Older People and Permanent Care: Whose Decision?

This paper looks at decision making when older people enterpermanent care, and focuses on power issues. The recent pastis reviewed and related to aspects of the current picture. Dementiaand capacity are a specific focus. The complexities of the workfor practitioners, together with their sometimes difficult workingenvironments, engender a climate which can be counter productiveto protecting the self-determination of older people.     

Support for Carers of Older People: The Roles of the Public and Voluntary Sectors in Sweden

This study examines the support services offered to informal caregivers, whether directly or indirectly, in Sweden over the period of a special investment initiative between 1999 and 2001. Data were collected in a Swedish county using two separate mail questionnaires in 1999 and 2001. The first questionnaire was addressed to each municipality in the region. The second questionnaire was sent to a random sample of voluntary organizations in the area. The findings showed that only the municipalities provided direct forms of relief service, day care and financial support. The voluntary organizations’ support for carers focused on support groups and training as well as services for older care users themselves. There was a significant increase between 1999 and 2001 in the number of municipalities providing information material and training for carers and using professional caregiver consultants. On the one hand, the Swedish public social care system appears to be following the international pattern in paying more attention to informal caregivers and investing in support services for them. On the other hand the findings did not show any growth in support provided by the voluntary organizations. Here Swedish welfare is dissimilar to other European countries, where it is increasingly common for voluntary organizations to play an important role as providers of support for carers.     

Old and Cold: Older People and Policies Failing to Address Fuel Poverty

Research, funded by the British Gas Help the Aged Partnership and carried out by the Institute of Gerontology, King's College London, explored the multidimensional issues of fuel poverty. A sample of older homeowners and private renters living in England, Scotland and Wales were interviewed in the Spring of 2003 to explore their experiences of keeping their homes warm in the preceding winter. It was found that almost half of the sample for whom full information was available were in fuel poverty. Government schemes failed to address some important issues. Grants were only available to those with “passport benefits”, excluding those who had minimal occupational pensions. Although most respondents had central heating, it was often old and ineffective, yet grants were not available to modernize them. Government schemes did not extend to paying for external and internal insulation for solid wall properties yet many older people live in such property. Several older people lived in rural areas not connected to mains gas. As mains gas currently provides the cheapest fuel, they faced high bills, yet government policies do not address the differential fuel costs in these areas. The culture of many older people in the study contributed to their living in cold homes. They lived frugally and usually turned heating off in daylight hours during winter. It was also a common practice to sleep in an unheated bedroom during winter and to keep the window open at night. Such practices are acknowledged to be unhealthy.     

Professional Perspectives on Decision Making about the Long-term Care of Older People

With the increasing pressure on social and health care resources,professionals have to be more explicit in their decision makingregarding the long-term care of older people. This groundedtheory study used 19 focus groups and nine semi-structured interviews(99 staff in total) to explore professional perspectives onthis decision making. Focus group participants and intervieweescomprised care managers, social workers, consultant geriatricians,general medical practitioners, community nurses, home care managers,occupational therapists and hospital discharge support staff.The emerging themes spanned context, clients, families and services.Decisions were often prompted by a crisis, hindering professionalsseeking to make a measured assessment. Fear of burglary andassault, and the willingness and availability of family to helpwere major factors in decisions about living at home. Serviceavailability in terms of public funding for community care,the availability of home care workers and workload pressureson primary care services influenced decision ‘thresholds’regarding admission to institutional care. Assessment toolsdesigned to assist decision making about the long-term careof older people need to take into account the critical aspectsof individual fears and motivation, family support and the availabilityof publicly funded services as well as functional and medicalneeds.     

Slicing Up the Pie: Allocation of Central Government Funding of Care of Older People

The allocation of central government funds is a critical element in the equitable provision of local authority‐commissioned and ‐provided services. A variety of approaches to allocating funding for social services for older people have been used over the years, most recently founded on ‘needs‐based’ formulae. In 2004, the Department of Health for England commissioned research to help inform the improvement and updating of the formula. The results of individual‐level analyses were compared with the results obtained from analyses of small area (ward‐level) data on service users. Both analyses were affected by problems of data availability, particularly the individual‐level analysis, and the Department of Health and the (then) Office of the Deputy Prime Minister decided that the formula calculations should be based on the results of the small area analysis. However, despite the differences in approach, both methods produced very similar results. The correlation between the predicted relative needs weights for local authorities from the two models was 0.982. The article discusses the strengths and weaknesses of each approach and developments that could allow a normative approach that would incorporate future policy objectives into formulae that, to date, have inevitably been based on historical data and service patterns.     

Modernization and Devolution: Delivering Services for Older People in Rural Areas of England and Wales

The modernization of public services, with its emphasis on managerialism, choice, co‐production and outcome focused service delivery, has been implemented to a certain extent in both England and Wales. Indeed, the welfare states in both countries share a great deal, particularly in relation to policy objectives and the expectations of citizens. Devolution has chiefly meant that the instruments used to deliver policy have separated, although it remains unclear whether this amounts to formal divergence. What is also unclear is to what extent have the experiences of those living within the policy environment in both countries separated or diverged? This article addresses this question using qualitative data composed of interviews with policy actors in six rural areas of England and Wales. By focusing on the discourses of people involved in modernizing and providing services for older people in rural areas, we bring out the impact of modernization for older people. What we show is that modernization engages both service users and the wider population who may one day become service users. But the emphasis on these groups unfolds in different ways in England and Wales. In England, where there has been a commitment to a customer citizen, policy at the local level has emphasized re‐enablement, community development and individual responsibility. In Wales, where modernization has focused on collaboration and citizenship, local policies have focused on service users, and on engagement with the voluntary sector. In effect, the policy environment provides a different context for the experience of ageing in both countries.     

Older People 'on the Edge' in the Countrysides of Europe

Relatively few comparative studies have focused specifically upon the socio‐economic conditions affecting the welfare of older rural Europeans. Such publications as exist are usually confined to single studies. In presenting a European overview of their ‘life‐world’ this paper focuses upon the general conditions of older rural Europeans, living in different types of countryside within a centre–periphery framework. These conditions are largely dependent upon the interconnectivity (nexus) between regional urban centres and the older people's types of settlement. The extent of the global socio‐economic flows between urban centres and countrysides is critical, especially for those living in less accessible and remote European areas. Older people's positive and negative outcomes are seen to occur within four possible urban–rural parameters. The first consists of two‐way socio‐economic urban–rural flows that are more likely to be of benefit to significant numbers of older persons, especially in urban fringe and accessible countrysides. The second parameter arises when there is a long‐standing impasse, where the lack of communication between the rural locality and urban centre hampers socio‐economic urban–rural flows, isolating older people, particularly in less accessible and remote countrysides. The third occurs when regional and local urban centres block or cut back socio‐economic flows to the countryside. The fourth takes place when the rural communities resist socio‐economic urban flows that they regard as a threat to their rural idyll. Exemplars within each of the four urban–rural alternatives help to show the applicability and workability of this four‐way exploratory approach.     

Settling In and Moving On: Transience and Older People in Care Homes

This paper reports on a study which examined the experiences of 46 older people who moved into nursing and residential care homes, interviewing them at four points, from before the move to up to six months afterwards. A key finding was that older people were actively involved in the process of settling into homes and forming new friendships. Participant data also indicated that these older people had often experienced many moves in recent years, as their need for care had changed, and following them through after their inclusion in the study indicated that, for some, there were more moves to come. These data place the debates about assessment, and the identified problem of "misplacement" in a different light. The problem is not simply one of improving assessment techniques so that needs and provision can be matched more accurately, but it may mean accepting that the needs of older people are likely to change over time. The question then is whether we can develop services and forms of provision which ensure that care moves to older people, rather than older people having to move to care.     

Sheltered Housing and Community

This paper considers the role of sheltered housing following the introduction of new community care arrangements in 1993 and examines the continuing uncertainty about its exact role as community care continues to develop. It reports on a study conducted in Shropshire, using a postal survey and interviews with older people and service professionals. The study highlights the importance of sheltered housing for older people, particularly in relieving them of concerns about maintenance and repairs, social isolation and security. These factors were crucial for their overall peace of mind and quality of life. While only a small proportion of tenants received help under social services' community care arrangements, the additional support, monitoring and service coordination provided by wardens helped some of them to remain in sheltered housing when residential or nursing home care might otherwise have been necessary. Sheltered housing was overwhelmingly popular with older people — but their satisfaction was closely associated with the availability and quality of the warden service. Although sheltered housing is not currently in vogue in housing policy, the paper argues that it plays a vital role in local provision for older people and needs to be more closely integrated into community care policy, while at the same time preserving the characteristics that make it popular with its residents.     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Reducing Burglary and Fear among Older People: An Evaluation of a Help the Aged and Homesafe Initiative in Plymouth

Despite their low levels of risk, older people have been targeted by a number of crime reduction initiatives. This article describes an evaluation of one burglary reduction initiative in Plymouth that involved the local Plymouth Homesafe scheme and Help the Aged. The scheme clearly targeted the more vulnerable groups within the community, and clients were extremely positive about the service and its implementation. However, there was little evidence that they expressed lower levels of fear of crime than did older people in general. This leads to a discussion of different levels of vulnerability and the way different subcategories of client perceived and benefited from the scheme.     

Helping Older People in Residential Care Remain Full Citizens

New Labour’s project of modernization has involved thepromotion of interlocking ideas about active citizenship andnew modes of democratic engagement combining to produce whathas described as ‘participative governance’. Concernsabout legitimacy, a ‘democratic deficit’ and theneed to shift power and responsibility to the ‘citizen’have led to the emergence of a range of new deliberative foraand democratic processes. This has led to debates about howto ensure that social diversity can be represented in the decision-makingprocess. A challenge has been how to engage with the issuesof an ageing population and represent older people in all theirdiversity. In recent years, there have been growing calls toextend advocacy rights to older people living in residentialcare. Mostly, this has been to ensure that as consumers, theyhave a fuller say in how their service is run. Older care homeresidents are service users but, as persons, should not be reducedto this role only; they are also citizens in the broadest senseand should not be cut adrift from debates at the national, localand community levels on issues that concern them. This paperexamines how the moves to bring older people into deliberativedemocratic processes have tended to focus on those in their‘Third Age’. Those in institutional settings, beingin the ‘Fourth Age’, occupy a much more marginalposition. This effective disenfranchisement is yet another reasonwhy, for many, the move into residential care—a difficulttransition for a variety of reasons—becomes regarded asthe ‘last refuge’. It contributes to the sense ofloss of identity, lowering of self-esteem and a reduced senseof personhood. This article accepts that there should be moreeffective involvement of care home residents in decision makingabout their personal care. However, there are dangers in adoptinga too narrowly consumerist approach. This can reinforce a reductionistview of care home residents simply as ‘service users’—aform of ‘othering’ in itself. As citizens and membersof a wider community, they should be included in consultationsabout any community and wider political debates that affectthem. Such a proposal implies a widening and deepening of advocacyservices available to this group. As most older people in residentialcare are there following the intervention of a social care professional,then ensuring that they have access to advocacy must surelybe a key task. This paper argues that this is frustrated bythe lack of suitable services. Without a significant investmentby the Government in independent advocacy services, not onlyis the social work task with one of social care’s coreclient groups rendered impossible, but the Government cannotdeliver on its own agenda of empowerment, active citizenshipand inclusion.     

Absent Role of the State: Analysis of Social Support to Older People with Disabilities in Rural China

China is experiencing rapid population ageing and already has 44 million older people with disabilities aged over 59 years. Yet social support of these older people with disabilities is undeveloped and not well researched. This article contributes by using a disability rights framework (right to life and protection, economic security and social support) to analyze local cases in rural China. It finds that, although the family is still the main provider of economic and care support to rural older people with disabilities, the absence of a state role in welfare provision has negative impacts on the well‐being of older and younger generations in rural families.     

Mainstreaming Equality: Implications of the Provision of Support at Home for Majority and Minority Ethnic Older People

This paper explores the potential impact and practical difficulties of mainstreaming equalities in support at home for minority and majority ethnic older people, drawing on two linked empirical research projects. Social care providers have long faced difficulties in catering for diversity of need. Recently, diversity within minority ethnic groups has increased, and there is now a statutory duty to promote equality. Research findings illustrate the complexity of exclusionary processes, with particular reference to the example of health care. There is a gap between the high‐level commitment to mainstreaming equality and people's lived experiences. Autonomy and choice are central to community care legislation, policy and practice guidance, but in reality, the research shows that choices are limited for both minority and majority older people. More user‐focused approaches and grassroots involvement may offer ways forward, despite some limitations of current models. In conclusion, the potentiality of a broad mainstreaming equality perspective is highlighted, but challenges include a need for a more grounded approach, better engagement with user groups and a need to focus on understanding issues of implementation.     

Older People's Family Contacts and Long-term Care Expenditure in OECD Countries: A Comparative Approach Using Qualitative Comparative Analysis

In recent decades there has been a suggestion that public and private long-term care (LTC) expenditure might be replacing traditional family care for older people. The decline of family contact is known to be more advanced in some OECD countries than others, with southern Europe identified as where family contact is still strong. This article explores at a country level whether there is an association between levels of expenditure on long-term care and the availability of family contacts. Qualitative Comparative Analysis is used as a comparative method, so as to use national quantitative indicators with a small sample of countries. An association between higher levels of family contact and lower levels of expenditure on LTC is suggested, but it is weakened by a number of untypical cases. Countries that defy this relationship have government care policies that seek to promote informal social care through the family contact that continues to be available. Austria, Canada, Great Britain and Japan are discussed in this context.     

Charging and Quasi-Markets in Community Care: Implications for Elderly People with Dementia

Social services authorities in the UK are increasingly involved in charging and fee collection activities with clients in receipt of community care services. This article explores the implications of these developments for elderly people with dementia. The starting point of the article is a critique of existing legal and administrative options for handling other people's money, including the difficulties and dilemmas raised for both paid and unpaid carers by the existing arrangements. This is then related to the failure of charging and fee collection systems which have developed as a result of the community care reforms to address the particular needs of elderly people with dementia. A case study of policies in one local authority is outlined and this is followed by the presentation of the view of 37 fieldlevel professionals who were interviewed in focus groups. The concerns of these respondents included the complexity of the assessment task, conflicts between care managers and finance/revenue staff, the difficulty of defining and responding to financial abuse, and dilemmas over the extent to which relatives and carers should be trusted. The final section of the article considers the implications of a move to quasi-markets in social care for elderly people with dementia, particularly in terms of their vulnerability to financial exploitation.     

Global Social Justice for Older People: The Case for an International Convention on the Rights of Older People

Older people are beginning to represent a large proportion ofthe general population and have become a major area for socialprogramming in many parts of the world. However, neglect orviolation of older people’s rights is common. Until recently,there has been a surprising lack of advocacy on the part ofnon-governmental organizations (NGOs) and human rights activistsfor a legally effective international convention on the rightsof older people, as compared with other vulnerable groups suchas children and women. This paper argues that the introductionof an international convention on the rights of older peopleis long overdue. Such an international convention should containcomprehensive and legally binding provisions which would requireratifying states to promote older people’s rights. Itshould be reinforced by a strong monitoring system that wouldinvolve key members of the international community. This paperoutlines the arguments in favor of the creation of a transnationalhuman rights agreement for older people and proposes that internationalNGOs and human rights advocates should work toward creatingsuch a convention.     

Give Them the Money: Is Cash a Route to Empowerment?

This article suggests it is important to unpack the notion of "empowerment" in community care so that the position of those who provide "hands-on" care is scrutinised alongside the empowerment of "users" of care. The particular case of the forthcoming Direct Payments legislation, whereby disabled people will be able to opt for cash rather than services and become employers of personal assistants, is considered. It is argued that both employers and employees in these care relationships are likely to be on low incomes, that the work is likely to be insecure and possibly unregulated, that there might be a problem of labour supply, and that in the long run, this form of employment might generate hardship for the workers so employed. Other forms of reconciling the interests of both users and "carers" are considered.     

A Brave New World of Personalized Care? Historical Perspectives on Social Care and Older People in England

Social care policy for older people in England continues to generate extensive discussion around the need to break with the past and to deliver a personalized response to need. This article explores the extent to which this represents a complete break with the past by looking at four key reports from the past, namely the Rucker Report (1946 ) on the break up of the Poor Law, the Seebohm Report (1968 ) on the personal social services, the Griffiths Report (1988 ) on community care and The Royal Commission on Long Term Care ( Sutherland Report, 1999 ). Each is interrogated in terms of how social care is defined, how services are to be delivered, how quality is understood and the assumptions made about who will be able to access services. This analysis is used to draw out key continuities in policy assumptions such as the primacy of family and the ongoing debate about ‘What is social care?’ and how it can be distinguished from health care. The article also argues that the voluntary sector has always been seen as a ‘key player’ in social care. Finally, the analysis of the four reports is used to trace the ever changing role of local authorities in the planning, purchase and provision of social care services for older people.     

Human Motivation and Professional Practice: of Knights, Knaves and Social Workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self‐interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy‐makers have sought to effect such changes has been through the “new community care” of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide‐ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self‐interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client‐centred ethos.