Saturday, 14 May 2016

Ageing badly


There is plenty of public discussion of the complex issues involved in being a parent, but far less about having parents. What I mean is the issues arising for people in middle-age having to care for and cope with their ageing parents. Those issues are made more complex by the way that families tend now to be dispersed geographically and the much longer live spans that are now common. The consequence is the necessity of engaging with the organization of care for the elderly. In the UK, at least, that organization is woefully inadequate and in crisis.
Longer live expectancy is both a consequence of medical care and a cause of the need for medical care. This in turn requires increased health expenditure, but in 2015 the UK health expenditure as a percentage of GDP was 8.5%: lower than Greece, lower than most west European countries, and far lower than the US. Against this, it has to be recognized that the UK system is far more efficient than others in translating expenditure into health outcomes. Maybe more important, though, is that increases in UK health expenditure don’t match increased costs (healthcare cost inflation is much higher than general price inflation) and increased demand (driven primarily by ageing).
But healthcare is only one part, and not necessarily the most important part, of the organization of ageing. Most health expenditure arises in the last two years of life; whether that life ends at 70 or 90. No, the real issue is the organization of care, and this is in complete crisis. Whereas it used to be provided mainly by local authorities, now there is a hybrid system of private care homes part-funded by local authorities. Budget cutbacks mean that the part-funding is increasingly inadequate; whilst the crazy financial engineering of some private home owners like the collapsed Southern Cross (discussed on p.115 of the book) exacerbates the problem.
The two aspects of health care and care homes are closely related. Both emergency and routine care departments of hospitals can’t discharge elderly patients because there is nowhere for them to go, especially if they are ‘unprofitable’ from a care home perspective. On the other hand, as a report this week highlights, in other cases the elderly are being discharged back to their own homes when they are incapable of coping, with horrific consequences.
All of this is absolutely to do with failures in the way that we organize. The privatized, often private equity firm-owned care home system is simply absurd, and passes on its inefficiencies to the public sector NHS. But beyond that is the obvious absurdity of dividing health and social care at all. There has been much talk of overcoming it, and some areas in England have made progress in doing so but overall the separation remains stubbornly in place.
As is often – perhaps always – the case, the issues relate to both organizations in the institutional sense (the structures of, in this case, health and social care) and to ideational organization (the construction of ‘health’ and ‘care’ as categories). Underlying the latter is perhaps also the more profound division of the public and private realms, so that health care is something that happens in the public domain of the hospital ward and social care something that happens in the private domain of the home (even if the home is an institutional ‘care home’). This in turn means that much suffering remains hidden (‘at home’) and experienced by both the elderly and their families as a ‘private’ problem, and possibly a stigma.
The psychology of this is undoubtedly very complex, since the relations between (adult, ageing) children and (aged) parents has the capacity to engender guilt, frustration, anger, fear and much else besides. Psychology has been much concerned with the relationships of children and parents in infancy, but perhaps much less so (at least, that’s my impression) with those in adulthood. The dynamics of the latter are surely taking new forms as extended old age and associated dependency become the norm rather than the exception.
In 1911 in the UK life expectancy was 51 years; by 2013 it was 81 years. In 1911 there were 107 people in Britain aged 100 or over; in 2013 there were 13,780. A similar pattern can be found across the developed world. Organizationally, and emotionally, we have not really caught up with these profound demographic changes.

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