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4.0 PROMOTING AND MAINTAINING HEALTH AND WELL-BEING

Health and Well-Being:

• Health takes on a particular significance in later life: The proportion of people with both a long-term illness and a disability increases with age: 13% of people aged 70 years and over have both a long-term illness and disability compared to 2% of 30-39 year olds. ⁶⁴ Many people in older age groups still consider themselves to be in good health even if they have a long-term illness which restricts their daily lives.
• Healthy life expectancy is increasing: A girl born in Scotland in 2000 could expect
  to live for 78.7 years: 57.5 (73 per cent) of these years could be expected to be spent free from limiting long-term illness, and 67.2 (85 per cent) years could be expected to be spent in good or fairly good general health. ⁶⁵
• Healthy ageing?: The majority (65%) of people aged over 50 years in Scotland are living without a long-term illness or disability. This compares with 91% of persons aged 0-49 years living with no long-term illness or disability. ⁶³ The majority of older people in Scotland continue to live in the community well into later life 45% of people aged 65 and over live at home, the majority in good health. ⁷⁰ Older people are more likely to feel that their health-related quality of life is poor. They are more likely than their younger counterparts to say that poor-health and pain affect their daily life, for example: 27% of men aged 75 years and over reported that ill health limited their ability to perform moderate activities 'a lot' compared with only 6% of men aged 18-24 years. ⁶⁹
• Health-related behaviours The likelihood of smoking falls with age; 19% of males and 24% of females aged 60-74 years smoke. ⁶⁶ Older people are more likely to drink alcohol frequently than younger age groups: 3% of males aged 16-24 years reported usually drinking every day, compared with 29% of those aged over 75 years. Older people are, however, less likely to have exceeded the recommended number of units in the last week: 31% of males aged 16-24 years reported drinking more than 21 units, compared with 15% of those aged over 75 years. ⁶⁷ Older people are less likely to undertake the minimum recommended amount of physical activity. Only 23% of men and 16% of women those aged 65-74 years were achieving it. ⁶⁸

Health is an important dimension of quality of life amongst people of all ages and takes on a particular significance in later life. The health behaviours and status of older people have typically been less of a focus among researchers than younger age groups. However, evidence points to the on-going importance of health status and behaviours and lifestyles across the life course.

Perceptions of health and ageing

Research ⁷¹ with older people in Scotland found that older people think about their health in two ways:

• The first focusing on physical fitness, youthfulness and appearance and orientated towards the future
• The second focusing on mental as well as physical well-being, functional capacity, independence and capability and orientated towards the future.

While it is believed that a person can influence their own health, this tends to draw on the first set of ideas. It is evident from research that people do not believe that a person can significantly alter their longer term life chances. A genuine interest in one's older self and future health is rare. Health related decisions are more likely to be prompted by a more immediate concern with loss of youth (especially for baby boomers) or by a health crisis (especially for those in older age groups and the most elderly).

HEALTH STATUS IN LATER LIFE

Perception of general health: How do the older population view their health?

Figure 45 shows self-assessed general health by age. Self-assessed health is a useful measure of how an individual regards their own condition generally, and is known to be related to the incidence of chronic and acute disease, as well as being a good predictor of mortality.

Figure 45: Self assessed general health by sex and age

Source: Scottish Health Survey (2003).

• Three-quarters of adult men (74%) and women (73%) in Scotland classified their health as either 'very good' or 'good'.
• Self-assessed general health was strongly associated with age. 56% of men aged 75 years and over and 55% of men aged 65-74 years rated their health as either 'very good' or 'good' compared to 88% of 16-24 year olds and 82% of 25-34 year olds.
• Amongst older age groups, males aged 65 to 74 were more likely to rate their health as 'very bad' or 'bad' (16%) than younger age groups.
• Women aged 75 years and over are slightly less likely than their male counterparts to rate their health as 'very good' or 'good': 51% compared to 56%.

In general, the odds of people reporting poor health increases steadily with age. Analysis of Scottish Health Survey 2003 data shows that:

• The likelihood of men aged 25-34 years reporting poor general health is 7 times higher than among men aged 16-24 years, and increases markedly with age to around 20 times higher among men aged 65 years and over.
• A similar pattern is evident for women, though the ratios are smaller: women aged 75 years and over are 9 times more likely to report poor general health than those aged 16-24 years.

These trends are mirrored in the reporting of long-standing illness, shown in Figure 46. This indicates that:

• Reporting of long-standing illness (both limiting and non-limiting) is strongly related to age.
• Around one sixth (17% of men and 16% of women) of 16-24 year olds years report at least one long-standing illness compared to two thirds (65% of men and 67% of women) of the 75 years and over age group.
• From the age of 55 onwards, the majority of both men and women report having a long-standing illness.

The prevalence of limiting long-standing illnesses increases with age to a much greater extent than the prevalence of non-limiting long-standing illness.

• Among men, 7% of those aged 16-24 years had a limiting long-standing illness compared with 44% of those aged 75 years and over; whilst the corresponding figures for non-limiting long-standing illness were 10% and 20%.
• A similar pattern is evident for women, 10% of those aged 16-24 years had a limiting long-standing illness compared with 52% of those aged 75 years and over, whilst 7% and 15% had a non-limiting illness.

Figure 46: Reporting of Long-standing illness and Limiting Long-standing illness by age

Aged 16 and over

Long-standing illness & limiting Age

Long-standing illness

Source: Scottish Health Survey 2003

Whilst the link between the prevalence of long-standing illness and ageing is well evidenced, many people still consider themselves to be in good health, even if they have a long-standing illness that limits their daily activity.

• Just 8% of adults rate their health as 'bad' or 'very bad', yet more than one in five (22%) report having a limiting long-standing illness.
• Those with a limiting long-standing illness were more likely to rate their health as 'very good' or 'good' than to rate it as 'bad' or 'very bad'.

Health-related quality of life

Questions concerning people's ability to undertake activities of daily living and how their health impacts on this provides a good measure of their ability to live independently and how health impacts on their quality of life. In much of the research, poor and worsening satisfaction with life amongst older people was clearly associated with decreasing ability to perform everyday tasks due to declining health.

First used in the 2003 Scottish Health Survey, the SF-12 is a widely used self-reported generic measure of health status, consisting of both physical and mental health components.

The data shows a strong relationship between age and response to questions, with older people more likely than their younger counterparts to report that poor health or pain affected their daily lives. The physical component scores of health-related quality of life therefore decreased with age in both sexes, for example:

• 6% of men aged 18-24 years said that ill-health limited their ability to perform moderate activities 'a lot' compared with 27% of men aged 75 years and over. The corresponding figures for women were 4% and 36%.
• 4% of men aged 25-34 years said that ill-health limited their ability to climb several flights of stairs 'a lot' compared to 23% of men aged 65-74 years and 34% of men aged 75 years and over.
• Men and women over state pensionable ages were more likely to report that they felt calm and peaceful all or most of the time during the past four weeks than adults younger than pensionable ages. Between 51% and 56% of men aged 18-64 years said they had felt calm and peaceful compared with 69% of men aged 65-74 years and 67% of men aged 75 years and over. A similar pattern is evident for women: between 40% and 46% of those aged 18-54 years had felt calm and peaceful; rising to 50% at age 55-64 years and peaking at 62% among those aged 65 years and over.
• The mean mental component health summary scores of the SF-12 were similar for all age groups in men, while scores for women increased slightly with age.

Much of the research on healthy ageing advocates that, since longer lives are not necessarily seen as better lives, there is a continuing need for health promotion messages which focus on a healthy quality of life, rather than simply longevity and extension of life for our ageing population.

Living with Disabilities

As well as understanding the prevalence of long-standing illness in the older population and their perception of general health status and quality of life, it is important to highlight that the probability of illness combined with disability increases with age.

Ill-health associated with the ageing process may be accelerated for people with a disability. People with, for example, severe physical disabilities may experience marked declines in their health well before they reach old age.

The prevalence, type and severity of disability increases with age. Recent Scottish Household Survey data ⁷² shows that:

• Prevalence of disability and long-term illness increases with age. This is particularly evident for those aged 60 years and over; for example: 7% of people aged 50-59 years have a disability compared to 11% of 60-69 year olds and 17% of people aged 70 years and over.
• People aged 70 years and over are slightly more likely to have a long-term illness than a disability ( 21% compared with 17%).
• The likelihood of having both a long-term illness and disability increases with age; for example: 9% of people aged 60-69 years and 13% of people aged 70 years and over have both a long-term illness and disability compared to 2% of 30-39 year olds and 6% of 50-59 year olds.
• People over 50 are more likely to have health problems associated with the legs and feet and age-related disabilities such as difficultly hearing, seeing, and arthritis.
• The incidence of age-related sensory and functional disabilities in particular is evident in the 75 and over age group. For example, 6% of people with a long-standing health problem or disability in the 70-74 age group have difficulty hearing; this increases to 16% of the 75 and over age group. Similarly, 7% of those with a long-standing health problem or disability, aged 70 to 74, have difficulty seeing; this increases to 14% in the 75 and over age group.

As expected, people with long-term illnesses or disability are more likely to experience difficulty with activities of daily living and more likely to need use of aids or adaptations in the household. This evidence is important in understanding the impact of people's illnesses on their ability to care for themselves and live independent lives.

• Activities found more likely to cause difficulty among older people with a long-term illness or disability are climbing the stairs, walking for ten minutes, standing for ten minutes, using the bus and housework. ⁷³
• Difficulty with activities which are suggestive of a higher degree of disability such as preparing main meals, washing and dressing - also show an increase with age. The use of aids and adaptations in the household due to illness or disability also increases with age. The most common aids and adaptations used by older age groups are handrails, walking sticks and bath/shower seats. ⁷⁴

Despite the fact that there may be increasing numbers of people with disabilities, it should be highlighted that the English Longitudinal Study of Ageing ( ELSA) shows that over 80% of all people aged 50 years and over report no difficulties with specific activities of daily living. ⁷⁵

Living Longer and Healthier?

As outlined in Chapter Two, it is clear from demographic evidence that people in Scotland are living longer. Health expectancies are as important as life expectancy in an ageing population. The question remains, however, whether people are living longer in poor health or in good health and whether older people will be healthier in the future than they are now.

There is a range of evidence on current trends in life expectancy and healthy life expectancy. However, the most robust evidence highlights the fact that healthy life expectancy is increasing and age-specific levels of ill health are declining.⁷⁶

Healthy life expectancy ( HLE) is defined as the number of years people can expect to live in good health. The discrepancy between healthy and total life expectancy therefore indicates the length of time people can expect to spend in poor health.

Figure 47: Life/Healthy expectancy at birth by gender Scotland 1980-2005

Scottish Executive (2004) Social Focus on Disability

Figure 47 shows the increases in healthy life expectancy since 1980.

• A girl born in Scotland in 2000 could expect to live for 78.7 years: 57.5 (73%) of these years could be expected to be spent free from a long-term limiting illness, and 67.2 (85%) years could be expected to be spent in good or fairly good general health.
• A boy born in 2000 could expect to live for 73.3 years: 54.5 of those years could be expected to be spent free from a long-term limiting illness and 64.6 years could be expected to be spent in good or fairly good general health.

In terms of quality of life, healthy life expectancy at birth (based on Self-Assessed Health) has also increased over the longer term but at a lower rate than the increase in overall life expectancy. The gap between life expectancy and healthy life expectancy is greater for women than for men, suggesting that women spend more years of their lives in poor health.

The Healthy Life Expectancy in Scotland (2004) report found that:

• Healthy life expectancy at birth has increased over time, but has not kept pace with the increases in life expectancy at birth;
• Both measures of healthy life expectancy at age 65 have increased over the last 20 years at a similar rate to life expectancy at age 65;
• The increases in healthy life expectancy and life expectancy are larger for men
  than women.

The major determinant of increasing future demand for care for older people in Scotland will be demographic change involving increasing numbers of older people and in particular the oldest old. The report highlights that the exact outcome will be affected by changes in age-specific levels of ill-health and disability and increases in healthy life expectancy. If past trends in age specific levels of ill-health and disability and past increases in healthy life expectancy continue, they will serve to mitigate to some extent the impact of an ageing population on the demand for care.

Inequalities in Health

As highlighted throughout this report, older people, like the population as a whole, are a diverse group. As with the population as a whole, inequalities exist within the older population linked to demographic factors such as sex, ethnicity and socio-economic status. Evidence on factors contributing to health inequalities is well documented. Inequalities can relate to:

• The determinants of health including life circumstances (eg, socio-economic factors)
• Health status
• Access to health care

The evidence suggests that healthy ageing can be achieved for the majority of people if they experience health-enhancing socio-economic, environmental and lifestyle factors throughout the life course.

The evidence highlights the following factors:

• Occupational group: There is an occupational difference in the prevalence of most health outcomes in older people including: heart disease, respiratory illness, self-reported poor health, long-standing illness and mental health symptoms. Men in routine or manual occupational class households are most likely, and men in professional or managerial class households were least likely, to report having each of these conditions. ⁷⁷ Similar trends related to occupational class are evident for health-related behaviours. For example, sedentary behaviour increased with age more rapidly for men and women in routine or manual households than for those in professional or managerial households. ⁷⁸
• Socio-Economic group: A study in England found that life expectancy for men from social class I and II was 2.6 years longer than that for men of the same age from social class IV and V. Older people from social class I and II could expect to live in good health, free from disability for a longer period and, hence, enjoy longer total life expectancy than people of the same age from social classes IV and V. ⁷⁹
• Geography/area deprivation: There are regional and area based differences in health. For example, people aged 50 and over are more likely to rate their health as 'good' in the East Renfrewshire, Aberdeen City and Eilean Siar areas. ⁸⁰
  Furthermore, negative perceptions of health increase with age in deprived areas. 28% of people aged 50-59 in the most deprived areas rate their health as 'good' compared to 60% of the same age groups in the least deprived areas. ⁸¹ There is a similar trend in older age groups. There are many reasons for area-based inequalities in health ranging from differences in the socio-economic characteristics of different areas, migration patterns of healthy older people, differences in lifestyle and other poorly understood issues relating to 'healthiness' or otherwise of different environments.
• Ethnicity: As highlighted, self-perception of health is highly correlated with age. There is little evidence on health of older minority ethnic populations. However, Census 2001 data ⁸² when broken down by age band, can show inequalities amongst the ethnic population. Within the 35-59 age groups, Pakistanis report the poorest health with only 81% considering themselves to be in good or fairly good health. The Chinese have the best reported health perception with 94% reporting good or fairly good health, in the 60 and over age group, Pakistanis report the poorest health with only 59% of people aged 60 and over reporting good or fairly good health. In comparison, the other white group (81%), Bangladeshi (80%) and other ethnic group (80%) reported the highest percentages of people in good or fairly good health.

Healthy Ageing

The lifestyles that people adopt across their life course influence and, in turn, are influenced by their health and well-being. Evidence of the lifestyles of different age groups in Scotland highlights the potential for improving the health and well-being of today's older people and also informs the debate about promoting healthy lifestyles in younger age groups in order to facilitate their healthy ageing.

Lifestyles encompass a wide range of health related behaviours; however, the main focus of this evidence is on:

• Mental health and well-being
• Smoking
• Alcohol
• Physical activity and exercise

Mental Health and Wellbeing

Research ⁸³ into the mental health and well-being of older people in Scotland, carried out in 2004, supported older people to prioritise the issues that affect mental health and well-being in later life. Key issues identified were:

• Family and friends (the family was a major factor in promoting positive mental health and well-being)
• Positive attitudes (having a sense of values, being open and tolerant of new ways of doing things, and being willing to learn)
• Keeping as active as possible (physically, socially and mentally)
• Maintaining capability and independence (loss of capability or loss of health were identified as the main barriers to mental health and well-being in later life)
• Negotiating transitions (retirement and the linked topic of resources; moving from the family home; bereavement). For some, retirement was felt to bring freedom, but for others it brought a sense of not being valued and loss of social contact

While we know about factors that promote mental well-being, there is a lack of detailed and reliable Scottish data on the extent to which older people experience mental health problems. Household surveys are thought to under-report people living in the community with mental health problems. This is partly because of the high proportion of people with dementia and other severe and enduring mental health problems who live in care homes, which are excluded from such surveys. ⁸⁴ Also, some national surveys exclude people over the age of 74. In addition, there is evidence that mental health problems among older people are under-diagnosed by health professionals.

Psychosocial health ⁸⁵ was measured in the Scottish Health Survey (1995, 1998 and 2003) using the GHQ12, a widely used screening instrument to detect possible mental health problems in the general population. Findings indicate that:

• Women aged 16 and over were more likely than men to have high GHQ12 scores, indicating the presence of a possible mental health problem (17%, versus 13%). This was true of all ages, though the differences between men and women aged 55-74 were smaller than for other age groups.
• The proportion of men aged 16-64 with a high GHQ12 score remained constant over the three years in which the survey was carried out, while it declined slightly among women, from 19% in 1995 and 1998 to 17% in 2003.

Analysis of a UK survey of psychiatric morbidity ⁸⁶ amongst people living in private households in the UK found that for older people:

• One in ten people aged 60 to 74 in private households in the UK had a common mental disorder (such as anxiety, depression and phobias).
• Women aged 60 to 74 were more likely than men to have a common mental
  disorder (12% of women compared to 8% of men).
• In the 60-74 age groups, people were more likely to be identified as having
  a common mental disorder if they were divorced or separated, on low income,
  in receipt of state benefit, or had long-standing health problems.

Smoking and Well-being

The likelihood of smoking falls with age, reflecting both a 'healthy survivor effect' as well as patterns of smoking cessation. ⁸⁷

Evidence from the Scottish Household Survey 2005 shows that:

• Self-reported smoking prevalence decreases with age, for example: 19% of males aged 60-74 years and 11% of males aged 75 years and over smoke, compared to 28% of males aged 16-24 years and 36% of males aged 25-34 years.
• The pattern is similar in females, with 24% of females aged 60-74 years and 11% aged 75 and years over smoking compared to 29% aged 25-34 years and 28% aged 16-24 years.
• Across all age groups, men and women are generally equally likely to smoke, with the exception of the 45-74 years age group where females are more likely to smoke than their male counterparts.

Figure 48 shows the trends in prevalence of smoking from 2003 to 2004.

• Between 2003 and 2004, the prevalence of smoking is estimated to have decreased most for those aged 16-24 years for both males (a fall of 3 percentage points) and females (a fall of 8 percentage points).
• Amongst older age groups, the prevalence of smoking amongst those aged 75 years and over has stayed the same.
• Amongst the 60-74 age groups, smoking amongst females increased slightly but decreased amongst the 45-69 age groups.

Figure 48: Trends in prevalence of smoking by age and gender, Scotland 2003 to 2004

Source: Scottish Household Survey (2005)

Physical Activity and Ageing

A wealth of evidence exists detailing the health benefits of regular moderate activity for older people. More specifically, regular lifelong exercise is linked to the decreased risk of cardiovascular diseases, osteoporosis, diabetes and some forms of cancer. ⁸⁸

Figure 49 shows data from The Health Education Population Survey ( HEPS) which samples adults aged 16-74 years in Scotland. It shows that levels of recommended physical activity in Scotland tend to decline with age and are fairly low for each age group. These patterns have been fairly consistent over time with some apparent peaks in 1999.

In 2003, HEPS estimates that:

• 57% of 16-24 year olds were achieving recommended levels of physical activity.
• This compares to 46% of those aged 45-54 years and 23% of those aged between 65-74 years.

Figure 49: Trend in percentage of adult respondents achieving recommended levels of physical activity by age group, Scotland, 1996 to 2003.

Source: Health Education Population Survey ( HEPS)

Older People are particularly likely not to undertake the minimum recommended amount of physical activity or to be completely inactive. This is most prevalent in the 65-74 age group.

Figure 50: Percentage achieving high, medium and low summary activity levels by age and gender, Scotland 2003

Source: Scottish Health Survey 2003

Figure 50 shows the percentage of males and females achieving low medium and high activity levels by age. It illustrates:

• Low activity levels are more prevalent in later life (aged 65 years and over) where between 47 and 61% of men and between 53 and 78% of women are inactive.
• Men are more likely than women to be in high activity groups across all age groups.

Participation rates in different activity types ⁸⁹ amongst the older population shows that:

• 74% of men and 78% of women aged 55 to 64 report some physical activity in the last four weeks compared to 91% men and 93% of women aged 25-34 years.
• Amongst women aged 55-64 years the most common activity types are: heavy housework (62%), sports and exercise (30%) and walking (24%).
• Amongst men aged 55-64 years, the most common activity types are spread across a greater range of types including: heavy housework (38%), sports and exercise (36%), gardening/ DIY (35%) and walking (25%).

Alcohol and Ageing

Recent research ⁹⁰ into alcohol and ageing has shown that, when comparisons are made of different age groups across a range of indicators (mean levels of alcohol consumption, proportions exceeding weekly limits, and problems associated with alcohol consumption), a decrease with age is generally observed.

More specifically:

• Older people report drinking smaller quantities than middle age people, who report drinking less than younger age groups.
• Patterns of drinking change with age. Compared with younger age groups, older people are more likely to drink every day and less likely to binge drink. Increased frequency of drinking with age is particularly pronounced in men. Recent Scottish Health Survey data ⁹¹ reports, for example, that 3% of males aged 16-24 years reported usually drinking almost every day compared to 29% of those aged 75 years and over.
• Exceeding recommended limits appears to decline with age, but a substantial minority of men aged 65-74 years drink in excess of recommended weekly limits.
• There are also generational differences in drinking locations. Older people are more likely to drink alcohol at home and someone else's home than younger age groups. ⁹²

Figure 51: Percentage exceeding recommended weekly alcohol consumption limits (21 units for men; and 14 units for women) by age and gender, Scotland 2003

Source: Scottish Health Survey (2003)

This picture is evident in Figure 51, which shows that the proportion of men and women exceeding the weekly limits decreases with age, although the pattern is different for men and women.

• Among men, the proportion who said they consumed more than 21 units per week is fairly uniform (at around 30%) up to the 55-64 age group.
• From the 65-74 age group among men, the proportion decreases, to 22% and then to 15% of those aged 75 years and over.
• Among men, the proportion who said they exceeded 21 units per week is fairly uniform (at around 30%) up to the 55-64 age group.
• From the 65-74 age group, the proportion of men exceeding 21 units' decreases to 22%, and to 15% of those aged 75 and over.
• For women, it is the youngest age group (16-24 years) who are the most likely to report drinking more than the recommended 14 units per week (23%).
• This proportion decreases to between 15% and 18% for those aged 25-49 years before a larger reduction to 11% in the 55-64 age group and to 3% of women aged 75 years and over.

Survey data also shows that consumption of alcohol amongst cohorts of older people, has been rising over time, suggesting that people may be taking patterns of drinking from a younger age through the life course into later life. The present generation of older people for example, drink more than their predecessors; this is also coupled with a rising number of older people exceeding the recommended levels.

The Alcohol and Ageing research ⁹³ report highlights that alcohol may have a potential negative impact on Scotland's population ageing healthily, specifically for the baby boomers. It concludes that:

'if the 20% of present 45-64 year olds (baby boomers) who exceed recommended levels do not reduce their drinking, the number of older people in Scotland whose drinking may be a threat to healthy old age will rise from 80,700 to 223,500 by 2031'.⁹⁴

This is echoed in other research ⁹⁵ which states that today's younger generations will need to avoid bringing alcohol related problems into tomorrow's ageing population.

PATTERNS OF HEALTH AND SOCIAL CARE

Older people are key users of both primary and secondary health and social care services in Scotland. For example, recent NHS statistics provided by ISD show that:

• There were at least 8.1 million contacts with GP Practice Teams (including District Nurses) by patients aged 65 years or over in the year 2004/05 in Scotland, accounting for around one third of all contacts.
• GP consultation rates increase with age from the 55-64 year old age groups upwards.
• There are corresponding higher rates of referral of older people to hospital outpatients departments, with 334 thousand people aged 65 and over being referred in 2004/05.
• In 2004/05, 196,000 people aged 65 plus were admitted electively to hospital (64% of these as daycases). This was 34% of Scottish elective hospital admissions. Older people have higher demand for surgery; the rate of elective admissions per thousand population 65 and over is 235 compared with 90 for under 65s.
• In 2004/05, there were 191 thousand emergency hospital admissions of people 65 and over, accounting for 41% of all emergency admissions.
• Emergency admission rates increase steeply for men and women up to the oldest age groups. Emergency admission rates are higher in men than women in all age groups, and the male excess increases with age. The number of emergency admissions in the oldest age groups have increased in recent years. For example the annual number of emergency admissions aged 85 years and over increased four fold between 1981 to 1999, and has been increasing since. It is difficult to determine how much the trends in emergency admission rates reflect positive factors such as more active and effective management of illness in older people; or how much they reflect adverse factors such as older people's loss of informal support networks and lack of community based care. ⁹⁶
• More than half of the medicines prescribed in the community are for patients aged 60 and over, who are all entitled to free prescriptions.

Older people's perception of health services

Research ⁹⁷ conducted into older people's perception of the NHS in Scotland confirmed that older people (defined as 60 or over in research) are generally satisfied with the health service. More specific findings from the research included the following:

• One in six older people (17%) say that they feel that as a group they receive a poorer service than other groups. Those who feel that way tend to say they feel undervalued and marginalised by the health service.
• The most common difficulties older people say they encounter when using the health service are long delays before appointments. Older people who feel that the service provided to their age groups is worse than others receive are particularly likely to highlight problems with doctors not listening to them or not giving enough time for consultations.
• When older people report a positive experience it tends to be because staff treated them with respect and kindness, rather than because they feel the level of service they receive is exceptional.
• The most common improvements older people would like to see in health services were: 'prioritise older patients/shorter waiting list times' (16%) and 'more staff' (12%).

Receipt of Care

Unpaid care

Recent research into unpaid care in Scotland ⁹⁸ has shown that older people are significant recipients of unpaid care:

• Two-thirds of adults in receipt of care were aged 65 and over.
• A significantly higher proportion of adults in receipt of care were from older smaller (28%) and single pensioner households (33%).
• Relatives are the most common source of outside support for people in receipt of care up to age 75. From age 60 upwards the contribution of home help increases, and for those aged 75 and over, the home help contribution exceeds that from relatives.
• Older people living alone were much more likely than people living with others not to receive the care they required.

Older People and Community Care

Balance of Care

The changing balance in the provision of long-term care to older people, particularly the shift in emphasis from long-term hospital care towards community care, is illustrated by the points below. Home Care and personal services aim to encourage older people and others in need to remain in their own homes for as long as they are able, and to live as independently as possible.

• Between March 2000 and September 2005 the number of residents in care homes for older people has decreased by 2 per cent from 34,402 to 33,716.99
• At September 2005 there were 46 care home places per 1,000 adults aged 65 years and over compared to a rate of 49 in March 2000. During this period, the number of care home residents aged 65 years and over has decreased by 2% from 34,402 to 33,716.
• The number of older people receiving home care services reached a low in 2002 at around 53,600 people. This has increased each year to 57,900 in 2005. Over this time we have seen a shift toward more intensive home care provision. ¹⁰⁰

Research ¹⁰¹ into older people and community care in Scotland found that local networks of community based groups and other social networks played an important role in providing support and in connecting people to community care services. Older people, whose first priority is to maintain independence, place a high value on having a wide choice of social and transport facilities and having access to services such as physiotherapy and chiropody. However, the extent to which services are utilised depends on older people knowing:

• Help is available
• What help is available
• How to access help when it is needed.

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