According to the World Health Organisation, most developed world countries have accepted the age of 65 years as a definition of “elderly” or older person. (WHO: 2012) However, in the UK, the Friendly Societies Act 1972 S7(1)(e) defines old age as, “any age after fifty”, where pension schemes mostly, are used, it is usually, age 60 or 65 years for eligibility. (Scottish Government: 1972) The term ageism, is defined as process of discrimination and stereotyping against people because of their age. Around a quarter of older adults in the UK, report having experienced age discrimination. (Age Scotland: 2012) It affects many institutions in society and has a number of dimensions, such as job discrimination, loss of status, stereotyping and dehumanization. Ageism is also about assuming that all older people are the same despite different life histories, needs and expectation. (Phillipson: 2011)
The policy, All Our Future also (Scottish Government: 2007) indicates that over the age of fifty, is a stage where life circumstances start to change in ways that can be significant for the future. An example of this can be; children leave home, change in working patterns, people have less work and more time for themselves. In addition, from fifty onwards, this can be a time when physical health may deteriorate, causing possible health problems, such as, osteoporosis, osteoarthritis or coronary heart disease. What is more, the state of general health overall, decreases substantially, people face changes in appearance, their physical state deteriorates and they are not as fit as they used to be. Surely, this must be difficult to accept! However, ageing can also cause some psychological effects, such as, changes in memory function, a decline in intellectual abilities, or even memory loss. As a result of a degenerative condition of brain’s nerve cells or brain disorders, many people may develop dementia, Alzheimer or Parkinson disease. Wilson et al. (2008) who draws attention to physical, biological and psychological effects of the ageing, pointing out that ageing is not itself a disease, but some specific diseases may be associated with this process.
Older people are a group that used to be in a marginal concern in the social work profession, but has recently moved to one of central importance. (Phillipson: 2011) This is caused by the remarkable speed of demographical change. The number of older people is increasing, both in absolute numbers, and as a proportion of the total population. The ageing of the population indicates two main factors: the downward trend in the birth rate, and improvements in life expectancy. (Phillipson: 2011) In Scotland, in 2010, there were an estimated 1.047 million older people age over 60, with older people being one fifth of the Scottish population. (Age Scotland: 2012) In the last hundred years, Scotland’s life expectancy has doubled from 40 in 1900, to just over 74 for males, and just over 79 for females in 2004. By 2031 the number of people aged 50+ is projected to rise by 28%, and the number aged 75+ is projected to increase by 75% (Scottish Government: 2007) This issue requires to be deeply analysed in terms of how society will be able to respond effectively to the complex needs of older people.
This part of the report takes into account the socio-political context of the welfare policy. Social work underwent fundamental changes from the 1960s, following broader ideological, political and economic developments. To understand the current role of social work within society and wider policy framework, particularly with older people, it is important to analyse the past that has reflected on contemporary practice. By the 1960s, more attention was beginning to be paid to the social consequences of capitalism, that started to be seen as the economic order of an unequal and unfair society. The strong critique of that system is known as radical social work, that grew on the ideology of Marxism. (Howe: 2008) The publication of the Kilbrandon Report (1964) consequently led to the introduction of Social Work (Scotland) Act 1968. This embedded social work firmly within the state sector, with the voluntary sector as complementary. (Ferguson & Woodward: 2011) Social work wanted to be seen as a unified profession, that offered generic services, to overcome earlier fragmentation and overspecialisation of services. Social workers were obligated by law, to assess needs and promote social welfare by providing services. However, the government of Margaret Thatcher began to weaken the state welfares responsibilities to help people in need, leading to the major ideological shift in 1980s called neoliberalism. As a result, the Barclay Report (1982) intended to clarify the role and task of social workers employed within statutory or voluntary sector. The later Griffiths Report (1988) was similar to Barclay Report, in terms of promoting greater choice, participation and independence of the service user and carers. However, neoliberalism undermines the role of welfare professionals, allowing the rich to become richer, and marginalise the poorest and most vulnerable individuals. (Ferguson & Woodward: 2011) Woodward and Ferguson (2011) argue that the neoliberal trend has been continued under the new labour government, leading to managerialism and bureaucratisation. Therefore, contemporary practice is drawn by extreme pressure of marketisation and managerialism, leading to a profession dominated by stress, frustration and strongly focused on meeting deadlines. The labour government has also been driven by the developments associated with consumerists ideas, such as, personalisation that places the service user at the centre of service design and delivery, or direct payments that emphasise independence and individual choice, through giving service users their own money, to buy their own services. (Woodward & Ferguson: 2011) For a long time, neoliberal economic and social policies in the UK speculated a very different concept of what social work should be about. The Changing Lives report of the 21st Century Social Work Review (Scottish Government: 2006) has brought a significant shift within social work polices, through an expression of dissatisfaction of social work, that was mainly caused by a lack of opportunity for relationship based working with service user. The policy has reshaped the profession, providing social workers with additional space to develop good social work practice. There have been initiatives to improve recruitment, and increase professionalism and standards within the workforce, as well as improve integration in the planning and provision of social work services. (Scottish Parliament: 2008) Integration has been developed through Modernising Community Care: An Action Plan (1998) and Community Care Joint Future (2000) that introduce Single Shared Assessment (SSA). In Scotland, Joint Future is the driving policy on joint working between local authorities and the NHS. The other key policy themes are personalisation, self-directed support, early intervention and prevention as well as mixed economy of care. (Scottish Parliament: 2008) Another significant report that brought about change in policy, and later, in Scottish legislation, is the Sutherland Report (1999). This provided free personal and nursing care on the basis of assessed needs. (Petch: 2008) The above review of social work policies framework, is a good illustration of the constantly changing role and function of social work. Social work operates within the wider context of a constantly developing policy, ideology and legislation. The reality and ideology has changed people and society to face a new challenges. Social work makes a key contribution to tackle these issues by working with other agencies to deliver coordinated support to increase the wellbeing of older people.
In terms of needs and issues when working with older people, the first thing to consider is the partnership of health and social care, especially within areas such as: assessment, care management, intermediate care and hospital discharge. The main problems are, tight budgets, resources and reconciliation of financial responsibility between bodies. Which always raises dispute who should pay for services? Wilson et al. (2008) stresses the importance of rationing services in social work, due to a low budget, which leads to delays in provision of services, and lack of time to develop more creative forms of practice. This causes unnecessary delays and constraints. One might expect that new Integration of Adult Health and Social Care Bill (Scottish Government: 2012) will resolve these problems by the joint budget and equal responsibilities of Health Boards and Local Authorities.
The next issue is the assessment and intervention process, that are seen as balance between needs and resources, evidence and relationship based practice. It can be an issue to find appropriate resources that will meet the needs of the individual. A major element during assessment is the relationship with service user, and that the appropriate methods of communication are adopted to identify the needs of older people. The practitioner must take the time to get know the older person and resist pressure from other professionals to do a quick assessment. (Mackay: 2008) In social work there is constant need to utilise evidence based practice on the grounds that it is empirical knowledge which guides the decision making process, such as three stages of theory cycle (Collinwood & Davies: 2011) There is no doubt evidence based practice is important, but this view may undermine relationship based practice, which is equally important. Rightly, Wilson et al. (2008) refers to relationship-based as a main feature of social work practice, that shapes the nature and purpose of the intervention. It is a unique interaction between the service user and the practitioner, that helps to obtain more information and define the best way of intervention.
The problem of autonomy and protection is another factor in the relationship when working with older people. This raises the question of capacity, consent and the deprivation of liberty of older people. This group of service users is often a subject of legislation that deprives their human rights, this is because they are likely to be affected by cognitive disorder such as dementia. The term dementia, includes Alzheimer’s disease, vascular and unspecified dementia, as well as dementia in other diseases such as Parkinson’s. It has been estimated that in the UK the number of patients diagnosed is 821,884, representing 1.3% of the UK population. (Alzheimer’s Research Trust: 2010) The assessment of incapacity or mental disorder is not straightforward and proves ethically and morally difficult for both service user and social worker. Social workers have to manage the balance between acting in accordance with the wishes of the individuals, and what is in their best interests. It has been suggested by policy and legislation that the views and wishes of people expressed through self-assessment would remain at the heart of intervention. (Wilson et al.: 2008)
Another issue is abuse of older people, which may have many forms, and can be very severe in extend. Older people are vulnerable to abuse, or indeed, not having their rights fully respected and protected. The problem came to public awareness not as long as few years ago. Despite the fact that legislation came into force through Adult Support and Protection (Scotland) Act 2007, it is estimated that elder abuse affects 22,700 people in the Scotland each year. (Age Scotland: 2012) Older people are a subject of physical, psychological abuse, neglect, sexual or financial harm, that normally takes place at home, in hospital, residential care or day centre. (Ray at al.: 2009)
Age discrimination is next issue one wish to consider, older people are disadvantaged because of their relatively low socio-political and cultural status in a contemporary society. They are repeatedly presented as a drain on resources as they no longer actively contribute to the growth of society. They do not work and do not pay taxes anymore. Older people are systematically disadvantaged by the status they now occupy within society. Wilson et al. (2008: p. 620) rightly suggests that old age is “socially constructed”. A good example of this is retirement, which officially, makes people old and unavailable to work, despite the actual physical and emotional state of the individual.
Other forms of social construction that significantly affect the experience of old age are class, gender, race and ethnicity. (Wilson at al.: 2008) An illustration of this can be the statement that older people have much more in common with younger people from their class, than they do with older people from other classes. (Philipson: 2011) Disadvantages and inequalities, experiences during life can magnified during the process of ageing, through differences in access to health facilities, health status and lifestyle that may influence life expectancy. There is no doubt that experience of ageing is subjective, and depends on many factors, but it seems to be a matter to firstly, consider class, gender and race at the first place. When discussing poverty and inequalities, the points to bear in mind are issues of discrimination of older women, who are less likely to have as great a pension as a male partner, due to the fact many women are paid a lower wage then men. Moreover, women tend to live longer than men, therefore, are potentially more vulnerable to live alone and in poverty. (Age UK: 2012)
There are many forms of disadvantage associated with older people in poverty such as; low income, low wealth and pension, debts or financial difficulties, feelings of being “worse off”, financial exclusion, material deprivation and a cold home. The first three are experiences by around 20% of older people, half of older people experienced at least one of the nine forms of poverty described above, and 25% had two or more. A minority 3% suffered from three or more forms of poverty. (Age UKa: 2012) In terms of ethnicity and race there are significant inequalities in the process of ageing. An illustration of this can be the black community of older people, who are more likely to face a greater level of poverty, live in poorer housing and have received lower wages. In addition, they are more susceptible to physical and mental illness often due to heavy manual work, racism and cultural pressures. (Phillipson: 2011) All these discussed factors must be taken into account when working with the older person.
It can be argued that one of the main needs of older people is the importance of active listening to this group of service users, who are often because of age ignored or disregarded. This is supported by Kydd et al. (2009) who highlights how important it is for older people to feel that they are being listened too. Another important need of this group of service users, is the need to stay at home as long as possible, which is supported by the policy, All Our Future (Scottish Government: 2007) that offers; free personal care, telecare development programme, care and repairs services or travel scheme free bus passes. The policy aims to improve opportunities for older people, foster better understanding towards this group of service users, create better links between generations to work together and exchange experiences. Improve health and quality of life by promoting well being and an active life within the community; enhance care support and protection of older people. Improve housing and transport as well as promote lifelong learning.
The last part of the report identifies policy framework and organisational responses. The discussion about social care for adults began in the UK through Green paper Independence, Well-being and Choice (Department of Health: 2005) and the subsequent White Paper, Our Health, Our Care, Our Say (Department of Health: 2006) these documents set out the agenda for future. This is based on the principle that service users should be able to have greater control over their own lives, with strategies that services delivery will be more personalised than uniform. The contemporary social work is driven by emancipatory issues such as social justice, empowerment, partnership and minimal intervention. (Dalrymple and Burke: 2006) Empowerment theory is the process of helping people gain greater control over their lives. Empowerment is not simply a matter of enabling or facilitating but it involves helping people to become better equipped to deal with challenges and oppression they may face. (Thompson: 2009) On the grounds of empowerment grew the idea of service user participation that came to law in 1990 through NHS and Community Care Act. (Ray et al.: 2012) There is still increasing acceptance that people who receive services should be seen as own experts in defining their own needs. This is in accordance with the exchange model of assessment presented by Smile and Tuson et al. (1993), where the social worker views the individuals as experts of their own problems. The role of the practitioner is to help the service user to organise resources in order to reach goals that are defined by the service user. The Scottish Government’s policies and initiatives addressing to older people, highlights the importance of developing services that focus on maintaining independence, encouraging choice and promoting autonomy, such as; Changing Lives (2006), All Our Future (2007), Independent Living in Scotland (2010), Reshaping Care for Older People (2012a). These policies highlight the importance of service user participation in the process of decision making and intervention. These tendencies of improving choice and autonomy of older people, have resulted in the creation of personalisation and self-directed support programmes.
Personalisation enables the individual to participate and to be actively involved in the delivery of services. Personalisation also means that people become more involved in how services are designed by shaping and selecting services to receive support that is most suited to them (Scottish Government: 2009) The programme directly responds to wants and wishes of the service user regarding service provision. Personalisation consists of a person centre approach, early intervention and prevention, and is based on mentioned above empowering philosophy of choice and control. It shifts power from the professionals, to the people who use services. (Department of Health: 2010) However, it could be argued that approaches which extend to service user control, in realty, can be seen as transferring risk and responsibilities form the local authority to the individual service user (Ferguson: 2007)
Another option, recently promoted by the government, is Self Directed Support (SDS), a Bill that was introduced into the Scottish Parliament last year, and recently has passed stage three. The bill seeks to introduce legislative provision for SDS and the personalisation of services and to extend the provisions relating to direct payments. (Scottish Parliament: 2012a) The SDS approach had been brought into Parliament previously, and was reflected in many reports and policy initiatives such as: Changing Lives, Reshaping Care for Older People. SDS allows people to make informed choices about the way support is provided, they can have greater control over how their needs are met, and by whom. Social workers, working on behalf of local authority, will have a duty to offer SDS if the individual meets the eligibility criteria. The four options to consider are; direct payment to the individual in order that that person will arrange their own support, the person chooses the available support and the local authority will make arrangements for the services on behalf of that person, the social worker will select support and make arrangement for provision, the last option is a mix of the above. (IRISS: 2012) The idea of SDS is a great opportunity for service users to expand their control over which services provided. However, this raises a question of how many people will be ready to utilise option one of SDS. Would an ordinary person, who uses the services, have the skills and knowledge to take responsibility for their own care, for example to employ their own carers, a personal assistant or to buy their own services. One could envisage that it could be possible if the role of social worker changes from care management, to brokerage and advocacy. A potential care broker will provide assistance to obtain and manage a support package, drawing on individualised funding. It can be questioned if social workers who are mostly accountable to local authorities are reliable to perform this task whilst working across three sectors. (Wilson at al.: 2008)
In conclusion, there is a shift from a paternalistic stance of social workers to viewing service user as experts of their own lives. From institutional care, through service led and needs led, to outcomes focus provision. A fundamental part of working with older people is to recognise and respond to the way in which they may be marginalized. This can be achieved by a deeper understanding of the process of ageing, and the issues that older people may face. Working with older people, based on new premises, will be focused on to maximise resources, and the role of the social worker will be transferred from care management to advocacy and brokerage. One may expect that active