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The Institute for Public Policy Research (IPPR) describes itself as the UK’s leading progressive think tank producing cutting-edge research and innovative policy ideas for a just, democratic and sustainable world (no pressure then!)

Using independent research and analysis it seeks to develop agendae for change and provide practical solutions to challenges across the full range of public policy issues.

In July 2008 the IPPR produced its report entitled ‘Older People and Wellbeing’ (Allen, 2008). This report is the first in and a series on older people and their well being as part of a programme exploring the ‘Politics of Ageing.’

The report highlights the lack of political interest in the welfare of older people. Although there are government and quasi-government departments dealing with some aspects of older people’s issues (e.g. Department for Work and Pensions), there is nothing comparable to the Department for Children, Schools and Families, which has widespread and overarching responsibility for young people. With care needs in the over 65 year old cohort expected to increase by over 80% in the next 50 years, the report suggests that discussions need to begin as to how the UK will cope with the increase in demand.

Demographics
Despite the well-documented improvement in health and increasing wealth leading to the longer life expectancy (although the report notes crucially, that not all the years gained are healthy years), there has not been a comparable improvement in levels of ‘life satisfaction’.

A general health survey produced by the ONS (2008) revealed that over a quarter of the over 75 year olds reported ‘poor health’. It is estimated there will be a 67% increase in the numbers of people with disability in the UK over the next 20 years, particularly because it is the over 75 year old that exhibits a significant decline in physical health, often with its attendant depression and other mental health problems. Interestingly, the overall proportion of disabled people in the UK has not altered over the past 10 years, which indicates that the expanding older population will not necessarily bring a proportionate increased health burden.

Wellbeing and Mental Health
The Easterlin paradox (developed in 1974) is the concept that people with higher incomes are more likely to report being happy. However, in recent times there has been a drive to use a range of indicators to measure life satisfaction and over the past 50 years in the UK, levels of wellbeing have remained fairly constant despite a noticeable increase in GDP/capita (PMSU, 2007).

When looking specifically at the wellbeing of older people (aged 65 and over) it is generally believed that overall life satisfaction is at its highest (Oswald, 2007). However, recent studies have shown that the prevalence of depression increases with increasing age and approximately 25% of older people will suffer from depression that ‘impacts significantly on their quality of life’ (Lee, 2006). With only a third of older people suffering with depression visiting their GP to discuss their symptoms, these statistics are likely to be gross underestimates of the true picture (Chew-Graham & Burroughs, 2004).

It would be preaching to the converted to say that older people should not be classed as one homogenous group and the problems faced by the ‘older old’ will be significantly different from those faced by ‘younger old people’. Predictably dementia, which is thought to affect 25% of 85 years and over, also has a significant impact on levels of wellbeing, for both sufferers and their carers.

Financial inequality
Financial inequality is an important stressor with an established detrimental impact on mental health and wellbeing. This places limits on the social participation, the quality of the housing and level of care available. Whilst the net disposable household income per head of population has risen by approximately 60% in the last twenty years, so the gap between rich and poor has widened. In just 12 years the share of this wealth in the hands of the richest 1% of the population has jumped from 17% to 21%. Whilst it might be expected that pensioners would have fared poorly compared to the working population, this is not so. Rises in occupational pensions, investments and state benefits has seen an average increase in income of 37% for the over 65s, compared to a 17% increase in average earnings for the working population. This has left the majority of pensioners better off today than their counterparts thirty years ago. However there is a stratification of wealth across the elderly population. A recent annual increase of 0.3 million pensioners in relative poverty identifies a worrying trend. The figure now stands at 2.1 million, a dismal number compared to the EU average. One of the ways financial difficulty may manifest is through the quality of housing available. Despite the total number of ‘non-decent’ houses falling in the UK from 9.1 to 6 million in 9 years, 2.2 million households with a person over 60 are still classified as unfit to live in (ONS, 2008).

The IPPR report advocates that many disadvantages faced in old age are part of a wider picture of financial and societal inequality present throughout life. Government initiatives to reduce these life-time inequalities have focused on the youngest in the population, to the detriment of older people. Reduction in child poverty will hopefully prove fruitful in eventually reducing poverty in all age groups, but will not rectify poverty in older people anytime soon.

Illness and Disability
A staggering 70% of new presentations of depression in older people relate to ill health or disability (ONS, 2003). The vicious downward spiral of chronic illness, leading to disability, decreasing physical activities of daily living, leading to social isolation, leading to loneliness and depression is well known (Prince et al., 1998).

Emotional support: the role of friends, family and religion
One of the most important protective factors for mental health discussed by the report is that of social and emotional support through friends or family. It often mitigates the detrimental effects of ill health on wellbeing (Prince et al., 1998). Other protective factors advocated include a sense of value within a community and strongly held religious beliefs. A third of men and nearly two thirds of women over 75 currently live alone, and of these 17% rate themselves as often or always lonely. This number is set to rise as more adults choose to live alone and more couples opt not to have children. There are an estimated one million socially isolated older people in the UK, a figure set to more than double in the next 15 years.

Care receivers and providers
Depression amongst elderly residents in nursing or residential care is rife, with one recent survey finding 40% of residents to be suffering from depression. This is double that found in the community (Godfrey & Denby, 2004). This may be because many elderly are transferred to care due to mental health concerns. However, the report found little evidence to support or refute this, and there are calls for further research into the reasons for so many in care suffering depression.

A crucial yet often overlooked element of nursing care for the elderly is the care provided by a loved one. Older people are more likely than any other age group to be informal carers, and provide hours of care equivalent to £15.2 billion a year. This comes at a personal price, with 28 - 55% of carers for those with dementia reporting high levels of depressive symptoms. The health service is financially reliant upon their work and dedication, and yet they are failing to receive sufficient emotional, financial and respite support from the government.

One of the main conclusions of the IPPR report is the need for a reappraisal of residential and community care. A stronger focus is required on the emotional support for the carers and those cared for, not just the provision of resources.

Age discrimination
The prospect of growing numbers of older people suffering mental health problems is made worse by widespread age discrimination exhibited by healthcare services, as highlighted by this report. Only half of older people who present to their GP with depressive symptoms receive any form of intervention, mostly in the form of pharmacological medication. More expensive services offered to younger patients such as talking therapy are often not provided to older people (Godfrey et al 2004, McCrone et al., 2006). This discrimination is also present at a public health level, with recent government initiatives on improving the provision of mental health services targeting resources on younger rather than older people. Those suffering from mental illness already face widespread prejudice by society due to misconceptions about these illnesses. Ageism by healthcare services is likely to act as a further barrier to obtaining help.

Age discrimination is not limited to health care, but transcends many aspects of society, such as the provision of leisure activities, employment, and the perceived value of the older person in society. These can impact significantly on the ability of older people to fulfil personally rewarding activities, on the financial income or self-esteem of older people, further decreasing wellbeing. The Department of Work and Pensions has acknowledged the presence of age discrimination in society, and has set out a strategy to address issues of wellbeing of older people. However the IPPR report concludes that sufficiently ambitious action has yet to be taken.

Unhappiness in old age is not inevitable, even for those with poor physical health and limited mobility. This report highlights the significance of support in fostering wellbeing and social and community participation for older people, particularly for those most at risk of isolation and exclusion.

Political appetite?
The report concludes that a number of recent and well-intentioned policy documents from central government have set out ways of improving levels of wellbeing among older people (e.g. Department for Work and Pensions 2005, ODPM 2006, Department of Health 2004). The report further notes that the overall focus of national policy continues to be children and young people to the detriment of the older population. Furthermore, it opines that sadly some of these documents have languished after launch and the proposals have not been acted upon. The report makes a very pertinent observation that the political appetite to drive through proposals sometimes appears to be lacking. We can only hope that this and similar future in-depth, well written and delivered reports serve to whet the appetite of those in relevant governmental departments for change in policies affecting the older person and hence improve their future wellbeing as a whole.

Michael Roach
4th Year Medical Student, University of Birmingham Medical School
Poonam Jain
FY 1, Hollyhill Unit, Birmingham.
Martin Curtice
Consultant in old age psychiatry, Hollyhill Unit, Birmingham

BGS Newsletter, March 2009
Issue 20 ISSN 1748-6343 20