7.09 – Age Discrimination vs Age Adjusted care

June 11, 2019

Presented by: Dr Jo Preston, Dr Iain Wilkinson, Jackie Lelkes

Faculty: Wendy Grosvenor, Sarah Vigor

Broadcast Date:  4th June 2019


Social Media / Website

Iain: https://twitter.com/jamesfrith1981/status/1115513317760602112?s=19

Jo: https://twitter.com/CourtneyBoen/status/1132339933971197953?s=03

Jackie: https://www.sciencedaily.com/releases/2019/04/190403193656.htm


CPD Log


Main Show Notes:

Learning Objectives

Knowledge:

  • To know that able to describe age discrimination and to understand the law relevant to this area

Skills:

  • To know how to challenge age discrimination when it occurs
  • To be able to design services that are age based by not age discriminatory

Attitudes:

  • To realise that age is just a number and making decisions based on this alone is illogical

Main Show Notes

Definitions:

Ageism: is… prejudice or discrimination on the grounds of a person’s age..

It’s been called the last acceptable prejudice.

That Age Old Question. Royal Society of Public Health

“to claim that it is better to preserve the lives of the young than those of the aged is to assume that the lives of the aged have less value than those of the young. “

Markkula Centre for applied ethics

We are going to talk about this but NOT talk about the ethics of treatment rationing for older people. The article that the quote comes from does this well – the link is in the show notes!

We have seen in the flow episode that a small number of ‘slower moving’ patients lead to a great decrease in the productivity of the system – an argument then comes about that by preventing these more complex patients coming to hospital (and the high cost that entails) then the overall system will work better, have more money and be more rosey.

Unfortunately life is not always that simple and whilst we know that hospitals are risky places for older people sometimes though they are the places that older people just need to be for a while.

David Oliver: Base care on need, not age BMJ 2016; 355

Quote from Age UK report:

“Undignified care of older people does not happen in a vacuum; it is rooted in the discrimination and neglect evident towards older people in British society. Age discrimination is the most common form of discrimination in the UK. Increased life expectancy is a positive development, but our view of older people focuses almost exclusively on biological decline, and we tend to discuss older people as a problem for health and social care services, a ‘demographic time-bomb’ or a crisis we cannot afford. In contrast, the economic and social contribution offered by older people – for instance in employment, volunteering, or caring for partners, children and other family members – is rarely acknowledged.”

Delivering Dignity

Also age UK report: How Ageist is Britain?

Recording team to briefly discuss this – bias is often to talk about the strain of older people and not the benefits..

Practical Definition

A survey of more than 1,000 experts in ageing and ageing in health care from across Europe for the Economist showed that 80 per cent were concerned about the standard of their own care when older and 51 per cent felt that older people were far less likely than younger people to have adequate assessment and treatment in their countries.

Kings Fund Blog – David Oliver

This is despite legislation being present in a most countries to explicitly stop this happening.

  • 76 per cent of 25-34 year olds state that they have been discriminated against at work because they were considered ‘too young’.
  • Eighty-nine per cent of 45-54 year olds said they have been discriminated against at work for being ‘too old’.

There is also evidence that reducing ageism will not only have a monetary benefit for society, but also have a health benefit for older persons. The cost in the USA was calculated in this article as: 1 in every 7 dollars spent on the top 8 health conditions (15.4%)!

https://www.ncbi.nlm.nih.gov/pubmed/30423119

Equality law

In the UK the relevant piece of law is The Equality Act 2010.

It is a protective law to prevent discrimination or unfair treatment in the workplace and society.  It covers a number of personal characteristics – so called Protective characteristics:

  • gender reassignment
  • being married or in a civil partnership
  • being pregnant or on maternity leave
  • disability
  • race including colour, nationality, ethnic or national origin
  • religion or belief
  • sex
  • sexual orientation
  • age

Gov.uk. Digital Inclusion and accessibility. [Internet]. UK: Government Equalities Office and Equality and Human Rights Comission: [2015 June 16th; cited 2019 May 8th]

Discrimination can come in a number of forms:

  • direct discrimination – treating someone with a protected characteristic less favourably than others
  • indirect discrimination – putting rules or arrangements in place that apply to everyone, but that put someone with a protected characteristic at an unfair disadvantage
  • harassment – unwanted behaviour linked to a protected characteristic that violates someone’s dignity or creates an offensive environment for them
  • victimisation – treating someone unfairly because they’ve complained about discrimination or harassment

Gov.uk. Your rights and the Law. [Internet]. UK: Gov.uk website; [cited 2019 May 8th)

Hospitals have to ensure that discrimination is prevented under the Public Sector Equality Duty therefore trusts and services must consider those with protected characteristics when planning and carrying out public duties or services.

All patients have a right to the following

  • access to health service
  • good quality of care
  • being treated by appropriately qualified and experienced staff
  • making decisions about medications and treatments
  • being protected from abuse and neglect
  • respect and confidentiality
  • complaining if you aren’t happy or things go wrong.

Age UK. Ageuk.org.uk [Internet]. UK. Age UK; [cited 2019 May 8th]

In 2012 it became illegal to discriminate against adults due to age.  This is unless the practice is covered by an exception from the ban or good reason can be shown for the differential treatment (objective justification).

Exceptions under the order are

  • Age based concessions
  • Age related holidays
  • Age verification
  • Clubs and association concessions
  • Financial services
  • Immigration
  • Residential park homes
  • Sport

In addition the following exceptions apply

  • General exceptions already allowed by the act
  • Positive action measures
  • “objective justification”

“There are no specific exemptions to the ban on age discrimination for health or social care services.  This means that any age-based practices by the NHS and social care organisations need to be objectively justified, if challenged.”

Gov.uk. Digital Inclusion and accessibility. [Internet]. UK: Government Equalities Office and Equality and Human Rights Comission: [2015 June 16th; cited 2019 May 8th]

Key Points from Discussion

The NHS constitution backs this up by stating that is it a :‘comprehensive service to all, irrespective of age, a duty to respect human rights, access based only on clinical need,’

An audit by the Healthcare Commission (2006) found that explicit age discrimination in policy has declined since the National Service Framework for Older People was introduced in 2001.

One of the most explicit forms of age discrimination in healthcare in the NHS is the upper age limit on some screening programmes by invitation, not indicated by disease prevalence or other clinical indicator. Upper age limits currently exist of 69 for breast and bowel cancer screening and 64 for cervical screening by routine invitation.

Another example (of indirect discrimination) would be the reduction in GP home visits over the last few years. Now people of any age can have a home visit – but it was a service used in the majority by older people. The but back from  22% in 1971 to 4% in 2006 will affect older poeple the most.

Clinical trials… we have talked before about this – so won’t again other than to say it’s a thing… a big thing!

Centre for Policy on Ageing Briefing Document

Teams: Geriatrics vs general medical teams – automatically there is an age bias there. But it is there to aim to deliver a better quality healthcare for older people – so isn’t that a good thing? Is age adjusted care ok? but age discrimination not ok?

It however goes both ways:

Age based care can be a good thing though and makes perfect sense in some situations- the older patient with complex healthcare needs for example – we know does better with a team dedicated to looking after them. But does this deny them access to say a cardiologist and therefore say the most up to date specialist treatment (TAVI, Dual chamber PPM etc etc) ? There is no blanket rule that can be applied to these things.

There is a transition of care in psychiatry services at 65… and many areas do not have well defined transition protocols…. but the 65 is often set in stone – regardless of the length of time a patient has been with the younger persons unit / team.

We have come along way though – for example there is no longer a situation there no NOFs can be on ITU for example or ITU will not accept patients over an arbitrary age cut off. Using more physiological based measures will be important here and I (iain) would argue that that is going to be frailty’s greatest give to geriatric medicine – the ability to quantify the physiology and turn age to just what it is… a number.

Either way there is an important step for all of us to not make older people ‘other’ and to resist any labelling of us vs them… this is destined only to drive a wedge between services and make this more difficult. This is something we can all roll model but also needs to be reflected in the way out public services are designed.

Public services should be designed with the aim of promoting equality between people of different ages, addressing the current and future needs of an ageing and diverse population, and eliminating discrimination against older people. We need to be alive to trends that appear to exacerbate age segregation, and we need to seek initiatives that can bring different generations together around issues of shared interest and importance.

Delivering Dignity NHS Confederation

What to do when you see it?

  1. Citizens advice have a helpline they reference called the: Equality Advisory Support Service (EASS)

https://www.citizensadvice.org.uk/law-and-courts/discrimination/about-discrimination/equality-advisory-support-service-discrimination-helpline/

2. Call it out and name it… sometimes stating how this made you feel.. “ when you said X to Mr J,,,, did you mean that to make him feel like that?”

This uses the SBI feedback model which can be helpful:

Situation

Behaviour

Impact:

https://www.mindtools.com/pages/article/situation-behavior-impact-feedback.htm

3. To inform a senior person – if it is about an individual their line manager or colleague, if it is about a service as a whole then the manager of that service in the first instance.

How to design services that are not discriminatory?

Just short section here:

Essentially use co-construction with your patients and involve them in the service.

Good example I hear of recently was the Isle of Man PD service who have regular service improvement meetings – with any patients that wish to come along also. This way the patients drive the agenda and ensure that over time the service becomes more and more of the service that they need.

Making our health and care systems fit for an ageing population. David Oliver Catherine Foot Richard Humphries. Kings Fund 2014

Conclusion:

The key thing is to talk to your patient and deliver a healthcare service that is focused on their needs and when developing your services to focus on a service designed in conjunction with the service users you are trying to serve.


Curriculum Mapping

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

  • NHS Knowledge Skills Framework
    • Core Dimension 3: Health, Safety And Security – Level 2
    • Core Dimension 6: Equality And Diversity – Level 3
  • Foundation curriculum
    • 1. Acts professionally
    • 3. Behaves in accordance with ethical and legal requirements
  • Core Medical Training
    • Principles of quality and safety improvement
    • Managing long term conditions and promoting patient self-care
    • Personal behaviour
    • Management and NHS structure
  • GPVTS program
    • 2.01 The GP Consultation in Practice – Core Competence: Maintaining an ethical approach
    • 3.05 Care of Older Adults – Core Competence: Clinical management
  • Geriatric Medicine Training Curriculum
    • 3.2.5 Rehabilitation in Older Persons
    • 3.2.8 Management
    • 9. Principles of Quality and Safety Improvement
    • 25. Management and NHS Structure
    • 26. Evaluating Performance and Developing and Leading Services (with Special Reference to Services for Older People)

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