Older People And Wellbeing

WWW.IPPR.ORG

OlderPeopleand Wellbeing byJessicaAllen July2008 ©ippr2008

InstituteforPublicPolicyResearch Challengingideas– Changingpolicy

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Contents 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 References ...........................................................................................................................................38

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Aboutippr 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:[email protected] www.ippr.org.RegisteredCharityNo.800065 ThispaperwasfirstpublishedinJuly2008.©ippr2008

Abouttheauthor JessicaAllenisHeadofHealthandCareatippr.HerpublicationsatipprincludeGreatExpectations (2007)andEquitableChoicesforHealth (2006).ShehaspreviouslyworkedattheKing’sFund,where sheco-authoredHealthintheNewsandFindingoutWhatWorks,andatLondonSchoolof EconomicsandUnicef.Shehaspublishedwidelyinnationalpapers,journalsandisafrequent commentatorinnationalprintandbroadcast.SheholdsaPhdfromtheUniversityofLondonanda firstclassdegreefromtheUniversityofBristol.

Acknowledgements Thisreportisthefirstinaprogrammeofworkatipprexploringthe‘PoliticsofAgeing’. ManythanksareduetotheCalousteGulbenkianFoundationwhohavesupportedthisfirstphaseof thework,drawingontheirlongstandinginterestinandsupportforolderpeople’swellbeing.Weare verygratefultothemfortheirsupportandtoAndrewBarnettinparticular.Thanksalsoinadvanceto theNorthernRockFoundationandtheIntelCorporationwhoaresupportingourfutureworkonthe PoliticsofAgeing. Thanksarealsoduetocolleaguesatippr,inparticularJuliaMargo,RuthSheldonandSoniaSodha. ThanksalsotoJohnCannings,KateStanley,GeorginaKyriacou,CatherineBithellandKellyO’Sullivan. Allomissionsanderrorsaretheresponsibilityoftheauthor.

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Introduction 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. TheSocialExclusionUnitreportproposedareviewofplansforanOfficeforAgeingandOlderPeople whichcouldprovidethekindofleadershipandcross-governmentworkingthatiscurrentlylacking. However,amoveofthiskindhasnotyettakenplace.Italsopromisedeffectiveactiontotackle

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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.

1.ThereareeightLinkAgePluspilots,whichaimtogiveolderpeopleaccesstomoreintegratedservices, includinghousing,transport,healthandsocialcare,work,andvolunteeringopportunities.

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1.Age,healthandhappiness 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.

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

Male Female

95

90

85

80

2053

2049

2045

2041

2037

2033

2029

2025

2021

2017

2013

2009

2005

2001

1997

1993

1989

1985

75 1981

No.ofyears

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

100

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Figure1.2.Male lifeexpectancyat birth–manual andnon-manual occupations, Englandand Wales,1972-2005 Source:Officefor NationalStatistics 2007a

No.ofyears

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

80 78 76 74 72 70 68 66 64

Nonmanual Manual

Figure1.3. Femalelife expectancyat birth–manual andnon-manual occupations, Englandand Wales,1972-2005 Source:Officefor NationalStatistics 2007a

No.ofyears

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

84 82 80 78 76 74 72 70

Nonmanual Manual

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

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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Figure1.4.Life expectancyat age65 Source:Officefor NationalStatistics 2008a

20 19 18 17 16 15 14 Male

13

Female

12 1981

1984 1987

1990

1993 1996

1999

2002

2005

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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Figure1.5.Actual andprojected agedistribution, UK,1981-2056 Source:ONS2008b

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.)

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

8.7

4.1

10.7

4.9

62.3

9.9

63.9

10.7

14.3

6.7

17.1

8.7

Yearsspentinpoorhealth Disability-freelifeexpectancy Yearsspentwithdisability Source:ONS2008c

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Table1.2showshowinGreatBritainin2004,justunderaquarterofmenand28percentofwomen over75consideredtheirhealthtobepoor.Forwomeninparticulartheperiodover75ismarkedbya significantdeclineinhealth,butforbothmenandwomenover75athirdofpeoplearestillingood healthandnearlythreequartersareingoodorfairlygoodhealth. Thereareclearimplicationsforwellbeing.Forthoseover75poorhealthaffectedoveraquarterofall people,makingthatgroupparticularlyvulnerabletodepression,socialisolationandexclusion. 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

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

66

23

11

Females

Allages Source:ONS2008c

Overall,theproportionofpeopleinGreatBritainreportinganillnessordisabilityhasnotchanged since1995.Thisisperhapssurprisinggiventheincreasesintheproportionofolderpeopleinthe populationandsuggeststhatanageingpopulationdoesnotnecessarilybringproportionatehealth challenges. Table1.3.Proportionofpeoplewhoreportedalimitinglongstandingillness,disabilityorinfirmity,Great Britain(%) Year 1975 1985 1995 2005 2006 Percentage

15

17

19

19

19

Source:ONS2006a

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

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Box1.1setsoutprojectionsonlevelsofdisabilityunderthreedifferentscenariosofhealth expectancy:acompressionofmorbidity,thatis,lessillness,anexpansionofmorbidity,meaningmore illness,andacombinationofboth. 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 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. Box1.2.Definitionofdisability ‘Disability’referstothedisadvantageexperiencedbyanindividualasaresultofbarriers,including physicalandattitudinalbarriers,thatimpactonpeoplewithmentalorphysicalimpairmentsand/or long-termillhealth. A‘disabledperson’isanyonewhoisdisadvantagedbythewayinwhichthewiderenvironment interactswiththeirimpairmentorlong-termhealthproblem.Thismayvaryovertime.

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

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Figure1.6.Agestandardisedrates oflong-term illnessordisability thatrestrictsdaily activities,by ethnicgroupand sex,Englandand Wales,2001 Source:Dunnell 2008

White British

Males Females

White Irish Other White Mixed Indian Pakistani Bangladeshi Other Asian Black Caribbean Black African Other Black Chinese Other ethnic groups 0

5

10

15

20

25

30

Percent 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:

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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. Box1.3.Howdowedefinewellbeing? Inthisreport,wetakeabroaddefinitionofemotionalwellbeing.Wedonotincludeseriousmental healthproblemssuchasdementiaorpsychoticmentalillnessessuchasschizophrenia.Thisis becausethecausesandtreatmentofseriousmentalhealthproblemsaresignificantlydifferentfrom thecauses,preventionandpossibletreatmentoflower-levelmentalhealthproblems.Mostpeople andorganisationsworkinginmentalhealthdistinguishbetween‘neurotic’orcommon‘low-level’ mentalhealthproblems,andpsychoticorseriousmentalhealthproblems,suchasdementia, schizophreniaandhallucinations. Wethereforeincludeasanindicatorofemotionalwellbeingtheincidenceoflow-levelmentalhealth problemssuchasdepression,anxiety,stress,panicattacks,phobiasandobsessive-compulsive disorders.Butemotionalwellbeingisbroaderthanjustthepresence(orabsence)ofcommon mentalhealthproblemsandsowealsoincludelifesatisfactionandlevelsofhappiness. Inthesecondphaseofippr’sworkonolderpeople,wewillrefineanddevelopadefinitionof wellbeinginolderpeople,basedonoriginalresearchwitholderpeople.(Meanwhile,inthisreport wedrawonexistingresearchtoindicatelevelsofmeasuredwellbeinginolderpeople.)

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.

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Figure1.7.British lifesatisfaction andprosperity Source:basedon PMSU2007

180 GDP per capita

170 160

% very or fairly satisfied

150 140 130 120 110 100 90 80 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Figure1.8.Life satisfactioninEU memberstates, 2001

Portugal

Not Satisfied

Greece

Source: Eurobarometer

France

Fairly Satisfied

Italy

Very satisfied

Germany Belgium Spain EU 15 Finland Austria UK Ireland Luxembourg Sweden Netherlands Denmark -60

-40

-20

0

20

40

60

80

100

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ThereissomecontroversyovertrendsinmentalhealthintheUK,withstudiesidentifyingthat measuredincreasesinprevalencearesometimesduetotheresimplybeingmorediagnosis.However, therearesomeindicationsthatmentalhealthintheUKisworsening.Usingmeasuresofmental healthproblemsin2001,theOfficeforNationalStatistics’PsychiatricMorbidityReport foundthat oneinfourBritishadultsexperiencesatleastonediagnosablementalhealthprobleminanyoneyear, andoneinsixexperiencesthisatanygiventime(ONS2001). Therewasalsoanincreaseintheproportionofpeoplereportingmentalillnessesandbehavioural disordersasthemedicalreasonunderlyingclaimsforincapacitybenefitandseveredisablement allowance,growingfrom33percentin2001to41percentin2007(Dunnell2008),asshownin Table1.3.Furthermore,aStrategyUnitreportonlifesatisfactionshowedariseintheincidenceof mentalhealthproblemsforbothmenandwomenbetween1993and2000(PrimeMinister’sStrategy Unit2007). Table1.3.Combinedincapacitybenefitandseveredisablementclaimants,measuredbytypeofmedicalreason, GreatBritain,2001and2007 2001 2007 Mentalandbehaviouraldisorders

33%

41%

Physicaldisorders

67%

59%

Totalclaimants(millions)=100percent

2.8%

2.7%

Source:Dunnell2008

Source:Oswaldand Powdthavee2007a

11.30 11.25 Average GHQ - 12 (Likert*)

Figure1.9. Average psychological distresslevels overtimein Britain: 1991–2004,based onGeneralHealth Questionnaire

11.20 11.15 11.10 11.05 11.00 10.95 10.90 1991 - 1994

1995 - 1999

2000 - 2004

*Likertscaleisapsychometricresponsescaleoftenusedinquestionnaires

OswaldandPowdthavee(2007a)reportthatmentalwellbeingisworseninginBritain.Figure1.9 showsforrepresentativesamplesofBritonsthatGeneralHealthQuestionnairepsychologicaldistress scoresrosefrom1991onwards.AndLordLayardhasarguedthatalltheevidencesuggeststhat incidenceofclinicaldepressionhasincreasedsincetheSecondWorldWar(Layard2003). Wellbeinginolderpeople MostolderpeopleintheUKarehealthyandhappyandmakevaluablecontributionstosocietyandto theeconomy.Infact,oldage,definedasover65years,isoftenseenasatimeofrelative contentment,althoughthereissomedebateaboutlevelsofwellbeinginolderpeople,justasthereis forthepopulationasawhole.Inthissectionwediscusssomeoftheoftencontradictoryevidence aboutlevelsofmentalhealthproblemsandwellbeinginolderagegroups.

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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. Figure1.10. Averagelife satisfactionscore byagegroup

5.5 Average life satisfaction score

Source:Oswald 2007

5.6

5.4 5.3 5.2 5.1 5.0 4.9 4.8 4.7 15 - 20

21 - 30

31 - 40

41 - 50

51 - 60

61 - 70

Age group

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.

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Figure1.11. Prevalenceof depression,by genderandage group

45

Male Female

40

Source:McCroneet al 2008

35

Cases per 1000 people

30

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15

10

5

0 15 - 24

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45 - 54

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Age group

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).

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Figure1.12. Projectedchange innumberof peoplewith depression,2007 to2026 Source:McCroneet al 2008

200 15 - 44 45 - 64 65 - 74

180 No. of people with depression (index, 2007 = 100)

18

75 - 84 85+ 160

140

120

100

80 2007

2009

2011

2013

2015

2017

2019

2021

2023

2025

Year

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.

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Thereissomedebateovertheprevalenceofmentalhealthproblemsamongolderpeople.However,it doesappearthatprevalenceofmentalhealthproblemsincreaseswithage,particularlyforthoseover 75,andthattheprevalenceofpoorwellbeingalsorises. Futuretrendsinwellbeingarealsodisputed,butasthenumberofolder oldpeopleincreasesthere islikelytobeacorrespondinggrowthintheincidenceofmentalhealthproblemsandlevelsof poorwellbeing.

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2.Factorsthatshapewellbeinginolderpeople 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.

200

150

100

50

6 20 0

4

20 05

20 0

20 03

1

02 20

20 0

20 00

9 19 9

98 19

19 97

95

19 96

19

94 19

93 19

91

19 92

19

19 90

8

89 19

87

0 19 8

Source:Dunnell 2008

250

19

Figure2.1.Net wealthperhead (from1987 baseline=100)

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).

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Povertyanddeprivation Forpensioners(menover65andwomenover60),realincomeandshareofnationalincomehave risensignificantlysince1979;andthegrossincomeofpensionerfamiliesaveragedoverallagesand familytypesroseby37percentinrealtermsbetween1994/95and2005/06,comparedwithan increaseofabout17percentinrealaverageearnings(ONS2008c). Figure2.2.Real incomeof pensioners, 1979-1996/7and 1994/5-2004/5 (from1979 baseline=100) Source:ONS2006b

Pensioners’averageincomerosefasterthanyoungerpeople’searningsbetween1996/7and2004/5 (25percentcomparedwith15percent).Theserisescamefromincreasesinoccupationalpensions, investmentsandbenefits. Theeffectoftheserisesinpensionerincomeshasbeenamovementofpensionersuptheoverall incomedistributionladder.Theproportionofpensionersineachfifthoftheincomedistributionin 1979and2004/5isshowninFigure2.3.In197947percentofallpensionerswereinthebottom Figure2.3. Pensioners’ positioninthe overallnetincome distribution,1979 and2004/5

50 1979 2004/5

45 40 35

Source:ONS2006b Percent

30 25 20 15 10 5 0 Bottom fifth

Next fifth

Middle fifth

Next fifth

Top fifth

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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). 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 Source:ONS2008c

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

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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:

• • •

Figure2.4. Sourcesof pensioners’ income,byage group

Single pensionershavelessthanhalftheearningsofmarriedpensioners. Olderpensionershavesignificantlylowerincomesthanyoungerpensioners(seeFigure2.4). Female pensionershave,onaverage,lowerincomesthanmen.Forexample,singleretiredmen hadanaveragenetincomeof£220perweekin2004/5comparedwith£186forsinglefemale pensioners(ONS(2006).

Other income

450

Earnings Investment income

400

Source:ONS2006

Personal pensions Occupational pensions

350

Benefit income 300

250

200

150

100

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0 Recently retired

Under 75

Over 75

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•

Therearegeographicalinequalities:pensionersintheSouthEastofEnglandandLondonhave onaveragehigherincomesthanpensionersinotherpartsoftheUK.Averageincomefromstate benefitsvariesmuchlessbetweenregionsthanothertypesofincome(ONS2006).

•

Minorityethnicgroups accountfor3.5percentofallpensionersinGreatBritainandthat 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). Figure2.5. GeneralHealth Questionnaire12 score(observed andagestandardised),by equivalised householdincome andsex(menand womenaged16or over) Source:Donovan andHalpern2002

Men

25

Women

20 15 % 10 5 0 Lowest

Second

Middle

Fourth

Highest

Equivalised household income quintile

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).

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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 2005analysisoftheprescriptionofpreventativemedicinefollowingheartattackshowedclearagebaseddifferences(Ramsayetal 2005,citedinLeathermanetal 2007). Ethnicity Thereisevidenceindicatingthatsomeblackandminorityethnic(BME)groupsareparticularly susceptibletocertainmentalhealthproblems,forinstancedepression,andingeneral,ratesofmental healthproblemsarethoughttobehigherinminorityethnicgroupsthaninthewhitepopulation. However,thosegroupsarelesslikelytohavetheirmentalhealthproblemsdetectedbyaGP(NIMHE 2003). Comparedwiththewhitepopulation,therearehigherratesofdepressionamongIndianandPakistani women,butlowerratesamongBlackCaribbeanandBangladeshiwomen.Maleratesofdepressionare

26

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Figure2.6. Percentageof peoplewith depression,by ethnicgroupand gender Source:McCroneet al 2008

7

Male Female

6

5

4

3

2

1

0 White

Irish

Black Caribbean

Bangladeshi

Indian

Pakistani

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

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andotherstodevelopandtailorappropriateservicesforparticularcommunities.Itisimportantthat moreresearchevidenceisundertakenandusedtoshapefuturepolicymaking. Gender Womenaremorepronetosomementalhealthproblemsthanmenare,particularlydepression,selfharmandeatingdisorders,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.AstheUKInquiryintoMentalHealthandWellbeinginLaterLife states: ‘[o]lderpeoplesaythatvisitstoorfromfriendsandfamilymotivatethemtogetoutofbedinthe morning.Havingsomeonetotalkthingsoverwithhelpsthemtocopewithworries.Manysaythatthe mostimportantthingistofeelwantedandneededbyothers’(Lee2006:42).However,thereare largenumbersofolderpeoplewhoexperienceisolationandloneliness.Estimatessuggestthat1 millionolderpeopleintheUKaresociallyisolatedandthisnumberisprojectedtoriseto2.2million overthenext15yearsiftheissueisnotaddressed(ibid). Asurveyin1992showedthatcomparedwithothercountriesinwhatwasthentheEC,peopleinthe UKhadlessdailycontactwithotherpeoplethanthoseinothercountriesexceptforDenmarkandan aboveaveragenumberofpeople–40percent–whoneverhadcontactwithfamilyorfriends (Eurobarometer1993).

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Increasesinthenumberofpeoplewithnochildrenorwithonechildarelikelytoimpactonwellbeing inlaterageascontactwithfamilyisconsideredbymanyolderpeopletobeveryimportantand havingfew,orno,childrenclearlymeanslesscontact. Figure2.7. Proximityto grandchildren

90 <30 minutes

Source:Presentation atipprseminaron grandparenting, 2008

30 minutes - 2 hours

80

> 2 hours 70

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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

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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). 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 Therehavebeensignificantchangesinlivingarrangementsoverthepast40years,withmorepeople livingalone,increasingthelikelihoodoflonelinessandisolationforolderpeople. WhiletheproportionofolderwomenlivingaloneinGreatBritainhasremainedstableoverthelast20 years,theproportionofoldermenlivingalonehasincreased,reflectingincreasinglifeexpectancyfor menover65andchanginglivingarrangements.Evenso,womenaged75oroverwerealmosttwiceas likelytobelivingaloneasmenaged75oroverin2006. Thereislikelytobeasustainedandsignificantincreaseinnumbersofpeoplelivingalone.Figuresfor Englandsuggestthat70percentofprojectedgrowthinthenumberofhouseholdsupuntil2026will Figure2.8. Proportionof single-person households,19712021

Under 65 Over 65

40

35

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30

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15

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0 1971

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1991

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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’sreportASureStarttoLaterLife setout 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 Forsomeolderpeopleretirementofferstheopportunitytoparticipatemorefullyinotheractivities andspendmoretimewithfamilyandfriends.However,forothersitisachallengingeventthatleads tolongperiodsspentaloneorinactive,feeling‘worthless’andhavingnopurpose.Onlyhalfofall retiredpeoplesaytheywantedtostopworkingandoverathirdsaytheyfeltforcedtostop(Lee 2006)and‘castaside’,whichclearlyundermineswellbeing.Retirementisoftenaccompaniedbya significantdropinincome,havingtoadjustexpenditure,movehomesordisposeofotherassets,also adverselyaffectingwellbeing.

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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. Manyolderpeoplecareforanotherfamilymember.InfacttheEnglishsocialcaresystemisrelianton havingenoughunpaidcarerstolookafterpeoplewhoneedit.Currentlythreemillionolderpeople providecarethatisworth£15.2billionayear(Moullin2007).Peopleaged50andover,particularly thoseaged50-59,aremorelikelytobeprovidinginformalcarethananyotheragegroup.IntheUK,

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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 Oneofthemostfrequentlysuggestedexplanationsforolderpeople’ssenseofisolationandsocial exclusionwithintheircommunityiscrime.Becomingavictimofcrimehasasignificantandlonglastingimpactonolderpeople’swellbeing,leadinginsomecasestoseriousdepressionandwithdrawal fromsocialengagement.Thereisevidencetosuggestthattheincreasedriskofdepressionasaresult ofcrimecanpersistoveralongperiodoftimeforolderpeople(ONS2008c).

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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). 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 Neighbours(includingnoisyneighbours) 7 6 5 5 2 4

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.

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Housingquality Housingqualityishighlysignificantforolderpeople’semotionalwellbeing.Poorhousingcontributes todepression,anxietyandstressandolderpeoplearemostsusceptibleastheyaremorelikelythan otheragegroupstospendlongperiodsoftimeathome. Therehavebeensomeimprovementsinhousingqualityinthelasttenyearsandin2005therewere sixmillionhousescategorisedas‘non-decent’,downfrom9.1millionin1996,theproportionofnondecenthomesfallingfrom45percentto27percent(Lee2006).However,sixmillionisstillalarge number.Theproportionofolderpeoplelivinginnon-decenthomesis34percent,justoverathird. Table2.3.PoorlivingconditionsinEngland,bytypeofhousehold,2005(%) Non-decent Poor-quality Energy-inefficient homes environments homes One-personhouseholds Agedunder60 35 20 10 Aged60andover 34 14 11 One-familyhouseholds Couple,nodependentchildren Agedunder60 25 16 11 Aged60andover 23 11 13 Couplewithdependentchildren 22 16 8 Loneparentwithdependentchildren 26 23 7 Othermulti-personhouseholds 28 21 9 Allhouseholds 27 16 10 Source:ONS2008c

Homesin seriousdisrepair 11 13

9 9 8 14 12 10

TheSocialExclusionUnitestimatedthat2.2millionhouseholdswithapersonover60liveinunfit housing(ODPM2006a).13percentofolderpeopleliveinhomesthatareinseriousdisrepair,slightly morethanforpeopleunder60.Cold,damphomesthatarepoorlyheatedhavebeenlinkedtoill healthandearlydeathsamongolderpeople.

Protectingolderpeople’swellbeing Insomerespects,whatfostersgoodemotionalwellbeinginolderpeopleistheconverseofsomeof thefactorsthatundermineit.Certainlyinalltheareaswedescribeabovethereismorethatcarefully targetedanddesignedpoliciesandservicescoulddotooffersupport.Belowweoutlinesomeother factorswhich,formanyolderpeople,helpprotecttheiremotionalwellbeing. Takingonanactivegrandparentingrole Olderpeopleoftenrefertobeinganactivegrandparenttotheirgrandchildrenasbothasourceof pleasure,andasgivingthemapurpose(Lee2006).In2007therewere13milliongrandparentsover theageof50intheUK(PMSU2008)andin2001almost90percentofpeopleaged60andover weregrandparents(ONS2001c).Inthefuturetherewillbeanincreaseinthenumbersofolder peoplenothavinggrandchildren,asfewerpeoplehavechildren,butalsointhenumbersof grandparents,asthepopulationages. Grandparentsprovide26percentofchildcare,morethananyothersource,eitherformalorinformal: 10percentisprovidedbyfriendsorneighboursand17percentinformaldaycare(PMSU2008). ThissavesfamiliesintheUK£3.9billioninchildcarecostsannually(Lee2006),andmakesahighly significantcontributiontothenationaleconomyandtothelivesofchildren. Thereissomeevidencethattheroleofgrandparentsisbecomingevenmoresignificant.InJune2003 30percentofgrandparentsdescribedthemselvesasafriendorconfidanttotheirgrandchildren,but

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thishadrisenbyAugust2006to58percent(PMSU2008).61percentofgrandparentsseetheir grandchildrenatleastonceaweekandafurther17percentseetheirgrandchildrenmonthly (informationfromparticipantsinaprivateipprseminar). Afterhavingamotherstayingathomefulltime,grandparentsarethemostpopularchoiceof childcare-giversformothers(Leachetal 2008),astheyareconsideredtoprovidethemostintimate andlovingcare.However,thereissomeevidencethatchildcareisconsideredaburdenoran obligationbysomegrandparentsandonestudyfoundthat39percentofgrandparentswouldliketo havealifefreefromtoomanyfamilyduties(informationfromprivateipprseminar). Thereisstillalackofinformationabouttheimpactonthequalityoflifeandwellbeingoffamiliesof grandparentsprovidingcarefortheirgrandchildren.Thequalityofcareprovidedbygrandparentsis highlyvariableandthereislittlesupportforthem,andnoregulation.Researchbycampaigning organisationshasfoundthatthemajorityofBritishgrandparentsbringinguptheirgrandchildrenhave experiencedfinancialdifficultiesasaresult,andreceiveverylittleexternalfinancialsupport. Exercise Forallagegroupsexerciseprotectsagainstmentalhealthproblemsincludingdepression,aswellas preventingphysicalhealthproblems:asmallnumberofepidemiologicalstudieshaveexaminedthe relationshipbetweenphysicalactivityanddepressivesymptomsovertime,findingexercisetogivea positiveeffectonmentalwellbeing. Despitethisevidence,thereiscurrentlylittleprovisionorencouragementforolderpeopletoexercise andwhatthereismostlyfocusesonthephysicalhealthbenefits.Butsomepositivestepsinclude measuresintheNationalServiceFrameworkforOlderPeople,developedin2001,totestoutwaysof encouragingolderpeopletotakeexercise,andfrom2008swimmingwillbefreeforpeopleover60. Educationandlearning Whilethelevelofeducationachievedasayoungadultisasignificantindicatorofemotionalwellbeing inlaterlife,continuingeducationandlearningisalsoimportantbothfordevelopinganactivesocial lifeandasasourceofmentalstimulationandfocus.Morethanathirdofpeopleintheirsixtiesin EnglandandWalesareinvolvedinadultlearning.OrganisationssuchastheOpenUniversity encourageolderpeople’sparticipationinlearning.However,fundingforcommunity-basedadult learningisverylimitedandmanycoursesvaluedbyolderpeoplearebeingcut:thefundingand nationalpolicypriorityisforcoursesfor16-to19-year-olds(Lee2006). Volunteering Volunteeringisconsideredveryimportantforolderpeopleandforallthecharitiesandservices thatdependonvolunteers.Volunteeringisassociatedwithincreasedlifesatisfaction,withsome evidencethatolderpeoplederivegreatermentalhealthbenefitsfromvolunteeringthanyounger agegroups.Itenablesolderpeopletomakeacontributionandisameansbywhichto participatesociallyandengageincommunitylife,whichreducesthelikelihoodoftheir experiencingdepressionandincreaseslifesatisfaction,improvesmoraleandselfesteem,creates largersocialnetworksandincreasesaltruisticbehaviour(Surretal 2005).Interestinvolunteering peaksintheyearsimmediatelyfollowingretirementandhelpsthetransitionfromworkinglife intoretirement.Nearlyaquarterofpeopleaged50andoverareengagedinformalvoluntary activity(Lee2006). However,therearebarrierstoolderpeople’sparticipationinvolunteering.Nearlyone-fifthof organisationsplaceupperagelimitsonvolunteeringopportunities,oronspecifictaskssuchas driving(Lee2006).Otherbarriersincludepoorphysicalhealth,lackofskills,fearofcrimeand lackoftransportonthepartofthewould-bevolunteerandwhiletheGovernment’scurrent effortstoboostvolunteeringnumbersfocusonyoungpeople. TheDepartmentofHealthiscurrentlydevelopingastrategyonvolunteeringinhealthandcare whichaimstoraisetheesteemandprofileofvolunteering,developsupportforvolunteers, evaluatethebenefitsofvolunteeringandallowcoherentinvestmentinvolunteering.Itis importantthatthefuturestrategyfocusesonhowtomosteffectivelysupportvolunteering

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forolderpeople,particularlytheolderoldandhowtoencourageandenableolderpeople whodonotcurrentlyvolunteertoparticipate.Thestrategypresentlyfocusesonvolunteeringin careandhealthservices,butitwouldbevaluabletobroadenthisfocusbeyondthoseservices andrecognisethevaluetohealthandwellbeingforvolunteers,whateverthesectorthey volunteerfor. Personalresilience Mostolderpeoplearenotdepressed,eveniftheyexperiencesignificantdifficultevents.Butfor others,similareventsdoleadtodepression,forawiderangeofreasons.Supportisveryimportant, butinternalpersonalfactorsintheformofself-esteemandself-efficacyinmanagingstressand difficultlifeeventsalsoplayasignificantrole.Lowself-esteemisapowerfulpredictoroflow-level depression(Surretal 2005).Therearecomplexexplanationsforhowself-esteemandefficacy develop,muchofwhichrelatetoexperiencesinchildhoodandarebeyondthescopeofthispaper.It issignificantthathavinggoodsocialsupportandanactivesociallifecanlessentheeffectoflowselfesteemandself-efficacy(ibid). Religion Researchhasshownthatreligionhelpssomepeopletocopewithdifficultlifetransitions,suchas losingajobordivorce,andcanfostergoodemotionalwellbeingforolderpeople(Donovanand Halpern2002).Thebenefitsstemfromgivingpeopleasenseofpurposeandcontinuedparticipation inasocialandsupportivesocialnetwork.Morebenefitsareexperiencedthroughactiveparticipation inreligiousevents.AccordingtotheBritishSocialAttitudesSurvey54percentofthepopulationin GreatBritainclaimedtobelongtoareligionin2006,afallof3percentsince1996. Respect Feelingvalued,respectedandunderstoodcontributestogoodmentalhealthandwellbeing(Lee 2006).Asdescribedearlier,agediscriminationandfeelingexcludedfrommainstreamsocietycan contributetopooremotionalwellbeingandlonelinessamongolderpeople.Thereisaclearneedto fosterandencourageolderpeople’sactiveparticipationandcontributiontocommunitygroups, schoolsandotherneighbourhoodactivities.Encouragingotheragegroupstorespectolderpeople andencouragemoresocialinteractionwiththemrequiressomequitefundamentalculturalshifts,yet therearetraditionsamongsomeethnicgroupsintheUKandabroadthatcouldoffertheUKsome excellentexamples.

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3.Conclusions WhileGovernmenthasarguedthatmanyexcludedolderpeoplerequireadditionalsupportandhelp, therequiredcoordinatedaction,prioritisation,resourcesandpoliticalandpublicappetitehavebeen lacking.Thefocusinthisreportonwellbeinghashighlightedthecomplexityofissuesandfactorsthat drivewellbeingforeveryone,notjustolderpeopleandthereareinequalitiesinthewaytheyare experiencedwhicharerelatedtowidersocialandeconomicinequalities.

Driversofwellbeing–summary Emotionalwellbeingisshapedbymanyfactors,includinggender,ethnicity,socio-economicstatusand inequalities,andphysicalhealth.Lackofdiagnosisandtreatmentofmentalhealthproblemsis widespread.Continuedparticipationinneighbourhood,familylifeandsociallifeareseenas particularlyimportantinprotectingemotionalwellbeinginlaterlife.Infact,theimpactofpoor physicalhealthisoftenmainlyfeltthroughtheresultingimpactonsocialandcommunity participation. Wehavehighlightedcontinuedandoftenworseninginequalitiesinincomeandphysicalhealthwhich compoundanddeepenexistinginequalitiesinolderpeople’smentalhealthandwellbeing.Thereis alsoaclearsocio-economicdivideinlaterlife,justasinchildhoodandearlieradulthood–being relativelypoorisasignificantriskfactorforpooremotionalwellbeinginlaterlife. Thereisaclearneedtotacklepensionerpovertyandhealthinequalities,andaneedformoretargeted interventionstosupportthosemostatriskofpooremotionalwellbeing.Therearespecifictrigger pointsinolderpeople’slives,timeswhenadditionalsupportisneeded,particularlyaroundretirement, bereavement,movingintoacaringroleandmovingintoacarehome. Beingabletomaintainarolewithinthefamilyandlocalareaandparticipateinsocialandcommunity lifeisseenasimportantforgoodemotionalwellbeing,buttherearemanyobstaclesforolderpeople. Changesinfamilyformationsandagrowingnumberofpeoplelivingalonearelikelytoleadto increasednumbersofolderpeoplefeelingisolatedanddepressed.Poor-qualityhousingcontributesto poorphysicalandmentalhealthforolderpeopleandjustoverathirdofolderpeopleliveinpoorqualityhousing. Similarly,poorlymaintainedphysicalenvironmentsandbeingavictimofcrimeunderminewellbeing andcontributetodepression,isolationandloneliness.Trafficproblemsareafurtherobstacleto communityparticipationandfeelingsofcontrol,bothofwhicharehighlyvaluedbyolderpeople. Inthesecondphaseofourwork,ipprwilladvocatemoreeffectivestrategiestosupportolderpeople, particularlythosemostatrisk,toparticipateincommunityandsociallife.

Futurework:internationalcomparisons Whileoldageissometimesassumedtobeatimeoflonelinessandisolationthisdoesnothavetobe thecase:othercountriesandcultureswhoseattitudestoageingaredifferentfromthoseintheUKdo nothavethesamelevelsofexclusionandunhappiness.Inthesecondphaseofthisworkipprwillbe exploringageinginothercountriesandculturesinmoredetailandassessingwhetherthemost successfulpolicies,servicesandapproachescanbeappliedintheUK.Wewillalsobeaskingolder peoplethemselveswhattheywouldfindmosthelpful,particularlyforthosemostatriskandduring timesofdifficulty.Wewillbeadvocatinganewapproachtoageinginwhichpromotingwellbeingand soundmentalhealthofallolderpeopleisapoliticalandpublicpriority.Wewillalsoexamineefficacy incaresystems,againusinginternationalcomparativeevidence.

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