Ageing in place: how can we ensure rural residents have choice, control and support to lead healthy, independent lives?

By 2040, over 40% of the UK population will be aged 50 years and over. Yet we are not ageing evenly – with one in three Local Authorities in rural and coastal Districts already having populations fitting this profile. On the one hand, ageing is a life-long process and older people are key contributors to our workplaces, communities and society at large. On the other hand, an ageing population has significant implications for public services; with older people (in general) more likely to access services such as health, care, and pensions than their younger counterparts. COVID-19 has seen urgent problems in social care become more acute. As part of pandemic recovery and future planning, Government is now paying increasing attention to improving services for older people. This includes the publication of the ‘People at the Heart of Care’ White Paper. What does ageing mean for rural communities – and what can be done to fix social care in rural places? Jessica Sellick investigates. 

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How old is an older person? This is not easy to define because expectations, capacities, needs, aspirations and biological ageing can take place at different rates for people of the same age. Typically, the term ‘older people’ can be used to describe people anywhere from aged over 50 years, over the age of 65 years and/or from your 60s. The poet Dante believed “old age” started at 45 years. Other descriptors include ‘elderly’, ‘aged’ and/or ‘senior’ – and there has been much debate about whether this language leads to discrimination. Rather than a specific age or age-range, sometimes older age is used to refer to people in later life, or who have reached retirement. Commentators also describe ageing as a gradual and continuous process of natural change that begins in early adulthood. Term such as the ‘grey brigade or army’ or ‘grey pound’  have also been used to describe the societal influence or purchasing power of older people. Again, there has been much discussion around whether these phrases lead to discrimination and/or whether brands and businesses overlook the spending power of older people.     

While the productivity, creativity and participation of older adults in the workplace, family life and communities is recognised, research from the Centre for Ageing Better highlights the often negative and harmful stereotypes about ageing and older age across many parts of society. The Centre for Ageing Better is working with partners to ‘reframe’ ageing and present a more positive and realistic narrative about older age. Here ageing is viewed as a life-long process where structural issues that can affect how an individual ages (e.g. policies, funding, housing) need to be tackled. The researchers found public attitudes to ageing to be more complex and nuanced – with people increasingly seeing it in a positive light.

Instead of simply looking at age (i.e., number of years), or viewing getting older as a time of decline, other measures such as frailty are now used to identify how healthy a person is and to identify whether they require care and support.  

How have public policy and decision makers seen older people? Since the 1990s Government has introduced many policy initiatives aimed at supporting older people. All of this has helped to increase the profile of older people’s issues: from the establishment of the Inter-Ministerial Group for Older People in 1998 to coordinate policy making, to the establishment of an Older People’s Advisory Group in 1999; and from a New Deal 50+ to assist older people to find employment in 2000 to the establishment of the Pension Service in 2002 and introduction of Pension Credit in 2003. 

Between 2010 and 2015 Government viewed retirement as an increasingly active phase of life where people have opportunities to continue contributing to society by working longer or volunteering in their communities; and take personal responsibility for their own wellbeing by working, saving and looking after their health. Fuller Working Lives: a framework for action, published in June 2014, explained how working longer benefits individuals, businesses, society and the economy. In March 2015 the Government published its report ‘A new vision for older workers: retain, retrain, recruit’ for improving the working lives of Britain’s over 50s.They also published guidance about employing older workers and working past 50. The Department for Work and Pensions (DWP) set out how it would provide digital services to ensure older people were not left behind and would be able to benefit from the increased independence that comes with digital competence. The Government also allocated £1 million to fund help to older people at most risk of long-term loneliness and social isolation. 

In 2017, the Government identified ‘ageing society’ as one of the Industrial Strategy’s four Grand Challenges. This included a mission to ‘ensure that people can enjoy at least five extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest’. 

Since then, Government focus has remained on helping people live more independently and healthily in older age. In January 2021 the House of Lords Science and Technology Select Committee published its report on ageing, science, technology and healthy living. The Committee assessed the feasibility of the Industrial Strategy’s mission and concluded concerted action is required in order to increase the number of years spent in good health in old age. In response, health services should be coordinated to better treat people with multiple age-related illnesses; and technology and services should be deployed more widely to support independent living in old age. Recent scientific discoveries reveal underlying processes of ageing, and the UK could play a leading role in developing treatments to address the root causes of age-related illnesses. The Government has since transitioned the Industrial Strategy into its Plan for Growth and its related strategies. 

More recently, the Government has committed to ‘levelling up’ across the UK to ensure no community is left behind in responding to, and recovering from, COVID-19. The Government has launched new investment programmes to support communities to regenerate town centres and high streets, support to get people into employment, improve local transport links and invest in local culture. In September 2021, the Government announced the Ministry of Housing, Communities and Local Government (MHCLG) was to be renamed the Department for Levelling Up, Housing and Communities (DLUHC). The Department’s current work includes growing a thriving older person’s housing sector. 

How do we care ‘about’ and ‘for’ older people? The term ‘adult social care’ can refer to all kinds of personal and practical assistance given to an individual which may take place in a range of settings. It can also cover assistance for those who care for others. Indeed, much care is delivered by informal, unpaid carers who may be family members, friends or neighbours of the recipient. In 2019-2020, for example, the Family Resources Survey (FRS) estimated that approximately 7% of the UK population were providing unpaid care. Unlike NHS health care, adult social care in England is not free at the point of use. Local Authorities play a key role in assessing the need for formal support. They are required to apply criteria to assess whether a person is eligible for formal social care. An individual may have to undergo means-testing, where depending upon their financial circumstances they may be liable for meeting a proportion or all of their social care costs. To meet the eligibility criteria in England, an individual will need to show that (i) their need for care and support arise from certain health problems, (ii) as a result they are unable to do certain things, and (iii) there is a significant impact on their wellbeing. 

On 7 September 2021, the Government published a paper setting out details of a proposed levy, based on national insurance contributions, to raise additional funding for health and social care. The Government has indicated that most of the proceeds of the levy would be directed towards the NHS first to tackle backlogs over the first three-years of the levy’s operation, with £5.4 billion of the expected £36 billion to be raised set aside for adult social care. 

The paper contains information about how people would pay for adult social care in England. Building on earlier proposals put forward by the Dilnot Commission, this includes proposals for a cap on personal care costs of £86,000 from October 2023; increasing the upper capital limit from £23,250 to £100,000 from October 2023; and increasing the lower capital limit from £14,250 to £20,000. If an individual has capital between £20,000 and £100,000 the Local Authority may fund some of their care but they may also have to contribute up to 20% of their chargeable assets per year in addition to their income. 

While many organisations and care providers have welcomed the extra funding that would be raised by the levy, they have queried how the Government will ensure the share allocated to social care will increase over time. Other bodies have questioned why the proposals only apply to the cost of care and not living expenses, that it fails to address geographical inequalities, and if the proposed £5.4 billion over three-years will be enough to achieve genuine transformation. 

More recently, on 1 December 2021, the Government published a White Paper setting out its 10-year vision for adult social care, and providing more information on funded proposals that will be implemented over the next three-years. The key proposal contained in the White Paper is the cap on how much individuals in England will contribute to their care costs from October 2023, and how care costs will be predictable and limited. Under the heading ‘People at the Heart of Care’, the Paper sets out three objectives to deliver person centred care: (i) people have choice, control and support to live independent lives; (ii) people can access outstanding quality and tailored care and support; and (iii) people find adult social care fair and accessible. The policies and proposed investment set out in the Paper include: 

  • At least £500 million so the social care workforce have the right training and qualifications – and where they also have their wellbeing prioritised. 
  • At least £300 million to integrate housing into local health and care strategies and to increase the range of new supported housing options available. 
  • At least £150 million to drive greater adoption of technology and digitisation across social care. 
  • More than £70  million to increase the support offer across adult social care – including assisting Local Authorities to better plan and develop the support and care options available. 
  • £30 million to help local areas innovate around the support and care they provide in new and different ways. 
  • Up to £25 million to work with the sector to kick-start a change in services provided to support unpaid carers.   
  • At least £5 million to pilot new ways to help people understand and access the care and support available – including a new national website to explain the upcoming changes. 
  • A new practical support service to make minor repairs and changes to people’s home to help them remain independent and safe. 

In response to the ten-year timescale, the Government notes how ‘we know that some of the challenges in social care cannot be quickly fixed. Therefore…we will continue working with a range of voices from across the care and support landscape to deliver the changes that we all want to see. This will include working closely with local authorities and supporting them so they have the right tools and capability to deliver the right care and support that puts wellbeing and personalised support front and centre. We will also engage with a diverse range of organisations and people, including those who draw on care and support or provide unpaid care’ (page 8). Overall the Government’s vision is one of offering people choice and control over the care they receive, promotes their independence and enables them to live well, and values an exemplary and committed workforce. 

According to The King’s Fund, the White Paper doesn’t take us very far forward in the right direction, and lack of money lies at the heart of the problem: ‘social care is getting just a small slice (£5.4 billion over three years) of the £30.3 billion raised by the Health and Social Care Levy, with the majority of the money going to the NHS. The cap has been reconfigured to be less generous to people with low and moderate assets. Once you have taken off the extra costs that the policy document creates for local authorities, the spending power increase in the Spending Review is only 1.8% at a time when social care costs – especially around workforce – and demand for services are surging…Though the vision includes a major focus on personalisation – choice and control – there are no measures to do that, despite an acknowledgement that current approaches are faltering. 

The Nuffield Trust has also called on the Government to back up its words with cash and taking bold and urgent action to pull social care back from the brink and deliver its vision: ‘there is a question about how thinly the funding committed to these proposals will be stretched…it also heavily banks on the actions of future governments and the assumptions that funding raised can be diverted from the NHS to social care. The sector is in the grasp of a deepening workforce crisis, losing as many as 42,000 staff in the last six months, but with no proposals to significantly address low pay…There are already long waiting lists for care and councils are already struggling to meet growing needs. Reform has been dodged for so long that we now find ourselves in a tough starting position’. The Rural Services Network (RSN) described how ‘Local Authorities in rural areas are suffering from years of historic underfunding compared to urban areas. They will be looking for financial reform to bridge the funding gap for Social Care budgets to ensure that they can meet growing demands on the service and current levels of unmet need’. 

Pre-pandemic some people were already unable to get help from their Local Authority and others found themselves in and out of the acute sector as they were discharged without proper care in place. Some people had to sell their family home and possessions to pay for their care – with the Office for National Statistics (ONS) starting to collect data on how many people fund their own care. The Government is now putting choice and investment (e.g. workforce, housing, technology) at the centre of helping those who need care, caregivers and their families. 

What impact has COVID-19 had on older people so far? The pandemic has tragically shown how poor health makes people more vulnerable to further health risks. The social care sector has borne the brunt of the pandemic in so many different ways. In 2020 care home providers notified the ONS and Care Quality Commission (CQC) of 19,248 provisional deaths involving COVID-19 occurring in care homes. In 2021 this figure was 11,229 (to 10 December). According to ONS data, in 2020 more than 800 social care workers lost their lives to COVID-19 since March 2020 – with their loss felt profoundly by their loved ones and staff. Families have been unable to visit their relatives – with data showing that around 97% of care homes closed to visitors during the first wave – with some losing touch with loved ones with dementia who will never recognise them again.  

In February 2021, Baroness Hodgson of Abinger asked the Government what assessment they had made of the impact of COVID-19 on those aged over 75 years. In his response, Lord Bethell described how “… it is a sad fact that this horrible virus targets over-75s more than any other group. We should all be proud of the country’s determination to protect the lives of the elderly and the infirm and give thanks for the vaccines that save so many lives. I assure my noble friend that the NHS has remained open to all and will catch up on the backlog for all those who need medical intervention, irrespective of age”. 

In September 2021, the House of Commons Health and Social Care, and Science and Technology Committees published their report on ‘Coronavirus: lessons learned to date’. This described how the resulting requirement to abandon testing people in the community during the early period of the pandemic cost many lives for a number of reasons, including many older people being admitted to care homes either from the community or hospitals in ignorance of their COVID status or that of staff working in care homes (page 80); and that care homes for older people regularly used bank or agency staff or employed staff regularly working elsewhere which led to a higher risk of infection (page 88). 

Age UK has published research showing how the pandemic has affected older people. It found: 

  • 27% (around 4.3 million older people) said they couldn’t walk as far. 
  • 25% (around 4 million) reported they were living in more physical pain.  
  • 17% (around 2.7 million) said they were less steady on their feet. 

Since the pandemic began many older people have relied, often for the first time, on the internet and digital devices to access services and support. ONS data pre-COVID found that 32% of those who had never or not recently used the internet were between 50 and 69 years of age (over 1 million individuals). Research commissioned by the Centre for Ageing Better sought to understand more about the effects of COVID-19 on digital skills and usage. The research highlights the importance of providing people with a small number of skills building sessions to build their confidence and use of being online; yet they found a lack of awareness amongst older adults of the digital support available. They recommended that small, local organisations be given more funding and resources to support digital inclusion; whilst recognising how non-digital channels still need to be supported. 

Throughout COVID-19 family, friends, neighbours and other informal carers have been expected to step-in or step-up the practical elements of care they were providing. Being a carer while rewarding and uplifting can also be incredibly challenging without the right support in place.  

The King’s Fund has noted how COVID-19 was magnifying the key challenges facing formal social care services, including: 

  • Means testing: adult social care is not free at the point of use like the NHS. 
  • Catastrophic costs: some people end up selling their homes to pay for their care.
  • Unmet need: many people go without the care and support they need. 
  • Quality of care: lack of choice and control. 
  • Workforce pay and conditions: many social care staff are underpaid and undervalued leading to high vacancy rates and high staff turnover. 
  • Market fragility: providers can hand back contracts or go out of business. 
  • Disjointed care: health and social care are not integrated around the individual and this causes issues such as delayed discharge from hospital.  
  • Postcode lottery: there is unwarranted variation between places in terms of access to care and the quality of care being provided.

Some of these points are echoed in a National Audit Office (NAO) report on the challenges facing the social care market in England in the context of the pandemic. This emphasised significant gaps in the Department for Health and Social Care’s (DHSC) understanding of the market. While the NAO acknowledged work underway by the DHSC to address data gaps, increase the capacity of local government and care providers, and strengthen system accountability and assurance; it also recommended that the Government develop a workforce strategy; develop a strategy for the range of accommodation/housing needed by people with care needs; assess the performance and cost data it needs to gain assurance on performance; and explore with the CQC how best to increase the visibility and transparency of provider’s financial sustainability. 

Workforce recruitment and retention were also flagged in a report from the Public Accounts Committee (PAC) on the impact of the pandemic on the care sector. The PAC called on the Government to set out a comprehensive, cross-Government reform plan for care and also emphasised the need for a workforce strategy for the care sector.  Other bodies commenting on the challenges affecting the adult social care sector during the pandemic include the Health Foundation, ADASS, and Carers UK. Similarly, Care England, which represents social care providers, has called for investment and policy support for providers and workers; with bodies such as Skills for Care, the Royal College of Nursing and trade unions all highlighting sector-wide staff shortages. 

In more recent work, the King’s Fund has suggested six things need to happen as part of a long-term wide-ranging reform programme for adult social care: (i) more money is needed to fund the current system; (ii) eligibility needs to be improved; (iii) workforce reform is essential; (iv) personalisation needs re-invigoration; (v) prevention needs to take centre stage; and (vi) carer support needs urgent attention. Will the Government’s social care levy and 10-year vision for social care address these issues? 

How can we support older people to age in rural places? Rural areas have a higher proportion of older people compared with urban areas. According to the Department for Environment, Food and Rural Affairs (Defra) Statistical Digest of Rural England (December 2021 edition): 

  • In 2020, the most prominent age groups in rural areas were 50-54 years and 55-59 years (comprising 7.7% and 8% of the rural population respectively). In urban areas the most prominent age groups are 25-29 years and 30-34 years (7.2% for both age cohorts respectively). 
  • The rural population has a higher proportion of those aged 65 years and over (at 25.4%) compared to the urban population (where 17.1% are aged 65 years and over). 
  • Rural areas in a sparse setting have the highest proportion of those aged 65 years and over – particularly settlements that are rural village and dispersed in a sparse setting (which have 30.7% of the population aged 65 years and over). 
  • Both rural and urban areas have seen an increase in overall population between 2011 and 2020. In rural areas the population increased by 6% and in urban areas by 6.6%.

In April 2021, the Centre for Ageing Better published its commentary on ageing in a rural place. This highlights how the geography of rural areas can prove problematic for the delivery of, and access to health and care services. For example, the lack of or distance from services coupled with poor transport infrastructure makes attending regular appointments difficult. Structures can also operate differently in rural areas – with Town and Parish Councils and District Councils providing housing, leisure and environmental services; County Councils delivering adult social care; Local Enterprise Partnerships supporting the business community; and NHS/ICS structures underpinning the health system. The commentary contains a number of practical solutions to help older people remain independent and be involved in their local community – from increasing levels of physical activity (e.g. promoting walking and cycling) and an increasing prevalence of remote working; through to the diverse, nimble and accessible VCS in reaching the people and places which other services cannot. Rural places are heterogeneous not homogeneous. 

In July 2021 Age UK and Public Health England published a joint report on ageing in rural and coastal communities. This identified five issues which need action: 

  • Loneliness and isolation: particularly for some groups of older men, carers, older LGBTQ+ people and older people from ethnic minorities who often struggle to identify peers in their local area. 
  • The digital divide: the rapid digitisation of services as a potential driver of inequalities. 
  • A lack of support networks among people who move to rural and coastal communities: people may need additional support to identify appropriate services and build peer networks in new communities. 
  • Gaps in public transport provision: this does not always take people to the places they want to go meaning people rely heavily on their cars. 
  • Gaps in support for carers and people with dementia. 

Echoing the Centre for Ageing Better research, the report contained a number of approaches to address these issues – from improving data collection and working with the Voluntary and Community Sector (VCS) through to supporting the development of peer-led services and making accessing services easier (e.g., reaching people through workplaces, community hubs, faith organisations).  

In 2020 Lincolnshire became the Centre for Ageing Better’s Rural Strategic Partner, complementing similar relationships with Greater Manchester and Leeds. Initial programmes of work are exploring healthy ageing (i.e., improving lifestyle choices and promoting physical activity), housing (improving accessibility and digital connectivity), and employment (developing age-friendly employment practices). Lincolnshire now joins a UK Network of Age-friendly Communities. 

In September 2021, the RSN and County Councils Network (CCN) published a joint report describing the quantifying the current state of care in rural areas. This analysed NHS England activity and financial data, and funding estimates and cost projections for adult social care in England. For example, county and rural unitary councils received 49% of all service requests in 2019-2020, up by 5.6% since 2017-2018. Nationally, those aged 65 years and over accounted for 71% of all service requests but in county and rural areas the share of requests received from this age group is disproportionately higher (at 75%). 

Between 2015-2016 and 2019-2020 county and rural unitary councils having absorbed substantially larger reductions to their core funding for adult social care than any other type of council (42.3%). Decreases in funding have been offset to a large extent since 2017-2018 by an increase in temporary grant funding. As a result of temporary grants, all council types except county and rural unitary councils have seen a rise in total grant funding in nominal terms, albeit small. By contrast county and rural unitary councils have seen an overall reduction of £128 million. The report identified the following unique issues facing rural areas when delivering social care: 

  • Resource – Government funded adult social care service costs are significantly lower in rural areas. 
  • Workforce – recruiting adult social care staff to work in rural areas is more difficult than in urban areas. 
  • Demographics – the higher average age and ageing population within rural areas places a higher burden on rural Local Authorities. 
  • Self-funders – the proportion of adults paying for their care is higher in rural areas. 
  • Care homes – the proportion of residential care homes in rural locations is higher than in metropolitan areas, encouraging service user inflow to counties. 
  • Sparsity – the time and costs involved in delivering personal care over large distances in rural and remote areas. 

Alongside demonstrating the severe strain the adult social care system is under, the report suggests that funding alone will not address these challenges: “investment needs to go hand in hand with the opportunities for service improvement and transformation which drive down long-term care costs through better demand management, integration with health and new approaches to service delivery” (page 3) and “reform must also set out a vision for social care based on a value and belief system that is focussed on promoting people’s independence” (page 37). In its rural lens review of People at the Heart of Care, the RSN drew attention to ‘fairness’ in expecting people in rural areas who draw on social care and support to be able to say: 

  • I and my carers can access good social care support regardless of where I live. 
  • I can access good social care regardless of my age. 
  • I can access good social care regardless of my financial means. 
  • I can access good digital care.
  • I can access preventative health initiatives regardless of where I live. 

Some of these unique issues were also identified in the Chief Medical Officer’s (CMO) annual report 2021. Focussing on health in coastal communities, the report highlights how “attracting NHS and social care staff to peripheral areas is harder, catchment areas for services are artificially foreshortened and transport is often limited, in turn limiting job opportunities” (page 2). 

For the past 2-years the National Centre for Rural Health and Care (NCRHC) has been providing the secretariat for a Parliamentary Inquiry into Rural Health and Care. Evidence provided to the Inquiry highlights how the costs of funding adult social care are an issue nationally, but rural Local Authorities are often spending a disproportionately high part of their budget on these services. Rural residents often face less choice and higher care costs than their urban counterparts. Recruiting and retaining social care staff in rural areas where demand for social care is high yet wages and career progression low and access to transport is poor leads to staff shortages. Ensuring parity of esteem between clinical and social care settings (e.g., hospital discharges are a key interface in linking clinical health and social care staff) is vital and social care roles should not be seen or treated as the poor relation to other health roles. The Inquiry is due to launch its findings and recommendations in 2022.

For me, what all of this research shows is that if we want older people to live independent, healthy, and fulfilling lives in rural areas we need to ensure they get the care they need, in ways that are personalised, financially sustainable, delivered in high quality settings by staff who are well trained, paid and valued, and that recognises and supports unpaid carers. We also need to recognise the role of the VCS in driving prevention and wellbeing. Successive Governments have promised but so far always struggled to deliver social care reform. There are no simple, one size fits all solutions, particularly for rural areas. While the current Government is committed to reform, it now needs to put in place the resources needed to deliver its ambitions and vision. Will investment and innovation right across the social care sector deliver for rural communities? Watch this space. 

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Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at The National Centre for Rural Health and Care (NCRHC). Her current work includes supporting health commissioners and providers to measure their response to COVID-19 and with future planning; and evaluating two employability programmes helping people furthest from the labour market. Jessica also sits on the board of a Housing Association that supports older and vulnerable people. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk. 

Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen