Senior Lecturer in Social Work, University of Gloucestershire, Cheltenham, UK
It has been 22 years since the introduction of the 1990 NHS and Community Care Act. This legislation propelled adult social care provision in the UK, from welfare services that were directly provided by local councils and paid from taxation, to a mixed economy of community care funded by the state, charity organisations and the individual. Other countries, such as Germany, Japan and the Netherlands, have come up with inventive schemes in the formof social insurance systems and tax-funded entitlements to pay for their community care. However, the UK has lagged behind with regard to a clear initiative to pay for adult care, especially in relation to older people.
The idea of the welfare state has remained at the forefront of many older people’s expectations of care, even today, despite changes within service provision. For example, Glasby (2007) found that, within the British context, the public perception of receiving subsidised care in older age far exceeds the funding that is available to meet this expectation. In addition to this, government policies have shifted from adopting a ‘one-size-fits-all’ attitude towards social care and health needs to promoting policies that highlight choice, independence and the prevention of ill health. This has placed an additional ambition on how social care is provided. This has led me to consider how older people from black and ethnic minority communities have fared in the last 22 years in relation to social care provision, and whether government policies related to choice have affected their access to more equitable social care.
Several factors have placed an added burden on the very targets that government policies want to achieve, especially in relation to black and ethnic minority communities. Some of these are linked to how and whether mainstream services adapt to the individual needs of differing ethnic communities, stereotypical beliefs that black ethnic minority older people themselves hold about being looked after by their extended family, and what community networks are available to support their care as well as what people can afford. These factors need to be considered within a population that is growing older. According to Age UK (2010), almost one in five of the population is over pensionable age (60 years old for women and 65 years for men). The number of older black and ethnic minority people is currently low, and represents about 8% of those over 60 years of age; most are of Pakistani, black Caribbean or Indian origin (Runnymede Trust, 2012). However, this situation is set to change, with a predicted rise in the number of older black and minority ethnic people to around 3.8 million aged 65 years or over, and around 2.8 million aged 70 years or over, by 2051 (Age UK, 2010).
It has long been the case that there have been generally lower levels of satisfaction with local authority and private sector service provision among older black and ethnic minority people (Atkin and Rollings, 1992; Butt and O’Neill, 2004; NHS Information Centre, 2009). This is reflected in the view that services are targeted towards the majority population and so are not culturally appropriate. For example, residential care homes are regarded as unable or unwilling to meet language and communication requirements, rituals related to religious practices, food requirements and end-of-life care (Lloyd, 2000; Badger et al, 2009). Although there has been some growth in residential care homes that cater specifically for black ethnic minority communities, the numbers are insignificant, and there is an ‘overall under-representation of BME older people in care homes’ (Badger et al, 2009, p. 25). Added to this is the problem of how to access and use social care services. Language barriers, together with lack of information about services, constitute a major block for older black and ethnic minority people (Butt and O’Neil, 2004, Manthorpe et al, 2009).
Community-based voluntary-sector organisations are a good source of culturally appropriate support for many black and ethnic minority people. These organisations are often financed from a range of funding streams that includes local authority, health or charity sources. Sustaining funding remains an enormous challenge for such organisations, especially within the current economic climate of austerity measures and cuts in public spending. Cutbacks in the projects and networks that actually support older black and ethnic minority people diminish their choices and also, ironically, compromise the current policy for providing personalised social care and healthcare. Coupled with this is the high cost of social care, and many older black and ethnic minority people struggle to pay. They are less likely to have private pensions and more likely to be reliant on the state pension, and they thus have a lower income than the majority population (Butt and O’Neill, 2004, Berthoud, 1998; Evandrou, 2000). Recent evidence shows that Bangladeshi and Pakistani pensioners live in 46% more poverty and black Caribbean pensioners live in 25% more poverty than their counterparts in the majority population (Runnymede Trust, 2012).
Poverty, lack of service provision and cultural expectations lead older black and ethnicminority people to rely on their families for care. This places a great strain on family relationships. Older people’s expectations that their families will care for them are not limited to a British context. For example, Prakash (1999) provides evidence of how urbanisation within the Indian context has had an impact on the way of life of older Indians. She asserts that traditional extended families are disappearing not only within urban areas, but also in some rural areas of India. This places additional pressures on families as older people’s expectations remain the same. In their view, residential care is perceived as unacceptable, and consideration of this would result in criticism from relatives around the world. The diasporic nature of many black and ethnic minority families means that traditional expectations and the social pressure to meet them find their way into day-to-day life in many different settings (Ahmed and Rees Jones, 2008).
Older black and ethnic minority people are placed in a vulnerable position by a combination of lack of access to services, poverty, service cuts and traditional expectations being placed on them. Professionals need to understand the challenges faced by older black and ethnic minority people and those who care for them, not just in relation to the well-being and dignity of these older people, but also in relation to the pressures that are created when choices are limited. They also need to be able to recognise when the pressures are becoming unmanageable. Recognition and prevention of elder abuse is an important issue that has only recently been formally acknowledged (Department of Health, 2000). Current guidelines aim to prevent abuse and, if this fails, to ensure that appropriate procedures are in place for dealing with incidents of abuse. Although a multi-agency response is emphasised, the lead responsibility for this task falls on local authorities and councils that are already stretched in commissioning care for mainstream populations who are also vulnerable.
Despite changes within welfare provision and the Equality Act 2010, which requires services to be proactive in addressing discrimination, older black and ethnic minority people continue to experience difficulties in accessing suitable care and services. Responses to their needs are still inappropriate, and it seems that either service providers will not make the effort required or there is a persistent failure to recognise racial identities and individual cultural needs. Older black and ethnic minority people themselves share some of the responsibility for this, in their unwillingness to respond to change. For example, some older people still harbour the idea that they will return to their homeland in their older age. This affects the way in which they adjust to changes in their circumstances when this reality is not possible. The nature of diasporas also means that what was initially considered to be someone’s homeland is no longer accessible to them. The lack of change in the attitudes of older black and ethnic minority people towards their circumstances means that some are living in poverty because they have not accessed the support that is available to them and which could enable them to pay family members or neighbours to care for them.
It is clear that the need for change cannot be the sole responsibility of social care and health services. Black and ethnic minority older people need to adapt to changes in their circumstances if they are to succeed in accessing resources and utilising family and community networks. It is also clear that community-based voluntary service organisations provide a valued service, and that failure to maintain this support also results in further isolation of older people. As our ageing population increases, it is imperative that we maintain a focus on older black and ethnic minority communities. Lack of attention will give rise to more poverty, poor health, stresswithin families and the potential for abuse. Although we all recognise that some austerity measures are necessary, leaving some groups of people within our society more vulnerable is not acceptable.