Feature

Neglected: the health of the older nation

The Health of the Nation strategy for England sets few targets for older people — and the result may be to seriously disadvantage their access to health care. Bill Bytheway explains why

There is growing recognition that ageism has been seriously neglected by the NHS. One issue that is beginning to receive serious attention, however, is the use of age bars to exclude older people from various forms of medical treatment.¹

The use of age to define categories of patients rarely seems objectionable, and yet bureaucratic exclusion on grounds of age is as important as prejudicial attitudes in sustaining an ageist view of later life.² The strategy outlined in the white paper Health of the Nation is a notable example of how age bars can follow the neglect of older people in the development of policy.³

It is significant that the white paper acknowledges — but then sets to one side — the WHO ideal of ‘health for all’. Instead the overall goal of the strategy for health is ‘adding years to life and life to years’. This places older people in a particularly vulnerable position. Ten of the 15 main targets set by the strategy are based on reducing mortality rates, and three of the other five include reductions in the incidence of life-threatening illnesses. This clearly indicates a bias in favour of adding years to life (as against adding life to years) and, in seeking to increase life expectancy, the strategy places a priority on reducing ‘premature mortality’. Associating the concept of premature mortality with the age of 65 year recalls, as Grimley Evans has pointed out, times when individuals were valued only as exploitable labour.⁴

It was with some obvious embarrassment that the Department of Health has since explained that the use of this convention ‘is not to be taken as meaning that deaths after 65 may not also be premature’.5 But, more fundamentally, associating the concept of premature mortality with chronological age is essentially ageist. A priority on reducing ‘premature mortality’ is not unrelated to the concept of passive euthanasia for ‘the elderly’. It is obvious that this aim, compared with ‘health for all’, will contribute substantially less to improving the health of older people.

In addition to the 15 ‘main targets’, the Health of the Nation strategy includes 10 ‘risk factor targets’. The formulation of these 25 targets is such that 29 statistical indicators will be monitored, each relating to a specific target population and to a specific target date.⁵ It seems inevitable that trends on these indicators will become increasingly important in determining NHS priorities. For example, the 1993 Department of Health review reports movement away from (rather than towards) the set targets for three of these indicators. The accompanying commentary indicates a certain shifting of priorities within the NHS in order to reverse these three trends.⁵

Fifteen of the 29 target populations are restricted to specific age bands. As a consequence, different age groups are excluded from a varying number of target populations (see table below). The table shows that there is a tendency to exclude the youngest and the oldest groups. This is echoed in the other 14 target populations which, although not explicitly defined by age, relate mainly to middle age groups including, for example, ‘pregnant women’ and ‘injecting drug users’.

In the strategy for each of the five priority areas, people aged 75 or over are excluded from the four targets concerning coronary heart disease and stroke, even though the white paper acknowledges that stroke is a cause of disability ‘particularly amongst elderly people’. The white paper includes charts which set the targets in the context of current trends in death rates from these causes. The discussion of these charts makes no reference to the fact that they are limited to persons under 75 — a clear case of older people being overlooked and made invisible.

Only one of the four targets for cancer, the second priority area, specifically excludes people aged 75 or over. But the first, relating to invitations for breast screening and current monitoring is based on the 50-69 year age group. Likewise, the second draws upon a screening programme for cervical cancer with a focus that similarly excludes those aged 70 or over.

None of the targets on mental illness are age-specific. In the discussion in the white paper however, there is recognition that older people are a vulnerable group. Attention in particular is drawn to the high incidence of depression and dementia in the oldest age groups, and to the prescribing of benzodiazepines to older people. Despite these concerns, no targets are set for these age groups. There are no targets either regarding the sexual health of people aged 65 years or over.

The three targets for accidents, the fifth priority area, are all age-specific and the third of these is to reduce the death rate from accidents of people aged 65 and over. But the only proposed action is for the DoH to consider ‘what research might be commissioned into the prevention of falls in elderly people’. In the accompanying commentary, the white paper notes that the Home Office is promoting smoke alarm ownership through TV advertising, that Age Concern has a mobile unit that ‘takes the fire safety message to elderly people’, and that the Department of Transport has issued a policy document which summarises the road safety problems faced by older people. This hardly constitutes a serious strategy aimed at achieving the set target.

The white paper does discuss the relevance of these five key areas for the health of older people. It recognises that preventive measures can be ‘just as successful’ in older as in younger people and, regarding coronary heart disease and stroke in particular, comments that these are a major cause of ill-health and mortality in older people and that ‘effective treatment and rehabilitation services will continue to be vital for the health of elderly people’. But such aims are not included in the set targets. People aged 75 or over, despite their greater need and the potential for effective treatment and rehabilitation, are excluded and no alternative targets are set.

It is not difficult to see the 15 main targets as reflecting the top priorities of the NHS over the coming 10 years. Eight of these targets specifically exclude people aged 75 or over, and it is likely that older people will have a lower priority than other age groups for two other targets. Only one target is specific to older people and, in pursuing this objective, the strategy effectively proposes no plan of action.

It follows that, in seeking to reach these targets, an under-resourced NHS will give even less attention to older people than it has previously. The targets that the NHS will be striving to achieve will not be in jeopardy should there be a substantial rise in morbidity and mortality among older people. Conversely, should there be an improvement in the health levels of older people, this will not be as a result of this strategy.

This analysis reflects the present government’s neglect of equity and of the goal of reducing inequalities in health, a goal that is incorporated in WHO targets.⁶ In his commentary on the preceding consultative document, Grimley Evans noted that ‘older people are conspicuously absent from most of its pages’. This is not true of the white paper. There are many worthy references to ‘the elderly’ and their health problems. What is absent, completely absent, are any targets for NHS service providers to work towards with regard to the health of older people. Clearly governmental anxieties about ‘the burden of age’ have had a powerful effect upon the development of its health policies.⁷ As long as managers struggle to deploy their limited resources towards achieving the ageist targets that have been set by the Health of the Nation strategy, we can expect the incidence of bars excluding older people from specific health services to rise.