In England the first recorded almshouse was founded by King Athelstan, the first king of all England, and Alfred the Great’s grandson, in York in the tenth century. Almshouses are charitable housing provided to enable people, typically elderly, who can no longer work to earn enough to pay rent, to live in a particular community. The Poor Law Act of 1601 provided some relief for those too ill or old to work, the so called ‘impotent poor’, in the form of a payment or items of food or clothing. Some aged people might be accommodated in parish almshouses, though these were usually private charitable institutions. The policy was to make the old and infirm as comfortable as they could be, and the able-bodied, if they managed to get in, uncomfortable. The Poor Law also created workhouses whose inmates had to go out and work. Then the New Poor Law of 1834 was enacted to make life harsher for those living in workhouses, so that they would prefer to be elsewhere. In 1871 payments for relief were reduced and children were expected to support their old parents. Some 2,600 almshouses continue to be operated in the UK, providing 30,000 dwellings for 36,000 people.
In France, the concept of convalescent homes was developed with the Hôtel-Dieu (originally founded in 651) and the Hôpital de la Charité in the seventeeth century. The first nursing homes in the United States were charitable institutions run by Catholics or Jews, in 1842. In 1853 Charless House, a charitable institution, was opened as a home for the friendless in St Louis. While intended to look after women of all ages, the persons admitted were predominantly older widows.
In the late nineteenth century old age began to be viewed as an illness. Being in a workhouse was degrading and many preferred death. Emmeline Pankhurst, a leading suffragette, described her experiences as a Poor Law Guardian in her autobiography My Own Story: ‘I found the old folks in the workhouse sitting on backless forms, or benches. They had no privacy, no possessions, not even a locker. After I took office I gave the old people comfortable Windsor chairs to sit in, and in a number of ways we managed to make their existence more endurable.’ In 1947 a Nuffield Committee argued that the character of workhouses needed to change, and that elderly persons should be accommodated in small homes to enhance their care.
The Second World War made life much harder for older people. As families became separated‚ or lost their main breadwinner‚ the problems faced by older people were compounded. People soon realised that the ‘poor law’ provision of the time was woefully inadequate. In 1940 a group of individuals‚ as well as governmental and voluntary organisations, came together to discuss how this situation could be improved and formed the Old People’s Welfare Committee. With the birth of the welfare state in the 1950s‚ local and national government money became available to fund local work with older people. In 1971 the committee became completely independent of government and got a new name—Age Concern. High unemployment in the early 1980s caused Age Concern to join in government job-creation and training schemes. It drew attention to the plight of older workers who were unable to return to work because of long-term unemployment or redundancy. Age UK, a new charity combining Age Concern and Help the Aged, came into being in spring 2010.
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The transition of the term ‘elders’ to ‘the elderly’ was probably due to the industrial revolution and improved health, leading to an increase in the number of older people. The economy had to be revised to accommodate an increased share of the population no longer in the work force. The first state pension in Britain was paid on the 1 January 1909, recognising the needs of the elderly. But it was just 5 shillings a week—£19.30 in today’s money—and went only to the poorest half a million aged over 70. You were only eligible for the new payment if your income was less than 12 shillings a week, and the pension could be reduced if you had too much furniture.
In the present system calculating your state pension is quite complex. The state pension age for men is 65, and that for women is increasing from 60 to 65 in 2020. For both men and women, the state pension age will then increase from 65 to 68 between 2024 and 2046. A single person on a basic state pension currently gets a maximum of £97.65 a week. The Over 80 Pension is a state pension for people aged 80 or over who have little or no state pension.
Before the Second World War there was virtually no interest in old peoples’ mental or physical health. Old age psychiatry was recognised as a speciality by the Department of Health only in 1989, but it is now a rapidly growing speciality within psychiatry. Dementia often brings critical needs for care, but sufferers who own more than £23,250 in property and savings will find that they must finance most of their care themselves. About half of all hospital and community care spending in England is for those aged 65 and over. Most of the old prefer to remain in their own homes and this often requires support from a carer if there is no support from the family. The preference of the elderly to remain at home is almost universal, but circumstances can make it necessary to leave. There is increasing diversity in family structure—in the UK about one third of the elderly have no children who could help caring for them. Divorce and single-parent families have also led to a decline in the traditional family. The relationship between ageing parents and their children and close relatives is complex. Allowing an elderly parent to live with the family may take up both valuable space and import some serious interference. Looking after a parent with dementia can be a nightmare. One understands the viewpoint of Agatha Christie: ‘I married an archaeologist because the older I grow, the more he appreciates me.’
Even so, there is a very high contribution by families to caring for the elderly. An estimated 6 million people in Britain provide unpaid care for elderly spouses, parents or disabled children. That’s nearly 10 per cent of the population. These carers get virtually no financial reward, though there have been unfulfilled promises by the previous government. They rarely get even one week’s holiday. Huge numbers of carers make a contribution to caring in later life. Wives and daughters are more likely to help with caring, as males hire carers rather than doing it themselves. Over 1.5 million carers are themselves aged over 65 and an estimated 8,000 are over 90. Increasingly, care involves very frail couples, where the traditional boundary between carer and cared-for becomes blurred. At present individuals and the state split the costs of paid care roughly 50/50. But paid-for care is dwarfed in scale by support provided by unpaid carers, usually family members. In April 2010 the Labour government published a White Paper on care for the elderly that proposed that no pensioner will have to stump up the fees for care homes if they are there for more than two years.
As many as one third of the over 85s need help climbing steps, and a quarter with bathing or showering. Both the government and local authorities want many more people to stay in their homes with support, rather than going into more expensive care homes. That policy has been welcomed by campaign groups, but they are now questioning whether enough effort is going into regulating home care, and whether local authorities are trying to provide it on the cheap.
There are over 21,500 care homes, nursing homes and residential homes providing adult and elderly care throughout the UK. In England an estimated half a million physically disabled elderly are living in care homes or long-stay hospitals, and most of these are paid for by the state. The sick are treated free on NHS, so the NHS is responsible for meeting the full cost of care in a care home for residents whose ‘primary need’ for being in care is health based. But if one is simply frail and needs to enter a care home one must pay, unless one’s assets are less than £23,250. A place in a care home in England costs an average of £24‚000 per year while a nursing-home place costs an average of £35‚000. Placing a relative in an average nursing home costs more than sending a child to Eton, one of the most expensive public schools in the land. It is estimated that older people spend in total about £6 billion for care out of their own money, and that the net spend by public authorities is similar.
Some one in four of the elderly in developed countries will need long-term care of some kind, an enormous number.
In the US, most elderly Americans live in homes they own—90 per cent live in their own home and most are satisfied with their living arrangements, and nearly half of those over 85 still live in their own homes. Just 4 per cent of adults aged between 75 and 84 live in an assisted living facility, and for those aged 85 and above it is 15 per cent. About half of retirees in the US expect to not move from their home. For decades, Americans have depended on nursing homes to care for them in old age. But as the population rapidly ages, more care is shifting from institutions to homes, and more responsibility is shifting to families—a change of major proportions. Sweden has one of the oldest populations—5 per cent are 80 or older, and, remarkably, 94 per cent of all Swedes over 65 years of age still live in flats or houses. When planning housing and housing areas, Swedish municipalities are required to ensure that they are adapted to the needs of older people and those with disabilities. A further goal is for commercial and public services to be easily accessible so that the elderly can continue living at home and looking after themselves.
In China, it is seen as a great shame to put a parent into a nursing home and many are living alone, since there is only one child per family to look after them. The cost of sharing a home with a relative is, for the most part, borne by them and not the state. There are some advantages, such as grandparents caring for the young while the parents are at work. China has more than 40,000 elderly care institutions with about 1.7 million beds for its population of 145 million over 60, of whom over two thirds live in rural areas. Dementia is very high in China and so many more nursing homes are needed. About 13 million people aged over 80 are now in dire need of care. About one third or half of the elderly in large cities are without support from their children or a livelihood.
For Holocaust survivors, ageing presents an enormous challenge. In Israel there are 50,000 Holocaust survivors living below the poverty line. Having survived Hitler and the Nazis, they are now struggling with a new obstacle, the ageing process. Many are now widows and widowers; they can feel isolated, depressed, alone and anxious. Each individual’s ability to cope with the challenges of illness and ageing is complicated by the suffering, loss and deprivations they experienced during the Holocaust. One son reported: ‘My father had to be put on a feeding tube because he couldn’t swallow. He kept asking me—Why are they doing this to me? They’re starving me like the Nazis did at Auschwitz.’
Seventy per cent of care in the home in the UK is now carried out by private companies. All councils have a duty of care to appoint only those private companies whose record of competence they can verify. In the UK the choice of those who will care for the elderly has recently been severely criticised: the NHS has had a special kind of auction to appoint organisations which will care for the elderly, particularly those with dementia, and those involved were asked to reduce their costs and then participate in reverse auctions, where bids are driven down, not up—the lowest bid being the winner of the contract. To choose a carer on such a criterion seems immoral, and one company that won such an auction had the contract removed a few weeks later as their caring was so poor. To ensure that proper care is carried out, spot checks on their performance should be mandatory. Councils must also insist that carers are given professional training. Many carers are young, inexperienced, paid low wages and left to cope virtually on their own. Whistle-blowing on bad employers must be encouraged.
Concern is also growing over the expansion of home-based care for the elderly after examples of neglect have been reported. Poor standards and numerous breaches of regulations were shown in an investigation by the BBC’s Panorama programme. There was evidence that some old people were being left alone for many hours; in one case, an 89-year-old woman was left for 24 hours before being found by her son lying in excrement. It seems that paid-for carers are not allowed enough time to give adequate care to vulnerable older people, and support services do no more than provide the minimum standard of care that they can get away with.
One suggestion is that neighbours should be paid to look after the elderly, as they already know and are friendly with the person and could provide personal care and also meals. Britain would do well to follow the French example and pay people who take time off to look after a dying relative or partner. Charities describe the care system as being in ‘crisis’ and one that will be dealt with head-on only when society accepts that the needs of the elderly are as important as those of newborn or disabled children. The number of over-85s will reach 4 million in the UK by 2051; for many of these a care home or nursing home will probably be the ultimate destination.
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Many dislike being in a care home and so avoid communal areas and spend most of their time in their rooms. Talking about dying is taboo. There is some concern that families do not visit inmates as often as they might. There is a tradition that pupils from schools visit lonely old pensioners both to talk and to help with housework. This may not continue as both pupils and pensioners may have to be officially vetted before such regular visits in order to avoid any abuse. This is a great shame, as even when a fish tank is brought into a nursing home the patients crowd around it and conversation increases. There is a test programme in Toyota Memorial Hospital in Japan where robots monitor and interact with patients, and elsewhere ‘companion robots’ are being developed which, it is claimed, could lead to some improvement in Alzheimer’s patients. Norway is also considering the use of robots in the future to combat staff shortages.
Caring for the severely ill elderly can be difficult and stressful. After two strokes, one patient was reported to be unable to even hold a child’s plastic drinking cup, and is also unable to reach the buzzer to summon staff. While his room at the home is clean, tidy and bright, there is nothing to occupy his mind as he cannot see or hear well enough to read or watch the TV, and conversation is difficult. His only stimulation comes from family visits, but they can be days apart and upsettingly brief. He shouts and cries as his frustration surfaces, which only adds to the family’s feelings of guilt and helplessness and increases their desire to cut the visit short.
Sir Michael Parkinson, who was appointed by the government in 2008 to promote dignity in care homes, described some homes he had seen as ‘little more than waiting rooms for death’ and said he had been appalled by letters members of the public had sent him. One had written saying her mother had been left naked, covered in urine and in full view in a side room at a hospital, while others had complained of patients’ use of alarm bells being ignored for so long that they soiled themselves. Older people in hospitals and care homes are being left without enough food and drink in incidents that are ‘absolutely barmy and cruel beyond belief’. Parkinson said staff and managers blamed bureaucracy for stopping them delivering more dignified care.
About 20 per cent of deaths in the UK occur in nursing or care homes. Often understaffed and with underpaid and poorly trained employees, many nursing homes endanger the lives of their patients. Those living in nursing homes receive poorer care than those living at home, because they are not given beneficial drugs; there is poor monitoring of chronic disease and overuse of inappropriate or unnecessary drugs. No study has examined the overall quality of care given to elderly patients in UK primary care, or has judged the quality of care against agreed, explicit standards in patients living in nursing homes compared with patients living at home. An example of problems is the case of a 94-year-old who was given notice to quit after she complained about the executive’s dog, which kept leaping up at her. She is frail, has restricted vision and arthritic limbs, and she is unable to dress or clean herself.
Patients with dementia and related mental health problems need an enriched psychosocial environment which meets their need for human contact and personal growth. Over 820,000 people in the UK live with Alzheimer’s and other dementias, costing the UK economy £23 billion per year—more than cancer and heart disease combined. Dementia research is severely underfunded, receiving 12 times less support than cancer research, even thou
gh around one third of us will suffer from some form of dementia before we die. There is as yet no basic training for healthcare professionals on how to understand and work with people with dementia. Dementia affects not just its immediate victims but also other residents forced to share their final years with sufferers. And it places a huge burden on the staff who have to look after the patients’ most intimate needs. The traditional cosy view of an old people’s home has long gone.
More than 2 million older people over the age of 65 in England have symptoms of depression‚ but according to a report by Age Concern the vast majority are denied any help. Falls by older people in nursing-care facilities and hospitals are common events that may cause loss of independence, injuries and sometimes death as a result of injury. Effective interventions are important and will have significant health benefits. The prescription of vitamin D reduces falls, as may a review of medication by a pharmacist.
Yet thousands of doctors specialising in the care of older people believe the NHS is institutionally ageist, a survey suggests. One third of doctors thought that the old should not get various kinds of surgery as it would not last them very long. Another survey found that almost one in three nurses would not trust the NHS to care for an elderly relative who was malnourished. Old people are left hungry on wards. Discrimination against the old also involves, for example, long waits for hip and knee replacements which people over 65 need most. A British Geriatric Society survey of 200 doctors found that more than half would be worried about how the NHS would treat them in old age. Dr Blanchard, who works in psycho-geriatrics, told me that there is little evidence for ageism in his area, but what will probably happen with the coming financial cuts is that his patients will be put back into general psychiatry, and this may lead to discrimination as the cost of their care is compared to that of younger patients.
You’re Looking Very Well Page 18
