A new approach is needed to meet the needs of older people in society, writes Eamon O'Shea
Historically, healthy ageing and health promotion for older people have not received much attention from policymakers in Ireland. "Adding Years to Life and Life to Years: A Health Promotion Strategy for Older People" marked the beginning of the Healthy Ageing Programme for older people as recently as 1995.
The objectives of the strategy focused on life expectancy, health status and autonomy for older people. The strategy recognised that the promotion of health for older people was not solely a matter for the Department of Health but for all departments and organisations whose policies and actions may potentially have an impact on the health of older people.
Five key areas were identified, based on the tenets of the Ottawa Charter: building healthy public policy; creating supportive environments; strengthening community action; developing personal skills; and reorienting health services.
Unfortunately, much of the thrust of policy in the past 10 years has been on supporting projects and programmes in relation to specific diseases, particularly heart disease and cancer, rather than in promoting a holistic view of ageing. This is not surprising given that formal national strategies have been in place for both cancer and cardiovascular disease for a number of years.
The medical model continues to dominate official thinking with respect to priority-setting at the national and regional level. The emphasis remains on cure rather than prevention, on medication rather than health promotion, on the medical rather than the social model. The formulation and implementation of measures to improve and enhance the participation of older people in economic, social and civic life have not been high on the policy agenda in Ireland.
Participation for older people is a multi-dimensional concept incorporating income, access to social care services, housing, transport and personal and social connectedness to family, friends and neighbours. The availability of health and social care services is a crucial factor affecting the quality of life of older dependent people living in the community. Older people can experience profound deprivation where such services are unavailable, fragmented, costly or of poor quality. Poor housing conditions can also impact on the health status of older people. The absence of suitable transport can lead to isolation and exclusion, particularly for older people living in rural areas. Connectedness to family and friends is also important for health and wellbeing.
In the UK, research suggests that the central elements of quality of life in older age include social relationships, neighbourhood social capital, activities and hobbies and social roles and activities. It is of concern, therefore, that Irish research suggests that a small but significant number of older people in this country are in borderline or inconclusive social networks.
A new model is needed to support a holistic and positive view of ageing in this country, particularly in respect of social care provision. Older people should be at the heart of decision-making in respect of living arrangements and service provision in the event of their physical or mental incapacity.
Greater choice, autonomy and empowerment for older people involves not just their participation in the determination of conventional health and social care services but a coming together of all relevant facets of active and inclusive ageing, including areas such as housing, transport, social networks, advocacy, spirituality and security.
Life is about more than public health nurse visits or home help availability, important as these are for older people.
The enhancement of quality of life for older people should be the barometer of success of the new model. Living at home connected to family and friends is seen by the majority of older people as critical for quality of life. Of course, quality of life is something that we should be thinking about now. For example, a sense of belonging, personal identity and social connectedness evolve over a lifetime. We have to nurture these things early in life if they are to make a difference later on. It is important, therefore, that we think about our life now in a reflective way, about the story or narrative of our life, the relationships that we have, the relationships that we might have in the future.
One of the difficulties of preparing for ageing is the disjointed nature of much of our thinking about growing old as something that afflicts rather than evolves. The reality is that me now matters for me later, and anything the government does or does not do in the future cannot change this fact.
When we talk about quality of life the voice that must be heard is the voice of the older person.
Currently, differences to do with older people have been flattened out, homogenised, or they have been neglected entirely. One consequence of this is that care for older people has been depersonalised, particularly in long-stay facilities. Of course, to personalise care you need to have the time to do it, trained staff, and you need the information to allow people to make the right choices as to where to go to get what they want. Older people are not commodities but are human beings with ongoing and deeply personal needs. We are not meeting these needs either at home or in long-stay care.
Now you could say this is a Utopian vision that would simply cost too much money to realise. But this brings us to how we prioritise, to how we view older people in the context of allocating public resources. Where do older people stand in terms of these resources? What is it about older people that puts them to the back of the queue when scarce resources are being allocated? These are questions for all of us, not only for government. We must address our own attitudes and our own expectations before government can do anything about allocation of resources.
We have to take the lead now and say that we do not want an ageist public policy perspective to take hold. We do not want older people to be last in the queue.
Prof Eamon O'Shea is director of the newly-established Irish Centre for Social Gerontology at NUI, Galway