Older␣People␣and Wellbeing

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OlderPeopleand

Wellbeing

byJessicaAllen

July2008

©ippr2008

InstituteforPublicPolicyResearch

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Aboutippr ...3

Abouttheauthor ...3

Acknowledgements...3

Introduction...4

1.Age,healthandhappiness...6

Demographicandhealthtrends...6

Lifeexpectancyandpopulationgrowth...6

Ageingpopulation...8

Healthylifeexpectancy ...9

Inequalitiesinhealthandlifeexpectancy...11

Trendsinwellbeing ...12

Definingandmeasuringwellbeing...12

TrendsinwellbeingintheUK ...13

Wellbeinginolderpeople...15

Futuretrendsinolderpeople’smentalwellbeing... 17

Summary ...18

2.Factorsthatshapewellbeinginolderpeople...20

Socialexclusion,inequalitiesandhealth ...20

Povertyanddeprivation...21

Physicalhealth ...24

Ethnicity...25

Gender...27

Lackofdiagnosis ofmentalhealthconditions...27

Relationshipsandsociallife ...27

Contactwithfriendsandfamily ...27

Maritalstatus ...28

Livingalone...29

Agediscrimination...30

Eventsandtransitionsinlifethatcantriggerpoormentalwellbeing...30

Retirement...30

Bereavement...31

Care:givingandreceiving...31

Communityparticipation ...32

Crimeandfearofcrime...32

Localenvironment...33

Housingquality ...34

Protectingwellbeing ...34

Takinganactivegrandparentingrole ...34

Exercise...35

Educationandlearning ...35

Volunteering...35

Personalresilience ...36

Religion ...36

Respect ...36

3.Conclusions...37

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TheInstituteforPublicPolicyResearch(ippr)istheUK’sleadingprogressivethinktank,producing cutting-edgeresearchandinnovativepolicyideasforajust,democraticandsustainableworld. Since1988,wehavebeenattheforefrontofprogressivedebateandpolicymakingintheUK.Through ourindependentresearchandanalysiswedefinenewagendasforchangeandprovidepractical solutionstochallengesacrossthefullrangeofpublicpolicyissues.

WithofficesinbothLondonandNewcastle,weensureouroutlookisasbroad-basedaspossible, whileourinternationalandmigrationteamsandclimatechangeprogrammeextendourpartnerships andinfluencebeyondtheUK,givingusatrulyworld-classreputationforhighqualityresearch. ippr,30-32SouthamptonStreet,LondonWC2E7RA.Tel:+44(0)2074706100E:info@ippr.org www.ippr.org.RegisteredCharityNo.800065

ThispaperwasfirstpublishedinJuly2008.©ippr2008

Aboutippr

Acknowledgements

Thisreportisthefirstinaprogrammeofworkatipprexploringthe‘PoliticsofAgeing’.

ManythanksareduetotheCalousteGulbenkianFoundationwhohavesupportedthisfirstphaseof thework,drawingontheirlongstandinginterestinandsupportforolderpeople’swellbeing.Weare verygratefultothemfortheirsupportandtoAndrewBarnettinparticular.Thanksalsoinadvanceto theNorthernRockFoundationandtheIntelCorporationwhoaresupportingourfutureworkonthe PoliticsofAgeing.

Thanksarealsoduetocolleaguesatippr,inparticularJuliaMargo,RuthSheldonandSoniaSodha. ThanksalsotoJohnCannings,KateStanley,GeorginaKyriacou,CatherineBithellandKellyO’Sullivan. Allomissionsanderrorsaretheresponsibilityoftheauthor.

Abouttheauthor

JessicaAllenisHeadofHealthandCareatippr.HerpublicationsatipprincludeGreatExpectations (2007)andEquitableChoicesforHealth(2006).ShehaspreviouslyworkedattheKing’sFund,where sheco-authoredHealthintheNewsandFindingoutWhatWorks,andatLondonSchoolof

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ThewellbeingofyoungpeopleintheUKhasrecentlybeenthesubjectofunprecedentedattention andscrutiny.Forexample,aUNICEFreportpublishedin2007causedshockandconsternationby suggestingthatdespiteadecadeofinvestmentandpolicyfocusonyoungpeople,theUKwasthe worstplaceinEuropetobeachild.Butwhatofolderpeople?Whiletheirplighthasnotbeenthe subjectofsuchextensiveanalysisorgovernmentfocus,theUKisnotalwaysagreatplacetobeold either.

AlthoughtheUKpopulationislivinglongerandisinbetterhealththanever,andolderpeopleare wealthierthantheywere,liketherestofthepopulation,olderpeoplearenotgettinganyhappier. Thereissomeevidencethatolderpeoplemaybebecomingdecreasinglysatisfied,lonelierandmore depressedand,duetodemographicchanges,thereareincreasingnumbersofolderpeople,manyof whomarelivingwithlowlevelsoflifesatisfactionandwellbeing.Thisisparticularlysoifyouarepoor, isolated,inillhealth,livingalone,inunfithousingorrundownneighbourhoodsandworsestillifyou areacarerorlivinginacarehome:andalloftheseriskfactorsapplytoalargeproportionoftheUK’s olderpopulation.

Thisreport,thefirstinaseriesonolderpeopleandwellbeingfromippr,describessomeofthekey socialtrendsintheUKandassesseshowthesemaybeimpactingonolderpeopleandtheirwellbeing.

Notaninevitability

Theover-65s,andparticularlytheincreasingnumbersofpeopleovertheageof80,havebeen relativelyneglecteddemographicgroups.Toomanyolderpeoplelivewithpreventabledepression, lonelinessandisolation.Unhappinessinoldageisnotinevitable,evenforthosewithpoorphysical healthandlimitedmobility.Thisreporthighlightsthesignificanceofsupportinfosteringwellbeing andsocialandcommunityparticipationforolderpeople,particularlyforthosemostatriskofisolation andexclusion.Thisanalysiswillbedevelopedinthesecondphaseofthisworkin2008and2009. Itisworthnotingattheoutsetthattherearesignificantnationaldifferencesinwellbeingamongolder populations,furtherenhancingthecasefortherebeingnoinevitabilitytothesituationintheUK.For example,inJapan,whereoldpeopleareaccordedgreatrespect,lifesatisfactionishighestamongthe over-65s.InHungary,bycontrast,theyoungarethemostsatisfiedandsatisfactionislowamong oldergenerations(DonovanandHalpern2002).

Thecurrentpolicycontext

Anumberofrecent,well-intentionedpolicydocumentsfromcentralgovernmenthavesetoutwaysof improvinglevelsofwellbeingamongolderpeople(see,forexample,DepartmentforWorkand Pensions2005,ODPM2006b,DepartmentofHealth2004).Buttheoverallfocusofnationalpolicy continuestobechildrenandyoungpeople.Furthermore,someofthesedocumentshavelanguished afterlaunchandtheproposalshavenotbeenactedupon.Thepoliticalappetitetodrivethrough proposalssometimesappearstobelacking.

TheSocialExclusionUnit’sreportonendingsocialexclusionforolderpeopleemphasisedtheneedfor strongleadershiptoprioritisewellbeingofolderpeople(ODPM2006a).Anumberofdepartments haveaconsiderableimpactonthelivesofolderpeople:theDepartmentforWorkandPensionshas formalresponsibilityforolderpeoplebuthastendedtofocusmostonissuesaroundbenefitsand pensions;theDepartmentofHealthfocusesonhealthandsocialcare;andtheDepartmentfor CommunitiesandLocalGovernmentonhousing,localgovernmentandurbanregeneration.However, theworkofthesedepartmentsisnotalwayssufficientlyjoinedupandthereisnodepartmentor officewithsoleresponsibilityforolderpeopleinthesamewaythattheDepartmentforChildren, SchoolsandFamilieshasresponsibilityforyoungpeople.

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inequalitiesandexclusionforolderpeople,andrecommendedasimilarapproachtotheSureStart programmethatexistsforyoungerpeople.Whiletheanalysisremainssound,implementationhas beenpatchyandthereisstillnoSureStartforLaterLife.

Thefirstcross-governmentstrategytofocusonolderpeople,OpportunityAge(DWP2005),contains manyexcellentproposalsaroundendingdiscrimination,tacklinginequalities,andofferingmore supportandinterventionsforolderpeople.Someofthespecificproposalshavebeenintroduced,and pilotssuchasLinkAgePlusarerunning.1_{However,aswiththeproposalsintheSocialExclusionUnit’s}

report,therehasnotyetbeensufficientimpact.Asthisreportdescribes,toomanyolderpeopleare stillstrugglingwithpreventablelevelsofunhappinessanddepression,withmanyremainingexcluded, sufferingfrompoverty,poorhousing,illhealthanddiscrimination.

OneimportantstrandofrecentnationalGovernmentpolicyactivityrelatingtoolderpeoplehasbeen socialcareandunpaidcare.Careneedsinpeopleaged65andoverareestimatedtoriseby87per centby2051from2002levelsandby2041thenumberofdisabledpeopleisexpectedtodouble comparedwith2002(Moullin2008).In2008theGovernmentlaunchedanationaldebate,leadingto aGreenPaperin2009,aboutthefuturecaresystem.Thesedebatesandstrategiesshowrecognition thatthecurrentcaresystemisinneedofamajorredrawingintermsoffunding,typesofcaresupport offeredandwhereandhowcareshouldbedelivered.Theneedforathoroughrethinkofwellbeingin laterlifeismadeallthemorepressinggiventheprojectedincreasesinnumbersofpeopleover65in theUKandotherdevelopedcountries.

Structureofthereport

InthefirstchapterwedescribethedominantdemographicandhealthtrendsintheUK,withafocus onpeopleof65andolder.Healthandwealthareoftenseenasstrongpredictorsoflevelsof wellbeing.However,asweshowinthesecondpartofthechapter,levelsoflifesatisfactionand wellbeinghavestagnatedoverthelast40to50years,despitebetterhealthandincreasingwealth. Somestudiesshowincreasedprevalenceofmentalhealthproblemsanddeterioratinglevelsoflife satisfaction,particularlyforpeopleover75.Ouranalysisofpopulationstructure,health,inequality andlevelsofwellbeingprovidesthecontextfortherestofthereport,whichfocusesoncurrentand likelychangesinthedriversofwellbeingforolderpeople.

Inthesecondchapter,inordertoassessexistingandfuturetrendsinolderpeople’swellbeing,we discussinmoredetailthemaindriversofwellbeingforthisgroup.Physicalhealthandrelativeincome levelsaresignificant,butthemostimportantfactorsrelatetosocialinteractionandcommunity participation.Weassesstrendsinolderpeople’sincome,highlightinglevelsofinequality,despite wealthincreasesforalmostallofthelast20years.

Wegoontoassessotherimportantdriversofpooremotionalwellbeingandthosethatcansupport andprotectgoodwellbeing.Thisanalysisisbasedaroundfourprincipalareas:levelsofsocialexclusion andinequality,relationshipsandsociallife,lifeeventssuchasretirementandbereavementandlevels ofparticipationincommunitylife.Thereareopportunitiesforpositiveactivitieswhicholderpeople valuetobebettersupportedbygovernmentandservices,whichcouldinturnreducetheprevalence ofdepression,isolationandloneliness.

Intheconcludingchapterwerecommendthatmoreneedstobedonetosupportolderpeople’s wellbeingandsetoutourintentionsforphasetwoofippr’sworkonthepoliticsofageing.

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Thischaptersetsthecontextforouranalysisofageingandfuturelevelsofwellbeingforolderpeople. Weexploredemographictrendsthatshowthatagrowingsectionofthepopulationwillbeover65in yearstocome.Therehavebeenstrikinggainsinlifeexpectancyandsomegainsinhealthylife expectancy,whichmeanthatweareallexpectedtolivelongerandinbetterhealth,althoughthisnot universalacrossallsocialgroups.

Inthesecondhalfofthechapterwegoontoexaminehow,despiteincreasesinwealthandadvances inhealth,therehavenotbeencommensurateimprovementsinnationalwellbeing–infact,onsome indicationswellbeingisdeteriorating.Thisstagnationordeclineinwellbeinghasbeennoticedwithin governmentandbyotheranalystsandtherearesuggestionsthatinsteadofusinggrossdomestic productasameasureofprogress,levelsoflifesatisfactionorhappinessshouldbeused.Wedescribe possiblefuturetrendsinolderpeople’slevelsofwellbeingandsuggestthatthenumbersofolder peoplewithlowwellbeingmayberising.Thismaybetheresultofanincreasingprevalenceofmental healthproblems,aswellasdemographicchanges.

Demographicandhealthtrends

Lifeexpectancyandpopulationgrowth

The20thcenturybroughtdramaticgainsinlifeexpectancyintheUK.In1901,babyboysborninthe UKcouldexpecttoliveforaround45yearsandgirlsfor49years.By2006babyboyscouldexpectto livefor77yearsandgirlsfor81years.Furtherincreasesareexpectedasmedicalinnovationcontinues. Figure1.1illustratesrealandprojectedgainsinlifeexpectancyformenandwomen.Thecohortlife expectancyprojectionstrytotakeaccountoffuturehealthandmedicalimprovements.

75 80 85 90 95 100

1981 1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033 2037 2041 2045 2049 2053

Male Female

Figure1.1.Male andfemalelife expectancy atbirth,UK, 1981-2056

Source: Government Actuary’s Department (www.gad.gov.uk/ Demography_data/ Life_Tables/docs/2 006/2006UKeolb. asp)

1.Age,healthandhappiness

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However,despitestrikingoverallgainsinlifeexpectancyforeverybody,thereremainsignificant differencesinlifeexpectancybetweensocialclasses.Professionalclasseshavelongerlifeexpectancy thanallothersocialgroups.Despitegovernmenttargetsandinterventionsthegapcontinuestowiden withlatestfiguresshowinga2percentincreaseininequalityformenand11percentforwomen between1995-7and2006-7(DepartmentofHealth2008).

Theincreaseinlifeexpectancyamongolderadultshasbeenparticularlydramatic,andasFigure1.4 shows,at65peoplecanexpecttogoonlivingforanincreasinglylongtime.Between1980-82and 2004-06lifeexpectancyatage65intheUKincreasedbyfouryearsformenand2.8yearsfor females.Thegapbetweenmaleandfemalelifeexpectancyisnarrowing(Figure1.4,nextpage). By2031theUKpopulationisprojectedtoincreasefromits2006levelof60.6millionto71.1million, accordingtoestimatesfromtheOfficeforNationalStatistics(ONS2008b),agrowthofjustunder11 millionpeoplein25years,oraroughaverageof0.4millionpeopleperyear.

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Non-manual Manual Figure1.2.Male

lifeexpectancyat birth–manual andnon-manual occupations, Englandand Wales,1972-2005 Source:Officefor NationalStatistics 2007a

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84 1972-76 1977-81 1982-86 1987-91 1992-96 1997-01 2002-05

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Femalelife expectancyat birth–manual andnon-manual occupations, Englandand Wales,1972-2005 Source:Officefor NationalStatistics 2007a

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Ageingpopulation

AstheUK’spopulationisgrowingitisalsoageingandby2020,oneinfivepeopleintheUKwillbe aged65andover,morethanthenumbersunder16.Asthepopulationislivinglongertheabsolute andrelativenumbersofolderpeopleinthepopulationareincreasing.TheageingoftheUK

populationposeschallengesintermsofcaringforolderpeopleandfinancingsupportforpeopleover 65(Moullin2007,2008).In2006therewere3.3peopleofworkingageforeverypersonofstate pensionage;thisfigureissettofallto2.9peopleby2031(ONS2008c).

AnageingpopulationisanissueformanyofthememberstatesoftheEuropeanUnion.IntheUK,16 percentofthepopulationwereaged65oroverin2007,lowerthantheEUaverageof17percent. SomeEuropeancountries,suchasItalyandGermany,havehigherdependencyratiosof19.9and19.8 percentrespectively(Eurostat2008).

Figure1.5depictstheagedistributionoftheUKpopulation.Itshowsthatby2020amuchlarger shareofthepopulationwillbeover75.

Theproportionofpeopleover75isprojectedtoincreasefasterthananyotheragegroup,whichis unsurprisinggiventheparticularlyrapidrecentincreasesinlifeexpectancyforpeopleover65.The highestagegroup,theover-85s,isalsoprojectedtorisesubstantiallyfrom1.9percentin2004to2.7 percentby2020.Andby2031estimatesindicatethattherewillbenearly3millionover-85s

comparedwith1.2millionin2006andaround0.6millionin1981(ONS2008b).

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expectancyat age65

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Healthylifeexpectancy

WhiletheUKhasagrowingandageingpopulation,withmarkedincreasesinlifeexpectancy,notall theyearsgainedarelivedingoodhealth.Forolderpeople,asforallagegroups,goodphysicalhealth isimportantformentalhealthandwellbeing.Thereisplentyofevidenceshowingthatchronichealth problemsanddisabilityoftenresultindepressionandothermentalhealthproblemsforolderage groups.ThisisdiscussedinmoredetailinChapter2.

Examiningtrendsinhealthgivesussomestrongindicationsofolderpeople’swellbeing.Healthylife expectancy,thatisexpectedyearsoflifein‘good’or‘fairlygood’health,islowerthanoveralllife expectancy.IntheUKin2004,babyboyscouldexpectatbirthtoliveingoodhealthfor67.9years andtobefreeofdisabilityfor62.3years(whiletotallifeexpectancyin2004was76.6).Therefore boyscouldexpect14.3yearswithadisabilityand8.7yearsinpoorhealth.Girlsbornin2004could expecttolive81years,with70.3yearsingoodorfairlygoodhealth,10.7yearsinpoorhealthand justover17yearswithadisability.(SeeTable1.1.)

Figure1.5.Actual andprojected agedistribution, UK,1981-2056

Source:ONS2008b

Table1.1.Lifeexpectancy,healthylifeexpectancyanddisability-freelifeexpectancyintheUK,bysex,2004

Males Females

Atbirth Atage65 Atbirth Atage65

Lifeexpectancy 76.6 16.6 81 19.4

Healthylifeexpectancy 67.9 12.5 70.3 14.5

Yearsspentinpoorhealth 8.7 4.1 10.7 4.9

Disability-freelifeexpectancy 62.3 9.9 63.9 10.7

Yearsspentwithdisability 14.3 6.7 17.1 8.7

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Table1.2showshowinGreatBritainin2004,justunderaquarterofmenand28percentofwomen over75consideredtheirhealthtobepoor.Forwomeninparticulartheperiodover75ismarkedbya significantdeclineinhealth,butforbothmenandwomenover75athirdofpeoplearestillingood healthandnearlythreequartersareingoodorfairlygoodhealth.

Thereareclearimplicationsforwellbeing.Forthoseover75poorhealthaffectedoveraquarterofall people,makingthatgroupparticularlyvulnerabletodepression,socialisolationandexclusion.

Overall,theproportionofpeopleinGreatBritainreportinganillnessordisabilityhasnotchanged since1995.Thisisperhapssurprisinggiventheincreasesintheproportionofolderpeopleinthe populationandsuggeststhatanageingpopulationdoesnotnecessarilybringproportionatehealth challenges.

However,thereisstillinsufficientevidenceintheUKtodeterminewhetheryearsgainedthrough longerlifeexpectancywillbematchedbyyearsofgoodhealth.Thereisanongoingdebateasto whetherfuturegenerationswilllivelongerbutmoredisabledlives,or,alternatively,livesthatare increasinglyhealthy(ipprTrading2007).IntheUnitedStatesthereissomeevidencetoshowthatthe periodoftimeduringwhichapersonexperiencesdisabilityisbecomingshorterandthatthereisan increaseinhealthylifeexpectancy(Jaggeretal 2006).However,theresultsofstatisticalprojections dependgreatlyonthedefinitionsofillnessanddisabilitythatareused.

Table1.2.Self-reportedgeneralhealthinGreatBritain,bysexandage,2006(%)

Good Fairlygood Notgood

Males

0–15 85 12 2

16–24 83 14 3

25–44 74 20 6

45–64 58 28 14

65–74 44 36 19

75andover 33 43 24

Allages 68 23 9

Females

0–15 87 11 2

16–24 78 18 3

25–44 70 21 8

45–64 59 26 15

65–74 43 38 19

75andover 33 39 28

Allages 66 23 11

Source:ONS2008c

Table1.3.Proportionofpeoplewhoreportedalimitinglongstandingillness,disabilityorinfirmity,Great Britain(%)

Year 1975 1985 1995 2005 2006

Percentage 15 17 19 19 19

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Box1.1setsoutprojectionsonlevelsofdisabilityunderthreedifferentscenariosofhealth

expectancy:acompressionofmorbidity,thatis,lessillness,anexpansionofmorbidity,meaningmore illness,andacombinationofboth.

In2002,peopleintheUKenjoyedmoretimewithoutadisabilitythanpeopleinmanyotherEuropean countries.Formen,onlySweden,Finland,Portugal,HungaryandFrancehaveahigherpercentageof yearslivedwithoutadisability,andforwomen,onlySweden,Finland,theNetherlandsandHungary (Eurostat2002).

However,simplybecausethenumbersofolderpeopleareincreasing,thenumbersofpeoplewitha disabilityorpoorhealthwillincreasedramatically.TheKing’sFundestimatesthatwithnochangein theprevalenceofdiseasesortheageofbecomingdisabled(anunrealisticassumptionbecausehealth needsandtreatmentschangerapidly),therewillbea67percentincreaseinthenumbersofpeople withadisabilityoverthenext20years.Thenumberofpeopleover85withadisabilitywilldoubleand thenumbersexperiencingoneofthekeydiseasesconsideredinthestudywillhaveincreasedbyover 40percentby2025(Jaggeretal 2006).Thenumberspotentiallyfacinglow-levelmentalhealth problemsandpooremotionalwellbeingasaresultofpoorhealthanddisabilitywillalsorise significantly.

Inequalitiesinhealthandlifeexpectancy

Goodhealthisnotspreadevenlyacrossthepopulationandhealthissignificantlyrelatedtosocio-economicstatus,ethnicity,genderandgeographiclocation.

Figure1.6(nextpage)showsdifferencesintheincidenceoflong-termillnessanddisability,measured byethnicgroupandgender,inEnglandandWales.PakistaniandBangladeshimenandwomenhave worsehealththanotherethnicgroups.Chinesemenandwomenhavethebesthealthandwhite groupsalsofarerelativelywell.

Box1.1.Levelsofdisability–threescenarios

Withacompressionofmorbidity,thereisapronouncedreductioninprevalenceratesofthemore severelevelsofdisability.Forexample,infemalesaged60to79,theprevalencerateforserious disabilityfallsfrom2.0percentto1.6percentbetweentheyears2004and2020.

Withanexpansionofmorbidity,theprevalenceratesformoreseriousdisabilityincrease,withthe situationdeterioratinguptotheyear2020.Forexample,theproportionoffemalesagedover80 whoareinthehighesttwodisabilitycategoriesisprojectedtoincreasefrom14.7percentto16.0 percent.

Withacombinationofcompressionandexpansionofmorbidity,theproportionoflivesprojectedto bewithoutdisabilityincreasesbetweentheyears2004and2020(withacorrespondingdecreasein theproportionoflivesexpectedtobedisabled).

Source:Rickaysen2005,citedinipprTrading2007

Box1.2.Definitionofdisability

‘Disability’referstothedisadvantageexperiencedbyanindividualasaresultofbarriers,including physicalandattitudinalbarriers,thatimpactonpeoplewithmentalorphysicalimpairmentsand/or long-termillhealth.

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Whiletherehavebeenincreasesinlifeexpectancyforeveryone,inequalitiesinlifeexpectancyand childmortality,measuredaccordingtosocio-economicstatus,haveactuallywidenedinthelast tenyears(DepartmentofHealth2008).Asthereisanassociationbetweenpoorphysicalhealth andpooremotionalwellbeing,thereisastronglikelihoodthathealthinequalitiesarelikelyto translateintowideningwellbeingandmentalhealthinequalitiestoo.

Trendsinwellbeing

Havingbegunbyexploringtrendsinpopulationstructureandhealth,inthissectionwediscuss thegrowingdrivetomeasurewellbeing,anddescribesomeofthemainmeasuresused.Wegoon todescribelevelsofmental-healthproblemsandwellbeingintheUKamongolderpeople.While levelsofhealthandalsowealthgivesomeindicationofwellbeingthereisevidencethatabovea certainlevel,increasingwealthandhealthdonotleadtomatchedimprovementsinfeelingsof wellbeing.

Definingandmeasuringwellbeing

Thenotionthatanation’slevelofwellbeingorhappinessismoreimportantthanitswealthhas beguntogaincredencewithinpolicyandacademiccircles(althoughthismaybechallengedin economicallytoughertimes).Thisinterestreflectsthefindingthatwhileincomeandwealthmay continuetoescalate,levelsofwellbeingstagnatewhenoneobtainsanannualincomelevelof £20,000.Thisistheso-calledEasterlinparadox,namedafteratheorypostulatedbyRichard Easterlinin1974.

IntheUKLordLayardhasbeenaleadingproponentofthedrivetoconsiderhappinessratherthan GDPasanindicatorofprogress,stating:

0 5 10 15 20 25 30

Other ethnic groups Chinese Other Black Black African Black Caribbean Other Asian Bangladeshi Pakistani Indian Mixed Other White White Irish

White British Males

Females

Figure1.6.Age-standardisedrates oflong-term illnessordisability thatrestrictsdaily activities,by ethnicgroupand sex,Englandand Wales,2001

Source:Dunnell 2008

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‘…GDPisahopelessmeasureofwelfare.ForsincetheWarthatmeasurehas shotupbyleapsandbounds,whilethehappinessofthepopulationhas stagnated.Tounderstandhowtheeconomyactuallyaffectsourwellbeing,we havetousepsychologyaswellaseconomics.’(Layard2003)

TheGovernmenthasacceptedthatwellbeingandlifesatisfactionareimportantmeasuresofprogress (DonovanandHalpern2002),andnotesthatthepublicalsosupportsthisnotionofprogress. Despitetheincreasingimportanceattachedtosociety’swellbeingorlifesatisfactionthereisnosingle, definitivemeasureused.InternationalbodiessuchastheOrganisationforEconomicCooperationand Development(OECD)arepromotingdebateaboutwhatprogressmeansandhowasharedviewof societalwellbeingcanbeproduced,basedonhigh-qualitystatistics.IntheUKtheOfficeforNational StatisticsandotherGovernmentofficesareexploringthemeasurementofsocietalwellbeingdrawing onarangeofindicators(Allin2007,DonovanandHalpern2002).

Howeverimpreciselydefined,Governmentstudieshaveusedmeasuresofhappinessandsatisfaction, asreportedbyresearchrespondentsthemselves,tocomparelevelsofwellbeingbetweenvarious groupsofpeople.Theredoesseemtobeconsistencybetweenthefindingsandageneralconfidence inthemeasuresofwellbeing.TheGeneralHealthQuestionnairesurveysareanimportantand frequentlyusedmeasureofwellbeing.Thequestionstrytoestablishlow-levelmentalhealth problems,particularlythoserelatingtostress,feelingsofhopelessnessandlowself-esteem.

TrendsinwellbeingintheUK

LevelsofwellbeingandlifesatisfactioninBritainhavestayedfairlyflatsincethe1950s(beforewhich theyhadbeenrising);seeFigure1.7,nextpage.

ThesefindingsarereproducedintheUS,Japanandmanyotherdevelopedcountries(Layard2003). Althoughinternationalcomparisonsaredifficultbecauseinterpretationsoflifesatisfactionvary,surveys showthatintheUK,lifesatisfactionin2001wasjustabovetheEUaverage;seeFigure1.8,nextpage. Thevariationsinlifesatisfactionarepartlyrelatedtohowunequalsocietiesare.PortugalandGreece, forexample,havehighlevelsofinequalityandtheircitizensarelesssatisfiedthanthoseinotherEU countries.TheWorldValuesSurveyin2007attemptedtocorrelatelevelsofinequalityandlife satisfactionacrossselectedcountriesworldwideandfoundthatthemostunequalcountrieswerethe leastsatisfied.ThesurveyfoundthatBritainranksinthebottom-halfofOECDcountriesforboththe averagelevelofsatisfactionandinequalitiesinthedistributionoflifesatisfaction,ranking17thforthe leveloflifesatisfactionand18thforequalityofGDPpercapita.TheGovernmenthasacknowledged thattheseinternationalcomparisonssuggestthereisscopetoimprovelifesatisfactioninBritain,and forittobemoreevenlydistributedacrosstheBritishpopulation.

Box1.3.Howdowedefinewellbeing?

Inthisreport,wetakeabroaddefinitionofemotionalwellbeing.Wedonotincludeseriousmental healthproblemssuchasdementiaorpsychoticmentalillnessessuchasschizophrenia.Thisis becausethecausesandtreatmentofseriousmentalhealthproblemsaresignificantlydifferentfrom thecauses,preventionandpossibletreatmentoflower-levelmentalhealthproblems.Mostpeople andorganisationsworkinginmentalhealthdistinguishbetween‘neurotic’orcommon‘low-level’ mentalhealthproblems,andpsychoticorseriousmentalhealthproblems,suchasdementia, schizophreniaandhallucinations.

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80 90 100 110 120 130 140 150 160 170 180

1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

GDP per capita

% very or fairly satisfied Figure1.7.British

lifesatisfaction andprosperity

Source:basedon PMSU2007

-60 -40 -20 0 20 40 60 80 100

Denmark Netherlands

Sweden Luxembourg

Ireland UK Austria Finland EU 15

Spain Belgium Germany

Italy France Greece

Portugal

Not Satisfied

Fairly Satisfied

Very satisfied Figure1.8.Life

satisfactioninEU memberstates, 2001

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ThereissomecontroversyovertrendsinmentalhealthintheUK,withstudiesidentifyingthat measuredincreasesinprevalencearesometimesduetotheresimplybeingmorediagnosis.However, therearesomeindicationsthatmentalhealthintheUKisworsening.Usingmeasuresofmental healthproblemsin2001,theOfficeforNationalStatistics’PsychiatricMorbidityReportfoundthat oneinfourBritishadultsexperiencesatleastonediagnosablementalhealthprobleminanyoneyear, andoneinsixexperiencesthisatanygiventime(ONS2001).

Therewasalsoanincreaseintheproportionofpeoplereportingmentalillnessesandbehavioural disordersasthemedicalreasonunderlyingclaimsforincapacitybenefitandseveredisablement allowance,growingfrom33percentin2001to41percentin2007(Dunnell2008),asshownin Table1.3.Furthermore,aStrategyUnitreportonlifesatisfactionshowedariseintheincidenceof mentalhealthproblemsforbothmenandwomenbetween1993and2000(PrimeMinister’sStrategy Unit2007).

OswaldandPowdthavee(2007a)reportthatmentalwellbeingisworseninginBritain.Figure1.9 showsforrepresentativesamplesofBritonsthatGeneralHealthQuestionnairepsychologicaldistress scoresrosefrom1991onwards.AndLordLayardhasarguedthatalltheevidencesuggeststhat incidenceofclinicaldepressionhasincreasedsincetheSecondWorldWar(Layard2003). Wellbeinginolderpeople

MostolderpeopleintheUKarehealthyandhappyandmakevaluablecontributionstosocietyandto theeconomy.Infact,oldage,definedasover65years,isoftenseenasatimeofrelative

contentment,althoughthereissomedebateaboutlevelsofwellbeinginolderpeople,justasthereis forthepopulationasawhole.Inthissectionwediscusssomeoftheoftencontradictoryevidence aboutlevelsofmentalhealthproblemsandwellbeinginolderagegroups.

Table1.3.Combinedincapacitybenefitandseveredisablementclaimants,measuredbytypeofmedicalreason, GreatBritain,2001and2007

2001 2007

Mentalandbehaviouraldisorders 33% 41%

Physicaldisorders 67% 59%

Totalclaimants(millions)=100percent 2.8% 2.7%

Source:Dunnell2008

10.90 10.95 11.00 11.05 11.10 11.15 11.20 11.25 11.30

1991 - 1994 1995 - 1999 2000 - 2004

Av

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Figure1.9. Average psychological distresslevels overtimein Britain:

1991–2004,based onGeneralHealth Questionnaire

Source:Oswaldand Powdthavee2007a

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Manyofthecontradictionsarisebecausesomanymentalhealthproblems,particularlyforolder people,remainundiagnosedanduntreated.Therehasbeenatendency,includinginGovernment,to viewolderpeopleasahomogenousgroup.However,theperiodafter65isnotexperienceduniformly andpeopleover80suffersignificantlyandgraduallyworseoutcomesthan‘youngerold’people.A singlegroupingbasedontheover-65shasthusledtoratherover-optimisticassessmentsofthestate ofwellbeingformanyolderpeople.Therearealsowiderinequalitiesinolderpeople’swellbeingthat relatetolevelsofpoverty,health,education,familycontactandsocialandcommunityparticipation, whicharediscussedinChapter2.

Inaninfluentialstudyoftheagedistributionoflifesatisfaction,BlanchflowerandOswald(2004) showedthatpeople’slevelsofhappinessfollowedaU-shapedcurve,withleasthappinessinmiddle age–apatternthatwasconsistentin72outof80countriestheystudied.Forbothmenandwomen intheUK,dissatisfactionpeakedataroundtheageof44,afterwhichlifesatisfactionimprovestoits highestlevelduringthelifecourse.

However,theassumptionsmadebytheU-shapedcurvefindingsarenotapplicabletoolderage groups.Theredoesseemtobeclearevidencethatthepost-80periodismarkedbyincreasing depression.Zaritetal (1999),whofocusedonpeopleover80,foundthatdepressivesymptoms increasedovertime,andthatthiswasassociatedwithpoorhealth(referredtoinSurretal 2005).A BerlinAgeingStudydrewsimilarconclusions(Wernickeetal 2000)andfoundthatthe‘youngerold’ (70-84)reportedconsistentlyhigherpositivewellbeingthanthe‘olderold’(85+)(referredtoinSurr etal 2005).

A2008King’sFundreport(McCroneetal 2008)suggeststhatreportedrelativelylowratesofmental healthproblemsforolderpeoplemaybeduetoinsensitivediagnostictoolsusedinthemostoften referred-tosurveyofmentalhealth,thePsychiatricMorbiditySurvey(ONS2001b).Arecentreport fromAgeConcernandtheMentalHealthFoundationalsoshowsthatratesofdepressionactually increasewithage(Lee2006).

TheKing’sFundanalysisfoundthatthereisnoreductionindepressioninolderage;infactforboth menandwomendepressionisathighestlevelsatthispointinlife.Thestudyshowssignificant numbersofolderpeoplewithdepression,andformentherearerapidincreasesinprevalenceover75.

4.7 4.8 4.9 5.0 5.1 5.2 5.3 5.4 5.5 5.6

15 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70

Age group

Av

er

ag

e l

if

e s

at

is

fa

ct

io

n

s

co

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Depressionisthemostcommonmentalhealthprobleminlaterlife.Estimatesvarybecausemuch depressionisunrecorded,butitislikelythat20to25percentofolderpeopleexperiencedepression thatimpactssignificantlyontheirqualityoflife(Lee2006).Inaddition,therearemanymorepeople whoexperiencepsychologicaloremotionaldistressassociatedwithisolation,lonelinessorloss.These problemsarenotrecordedbythehealthormedicalcaresystembutcontributetopooremotional wellbeingandlowlifesatisfaction.Thenumbersofolderpeoplewithpooremotionalwellbeing,aswe havedefinedit–includingothercommonmentalhealthproblemsandpoorlifesatisfaction–are likelytobemuchhigherthantheestimatesof20to25percentofolderpeoplewithdepression. Someseriousmentalhealthproblems,particularlydementia,haveahighlysignificantimpactonolder people.Dementiaisparticularlysignificantbecauseitaffectssomanyolderpeople,asmanyas25per centover85,andbecauseitaffectsfamilyandfriends.Peoplecaringforpeoplewithdementiahavea muchhigherlikelihoodofbeingdepressedthemselvesandsorisingnumbersofpeoplewithdementia arelikelytohaveadoubleimpactonwellbeing.

Futuretrendsinolderpeople’smentalwellbeing

Depressionandanxietydisordersaresettobecomemoreprevalentinthenext20yearsdueto increasingnumbersofolderpeople,accordingtoMcCroneetal (2008),withthesuggestionthat increasesinprevalencewillbedrivenbydemographicsalone(seeFigure1.12,nextpage). However,thesomewhatoptimisticassumptionthattheprevalenceofmentalhealthproblemsis notincreasingforolderpeoplecontradictsotherevidenceweoutlinedearlierthatsuggeststhat mentalhealthproblemsarebecomingmoreprevalentacrosstheUKpopulation.Additionally,as wehavediscussedthenumberofolderpeoplewillrise,onitsownleadingtoasubstantial increaseinthenumberofolderpeoplewithmentalhealthproblemsandgeneralpooremotional wellbeing.CurrentlyaboutthreemillionolderpeopleintheUKsufferfromamentalhealth problemandthisisexpectedtorisebyonethirdoverthenext15years(Andersonetal 2008), andthereareestimatedtobecurrently2.4millionolderpeoplewithdepressionsevereenoughto impairqualityoflife.Thesefiguresarelikelytobeunderestimatesasonlyonethirdofolder peoplewithdepressiondiscusstheirsymptomswiththeirGP(Chew-Grahametal 2004).

0 5 10 15 20 25 30 35 40 45

15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85+ Age group

C

ase

s p

er

1000 p

eop

le

Male Female

Figure1.11. Prevalenceof depression,by genderandage group

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Additionally,forpeopleagedover80therearefurtherdownwardtrendsinwellbeing.And

althoughseriouscasesofmentalhealtharenotthefocusofthisreport,itisworthnotingthatthe numberswithseriousmentalhealthproblemsanddementiaaresettorisesubstantiallyas

numbersofolderpeople,andthoseagedover85inparticular,grow.Thiswillhaveawideimpact asincreasingnumbersofcarers,familyandfriendsfindtheirqualityoflifemayworsenasaresult. Forfourreasons,then,wecanexpecttoseeasignificantincreaseinthenumbersofolderpeople withpooremotionalwellbeing:

1.Mentalhealthproblemsmaybebecomingmoreprevalentacrossthelifecourse. 2.Thenumberofoldpeopleissettorisemarkedly.

3.Thenumberandproportionofolderoldpeoplearealsoincreasing.

4.Therewillbeariseinthenumberofcarers,whoareathigherriskofdepressionthantherest ofthepopulation.Manyofthesecarerswillbeolderpeople,caringforspousesoreven parents.

Summary

TheUK’spopulationisageingbecausethebirthratehasbeenfallingforthepast30yearsandlife expectancyandhealthimproving.Thenumbersofolderpeople,bothinabsolutenumbersand proportionately,willincreasesignificantlyandmorepeoplewillsurvivepasttheir85thbirthdayand manypasttheir100th.Thereissomeevidencethatpeoplearealsolivinglongerinbetterhealth– althoughbothhealthandlengthoflifecorrespondcloselytosocio-economicstatusandalsoto ethnicity.

WhiletherehavebeenstrikinggainsinhealthandwealthintheUK,thesehavenottranslated intoimprovementsinlifesatisfactionandhappiness,incommonwithothercountries.Indeed, thereissomeevidenceofworseningtrendsinmentalhealthproblems.Wellbeingisbecomingan increasinglyimportantmeasureofprogressandontheavailableevidenceprogressseemstohave stalledintheUK.

80 100 120 140 160 180 200

2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 Year

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it

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, 2007 = 100)

15 - 44

45 - 64

65 - 74

75 - 84

85+

Figure1.12. Projectedchange innumberof peoplewith depression,2007 to2026

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Thereissomedebateovertheprevalenceofmentalhealthproblemsamongolderpeople.However,it doesappearthatprevalenceofmentalhealthproblemsincreaseswithage,particularlyforthoseover 75,andthattheprevalenceofpoorwellbeingalsorises.

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Manyolderpeopleenjoylife,butasignificantproportionstrugglewithloneliness,isolation,low-level mentalhealthproblemslikedepressionorevenmoreseriousproblemsthatleadtosuicide.Certain groupsofolderpeopleareatmoreriskofpooremotionalwellbeingthanothers:thesearetypically thepoorest,theveryelderly,someminorityethnicgroups,themostisolated,thosewithworse physicalhealth,and,themostsignificantthoughoftenneglected,thosewithoutanactivesocialor communitylife.

Thischapterassessestrendsinthekeydriversofolderpeople’swellbeing–boththosethataffectit negativelyandthosethatcanimprovewellbeingandprotectolderpeopleagainstdepression, lonelinessandisolation.Wecontendthatthereisfarmorethatpolicymakerscandotoprotectand fosterabettersenseofwellbeingfortheUK’sgrowingnumberofolderpeople.

Socialexclusion,inequalitiesandhealth

Levelsofwealthhaveincreasedforalmosteveryone,butnotequallyandthereisevidenceof wideningincomeinequalitiesbetweenthetopandbottomgroups.Forolderpeopleincomeand wealthhaveincreasedmorethantheaverage,although2006-7figuresshow300,000more

pensionersinpovertythanthepreviousyear,perhapsindicatingareversalofthistrend.Over-75sare faringrelativelybadlywithlowerincomesthanthe65-74agegroup.

HouseholdwealthmorethandoubledintheUKbetween1987and2006andpeoplearespending twoandahalftimesmoreongoodsandservicesthanin1971(Dunnell2008);seeFigure2.1.Over theperiod1987to2006realhouseholddisposableincomeperheadrosebyaround60percent.

Therisesare,however,unequallydistributedandtheshareofwealthofthewealthiest1percentof thepopulationwas21percentin2003,havingrisenfrom17percentin1991.Incomeinequalitywas atitshighesteverlevelin2006-7(Breweretal 2008).IncomeinequalityintheUKishigherthanthe Europeanaverage.IntheUK,thetop20percentoftheincomedistributionreceives5.4timesgreater ashareoftotalincomethanthatreceivedbythebottom20percentofthepopulation,comparingto anEUaverageratioof4.8(Eurostat2007).

Thisissignificantbecauselevelsofinequalityinincomeandwealthareveryimportantinshaping levelsofsatisfactionandwellbeingamongthegeneralpopulation.Wideinequalitieshavebeenfound tobedetrimentaltowellbeing,causingstressandunhappiness(PickettandWilkinson2007).

2.Factorsthatshapewellbeinginolderpeople

0 50 100 150 200 250

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Figure2.1.Net

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Povertyanddeprivation

Forpensioners(menover65andwomenover60),realincomeandshareofnationalincomehave risensignificantlysince1979;andthegrossincomeofpensionerfamiliesaveragedoverallagesand familytypesroseby37percentinrealtermsbetween1994/95and2005/06,comparedwithan increaseofabout17percentinrealaverageearnings(ONS2008c).

Pensioners’averageincomerosefasterthanyoungerpeople’searningsbetween1996/7and2004/5 (25percentcomparedwith15percent).Theserisescamefromincreasesinoccupationalpensions, investmentsandbenefits.

Theeffectoftheserisesinpensionerincomeshasbeenamovementofpensionersuptheoverall incomedistributionladder.Theproportionofpensionersineachfifthoftheincomedistributionin 1979and2004/5isshowninFigure2.3.In197947percentofallpensionerswereinthebottom Figure2.2.Real

incomeof pensioners, 1979-1996/7and 1994/5-2004/5 (from1979 baseline=100)

Source:ONS2006b

0 5 10 15 20 25 30 35 40 45 50

Bottom fifth Next fifth Middle fifth Next fifth Top fifth

1979 2004/5 Figure2.3.

Pensioners’ positioninthe overallnetincome distribution,1979 and2004/5 Source:ONS2006b

P

er

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fifth,asmeasuredbeforehousingcosts,andby2004/5thisproportionhadalmosthalvedto25per cent.However,thisstillmeansthataquarterofpensionersareinthebottomfifthforincomeand nearlyathirdmoreareinthesecondfifth.

Althoughthefiguresforpensionerpovertyshowsignificantimprovementsince1990,in2005/6just overafifthofallpensionerswerestillreceivinglessthan60percentofthemedianincome.This increasedto23percent(afterhousingcosts)in2006/7.Thereisalsoanagegradienttopensioner povertywith18percentof65-to69-year-oldsreceivinglessthan60percentofmedianincome, comparedto32percentoftheover-85s(DepartmentforWorkandPensions2008).

Themostrecentfigures,for2006-7,showaworseningtrendforrelativepensionerpovertyand between2005-6and2006-7therewasanincreaseof300,000inthenumberofpensionersinrelative povertyafterhousingcosts,bringingthetotalto2.1million.In2006ratesofpovertyamongolder peopleweremuchhigherintheUKthaninmanyotherEuropeancountries.TheUKpovertyratefor over-65scomparesunfavourablywiththe2006EUaverage(Eurostat2007).

Lookingatawideragegroup,in2006theSocialExclusionUnitfound3.4millionpeopleover50lived inrelativepovertyand1.2millionpeopleover50inEnglandfacedsevere,exclusion(ODPM2006a). Aroundhalfofpeopleover50suffereddisadvantagewithrespecttooneaspectoftheirlife. Povertyhasaclearrelationshipwithpooremotionalwellbeingacrossthelifecycleandworsening incomeinequalitiescompoundthat.Andtheevidencethatpovertyatanearlyage,evenprenatally,is astrongpredictorofoutcomes,isclearandunequivocal(Bamfield2007).Asthefirstreportfromthe UKInquiryintoMentalHealthandWellbeinginLaterLifestates:

‘Disadvantageinchildhoodorearlyadulthoodoftenleadstoimpairedphysical andmentalhealthinlaterlife.Earlyvulnerabilitytomentalhealthproblemsis predictivenotjustofmentalhealthproblemsinlaterlifebutalsoofpoor socialisation,criminality,lackofparticipationandrelationshipdifficulties.On theotherhand,advantageinchildhoodorearlyadultlifemayresultinbetter physicalandmentalhealthinlaterlife.’(Lee2006:14)

Table2.1.Individualslivinginhouseholdsbelow60percentofmedianhouseholddisposable incomeintheUK(%)

Years Children Pensioners Peopleofworkingage

1990–91 27 37 15

1991–92 28 32 16

1992–93 29 28 16

1993/94–94/95 27 24 15

1994/95 25 24 15

1995/96 24 24 14

1996/97 27 25 15

1997/98 27 25 15

1998/99 26 27 15

1999/2000 26 25 15

2000/01 23 25 15

2001/02 23 25 15

2002/03 23 24 15

2003/04 22 23 15

2004/05 21 21 14

2005/06 22 21 15

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TheGovernmenthasactedonthisevidenceandinvestedsignificantlyintryingtoreducethenumber ofchildrenlivinginpovertyandin2006/7therewere600,000fewerchildreninrelativepovertythan 10yearspreviously.Theinvestmentsmadeinearlyyearsandchildhoodhaveachievedagreatdeal andiftheimprovementsaresustainedthroughadulthoodtherearelikelytobefewerolderpeople withemotionalandmentalhealthproblemsasaresult.

Theimperativetoinvestearlytoachievelifelongbenefitshasdominatedthepolicyagendaforthelast tenyears,andhaspartlybeenaresponsetothedemandsforclearcost-efficacybytheTreasury.The Treasuryhasacceptedthatearly(inageterms)interventionhaslong-termgains.However,tosome extentthisapproachhasworkedagainstolderpeople,whohavenotreceivedanythinglikethe resource,attentionandfocusastheyoung.Thisshouldberectified:asoldagebecomesincreasingly longaspeopleliveforlonger,thereisevidencethatinvestmentinearlyoldagewillpayoffinolder oldage.Moreover,therearecompellingethical,moralandsocialjusticereasonsforfurthersupport andinvestmentinolderage.

Inequalitieswithintheover-65group

Highlevelsofinequalityareincreasinglybeingrecognisedasdetrimentaltoemotionalwellbeingand mentalhealth–resultinginenvywhichcausesstress,andthefeelingofrelativefailure.Withinthe over-65agegroupitself,thegainsinincomeandwealthhavenotbeenspreadequally:

•

Singlepensionershavelessthanhalftheearningsofmarriedpensioners.

•

Olderpensionershavesignificantlylowerincomesthanyoungerpensioners(seeFigure2.4).

•

Femalepensionershave,onaverage,lowerincomesthanmen.Forexample,singleretiredmen hadanaveragenetincomeof£220perweekin2004/5comparedwith£186forsinglefemale pensioners(ONS(2006).

0 50 100 150 200 250 300 350 400 450

Recently retired Under 75 Over 75

Other income

Earnings

Investment income

Personal pensions

Occupational pensions

Benefit income Figure2.4.

Sourcesof pensioners’ income,byage group

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•

Therearegeographicalinequalities:pensionersintheSouthEastofEnglandandLondonhave onaveragehigherincomesthanpensionersinotherpartsoftheUK.Averageincomefromstate benefitsvariesmuchlessbetweenregionsthanothertypesofincome(ONS2006).

•

Minorityethnicgroupsaccountfor3.5percentofallpensionersinGreatBritainandthat proportionisgrowing.Someethnicminoritypensionershaveloweroverallincomethantheir whitecounterparts.Alargepartofthisdifferenceisduetoethnicminoritypensionersbeingless likelytoreceiveoccupationalorprivatepensions.Theyarealsolesslikelytoreceivestate retirementpension(ONS2006).

Incomeinequalitiesamongolderpeoplecompoundexistingdeprivationandphysicalandmental healthinequalitiestoproducesignificantlyhigherlikelihoodofpooremotionalwellbeingforthose groups.

TheOfficeforNationalStatisticsstatesthat:‘Commonmentaldisordersaremoreprevalentinmanual socio-economicgroupsthaninnon-manualsocio-economicgroups.Theprevalencewashighestin SocialClassV(18percent)andlowestinSocialClassesIorIIcombined(6percent)’(ONS2003:xii). SuicideratesinthemostdeprivedareasinEnglandandWalesfrom1999to2003weremorethan doublethoseintheleastdeprivedareas(Dunnell2008).

Thestrongassociationbetweenlevelsofdeprivationandpooremotionalwellbeingispartlyexplained bystressesassociatedwithpoverty–strugglingtomakeendsmeet,poorhousingconditionsand widerphysicalenvironment,fearofcrime,andrelativelypoorphysicalhealthareallexperiencedmore themoredeprivedyouare.Thestressassociatedwithlivinginanunequalsocietyisincreasinglyseen asvitalinunderstandingtheriseofpoormentalhealthandwellbeingin‘rich’societies(Pickettand Wilkinson2007).

Figure2.5showshowstress,asmeasuredbytheGeneralHealthQuestionnaire12score,relatesto incomelevelandgender.

Physicalhealth

Thereisawealthofevidenceshowingthatphysicalhealthiscloselyassociatedwithemotional wellbeing.Thisisparticularlyrelevantforolderpeople,whosuffermuchhigherlevelsofchronicill healththantherestofthepopulation.Healthisoverwhelminglyfelttobethemostimportant determinantofhappinessamongtheover-55s.Ithasbeenestimatedthatupto70percentofallnew casesofdepressionarisinginolderpeoplemaybecausedbydisabilityassociatedwithillhealth(Surr etal 2005,ONS2003).Moststudieshavefoundthatprevalenceratesofdepressionare

approximatelydoubleforolderpeoplesufferingillhealthanddisabilitycomparedwiththosewhoare healthy.IntheEUalmostoneinthreepeopleaged85oroversaytheyareseverelylimitedbyphysical ormentalhealthconditionsintheactivitiestheynormallydo(Eurobarometer2007).

0 5 10 15 20 25

Lowest Second Middle Fourth Highest

Equivalised household income quintile %

Men

Women

Figure2.5. GeneralHealth Questionnaire12 score(observed

andage-standardised),by equivalised householdincome andsex(menand womenaged16or over)

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Princeetal (1998)suggestedthatimmobilityassociatedwithphysicalillnessbringsaboutisolation andlimitedcontactwithfriendsandneighboursinthelocalarea,leadingtolossofintimacyand reducedsenseofcommunity,furtherexacerbatingisolation,lonelinessanddepression.Verhaaketal (2005)(citedinSurretal 2005)providefurtherevidenceofthis:fromanationalpanelofGPs’ patientsfollowedovermorethan15years,themostimportanteffectfrommentaldistressamong chronicallyillpeoplewasthesocialimpactofillhealth,ratherthantheillnessitself.However,the relationshipwecurrentlyseeintheUKbetweenage,poorphysicalhealthandpooremotional wellbeingisnotinevitable:servicesandcommunityinterventionsaimedatreducingsocialisolation andimprovingcommunitysupportcanreducetheseimpacts.

Moreover,whilephysicaldisabilityisariskfactorfortheonsetofdepression,depressivesymptoms caninturnleadtoincreaseddisability.AFinnishlongitudinalstudyexaminingtherelationship betweendepressionandphysicaldisabilityreportedthatdepressedolderpeoplewereathighriskfor physicaldisabilities(KivelaandPahkala2001,referredtoinSurretal 2005).

Theneedtoencourageandsupporthealthylivingforover-65sisimportant,bothtoimprovephysical healthandtosustainemotionalwellbeingforolderpeople.However,healthimprovementcampaigns andpublichealthmeasuresaremostlygearedtowardsyoungeragegroupswitholderpeople’shealth oftenneglecteduntilpeoplebecomeillandrequiretreatment.Physicalactivity,eatinghealthilyand drinkingsensiblyareallcloselylinkedtobothgoodphysicalandmentalhealthforolderpeopleaswell asyoungerpeople.Acrossallagegroupslevelsofphysicalactivity,goodnutritionandsensibledrinking aredeclining.Levelsofobesitycontinuetoriseinbothchildrenandadultsandtheproportionof alcohol-relateddeathsintheUKmorethandoubledbetween1991and2006(ONS2008c). Inthenext10yearsandbeyondtherewillbeevenmoresignificantimpactsastoday’smiddleaged andyoungerpeopleageandtherisingburdenofobesity,poornutrition,smokingandexcessive drinkingimpactonolderpeople’sphysicalandmentalhealth.

Alcoholabuseisbothacauseandasymptomofseriousandlow-levelmentalhealthproblems,social exclusionandisolation.Approximately10to30percentofolderpeoplewhoabusealcoholbecome depressedandtheyarealsoatgreaterriskofsuicide(Beeston2006).Figuresalsoshowthatolder menarecurrentlybetweentwoandsixtimesmorelikelythanolderwomentoabusealcohol.

Althoughalcoholabuseisaproblemforpeopleofallages,itismorelikelytogounrecognisedamong olderpeople.

Theproportionofover-65swhosmokedintheUKwashigherthantheEUaveragein1999,

particularlyforwomen–almostoneinfivewomenagedover65smokedintheUKin1999compared withjustoneintenonaverageintheEU(SwedishNationalInstituteofPublicHealth2006).Smoking rateshavefallen,however,intheUKsince1999.Smokingiscloselyassociatedwithdeprivation,with moredeprivedgroupsmorelikelytosmoke,andisatleastpartlyresponsibleforwideninginequalities inhealthbetweensocio-economicgroups.

Thereisaclearneedtoinvestinhealthpromotioncampaignsaimedatolderpeopleandtocontinue todriveinitiativesandinterventionstoimproveolderpeople’shealth.Aswellasreceivingfewer diagnosesandlesstreatmentformentalhealthproblemsthereisalsosomeevidencethatolderpeople receivelesspreventativetreatmentsfromhealthservices(Leathermanetal 2007).Forinstance,a 2005analysisoftheprescriptionofpreventativemedicinefollowingheartattackshowedclearage-baseddifferences(Ramsayetal 2005,citedinLeathermanetal 2007).

Ethnicity

Thereisevidenceindicatingthatsomeblackandminorityethnic(BME)groupsareparticularly susceptibletocertainmentalhealthproblems,forinstancedepression,andingeneral,ratesofmental healthproblemsarethoughttobehigherinminorityethnicgroupsthaninthewhitepopulation. However,thosegroupsarelesslikelytohavetheirmentalhealthproblemsdetectedbyaGP(NIMHE 2003).

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moreuniformalthoughwhiteandPakistanimenfareworsethanmenfromotherethnicgroups.There islikelytobeconsiderableunder-diagnosisandunderreportingofdepression,particularlyformen. InBritain,researchintothephysicalandmentalhealthofolderpeoplefromBMEgroupsisinits infancy(Smaje1995).Butpoorerphysicalhealthandhigherlevelsofpovertyhavebeenreported amongsomeminorityethnicgroups,asdiscussedearlier,andbothareriskfactorsfordepressionin olderage.

A2005studybyNazrooetal,basedoninterviews,foundthatthereweresixmainfactorsthat influencedthequalityoflifeofolderpeople:havingarole,supportnetworks,incomeandwealth, health,havingtime,andindependence.Whilethiswasthecaseforallolderpeople,thewaysthe factorswereexperiencedwereinfluencedbyaperson’sethnicity.Forexample,theextentoffamily networks,thelevelofpensionresources,orhealthcanallbeshapedbyethnicity.Theinterviews identifiedsocial,practicalandemotionalsupportaskeytoagoodqualityoflife.Partner,family, friendsandreligionemergedasthemainsourcesofsupport.

Intermsoffamilyandfriendshipsupport,olderpeopleintheIndianandPakistanigroupsfaredwell comparedwiththewhitegroup.Theresearchalsoshowedreligiontobesignificantintermsof emotionalandpracticalsupport.Theroleofreligioninhelpingprotectolderpeopleagainstdepression andpooremotionalwellbeingisdiscussedlaterinthischapter.Itisworthnotingherethatforsome BMEgroups,relativelyhighlevelsofreligiousbeliefandparticipationhelpedprotectagainstpoor emotionalwellbeing.

Formanyolderpeoplelossofrespectorstatusisoneofthecontributoryfactorsthatleadstopoor emotionalwellbeing.Theroleofolderpeoplewithincommunitiesandfamiliesvariesaccordingto ethnicity.ForinstanceolderPakistaniandIndianpeopleinmulti-generationalhomesretaintheir statusasheadofhousehold,eveniftheyhavedecliningphysicalhealthorneedacarerathome;this isoftennotthecaseinotherethniccultures(Nazrooetal 2005).

TherearelessonstobelearntfromdifferentcommunitieswithintheUKaswellasfromabroad,both fortheapplicabilityandtransferabilityofapproachestothewidercommunityandtohelpgovernment

0 1 2 3 4 5 6 7

White Irish Black Caribbean Bangladeshi Indian Pakistani Male Female Figure2.6.

Percentageof peoplewith depression,by ethnicgroupand gender

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andotherstodevelopandtailorappropriateservicesforparticularcommunities.Itisimportantthat moreresearchevidenceisundertakenandusedtoshapefuturepolicymaking.

Gender

Womenaremorepronetosomementalhealthproblemsthanmenare,particularlydepression,self-harmandeatingdisorders,with14percentofwomencomparedwith9percentofmenhaving disordersofthiskind(ONS2003).Numerousresearchreportsandalargebodyofevidenceindicates thatwomenreportmoredepressivesymptomsthanmen,bothatyoungeragesandlaterinlife(Surr etal 2005).Thesituationdeterioratesformen,too,astheyage,andtheybecomeincreasingly susceptibletodepression.

Lackofdiagnosisofmentalhealthconditions

Acrosstheagespectrummanymentalhealthconditionsarenotdiagnosedortreated.Forexample, theKing’sFundfoundin2008that51percentofpeoplewithanxietydisordersarenotincontact withservicesandofthosewhoare,46percentdonotreceivemedicationorpsychologicaltherapy (McCroneetal 2008).

Lackofdiagnosisisparticularlyacuteinolderpeopleandtherearealmostcertainlyhigherlevelsof depressionandpooremotionalwellbeingforthisgroupthaniscapturedinstatistics.Ofthoseolder peoplewhododiscusstheirdepressionwiththeirGP,onlyhalfreceivetherapyortreatment.Fewer thanonein10arereferredtospecialistmentalhealthservices,andingeneraltheyarenotofferedthe rangeoftreatments,suchastalkingtherapies,thatareavailabletoyoungerclients(Godfreyetal 2004).

TheNationalServicesFrameworkforolderpeoplesuggeststhatunder-detectionofmentalillnessin olderpeopleiswidespread,duetothenatureofthesymptomsandthefactthatmanyolderpeople livealone(DepartmentofHealth2004).Thelackofdiagnosisandreportingofmentalhealth problemsinolderpeopleiscompounded,andpartlycausedby,awidespreadlackoffocusonolder peoplewithinmentalhealthpolicy.Mentalhealthinitiativeshavetendedtotargetadultsofworking ageandchildrenandyoungpeople(Lee2006).

Relationshipsandsociallife

Contactwithfriendsandfamily

Themostimportantfactorsunderlyingolderpeople’smentalhealthandwellbeingaresocialand communityparticipation.Thereisasizeablebodyofresearchevidencelinkingthestrengthandquality ofsocialrelationshipsandcommunityengagementtohealth,wellbeingandqualityoflifeforolder people(BerkmanandSyme1979,Beekman2000,Gottlieb1987,Smithetal 2002,reviewedbySurr etal 2005).Higherlevelsofsocialsupport,specificallyfrequencyofcontactwithfriends,reducethe risksfordepressionevenforthosewithpoorphysicalhealth(Princeetal 1998).Conversely,lackof socialsupportisassociatedwithincreasedmortalityandpoorhealth.

Havingaclose,confidingrelationshiplessenstheimpactofdepression.Italsohelpsindealingwith majorlifeeventsandstressincludingchronicillness(Surretal 2005).Thisisrecognisedandvoicedby olderpeoplethemselves.AstheUKInquiryintoMentalHealthandWellbeinginLaterLifestates: ‘[o]lderpeoplesaythatvisitstoorfromfriendsandfamilymotivatethemtogetoutofbedinthe morning.Havingsomeonetotalkthingsoverwithhelpsthemtocopewithworries.Manysaythatthe mostimportantthingistofeelwantedandneededbyothers’(Lee2006:42).However,thereare largenumbersofolderpeoplewhoexperienceisolationandloneliness.Estimatessuggestthat1 millionolderpeopleintheUKaresociallyisolatedandthisnumberisprojectedtoriseto2.2million overthenext15yearsiftheissueisnotaddressed(ibid).

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Increasesinthenumberofpeoplewithnochildrenorwithonechildarelikelytoimpactonwellbeing inlaterageascontactwithfamilyisconsideredbymanyolderpeopletobeveryimportantand havingfew,orno,childrenclearlymeanslesscontact.

Figure2.7showsdifferencesinphysicalproximitytograndchildren,byageandsocialclass.Itshows thatproximitytendstoreducewithincreasingage,justwhensupportintheformofcontactismost neededbyolderpeople.Italsoshowsthatnon-manualgroupstendtolivefurtherawayfrom grandchildrenthanmanualgroups.

In2005theBritishSocialAttitudesSurveyaskedrespondentshowmuchtimetheyspentwithfriends andfamily.Womentendedtospendmoretimewithbothfamilyandfriendsthanmen:65percent statedthattheysawmembersoftheirfamilyorotherrelativesweeklyornearlyeveryweekand63 percentsawfriendsweekly,comparedwith57percentand58percentrespectivelyformen(ONS 2008c).Formanyolderpeoplecontactdeclinesforreasonssuchasbeinginpoorphysicalhealth, movinghouseorintoacarehome,orbecomingacarer.Astudyexploringtrendsinlonelinessamong olderpeoplefoundthatnearlyafifthfeltlonelyandisolated(Actoretal 2002).

Researchintowhatolderpeoplevalueaboutcloserelationshipsshowsthatfeelingusefulandgiving supportandhelptoothersisparticularlyimportanttothem.Thereisagrowingliteratureonthe benefitsandvaluetoolderpeopleofvolunteering,whichisexploredmoreattheendofthischapter. Maritalstatus

Nevermarryingisassociatedwithalowprevalenceofmentalhealthproblems,withjust8percentof menand4percentwomenwhodonotmarryexperiencingsuchproblems.Divorceandseparation resultinahighprevalenceoflow-levelmentalhealthproblems(experiencedby19percentof divorcedorseparatedwomenand17percentofmen).Marriageisassociatedwithalowprevalence

0 10 20 30 40 50 60 70 80 90

< 60 60 - 69 70+ Manual Non-manual

<30 minutes

30 minutes - 2 hours

> 2 hours

Figure2.7. Proximityto grandchildren Source:Presentation atipprseminaron grandparenting, 2008

P

er

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ofmentalhealthproblemsinmen(7percent)but,significantly,marriedwomenhadahigher prevalence(12percent).ThisappearsalsotobethecaseacrossEuropewithevidencefrom13outof 14Europeancountriesshowingthatmarriagewasaprotectivefactorformenbutariskfactoramong womenwhenitcametolow-levelmentalhealthproblems(ONS2003).Thereforetrendsinmarriage anddivorceareimportantinunderstandingtrendsandpatternsofmentalhealthproblemsand emotionalwellbeing.

Livingalone

Unsurprisingly,reportedlevelsoflonelinessarehigheramongthosewholivealonecomparedwith thosewholivewithothers.Amongthoselivingalone,17percentratedthemselvesas‘often/always lonely’comparedwith2percentlivingwithothers,and80percentofthe‘oftenlonely’livedalone (Actoretal 2002).

Therehavebeensignificantchangesinlivingarrangementsoverthepast40years,withmorepeople livingalone,increasingthelikelihoodoflonelinessandisolationforolderpeople.

WhiletheproportionofolderwomenlivingaloneinGreatBritainhasremainedstableoverthelast20 years,theproportionofoldermenlivingalonehasincreased,reflectingincreasinglifeexpectancyfor menover65andchanginglivingarrangements.Evenso,womenaged75oroverwerealmosttwiceas likelytobelivingaloneasmenaged75oroverin2006.

Thereislikelytobeasustainedandsignificantincreaseinnumbersofpeoplelivingalone.Figuresfor Englandsuggestthat70percentofprojectedgrowthinthenumberofhouseholdsupuntil2026will

Table2.2.Proportionofmenandwomenlivingalone,byage,GreatBritain,1986and 2006(%)

1986 2006

Womenaged25-44 4 8

Womenaged75+ 61 61

Menaged25-44 7 14

Menaged75+ 24 32

Source:Dunnell2008

0 5 10 15 20 25 30 35 40

1971 1981 1991 2001 2011 2021

Under 65 Over 65 Figure2.8.

Proportionof single-person households,1971-2021

Source:PMSU2008

P

er

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bebecauseofanincreaseinsingle-personhouseholds.Manyofthesearehometopeopleaged65 andover.Theproportionofmenandwomenbetween25and44livingalonehasdoubledandas thosepeoplegetolderthiswilllikelyincreasetheproportionofolderpeoplelivingalone,making policyinterventionandsupportforsocialengagementforolderpeoplelivingaloneevenmore important.

Agediscrimination

Discriminationagainstpeoplebasedontheirageiswidespreadandcomparedwithotherformsof discriminationisoftenseenas‘acceptable’.Thiskindofdiscriminationunnecessarilyexcludesolder peoplefrommanyservices,publicplaces,communitylife,leisureactivities,employment,mainstream culture,mediaandpublicdebate.Suchneglectfostersaculturethattendstooverlookorignorethe viewsofolderpeopleandmakethemfeel‘castaside’.AsurveyoftheEUcountriesin2007indicated thatintheUKahigherthanaverageproportionofpeoplethinkthatagediscriminationiswidespread (51percentcomparedwiththeEUaverageof46percent),ranking18thoutof25countries (Eurobarometer2007).

In2005theDepartmentforWorkandPensions,whichhasresponsibilityforolderpeople,setouta promisingandambitiousstrategyforimprovingolderpeople’swellbeing.Whilemanyoftheproposals haveyettobeactedon,thedocumentacknowledgestheperniciouseffectsofageismand

discrimination(DWP2005).Followingthis,theGovernment’sreportASureStarttoLaterLifesetout thateveryone,includingolderpeople,hastherighttoparticipateandcontinuethroughouttheirlives inhavingmeaningfulrelationshipsandroles(ODPM2006b).However,therehasnotbeensufficiently sustainedorambitiousactiontocounterwidespreaddiscrimination,althoughitistooearlytojudge thesuccessofrecentdiscriminationlegislation.

Discriminationalsohappenswithinfamilies,witholderpeople’sneedsmarginalisedorignored.The extenttowhichthishappenscanreflectdifferencesinethnicgroups.ForinstanceinBengaliand someotherAsiancultures,ageisreveredandpeoplegainfamilyandcommunityrespectastheyage. Olderpeoplewithmentalhealthproblemsfaceadditionaldiscrimination.Prejudiceagainstpeople withmentalhealthproblemsiswidespreadandcontributestounder-diagnosisoftheseproblems acrosstheagespectrumandareluctanceforpeopletoadmittothemselves,theirfamilyorhealth servicesthattheyhaveaproblemofthisnature.Forolderpeoplethiskindofdiscrimination exacerbatessomeofthemostchallengingproblemsassociatedwithageing,includinglossofsocial life,respectandfeelingisolatedandexcluded.

Eventsandtransitionsinlifethatcantriggerpoormentalwellbeing

Thereisevidencethatparticularlifeeventsarepowerfulriskfactorsintheonsetofdepressionamong olderpeople(Surretal 2005).Theseincludeonsetofpoorphysicalhealth,bereavement,retirement, divorce,illnessofaclosepartnerandtakingoncaringroles.Thesefactorsareparticularlyprevalentfor olderpeoplebecausethelikelihoodofadestabilisingandnegativelifeeventishigherinolderage. Inacommunity-basedstudy,BrilmanandOrmel(2001)foundthateventsthatcausedseverestress (particularlydeath,physicaldisabilitiesandhospitalisationofsomeoneclose)wereassociatedwith onsetofthefirstepisodeofdepressionamongolderpeople(citedinSurretal 2005).Theincidence anddurationofdepression,stressandanxietyfollowinganegativelifeeventarepartlydependenton previouslifeeventsandpersonalresourcesandcapacitytocope,andpartlyonsupportavailableboth fromfamilyandfriendsandfromservicesandcommunity-basedinterventions.

Retirement

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One-thirdofadultlivesarelivedinretirementandaslifeexpectancyincreasesandworkpatterns change,thisproportionwillincrease.Theaveragenumberofyearsweliveinretirementhasalready nearlydoubledoverthepasthalf-century,from11toalmost20years(Lee2006).

Bereavement

Mostpeoplefacebereavementandgriefastheyage.Womenareatgreaterriskbecausetheyare morelikelytolivelongerthanmen.Cross-sectionalsurveys(forexample,theGeneralHousehold Survey)showthataround50percentofolderwomenarewidowedcomparedwith20percentof oldermen,andtheproportionsincreasewithage.Whereasjustunderathirdofwomen(28percent) and9percentofmenuptoage74arewidowed,thecorrespondingrateforthoseaged75andover is62percentand28percentrespectively.

Whilebereavementistraumaticandstressfulforeveryone,mostolderpeopleeventuallymanagethe distressandadjust.Forsome,levelsofwellbeingrecovertothesamelevelsorhigherasbeforethe bereavement(Oswald2007).However,someresearchdescribeshowbetween10and20percentof olderpeoplesufferseveregriefwhichcan,ifunsupported,leadtoseriousdepression,chronicill health,anddisability(seeSurretal 2005).Bereavedmenareatgreaterriskofdeaththanwomen, particularlyduringthefirst12monthsfollowingbereavement.Suicideratesanddepressionarealso significantlyhigherinbereavedmen.

Thereissomeevidencethatsocio-economicfactorsimpactonthewaybereavementisexperienced. Forexample,highereducationalstatusandincomelevelsmayplayaprotectiverole,again

highlightingthelikelihoodoffurtherinequalitiesinwellbeingandtheneedforcarefullytargeted interventions.Bereavementmayinvolvesignificantchangesandfurtherlosses,forexamplelossof income,relocationandlossofcontactwithfamilyandfriends.Targetedandeffectivesupportto bereavedolderpeoplecouldhelpthemthroughtheimmediateshort-termperiodandhelpimprove theirlong-termwellbeing.

Care:receivingandgiving

Asurveysuggestedthatdepressionaffectedoneinfiveolderpeoplelivinginthecommunity,risingto twoinfiveforthoseincarehomes(Godfreyetal 2004),withmuchgoingundiagnosedand

untreated.Mentalhealthproblems,includingdepression,arealsoamajorreasonforadmissionto nursingandresidentialcare.

Thereisalackofresearchintowhysomanycarehomeresidentsaredepressedandwhetherthey werealreadydepressedwhentheyenteredortheybecomedepressedasaresultofdoingso.Care homesvaryinthewaythatdepressedolderpeoplearetreatedandhowattemptsaremadetoprevent depression.Again,thereisalackofresearchinthisareaintheUK.

ipprhasfoundthatpeoplereceivingandgivingcarearenotreceivingthesupporttheyneed.And whilemostanalysesconcentrateonthecostsofcareandtheneedforincreasingsupplyofcarersand carehomes,itisimportanttofocusalsoonthequalityofcaregivenincarehomesandbycarers. Moreresearchwouldatleastallowidentificationofbestpracticeandpromotionofwellbeingasagoal initself(Moullin2007).

AstudybytheDepartmentofHealthandAgeinginAustralia,whichinvolved1,758olderpeoplein 168carehomes,foundthattheywereaffectedbybeingunabletotakepartinactivities,poor relationshipswithstaffandotherresidents,andnotbeingvisitedenough(referredtoinO’Hanlonet al 2007).Therearealsolikelytobesignificantvariationsinthedetectionandtreatmentofdepression, justasthereareinthewidercommunity.Insomecases,depressionamongolderpeopleincarehomes hasbecomenormalisedandstafffailtoseethatdepressiondoesnothavetobeanormalpartof ageingoranecessaryconsequenceoflivinginacarehome.

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14percentofpeoplecarefororlookafteradependentpersonof65yearsorolder,justabovethe EUaverageof12percent(Eurobarometer2004).

Formanypeople,givingcareisrewardinganddoneoutofchoice(Moullin2007,2008).However,for toomanypeoplegivingcareisnotjustachoicebutanecessityandtheamountofcaretheyhaveto give,unsupportedbyservices,hasadamagingimpactontheirphysicalandmentalhealth,canharm theirlifechances,andunderminetheirsenseofwellbeing.Inonestudy,thosewhowerebeginningto givecareatanintensiverate(over20hoursperweek)hadincreasingsymptomsofdepressionthe moreintensecaregivingtheygave,poorerself-reportedhealthandhealthbehavioursandoutcomes thatbecameprogressivelyworseovertimethanthoseoftheirpeergroup(Surretal 2005). Evidencelinkingmentalhealthproblemswithcare-givingtopeoplewithdementiaisseenasrobust. Fromtheirreviewofstudiespublishedduringtheperiod1989to1995,Schulzetal (1995)foundthat virtuallyallstudiesreportedhighlevelsofdepressivesymptomsamongcare-givers(28to55percent) (citedinSurretal 2005).Giventhatthenumbersofolderpeoplewithdementiaaresettorise,the impactoncarers’wellbeingneedstobeconsideredurgently.

Thereisclearlyfarmoretobedonetosupportcarersandpreventthemfromexperiencingdepression andworseningphysicalhealth.ipprinitsargumentformore,bettertargetedsupporttobeofferedto carershassaid:‘ajustsocietycanbejudgedonhowitsupportspeoplewhoneedcaretolive independentlives.Butcareforadultshasrarelyreceivedtheattentionitdeserves’(Moullin2008:4). Lookingatattitudestowardscaringforolderfamilymemberswhoneedregularhelp,intheUKa substantiallylowerpercentageofpeoplethantheEUaveragesaytheyshouldlivewiththeirchildren (20percentcomparedwith30percent).AhigherthanaverageproportionofpeopleintheUKsay publicorprivateserviceprovidersshouldvisittheirhomeandprovidethemwithappropriatehelpand careinstead.Two-thirdsofBritishpeoplethinkdependentpeoplehavetorelytoomuchontheir relatives–lowerthaninmanycountriesbutsignificantlyhigherthanFinlandandDenmark,for example(Eurobarometer2007).

Publicopinionofwhetherpeoplewouldbeprovidedwithappropriatehelpandlong-termcareinthe futureshouldtheyneeditalsovariesgreatlyamongthecountriesoftheEU,withGreecehavingthe highestproportionofpeoplebelievingthis,at89percent,followedbyBelgiumat88percent.The UKislowestamongEUmemberswithonly61percentbelievingtheywillreceiveappropriatecare whentheyneedit(Eurobarometer2007).

England’ssocialcaresystemforolderpeopleneedstobereappraised,bothforthoseincarehomes andforthosegivingandreceivingcareathome,withagreateremphasisonemotionalhealth. Currentlymostofthepolicydebatesandresearcharebasedonfundingandsupplyconcerns.While theseareimportant,thereisaneedtoensurethatthedebatesdonotlosesightoftheoverall ambitionofthesocialcaresystem:toprotectandsupportpeoplewhoneedcaretolivehappyand independentlives.

Communityparticipation

Inouranalysiswehavehighlightedtheimportanceforolderpeopleofhavinganactivesociallife. However,manyfactorsmitigateagainstolderpeople’sactiveparticipationintheirlocalcommunity. Physicalaccesscanbeasignificantbarriertoparticipation,forexamplebusyroadscanbevery difficulttonegotiateforpeoplewithlimitedmobility.Andfearofcrimeorfearofyoungpeoplein publicspacesmayalsopreventolderpeoplefromaccessingandusingpublicspaces.Inthissectionwe describesomeofthemainbarrierstocommunityparticipationandaccessforolderpeople.

Crimeandfearofcrime

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AccordingtotheBritishCrimeSurveyover-60saretheagegrouptheleastlikelytobeavictimof crime.Overalllevelsofcrimearefalling,whichshouldfurtherreducetheimpactofcrimeonolder people.However,theincreaseinnumbersofolderpeoplewillinalllikelihoodresultinincreasesin numbersofoldervictims.

Fearofcrimeisalsooftenreportedtocontributetoolderpeople’sisolationandexclusionfrom participationincommunitylife.TherehasbeenafallinfearofcrimeinEnglandandWalesinallage groups.

In2003intheUK,theover-65shadslightlyhigherlevelsoftrustinpeoplethanyoungeragegroups. ThiswasnotthecaseinotherEuropeancountriesexceptforPortugalandFinland(SwedishNational InstituteofPublicHealth2006).

Localenvironment

Thereareage-relateddifferencesaboutwhatpeoplefindmostproblematicintheirlocalarea.People over65aresomewhatlesslikelythansomeotheragegroupstoviewlitter,teenagershangingaround, vandalism,crime,drugs,graffiti,anddrunkanddisruptivepeopleasseriousproblems(ONS2008c).

Peopleover65findtrafficthemostproblematicofallthepotentialissuesinaneighbourhoodand fromthisONSsurveyappearsurprisinglyunworriedaboutteenagers,crimeanddrugs.Forolder peopletrafficpresentsasignificantobstacletoleavingthehouse,socialisingandparticipatingin communitylife.Inadifferentstudyof600olderpeoplebyScharfetal (2002)carriedoutinthe mostdeprivedwardsofthreelocalauthoritiesinEngland,particularfeaturesofthephysical environmentweresourcesofstressandanxiety:deteriorationinthephysicalfabric–lackof maintenanceofbuildingsandpublicspaces–andenvironmentalproblemssuchastrafficnoise andpollution.

UsingdatafromalongitudinalstudyofageinginAmsterdam,Knipscheeretal (2000)explored therelationshipbetweenthephysicalenvironmentanddepressioninolderpeople(citedinSurret al 2005).Theyfoundthatlivinginahighlyurbanenvironmentincreasedpooremotionalwellbeing andlow-leveldepressionamongolderpeople.Highlyurbanenvironmentswereassociatedwith worsehousing,ahigherriskofbeingavictimofcrime,worsetrafficandhavingfewersocial contactswithintheneighbourhood.Allofthese,aswehavedescribedabove,arerisksforpoor emotionalwellbeinginolderpeople.Ontheotherhand,feelingabletoinfluencetheenvironment andhavingacommunityrole,decreaseddepressivesymptomsinolderpeople.

Table2.3.Aspectsoftheirneighbourhoodhouseholdersviewedasaseriousproblem,England:byage, 2006/07(%)

16–24 25–34 35–44 45–64 65andover Allaged16 orover

Traffic 12 17 19 21 19 19

Litterandrubbishinthestreets 14 13 13 15 11 13

Teenagershangingaroundonthestreet 15 18 16 13 8 13

Vandalismandhooliganism 11 11 10 10 8 10

Crime 14 13 12 11 7 10

Peopleusingordealingdrugs 9 10 10 10 5 9

Noise(excludingnoisyneighbours) 8 7 6 7 6 7

Dogs 8 8 8 6 5 7

Graffiti 5 5 5 5 4 5

Peoplebeingdrunkordisruptive 8 8 6 5 2 5