer work in the community we live in … No longer do you know Mrs Jones three doors down”. Others felt that human nature was communal and that this had in fact altered little “If we just concentrate on what makes the individual happy or not happy… They prefer to be pack animals rather than isolated … They prefer to be contributing to society rather than isolated from society” and “I think there is enough wholesomeness in society … We don’t like seeing beggars in the street. We
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don’t like seeing misfortune”. There was also a perception that individuals were not as isolated from society as others might have felt “I think it is one of these fallacies, one of these myths that people are disjointed by families, disjointed from their communities because if you look at the social networks of older people, a majority of them still are relatively integrated. They have family and they are in contact with friends and neighbours”.
Some discussion took place on measures that could be taken to preserve the fabric of society and for one participant this was a major challenge “there will have to be a huge shift actually organised to make up the deficits in terms of social fabric” and for a number of participants community involvement and action was key to this “I

was thinking about was more what can society do to make the life healthier for people who are 85 so for example can we develop communities that are more supportive of people who live on their own. That is not social engineering. That’s just giving people who live alone an opportunity to live together in the same community”.

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Expectations … … a completely different set of values

The expectations of those drawn from all age groups received some attention from participants. Whilst, as will be seen, much discussion centred around the expectations of the so-called ‘baby boomers’ and their children there was some discussion about whether expectations continued to remain the same “some of the

issues are people’s expectations, at what stage do they peak? Peoples expectations peak at different times”. Some concern was also expressed that people had

unrealistic expectations of their older age particularly in respect of the level of functioning they could expect. This in turn, it was felt by some, could and would lead to increasing demand placed on health and social care services where there could be an expectation that all physical functioning issues could be ‘fixed’. It was felt by one participant that a differentiation needed to be made between needs, wants and demands and a fear by another that expectations were being raised that could not be met “you raise peoples expectations and cannot deliver on what their

expectations have been raised to., The NHS is a classic, particularly with this present government where the expectations have been raised beyond the ability for the service to provide”.

However, much of the discussion focused around the expectations of the ‘baby boomer’ generation, that is those people born after the war until about 1964, and also of the expectations of the children of these people. It was felt particularly important that an attempt was made to understand the expectations of these age groups because they were likely to be very different from those who are currently 85 “at the moment perhaps we are thinking at our age things would be like they are

for an 85 year old now … they won’t be because there will be a different generation of people at that age with different experiences”. This was likely to impact on what they expected from society “What will their expectations of the infra structure be? I mean issues like personal responsibility for health, carrying on working and being active to participate economically”.

It was felt that the structure of the baby boomers generation was very different from their parents “completely different trends in the last twenty years in terms of marriage, divorce, people living singly, the number of children they have”. This was perceived to lead to “a completely different set of values”. There was some debate about whether this had resulted in a generation that were more individualistic and less concerned about others and this was particularly attributed to those younger than the baby boomers “my impression of people younger than me is that they don’t seem to care about people at all” yet at the same time were more dependent

“with an expectation that if something goes wrong its not my fault it is somebody else’s fault and they will pick up the pieces”. However, for other participants both
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baby boomers and their children were perceived to be more socially responsible and to have become less dependent on others “I believe people will be taking more

responsibility for their own health, for their own lifestyles, for their own accommodation”.

There was a perception that these generations were more consumerist in their outlook, with the higher expectations which came with this, and less willing to accept the status quo. Whilst it was felt by some that this was socio economically derived there was a view that baby boomers and their children were more likely to have travelled, to have been university educated and to be able to access and use technology, particularly in terms of multi media resources, which was likely to increase their expectations of health and social care services. There was some debate about whether there might be some differences between baby boomers who had been recipients of the welfare state and their children who had grown up to expect the state to provide less, for example in terms of free higher education and pensions. There was also recognition that changing attitudes to debt and consumption were likely to have an important impact on the future economy needed to support a growing older population. Whilst it was felt important to understand the expectations of younger people there was a recognition that it was difficult to get them to think about ageing. Given the role of health promotion in contributing to healthy ageing it was clear that the seeds for this needed to be sown in younger people. “You have got to

somehow change perceptions and some of the best ways of changing perceptions actually aren’t targeting that particular audience but going almost a couple of generations down … education of a younger generation not necessarily our generation”. This was also felt to be important in terms of shaping realistic
expectations for the future. There was however some cynicism about whether younger people could ever be able to think other than short term “I don’t think you

will ever persuade younger people to think about age .. How do you get a twentyfive year old to think about you will retire one day, you will need a pension”.

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What is Ageing? … … isn’t healthy ageing about what makes you happy?

There was much discussion regarding the construction and conceptualisation of ageing. One participant stated that we start ageing perhaps not from the day we are born but from aged seven onwards and that therefore as a concept age could not just be restricted to those aged 50 and over. There was however much discussion about what it meant to be ‘old’. Some participants felt that many within society were healthier at older ages than had been the case in past generations

“just a generation ago a lot of people seemed old at 50 … and I suppose they thought of themselves as being old at 50”. This could partly be attributed to the

age distribution of participants and their relative proximity to older age themselves

“I thought 50 was old when I was in school, but you know 50 is very young”. Overall there was much agreement that “70 becomes the new 60” and that “the 85s will become today’s 70”.
This reflects an optimistic view of a continuing upward curve in both life expectancy and quality of life. “I have heard optimistic forecasts that in the not too distant future people might routinely live to be 120” and “I think with the age

structure, the average life expectancy goes up every year now …so that means there will definitely be more people around and healthier people at that stage. That’s an actual trend, it won’t go backwards unless some disaster strikes us” and as
evidence for this one participant cited the number of hundredth birthday telegrams the Queen sends out from 200 in the 1950s through to 3,500 more recently, including of course one to her own mother. Nor was it necessary to attribute ageing even to those entering their eighties and beyond “there are stacks of 80 year old pluses just living in the community, happily living ever after” and no desire even to consign those in their nineties to constructs of being old. It was felt important by a number of participants not just to readjust the scale of chronological ageing but rather to fully embrace the concept of being non ageist. However, there was not entire agreement on a rosy future of an increasingly older yet healthier population. The issue of obesity was cited in particular as a threat that might actually reverse the trend of accelerated longevity. Moreover there was a view that the benefits of this healthier older society might not be evenly distributed “part of the problem we have in Wales, like in the rest of the UK, is that

our twenty year olds are ageing badly, our thirty year olds are ageing badly, our fifty year olds are ageing badly”. The concept of premature ageing which, as will be

seen, could be linked to a number of determinants including socio economic, genetic and lifestyle was an important issue to grasp and one which was not necessarily linked to an older age number.
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The need to escape from a chronological definition of ageing was also evident in discussions regarding the negative stereotyping the application of this number can mean. “We are obsessed with age. Immediately you start to talk about age as a

figure, then you stereotype the whole of society and that’s a fundamental problem” and that “being old is bad”. It was felt that this stereotyping could and did lead to a

position in which older people lose certain roles in life and come increasingly to live in a society in which they are not valued. It was felt that ageism, despite increasing legislation to guard against it, still played a negative role in the lives of many. Hospitals were particularly mentioned as still finding it difficult to move away from ageist perceptions in providing health care services and it was felt by some that this was built into the very structure of a society that rewarded only those who were currently economically active. The very existence of a retirement age was perceived by some to be an ageist phenomenon “When you are 65 that’s it.

You retire whether you like it or not and that means that you are on the scrap heap because your productive life has gone”.

The concepts of frailty and functioning were seen to be more useful for policy makers and those providing services alike “that’s the advantage of the concept of

frailty because you are engaging with a developing situation irrespective of age or who they are, or what they are, as soon as they become frail the system needs to jump in”. Frailty did not have to be associated with ageing and the latter was also

often perceived to be used as a proxy for disability which was not perceived to be helpful, either for those with disabilities or older people. For many participants functioning was key “most of us would be happy to age as long as we are not impaired” although it was accepted that definitions of functioning were highly subjective “It’s the ability to do what you want to do. People differ in what they

want to do …. I want to be able to do all that I can, I want to be able to be all that I’m able to be and that’s a definition of health in my book”. Whilst physical functioning

was seen as important, views also emerged about the importance of mental health in a healthy older age “The WHO does identify mental illness as the biggest challenge facing industrial societies” and “Is that going to be a number one problem

proportionately, clinical depression, senile dementia. We often don’t think about that”. For some participants this was clearly linked to the nightmare of a lonely 85th birthday with social isolation a frightening prospect “I think this is something we have to overcome, it’s the isolation of the person”.
On a positive note one participant had a particularly upbeat perspective on the benefits of an older chronological age “All the fun I have is with elderly people.

Their intellectual function is absolutely superb because they have got such a wealth
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of experience going back to the last century and that comes out in the conversation, the humour the whole lot”.
Quality of life was therefore important to many participants in defining healthy ageing. “Physically active and mentally active” and that was “very much twinned

with independence. I think it is not necessarily living on your own but it is the independence to do what you want to do, when you want to do it”. Ultimately “isn’t health in ageing about what makes you happy” and in describing an encounter with an older man one participant summed up his view of a good healthy age “for him being able to walk out with the dog for an hour, stop and have a pint, read the paper, he was over the moon really, he was so happy. Perhaps he can’t play football now, but he is still physically active and mentally active and happy, so to me he seemed to be ageing healthily”.

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The Health Class Divide … death and disability comes a little bit earlier

The notion that healthy ageing was determined by socio economic factors was discussed at most of the dinners. There was a concern expressed by some that the optimistic view of healthy ageing was not a reality for those outside the middle classes “We’re steering for the middle class concept. People can look after

themselves, people can make decisions, people can control their lives – not everyone is in that position as far as I’m concerned”. For some participants the
bounty of a wealthier, longer living society was not available to those who were poor “When you look at ill health in Wales, you have to look at housing, poverty and people finding themselves in a situation where they are just not capable”. This was then linked to these individuals being able to make decisions about their lives with some taking the view that socio economic factors clearly impacted on peoples ability to make choices about how to live “perhaps we’re all lucky round this table led to a situation in which the more negative attributes of ageing were likely to hit working class individuals earlier than their middle class counterparts “if you look

that we’re all able to make certain choices, there are an awful lot of people out there who can’t make the choices because they don’t have the wherewithal”. This at valley communities, one of the features you notice is that death and disability comes a little bit earlier”.
The impact of socio economic factors on choice could be seen not just in fewer opportunities to choose working patterns and have adequate financial resources in older age but also making individuals less able to access health promotion and disease prevention messages. For many participants health promotion was a key determinant of healthy ageing “If you take more responsibility for your future, you

take more exercise, you cut down on your alcohol intake, you stop smoking and you have a good diet, you will live longer” but some accepted that this was not so easily accessed by impoverished people “I am more than capable of taking in that message than somebody perhaps who is living on his or her own in a council flat somewhere”. As will be seen, smoking was identified as a key element in early
death and illness and it was recognised that smoking was more prevalent in lower socio economic groups “Smoking is a phenomenon of the so-called lower classes and that’s a key factor in why they are so unwell” and that reasons for this could be attributed to the nature of life in poorer communities “Why do these people

smoke? I do smoke the occasional cigar, but probably the occasional cigar doesn’t do me too much harm (hopefully) but I can afford to smoke the occasional cigar. I don’t need to smoke 40 cigarettes a day, but if that is the only pleasure you have in life”.

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Obesity was also recognised as being a future problem for healthy ageing and again it was felt this was more of an issue amongst poorer people for whom accessing healthy eating messages was challenging “for so many families it is a real struggle to get a meal on the table of any kind let alone work out the nutritional value” and

“if you haven’t got the choice to make healthy decisions about food and about where you shop” then it did not matter how much information was provided by

government. For one participant this meant that without an opportunity to find meaning in life then an individual did not have to “hit rock bottom to realise that

one of the few things that you are going to do every day is have a fry up and smoke. It doesn’t matter how many politicians are going to tell you that’s bad for you, it isn’t going to make any difference”. There was however a view that there was some potential for “advocates for those people who are at the lower end of the economic scale to give them the information to allow them to make better choices”.

It was also felt by some that this lack of choice not only resulted in poorer health status but also an inability to effectively access health and social services to meet their needs “middle class people tend to always demand access to new services when they become available”. There was however a fear that the demands of sicker, poorer people on the health service would place it under huge strain and would become unacceptable to the healthier middle classes “I think what will start

to be seen particularly with the public health system is that people with disadvantage are actually a threat to those with an advantage because of the calls they are making on the health service” and that “the wealthy sector will revolt at having to subsidise the ill health of the poor sector”. However, for a number of participants there was a clear view that “the National Health Service still needs to cater for those people who can’t cater for themselves”.
The view of the impact of the class divide in health was not uniformly accepted by all participants with some more individualist perspectives emerging, suggesting that this might not just be an issue for those with low incomes, leading to discussions regarding the nature of personal and state responsibility within society.

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Responsibility … the people who don’t change will die

There was considerable discussion at the dinners about the role of the individual in taking responsibility for him or herself and the role of the state in taking responsibility for its citizens. This was linked to understandings of class and socio economic factors, together with the expectations of the ‘baby boomer’ generation and their children. This was also related to notions of dependency, both on others, but more specifically on society, to provide solutions to individual problems and provide services to meet needs, demands and wants. Some very strong views were expressed on whether people had increasingly grown to be dependent on the state and unwilling to take individual responsibility “I’m

part of that generation, I hope I don’t suffer from it, but won’t take responsibility for anything either. You have got a culture that now sues everyday. It doesn’t matter what you do, you sue for something”. This led to a view of dependency “At the moment the opposite to independent is a growing dependence on the society in which we live not on individuals in our society” and a view that “The more they are propped up the more they have to be propped”. A view emerged that those who
took more individual responsibility, in particular for their own health, would benefit from this “The interesting quirk is that the people who will survive are the

people who will have taken responsibility for their health. Apart from the genetically unlucky, if you do change your lifestyles and you do stop smoking, you will survive and enjoy older life much better. The people who don’t change will die”. For some the arguments for taking personal responsibility were clear “There is no doubt you can take great personal responsibility for your health. We don’t actually say ‘look you have to take responsibility if you want to have a healthy lifestyle into your 80 years’ … there are serious moral responsibility issues which nobody takes on board”.
For those with this perspective there were clear links to the establishment of the welfare state and dependency upon it. This was particularly linked, in respect of healthy ageing, to the NHS which was perceived by one participant as creating a

“culture of dependency”. “The problem we have is a very fundamental one, it’s the National Health Service. The NHS has taken ownership of health away from the individual. And what the NHS has said is that the principles of it are that you can do what you like but the great NHS will fix it for you” and that this could be seen at a practice level “I said to all my patients ‘just like that dear’ and ‘I will do it for you’. That would make you feel good, that would make me feel good. People need to be taught how to manage themselves in order that they can take control of themselves”.
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Issues of unemployment were seen to be of particular significance “We are now

faced with probably the highest unemployment levels that we have had for quite some time. The drop in employment is drastic and now we are left with this economically inactive people and the hardest of all to employ, and when I say that I say that with the greatest respect to them, because of their associated problems there will always be a hardcore of people who will not be employable for whatever reason but we have got so many of those and with that comes all the trappings and whatever else”. And for one participant these trappings included a benefits system that did not encourage some individuals to seek employment “in some valleys it is a third generation unemployment so then they just think whatever the benefit the state will throw at them is the way forward”.
However, some participants held very different views on these issues of individual responsibility. For some this was strongly linked to structural understandings of society and of how far middle class individuals could expect people from lower socio economic groups to adopt their ways of thinking “Or is it a matter of choice

and self responsibility? And those of us who use the responsibility discourse may be imposing on others whose levels of disadvantage are such that they can’t act responsibly in the way that we hope all of us would”. For one participant the very concept of independence was overrated “Isn’t the joy that people got out of that was that they were interdependent. Isn’t that the real value so maybe we have got to rethink this thing about saying independence is the best thing”. A view also structure of the medical day and then you go home and it can actually take you self confidence away at any age”.

emerged that poor health could quickly cause an individual to become dependent particularly on entering hospital “you suddenly become very dependent on the

For some the welfare state and in particular the NHS did not have negative connotations “The NHS was based on the principle that people would receive the

treatment they need, irrespective of whether they can afford it. What you’re saying is that people should be rewarded according to their ability to look after themselves. You have to accept that some people are more able to look after themselves than others”. For a number of participants there was a view that society would continue to expect welfare provision “citizens are quite right to say that the social contract has minimal obligations both from the state and the individual and as far as the state is concerned, good education and good health care will continue to be a central part of the social contract. I would be astonished if that changes”.
The state was also seen by one participant to offer potential for changing peoples attitudes to their own health “My take on the nanny state role is that there is a
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certain kind of infra structure which you have in the state to which you can actually use creatively” for example in increasing levels of activity and changing eating habits “I don’t think it needs to be a nanny state, I just think it needs to be a sensible application of infra structure”. Providing “opportunity so that people can contribute economically rather than be dependent on the state” was seen as an
important element in a progressive society and for those who took a more individualistic perspective “communication and persuading people that they have

to take responsibility for what they are doing today for tomorrow and I think that one has to be radical in how we are doing and how we are thinking of the future”.

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Health and Social Care … what we have is a National Illness Service

Unsurprisingly, perhaps, given the backgrounds of the participants and the subject under discussion, some time at all of the dinners was devoted to discussing health and social care services. Despite optimistic views regarding healthier ageing in the future there was a perception amongst some that an older population, and one which had increased expectations, would place increasingly heavy demands on health and social care services “if people are healthier longer they will all have their

acute conditions or their chronic conditions all at the same time and they will all have to be dealt with at the same time” and even a view from one participant that there would not be a National Health Service there to provide these services “I don’t think there will be a public health service as we have got it now. I think it will be private if you can pay for it because the NHS can’t afford to run as it is now from where I am sitting because we can’t afford to everything that everybody wants”.
Whilst many felt that there would be a continued NHS some questions were posed regarding definitions of health and a biomedical treatment oriented NHS “ a lot of

our health services are designed to treat diseases, yet really what we should be doing is managing patients” “what we have is a National Illness Service which is treating ill health and until that service begins to address a need to actually stimulate good health rather than treating ill health”. It was felt that a greater
emphasis needed to be placed on preventative strategies in order to keep people more healthy and living longer with less of an emphasis on acute care.

However, for some this emphasis on the hospital sector could be attributed to the incentives, particularly financial, that underpinned the performance management of both health and social care. “in its waiting list initiatives, in the way that it is

measured politically, and politicians have set themselves up for this horrible measure of how many people are on the waiting list not what quality service is on offer. The whole system has set itself up to not be a health service, it’s a treatment service” and “the performance targets we’re talking about aren’t geared to sustaining the independence agenda” and it was felt that reducing the level of
dependency would reduce the demand for services. Whilst simply rewarding activity was felt by some to be counter productive this did not reflect a general disagreement with reward systems “I agree that you could look at rewarding in

principle, but I would give it to the awarding institutions that they’re increasing the number of preventative and health promotions” and that movement should be made away from the NHS ‘Animal Farm’ approach “In Animal Farm it was four legs good two legs bad. In the NHS its 400 operations good, 200 bad” and that “actually the rewards should go to people with lower referral rates”.
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This was not an issue confined just to healthcare with, for example the funding structure in social care potentially leading to perverse decision making “so you’ve

got people getting partners out of bed five times a night because what they actually needed was a commode” and “one of the biggest criticisms that we got about Social Services was the way in which that ‘little bit of help’, in particular the old fashioned home help services and that sort of small level of care, now has been taken right out of social service provision and all the resources that were available were going to the most dependent and equipped ”. Withdrawing help to the less dependent ultimately could lead to their becoming more dependent and “If you think of it in terms of investment that is surely upside down”.

This can be related to views regarding the divide between health and social care. For some this was related to resourcing “when social care breaks down because it’s under resourced and cannot respond quickly, health is over resourced” and could therefore respond more rapidly when many of the issues regarding healthy ageing were perceived to be social. But for some the divide between the two sectors was breaking down, for example as a result of the problems in discharging patients. For some “the distinction between health and social care are neither here nor there because some people’s definition of health is about function” and one participant took this even further “I think the fundamental problem is we’re still talking health

and social care whereas the solution probably doesn’t lie within health and social care, it’s a change in culture in society, looking at social inequalities and getting people to change the way they actually behave”.

However it was clear that not being able to access health and social care services had major implications for healthy ageing. For one participant playing tennis was a major part of his healthy ageing but having injured his knee and being told that he had to wait a year before surgery “What the hell, its not routine to me! It’s completely buggered up my lifestyle”. At another level was the “revolving door syndrome” of those who were more dependent in older age who “have had services

withdrawn from them in terms of preventative and supervisory services”.

However, it was felt by some that where health and social care worked effectively together “runs unified assessment process, start picking up the frail elderly or the chronic sick and really manage them in a constructive and positive way” fewer people would end up “falling off the cliff”.

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Health Promotion … we have reversed the process of extending old age

Health promotion and disease prevention figured significantly in all of the dinner discussions. For many participants the determinants of a healthy ageing lay in the lifestyles of children and young people “if you look at health then many of the predeterminants are occurring when the children are in their teens and younger”. For a number of participants particular risk taking activities were likely to impact on health and longevity “Cigarette smoking, obesity and exercise. We all know that. We

all pay lip service to it but every year we are getting more diabetics, every year more people are dying of cancers which are preventable if they don’t smoke and every year people are getting a lot of degenerative conditions which are largely related to a lack of exercise”. As has been seen, for some participants the ability to

take up health promotion messages was affected by socio economic factors with those in poorer communities more likely to smoke and be overweight. Ultimately, for one participant this could lead to a situation in which “we have reversed the

process of extending old age because everyone will be dying younger again as they were in the tobacco society of the kind of post war years when smoking was almost advocated”.
Smoking was cited as one of the major causes of reduced life expectancy and poor quality of life. “A hundred thousand people in this country die as a direct result of cigarette smoking” and that smoking had become more prevalent among young people, particularly young women, and, as has been seen, amongst younger people in lower socio economic groups. The legality of cigarette smoking was seen as contributing to this as was the role played by the tobacco industry “Why do young

females smoke excessively? Now that has got to be some sort of clever advertising” with a perverse response by society “We are spending thousands of pounds on tonsillectomies for two years on the risk of getting CJD and we are quite happy for newsagents to sell tobacco or cigarettes. It beggars belief”. It was felt by some

participants that a black market in cigarettes had also made smoking more accessible “I worked in Merthyr and a fair proportion of the cigarettes that were smoked on Merthyr High Street were illegal” and “You only have to sit in one of the pubs and you get offered them”. Action taken to reduce levels of smoking was felt to offer major benefits “If you do something seriously about cigarettes you save the

lives of forty per cent of the people who die every year or at least you delay their death very substantially”.

The issue of obesity was also felt to threaten a healthily ageing society. This was attributed both to eating too much (of the wrong kinds of food) and not taking sufficient exercise. The development of the fast food industry “the MacDonald’s era” was seen as playing a key role in the eating habits and that much of this had
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been inherited from the United States “I went to Florida this year and to see what

they eat. I mean I thought I could eat. We went to a restaurant and ordered a portion of chips and eight people had a really good feed out of it. This is one portion. This was frightening”. The point was made by one participant however

that in the United States coronary heart disease was actually on the decline. It was also felt by some participants that younger people were not being educated in either nutrition or cooking. It was also recognised that more sedentary lifestyles were impacting on obesity although there was not a uniform agreement on the benefits of exercising “I had friends who dropped dead jogging”. A number of suggestions were made by participants of measures that could be used to promote good health. As has been suggested, it was felt that this needed to begin with young people and children although one participant felt it was important that health promotion messages are continued throughout life. In terms of smoking, legal measures such as banning smoking in public places were seen as one way of reducing this problem “You could ban them in public places and invest in treatments that break the addictive picture” although not all participants felt that this would be easy to achieve “I agree with you entirely but you know I am not sure

whether you can police that effectively or whether the public backlash which would make policing of it more difficult”. Views also emerged about pressure that could
be placed both on the tobacco and food industries which included for example more heavily taxing “unhealthy food” and “banning chips from school canteens”.

Education was seen as key, by many participants, in dealing both with smoking and obesity “educating not just the elderly but changing the way we educate society and that means the children and upwards”. “Healthy schools” were seen as the major weapon in this armoury in teaching “life skills” and some participants had examples of where these health promotion messages had worked in the past “I was

most impressed with my kids, when they were in primary school, about the anti smoking message. We went to a wedding. I used to be a smoker and I decided to have a cigarette at the wedding and my daughter was in tears because she fairly recently had this lesson in school about the dangers of smoking and so on at aged nine. That to me was a quite powerful message”.
It was accepted however that this message was not easily spread amongst all members of society. A community rather than individual approach was advocated by a number of participants “the whole world of health promotion moving away

from individual education toward what is called investment in social capital and building of communities and so on”. Providing facilities in the community were

seen to be one aspect of this and a particular example was cited in the Rhondda Valley “there is a community centre there where they have invested a lot in
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teaching … its beautifully designed … and its one of the few places that I come into now where people go and think ‘we matter, this has been built for us’”.

Undertaking health promotion measures in a primary care setting, such as lifestyle clinics in community pharmacies, were also seen by some to be potentially impactful. Employers were also seen by one participant as potentially having a major role to play in health promotion through the development of a new concept of occupational health “things like keeping people healthy in the workplace is a very direct incentive” and a system that was “occupationally sensitive” would focus on how “you are going to keep people active and in employment”.

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Carers … it restores all your faith in human nature

Whilst statutory, private and voluntary health and social care organisations elicited considerable discussion there was also an emphasis on the role of carers in an ageing population. A number of participants praised the role of carers:

“One of the really gratifying aspects of my job is we’re engaged with my fellow human beings who have a caring role. It really is quite emotional. You get mam who’s on the way out, the daughter comes along and says “she’s been a fantastic mam to me, I really feel I want to care for my mother at home” And it restores all your faith in human nature”. Whilst it was perceived that “caring is a very worthwhile profession to be in” there
was recognition that it was often undervalued in financial and other terms within society:

“I think caring is something which should be given a respectability. One must realise if you don’t have those carers then you pay £400 a week”.

This was coupled with a view that this would be increasingly unacceptable to younger members of society, particularly in acting as paid carers, who were unwilling not just to work for those rates of pay, but also antisocial hours “young people don’t want to do the job” and “until we can make that a profession and give

people the status, people are turning away from it”.

Ultimately it was felt this could result in a situation in which there were few carers available and that might even result in drastic measures by government for example in introducing a form of national service in caring “If eighteen to twenty

year olds spent a year doing care work”

“I think that many people might then find that it was actually something that wasn’t what they imagined it to be”.

and that this might encourage some people into caring roles:

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Homes and Institutions … a crematorium on the corner

There was considerable discussion at all of the dinners about what role a home played in promoting healthy ageing. Unsurprisingly some of this focused on the dilemma of entering a nursing or residential home with some very different views emerging. For many participants the concept of living and dying in your own home was powerful and one which dominated their ideas of how they would be spending their 85th birthday “the thought of being taken out of my own surroundings and the

qualities of things around me that I aspire to all of my life and be put into some sort of other environment is horrifying really” and “it’s like going to public school at the age of 85. There’s some old boy down the bottom exposing himself – it’s a horrible solution. If you can actually manage to live and die in your own home, that is a superb end”. When considering this option for parents there was also a
considerable amount of guilt on the part of children although for one participant this was perceived to be “very much a UK cultural thing. If you go to Scandinavia,

for instance, it is no shame at all to ‘put Granny in a nursing home’ whereas in our society that is still seen as if Granny goes into a nursing home it is because of a failure in the family or something outside” but for another participant “to put somebody in a home at that stage is still sending somebody away to die”.
However, this negative view of institutional care was the subject of some debate with a view that entering a residential or nursing home might well be the best and most preferable option for some older people and that could continue into the future “if it’s a choice of being in one’s home and not being able to cope or being in

a residential setting where I knew I was going to be well looked after, then I think I would plump for the latter”. Nor was staying at home always the best solution for the family “The patients always want to go home. It’s not always the best thing for the family”. Some participants brought their own experiences to the table “My mother went into care a week before her 85 th birthday and it was quite an emotional time for her, but she had actually made that decision” and that much
depended on the ethos and quality of the residential and nursing home. It was felt by one participant that the emphasis on home ownership could contribute to a society in which “We are going to have lots and lots of people living on their own in

their own homes. What goes with that, as they become more infirmed they require more services but they become more isolated and less happy. Should we be thinking about a policy that discourages people as they get older from having their own homes?”
For one participant her mother’s move into sheltered accommodation had been a life affirming experience “she’s just moved within the last four years into sheltered

accommodation … she’s now found a new circle of friends and she’s now found
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enough support to enable her to live independently and that has been a very positive move”. This experience was noted as being in sheltered housing and there

was some discussion about the differences between nursing, residential and sheltered housing options. It was felt by one participant that there was a shift in those entering nursing and residential care from “a lot of old people who needed

minimal supervision to residential care where now what we’ve got is a high percentage of demented people who may seem safe within the environment, but certainly if they go outside that environment have got serious deficiencies in their mental functions. And the level of care that is required couldn’t be higher”.
Sheltered housing was seen as an important housing option choice “we all say in

their own home but it is not necessarily that, it is in a home of their own and that doesn’t necessarily mean staying in the same place they have lived in for the last fifty years which carries all the memories of the partner who is no longer with them and the kids who have gone”. However, it was felt by a number of

participants that concepts of sheltered housing had and would continue to develop as new housing options emerged. One participant cited the Dutch approach “where

it’s very much phased and sympathetic in a way, so you live in a village where there are sets of areas to care for you. There are young people there, there are old people there, there’s a nursing home there, there is also a crematorium on the corner of the square”. A housing association in London was also identified which had brought the concept of ‘loft living’ to older people “They would stay there all their lives and it is geared for that. Access to their own apartment but loads of communal spaces throughout” and a view that this was an attractive option because as an older person “You want what other people want. You want a furnished apartment with your terrace, gym in the basement and integral swimming pool and all sort of stuff and here is one plan that has solved all of them very, very quickly”. It was also felt
that the advance of technology and the future nature of buildings could allow people in their own homes. “I think what we should be encouraging is people living

in their own home … therefore architectural design plans should be such that they can cope” and that building regulations should be put in place to facilitate this.
Anticipating future housing needs was also seen to be an important in promoting a healthy older age and that we should “encourage people to make the right moves for a life style that they perceive they want in the future” and for one participant his mother had achieved this “My mother … was very, very planned in terms of

retirement, where she was going to get her home and it was in the middle of a village, a big village, a flat with a shop very nearby and where she could see people walking by and she glories in the right choice”. Perhaps most importantly of all for
participants was the notion that older people would have choice in their housing options even if this was to live in what baby boomers might consider sub standard
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housing and that policy makers should not assume that one response would suit all people.

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Technology … you can’t hug an email

The issue of technology in supporting housing options was expanded into a general discussion regarding access and use of future technology to promote healthy ageing. This was linked for some to the increased use of technology amongst ‘baby boomers’ and more particularly their children “we are talking about a generation who have grown up with technology” although it was felt that older people could take on board the benefits of a growth in technology “we are growing up with it. We are evolving with it” and although many participants had stories of how they could not use video or more recently DVD recorders there was a perspective that “we all

will be much more savvy than we are now”.

A number of examples were given of where technologies were impacting on older peoples lives “Do you know in Spain they are running a pilot where older people

live in communities with Broadband access and they get a GP consultation live every morning. They are old, very frail people continually linked on Broadband who are able to convey how they are feeling every day and that is providing a service that is stopping them having to go into a home or have a carer in the home with them”. For some though the prospect of this supported living was not attractive “You know my doomsday vision is that somebody will wake in the morning in 2045 with an illness, will go on the internet and get a consultation, get a prescription on the internet and they will go to a hole in the wall, put a card in and get their medicine out and go home again”.
The increasingly important role of information clearly linked to developing information technology also merited discussion. Younger people were particularly cited as using modern information technology, predominantly through the internet, as a means of informing themselves and making demands for services although some concerns were expressed about the ability of individuals to critically appraise what they accessed “We are probably a generation where information – there is

information overload. We have masses of information but we have no knowledge and we need real skill in translating this”. It was felt by some that there were very
different levels of information transfer emerging with important lessons for communicating information to individuals. Moreover the development of information strategies to support professionals and organisations was seen as important “information technology is key” with some critique of current intentions

“The information pathway currently is very focused on waiting lists, putting bums in beds, that sort of philosophy so the whole thing doesn’t engage quality of care”.

Technology was also seen to play a part in developing medicines of the future which would impact on the ageing process “people with Alzheimer’s disease and so
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forth will actually be able to restore their brain mass which they have lost and that it will be perfectly possible to alter the mental function of people who get older in a more positive way”. An optimistic view of the future of medicines emerged from one participant “In terms of medicines being able to modify medicines to an individual is not that far away. It will certainly be here before 2050 and that will mean that each person genetically will have the medicine that suits them. There will be no side effects. It will keep them fit” although not all participants felt the future lay in medicines “If they need a medicine in the first place”.
There was also some disquiet amongst some participants about how realistically society could expect individuals to take on technological developments and that research into the uptake of technologies tended to use “enthusiastic volunteers.

They were often the parents of the technologist … they did not represent the general population”. For one participant society in general did not easily take on board technological advances “I think technology is important but I think it is interesting the human species puts dampers on technology and to some extent integrates it at its own pace both in organisations and in the personal life” and for another a question mark over whether we could pay for the future “Its not that we can invent these things but can we afford them? You made a point that you have a brand new service like the walk in clinics and in two years it is completely clogged up and that is one of my concerns how we can get technology and how we can afford them”.

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Finance … it underpins the whole structure of old age

Finance and a healthy ageing were seen to be closely linked in the mind of many participants particularly for the older people of the future “I think it underpins the whole structure of old age in thirty or forty years time”. Of particular concern was pension provision and the impact a much older population would have on the economic and financial structure of society. “The population that is actually producing the gross national product is shrinking” and that this was in inverse proportions to growing numbers of older people who were greater consumers of state sponsored services, for example in health and social care. There was some debate at all of the dinners about whether the working population would be able to afford to support the pensioner population and what this might mean in terms of retirement and levels of pension benefits “The people who are currently working

drops down but the number of pensioners goes up. Either we have all got to pay an awful lot more or we pay them less in which case they get into poverty and they are not looked after”. Concerns were expressed that even those who had made pension
provision, for example in final salary schemes, could find the benefits associated with these ultimately “stripped away”.

Particular concerns were expressed that people, particularly younger people, were not making adequate pension provisions “Maybe we need to educate people a lot

younger about how they need to start preparing for retirement at a much earlier age” although not everyone was hopeful that younger people would take this message on board “And when you’re 20, 35 nowadays the reality is that however much us old fogies say you ought to be putting money aside for your pension they can’t”. There was also some debate about how much in terms of financial resources

older people actually needed. Whilst it was accepted by some that growing expectations of the ‘baby boomer’ generation might require additional funding it was also felt that older age might actually not require such a high level of income

“because when you retire you don’t need all that money. You never need a change of car … your mortgage has gone and probably the money you spend on your kids has gone”. There were however some concerns that individuals might need to be Government? It’s wonderful isn’t it. They give you money and they put you into a situation where you have to go into a residential home or care of some sort or another, and then they take it all back”. For one other participant the role of
government in the future economy was clear:

able to pay for some health and social care services, in particular long term care, and some cynicism about the role of government “Is this all being driven by the

“the Government of the day is going to have to make the economy work isn’t it? Its going to stop people retiring if they haven’t got enough of a workforce its going to
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make you reproduce and you know that’s the reality the government is going to have to make the economy work and it will do what it needs to do to make that happen, there’s no choice really”.

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Retirement and Work … please can we engage you on how you can continue to contribute

Financing a healthy age was linked to future patterns of work and retirement. However, work had, for participants, a wider importance particularly in the role it played in valuing older people. For a number of participants, as has been seen, value in society was determined by economic activity and participation and a number of people very clearly saw themselves working on their 85 th birthday. One participant attributed a number of benefits to his father’s continued work “he is

still working full time in the same job that he’s been at for the last 30 odd years and he’s not self employed. … It’s obvious that his getting up in the morning and going to work every day is the reason why, or one of the major contributors to the reason why, he is mentally very alert, physically very fit”. For a number of participants
working provided a form of identity and considerable opportunities for socialising both of which were seen to be beneficial.

However, not all participants wanted to continue working into their older age “I

certainly won’t be working. I can assure you of that because I can see absolutely no reason for doing the same things I have done for thirty odd years through the rest of my life”. It was also accepted that there were some jobs that could not be carried into older age and that “I don’t think people will be working because there is so much stress at work”. Some participants expressed concerns that middle class
notions of the attractiveness of work should not be transferred to those in other socio economic groups for whom the release from work might be advantageous.

Many participants felt that having choice over the type and nature of work undertaken in older age was key. There were concerns that whilst legislation was being introduced which would allow people to carry on working that doing something different with life in older age would require resources that might not be available to all members of society who might be forced to remain in jobs they did not want to do and which had a detrimental effect on their health “These of participants felt it was likely that the age for pension entitlements would be raised keeping people in paid employment for longer periods of time. There was some debate about what the actual concept of retirement meant

choices aren’t available to everyone, and perhaps the kind of things we wanted to do wouldn’t be the kind of economic driver which society needs either”. A number

“retirement means poverty for a lot of people and they’re the very people who may be forced to work to generate an income to supplement their meagre pensions”.

However, it was felt by others that society could take a positive role in encouraging people to work on beyond what might normally be considered as retirement age
Happy 85th Birthday – The Analysis Page 37 of 43

“so people could work on and there was a lot of flexibility around it, so they could actually go to one or two days per week, different hours, flexi working, perhaps a different job within the industry they worked or perhaps something completely different”. Flexibility and choice were seen as key elements by many of working in older age allowing people to “wind down” if they wished. One participant suggested that “what we should be doing is rewarding people as they go through society” by paying for pensions but “please can we engage with you on how you can continue to contribute”.

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Unthinkables … whether we will survive

As participants had been encouraged to ‘think outside of the box’ it was to be expected and relished that some came up with some very different views of the future. As has been seen some individuals discussed the difficulties of predicting the future. For others the future could be affected by catastrophic events “The

biggest threats we face are external. I mean the worrying things in today’s world is nuclear proliferation” and this was coupled with the ever present threat of terrorism with a fear over “whether we will survive as a race”. Terrorism and the
fear of violent revolutionary activity was for a few participants linked to a society which “does not have a social contract that is more or less going to tie everyone in”. For one participant this, coupled with the growth of technology, presented a major threat:

“If there is increasing dependence on a high tech world in a society where inequalities were increasing that would increase the sense of threat of hatred and jealousy and competition because the more successful we are technologically, the more we are part of the modernising project, the more of a threat we are to those who want to undermine society and it won’t take much. You only have to turn off the computers for three days in modern society and forget it”.
For other participants the internal threats engendered from the changing composition of an ageing society were of particular concern. Encouraging immigration was seen by a number of participants to offer solutions to potential problems “Immigration from second and third world countries” who would “work hard in jobs that not many people around here want to do” and that this economic migrancy should be encouraged by government. This was not a view supported by all “I don’t think that economic migrants or whatever is the answer” and it was noted that previous waves of migrants brought in to do unpopular jobs might not wish ultimately to stay in this country. Encouraging the population to have more children was also discussed by some participants as another mechanism of increasing the economically active base of the population although a very reasonable view was taken of the means of achieving this “I don’t think you can encourage people to have children but you can

probably remove some of the barriers … and in that sense create more possibilities to make the sort of size family they think is ideal rather than what they think they can afford”. If increasing the supply of population was one potential solution to future problems decreasing the existing population was another “whether euthanasia becomes an option? When you have had enough you just turn the battery off”.
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Death … have a nice silent coronary

For some participants ageing was ultimately linked with death and for some with our inability to accept death and the consequences of this in terms of quality of life. A number of participants noted a current emphasis in society on extending life and as one participant stated:

“extension of life is no good to anybody. Extension of life with quality is a very different issue”

Most participants agreed that they only wanted to continue their life, at any age, if it retained a good quality although it was accepted that this was a somewhat subjective concept. Some concerns were expressed that society avoided the subject of death and took overly heroic measures to prolong life: “Society expects us to go out and save lives at all times and at all costs” and that there “comes a time when we pass over that barrier as it were then we might

welcome death”.

For one participant ‘turning the battery off’ was to be considered:

“If I am incontinent, if people treat me in a patronising way, if the young can’t bother anyway, if I am living in a world that I don’t understand technologically, if I can no longer do the things that are important to me”.
One participant had a view of the end of life that many would aspire to:

“things are getting better, you live to 90, have a nice lunch, full abilities and then you pop off and have a nice, silent coronary at four o’clock in the afternoon, good result”.

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Participants enjoyed the format of the discussions and welcomed the opportunity to meet and talk about Healthy Ageing. For most, giving serous thought to what this meant to them was both new and interesting, for some it was a little unnerving. It is interesting to note that participants did not confine themselves to examining issues pertinent only to health and health services demonstrating the wide range of factors which impact upon health in general and healthy ageing in particular. Discussions were wide ranging and challenging with strong views emerging for example in discussing the future of public services and the nature of personal and state responsibility. The discussions raised issues for the individual, the communities we live in and government in terms of policy responses. It was clear that the determinants of healthy ageing were multi-faceted and included elements, such as finance, that we might not normally associate with health issues. Moreover, this demonstrated the ways in which society is interdependent. This is a complex area and there are no simple answers. There are, however, a number of challenging questions that we need to be addressed. This project has attempted, through this analysis and the report “Happy 85 th Birthday?” to pose some of these questions and the authors would welcome responses to these challenges and views on how we should take forward both research and discussion. We hope to progress the discussion of the various themes and questions raised within both the analysis and the report through a series of articles and presentations. It is important that we continue to progress the debate on healthy ageing and the number of reports and media attention paid to the future of an ageing population demonstrates how important an issue this is and will be. There is, however, also a place for discussing distinctively Welsh solutions to the challenges of healthy ageing reflecting our political, socio-economic and cultural perspectives. The debate on healthy ageing should not just be conducted in the context of today’s old. Rather the people who will be old also need to be involved now so that they can shape their future world.

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List of Participants
Dr David Bailey Dr Vanessa Burholt Dame June Clarke Professor David Cohen Mr Ian Cowan Dr Edward Coyle Mr Phillip Davies Mr Phil Davies Ms Phillipa Ford Mr Huw Gardner Dr Jonathon Grey Mr John Griffiths AM Mr Simon Hatch Mr Gwyndaf Hughes Mr Peter Johns Mr Peter Haydn Jones Ms Lesley Jones Mrs Ann Jones AM Mr Mario Kreft Mr Dean Medcraft British Medical Association Wales Deputy Director, Centre for Social Policy Research and Development, University of Wales Bangor Professor Emeritus, University of Wales Swansea School of Care Sciences, University of Glamorgan Superintendent Pharmacist, Rowlands Pharmacy Director, Wales Centre for Health Head of Performance, Improvement and Planning, South East Wales Regional Office of NHS Wales Manager for Wales, Alzheimer’s Society Policy Officer for Wales, Chartered Society of Physiotherapy Director, Social Services & Housing, City & County of Swansea Clinical Director Medical Genetics, Institute of Medical Genetics, Cardiff Deputy Minister for Health and Social Services, National Assembly for Wales Manager Wales, Parkinson's Disease Society Social Policy Development Officer, Citizens Advice Cymru Chief Officer, Association of Welsh Community Health Councils Chief Executive Officer, Community Pharmacy Wales Researcher, Institute of Rural Health National Assembly for Wales Head of Policy & Public Affairs, Care Forum Wales Finance Director, South East Wales Regional Office of NHS Wales
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Happy 85th Birthday – The Analysis

Mr David Melding AM Dr Ian Millington Ms Lorraine Morgan Rev Robin Morrison Mr Phil Parry Professor M S J Pathy Mr Alan Screen

Chair, Health and Social Services Committee, National Assembly for Wales Member, GPC (Wales) Chair, Gerontology Practitioners Network Church and Society Officer, Church in Wales Chairman, Community Pharmacy Wales President, Age Concern Cymru Welsh Executive of the RPSGB

Ms Helen Swindlehurst Rural Proofing Officer, Institute of Rural Health Mr Rhodri Glyn Thomas AM Plaid Cymru Spokesperson on Health and Social Services, National Assembly for Wales Mr Greg Walker Dr Philip White Dr W E Wilkins Ms Buddug Williams Mr Byron Williams Professor Bob Woods Policy Adviser, Royal College of Nursing Wales British Medical Association Wales Clinical Director for Medicine, Bro Morgannwg NHS Trust Development Officer Wales, Genetic Interest Group Director of Housing and Social Services, Ynys Mon County Council Director, Centre for Social Policy Research & Development, University of Wales Bangor

Happy 85th Birthday – The Analysis

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