Introduction

Policy seems to be an area that many pre-registration nurses find challenging. It can be difficult to grasp and seem remote from, and unrelated to, nursing practice. However, for nurses working in health and social care services that are funded predominantly by government expenditure, policy has a direct impact on both the broad environment in which nurses work and the way in which nurses work with older people. We may not always appreciate the wider implications of social policy. As students entering the nursing profession, it is important that you have a clear understanding of social policy and how it has both defined the history of care services for older people and will shape the direction of care and service delivery in the future.

In this chapter we give a brief summary of what we understand social policy to be. There is then a broad overview of recent trends in social policy before particular consideration is given to four areas of policy that have a direct impact on nursing work with older people: the National Service Framework for Older People, dignity, working with people with dementia and long-term care. Later in this book, there is a discussion of policy relating to working with carers of older people. Throughout the chapter we explore how this policy can help you during your clinical placement learning experience, whether in a specialist ‘care of the older person’ placement or for any older person that you may come across in other placements, such as community nursing.

What is social policy?

According to Dean (2005), social policy is the study of human wellbeing. In particular it is concerned with the role of government in providing (or working with the voluntary and private sector to provide) such wellbeing (Peckham & Meerabeau 2007). Social policy tends to be viewed as the response of government to particular social problems. During the Second World War, Beveridge identified five ‘giants’ that needed to be slain – want, disease, ignorance, squalor and idleness (old fashioned language for poverty, sickness, poor education, substandard housing and unemployment).

Even Florence Nightingale considered the need for some of these to be addressed and wrote about how nurses could help with the outcomes of these in terms of ill-health in her Notes for Nursing which was first published in 1859. In her chapter on Health of Houses, for example, she highlights ‘five essential points in securing the health of houses’, namely: pure air, pure water, efficient drainage, cleanliness and light. She considered that, without these, ‘no house can be healthy’.

Activity

Obtain a copy of Notes for Nursing by Nightingale from the library and read this chapter. Consider how her views on the issues of cleanliness, housing and other topics are different from those of William Beveridge’s report in 1942, which was to make a significant contribution to the health of children at that time, many of whom are now the older population. You may need to access some of this report to do this and there are a number of Internet sites that are useful for this purpose. Here is a link to the national archives, but there are many more: http://www.nationalarchives.gov.uk/pathways/citizenship/brave_new_world/welfare.htm (accessed April 2012).

In the twenty-first century, Spicker (2008) has identified the following areas to be of relevance to social welfare:

• Policy and administrative practice in social services, including health administration, social security, education, employment services, community care and housing management.

• Social problems, including crime, disability, unemployment, mental health, learning disability and old age.

• Issues relating to social disadvantage, including race, gender and poverty.

To put this into perspective in relation to the impact that this could have on services and the needs of older people in future, consider the statistics in Box 2.1.

Box 2.1 Older people in the UK

The population of the UK is ageing. Over the last 25years the percentage of the population aged 65 and over increased from 15% in 1985 to 17% in 2010, an increase of 1.7 million people in this age group. Over the same period, the percentage of the population aged under 16 decreased from 21% to 19%. This trend is projected to continue. By 2035, 23% of the population is projected to be aged 65 and over compared to 18% aged under 16.

Not only is the population ageing, but there has been progressive ageing of the older population itself. Most striking has been the increase in the number and proportion of the ‘oldest old’. In 1985, there were around 690 000 people in the UK aged 85 and over, accounting for 1% of the population. Since then, the numbers have more than doubled reaching 1.4 million in 2010 (2% of the UK population). By 2035, the number of people aged 85 and over is projected to be 2.5 times larger than in 2010, reaching approximately 3.6 million and accounting for 5% of the total population.

(From http://www.ons.gov.uk/ons/rel/mortality-ageing/focus-on-older-people/older-people-s-day-2011/stb-opd-2011.html#tab-Older-people-in-the-UK: accessed January 2012)

Recent trends in health and social policy relating to older people

Before 1997, policy initiatives that had an impact on nursing work with older people were relatively rare. During the 1980s and 1990s, the main changes tended to have the goals of containing cost and promoting choice. The Labour Government of 1997–2010 saw much more activity related to health policy with a seemingly unending stream of initiatives aimed at improving health care in general. Older people became a major focus of much of this activity. While the dual goals of cost containment and choice remained, new emphasis was also placed on improving the quality of health and social care.

Quality has been a major theme within health policy since 1997, but its relevance to older people was heightened with a series of newspaper reports which described hospital care that was undignified and failed to meet basic human needs and led to the decision by the Health Secretary at the time to commission a report into the care of older people on acute wards (Health Advisory Service 2000).

Paper to read

See the Healthcare Improvement Scotland Website for a range of resources on this topic and others in this book:

http://www.healthcareimprovementscotland.org/welcome_to_healthcare_improvem.aspx (accessed April 2012).

This report highlighted a number of deficiencies in care for older people and was a major stimulus in ensuring that older people were one of the early groups of patients to have a national service framework (Department of Health (DoH) 2001).

Since 2001, when the national service framework was first published, numerous policy initiatives that have an impact on the care of older people have been issued by the Department of Health. The ones most likely to be encountered in student practice placements are listed above. Each of these are now considered together with a few suggestions as to how you might explore the ways in which the policies have been implemented and how this will affect your nursing practice.

The National Service Framework for Older People

When introduced, the National Service Framework for Older People (DoH 2001) became the driving force for changing the way in which older people were cared for by the NHS. It was based around eight standards (see Box 2.2), many of which have now been superseded by more recent initiatives. However, the former National Director for Older People in the Department of Health, Iain Philp, has argued that the framework provided stability in health policy related to older people (Philp 2009) so it is worth considering the principles that underpinned its development: the promotion of person-centred care and rooting out age discrimination in the NHS.

Box 2.2 The standards of the National Service Framework for Older People

Standard one: rooting out age discrimination

Standard two: person-centred care

Standard three: intermediate care

Standard four: general hospital care

Standard five: stroke

Standard six: falls

Standard seven: mental health in older people

Standard eight: the promotion of health and active life in older age

(DoH 2001)

The standard on person-centred care had the goal of ensuring ‘older people are treated as individuals and receive appropriate and timely packages of care’ (DoH 2001:23). In particular, healthcare professionals were required to:

To meet the standard on rooting out age discrimination, all NHS organisations were required to review all policies to ensure that access to treatments and services were based on clinical need and not constrained on account of the age of the individual. Taking these two standards together, it can be seen that the focus on choice and quality was at the forefront of government thinking.

Activity