HAPPY 85TH BIRTHDAY by dfhercbml

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									HAPPY 85               th

BIRTHDAY?

THE ANALYSIS

  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.




                                 Acknowledgements
        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.




Happy 85th Birthday – The Analysis                                                   Page 2 of 43
                                     Contents
Page Number


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


Appendix. List of Participants                         41




Happy 85th Birthday – The Analysis                     Page 3 of 43
1.        Introduction

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 85th 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 85th Birthday?” takes these themes and poses a series
Happy 85th Birthday – The Analysis                                        Page 4 of 43
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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2.        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 85th 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 85th 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?



Happy 85th Birthday – The Analysis                                      Page 6 of 43
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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3.        What Will You Be Doing on Your 85th 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,
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
discussed that when we got older then whether we were in wheelchairs or zimmer
frames or not we would have a rock band”.

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 100th 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 85th 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 85th 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?


Happy 85th Birthday – The Analysis                                         Page 8 of 43
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”.




Happy 85th Birthday – The Analysis                                       Page 9 of 43
5.        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
Happy 85th Birthday – The Analysis                                         Page 12 of 43
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”.




Happy 85th Birthday – The Analysis                                        Page 13 of 43
6.        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
Happy 85th Birthday – The Analysis                                       Page 14 of 43
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 twenty-
five year old to think about you will retire one day, you will need a pension”.




Happy 85th Birthday – The Analysis                                     Page 15 of 43
7.        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

Happy 85th Birthday – The Analysis                                           Page 17 of 43
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”.




Happy 85th Birthday – The Analysis                                      Page 18 of 43
8.        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
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
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
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”.



Happy 85th Birthday – The Analysis                                          Page 19 of 43
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.




Happy 85th Birthday – The Analysis                                       Page 20 of 43
9.        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”.

Happy 85th Birthday – The Analysis                                              Page 21 of 43
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
emerged that poor health could quickly cause an individual to become dependent
particularly on entering hospital “you suddenly become very dependent on the
structure of the medical day and then you go home and it can actually take you self
confidence away at any age”.

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
Happy 85th Birthday – The Analysis                                          Page 22 of 43
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”.




Happy 85th Birthday – The Analysis                                       Page 23 of 43
10.       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”.

Happy 85th Birthday – The Analysis                                          Page 24 of 43
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”.




Happy 85th Birthday – The Analysis                                          Page 25 of 43
11.       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 pre-
determinants 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
Happy 85th Birthday – The Analysis                                        Page 26 of 43
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
Happy 85th Birthday – The Analysis                                      Page 27 of 43
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”.




Happy 85th Birthday – The Analysis                                      Page 28 of 43
12.       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”
and that this might encourage some people into caring roles:
“I think that many people might then find that it was actually something that wasn’t
what they imagined it to be”.




Happy 85th Birthday – The Analysis                                        Page 29 of 43
13.       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 85th 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
Happy 85th Birthday – The Analysis                                         Page 30 of 43
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
Happy 85th Birthday – The Analysis                                          Page 31 of 43
housing and that policy makers should not assume that one response would suit all
people.




Happy 85th Birthday – The Analysis                                    Page 32 of 43
14.       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
Happy 85th Birthday – The Analysis                                        Page 33 of 43
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”.




Happy 85th Birthday – The Analysis                                         Page 34 of 43
15.       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
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
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:

“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
Happy 85th Birthday – The Analysis                                        Page 35 of 43
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”.




Happy 85th Birthday – The Analysis                                Page 36 of 43
16.       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 85th 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
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
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
“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”.




Happy 85th Birthday – The Analysis                                      Page 38 of 43
17.       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”.
Happy 85th Birthday – The Analysis                                        Page 39 of 43
18.       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”.




Happy 85th Birthday – The Analysis                                         Page 40 of 43
19.       Conclusions

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 85th 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.




Happy 85th Birthday – The Analysis                                      Page 41 of 43
Appendix
List of Participants

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

Happy 85th Birthday – The Analysis                                              Page 42 of 43
Mr David Melding AM                  Chair, Health and Social Services Committee, National
                                     Assembly for Wales
Dr Ian Millington           Member, GPC (Wales)
Ms Lorraine Morgan                   Chair, Gerontology Practitioners Network
Rev Robin Morrison                   Church and Society Officer, Church in Wales
Mr Phil Parry                        Chairman, Community Pharmacy Wales
Professor M S J Pathy                President, Age Concern Cymru
Mr Alan Screen                       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                       Policy Adviser, Royal College of Nursing Wales
Dr Philip White                      British Medical Association Wales
Dr W E Wilkins                       Clinical Director for Medicine, Bro Morgannwg NHS
                                     Trust
Ms Buddug Williams                   Development Officer Wales, Genetic Interest Group
Mr Byron Williams                    Director of Housing and Social Services, Ynys Mon
                                     County Council
Professor Bob Woods                  Director, Centre for Social Policy Research &
                                     Development, University of Wales Bangor




Happy 85th Birthday – The Analysis                                              Page 43 of 43

								
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