Ageism in health and caring to make a difference
The Royal Commission into Aged Care Quality and Safety comes at a crucial time. The poor care of many aged care residents has prompted deep concern about standards of care and about the broader issue of how care should be funded and by whom.
The Consumers Health Forum supports the principle that older people are full citizens and should have access to the full range of health care – regardless of where they are living.
They should access health care in the same way as others – using their Medicare card and getting services where they live at home, in residential care or in a hospital, as and when required.
However, ageism and health care generate considerable debate about implications of resource allocation made more challenging in an era of historically rapid ageing of the population.
We often hear it is the ageing of the population that is putting pressure on the health system – as though this is unexpected and could be avoided. It’s often said in a blaming way.
We also hear terms like ‘bed blockers’ for older people staying in hospital longer than the average length of stay as though they don’t have a right to be there.
So, the language is often ageist. That is even though there is respectable evidence suggesting ageing of the population is not the primary cause of increased health expenditure. The main drivers of rising health costs are changing patterns of care, including increased use, costly technology and higher quality care. In essence we can do more and so we do – for everyone and not just older people.
CHF supports a sustainable health system. We know we need to make decisions about allocating scarce resources: funding, workforce infrastructure and equipment.
This allocation should be need and evidence-based. This means getting rid of low value or unnecessary care for all age groups including older people.
We don’t want anyone to have ‘futile or non-beneficial care’ when an individual is near the end of life and care is not going to lead to a different outcome.
However, that point should be defined not by age but by the stage in the progression of a person’s disease.
We also don’t want anyone over-diagnosed, given tests and treatments which are not necessary: this is part of the waste we have in the health system today.
But we do want everyone given the opportunity to receive care that can make a difference, that is beneficial because it might extend their life – giving them a cure and/or an improved quality of life.
As Sam Shortt writes in an article titled ‘Venerable or vulnerable? Ageism in health care,’ 
“The two sides of the argument basically divide along the following lines:
- Those who support differential treatment of older people, with the allocation of resources on the basis of age-related ability to benefit. This is ageism but seen as a positive for society, a rational allocative decision.
- Those opposed to age-based policies, for them the term has a far more sinister connotation; it is an exercise in discrimination based on an inaccurate stereotyping of the ageing process in terms of deterioration and dependency.”
Ageism in health manifests in many ways:
- Upper age limits for certain health services – sometimes called the ‘fair innings approach’, the age at which people are not seen as deserving more health services as they have reached the natural age span. We used to talk of three score years and 10 (70) but now would probably put this at 80. This is often explained as, ‘they have had their share of resources/why give it to them? They’ve had a good life’.
- Access determined by age. An example of breast cancer screening – routinely is for women aged 50-74. It is available for women over 74 but they are not sent reminders and it is not clear on promotional materials that is the case.
- We hear from women over 70 about the difficulties they have had in getting breast reconstruction after mastectomy with one woman reporting that her surgeon actually asked her, “Why would you want this? You are too old for it to matter.”
- Another way ageism manifests itself is to quantify expected benefits for a given intervention. Often discussed in health technology assessment and allocation meetings is the benefit of treatments in terms of years of life gained. This is biased against older people. They may not be eligible for a treatment because of an assumption about how much longer they will live and that this would not give a good ‘rate of return’ on the investment.
- This attitude can shadow the work of the Pharmaceutical Benefits Advisory Committee when looking at subsidizing new drugs and the Medical Services Advisory Committee looking at putting new items on the MBS.
We shouldn’t forget that there can be circumstances when ageism can be beneficial:
- In some cases, it is appropriate to have different services for age cohorts because the treatments are different/people have different needs. We see this in mental health, such as:
- Youth mental health services like headspace having an upper age limit of 25
- Adult mental health services with specified age ranges, for example, in the North Metropolitan Health Service in WA adult services are for 18-65 years
- Older persons’ mental health services for over 65s. The North Metropolitan Health Service has a designated service.
- Somewhere between 10 and 15 per cent of older people experience depression and up to 35 per cent in residential aged care. We know many older people do not seek treatment. Many people including, unfortunately, some clinicians think being depressed is a normal part of ageing and does not need intervention. This is ageist. To combat that we need services targeted at this vulnerable group.
So how can we combat ageism in health?
Treatment decisions should be made on evidence. Many clinicians have their own ageist bias about what is appropriate ‘for older people’ and so do not follow the evidence. This bias needs to be made more transparent and efforts made to move clinicians to a more evidence-based practice.
In Australia we think only about 60 per cent of health care is based on evidence – that leaves a big area for improvement. We have the Atlas of Health Care Variation and are looking at why variation occurs – perhaps this could include looking at ageism as a factor.
Better information around options for end-of life care – having conversations with older people about what interventions they do and don’t want. Involving people in the decisions about their care combats ageism as it stops someone else making a judgment based purely on age. We have advanced care directives and they are an important part of that discussion so let’s promote them. We also need to educate the whole population about ‘futile care’ as it is often offered in response to the family demanding “that everything be done”.
Remove ageism at the planning stage by ensuring adequate provision is made for older people’s access to primary, home and long-term care. The existence of the very long waiting times for community care packages is an example of poor planning and not anticipating real demand.
Finally, older people need to be included in all aspects of health – the adage ‘nothing about us without us’ is very true.
Older citizens need to be involved in policy, service research, design and implementation – not just in ‘aged care’ policy and services but across the health system. They can call out ageism in all spheres and make suggestions about overcoming it.
 Shortt S 2001 venerable or vulnerable? Ageism in health care Journal of Health Service Research Policy Vol 6 No 1