as he ran, the donkey lashed out at him with a hoof, and then, for good measure, as he began to get up some speed, the cock swooped down and pecked at his face and ears. He was terrified; the people in the cottage were all armed. The robbers would have to give up and go far far away.
And the animals lived there happily in retirement ever after.*
In the week before Christmas 2003, a case hit the headlines in all the papers entitled variously: ‘Betrayed’, or’ Frozen to death’, or, in The Guardian, ‘Cold and Old’. An elderly husband and wife, who had lived in the same house in London for 63 years, had died at the ages of 89 (of emphysema and hypothermia) and 86 (of a heart attack) respectively. No real surprises here, except their gas supply had been cut off for non-payment of bills. Yet they were not poor. There was £1,400 in cash in their home and a further £19,000 in a building society account.
They were finding it harder and harder to cope, a nightmare that overtakes many older people and is feared by even more. They may not have Alzheimer’s disease, but at the end of their lives they often find it hard to organize things and get their paperwork sorted, to catch up with the bills and the personal administration, and to keep their affairs in order. Two of the commonest causes of winter deaths are, as we know all too well, heart and chest diseases. Yet the excuse used by British Gas for cutting off their gas supply but not alerting the local social services was the Data Protection Act–i.e. on privacy grounds. The Data Protection Act’s Information Commissioner responded immediately by saying that this was a nonsensical excuse, and there is no doubt that some considerable incompetence was involved. Yet the seriousness of the case lies in the fact that two perfectly innocent, old and frail people–hitherto just about coping with the vagaries of life in their own home–died because no one noticed that they were a bit confused.
This chapter discusses how we view older people, whether we treasure them or simply want them to die. It looks at whether older people can control their own deaths, or whether they are liable to be abused and neglected in their last months and days, and at the question of euthanasia and how we ration healthcare.
It also examines the poverty of many older people, and the general neglect they often experience within the health and social care system and asks: is this how we want our parents to be treated? Is this how we want to be treated ourselves? Has our aversion to risk made us mechanistic and unkind? Has government made a mistake in refusing to allow more funding for the care of older people in care homes and nursing homes?
Finally, it looks at the question of how older people have been slow to use their political muscle and whether that might change.
Poverty
As well as the difficulty of coping with personal administration, nightmarish though that may be, many old and frail people also have to cope with extreme poverty. Whilst the focus of much public policy in recent years has been on child poverty, poverty is still a major issue for many older people. This is especially true of what is described by the Faculty of Public Health as ‘fuel poverty’, which is where any household has to spend more than 10 per cent of its income on keeping warm. For older people, this is not uncommon: they need their houses to be warmer than younger people do, and often live in poorer quality housing than younger people. Though there are government programmes to address this, the ‘warm front’ programme, aimed at preventing some of the worst excesses of winter deaths by providing better insulation and heating, is only worth £400 million. But the £1.9 billion spent on winter fuel allowances may be a less than efficient way of tackling the problem. For many older people are still seriously poor. Inequality amongst retired people is even greater than amongst the working population. The top 20 per cent of pensioner couples have a retirement income averaging around £45,000 per annum, whilst a quarter of all pensioners–over two million people–live below the poverty line (£5,800 for a single person.) The Guardian, on the day of the particular story cited above, called for the Government to add to its target for the abolition of child poverty by 2020 a similar target for the abolition of older people’s poverty as well.
The Very Old and Frail
Terrible though the problem of poverty is for many older people, and disastrous though some parts of our pensions system have turned out to be, particularly for those whose company pensions have simply disappeared, the main focus of this chapter is not older people in general. For the majority of the relatively young ‘older people’-the Third Agers, up to 75 or 80-life tends to be quite pleasant, reasonably financially stable, and, until ill health sets in, fun. There is much to be written about this age group and its changing expectations, and our own, as working longer seems likely to be the norm in order to fund future pensions.
But for a particular group amongst the elderly, life is very different: the very old, the very frail, people who need continual care of one kind or another. Much of the media’s attention has focused either on older people who make up the bulk of patients in any NHS ward-especially those amongst them who do not need to be there and who are termed, unflatteringly and unfairly, bed blockers-or on those who have Alzheimer’s disease and other forms of dementia. But the majority of very frail older people are neither bed blockers nor people with dementia, yet they need our support and respect.
So who are they? There were some 737,000 people between the ages of 85 and 89 in the UK in mid 2002,* and a further 387,000 aged 90 and over. That’s over a million people over 85, and growing. The total population of England and Wales is only expected to grow by 8 per cent between 1991 and 2031, whilst of those aged 85+ it will have grown by 138 per cent. So the so-called dependency ratio will escalate. By 2031 there will be 79 dependants for every 100 of working age. This is expensive, and new. It is costly for both pension provision and healthcare, for the over-85s already cost the health and community services five times as much as those aged 5-64. Some 10 per cent of all hospital and community health resources are spent on people of age 85 and over.† The impact on families will be huge. The State is unlikely to be able to provide the full costs of care. The implications for families, and for the individuals themselves, are colossal.
It is a vast change, and we have not kept pace with the changes it demands of us, either ethically or politically. The ‘time bomb’ argument was very fashionable in the late 1980s and the 1990s, and still rears its ugly head, despite the fact that people are now more worried by growing suspicion that our increasing longevity has only resulted in pushing the period of frailty to a later age. Indeed, it may be that by increasing our calendar age we are imposing upon ourselves a longer period of frailty and dependence than hitherto. We are certainly seeing an increase in the numbers of people with Alzheimer’s disease, and the Alzheimer’s Society suggests that there will be around 840,000 people with Alzheimer’s in the UK by 2010, rising to more than 1.5 million by 2050. This echoes US figures, where the Rush Institute for Healthy Aging claims that more than 13 million Americans will have Alzheimer’s by the middle of the 21st century.*
cases?’ Community Care (2003).
Whilst demographic predictions have been wrong before, the increase is certainly taking place and the theory that longevity may not always give one a healthier old age is beginning to look worth examining. However, others argue that the high-dependency period, particularly in terms of NHS hospital use, has simply shifted to an older age and is still roughly parallel with previous experience, being the last three years of life at whatever age.† But it also has to be said that since 1969 admissions of people over 64 to NHS beds has quadrupled, whilst for the rest of the population they have barely doubled. It is not clear how much of this is to
