Active Ageing Strategy: Policy Review

By Angela Maguire – 2nd Year Undergraduate Student – Social Work

Introduction

From my experience working in Accident and Emergency, I have noticed an increase in age of elderly patients presenting.  I recall having trouble locating a patient record while booking a 97-year-old into the department as there was no history of hospital appointments or admissions.  Fascinating, I thought, to have arrived at this age without medical intervention, but not uncommon I learned over time.  Given the ageing population is of interest to me, I have chosen to review The Active Ageing Strategy (Department for Communities (DfC), 2020).  This policy consists of six outcomes; each comprises various programme initiatives, two of which I have selected to review. 

The chosen initiatives are: ‘Dementia Services’ within outcome three: ‘Older people live healthier for longer’ and ‘Dignity – decision making (Mental Capacity)’ within outcome 6: ‘Older people’s dignity and human rights are respected DfC (2020).  Referring to old age, this is usually defined as the pension age, 65+ (Hugh & Daly, 2021).  This review aims to identify the challenges and opportunities of an ageing population and the chosen initiatives.  It endeavours to explore the attitudes and responses of government and society and critically examine how policy seeks to improve the welfare and well-being of older people in accommodating for an ageing population.

Understanding the policy issue

Population ageing is a result of two, possibly related demographic effects: rising life expectancy and declining fertility rates (Bongaarts, 2009).  A rise in life expectancy increases the average age of a population, while a decline in fertility decreases natality causing a reduction in the number of younger people (Spicker, 2015).  Improvements in life expectancy from 1915-2015 show an increase of 31 years from 48-79 for males and 29 years from 54-83 for females in the United Kingdom (UK) (Office for National Statistics (ONS), 2017).  The Department of Health (DoH), (2017-2019) publication Life Expectancy in Northern Ireland reflect similar statistics.  Austad (2006) suggests the gender gap in life expectancy is due to gender-related biological differences. 

However, Rogers et al, (2010) emphasise the role of social and behavioural factors, such as smoking, alcohol use and occupational hazards in contributing to men’s shorter life expectancy.  In addition, psychological influences play a significant role.  Ferraro and Nuriddin (2006) found that psychological distress is associated with increased mortality though the patterns differ by gender, with men more likely to die from heart disease and women from cancer under high distress. 

These findings highlight that understanding gender disparities in life expectancy requires a multidimensional approach that goes beyond biological explanations.  As life expectancy continues to rise, particularly among older age groups, attention is increasingly turning to the implications of population ageing.  The fastest growth is that of the ‘oldest old’, those aged 80 or over (Baldock et al., 2012).  In 2019, Northern Ireland’s (NI) population of over 85-year-olds was 39,000 with this expected to rise to 103,000 by 2051 (NISRA, 2019).  Dwyer and Shaw (2013) highlight that advances in medical science, the elimination of many infectious diseases and improvements in health awareness, hygiene and sanitation have also contributed to the global increase in life expectancy over the past century. 

Changes in birth rate from 1915-2015 show a decrease from 28,082 to 24,215 (NISRA, 2018).  The economic uncertainty that women of childbearing age continue to face and their increased participation in the labour market is said to have played a part in this downward trend (Da Rocha & Fuster, 2006).  The number of children aged up to 15 is projected to decrease over the next 25 years from 393,500 in mid-2018 to 351,100 in mid-2043.  Thus, the number of people aged 16-64 is projected to decrease from 1179,900 to 1156,700, but the number of people aged 65+ is expected to increase from 308,200 to 481,400 forecasting an increase of 56.2% (NISRA, 2018).  A fall in birth rate and a rise in the elderly population, especially if health is not improved, will put additional pressure on public finances and a smaller working-age population supports increased spending on health, social care and pensions, leaving economic development unsustainable (Green & Clarke, 2015). 

NI has maintained the highest working age (16-64) economic inactivity rate in the UK for the past 30 years, with a rate of 27.2%, primarily due to long term sickness and disability (NISRA, 2019).  This comparison the overall UK rate is notably lower at 21.8% (ONS, 2021).

In NI, 37% of men and 47% of women aged 65-74 were deemed physically inactive, undertaking less than 150 minutes of exercise per week.  This rose to 50% of men and 68% of women of those aged 75+ (Burns et al., 2017).  According to Sheehan and O’Sullivan (2020), physical inactivity has been associated with a decline in mental health and is linked to the development of dementia.  Governments have become aware of these issues through the increase in mental health conditions, for which The Mental Capacity Act (NI) 2016 (MCA) was introduced and the prevalence of dementia cases, particularly during the COVID-19 pandemic (WHO, 2020).  Higher levels of economic inactivity in NI, particularly due to long-tern illness, may reflect and contribute to broader public health challenges, including physical inactivity and the growing burden of age-related conditions, such as dementia.

Dementia is the category of brain disease causing a long-term decrease in mental capacity (Devi, 2017).  Symptoms of dementia include a decline in memory, reasoning and communication skills and a gradual loss of skills needed to carry out daily activities (NHS, 2020).  Dementia is a progressive disease that can affect people of any age but is most common in older people.  It is estimated there are 20,000 people in NI living with dementia, based on diagnosed cases only.  This number is projected to rise to 60,000 by 2051 (NHS, 2020).  Caring for someone with dementia and mental capacity impairment can be physically and emotionally difficult, ‘this means supporting their brain’s ability to organise the world as they see it, in a manner that doesn’t affront their dignity, while still allowing them to flourish’ Devi (2017:171).  It can be difficult if the carer has no support and is unsure where to access help (Dementia Together NI, 2017).  Without proper resources, training and support, carers can experience significant physical, emotional and financial strain resulting in carers burnout (Hiyoshi-Taniguchi et al., 2018).  Such strain can potentially compromise the quality of care provided to the individual being cared for, thereby impacting their dignity and well-being. 

Addressing the policy issue

In 2011, The Department of Health (DoH) published a regional strategy, Improving Dementia Services 2011.  It recognised that the ageing of the population would result in an increase in the number of people living with dementia.  The strategy highlights that providing care for people with dementia already poses challenges for service providers, whether in independent or statutory sectors, and the anticipated increase is expected to place additional pressure on care and support services, as well as those providing formal care.  It acknowledges the considerable human cost to people and their families living with dementia and stresses the importance of caring for carers.  The strategy recognises the need to support the person and their carers to remain in their home environment and maintain their independence as far as possible (DoH, 2011).  This approach helps preserve their health, rights and dignity, while also managing symptoms (Downs & Bowers, 2008).

AgeNI, formed in 2009, is the leading charity for older people in NI.  ‘AgeNI are at the forefront of change, enabling older people to have a voice and to remain independent for as long as possible, supporting those in society who need help and inspiring people to enjoy later life’ (AgeNI, 2019).  In 2011, AgeNI called on the NI Executive to put demographic ageing at the heart of budget planning.  The Programme for Government 2011-2015 proposing commitments to extend age discrimination legislation to the provision of goods, facilities and services led to a process of review and consultation.  However, in 2014, following delays and spending cuts concerning the commitments, AgeNI (2014) stated ‘in the context of an ageing society, more needs to be done, not less.’  A Queens University study by Carney (2015, cited in Campbell, 2016) noted, ‘In general, policy responses have been slow to catch up with demographic change and, at present, there is a vacuum.  A draft Active Ageing Strategy 2014-2020 (DfC, 2014) was published, however, disappointingly, the final version of this strategy is yet to be published.’  Whilst the study acknowledged there was evidence of constructive planning, it stated, ‘if policy changes are to keep up with the speed at which our population is ageing, more must be done and soon’ Carney (2015:23).

As the NI Assembly 2011-2016 mandate ended, proposed age discrimination legislation was still pending, however, a long-awaited Active Ageing Strategy 2016-2021 (DfC, 2016) was finally published.  The Active Ageing Strategy was due to end in 2021, although this was relaunched in 2020 when the DfC got leave from the Minister to extend the strategy until 2022 due to the pandemic (DfC, 2020).  The strategy is aimed at underpinning the overarching objectives of extending life expectancy, the reduction of inequality and the development of streamlined cost-effective services.  The strategy’s vision is to establish NI as an ‘age-friendly region, where people are valued as they get older and supported to live actively to their fullest potential; with their rights respected and dignity protected’ Active Ageing Strategy (2016-2022:5).  The purpose of the strategy is to transform attitudes to, and services for, older people.  It aims to increase understanding of the issues affecting older people and promote their rights, contribution and value.  

The strategy outcomes contribute to the ‘confidence of over 60-year-olds as measured by self-efficacy’ Active Ageing Strategy (2016-2022:9).  The outcomes are informed by the five themes of the United Nations Principles for Older People (UNPOP) (1991).  These are: independence, participation, care, self-fulfilment and dignity and are adopted by the General Assembly of the United Nations.  In practice, the integration of the UNPOP into the Active Ageing Strategy could have far reaching implications for older peoples social, economic and health outcomes.  By empowering older adults, encouraging self-efficacy fostering greater participation and dignity, the strategy can contribute to more age-friendly communities and reduce ageism in various sectors of society.  However, challenges related to accessibility, resources and societal change must also be considered to ensure the success of this approach.  Since the Active Ageing Strategy is a strategy of the Executive, various departments contribute to its delivery and the improvements of services for older people (DfC, 2016).  

Critical analysis of policy response

Given this is a cross-cutting executive strategy involving various stakeholder contributions, the Department for Communities cannot commit to the delivery of each project therefore there is no guarantee the strategy is going to achieve effective implementation (AgeNI, 2014).  Additionally, projections for ageing population statistics have been provided up until 2051 by government and as Carney & Nash (2020) rightly point out, where is the planning for these statistics?  Planning may have been affected by a number of changes including female entry into the labour market, the rolling back of the welfare state and the retirement age and pension entitlements (Duvvury et al., 2018).  Economists may interpret an ageing population as a warning sign for potential labour shortages, increased dependency ratios and economic strain.  In my view, a possible solution to this could lie in increasing the number of migrant workers to strengthen the economy. 

In response to the projects on dementia, the Active Ageing Strategy proposed phase 1 – dementia services, which include several projects focusing on: awareness, raising; information and support; training and development; delirium and short breaks and support to cares.  Although the initiatives focused on delivering awareness of dementia and signposting services, it makes no specific reference to dementia or dignity and has no individual outcome for older people.  Although dementia services were included as part of the Bamford Review (2007) of Mental Health Services, the growing prevalence of dementia and the scale of the work involved in implementing change calls for work on this strategy to be driven forward on its own merits, separate from the wider Bamford agenda (DoH, 2007).  To ensure dementia services are prioritised independently of the broader Bamford Review, several key steps could be taken.  For instance, establishing a dedicated dementia strategy, expanding dementia specific research and enhancing workforce training and development could address the needs of individuals with dementia.  These actions would not only promote a tailored approach to dementia care but also ensure that resources and efforts are concentrated specifically on improving the lives of those affected, without being overshadowed by broader health policy changes.

While many of the projects are useful for older people living with dementia, for example, the Learning Development Framework, which promotes the five themes of the UNPOP, some of the initiatives may be seen as failing to promote participation.  These include the NI Website, Patient Portal and Dementia App, which may be difficult for older people to access due to technological barriers.  Although the strategy was extended, the pandemic undoubtedly interrupted the delivery and effectiveness of projects, as a result of the cessation of GP appointments and face to face assessments and services. 

Older people are most at risk in the community, both physically and health-wise and this risk hugely increased during the lockdown when interaction was compromised by isolation (WHO, 2020).  This also impacted the intergenerational effort older people enjoy (Duffy, 2021).  Where are older people’s rights in this?  To address these rights in future emergencies, government policies must prioritise social inclusion, healthcare access and intergenerational connections for older people.  Strengthening legal frameworks for the protection of older people’s rights during crisis will be essential to avoid further marginalisation and community-based support systems and technologies, such as, virtual connections could help to mitigate the effects of isolation.

Phase 2 of the strategy finished on 31st March 2022; however, analysis and evaluation of the projects have been delayed due to the pandemic, despite the strategy’s year extension.  Since this remains inconclusive, the full extent to which the lockdown has impacted older people and dementia statistics remain unknown (DfC, 2016).  AgeNI welcomed the key elements of the UNPOP and the recognition that ageism and poverty are causes of disadvantage experienced by older people. 

However, it highlighted that age discrimination legislation has still not been passed.  Unlike England, Scotland and Wales where the Equality Act 2010 combines all discrimination laws, NI is the only part of the UK without age discrimination legislation beyond the workplace (InvestNI, 2019).  This calls for the introduction of legislation to outlaw unjustifiable age discrimination (Equality Commission for Northern Ireland, 2022).  In practice, the introduction of age discrimination legislation in NI would significantly enhance the rights, dignity and opportunities of older adults.  It would safeguard them from unfair treatment, empower them to engage fully in society and promote a more inclusive, equitable society.  Additionally, it could contribute to more economic resilience and improved intergenerational relationships, ensuring that people of all ages are treated with respect and fairness. 

In relation to decision making and mental capacity within the Active Ageing strategy, The Mental Capacity Act (NI) 2016 represents a pioneering legislative approach for everyone regardless of mental disorder or disability.  This fusion legislation is the first of its kind, setting NI apart from other jurisdictions, such as England and Wales, where separate acts, The Mental Health Act (1983) and The MCA are used.  While this integrated approach is a progressive development, it is important to note that unlike England’s fully implemented 2005 MCA, the NI legislation remains only partially enacted (Gerard et al., 2017).  AgeNI’s overall response indicates that further work is required to develop the strategy, the action plans and the process of monitoring and implementation to ensure that the Executive’s commitment to older people delivers real and meaningful change (AgeNI, 2019).

Conclusion

The ageing population is at its highest rate in history and increased mortality is one of the greatest successes of public health.  However, its goal extends beyond increasing life expectancy to ensuring those additional years are lived in good health and free from disability, maximising the benefits of this demographic change.  Given the challenges of an ageing population, the DoH (2016) sought to tackle the issues by developing the Active Ageing Strategy to improve the livelihood and wellbeing of older people.  Although the Active Ageing Strategy provides a comprehensive list of actions, the need for age discrimination legislation and the full implementation of the MCA have been highlighted.  In addition, the Active Ageing Strategy makes no explicit reference to dementia or dignity.  It broadly defines its vision as one where NI is ‘an age-friendly region, in which people grow older, are valued and supported to live actively to their fullest potential, with their rights respected and their dignity protected’ Active Ageing Strategy (2016-2022:5).

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