Factors affecting the ability of older people to live ... · PDF fileFA CTO RS AFFECTING THE ABILITY OF OLDER PEOPLE TO LIVE INDEPENDENTLY ... FA CTO RS AFFECTING THE ABILITY OF OLDER

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FA C TO R S A F F E C T I N G T H E A B I L I T Y O F O L D E R P E O P L E TO L I V E I N D E P E N D E N T LY

FOREWORD

As part of Government’s contribution to the International Year of

Older Persons in 1999, the Minister for Senior Citizens allocated

funding for a research project investigating factors that enable older

people to maintain their independence.

I am very pleased to introduce this research to you.

With New Zealand’s ageing population, it is crucial we continue to

extend our understanding of the changes that we as a country need to

make so we can best adapt to and benefit from this change.

The Government has a commitment to promote positive ageing. We

know that many people express a preference to maintain their

independence as long as possible.

This research has provided an opportunity for older people, and those

who work with them, to suggest ways that Government, communities

and individuals can contribute towards the Government’s goal of

maximising the independence of older New Zealanders.

I am sure that this research will make a useful contribution to future

policy advice in this area.

I would like to thank the authors for their contribution to a very

successful International Year of Older Persons.

Dame Margaret Bazley, DNZM

Chief Executive

Ministry of Social Policy

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IntroductionThis research was undertaken as partof the national observance of theInternational Year of Older Persons. Thepurpose of the research was to identifyand investigate factors that allow olderpeople to remain independent. Theproject was undertaken by Gray MatterResearch and was jointly managed by theSenior Citizens Unit and the ResearchUnit of the Ministry of Social Policy. Thefindings of the research will be useful inthe development of policy to meet theneeds of an ageing population.

The context

As in other western countries, olderpeople are growing as a proportion ofthe New Zealand population. In 1996,just under 12% of the population wasaged 65 or over. This proportion isexpected to peak at around 25% of thepopulation in 2050. The most rapidincrease will be in the “old old”. By 2031,people aged 80 and over are expected tomake up 27% of the population of thoseaged 65 and over. The ethniccomposition of this population willbecome more diverse as the proportionof older Maori and Pacific peopleincreases. Maori are now 3% of olderpeople, and are expected to be 5% of theolder population in 2011. Pacific peopleare 1% of the older population now andexpected to rise to 2% by 20111.

Ageing can involve not just superficial

changes but decreased mobility anddexterity, decreased strength andstamina, and reduced sensory acuity.Statistically, the probability of morbidityor illness and some disabilities increaseswith age. Older age is associated with anincrease in the prevalence of chronicdiseases including heart attack, stroke,arthritis, osteoporosis, cancer anddementia. Older people are also likely tosuffer more severe non-fatal injuriesfrom falling2. Older people are oftenmore affected by, and take longer torecover from sicknesses, such asinfluenza.

On the social side, ageing can involveisolation from family and friends,including the loss of peers. Thecomposition of neighbourhoods maychange as older people die or move outand younger families move in. To “age inplace” successfully requires planning andoften support from health and disabilitysupport services, as well as family, andphysical changes to one’s home.

One of the key challenges facinggovernment is to find appropriate, cost-effective and fiscally affordable ways toassist people to live independently.

The relationship betweenage, level of disability and livingindependently

Ageing does not occur at a uniform ageor rate. There are different views onwhether the expected average duration ofdisability and illness will increase,decrease or stay the same as lifeexpectancy increases, with most seeing

1 Statistics New Zealand, 1998, New Zealand Now 65 plus2 Smith, R., 1998, “The cost effectiveness of home assessment and modification to reduce falls inthe elderly” in Australia and New Zealand Journal of Public Health, Vol.22 No.4, 436-440

PART I: INTRODUCTION

FA C T O R S A F F E C T I N G T H E A B I L I T Y O F O L D E R P E O P L E T O L I V E I N D E P E N D E N T LY

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the long-term links between longevityand the health of older people as unclear.One view is that medical advances andchanges in lifestyle will compress theonset of mortality and disability into ashorter period. Another view is that thecurrent experience, where improvementsin health are not quite keeping up withincreases in life expectancy, willcontinue. That is, on average, disabilityor illness will occur at older ages, but theperiod of disability or illness will belonger. A recent report on long-term careconcluded that, for the United Kingdom,the best evidence suggests that factorsthat are causing people to live longer arealso resulting in extra years of life beingfree of severe disability3.

Most older people do live independently.At the 1996 census, 92% of people 65and over, and 87% of people 75 and overlived in private dwellings. That is, theylived at home, with or without familycare or other health or welfare services.There are degrees of independence orinterdependence amongst those living ina domestic setting. Most disabled olderpeople, including those with severedisabilities and high dependency onothers, presently live in privatehouseholds.

On average, levels of disability and needfor support increase with age. However,many older people with a disability4 orwho are ill do not access formal support

services at all. In 1996/97, the disabilityrate for adults aged 65 -74 was 414 per1000. More than half of these (384 per1,000) had a disability requiringassistance. Adults aged 75 and over had adisability rate of 661 per 1000; with overhalf the people in this age group (550 per1000) having a disability requiringassistance5. In 1996, 75% of adults over75 with a disability, including those witha Level 2 or Level 36 disability held aCommunity Services Card. Around 17%of New Zealand Superannuationrecipients also receive a DisabilityAllowance, an income-tested and cappedpayment to cover regular, additionalcosts that arise as a result of a disabilityor ongoing illness.

As expected, older people receivinginstitutional care have a greater averagelevel of disability than those who areliving independently. There is, however,no unambiguous point of transition, andsome people living independently havehigher levels of disability than otherswho are in institutional care.

The research project

The New Zealand Government has acommitment to Positive Ageing.Government supports the principle thatolder people should be encouraged toremain independent and self-reliant aslong as possible. At the time this researchwas commissioned, the Ministry ofSocial Policy, for example, contributed to

3 Royal Commission on Long Term Care, 19994 A disability is defined as any limitation in activity resulting from a long-term condition or healthproblem. Status is self-ascribed.5 Health Funding Authority and Ministry of Health, 1998, Disability in New Zealand: Overview of the1996/97 Surveys, p.73, also Appendix Table 3.10, p1586 Level 2 represents those who require assistance to live independently, but do not require this assistanceon a daily basis; Level 3 represents those who require intensive assistance on a daily basis.

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government strategic result areasthrough the following key result goal:“Positive attitudes to ageing encourageand support older people to remain selfreliant. Through this they can participatein their own well-being and that of theirfamilies.”

One of the goals of Disability SupportServices7, funded through Vote Health, isto maximise independence8. This goalstates that: “The Government remainsfirmly committed to the concept ofproviding a range of services for peoplewith disabilities, designed to supporttheir ability to live independently withinthe community. The basic prerequisitesof living independently include access toinformation, equipment andenvironmental support services, income,appropriate housing and personalsupport services. The Governmentremains committed to assisting with theprovision of independent living settingsin the community and in people’s ownhomes, rather than institutions, whereverpossible.”

A 1995 report of the National AdvisoryCommittee for Core Health andDisability Support Services9

recommended that ‘ageing in placeshould be supported, as most peopleprefer to remain independent in theirown homes for as long as possible ratherthan move to rest home or residentialcare’. In addition, older people have the

skills, experience and knowledge tocontribute to society, and continuedproductivity in older age has benefits forthe individual concerned, thecommunity and the state10.

While there have been a number ofgovernment initiatives to support theseprinciples, the government identified aneed for further information andresearch on the factors that determinethe ability of older people to maintaintheir independence and contribute tosociety. The information will fill aknowledge gap and assist government tomake decisions on policy priorities thatmay reduce the fiscal risk of an ageingpopulation.

1999 was the International Year for OlderPersons, which made it particularlyappropriate for government tocommission research in this area. Thestudy was undertaken in three stages.

Literature review

The first stage was a review of NewZealand and international literature onfactors that contribute towards olderpeople maintaining their independence.It reviewed the literature under fourmain headings:

1. Factors that maintain the health ofolder people.

2. Environmental factors that help olderpeople maintain their independence.

7 Ministry of Health and Health Funding Authority, 1998, Disability Support Services Strategic WorkProgramme: Building on the New Deal Ministry of Health pp14-158 Under the present funding arrangements, older people requiring support are defined as having disabilities.9 Richmond, D. et al., 1995, Care for older people in New Zealand A report to The National AdvisoryCommittee for Core Health and Disability Support Services10 Senior Citizens Unit, 1996, Issues Papers for the Minister for Senior Citizens, p7-1


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3. Factors which make it more probablethat an older person who is ill or has adisability can live independently.

4. Personal services and other initiativesthat enable people to stay livingindependently.

The review also highlighted barriers thatrestrict older people’s independence andexamined literature on the incentivesolder people have to invest inindependent living.

The review used census data to identifysignificant trends in the proportion ofpeople living at home. It compared thecircumstances of men and women, andpeople in different ethnic, income andage groups. It also discussed data onhealth expenditure on institutional andhome-based care of older people.

The main points of the literature revieware summarised in Part II of thispublication.

Empirical research

The second stage of the research used keyinformant interviews, focus groupdiscussions and letters to identifysignificant factors that contributetowards the maintenance ofindependence of older people. Theresearch explored the experiences of arange of older people in New Zealandand the views of informants workingwith older people or having expertise inthis area. It was designed to complementthe findings of the literature review.Because of the relatively small scale ofthe research, its findings are necessarilyindicative rather than conclusive. Theresearch report is included as Part III ofthis publication.

Suggestions for change

The third stage was to draw togethersuggestions for change arising from boththe literature review and the empiricalresearch. These are included as Part IV ofthis report.

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Factors that maintain thehealth of older peoplePolicy makers and service providers areinterested in the extent to which highproportions of older people can liveindependently in the future. However, itis clear from the literature that livingindependently does not simply meanliving at home.

Living independently means having aquality of life which involves remainingactive and contributing to thecommunity, while living either in aseparate dwelling, owned or rented,alone or with friends, relatives or carers,or in a retirement village. Internationally,higher levels of formal care are beingprovided outside institutions, with thegrowth of assisted and group livingsituations being an important part of thistrend. According to Kane (1995) thissuggests that the distinction betweenindependent living and institutional careis likely to be blurred in the future. Thisreview considers factors that promote orhinder independent living.

As noted previously, the probability ofmorbidity or illness, and somedisabilities, increases with age. Theprobability of having Alzheimer’s Diseaseor related dementia, for example, is 1 in10 over age 65 and 1 in 5 over 80 (PrimeMinisterial Task Force on PositiveAgeing, 1997a). There are differences inthe morbidity patterns of women andmen.

The 1992/93 New Zealand Health surveyshowed that 86% of people 75 and over

have some type of disability or long termimpairment. One third have somehearing loss. Thirty-six percent of menand 42% of women have partial mobilitylimitation, with 21% of men and 31% ofwomen having severe limitation (Triggset al., 1994, cited in Davey, 1998). The1996 Household Disability Surveyrecorded 66% of women and men aged75 and over, as identifying as having adisability (Health Funding Authority andMinistry of Health, 1998).

Healthy lifestyles

The link between lifestyle and health inolder age is well documented. Accordingto a National Health Committee report(National Health Committee, 1998),much of the physical decline associatedwith old age can be attributed toinactivity rather than the ageing process.The report concludes that between onesixth and one fifth of the 7,800 deaths inNew Zealand each year from coronaryheart disease, colon cancer and diabetesare attributable to physical inactivity.Physical activity can also reduce otherrisk factors including obesity, high bloodpressure and feelings of depression andanxiety. Moderate exercise also helpsbuild and maintain healthy bones,muscles and joints thereby reducing therisk of falling and also improves olderpeople’s ability to perform daily tasks.

A large number of reports andpublications, including the New Zealandreport Active for Life (1998), suggestsuitable activities for older people. Theserange from gardening, swimming andusing a wheelchair to walking.

Social, emotional and mental health

Good social, emotional and mental

PART II: SUMMARY OFRELEVANT LITERATURE


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health is a critical ingredient in successfulageing.

There is a general consensus that later lifesickness and suffering can be partiallyalleviated by a frame of mind thataffirms and embraces life. When peopleare ‘health conscious’ they tend to believethey can manage their own health. Mottand Riggs (1992), for example, foundthat many older people with multipledisabilities had a positive healthperception due largely to a feeling ofindependence and a sense of control overtheir own lives. Similar findings emergedfrom a study on the health and wellbeing of older Maori people (TePumanawa Hauora, 1997).

An extensive review of gerontologicalresearch shows quite conclusively thatregular engagement in meaningfulactivities contributes to the overall healthand welfare of older people (Seedsman,1991). Overseas studies havedemonstrated that older people athighest risk of mental illness are thoserecently discharged from hospital, therecently widowed, living alone and thepoor and socially disadvantaged. Men aremore at risk of mental illness thanwomen (Melding, 1997). Suicide risksamongst older men in New Zealand aresecond only to the rate of suicide inyounger men (Ellis and Collings, 1997,cited in Age Concern, 1999).

Income

Income is a predictor of health status.The links are two-way. Lower incomeslimit options for purchasing health care,

health insurance, appropriate housingand other goods and services that canassist in the maintenance of health. Inaddition, poor health tends to limitincome-earning opportunities.

Older people have lower incomes thanaverage. In 1996, the median annualincome for someone aged 65 or over was$12,040, compared with the medianincome for all New Zealand adults of$15,600. The main income source forpeople aged over 65 is New ZealandSuperannuation (NZS). The 1996 censusrecorded a lower proportion of olderMaori (78.4%) receiving NZS than theproportion of the whole over 65population (90.7%). It is not clear whythis discrepancy exists. Older Maori alsohad a lower than average annual income($10,380). Income levels for older Pacificand Asian people were lower withaverage incomes of $8,900 and $8,440respectively. Part of this difference relatesto access to NZS, which is subject toresidency criteria11. Only 38% of olderAsian people and 46% of older Pacificpeople received NZS (Statistics NewZealand,1998d).

One possible source of additionalincome for older people is paid work.Labour force participation rates for NewZealand men between 55 and 64 weregenerally dropping in the late 1980swhen NZS was available from age 60, butare now starting to increase12. The shiftshave been more pronounced for 60-64year olds. For women in their late fifties,labour force participation has trendedupwards over the last ten years and for

11 Living in New Zealand a total of ten years since age 20, and five years since age 50.12 The labour force includes those in full-time and part-time employment and people who are

unemployed and seeking work.

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women in their early sixties, labour forceparticipation has increased significantlyover the last four years. Women’s labourforce participation is still substantiallylower than men’s for the latter age group.

A potential source of income is therelease of equity in housing that olderpeople own. This may occur through‘trading down’, that is selling largerfamily homes and moving to smallerunits. There is little research into howoften this occurs or how successful it is.

Equity release schemes are anotheroption but take-up of these in NewZealand is low (Davey, 1998; Kennedyand Mackay, 1996). Despite the resistanceto such schemes, Davey and Kennedyand Mackay believe that the prospects forcommercial equity release schemes aregood and they stress the need forgovernment endorsement and a Code ofPractice.

Environmental factors thathelp older people maintaintheir independenceAttitudes and perceptions

The diversity of older people means thereis no general experience of living as anolder person. Nevertheless, in a range ofsurveys, older people have identifiedcommon factors that determine qualityof life. A New Zealand survey, involvingface to face interviews with 1000 peopleover 60, found that three factors, anadequate income, good health and socialcontacts, were determinants of eachindividual’s quality of life (ColmarBrunton, 1990). After reviewing a rangeof surveys, Day (1996) added threeadditional factors: a sense of security,

self-management, and having a respectedplace in the community. These factorsare closely related with self-esteem, ahealthy mental state, and the ability tomaintain a positive outlook. Moreover, acommon theme in both pieces ofresearch is that older people withdisabilities commonly perceivethemselves as “well and healthy”.

A survey of 397 kaumatua who lived innon-institutional settings had findingsconsistent with those noted above. Forthat group, higher standards of healthwere significantly associated with activemarae participation and culturalaffiliation, home ownership and higherincomes. Among the kaumatua surveyed,impaired vision or hearing was common,but mental health problems were not (TePumanawa Hauora, 1997). Maori whoare involved in the Maori communitybenefit from the respect and statusaccorded older people, and especiallykaumatua. According to Maaka (1993),older Maori who are alienated from theirculture can suffer from a strong sense ofisolation.

Housing

Having appropriate housing can enhancepeople’s ability to adjust to disability andillness and make it more likely that theycan continue to live independently. Theliterature, both in New Zealand andoverseas, suggests that older peoplegenerally want to live in their ownhomes, whether owned or rented, as longas possible.

More than 9 in 10 older people live inprivate dwellings, a proportion that hasremained fairly constant over the tenyears 1986-1996, despite the ageing of


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the older population. In 1996, 84% ofolder people in private dwellings wereowner-occupiers. The proportion ofolder people living on their own hasincreased in the last 30 years. In 1966,1 in 5 older people lived on their own,compared with almost 1 in 3 in 1996.Three in five women in their eightieslived alone (Statistics New Zealand,1998e). While the proportion of olderMaori people living alone is currentlylower than for the population as a whole,the numbers living alone are likely toincrease (Te Pumanawa Hauora, 1996).A similar trend is predicted amongPacific people.

Research suggests that tenants, inparticular, fear that they will be forcedinto smaller accommodation as they getolder (Rushmoor, 1998). Bed-sittingrooms or one-bedroom flats can restrictsocial contact with families and theability to engage in hobbies orrecreational activities. Lack of facilitiesfor caregivers can lead to unnecessaryentry into hospital/residential care, eitherin the short or long-term.

Thorns (1993) notes that retired owner-occupiers in New Zealand may have ahigh asset base but a low annual income,which can impose hardship. Some areable to take advantage of rates rebatesfrom their local authority and the SeniorCitizens Unit (1996) reports that 33% ofthose receiving a rates rebate were singlesuperannuitants living alone.

Home maintenance is a concern forolder owner-occupiers, and the literatureidentifies the value of and need for home

maintenance and related support servicesfor older people (Taylor et al., 1981;Hereford, 1989; Rushmoor BoroughCouncil, 1998).

Hereford (1989) reported on theSupportive Services Program for OlderPersons in America. This tested thefeasibility of requiring older people (and/or their caregivers) to pay for servicesthemselves, and found a strong demandfor handyman, minor home repair andhousekeeping services, particularly fromwomen living alone. Another Americanstudy investigated why older people donot make modifications to their homeseven when they agree that these are ahigh priority (Steinfeld and Shea, 1998).The authors found that while economicconstraints were important, so wereolder people’s perceptions both ofthemselves and of the problem. Somethings were perceived as ‘too muchtrouble’ despite their obvious value. Inother cases, individuals either denied achange in their status or blamed theirown limitations as the cause of theproblem.

Research on migration trends confirmsthat older people who move tend to doso first for amenity or retirementreasons. Widowhood or moderatedisability may lead to a second move tobe closer to family or medical services(Silverstone and Horowitz, 1992). Thistrend is also evident among HousingNew Zealand tenants13 and raises thequestion of how much accommodationshould be modified to meet the needs ofparticular tenants or residents.

13 Personal communication, Sherry Carne, Housing New Zealand

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Transport

Many studies, including one by Mott andRigg (1994) have found that geographicalisolation and lack of public transportlimit older people’s ability to be involvedin social life, confining many to activitiesin their own, or at most, an adjacentsuburb. Older people do not wish to beseen as too demanding and limit theirrequests to ‘really important errands’such as doctor’s appointments,minimising requests for shopping andnot asking for transport for reasons suchas visits to friends (Legge and Cant, 1995).

The proportion of older people whohold current driver licences decreasessignificantly with age. In August 1996,approximately 65% of New Zealandersaged 71 or over held driver licences. Forpeople aged 81 and over, less than thirtypercent held driver licences. The LandTransport Safety Authority has recentlyreviewed driver licensing for olderdrivers. A 1996 discussion paper reportsthat compared to other age groups,drivers aged 71 and over are involved infewer crashes per year but have a higheraccident rate per kilometre travelled(LTSA, 1996). In addition, older driverstend to be more fragile and will suffermore severe injuries than youngercasualties in the same crash do.

Changes effective on 3 May 1999 relaxedthe driver retesting provisions for olderdrivers. A medical test is now firstrequired at age 75 and the first practicalre-test at age 80. Both medical andpractical tests are required every twoyears thereafter. The new policy retainsprovisions to restrict licences forparticular conditions, such as time of theday or a specific location.

The availability and affordability ofpublic transport in New Zealand variesacross the country and is theresponsibility of Territorial LocalAuthorities. At present, Transfundsubsidises public bus, ferry and railtransport. It also helps fund social servicetransport programmes but this maychange in the future.

Friendship andcommunity participation

The support of family and friends is animportant component of independentliving. Research indicates that there maybe gender differences in both the needfor, and ability to maintain socialnetworks. A 1990 Colmar Brunton studyfound the norm for women living alonewas frequent contact with familymembers. Several studies have found agreater openness among women tomaintaining and establishing newfriendships in older age (Armstrong,1991; Bonita, 1993). However, Riggs(1997) found that friendships played asignificant role and helped men adaptwhen their spouse had died.

Factors which make itmore probable that anolder person who is ill orhas a disability can liveindependently

Family support and care

There is a consensus within research thatthe presence or absence of familysupport is a prime factor in determiningwhether or not an older personcontinues to live independently (Tilsonand Fahey, 1990; Richmond et al., 1995;Kendig and Brooke, 1997).


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Different cultures regard institutionalcare differently. It has sometimes beenassumed that Maori and Pacific extendedfamilies will provide care for older familymembers. However, a Ministry of Healthreport (1997a) notes that ‘the role of theextended family in the long-term care ofelders should not be taken for granted,particularly as 80% of Pacific incomeearners have an income less than $20,000per annum. This compares with 64% ofincome earners in the total population.’

The key factor influencing family care isagreed to be not family size but having aspouse or a daughter (Prime MinisterialTask Force on Positive Ageing, 1997,p.30). From a national sample of 3000,Abbott and Koopman-Boyden (1994)found that over one-third of the totaladult population is providing regularinformal care to older people, withpeople who are retired, unemployed andhomemakers providing the largestamounts of care.

The breakdown of care can occur due tothe poor mental health of the olderperson and/or of the carer. Carer stresshas become of increasing concern andcan be linked to elder abuse and neglect.Keys and Brown (1993) support a multi-agency approach to dealing with elderabuse, which is in effect the approachadopted in New Zealand. There arecurrently 22 elder abuse and neglectservices in operation, of which 14 areprovided by Age Concern. TheDepartment of Child, Youth and Familyfunds these services.

Issues for women

Women live longer than men, and aremore likely than men to live alone in oldage. Living alone and having loweraverage incomes are factors that leadwomen into institutional care at higherrates than men at older ages.Comparative statistics from the 1996census are shown in Table One below.Some older people are also resident inother institutions, such as publichospitals, but these figures are small anddeclining.

Steinburg (1997) identified transport,perceptions of safety and security, poorbody image, poor self esteem, lack ofconfidence, stereotypes of women’sinability to make informed medicaldecisions or choices, and society’sdevaluing of older lives as barriers to selfhelp or correlates to dependence forwomen. Older women placed particularemphasis on functional environmentsand communities.

The interaction between doctors andolder women is a common theme in theliterature on the loss of women’sindependence. Steinburg (1997) notedthat older women considered that GPsdid not relate well to them and neglectedimportant issues such as incontinence,oral health, polypharmacy and

14 This category includes non-private dwellings providing supportive accommodation for the aged orretired. The provision of meals is a minimum requirement for supportive accommodation. Thiscategory may therefore include living arrangements such as Abbeyfield houses and some servicedapartments in Retirement Villages.

Table 1: Percentages of men andwomen in rest homes: 1996 census14

Age group 80-84 85-89 90-94 95+Men 6.3% 12.8% 24% 33.1%Women 10.1% 22.0% 38.3% 50.6%

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alcoholism. The failure to manageincontinence, in particular, is often amajor factor in determining admissionof an older person into a rest home.

Personal services,and other initiatives thatenable people to stayliving independentlyWhile most of the costs associated withliving independently are met byindividuals, and most of the care olderpeople need is provided by families,government has a key role in enablingindependent living, particularly in thearea of health and home-based services.

Public Health approaches

Preventive programmes can reduceillness and accident rates for olderpeople, and thereby reduce the flowthrough to institutional care. However, asyet there is not much evidence of thecost-effectiveness of comprehensiveapproaches to reduce the possibilities ofinjury at home. An AccidentCompensation Corporation initiative,the Community-Based Fall PreventionDemonstration Projects for Non-Institutionalised Older Persons, wasestablished in 1997 to reduce theincidence of injuries, their severity andtheir costs in people over 65 years of agewho live independently. While it is toosoon yet to say whether it has beeneffective, early indications are positive.

The provision ofhome-based services

Much of the literature on the provisionof home-based services has focused ontheir cost effectiveness compared withinstitutional care. There has been

relatively little evaluation of the range ofother supports that arguably contributeto independent living, particularly in theNew Zealand context.

In 1996, Waitemata Health carried outthe most substantial New Zealandstudy to date of home-based services asan alternative to institutional care(Richmond and Moor, 1997). Thestudy found no difference in deathrates and no statistical difference inactivities of daily living, morale,mental status or support needs betweenthose receiving care at home and thosein institutions. Those in the home caregroup were more satisfied with theirliving arrangements. When the cost ofsecondary health care was included, theweekly cost of the home careprogramme was substantially less thanresidential care - $353.95 comparedwith $508.47 per week. No costs wereimputed for family carers.

The picture for family carers was lesssatisfactory. Two-thirds of the carers ofthose at home admitted feeling at somepoint that their relative would be betteroff in institutional care. The stress levelsof home care carers remained higherthan those of rest home carers, and theirmorale was lower. The study concludedthat case-managed home care has thepotential to reduce the costs ofcommunity care. Challenges remain tofind ways to better alleviate carer stressthrough case management (Richmondand Moor, 1997).

In a review of the literature, Fine andThompson (1995) concluded that it ispossible to support people at extremely


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high levels of disability in their ownhomes. As in the Waitemata Health studydiscussed above, many studies havefound some advantages for consumers inremaining at home. In some studies,carers were also better off. However thecosts of caring for people with high levelsof need were often higher thanalternative provision in residential care.

Kane (OECD, 1996) sees a need to shiftaway from the institutional care/homecare dichotomy, towards trying toidentify optimum transition points tofavour one type of care over another.She argues that specialised residentialcomplexes and the growing phenomenonin the United States of NaturallyOccurring Retirement Communities(NORCs) are resulting in favourableeconomies of scale by bringing servicesto where people live.

The evidence on the value of providinglow intensity services to people who arenot at risk of institutionalisation isinconclusive and seems to depend onwhat outcomes are included in theassessment of benefits. Fine andThompson caution against reducingservices to people not at risk ofinstitutionalisation, because of thepositive impact of services on quality oflife, and the evidence that some relativelylow cost services, such as delivered meals,community transport and social daycare, assist in maintaining independence.

Approaches to assessing need

The literature consistently argues thatproviding people who have complex orhigh levels of need with low levels ofstandardised services is relativelyineffective.

Bebbington and Davies (1993) note thatpolicies targeted at those most in needcannot pick out even a majority of thoseat very high risk well in advance, giventhe random nature of many events whichprecipitate the need for admission toinstitutions for long-term care. Withformula approaches, field staff(assessors) tend to make their decisionon need first, then try to work their waythrough the forms to yield the requiredscore. The authors argue that few systemshave depended only on allocationsdetermined by simplistic formulae, andwhere they have, there have been somedire results. They see a much strongercase for using tools rather than formulaeto assess whether people need a serviceor not.

Age Concern, the National Health andDisability Committee (1995) and theRichmond study assert that the value andeffectiveness of multidisciplinaryassessment, treatment and rehabilitation(A,T and R.) services for older people areunequivocally proven. Richmondreferences studies that show thisapproach significantly reducing day stayin hospital, morbidity and mortality.

Accessibility andappropriateness of services

A number of studies have considered thephilosophies underlying service deliveryfor older people. Russell and Oxley(1990), for example, argue that ‘it isvitally important to see in culturalcontext the meaning of domiciliaryservices as experienced by recipients andadapt service delivery accordingly’.

A number of studies in New Zealand andoverseas have identified problems in

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service delivery. Te Pumanawa Hauora(1997) reports that while kaumatuamake a strong contribution to whanaulife, they face barriers to accessingservices for themselves. These includecost, lack of culturally appropriateservices, lack of appropriate informationand the need for integrated services.

A Ministry of Health report (1997)identifies similar accessibility problemsfor older Pacific people.

Lack of publicity about existing servicescan lead to what Gilmour (1998) calls‘rationing by ignorance’. She discussesthis in the context of respite care forolder people with dementia, of whom atleast 80% are living in the community.Respite services are not widely publicisedor understood, leading to lower demand.

Richmond et al (1995) also identified anumber of concerns about the limitedskills of doctors in meeting the age-related needs of older people. Thisincluded the failure of doctors to adviseon aids and refer people to specialists,and the failure of the two-wayinformation flow between hospitals andGPs. In their view, GPs are not able tojudge whether or not a person reallyneeds residential care. The Older People’sHealth Forum also raised the issue ofdoctors’ tendency to prescribe high levelsof drugs for older people. The Forumadvocates prescribing the lowest possibledose of a drug and the consideration ofalternative non-drug therapy as aprinciple of elder care (p21).

The more institutional care an individualreceives, whether short-term or long-term, the greater the likelihood of theirentry into residential care. Hennessy

(1996) noted that entry into residentialcare frequently occurs not after a longperiod of decline but rather as a result ofa sudden loss of faculty with injury orillness, followed by a spell in hospitalreceiving acute care. Many residentialcare placements are therefore fromhospital rather than directly from thecommunity. He saw this as pointing to aneed to focus on post-acute care andrehabilitation.

The Health Funding Authority hasrecognised this issue and is currentlyfunding the Canterbury Elder Care pilotproject, which aims to integrate andimprove health services for older people.As part of the pilot, a number of projectshave been instigated including the Strokeproject, the Broken Hip project and theSimplified Funding project. Projectteams have also been established todevelop new models for dischargeplanning and for ongoing care in thecommunity.


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This part of the report is in five sections:

I. Introduction

II. Personal factors that affect theindependence of older people

III.Environmental factors that affect theindependence of older people

IV. Services that help maintain theindependence of older people

V. Summarising the issues for Maori.

IntroductionAs part of its contribution to the“International Year of Older Persons1999”, the Government commissionedthis research into the factors that helpolder people15 maintain theirindependence.

In this study, “independent” has beendefined as remaining active andcontributing to the community, whileliving either in a private residence alone,or with a partner, friends, relatives orcarers, or in a retirement village. “Livingindependently” specifically excludesliving in any form of residential care, butdoes include those who receive in-homeassistance such as personal care andmeals on wheels.

The aim of the research

The aim of the research was to identifythe factors that contribute to themaintenance of independence of olderpeople and their continuing communitycontribution. Most people prefer toremain living independently rather thanmove prematurely into residential or rest

PART III:RESEARCH REPORT

home care. The Government also wantsto encourage older people to remain athome, independent and self-reliant, foras long as possible. Older people haveskills, experience and knowledge tocontribute to society. They are, andshould be, valued and valuable membersof the community.

Information sources

Information for the research wascollected through key informantinterviews, focus group discussions andletters. The main findings of theliterature review completed as part ofthis project are summarised in relevantsections of this report.

The key informants were people who areknowledgeable about and/or who workactively with older people. They includedservice providers, local authorityworkers, health professionals, membersof community groups, researchers andacademics. They were chosen inconsultation with the Senior CitizensUnit to provide a range of expert opinionand to canvass the views of the majoradvocacy groups for older people. Wherepossible, key informants wereinterviewed in the areas where focusgroups were held, for example, inTaihape and Kapiti. The researchers alsosought the views of informants in theSouth Island. The full list of informantsis included in Appendix II and theinterview guide used for most of theinterviews is in Appendix III.

Focus group discussions were held witholder people themselves. They wereinvited to discuss both the factors that

15 People aged 65 and over unless otherwise stated.

15


help older people maintain theirindependence and any barriers toachieving this. They were also asked tomake suggestions for improving bothpolicy and service delivery and, inparticular, to identify interventions thatthey consider would be cost effective.The groups comprised 51 people fromWellington, the Kapiti Coast, Taranakiand Taihape. These areas were chosen toinclude urban, provincial and ruralsettings. While practical considerationslimited the number of interviews anddiscussions, older people from otherareas were encouraged to write in givingtheir views and many did so. Within theresearch areas, the researchers sought theviews of older people of different gendersand ages and in different circumstances.

The ages of focus group participantsranged from the mid-50s to the 90s. Halfthe total, 25 out of 51, were in their 70sand 17 were in their 80s. One was in his90s. The proportions of women and menreflect the demographics of the age group– women outnumbered men at 36 and 15respectively. One group consisted entirelyof Maori men and women, anotherincluded two Maori women. Details arein Appendix II. The interview schedulethat formed the basis for the discussionsis included as Appendix IV.

While these discussions included olderpeople of varied ages and in differentcircumstances, they included few olderpeople who were isolated, depressed orhad severe disabilities. Three of the eightfocus groups were drawn from friendshipgroups, while one group consisted ofvolunteers at a local community centre.This raises the possibility of bias in theresults and the findings may not be

representative of the views of olderpeople generally.

Older people and family members werealso invited to write in describing whathas helped or hindered them inmaintaining their independence.Seventy-three people responded. Sixty-four of these were older peoplethemselves, nine were family members,friends or neighbours. Representatives ofseveral organisations also wrote. Excerptsfrom those letters are includedthroughout the report.

The key informant interviews, focusgroup discussions, and letters drew on awide range of opinion. While the viewsof active older people were well covered,those of older people who are isolated orwho have severe disabilities wererecorded mainly through the opinionsand experiences of key informants andfamily members. The interviews,discussions and letters have largely beenconsistent with the findings of theliterature review, and have added depthand weight to the findings of those otherstudies.

Personal factors thataffect the independenceof older peopleThis section considers a number ofpersonal factors that affect theindependence of older people. Theseinclude older people’s own attitudes tolife, their social networks, health andwellness issues, financial circumstancesand paid work. While individuals have adegree of control over some of thesefactors, the extent of this control variesconsiderably. They are collected underthis heading because individuals’


16

16 The Prime Ministerial Task Force on Positive Ageing, 1997a17 Te Pumanawa Hauora, 199718 Colmar Brunton Research, 1990; Day and Alice, 199619 Age Concern, 1999, “Successful ageing: an education resource”

personal situations affect the way theyrespond to environmental and otherfactors.

Attitudes of older people

“After 50 years of happy marriage, myhusband died two years ago. I amalmost 90 years of age. A friend and Iring each morning for a brief chat. Ithelps in every way to keep active –exercising, planning and thinking ofsome good to do for somebody orsomething. It keeps one thinkingoutwards. Accept invitations – youcannot back out later when that wouldbe so easy and self-defeating. Youprobably enjoy it anyway. It’s justmaking sure you participate. Keep anactive interest in your religion orculture even to encourage others. If youare a good listener, you add to yourstore of knowledge and some goodstories to help others be happy andeven laugh!” – Nelson

The Prime Ministerial Task Force onPositive Ageing16, along with AgeConcern and the Senior Citizens Unit,identified positive attitudes to ageing andstrong social support systems asimportant in maintaining the health ofolder people. This research supports thatview. Evidence gathered during the studyshows that the attitude of older peoplethemselves has a significant impact ontheir wellbeing and mental health. Thisin turn affects their independence andtheir ability to participate in communitylife. The benefits of a positive attitude

seem to be independent of ethnicity orculture. For example, Maori who areinvolved in the Maori community benefitfrom the respect and status accordedolder people, and especially kaumatua. Arecent study17 shows that kaumatua aregenerally optimistic about ageing, despitetwo-thirds taking medication and havinga major or minor disability.

The diversity of older people means thereis no general experience of living as anolder person. Nevertheless, in a range ofsurveys, older people have identifiedcommon factors that determine qualityof life. These include an adequateincome, good health, social contact,security, self-management and having arespected place in the community. Thesefactors are closely related with self-esteem, a healthy mental state, and theability to maintain a positive outlook18.

Age Concern NZ’s recent consultationswith older people19 about positive ageingidentified the following key attitudes asimportant to successful ageing:

• learning to live within limitations,adapting

• optimism

• believing that you are personallyresponsible for the way your lifeprogresses

• maintaining a sense of adventure

• guts and determination

• confidence and courage

• a sense of humour.

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There is general agreement that later lifesickness and suffering can be partiallyalleviated by a frame of mind thataffirms and embraces life. When peopleare health conscious they tend to believethey can manage their own health. Atheme in research is that older peoplewith disabilities commonly perceivethemselves as ‘well and healthy’.

Key informants, correspondents andparticipants in focus group discussionsstrongly agreed with this view. Typicalcomments from older people included:

“There is nothing that any oneparticular agency can do to keep aperson healthy and outgoing. Peoplehave to do things for themselves.”

“It’s not what happens to you thatdetermines whether or not you go intoa rest home - it’s about what you makeof what has happened. It’s all aboutattitude and how you deal with things.”

A strong faith was important to manyolder respondents and a number pointedto the influence of the Depression andthe Second World War in forming theattitudes of their generation. Theydescribed themselves and their peers as‘frugal and economical’, with a ‘mindsetto overcome difficulties’ and a ‘longhistory of survival on very little and a lotof hard work’. One woman in a ruraltown believed the attitude typical of hergeneration was:

“Don’t complain, be grateful, don’t askfor help. It’s hard to ask for help – we’reproud and independent. People say,‘Ring me’, but I’m not used to ringingpeople.”

Almost without exception, the olderpeople who contributed to the studyexpressed a strong desire to remainindependent as long as possible:

“I don’t want to end up in hospital or ahome. You prefer to stay in your ownhome with your own things. I won’t begoing there unless I just cannot doanything - as long as I can eat, keepclean, dress myself, I’ll stay home.”

Both older people themselves and keyinformants acknowledged that self-reliance can be both good and bad. Forexample, older people’s reluctance toseek or accept help may actually limittheir ability to stay living independently.Those who have a flexible attitude andaccept the changes associated with olderage are more likely to acknowledge thatthey may need help to manage, thusaverting a premature shift into residentialcare.

Social networks

“I am an active independent memberof the Red Cross, an active member forHospice on Rose Day and of ChristmasTree for Cancer. I have been a memberof the 60s Up Group from when webegan 13 years ago. I am 91. I live onmy own and take pride in my cookingand enjoy eating it. My husband died16 years ago. He was my model indeedbecause I continued this work after hedied and felt I was helping someone. Itis better to live in your own home withall your familiar photos. Memories ofyour lost partner are as important asfood for your brain. Keep in touch withyour friends, make them welcome andenjoy a good laugh. Use your phoneand call the housebound.” – Browns Bay


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“I’m 87 years young, live alone andlove it. I don’t want to be organisedinto going into the community “toparticipate in society”. For heaven’ssake, thousands of us just want to liveour lives in our own surroundings withour own furniture and knick-knacks aslong as we can, as long as the house isas clean and pleasant as we are usedto.” – Wellington

Social networks include familyrelationships, networks with neighboursand friends and membership of clubsand organisations. Individual need forsocial contact, and the quality andquantity of contact, varies considerably.In general, a lack of social support iscorrelated with poorer mental healthamongst older people. Loneliness anddepression tend to be more commonamong frail older people.

Older people’s ability to cope withchange in older age depends very muchon their previous life development andhow well they have coped with changesin the past. One key informant notedthat while older people are unlikely toalter the patterns of a lifetime, their senseof self worth and esteem could affecttheir ability and willingness to retaincontact with others.

Community involvement wasparticularly important to participants ina focus group discussion with Maoriolder people, many of whom hadextensive marae responsibilities.

Being actively involved in theircommunities was also important toPacific people interviewed as part of aseparate ongoing project20. They toowere expected to take on additionalresponsibilities as they grew older, whichcould be demanding and tiring.

Family relationships

Family relationships are especiallyimportant. They can offer anopportunity for mutual emotional andpractical support between thegenerations, and for “the exchange ofknowledge, experience and insights,enablement and caring”21. Researchshows that the presence or absence offamily support directly affects olderpeople’s ability to live independently.

Like positive attitudes, the importance ofemotional contacts between familymembers is recognised in all cultures. Astudy of Chinese and European familiesin New Zealand22 concluded that “filialobligations are defined in essentially thesame hierarchical order by both cultures,both genders and both parents andchildren”. Both cultures rate respect forand maintaining contact with olderfamily members ahead of obedience,making parents happy and materialobligations such as financial support andcare giving.

The nature of social contact is affected byfamily mobility, by the pressure of familymembers’ other commitments, andpersonality differences. Telephone

20 Elder research project being undertaken with members of the Samoan, Tokelauan and Cook Islandcommunities by the Pacific Health Research Unit, Whitireia Community Polytechnic.21 From the draft “Charter for a Society for All Ages for International Year of Older Persons 1999”.22 Ng, Sik Hung et al., 1999

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contact is important and some olderpeople had become familiar with emailin order to keep in touch. While many ofthose who took part in the study receivedboth emotional and practical supportfrom their families, others did not. Thelatter group relied mostly on their ownresources, as well as on their contactswith friends and community groups.A number of those interviewed talkedabout how their family had becomescattered, with children living in othercentres in New Zealand or overseas.

“Families move a lot these days. If yougo and live next door to them theymove somewhere else.”

Several described intra-family conflictsthat made them unwilling to seek help;many were aware of how busy familymembers were:

“They are so busy they haven’t even gottime to do their own things. You can’texpect them to help.”

The range of family situations covered ininterviews and discussions highlights thecomplexity of family relationships andthe difficulties older people may face inasking for help.

Some Maori participants appreciated itwhen whanau were able to come andhelp out, including staying the night ifnecessary. Others commented that theyhad to be self-reliant because theirwhanau was no longer around. Oneparticipant in a Maori focus groupthought that:

“The government should fundkaumatua hui. It’s great when we can

get together and korero and share withthe young people our stories.”

Older people also discussed the need tomanage their contacts with their families.One described what happened when herhusband died:

“The family was in and out quite a lotand I asked for some space because weare private people. They were doingtheir duty but now they leave me alone.If I want help I will ask for it. I ask if Iwant to go to the beach. I couldn’t driveby myself. I have to swallow my prideand ask if I want a crayfish.”

Pacific elders interviewed for theWellington study appreciated havingtheir own space and a number preferredto live on their own or with their spouserather than with their children. This gavethem more control over what theycooked, who they socialised with andhow often they saw their children.Because of their communitycommitments, some had more contactwith their peers than with their childrenor grandchildren. This pattern may notbe typical of all Pacific families.

Key informants agreed that while familysupport can make the difference betweenindependence and dependence for manyolder people, they should also be allowedto live their own lives and take somerisks. It is important that family do nottake over and impose their ownconcerns. They must be realistic aboutwhat help they can offer and not beoverprotective or do too much.

Friendship networks

The literature suggests that men and


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women may differ in both their need for,and ability to maintain, social networks.According to some studies, older womenare far more likely than older men toseek out others to satisfy their social andemotional needs23. An American study24,for example, found that older womenwith disabilities formed new friendshipsin older age and extended the friendshipnetwork to include more kinds of friendsthan previously, such as younger people.They had less concern than in the pastwith maintaining the equity of exchangethat is typically associated withfriendship. This meant that the olderwomen were able to accept instrumentalhelp, which helped them maintain theirindependence. Others have found thatfriends as well as family members play asignificant role in helping older peopleadapt when their spouse dies.

Key informants stressed the importanceof friendships.

“It is important for older people tobuild up relationships. The frail elderlyare often lonely and feel isolated. Youlose some of your independence if youdo not have a circle of friends. If youhave friends there is a bigger range ofactivities that you can share.”

Neighbours

Correspondents and focus groupparticipants mentioned the importanceof having close friends or at leastcompatible neighbours in the vicinity.Neighbours can provide social supportand help in an emergency. Examples

given included help with medication andafter falls, as well as practical help withchores such as shopping, transport,mowing lawns, chopping firewood anddoing small maintenance and repair jobs.Several older people commented onchanges in their neighbourhood that ledto their increasing isolation as trustedneighbours moved away or died. Forsome, these changes had precipitated amove to a more congenial environment,such as a retirement home or a suburbwith a high proportion of older people.A resident in a retirement villagecommented:

“There is no longer the street supportoutside that there used to be. The level ofsupport here is similar to what used to bein communities when I was a child.”

Social support from friends andneighbours can help protect older peopleagainst illness, enhance their ability tocope with stress and improve illnessoutcomes25. Both correspondents and keyinformants referred to the value of homevisitors for the house bound, who haveless ability to maintain friendships. AgeConcern, churches and communitygroups provide a home visitor service insome areas, which can lead to newfriendships for older people.

Interests and activities

Many focus group participants andcorrespondents belonged toorganisations or clubs. These includedfriendship, educational and activitygroups, sports and fitness groups,

23 Bonita, R., 199324 Lewis, 199725 Pearlin et al., 1996, cited in Kendig, H. and Brooke, L. (1997)

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gardening, art and craft groups, carers’groups, and service groups such as RedCross, Maori Women’s Welfare League,church groups, Probus, Rotary and theCountry Women’s Institute. Participantsdescribed the benefits of belonging toclubs as companionship, improvedhealth, greater confidence and anopportunity to “keep an eye on eachother”. They acknowledged that while inmost communities there is plenty to do,older people do need to know where togo and have the confidence to take thefirst step. Marae and churches form thenatural hub of a social network for manyolder people.

Indeed for some Pacific elders, thechurch can take the place of the village intheir home islands. But not all olderpeople have church affiliations and mayneed support and encouragement to seeif taking part in an organised activitysuits them. Several participantsrecognised that:

“Lots of people fall through the cracks.If people are introverted, don’t belongto all those clubs, or if they live out inthe country, no one knows about them.They won’t ask for help from someonethey haven’t built a relationship with.People say, ‘Why doesn’t she ask?’ butit’s not that easy.”

“Ironically, other people’s positiveattitude can make it harder for shypeople to break in. It’s very hard fornewcomers to the area to fit in”.

Some correspondents reported that theirsocial networks had become restricted as

a result of deafness, poor eyesight orreduced mobility. For some, this was acause for resignation, others wanted asocial group that accommodated theirparticular disability, for example, a groupspecifically for those who were hard ofhearing. Overseas studies confirm thatvisual and/or hearing impairment areassociated with a significant worsening inquality of life26. Mobility is also an issue:lack of access to transport adverselyaffects the size and type of older people’ssocial networks27.

Volunteering

Focus group participants, key informantsand correspondents emphasised thevalue of older people participating involuntary community activities. The typeof voluntary activities older people seemto prefer include those that providesupport for other older people. Usuallythis happens on a voluntary basis andsometimes without adequate support.Examples of such activity by older peopleincluded home visiting, advocacy,participating in training and supportgroups, providing social, educational andrecreational services and engaging inactivities associated with organisationslike the Arthritis Foundation, StrokeSupport, the Red Cross, Safer Steps, foodand clothing banks and church groups.While focus group participants andcorrespondents acknowledged therewards of involvement in terms ofconfidence building and personalsatisfaction, many were finding theirinvolvement increasingly stressful. Keyinformants reinforced this view.

26 Carabellese, C. et al., 199327 Cant, R. and Legge, G., 1994


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“If older people make a voluntarycontribution to the community, e.g.helping with meals on wheels, theyneed to know that the service isappreciated. Many older people whohave done voluntary work for yearswould like to get out of such work butthere is difficulty in findingreplacements. There are particularissues for older people e.g. older driverswho find coping with modernmotorways and traffic densitiesstressful and strenuous.”

Volunteering in rural areas also had itsdrawbacks:

“Volunteers are generally older – youcan’t expect them to drive on those[country] roads or that distance.There’s no transport to get the olderpeople into day programmes or Careand Craft either. They lose theirlicences, their families get bogged downbut there’s no one available to mind theoldies for respite care.”

Health and wellness issues

“The most important thing at this ageis to stay independent by keeping fit,physically and mentally. Know yourimmediate neighbours, make newfriends where possible by joining clubsand groups, and have some definitecommitment, such as voluntary work,which involves service to other people.The best group I joined at 65 is atramping club for over 40s and I hopeto be still tramping with my pack at80!” – Christchurch

The link between lifestyle and health inolder age is well documented. Indeed,there is a certain degree of circularity instating that people who enjoy goodhealth also maintain greaterindependence in old age.

A number of social and economic factorshave been shown to have an influence onhealth. These include “income andpoverty, employment and occupation,education, housing, and culture andethnicity”28. However, research has alsoshown that it is possible to reduce,postpone or prevent disability andhandicap in older people throughpromoting healthy lifestyles. Risk factorsinclude smoking, nutrition and alcoholconsumption together with bloodpressure, body weight and blood sugar29.A healthy lifestyle includes both physicaland mental activity. A recent report30

notes that there is good evidence thatstopping smoking is beneficial, even inold age, and recommends that subsidisedsmoking cessation programmes shouldbe available to older people. The reportalso notes that “the relationship betweensocio-economic status andcardiovascular disease persists in old ageand risk factors cluster around the lesswell educated and less affluent for whomthe need to prevent cardiovasculardisease is greatest”.

Good health is the most important factorin maintaining independence in olderage. Focus group participants andcorrespondents were aware of theimportance of exercise, sensible eatingand mental stimulation.

28 National Health Committee, 1998b29 Richmond, D., Baskett, J., Bonita, R., and Melding, P., 199530 National Health Committee, 1998b

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The cost and uncertainty of medical carewas a concern to focus groupparticipants and correspondents, severalof whom wanted “free medical care withimmediate access rather than a two-yearwait”.

Physical activity

“There is a huge advantage in beingphysically fit. Now aged 70, I run threemiles most mornings and often walkthe same route in the afternoon. I havea large garden and do all thegardening, hedge cutting twice yearlyand lawn mowing. I grow all my ownvegetables and fruit and follow the NZHeart Foundation guidelines to healthyeating.” – Marlborough Sounds

According to a National HealthCommittee31 report, much of thephysical decline associated with old agecan be attributed to inactivity rather thanthe ageing process. For example,approximately one sixth of the 7,800deaths in New Zealand each year fromcoronary heart disease, colon cancer anddiabetes are attributable to physicalinactivity. Physical activity can alsoreduce the likelihood of coronary heartdisease, colon cancer and diabetesobesity, high blood pressure and feelingsof depression and anxiety. Moderateexercise helps build and maintain healthybones, muscles and joints. This reducesthe risk of falling and improves olderpeople’s ability to perform daily tasks.Suggestions for suitable activities forolder people range from gardening,

swimming and walking to using awheelchair.

Focus group participants andcorrespondents engaged in a wide rangeof activities including aqua fitness,croquet, walking, bowls, pool, yoga, golfand gardening, or attending a women’shealth group, a gym group or exercisegroups for stroke victims or arthritissufferers. Older Pacific people also spenttime mending nets, fishing, carving,weaving mats, and quilting. Allparticipants and respondents describedimprovements to their sense of wellbeingas a consequence of their activities. Theseimprovements included feeling physicallyfit, recovering more quickly fromoperations or illness, being moreoutward looking, enjoying life more,being able to do more for themselves,including gardening, and maintainingcontact with friends.

While much physical activity is self-motivated and needs no organisationalsupport, a number of organisations,notably the Hillary Commission forSport Fitness and Leisure, promote orsupport participation in physical activityby older people. Increasing levels ofphysical activity has been described as“today’s best buy” in public health,because of the significant benefits thatcan be gained.

31 National Health Committee, 1998a


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Mental activity

“Becoming widowed in my 70sI moved into one of the delightfulcottages of a retirement village. Afterthe initial interest of furnishing it withmy bits and pieces, I arrived at my80th birthday with a burning desire tofind something to do to fill my dailyhours, besides my little laundry andcooking. At 80 years, without tertiaryeducation, I enrolled in acorrespondence course for EnglishLanguage and Short Story Writing. Toeveryone’s surprise, I ended up afterapplying my mental capacity for 2 1/2

years with 5 As and a Diploma and amost satisfying amount of enjoyablehours. Learning to use the wordprocessor, typing and sending inassignments was a discipline that madea great difference to my days.” – Timaru

“Books and writing have always beenpart of my life. For six years I have helda literary circle in a local rest home. Wehave read so much and discussed manythings and older members come outwith distant memories.”– New Plymouth

Studies have also found that it is possibleto slow down or even reverse mentaldecline associated with ageing througheducation and training. Once again,participants were engaged in a widevariety of activities including study,writing, membership of historical andsimilar societies, reciting whakapapa andgetting to grips with new technology. Anumber were members of SeniorNet andhad taken courses in word-processing,genealogy, communications, managing

databases and computer art. Someenjoyed using email to keep in touchwith their children and grandchildren.The University of the Third Age (U3A)attracted some older people, particularlythose from professional backgrounds.Like SeniorNet, the U3A has adopted aself-help model with a lot of the teachingbeing done by members, which alsohelps keep them mentally active.

Some local authorities in the larger citiesprovide mobile library services to resthomes, as well as having talking books orlarge print books available for peoplewith visual impairment. However, theseservices are coming under increasingpressure as local authorities seek tomanage their budgets.

Financial Circumstances

“To my mind the greatest assistance wehad to becoming independent was thatI was fortunate to live in an era ofhistory in which I was able to retainfull employment for the whole of myworking life. In addition to my income,wives of many folk like myself alsoworked and established and paid offthe biggest asset they possessed, theirhome. Once a home is bought and paidfor, the accumulation of savingsaccelerate.” – Waikanae

“The major threat to myindependence, and that of manyspinsters I know, is a financial one.Unlike our married, or once marriedsisters, we are less likely to own ourown homes. Therefore we must payhigh rent to landlords, in my case $150per week, totally unfurnished. TheTransitional Retirement Benefit is $187per week and the Old Age Pension with

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Living Alone Allowance is $210 perweek. A factor that has never beentaken into account is that spinsters ofmy generation:• had no access to mortgage finance• worked the best part of our livesfor 33% less than the wages or salary ofmales for the same job• had no option but to pay a hugeamount of our income into deadmoney rentals• had no access to employer-subsidisedsuperannuation benefits.” – Wellington

Older people have widely differentfinancial circumstances, due to differentlife experiences. Their financial situationin older age is attributable in part toenvironmental factors and in part topersonal choices. The discussion offinancial matters is included in thePersonal Factors section of this report,but influence of factors over which theyhave no control needs to be borne inmind.

Older people are more likely to ownrather than rent their homes comparedwith the adult population as a whole, andto own their house without a mortgage.Older people have lower incomes thanthe average for all adults, with olderMaori, older Pacific and older Asianpeople respectively having the lowestincomes. Younger old people tend tohave higher incomes than older oldpeople, and men more than women32.In equivalent income terms, that is acomparison that takes account of the

size and structure of household, olderpeople, both couple households andthose alone, have less income on averagethan most other household types, apartfrom single parent families, and young,two parent families. On average, olderpeople living alone had more purchasingpower in 1996 than in 1982, but still hadless available income than older coupleswhose average purchasing power wasslightly less in 1996 than in 1982.33 Whatis not well understood is the extent towhich older people have differentexpenditure needs than other groups,and how this affects their standard ofliving.34 As an example, older people aremore likely to own their home freeholdand therefore, on average, theiraccommodation costs will be lower.However, this may change with increaseduse of retirement villages and otherserviced accommodation that includessubstantial annual levies. On the otherhand, their need for medical care isgreater than for the population onaverage.

The most important income sourcefor older people is New ZealandSuperannuation (NZS), which is a flatrate pension now available to allqualifying older people35 on a nonincome-tested basis.

In 1997/98, an estimated 407,305 people,around 90% of all people at or over 62,the qualifying age for NZS at the time,received NZS. Of those receiving NZS,25% had no other income. A further

32 Davey, J, 1998a33 Statistics New Zealand, 1999, New Zealand Now-Incomes fig 5.634 The Ministry of Social Policy will assume responsibility for a study on the standard of living ofolder people, initiated by the Super 2000 Taskforce, which should throw light on this question35 Residential criteria apply. The age of eligibility is currently being raised to 65 by 2001


26

21% had up to $1,000 per annumincome in addition to NZS, and 24% hadbetween $1,001 and $5000 per annumincome in addition to NZS36. Insummary, 70% of older people in NewZealand relied on NZS for their income,while a minority had a substantialincome in addition to NZS, largelysourced from pension schemes andearnings.

It is difficult to predict future trends inthe income of older people. On the onehand, labour force participation hasbegun to increase for both men andwomen at pre-retirement age, and forthose aged 65 and over, although thelabour force participation of women isstill substantially below that of men. Thisis discussed further in the followingsection. There is evidence of greaterawareness of the importance to save forretirement and of people taking actionsuch as budgeting, debt repayment andsaving37 .

On the other hand, not everyone is ableto increase their paid work. A wideningdistribution of earnings, and the impactof a larger number of user charges,particularly on people with dependants38,may mean fewer people are able to savefor their old age in future.

The importance ofincome to independence

Income is the single most importantdeterminant of health status39 . The linksare two-way. Poor health tends to limitincome-earning opportunities. Lower

incomes limit people’s ability to buyhealth care, health insurance, appropriatehousing and other goods and servicesthat can help maintain their health.

A number of key informants noted theimplications of fewer health choices forthose on low incomes than those onhigher incomes. Two observed that:

“Low-income people have to take shortcuts, including health. On the otherhand, those on a high-income canbecome obsessed with health and gettests for all sorts of things. This involvesa high level of expenditure and cangenerate anxiety.”

“Funding tends to focus first on safetyand security and then on maintenance.Life enhancement comes third butshould be regarded as of equalimportance with the first twocategories. It is difficult for thosedependent solely on the benefit toafford those things which wouldimprove their quality of life. All olderpersons, regardless of wealth, havecommon problems of isolation andloneliness. Those with money may stillbe lonely but money usually gives themmore choice and allows them topurchase things which can help.”

36 Department of Statistics, 199837 Personal communication, David Feslier, Office of the Retirement Commissioner38 The impact of user charges can be attenuated for some groups by tax changes or targeted subsidies39 National Health Committee 1998b, p.23

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New Zealand Superannuation

“Super isn’t meant for holidays orbuying cars – it’s just for living on. Upuntil a couple of years ago, I thought itwas quite generous. I think it’stightened up – with electricity goingup. It’s subtle rises all the time.”– Wellington

While some focus group participantswere able to manage on their NZS, mostwere finding it increasingly difficult to doso. They referred to the pressures ofincreases in rates, electricity charges andhome maintenance. A common beliefwas that the NZS would reduce in thefuture, or not keep up with price rises.

Single people faced particular problemsin that many had the same outgoings ascouples. Some couples, including somewho had moved into retirement villages,were concerned that if one partner died,the other may not be able to afford tostay on in the home.

“You lose a third [on your super]. It’stoo big a drop for a single person. It’sthe monthly fee we worry about - itcovers gardening, window cleaning,rates, rubbish and house washing.”

Supplementary income support

The main sources of supplementaryincome assistance accessed by olderpeople are the Disability Allowance40,accessed by approximately 18% of NZsuperannuitants, and theAccommodation Supplement, accessed

by 5% of NZ superannuitants. A smallnumber of superannuitants also accessSpecial Needs Grants and advances onNew Zealand Superannuation or theSpecial Benefit.

The take-up of supplementary assistance,and the Community Services Card thatenables low-income people to accesshealth subsidies, is lower than one mightexpect given the income levels of olderpeople.

Several correspondents noted that, evenwith a Disability Allowance, and thehome help provided free of charge to lowincome people41 through disabilitysupport services, they had to draw ontheir retirement income to pay for thefull range of services they needed to liveindependently.

Financial insecurity

“We are not eligible forAccommodation Supplement if wehave any “money in the bank”, nor anyof the other “tag ons” like specialbenefits or food grants, so we have todraw down on our savings. We needthe savings because we have no houseto sell if we need money for operations.It’s a very frightening situation tobe in.” – Wellington

Being unable to manage the financialrisks of the additional costs of poorhealth or disability, or being unable toplan expenditure with any degree ofcertainty, reduces the quality of life andsense of independence of older people.

40 Figures at June 1998. The DA currently provides up to $43.23 per week to single adults with anincome below $20,813 pa, and to couples with an income less than $29,933 pa. for regular ongoingadditional costs of a disability.41 Older people who meet the income test for the Community Services Card, qualify for free personalcare and home help where they are assessed as needing it.


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Uncertainty about the level ofsuperannuation, and fluctuating interestrates for those with savings, increaseolder people’s anxiety. Money was aparticular concern for some older Pacificpeople42. Some were anxious about beingable to pay their rent or their mortgages.Others worried that they did not haveenough money to meet their familyresponsibilities. Those who had recentlycome to New Zealand from small islandcommunities where money was lessimportant were experiencing the mostdifficulty.

Those older people who did have someinvestment income have been affected bythe prevailing low interest rates. Anumber of older people wrote describingtheir situation. Most suggested that taxesbe reduced or eliminated on investmentincome for older people.

A number of respondents discussed thedifficulty of borrowing money, evenwhen doing so could enhance theirindependence:

“Finance should be easier for the elderlyto get. You can become an active personagain if you have a mobility scooter buta mechanised scooter is very expensive.The government financed returnedservicemen, why can’t they do it for theelderly? You’d think we had stoppedpaying taxes. You can’t borrow on yourhouse or your pension.”

Costs of care

Some resentment about the lack of

subsidised support for home-based andmedical services for those with modestadditional incomes, and the income andasset test that applies to residential care43,was expressed in focus groups and letters.“They take all you have”, was one view.

Key informants pointed out that not allfamily members or older people areaware of the cost of residential care.Many resist paying for home careservices; others realise, perhapsreluctantly, that this can be cheaper thanpaying for residential care:

“If older people or families have moneythey have choice – they can buy extraservices. Only personal cares areneither income nor asset tested. Therest are dependent on having aCommunity Services Card. Whenfamilies realise what the cost of resthome care is, they are often prepared topay more for home care.”

Responses to financial insecurity

One source of income that has beensubject to discussion in New Zealand,but accessed by very few older people, isthe release of equity in housing that theyown and in which they continue to live.At 84%, New Zealand has high homeownership rates amongst older people.

Reasonably common in some areas ofthe country, is releasing part of thecapital by selling larger family homes and“trading down” to a smaller house orpensioner flat. Where house prices are

42 Elder research project being undertaken with members of the Samoan, Tokelauan and Cook Islandcommunities by the Pacific Health Research Unit, Whitireia Community Polytechnic.43 A subsidy to cover the full cost of residential care is available to couples with no more than$30,000 in joint assets if both partners are in residential care and $45,000 if only one partner is incare. For individuals, the subsidy is only available to those with assets under $15,000.

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high, as in cities such as Auckland orWellington, the amount of capital thatcan be released is limited, and in areaswere house prices are depressed, tradingdown may not be an option. There arealso disincentives for older people whoaccess supplementary assistance or havea partner accessing the residential caresubsidy, to trade down.

Equity release schemes are anotheroption. These generally take one of twoforms: mortgage and annuity scheme, orreversion plans where houses are sold ata discount to investors but the residentretains occupancy rights for life. Onestudy44 notes that “fear of indebtedness,misgivings about government policydirections, and to an even greater extent,suspicion of the schemes themselveshave emerged as constraints to take-up.”In the view of some older people, suchschemes cut across the major base forinheritance and conversion rates are notvery favourable. The schemes alsoinvolve risks for providers whereproperty drops in value or clients livelonger than anticipated. Nevertheless,according to Davey45, the prospects forcommercial equity release schemes arepromising, particularly with governmentendorsement and a Code of Practice.

Members of one focus group discussedolder people being able to access funds,using their homes as a source of debtrepayment:

“A positive move could be financialbacking for people to make necessarypurchases e.g. a community bank toadvance money on the security of ahouse. Repayment would come laterout of the estate. The problem would beaccumulating interest.”

How to fund long-term care services,whether provided in residential care or athome, in a way that enables older peopleto have some certainty about theirfinances, is a concern in many countries,and discussed further in Section VI.

Enduring Powers of Attorney

Several participants discussed financialplanning, particularly the importance ofEnduring Powers of Attorney (EPAs)46.These can allow family members to makedecisions that can help older people stayhome longer. The cost of an EPA was anissue for some who suggested that Workand Income New Zealand (WINZ) couldmake a grant or a loan to encourageolder people to plan for their futures inthis way. One key informant noted withregret that there is no one in thecommunity designated to help olderpeople who have no one to fill the EPArole. Such a person would need to fullyunderstand the welfare responsibilities ofbeing a welfare guardian. They wouldneed to be respectful and not take overthe older person’s financesinappropriately. They saw this as animportant role for which training couldbe developed.

44 Davey, J., 1998b45 Davey, J., 1998b46 Enduring Powers of Attorney (EPAs) can be set up to manage property or for personal welfare. Aproperty EPA gives authority for someone to look after a person’s financial and property affairs andto act on their behalf during their lifetime, if they are unable to do so. It can come into operation atany time. A personal EPA gives an individual responsibility for a person’s personal care and welfareand begins to operate only when the person granting it becomes mentally incapacitated.


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Paid work

“Having a job, voluntary or otherwise,helps older people remain in thecommunity and participate fully insociety. Many employment businessesare just not interested in people overabout 40.” – Wellington

Past discussions on income adequacy forolder people have frequently focused onretirement income. More recently,attention has moved to enabling peopleto stay longer in the workforce. Thisrepresents a significant shift from theearly 1980s when earlier, rather than laterretirement was being promoted. Recentchanges to the Human Rights Act in NewZealand now make age-relatedcompulsory retirement unlawful.

In 1998, 41.9% of 60-64 year-olds and6.1% of those aged 65 and over were inthe labour force. Since 1991, there hasbeen some increase in labour forceparticipation within the 60-74 age group,mainly due to the growth in women’sparticipation47. Participation is higher forPakeha than Pacific populations andMaori, and significantly higher for menthan women. Unemployment rates arealso higher for Pacific populations andMaori, than for Pakeha48.

However, continuing work is not anoption for all. Age-related disability andillness do affect a significant minority ofpeople in their fifties. Maori can faceobligations as kaumatua even before theyreach their fifties, a responsibility that is

all the more significant asproportionately fewer Maori thannon-Maori live into old age49.

Older workers have some differentcharacteristics from younger workersand often seek flexible or part-timearrangements. Older workers bring anumber of benefits to the workplace.These include a positive influence onyounger workers, high morale,motivation and productivity50.

There are also costs to employing olderworkers. These will vary depending onemployment contracts but may includehigher wages, higher costs of healthinsurance, more time off work for somegroups of older workers, and longerrecovery time from workplace accidents.

Very few people involved in this studydiscussed paid work, although one keyinformant thought there would be valuein private firms offering older peoplepart-time jobs, not necessarily in theirprevious line of work.

Environmental factors thataffect the independenceof older peopleOlder people have some control overpersonal factors that affect their lives.They have less control overenvironmental factors such as theattitudes of others towards older people,housing options, public transport, andtechnological change. Yet all these factorscan affect older people’s ability to remainindependent.

47 Statistics New Zealand, 1999, Labour Market 1998, Wellington48 Davey, J, 1998a49 Maaka, R., 199350 Age Concern, 1999

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Attitudes towards older people

“The government should acknowledgeand encourage [older people’s]knowledge, wisdom and skills byrecognition. In Sydney a SeniorCitizens Card allows cheaper publictravel and other benefits, but moreimportantly it states: ‘The holder ofthis card is a valued member of ourcommunity. Please extend everycourtesy and assistance’. ” – Dunedin

“The self-esteem that comes fromfeeling that you still have somerelevance to the world is veryimportant for mental wellbeing. This isoften lacking in the old and leads tofeelings of worthlessness anddepression. The latter situation hasbecome more evident in the modern‘throw away’ society, where old isequated with useless.” – Auckland

Over recent years there has been agrowing perception of older people as“dependent” and a burden to society51.This perception causes some olderpeople to lose confidence andassertiveness both in makingcontributions to society and in dealingwith their own needs. Little is said aboutthe positive economic benefits of anageing population. These include theconsiderable contributions older peoplemake to their family and to society.Service providers sometimesunderestimate the ability of older peopleand their families to understand and

negotiate their own support needs. Theyalso sometimes provide assistance in away that makes the recipient dependenton it.

Attitudes to older people need to bepositive in several areas. Particularlyimportant are not discriminating againstolder people, enabling them to remain inthe workforce, flexible retirementprovisions, encouraging community andvoluntary contribution, and encouragingand facilitating continuous learning,recreation and positive living.

Creating positive attitudes about olderwomen is particularly important.Women experience more discriminationin old age than men, and more negativestereotypes about being older from ayounger age52. On average, they livelonger than men and are more likely tolive alone and need care. This also meansthere are potentially more payoffs fromfostering positive attitudes, both forolder women themselves and forgovernment expenditure.

Focus group participants,correspondents and key informantsagreed that myths and stereotypes aboutageing can be harmful. They stressed theimportance of being valued andidentified several ways of achieving this:

• Including older people in communityactivities, such as community fairs andfestivals and promoting links withschools.

• Providing services in a way that isuser-friendly for older people. Services

51 The Prime Ministerial Task Force on Positive Ageing, 1997a52 Russell, R. and Oxley, H., 1990


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include those provided by thecommercial sector, such as banking andtelephone services, as well as servicesprovided by government and localauthorities.

• Portraying older people inadvertisements in a positive way, forexample, using modern equipment.

• Allowing time for and helping olderpeople to become familiar with newtechnology, such as ATMs and telephonebanking, automatic telephone answeringmachines and computerised cataloguesin libraries.

• Allowing time for people in their dailyactivities, for example, getting on andoff buses.

• Recognising the contributions they havemade throughout their lives and stillmake as older people.

• Encouraging respect for older people.

• Educating the public about disabilitiescommonly associated with age, such ashearing impairment and loss of sight.

• Publicising the positive aspects of workboth for older people and employers.For employers, these include a positiveinfluence on younger workers, highmorale, motivation and productivity.For older people, there are incomebenefits and potential for more savingas well as opportunities to maintainphysical and mental agility.

• Changing government and communityattitudes that imply that older peopleare “bludgers”.

A key informant working with olderpeople noted:

“In our society older people are notgenerally valued. They feel they are aburden to society, which doesn’t helptheir independence. Most people wantto be independent and remain in theirown home even if others think they

need help. They believe they will loseindependence as soon as they go intocare. Older people must be allowedchoice and control. Independence canbe taken away very quickly,particularly if their standards are‘lower’ than those who wish to help.Even those with health needs cansurvive much longer if they areencouraged to be independent. Theattitude of the older person isimportant, but so to is the attitude ofothers towards older persons.”

Several key informants and focus groupparticipants acknowledged that there is aperception in the wider community thatsome older people are selfish. Theyattributed this view in part to olderpeople’s expectation that the taxes theypaid during their working lives wouldpay for services now, and in part toyounger people feeling under pressurebecause of the need to pay more foreducation and health services and havingto save or their retirement.

The Task Force on Positive Ageingoutlined goals and an action plan aimedat improving attitudes to ageing andparticipants in this research werestrongly in favour of this happening.

Housing

“Owning my own home and living inan area of Auckland where I have aunit, can see the sea and have mygarden to work in is very good for me.”– Auckland

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“The trouble of shifting applies harshlyto old people when the garden, lawnand house cleaning grow too much. Itwould save a lot of trouble if shifting toa smaller dwelling was easy and cheap.See if local bodies, charities orgovernment will build for easyshifting.” – Waikanae

Satisfactory housing is a key factor inenabling people to age successfully “inplace”. One UK study claims that “welldesigned, easy to manage, affordable,warm, and safe housing is as importantto independent living as inputs of care”.53

Living arrangements

More than 9 in 10 older people live inprivate dwellings. This proportionremained fairly constant over the tenyears 1986-1996, despite the fact that theolder population included an increasingproportion of people over 85.

In 1996, 54% of older people lived with aspouse or partner, just over 10% livedwith their children and one in three livedalone. Over 70% of the older peopleliving alone were women, and thispercentage is higher in older agegroups54. The proportion of older Maoripeople living alone or with a partner iscurrently lower than for Pakeha, but isincreasing. Twenty percent of olderMaori live in multiple familyarrangements. Around half of all olderPacific people live in multiple familydwellings, and this is expected to declinein the future55.

Housing decisions

In 1996, 84% of older people living inprivate dwellings were owner-occupiers.Homeowners discussed the emotional,financial and practical implications ofhome ownership. Participants in severalfocus groups had recently moved to newaccommodation and they talked aboutthe emotional impact of moving out oftheir own home, whether by choice or ofnecessity. Some had to move because ofdifficulties with access, others left oldhomes with large sections in favour ofsmaller, more manageable properties.Deteriorating health was a reason forsome focus group participants to moveinto more appropriate accommodation,such as a smaller house or a retirementvillage. Loneliness and fears aboutsecurity also contributed to the decisionto move. In several places, the supply ofaffordable, modern housing wasextremely limited, reducing olderpeople’s options.

Older people’s satisfaction with theirhousing situation was related to thechoices they had made. For example,those who had moved to a moremanageable house had done so to retaintheir independence, but so too had thosewho had chosen to move to a retirementvillage. Both these groups of peopleconsidered themselves to be at least asindependent as they were previously withmore time to pursue their own interests.At the same time, those who had decidedto stay in their own homes were alsoquite happy with their level of

53 Oldman and Pleace, 1995, cited in Austin, P., Cram, F., and Kearns, R., 199554 Statistics New Zealand, 199855 Davey, J., 1998a


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independence, which suggests the abilityto make a choice is the key factor inperceptions of independence. Those whowanted to move but could not findappropriate, affordable housing wereleast satisfied.

Rental accommodation

“Persons on fixed incomes soon becomequite unable to pay high rents, so whathappens then? “Homes for the elderly”also become increasingly dear, so theelderly cannot afford them. It is all avicious circle.” – Wellington

“The main problem in our village isthe conflict between centralgovernment and local government as towho is responsible for housing. Everytime there is notification of a rentincrease by council, anxiety occurs…We do not just live to eat. Our livesmust be balanced and to me secureadequate housing and rent gives us astate of security that allows us to beindependent and consequently manageour own lives. But to have to front upmaybe, to a Work and Income office toapply for rent supplement is loweringthe quality of our lives. It isdisrespectful to us in that I have neverhad to do this and I worked for 48-50years looking after myself.” – Auckland

In 1996, 11% of older people rented theirhomes, with a higher proportion ofwomen than men doing so. Of thisgroup, just over a third (35%) rentedfrom Housing New Zealand, just under athird (31%) rented from private

landlords, 29% rented from localauthorities while 6% rented from otherorganisations. Older Maori are morelikely to live in rental accommodationthan are older Pakeha people.

The proportion of older people rentingaccommodation has remainedreasonably static over the last 15 years.This may change in the future as homeownership rates dropped for 20-39 yearolds between 1991 and 199656.

The literature suggests that older peoplegenerally want to live in their ownhomes, whether owned or rented, as longas possible. Tenants, in particular, fearthat they will be forced into smalleraccommodation as they get older. Bed-sitting rooms or one-bedroom flats makeit harder for family members orcaregivers to stay overnight. There is alsolimited space for hobbies. One focusgroup participant had had thisexperience:

“I took one look at the kaumatua flatwhich was very nice but small - onlyone bedroom so I couldn’t havewhanau to stay, so I decided to stay inmy own home.”

Home maintenance and modification

“I would not be the only one sufferingnow from worry about maintenance.I’ve been able to save money from myonly income, superannuation, for paintsupplies but I’m unable to pay someoneto do the painting. Oh, to be able to bemore physical.” – Howick

56 Davey, J., 1998a

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“Prices for essentials never cease to rise- we do need concessions on our rates,phone and light accounts. Anyconcession offered by the Council isassessed on earnings well below whatanyone’s super is. It has not beenchanged for umpteen years and isabsolutely useless.” – Palmerston North

Many focus group participants,correspondents and key informantsraised the issue of the cost ofmaintaining houses. They referred to theimportance of affordable tradespeopleand the availability of family,neighbourly or community support.Maintenance was a particular concern toolder people whose sole income wasNZS. Many correspondents and focusgroup participants expressed concern atthe rising cost of rates.

Cost and practical difficulties makerepairs and maintenance a majorconcern for older owner-occupiers, andparticularly for women. Some olderpeople do not modify their homes to suittheir changing needs, even when theyagree that this is a high priority. Somecannot afford to do so, others do nothave the energy to make changes or denythat they need to do so57 . Onecorrespondent questioned the costeffectiveness of making such changes,which are rarely seen as enhancing thevalue of a house. Limited life expectancy,and the fact that most older people donot realise the investments they make intheir homes before they die, furtherreinforce the disincentives to invest in

modifications. Despite these concerns,the literature identifies the value of andneed for home maintenance and relatedsupport services for older people,especially where income is a limitingfactor 58.

The Health Funding Authority providesgrants to older people with disabilitieswho need to make essential homealterations. However, grants foralterations that cost more than $7900 aresubject to a means and asset test.

Several initiatives in New Zealand aim tohelp older people both carry out andmeet the cost of home repairs andmaintenance. Voluntary organisationssuch as Age Concern and Grey Power areaware of the cost of home repairs andmaintenance. In some areas they offer ahome handyperson service to providelow cost, reliable building, plumbing andelectrical repairs to older people. AgeConcern in Kapiti, for example, providesvolunteer drivers, home handypeople,home visitors, security systems, and aradio programme on the local radiostation on legal issues for older people.“Hire a Hubby” is a commercialapproach to offering similar services.Superannuitants can apply for anadvance on their New ZealandSuperannuation to meet the cost ofhome maintenance and repairs. Themaximum advance is $1000, which mustgenerally be repaid within two years.

A recent New Zealand study concludedthat energy efficiency improvements tothe housing of older people and those

57 Steinfeld, E. and Shea, S., 199858 Taylor, B.B., Neale, J.M. and Allan, B. C., 1981; Rushmoor Borough Council, 1998; Hereford andRussell, 1998


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with disabilities provide significanthealth and quality of life benefits as wellas reduced energy costs. The study notesthe importance of affordable heating,good lighting and safe hot water systemsto the health of older people and this iswell documented in the literature.Nevertheless, older people tend to live inless energy efficient homes and often faceparticular difficulties improving them.A number of specific potentially costeffective measures, such as draughtstopping, were identified in the study59.

Housing alternatives

“We need a pensioners’ complex, withsecurity, a community hall to meetothers, transport to shops and doctorand help if needed, especially when youare sick. I have made enquiries and thehouses are usually quite expensive tostart with. The fee to cover the cost offacilities is beyond an ordinary exworking person like myself. I don’t needthe golf course, swimming pool etc –only somewhere to meet and talk toothers.” – Kaitaia

New Zealand has a limited number ofhousing options for older people whodevelop disabilities or want to movefrom family homes. These includeretirement villages and kaumatua flats.Research on changes in housing confirmsthat older people who move tend to doso first for amenity or retirementreasons. Widowhood or moderatedisability may lead to a second move to

be closer to family or medical services60.This trend is also evident amongHousing New Zealand tenants61.

Retirement villages have been activelypromoted in recent years. In 1998, 2.8%of the total New Zealand populationaged over 65 lived in a retirement villageeither in independent units or servicedapartments where residents may receivemeals, cleaning and a variety of othercare options. Some retirement villagesprovide a continuum of accommodationand care options so that residents canstay in the same village, even when theyneed substantial levels of care.

The proportion of people living inretirement villages is increasing, but thisis not an option for all older people. AgeConcern suggest that people might wantto consider a retirement village if they:

• live alone, and would like morecompany and entertainment whileretaining their own space

• are concerned about personal securityand the security of their property

• want to be independent, but would likecare and assistance to be available ifneeded

• want to be free of house and/or gardenmaintenance, or can no longer managetheir current property withoutassistance62

A 1990 study63 found that fewer than onequarter of those surveyed were interestedin living in a retirement village. The mostappealing factors about retirement

59 NZCSS, 199860 Silverstone, B. and Horowitz, A., 199261 Personal communication, Sherry Carne, Housing New Zealand62 Age Concern pamphlet Retirement Villages63 Colmar Brunton Research, 1990

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villages were companionship, availabilityof medical care and emergency help. Incontrast, the factors that mostdiscouraged people from wanting to livein this environment were perceived lossof independence (39%) and privacy(28%). A quarter wished to live in acommunity with people of all ages.

Other options

A number of kaumatua flats were builtunder a programme operated by theformer Department of Maori Affairs.However, the scheme ceased when themainstreaming of funding for Maoriprojects was introduced. Existing flatswere transferred to local authorities,marae, runanga and other organisations.There is now no comparable fundingprogramme to support their ongoingdevelopment.

Two Abbeyfield houses have also beenestablished in New Zealand. These arebased on a British concept and aredesigned for people who live alone butdo not want to be on their own. Thehouses accommodate between 8-10residents, each of whom has a bedroomwith an ensuite. Other facilities areshared and a cook/housekeeper providesmeals. Residents are charged rent that isaffordable for those dependent on NZS,with some accessing the accommodationsupplement.

The Health Funding Authority hasrecently contracted Abbeyfield on a pilotbasis to support the establishment ofmore Abbeyfield societies in the country,and to develop their monitoring of thehealth and support needs of residents.

The society is confident that theirhousing prevents some ill health andcalls on health services, as well aspreventing or delaying entry intoresidential care. The barrier to expansionis the need for capital finance for aroundhalf the value of new properties. There iscurrently no programme within centralgovernment that funds communityorganisations to provide housing forolder people.

Research generally suggests thedesirability of having various levels ofsheltered care available in thecommunity64 . The trend towardsincreasing diversity in housing for olderpeople, and in particular housing thatincludes assisted living, is expected tocontinue. It is consistent with thegrowing numbers of older people livingalone, and the trend away from largescale, institutional care. In the UnitedStates, specialised residential complexesand the growing phenomenon ofNaturally Occurring RetirementCommunities (NORCs) are resulting infavourable economies of scale bybringing services to where people live.

NORCS are becoming a feature of NewZealand too, with heavy concentrationsof older people in Tauranga and KapitiCoast, for example. One author arguesthat, in the future, the distinctionbetween care at home and in aninstitution will blur to the point where“the very notion of ‘institution’ forpeople who live in housing where long-term care is available, will become ananachronism”65.

64 For example, Richmond, D., Baskett, J., Bonita, R., and Melding, P., 199565 Kane, R. A., 1996


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There is debate in the literature onassisted housing as to how muchaccommodation should be modified tomeet the needs of particular tenants orresidents. One point of view is thatresidents should move to a moreprotected environment when their healthappreciably declines. Another viewfavours providing practical support andservices as they are needed, to allow olderpeople to age in place. In both cases,managers of rental housing or housingcomplexes need to work collaborativelywith social workers or resident advocatesto achieve a balance between the needs ofageing residents and the demands of theenvironment.

Assuming a future scenario of morehousing for older people that providesfor assisted living, the decision-makingaround adapting current environments,or moving into a more protectedenvironment, points to the need formore skilled advice in this area. Suchskills will be important in retirementvillages, public housing and communityhousing for older people. Good housingdecisions are critical to maintainingindependence. Organisations likeHousing NZ, for example, face thequestion of how much their housingstock should be modified for olderpeople or maintained for generic use.Housing designs and modifications thatsuit older people are also likely to suitother groups such as parents of babiesand young children. These include rampsfor easy access, flat entry to showers andbathrooms, rails and other supportive orprotective devices, wide doorways thatcan be negotiated by prams andpushchairs and so on. The benefits of

housing design need to be considered ina wider context.

Achieving the appropriate balancerequires a level and type of skill thatmanagers are not necessarily trained for.Some authors suggest managers shouldreceive this training, while others believethere is a role for social workers increating supportive housingenvironments for older people as theyage in place.

The topic of housing options for olderpeople attracted considerable commentfrom focus group participants,correspondents and key informants. Thebig issue was the lack of housing optionsfor those with limited means. Theyidentified a shortage of appropriate andaffordable rental accommodation.Several thought this was a localgovernment role:

“It is the role of local government toprovide appropriate accommodationfor those unable to provide their own.Housing stocks must be affordable andacceptable. There needs to be a varietyof types of accommodation, includingthose wishing to live in a more hostel-like manner but with privacy. Olderpeople need both independence andcompanionship.”

Several key informants stressed the needfor more supported accommodation toprovide choices along a continuum ofcare for older people:

“The main need is supportedaccommodation on the Abbeyfieldmodel. We need lots and lots of them,with a housekeeper who can providesome personal cares. That set-up offers

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emotional care and support. It wouldsolve a real ethical dilemma we facewhere people have valid needs like thatbut can’t go into care. It’s a goodexample of where government agenciesneed to work closely together. Whoseresponsibility is it to provide suchhousing? Housing NZ needs to providesome properties and the health systemneeds to manage them. Even withpensioner housing, you need a properlytrained residential manager.”

Kaumatua flats can provide support forresidents. Key informants in one areadescribed how the kaumatua flats werebuilt next to the marae. Residents kept aneye on each other and people at the maraewould cook for them if they were sick.Other Maori respondents referred to theloss of their land, which means:

“We don’t have our own place anymore. This means a loss of our spiritualself, not to mention what we could havedone if it had never been taken.”

Transport and local amenities

“[My mother] is dependent on othersfor transport, and many of the peopleshe depends on are elderly themselves.She now has no transport to church onSunday, which is a grief to her, eventhough someone takes her to aWednesday communion service. Shouldtransport to other groups fail she couldbecome virtually housebound. Thiswould have a detrimental effect on herwell being as she would no longer feelshe was a valued member of society,able to make a contribution, howeversmall.” – Paekakariki

“I had two strokes in 1997. As amember of the Stroke Club I receivedhalf price taxi vouchers enabling me tovisit my chemist, the supermarket andthe hospital. I go periodically to thehospital for my pacemaker check-up.What helped most were church friendswith cars who offered to ferry meanywhere. I can now walk but I wouldlove someone to walk with me in caseI fall.” – North Shore City

Older people require easy access totransport both for daily living and tomaintain their social networks. Withoutaccess to suitable transport, older peoplemay become “prisoners of space”66. Adultchildren, other family members andfriends may provide help with transportbut one New Zealand study found thatthis is usually much less than is needed67.The focus groups confirmed that olderpeople do not wish to be seen as toodemanding and limit their requests to“really important errands” such asdoctor’s appointments, minimisingrequests for shopping and not asking fortransport for social reasons such as visitsto friends.

When older people can no longer drive,at best they become dependent on othersand at worst they lose the ability to goout at all. Many have to rely on family,friends or community groups to providetransport for shopping, doctor andhospital visits and transport to church,clubs and social outings. The Older andBolder group in Taihape took account oftransport problems in arranging outings:

66 Rowles, G.D., 197867 Legge, V. and Cant, R., 1995


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“When we go on Older and Bolder tripsout of Taihape, we build in time forshopping. People have more choice, andcan get things they can’t get in Taihape,such as a wider range of shoes. Gettingto appointments is also a problem.Senior Citizens has a health transportservice run by volunteers. There is onlyone taxi in Taihape, and older peoplecan’t afford it. A lot of families havemoved away. The population is falling,so it is harder to rely on families.”

While many correspondents and focusgroup participants relied on family toprovide most of their transport,community groups also played animportant role:

“Mostly family provide transport butthe Centre will pick up people and takethem to appointments if necessary.They have a van at the marae that isused to take older people shopping,on outings and to hui. We provide ahearty lunch on outings so that olderpeople do not need to cook a mainmeal at night.”

Some68 argue that loss of access totransport is a public problem for whichpublic policy remedies must be sought.Among adults in New Zealand, relianceon public transport increases with ageand is greater among older women thanamong older men. At advanced ages,proportionately more people cease todrive, generally as a result of incapacityor lack of confidence. In addition, manyolder women are of a generation whonever learned to drive. In 1996, fewer

than thirty percent of people aged 81 andover held driver licences.

Currently, a proportion of petrol taxrevenues is distributed to regionalauthorities to assist them fund publicpassenger transport (buses and trains),and programmes for the “transportdisadvantaged”. These includeconcessionary fares and the TotalMobility Scheme, which provides a 50%subsidy on taxi fares to people withdisabilities who are limited in theirability to use public transport.

Concessionary fares and the TotalMobility Scheme vary from region toregion. The Total Mobility Schemes inmany areas are under considerablepressure and access is restricted. Theservice was highly valued by recipientsbut some pointed out that even with a50% subsidy, taxis were still expensive.One key informant noted that:

“Some Territorial Local Authorities say[the scheme] is a social welfare issueand central government should befunding it. They don’t see it as acommunity issue.”

Under proposed changes to the fundingof public transport,69 the subsidies fromcentral government would cease. Instead,“regional councils could collect anannual regional passenger transport levyfrom all public and some other road[service] providing businesses topurchase public transport services ofbenefit to road users”. Should thesereforms be implemented, subsidies forpublic transport and other services for

68 see Legge and Cant, 199569 Ministry of Transport, 1998

41


the “transport disadvantaged” will nolonger be influenced by centralgovernment funding or subject tonational oversight, but will bedetermined and totally funded at aregional level.

The Mobility Parking Scheme run byCCS has benefits for older people with adisability who have private transport. Itis self-funded through charging users $35for a five-year mobility sticker. Localbranches work with local authorities andprivate firms to get their support.

Focus group participants, key informantsand correspondents identified transportas a major issue for older people. Whilein some areas, like Wellington, publictransport was described as “excellent”, inmany other areas it is inadequate or non-existent. Most buses are difficult to geton and off, with only a few “kneeling”buses available in the major cities. Olderpeople also feel pressured to hurry ingetting on and off buses, and taxis areconsidered too expensive.

Focus group participants wanted morepublicity about the restricted licenceoption, where drivers are licensed todrive in a limited locality or at certaintimes of day. Some suggested thatdefensive driving courses for olderpeople would be useful. However theseare expensive and not readily available.While the Land Transport SafetyAuthority funds “Safe With Age” drivereducation programmes for older people,they are of limited availability. Focusgroup participants noted that olderdrivers are vital for services like volunteer

drivers and meals on wheels, so it isimportant that as many older drivers aspossible retain their licences.

Those who needed and could affordelectric mobility scooters described howthese had increased their independence:

“Without it, I would be tied to thehouse or dependent on other people.With it, I do my own shopping, attendmeetings, visit friends, take it on thetrain, visit the museum and attenddaytime concerts. I really would urgeanyone who has a mobility problem totry to obtain one.”

However, cost is a problem and somewould like to see a grant or subsidy forscooters, or a rental system of some kind.Key informants also referred to the needfor local authorities to provide space formotorised scooters, and their reluctanceto do this.

Safety in moving around

The Senior Citizens Unit70 reports thatolder people are over-represented inpedestrian accident figures and have ahigher than average ratio of death toinjuries. Attention to hazards couldreduce the likelihood of accidents andincrease older people’s actual andperceived levels of safety. Suggestionsincluded improving the design ofshopping centre parking areas andpaying more attention to the needs ofolder people by, for example, providingmore public seats at bus stops, in parksand on the roadside. Surveys of olderpeople have identified a number of safetyconcerns that could be remedied fairly

70 Senior Citizens Unit, 1996


42

easily. Suggestions for improvementinclude better street lighting, footpathrepairs, paying attention to the locationand timing of pedestrian crossings, andgreater control over the inconsiderate useof cycles and skateboards71.

Focus group participants,correspondents and key informants alsoreferred to the need for ramps, wellmaintained pavements, sound and tactiletraffic signals, pedestrian crossings, goodstreet lighting, public seating, and, insome areas, cycleways on the inside,rather than the outside of parked cars.All of these provisions help maintainolder people’s independence.

Overall, focus group participants werecomplimentary about the efforts madeby local councils to improve safety andcomfort in local environments.

Security

“The three things in order ofimportance that help me keep myindependence are (1) my dog, (2) mycar, (3) my cordless phone. My dog,which I bought as a puppy, is of a largebreed. The dog is my ‘shadow’, neverruns away and is always with me, bothinside and outdoors. Because of this, Iam never lonely or frightened. My caris necessary for occasional shopping,visits to the doctor, hairdresser andother things. The cordless phone can becarried around the house and gardenso that I never need to run to answerthe phone and can make a call if Iwant to.” – Alexandra

Many of the older people whoparticipated in the study had no

concerns about security. This included ahigh proportion of those living in theirown homes. Several correspondents andfocus group participants commented onthe value of medical alert and otherhome alarm systems in maintaining theirindependence. Most focus groupparticipants had smoke alarms, anumber had security lights, and severalhad burglar alarms. They appreciatedgood street lighting and had confidencein the community police in theirneighbourhood. For one, security lightshave made all the difference:

“I come home, enter the garage withthe automatic door, and from insidethe garage I can turn on the outsidelights and some inside. I used to bevery nervous. I just don’t worry now.”

Key informants were more likely to referto security issues, with one describingthem as the “biggest single reason whypeople go into retirement villages and afactor in opting for rest home care”.Another referred to the fear of being intheir own home as a threat toindependence, particularly for womenliving alone. Negative recent publicityabout attacks in private homes has nothelped, as many no longer feel they areliving in a safe society. Almost all thosewho had decided to move to a retirementvillage or into pensioner housing wereinfluenced by concerns about security.Some saw it as an advantage that, whenone partner died, the remaining spousecould stay on in a secure communitywith support.

Several participants wanted thegovernment to increase numbers in the

71 Keys, F. and Brown, M., 1993

43


police force. They thought that if thishappened, more police and trafficofficers would patrol the streets and dealwith skateboarders and “careless drivers”.Others thought that older people neededto take more responsibility for their ownsafety. One commented:

“Individuals have to get smart andlearn not to be duped e.g. opening thedoor to people they don’t know andgetting more than one quote for a job.The biggest group of vulnerable olderpeople is single older women livingalone in rented accommodation.”

Technology

“I think one of the most difficult thingsfor our generation is trying tounderstand and cope with the newtechnology. Banks closing localbranches, especially in the country, isreally hard and frustrating.Answerphones and having to deal withrecorded voices instead of a person isinfuriating. By the time you push theright button you’ve lost the connection.So far I’ve resisted using a windowbank and Eft-pos and intend to do soas long as possible.” – Christchurch

While a number of older peoplerecognised the importance forindependence of keeping up withtechnology, many were put off bychanges in banking technology and bythe increasing impersonality oftelephone contact with governmentdepartments. While some usedautomatic teller machines (ATMs) andEft-pos, very few used telephonebanking.

“I won’t use a telephone to do mybanking as I want to see the people faceto face.”

Some were nervous about using ATMs:

“I’m nervous about using a ‘hole in thewall’ if there’s a lot of people around.I’m anxious people may be wonderingif I’m a suitable person to hit on thehead. Once I was surrounded by a lotof teenagers who demanded money.”

Several commented on the reduction inservices by government departments.Both the Inland Revenue Department(IRD) and the Department of Work andIncome have become more telephone-oriented which can be a problem for olderpeople. The IRD used to have a home-visiting service and ran clinics in smalltowns. Both of these services have ceased.Key informants also raised this point.

Some older people found it hard tolocate government agencies anddepartments in the telephone bookbecause they did not recognise thenames, which did not always relate totheir function. Some had problemstalking on the telephone because ofhearing difficulties. Others had problemsdue to impaired vision. The Royal NewZealand Foundation for the Blind(RNZFB) argued for stronger disabilitylegislation to deal with this. Suchlegislation might cover:

• the need for speakers on buses andtrains to let people know what bus ortrain it is and what stop they havereached

• standards for banking such as ATMs withbraille and voice feedback repeating theinstructions on the screen


44

• more use of voice and tactile markingsin the environment

• telephone services with large numbertelephones and telephone accounts inbraille

• menus in braille

• hearing loops in public buildings andtelephones. Hearing loops are wiresinstalled in buildings or in telephonesthrough which broadcast sound orannouncements are fed. People withhearing aids can tune into the loop andpick up the sound directly

One correspondent pointed out thatsmoke alarms and appliances such asmicrowave ovens need to have a lowfrequency tone or ring so that those witha high frequency hearing loss can hearthem.

SeniorNet is an organisation aimed atolder people who have been “missed bythe computer generation”. As well ashelping older people master the newtechnology, it encourages them to remainmentally alert and socially active. It givesthem the satisfaction of achieving newskills. Some local authorities providesubsidised facilities, and the tutors areusually older people who volunteer theirservices. Members of SeniorNetappreciated the opportunity to use theInternet and keep in touch with theirchildren and grandchildren using email.Others used computers for wordprocessing, accounting and business.However, funding limitations restrictopportunities for expansion which somesaw as indicative of the low priority givento education initiatives for older people.

Services that helpmaintain the independenceof older peopleThis section begins with a discussion ofgeneral services. This is followed by adiscussion of personal services, endingwith a discussion of support and servicesthat help maintain the independence ofolder people with an illness or disability.

General servicesHealth promotion and injury prevention

“I am an 88 year-old widow livingalone in a flat, and last year I had tohave an operation for a kneereplacement. I had it done at a privatehospital at a huge cost. I now havearthritis in my other leg and hip andhave used all my savings, so have tosuffer. I haven’t transport, but the TotalMobility vouchers have been of greathelp in enabling me to do my weeklyshopping by half-price taxi fares. I dohave a little home help, as I am in atwo-storeyed flat and a gardener once amonth, both paid for by members ofmy family. Otherwise I would have tothink of a rest home, which, heavenhelp, I would hate.” – Lower Hutt

Influenza immunisation, the ACC fallsprevention campaign and the HillaryCommission Kiwi Seniors initiative areexamples of preventive programmes thatcan reduce the illness and accidents ratefor older people. This reduces the flowthrough to other services, includinginstitutional care in the cases where ashort-term event triggers a higher levelof care need in the longer term.

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Some community groups offer healtheducation and wellness programmes aswell as monitoring the welfare of olderpeople in their community. RelationshipServices has developed guidelines toensure that counsellors know aboutissues older people commonly face, andsuggests strategies for dealing with them.Relationship Services receives requestsfor counselling from older persons, orhas older persons referred to them. Theservice recognises that older age is a timeof life-style changes, which includeadjusting to such things as retirement,bereavement of partner,intergenerational issues, and changes inrelationships, including divorce.

Many community organisationsproviding health support services receiveonly modest funding from governmentand raise most of their funds throughother avenues. They have to meetstringent accountability requirementswhich some saw as disproportionate tothe sum provided and a hindrance to thework of the organisation.

“The Association gets a small amountof funding from the HFA – around$8,000 from a total budget of around$95,000. In return for this money wehave to provide our services to allpeople, regardless of whether they aremembers or not. For their $8,000,which comes in four lumps of $2,000,we have to provide monthly reports,and renegotiate each year. They ask fora huge amount in return for a smallsum. It takes 3-4 hours per month of afield worker’s time to complete thestatistics and reporting requirements.

We have one paid worker and one fieldworker. Telecom gives us a fax machineand the council charges residentialrates otherwise all the rest has to beraised.”

The quality of GP servicesfor older people

The poor quality of interactions betweendoctors and older women is a commontheme in the literature on the loss ofwomen’s independence. One study72

noted that older women considered thatGPs did not relate well to them andneglected important issues such asincontinence, oral health, polypharmacyand alcoholism. The failure to manageincontinence, in particular, is often amajor factor in determining admissionof an older person into a rest home.

One Maori health group offered a freeGP service on Wednesday afternoons toCommunity Services Card holders:

“Older people often run out ofmedication e.g. for diabetes and bloodpressure and they can’t afford to paythe doctor to get more. This gets roundthat. We also have podiatry clinic oncea month, a monthly wellnessprogramme and a weekly fitnessprogramme.”

The Taihape Older and Bolder Groupliaised with District Nurses to buildstrategies, especially for confused olderpeople and for home visiting. Thisarrangement worked well, with all partiesagreeing that the service helped preventpremature entry into care. Theseinitiatives were successful and

72 Steinberg, M., 1997


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appreciated. However, the communitygroup received no health funding forproviding this service.

Other support services

“The St John’s emergency alarm systemshould be more widely advertised andmade affordable to older people wholive alone to give reassurance that helpat any time is only a phone call away.Meals on Wheels is a wonderful servicefor the ailing elderly and the Red Crossdo a wonderful job, but now is the timeto revamp the service and make itattainable to all older people no matterwhat the state of their health is. Thiscould be at a small cost to theindividual, who would I’m sure, gladlypay to have a meal prepared anddelivered to them. Age Concern does agreat job for the elderly in their ownhomes, giving them caring support, aidand companionship, and all donevoluntarily.” – location not stated

Not all the support services that helpolder people remain independent areassociated with their health. Meals onwheels, security services and practicalsupport can do much to aid theindependence of older people.

Home delivery of groceries andprescriptions is common in somesuburbs and small towns but lesscommon in the cities. One key informantnoted the introduction of an Internetordering service by a large supermarketchain. It includes a $15 delivery fee. Theycited this as an example of a service thatis not suited to older people, relativelyfew of whom have computers or canafford the fee, and suggested thatsupermarkets might consider an

alternative for those who need homedelivery but cannot afford to pay for it.

Financial organisations like insuranceand trustee companies do target olderpeople with information and participantsappreciated their willingness to providespeakers for groups. Information on theDepartment of Work and Incomeentitlements, IRD requirements orstrategies for managing money can helpolder people retain control of theirfinances and their independence. Manywanted more information, particularlyon entitlements, but, as noted above, thiscan be difficult to access, for example,through the reliance on touch tonetelephones.

Some local authorities havedemonstrated innovative approaches tomeeting the needs of older people. InAuckland, for example, one city councilhas a council representative at AgeConcern meetings who can passinformation to and from the council.The council also has a disability advisorygroup, whose members go out on sitevisits and advise on access issues.Another city council recently ran aforum with the local disability networkand has established an internal workinggroup to look at disability needs,including the provision of mobility carparks, seating, kerbing and space formobility scooters.

Personal servicesAccess to specialist and acute care

Timely specialist and acute care can becritical to preventing longer term careneeds. The ageing of the populationbrings with it increased demand forspecialist and acute care, as older people

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use more health care than youngerpeople. Some rationing of governmentexpenditure on health care does and willcontinue to occur.

Unevenness in the funding of healthservices for older people can beproblematic, with smaller centres andrural areas being especiallydisadvantaged. Psychogeriatric servicesand support for the confused elderly andtheir families are generally under-resourced, and the voluntary sectorneeds financial support foradministration and field officers. There isa need to develop programmes consistentwith the concept of “ageing in place”, aswell as multidisciplinary healthpromotion and education programmesfor older people73. Integration of servicesand funding is a critical issue for thefuture. At the policy level, the NationalHealth Committee has expressed concernabout the pressure that waiting lists foracute services place on the demand forDisability Support Services (DSS)support, within fixed budgets74.

Focus group participants identified anumber of problems in accessing healthservices, particularly specialist care. Insome areas, some specialists visited on aregular basis. In another, a 10-minutetelephone consultation was availablewith a specialist from the local hospital.This was a new service which someregarded as a dangerous trend, althoughthey acknowledged that it did increasethe range of services available. In ruralareas, there are costs over and above theactual cost of medical services:

“We need transport andaccommodation allowances forspecialist services. If someone has to goto a public hospital, directed by theirGP, and they need to stay overnight,they need accommodation andtransport. At present, it’s old peopledriving old people – they get a grant forpetrol - but it’s a basic essential service.There’s no payment for the cost ofstaying.”

Others referred to the long-term costs ofdeferring medical treatment. There wasresentment about the age bias that wasseen to be part of the priority settingformula for operations.

“The waiting lists are very stressful.The booking system is inequitable,frightening. You lose points if you areolder. Older people minimise theirproblems because they don’t want to bea nuisance. The present system is nextdoor to euthanasia - if you’re 70 we’llkill you off.”

“There’s a huge irony in thegovernment spending lots of money tosupport people in their own homeswhile they wait for a cataractoperation, which should be able to bedone very cheaply and quickly. Infuture we will have more people at thepoint where they will need care becauserelatively minor ailments are notattended to early enough.”

Costs of health services

Paying for health services privately is an

73 Richmond et al., 199574 National Health Committee, 1999


48

option for a limited number of olderpeople. The cost of private healthinsurance can be prohibitive for olderpeople, with correspondents quotingprices ranging from $1500 to $5000 peryear. Hearing aids are also expensive – upto $3000 for modern aids. Governmentsubsidies are available for people whoneed these aids for their work, but theyare not available to non-workers.Spectacles are also expensive but theseare not subsidised, yet both spectaclesand hearing aids can enhance theindependence of older people. Anadvance on New ZealandSuperannuation is available to purchasethese aids, however an older person withno additional income may have difficultyrepaying the advance.

Pacific people who are not New Zealandcitizens can also be required to pay forhospital care. Sometimes families bringolder family members to New Zealand tolive with them, but these older people arenot eligible for free medical care orequipment. Some health professionalshave proposed that a pool of equipmentbe established for hire or borrowing bynon-residents so that they can care fortheir older people appropriately.

Support and services that helpmaintain the independence of olderpeople with an illness or disability

Failing health is a major reason for lossof independence. Several key informantsemphasised the need to acknowledge theinterrelationship between health andwellbeing and services and needs. Oneidentified the need for a continuum ofservices:

“One of the big factors for security ofretirement is older people knowing that

the range of services they might need isavailable. In the past, we only had ahospital with a rest home andcontinuing care. We’ve since developeda range of services from community tocontinuing care so they can have thatsecurity. They know there’s somethingthere that will repair them quicklywhen they get acutely ill. They alsoknow that as they gradually deterioratethey can stay in the community withtheir friends and relatives.”

Family care

“My husband suffers dementia causedby a blood clot to the brain. At 93,surgery is not an option, but hisdisturbed nights and confusion are sotiring on me. Lack of sleep over 18months has brought me down.Although our wish is to care for him athome it is becoming obvious that thismay not be possible for much longer.One thing the health system doesn’tprovide is someone to sleep in so thecaregiver can recharge her batteries foranother day. Lack of sleep is the mainproblem as the patient invariablywants to be awake and roaming thehouse during night hours. Can youhelp us?” – Napier

“My mother had a stroke 41/2 yearsago. She was hospitalised for threemonths and came home to 24-hourcare. For Mum to remain at home, weneeded the following:• Initial nursing help, support and

demos on showering etc• Furniture - bed and a chair, aids,

stools, handles, walker etc• Meals on wheels and meals from

family for the first year

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• Paper boy who brought the paper inand milkman who brought milk toterrace

• Family to do grocery shopping andother shopping when needed

• Community groups who collected herfor stroke group, blind outings etc

• Household help once a week wasreally not enough, family didremainder

• Family to do gardens and paid manto do lawns

At times we found it difficult…but weare proud we did it for Mum. She wasa lovely happy person to be with.”– Blenheim.

Whether or not an older personcontinues to live independently dependsto a large extent on whether they havefamily support. Individuals who do nothave a family carer tend to move intoresidential care earlier than those whodo. The presence of a live-in carer isparticularly important for older peoplewho have an illness or disability.

Family care is common. A 1994 NewZealand study75 found that more thanone-third of the total adult populationwas providing regular informal care toolder people, with people who wereretired, unemployed and homemakersproviding the largest amounts of care.A survey showed that over half the helpprovided to older people to prepare food,bathe, do housework, get out and shopwas provided by family and friends76.

Providing care to family members canhowever be stressful, and the breakdown

of this care is another factor thatdecreases the likelihood of independentliving. A comparative study of residentialcare and home care for older people inAuckland scored home care ahead oncosts and client satisfaction, but foundhigher stress levels existed for familycarers77. Key informants noted thatfamilies and caregivers vary considerablyin their ability to care – both emotionallyand practically. Their attitude isimportant and affects the level of riskthey will tolerate. This in turn affects theolder person’s ability to remainindependent. Education and supportmay increase family members’ ability andwillingness to care appropriately for theolder person. One health professionalcommented:

“We often have to work hard withfamilies, to encourage them to giveolder people a chance. We need to listento the family’s concerns and try to dealwith them, thinking through the worstpossible scenarios and theirimplications. Families get really worndown. Some families are really positive,others undermine the stay at homeoption. The role of social workers is tomake sure the family has all theinformation they need to make adecision. They need to encourage thefamily to think of what will give theolder person the best possible care,rather than automatically assumingthat having them home is the bestoption. That can help the familymember let go. Moving into a resthome is not necessarily a failure.”

75 Abbott, M. and Koopman-Boyden, P., 199476 The 1992-93 household health survey, cited in “NZ Now: 65 Plus”, Statistics New Zealand, 199877 Richmond, D. and Moor, J., 1997


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Carer stress is also a factor in elder abuseand neglect. Services to deal with thishave been established in New Zealand,with many being provided by AgeConcern. An elder abuse co-ordinatoracts as a first point of contact for allenquiries concerning elder abuse andneglect, and makes referrals, asappropriate, to a range of existingintervention services for clients. In 1998,the Senior Citizens Unit worked with theformer NZ Community Funding Agency(now the Department of Child, Youthand Family) to develop service standardsfor elder abuse and neglect preventionprogrammes. Child, Youth and Familyoutreach workers monitor the servicesand their adherence to the standards.One key informant described a differentkind of abuse. In this case, she referred toolder Maori people, but other olderpeople could be in a similar situation.

“People don’t think they are abusingthe elderly when they go to visit andtake a couple of mokopuna with them.That person may be getting meals onwheels. The elderly can’t eat in front ofthem so the children get the food andthe older people go without. They askfor money on pension day to fill theircupboards but the cupboards of theelderly are not being filled.”

Some key informants referred to the costof caring, noting that it can be financiallydifficult for some caregivers to give uptheir careers. One suggested that anoption similar to parental leave could beuseful. In Pacific communities, someschool age children stay home from

school to look after an older parent orgrandparent, especially when the latter issick or has a disability.

A strategy for family caregivers

Acknowledgement and support of thecontribution of family carers is of botheconomic and social importance. It hasbeen estimated that if caregivers ceasedto provide care, New Zealand wouldneed 50,000 to 60,000 additionalresidential care beds78. One writer79

argues that those who provide the mostcare should be treated as clients in theirown right, with a system that providesthem with support, training and advice.Increases in the complexity of care in thehome means that family carers, as well asworkers, need better training. They alsoneed professional advice and support,help with housework, moreunderstanding from family and friends, aregular holiday, an occasional night sitter,and an occasional half or full day off.Several carers, most of them older peoplethemselves, wrote describing thepressures of caregiving. The greatest needwas for night care and weekend relief.

The beginning of a strategy that focuseson carers is evident in New Zealand.Carers are entitled to respite care basedon an assessment of their needs.However the level of respite careprovided falls a long way short of whatmany carers would like, particularly interms of weekend, evening and overnightrelief. Relief care is available for up to 28days per year for those cared for full-timeby family.

78 Abbott, M. and Koopman-Boyden, P., 199479 Hennessy, P., 1996

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In the 1998/99 financial year, a sum of$500,000 was available through the HFAfor developing training packages forcarers. The funding will continue for afurther three years. The project is in itsearly stages and will include videos andtraining packages for caregivers. Theuptake of training will depend on anumber of factors including the carer’swishes, the availability of trainingpackages, and the availability of reliefcare while undertaking training.

Carers are entitled to the DomesticPurposes Benefit if they meet the benefitincome test. At 31 March 2000, only2.1% of recipients of the DomesticPurpose Benefit were carers of the sickand infirmed of any age.

Services provided at home

Home-based services are essential tokeep many older people out ofresidential care, and to prevent the healthand abilities of even greater numbers ofolder people from deteriorating. As partof a broad consensus on the value ofmoving away from using hospitals toprovide long-term care for older people,and of keeping people with low levels ofdisability out of institutional carealtogether, New Zealand has movedtowards integrating funding forinstitutional care and many home-basedservices and support through DSS. Therehave subsequently been increases inexpenditure on home-based services80.Further increases are anticipated as thepopulation ages.

Services provided to older people with a

disability or illness at home include:homecare - personal care, such asbathing and toileting; housework,including cooking and shopping;equipment; visits from medical or healthprofessionals, for example to providemedication; and visits from “homevisitors” for social contact. Participantsin this study who received home helpwere immensely appreciative of it,describing it as moral as well as practicalsupport. Nevertheless, the conclusion ofthis study is that the mix and quantity ofservices being provided is less thandesirable.

“My wife was discharged from hospitalin September 1998. She was sent homeunable to walk. The staff at the localhospital were convinced we would notbe able to handle the problems so wewere left without critical information– we were alone! What helped?A nephew who informed us there washelp from Homecare 2000, so Icontacted Community Health at thelocal hospital. Next I found out therewas a social worker at the hospital andthe system began to function afterabout a week of frustration. Then wewere able to contact the OT81 at thehospital and find out we were servicedby a “unit” some kilometres away,where resources were available.Homecare2000 provides 5-day supportfor the patient (one hour a day). Thequality is excellent but the weekend is,in many cases, a real problem. Thefamily is not the coherent unit it usedto be and it has proved quite impossible

80 Health Funding Authority and Ministry of Health, 199881 Occupational therapist


52

for our family to provide weekend care.The solution - ‘Panacea’ will supplystaff and we will pay for help. St Johnsprovides a night care service for whichwe pay, to put my wife to bed andmake her comfortable. And we two aresome of the happiest people in our areaand hope to celebrate our 60th weddinganniversary in December 1999.”– Auckland

“My neighbour is 82 and nevermarried, having looked after her ownparents for many years. She is riddledwith arthritis but extremelyindependent. The last few years she hasmoved around her unit with the aid ofa walker but, due to several steps atboth the front and back door, she hasnot been out of the house for at least sixyears. She has been visited by severalorganisations and the only help theycould suggest was physio. It appearsthat there just aren’t the peopleavailable for home visits. As old ageisn’t covered by ACC, it is, to an elderlyperson, just another cost to add to thegardener, lawn mower man and weeklyhome help who supervises her shower.There is an immediate need for homevisits by physiotherapists to help theelderly maintain confidence inmovement and stay in their ownhomes.” – Auckland

Accessing services at home

There are a number of different routes toaccessing care at home. Care needed as aconsequence of an accident is providedfree of charge through ACC, and postacute care is generally provided free ofcharge through public hospital services.In most cases, services needed to meet anongoing illness, or disability, and are

accessed through DSS. The assessment ofneed for services is carried out separatelyfrom the provision of services andequipment. There are some regionaldifferences in the approach to assessingneed and the types of services provided.Home care services are provided free ofcharge to older people who qualify for aCommunity Services Card due to theirlimited means. People with sufficientmeans typically organise their own careand services.

While there is a high level ofappreciation for these services, a numberof studies in New Zealand and overseashave identified problems in servicedelivery. These include emotional,economic, physical, knowledge andcommunication barriers to access.Several key informants andcorrespondents commented on thedifficulty of obtaining information:

“It’s very hard to get reliableinformation on entitlements. Peopledon’t know where to go. IncomeSupport does not advertiseentitlements or grants. They need toknow about their entitlements –they’re always changing the rules. Staffare very difficult to deal with. Peopleneed to be assertive and empowered tobe successful.”

Some focus group participants suggestedpublishing information on entitlementsand agencies in local papers, andbroadcasting it on television and talkback radio. Others believed there is aneed for advocates to help older peopleunderstand the health system and tonegotiate on their behalf. In their view,success in obtaining services can

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sometimes depend on the sympathy andskills of the older person’s GP. Somefocus group participants maintained thatgovernment resourcing of advocacygroups would be beneficial.

Health professionals and agenciesproviding care also need to becomeskilled in meeting the age-related needsof older people. This covers providing anappropriate carer as well as appropriatecare, and dealing with people’sperceptions of the servicesympathetically:

“Perceptions are crucial. They reflectthe amount of power people feel theyhave in accessing services. The amountis determined by the service co-ordinator based on need – people haveto have bureaucratic assessments andfeel powerless.”

“A key to quality home help services isthe careful matching of the personbeing supported with the help, whichmeans that there is high quality socialinteraction.”

Services provided at home need toconsider differences in culture, genderand class, as well as the “little cultures”which older people construct forthemselves. Studies show that whilekaumatua make a strong contribution towhanau life, they face barriers toaccessing services for themselves. Barriersinclude cost, lack of culturallyappropriate services, lack of appropriateinformation and a lack of integratedservices82. Some Maori focus group

participants noted that in their area:

“There are no Maori assessors whenthey come out to see what we need.They always come with a Maoriworker, but it would be nice to have aMaori to talk with about our needs.”

Maori also raised the inappropriatenessof DSS assessment processes in a recentinvestigation into the homecareindustry83. Examples raised included theuse of non-Maori assessors in Maorifamilies, the focus of assessment andtasks on the individual with a disabilityas the “client” rather than the household,and maintaining contact about changesin need by phone rather than face to face.

Lack of flexibility in service provisionwas seen as a major barrier toindependence. Key informants referredto the need for more flexibility in thekinds of tasks caregivers can do, as wellas the time they are available. At present,decision-making on the provision ofservices varies by region. Caregivers insome areas are not allowed to do“outside” tasks and none can givemedication. In rural areas, the formerrestriction is particularly relevant.Although older rural residents may beentitled to a disability allowance to coverextra services, such as chopping andbringing in firewood, it can be difficult tofind someone who can call in as often asis needed. In both urban and rural areas,the inability of caregivers to givemedication attracted considerablecomment:

82 Te Pumanawa Hauora, 1997, p4583 Burns, J., Dwyer, M., Lambie, H. and Lynch, J., 1999


54

“Caregivers theoretically can’ttransport them. They can’t chopfirewood, which is considered anoutside job. They can’t give medication– this is a huge problem, especially inrural communities. It puts thecaregiver in a difficult situation.District Nurses can’t visit every dayand people have blister packs84. Theysimply have to watch them actually putthe pills in their mouths.”

In more urban or suburban areas,shorter allocations of time for deliveringhome care might be more effective. Oneperson suggested the following approach:

“At present, care is only available inunits of one hour. There could be tenminute slots where one carer has anumber of people and just pops in tocheck they’re OK, give medication etc –monitoring. There is unevenness in theavailability of home care – when it’seasy to access it, it can keep people outof care; when it’s not, they have to gointo care.”

Having appropriate services available wasraised as an issue. Some people foundthere were no services available:

“It’s difficult to find people to sleepovernight. If the government providedpayment for people to sleep over, thiswould mean we’d stay longer in ourown homes.”

Others did not know how to accessservices, even if they were willing to pay.One woman in her late eighties, for

example, wanted help with houseworkbut did not know how to access theservices of someone reliable andtrustworthy. There is obviously scope forpublicising services better.

Some contributors debated the nature ofappropriate home support, noting thatwhile home care services can help olderpeople remain at home, they can alsoentrap them:

“Physical frailty can cause chronicillness. Older people can get help withmeals, cleaning and showering, butthey need to be able to get through theday on their own, using the toilet andmaking cups of tea. Those living alonemay become socially isolated. Orcaregivers [either family or paidworkers] may do too much and takeaway the last shreds of independence,for example, not encourage the personto dress herself.”

Inefficiencies and delays in providinghome support services can adverselyaffect an older person’s ability to remainindependent. Access to equipment was aparticular concern. One healthprofessional commented:

“Home modifications can take months.It can take 10 weeks to get approval forrails on a path. In one case, the OT 85

had to go back and get an extra quote.It’s hard not to be cynical that this is acost-saving strategy. Trialingequipment is another example. It usedto be easy to borrow equipment to trial.You can’t put in a funding application

84 These are packs prepared by pharmacies with medication sorted into appropriate dosages85 Occupational therapist

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till you’ve trialed it. You have to waitages for applications to be considered,meanwhile the equipment has gone onto the next person and the client is leftwithout anything.”

Another sought easier access toequipment such as wheelchairs:

“To help family members take olderpeople out. It improves their sense ofwellbeing, relieves depression andmeans they can go to tangi, huiand so on.”

Several key informants highlighted gapsin respite care. Currently, temporary carein rest homes is available for up to 28days per year when a carer is notavailable to care in the home. Whilemany saw this as an excellent andnecessary service, it is not available forone-off purposes, for example, for asingle person who has a heart attack.If subsidised care was available, anindividual could convalesce in a resthome and reduce the likelihood that he/she will either stay in hospital longerthan necessary or go home too early.This kind of subsidised care is availablethrough ACC to older people who havean accident.

The lack of subsidy or payment for nightcare also drew comment. Focus groupparticipants, key informants andcorrespondents all cited examples ofcases where the lack of such care hadmeant that an older person had had to gointo care. One health professionalpointed out that paying for such care was

still cheaper than paying for full-timecare. Another commented:

“We need better night care services –it’s a resourcing issue. Home Supportproviders are stretched to meetdemand. They can’t always turn up ontime – this can make a real differenceto older people. So the issue is not onlythe number of hours but timeliness –people need to be able to organisetheir lives.”

Managing the costs of care for bothgovernment and individuals

The question of income security in oldage is being addressed with greater andlesser degrees of success by most OECDcountries, including New Zealand. Lessattention has been paid to funding thecosts of care on a long-term basis ineither institutional or home-basedsettings. In New Zealand, care on a long-term basis is funded through a mixtureof private and public expenditure. Olderpeople must have assets below a specifiedlevel before they qualify for a residentialcare subsidy. They must also contributeany income they get towards their careup to a maximum of $636 per week86.

The current policy mix in New Zealandprovides different subsidy levelsdepending on the care being accessed. Atthe home services end, there are concernsthat people who cannot access subsidiesdo not always pay for, and thereforereceive, the services they need. Thistendency is confirmed by research87, andcan result in more rapid deterioration inhealth. As one key informant commented:

86 Residential Care Subsidy: Income Series (undated) – Booklet published by Work and IncomeNew Zealand (WINZ), Reference Code A3/787 Bebbington, A. and Davies, B., 1993


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“Costs can be high and a lot of elderlyhave grown up expecting it all to befree. They won’t part with money iftheir life depends on it and sometimesit does. They have been frugal andsaved and want to pass their money on.”

Several key informants discussed the costof home care services with one notingthat making the service free toCommunity Services Card holders puts alot of financial pressure on the system.Different suggestions were made as tohow the system could be made fairer andresources freed up for those who reallyneeded them.

At the institutional care end, a smallpercentage of older people are vulnerableto their savings being eroded veryrapidly, at up to $30,000 a year, whenthey or their partner require permanentresidential care. Of concern also is theextent to which better-off couples andindividuals plan their financial affairs inorder to avoid their assets and savingsbeing eroded.

Reliable mechanisms for paying for long-term care, whether at home or in anassisted living or residential setting, areneeded, so that people have somecertainly about payment for theirservices88. There is general agreement inthe literature that uncertainties for bothpurchasers and insurers make it unlikelythat private competitive markets willprovide adequate insurance for long-term care89. The risk of the burden oflong-term care costs for individuals is sogreat that most writers agree that

government needs to be a major player inthis area. This is also important forequity, as asset-testing sets up incentivesfor ways to reduce assets through earlygifting and other means90.

There is no consensus over whethersocial insurance or government fundingis the best method to fund the costs oflong-term care. Most countries havesome mix of insurance and tax-basedfunding, and some have user charges.Germany has moved towardsintroducing compulsory insurance forlong-term care. France and Japan havehealth insurance schemes that provideconsiderable coverage of long-terminstitutional care in hospitals andelsewhere.

Summarising theissues for MaoriImproving life expectancy is animportant issue for Maori, so that moreMaori reach old age. The gap betweenthe life expectancy of Maori and non-Maori is expected to close, as the lifeexpectancy of both groups increases,although at a slightly faster rate forMaori than for non-Maori. Maori arenow only 2.9% of the population over 65but that proportion is expected to rise to4.8% by 2011.

Maori in old age have less income thannon-Maori. In 1996, the median annualincome for an adult over 65 was $12,040,while for Maori it was $10,380. OlderMaori are also less likely to be in paidemployment than Pakeha.

88 Hennessy, P., 199689 Goerke, L., 199690 St John, S., 1993

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Income is a predictor of health status, afinding supported by a 1997 study91

which found significant differences in thehealth status of kaumatua according toincome. Incomes of less than $20,000were more often associated with low, thanwith high, health scores. A more recentstudy92 found that older Maori had higherhospitalisation rates from injuries,cardiovascular disease, diabetes,respiratory disease and most cancers thannon-Maori. Given their income status,older Maori rely heavily on stateprovision of health care.

The growing proportion of older Maoriwill have implications for health services.

Maori in this study, as in earlier studies,wanted more appropriate provision ofhealth services, for example, Maoriassessors for disability support services.Some believed that health service deliverywould also be improved by more homevisits by health professionals93. TwoMaori key informants gave examples ofpositive health initiatives designed tomeet the needs of older Maori people. Inone case, health clinics and educationprogrammes were provided on a localmarae, as part of a health service fundedthrough the HFA. The providers of thisservice would like to see the HFAconsider funding rongoa, or traditionalMaori medicine. In another service, alsofunded through the HFA, a Maori nurseattached to a local clinic visited olderMaori in their own homes.

Maori focus group participants

emphasised the importance of communityinvolvement to the independence of olderMaori, while acknowledging that thedemands on older people can be tiring.Older Maori benefit from the statusaccorded to older people, especiallykaumatua who are generally optimisticabout ageing. However, age-relateddisability or poor health can result inweakened marae participation andweakened cultural identity94. Participantsin the study suggested that thegovernment fund kaumatua hui tostrengthen cultural identity andcommunity links.

Maori are less likely than non-Maori tolive alone or with a partner - 20% live inmultiple family arrangements. They arealso more likely to be in rentalaccommodation. In the study of the healthand well-being of older Maori, thosekaumatua who did not live in their ownhome were more likely to report poorerhealth95. A number of kaumatua flats builtunder a programme operated by theformer Department of Maori Affairs havenow been sold to marae, runanga,community trusts and local authorities.These can provide a supportiveenvironment for residents, particularlywhen whanau are not able to providesupport. There is no comparable fundingprogramme to support their development.Some Maori focus group participantsdrew attention to the negative impact ofthe loss of their land, which not onlyrestricted their housing options but alsomeant a loss of their “spiritual self.”

91 Te Pumanawa Hauora, 199792 National Advisory Committee on Health and Disability, 199893 Te Pumanawa Hauora, 199794 Te Pumanawa Hauora, 199795 Te Pumanawa Hauora, 1997, p.60


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Suggestions for changerelevant to the goal ofmaximising “ageing in place”

Critical supportissues for older people

This research identified a number of areasas critical to the independence of olderpeople.

Most importantly, what individuals do,and what happens to them before theybecome old, influences independence inold age. Individuals can enhance theirchances of retaining independence byhaving a successful, healthy and active lifebefore and after reaching old age.Financial resources, an active mind, goodrelationships with family and friends,fitness and health, and good self esteemare all associated with being able to stayliving independently. Even when seriousdisability or illness occurs, these personalresources and social capital increasechoices and enhance the likelihood that anindividual can access services, besupported informally, and stay livingindependently. From the perspective ofhabits and confidence, older people aremore likely to be active and happy inretirement, if this has been the case earlierin life.

There are, however, no guarantees. Oldage is probably the most difficult phase oflife for which an individual has to plan.Individuals face more uncertainty aboutkey areas of their life when old than atany other life stage. These include howlong they, and any partner, will live, and in

what state of health. From these, flowuncertainty about how long they willhave the capacity to earn from work, toundertake jobs around the home, todrive and get around unassisted, to see,hear and communicate, and to remainactive and motivated.

Individuals have different earningpatterns and expenses over their lives andtherefore widely different capacities tosave for their needs in older age, and toprovide a buffer against the unknowncosts of ill health, disability andlongevity.

Other areas critical to independence inold age emerged from the research. Whilethe importance of different factors toindividual older people varies, they wereraised in approximately the followingorder of priority:

• positive attitudes to ageing

• income

• support with personal health needs andneeds arising from disability anddegenerative conditions

• housing and security

• access to transport

• recreation, education and use of publicamenities

• work

Positive attitudes to ageing

Positive attitudes towards older peoplemake a difference to their independence.A theme throughout the literature, andin the focus groups, letters andinterviews, is that “costs” to society flowfrom the prevalent view that older peopleare “dependent” and a burden to society.This occurs because regarding olderpeople as dependent:

PART IV: SUGGESTIONSFOR CHANGE

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• fails to preserve an active and usefulrole for them

• makes them less assertive and confidentin looking after their own needs andcontributing to society more generally

• contributes to their sense of isolationand depression

• leads to services and amenitiesdisregarding the needs of older people,or hindering their independence

• accentuates divisions between youngand old

Older people made a number ofsuggestions to improve attitudes towardsolder people including:

■ More active support for a positiveattitude towards older people, led bycentral and local government. Onecontributor described an Australianidentity/entitlement card for seniorcitizens which has a supportive sloganon one side.

■ Encouragement of staff in firms andgovernment agencies to treat olderpeople with respect.

■ Instigation of a nation-wide projectencouraging older people not to beafraid of change.

■ Specific inclusion of older people incommunity activities.

■ Promotion of links with schools.

■ Portrayal of older people inadvertisements in a positive way.

■ Publicising the positive aspects of workboth for older people and for employers.

■ Educating the public about disabilitiescommonly associated with age, such ashearing impairment and loss of sight.

Our overall impression was that moreneeds to be done in all sectors to improveattitudes towards, and responsiveness tothe needs of older people. Serviceproviders, in particular, could benefitboth their businesses and taxpayers byavoiding the trap of treating older peopleas dependent. As older people become alarger proportion of the population, theirnumbers and consumer power will addtraction to positive attitudes set in placenow.

Policies that focus on costs can result inpolicy for older people being viewednegatively. The emphasis shifts to whatcan be taken away, rather than beingcentred on ways to help older peopleachieve greater levels of independenceand productivity.

Other key areas

The other areas identified in this study ascritical to the independence of olderpeople largely relate to support needsand the provision of services. Thefollowing discussion firstly elaborates oneach area, including the issues raised byolder people themselves, then looks atthe roles of different sectors in bettersupporting independence.

Service and support – issues and gapsIncome

Financial insecurity was a major issue formany of the older people who took partin this research. They were particularlyconcerned about the unpredictability ofcosts, especially for surgery and long-term care, and the erosion of theirinvestment income through fallinginterest rates. In letters, interviews anddiscussions, older people made a numberof suggestions for change. These included:


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■ Increasing the benefit for people livingalone – many of their costs are the sameas those of a couple, particularly rates,insurance and utilities such as a phone.

■ Making it easier for older people to raisemoney, e.g. for home repairs, to buymobility scooter, etc. This could be acharge on older people’s estate throughan equity release system.

■ Supporting community groups to providefinancial advice, help older people withpaying their bills and act as an EnduringPower of Attorney.

■ Providing tax relief for older peoplewhose income has been affected by fallsin interest rates.

■ Making expenses associated with carefully tax deductible e.g. extra homecare and home help, paying for someoneto stay overnight.

Personal health needs andneeds arising from disability

Having speedy and affordable access tohealth services was a major concern forolder people, many of whom wrote ortalked about their anxiety about havingto wait for health care or not havingsufficient post-operative or long-termsupport. They identified a number ofgaps in social supports and referred to alack of co-ordination between personaland disability services. Some mentionedthe variable quality of GPs’ knowledge ofthe needs of older people andmanagement of conditions such asincontinence. Some older people in theirlate 80s were caring for partners of asimilar age and they and other caregiversnoted the stresses they were under andthe need for more support and relief. Thearea of health and disability supportservices attracted the most

recommendations and suggestions fromolder people, including:

■ Having more specialist medical servicesavailable locally, through visitingservices or mobile clinics.

■ Reinstating district nurses and socialworkers in the community.

■ No restriction of health services on thebasis of age.

■ Providing public hearing aid clinics andhelp with buying hearing aids.

■ Early intervention for ailments, such ascataracts and hip replacements, to savecosts later and improve quality of life.

■ Providing more funding for field officersand co-ordinators of support groups andhome visitors.

■ Streamlining accountabilityrequirements for voluntaryorganisations.

■ Funding rongoa - traditional medicine.

■ Restoring subsidies on drugs, forexample, for hypertension.

■ Subsidising Medic-Alert and other safetyalarm systems.

■ Subsidising care in rest homes for peoplewho have been ill, so that they don’thave to stay in hospital longer thannecessary or go home too early.

■ Increasing Assessment, Treatment andRehabilitation services and have themmore widely available.

■ Having Meals on Wheels available in theweekend.

■ Improving co-ordination of the homesupport services available to people.

■ Increasing the flexibility in what homehelp can do – e.g. give medication,clean windows, change light bulbs, chopfirewood.

■ Having a pool of health equipmentavailable for hire, particularly for those

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with non-resident status who are notentitled to equipment.

■ Funding home visits by physiotherapists.

■ Speeding up approval for homemodifications and applications forequipment.

■ Funding a mix of home care providers toincrease diversity.

■ Supporting services to be culturallysensitive.

■ Paying for overnight care to enablecarers to get some sleep.

■ Providing more support for carers.Suggestions included increasing respitecare, establishing a system like parentalleave so that carers can retain theirjobs, and promoting family-friendlyworkplaces.

■ Providing more appropriate assessmentprocesses for Maori.

Housing and security

After health, housing was the mainconcern of older people. Many identifieda lack of affordable rental or ownershiphousing options in their community.They also expressed a need for a range ofsupported accommodation, especially forlow income people who could not affordto buy into commercial retirementvillages.

While a few correspondents would like astronger community police presence,many had taken steps themselves toincrease their security by installingsecurity lights, personal and housealarms and smoke alarms.

■ Supporting more housing alternatives,including local authority and communitygroups wishing to provide supportedaccommodation for people with lowincomes.

■ Supporting warden or live-in person inhousing complexes.

■ Help with maintaining homes becausethe current provision through theDepartment of Work and Income is notwell known and not enough.

■ Providing more support for communitygroups that offer home help and homemaintenance services.

■ Strengthening building codes to ensurethat buildings are user-friendly for olderpeople – examples include improvingsafety of steps by requiring railings evenon short flights of steps and ensuringtreads do not overhang risers.

■ Providing some support to older peoplewanting to move house, includingcheaper legal fees.

■ Providing more help for older people tomaintain gardens and lawns so that theycan stay at home. One suggestion wasfor a closer arrangement between localschools and older people following theexample of a South Island school wherelocal school children do “communityservice”.

■ Helping with making homes more energyefficient.

■ Providing smoke alarms and telephoneswith low frequency ringing options forolder people.

■ Providing more community policing.

Transport

Concerns about transport were raisedalmost as often as concerns abouthousing. Lack of accessible, affordabletransport isolated older people in theirown homes. It limited their access tohealth services, reduced their ability todo their own shopping and obtainpersonal services, and reduced theiropportunities for social interaction.Many found it demeaning to have to askfor help; others had few people on whomthey could rely.


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The high cost of individual taxi servicesput them beyond the reach of most olderpeople and while the Total MobilitySystem was greatly appreciated, itsavailability is severely restricted.Participants in the research made anumber of recommendations in relationto transport, including:

■ Providing more support for publictransport.

■ Developing transport systems that areuser-friendly for older people e.g.accessible buses.

■ Providing consistent and stable supportfor transport for older people, especiallyin rural areas, for access to health andhospital services and also for otherpurposes, such as shopping and socialneeds e.g. attending groups.

■ Providing more funding and moresecurity of funding for the Total MobilitySystem.

■ Providing more publicity for therestricted driver licence option toenable some older people to continuedriving.

■ Requiring warrants of fitness only once ayear for cars that only do a low mileage.

Recreation, education andpublic amenities

Many of the recreation and educationactivities enjoyed by older people areprovided by community groups, usuallywith some support from governmentfunding agencies or local authorities.Participants in the research appreciatedthe support they got, but did not alwaysappreciate the effort they had to put in toobtain and account for relatively smallgrants.

Many participants were positive aboutthe efforts their local authority made tomake civic amenities user-friendly and

wanted more of the same. Some werewilling to share in decision-making sothat the views of older people are heard.Their specific suggestions included:

■ Involving older people in policy making.

■ Local authorities continuing to supportsocial services such as resource centresand community centres.

■ Local authorities continuing to payattention to pavements, street lighting,crossings, access, seats so that publicareas are user-friendly for older people.

■ Improving the design of parking areas,e.g. in shopping malls, so that walkingspaces are clearly identified.

■ Providing cycle-ways on the inside ofparked cars to increase safety for olderpeople.

■ Local authorities maintaining verges inresidential areas - currently this has tobe done by residents and is a burden forolder people.

■ Reinstating home milk delivery.

■ Providing more mail boxes locally.

■ Supporting the home delivery ofgroceries.

■ Providing more stable funding forvoluntary agencies.

■ Using schools as centres of learningoutside school hours.

■ Continuing and increasing support forlocal groups.

■ Maintaining services such as mobilelibraries, talking books and large printbooks.

■ Encouraging more sponsorship ofactivities for older people.

Work

Relatively few of the older participants inthis project were in paid work, althougha large number were active in a voluntarycapacity. Some were feeling pressured bythe demands of voluntary work and were

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concerned that changes to the retirementage would reduce the pool of voluntaryworkers.

Sector roles in the maintenanceof independence in old age

As is evident from the discussion above,the actions of individuals, familymembers, private and not-for-profitorganisations, community groups andneighbourhoods, and local and centralgovernment all impact on the goal ofolder people to live independently.

Most of the issues raised by older peoplein this project referred to areas wheregovernment action was seen asimportant. This is perhaps not surprisingconsidering that the project was fundedby central government, and the large rolegovernment plays in the service areasidentified.

The roles played by the different sectorshave arisen from New Zealand’s uniqueset of historical and culturalcircumstances. The responsibilities ofeach sector have not been clearlyidentified and articulated. The debateabout government and individualresponsibilities for retirement income isa high profile example of the complexityof resolving responsibilities.

Roles do not always matchresponsibilities. The private sector, and insome cases the voluntary sector, providesservices as a business, but the servicescan be paid by government or other thirdparties, rather than by their clients. Rolesare also shared, for example, wherefamilies and health professionals bothprovide care. Roles change over time andare influenced by demographic changeand migration. The reframing of New

Zealand’s social policy to reflect changedviews on the role of government and thebest ways to achieve welfare hasimportant implications for future rolesin supporting the independence of olderpeople. Prevalent values include:

• families being self reliant when they can

• support from government being providedto individuals rather than to services,often targeted on the basis of income

• the importance of choice and diversityin services, particularly for Maori andPacific peoples

• a larger role for private sector services

• contracts for services replacing grants inthe non-profit sector

This section considers the roles of thekey players in maintaining theindependence of older people.

Individuals, spouses and families

As discussed earlier, life beforeretirement largely sets in place the mainfactors that influence the ability of olderpeople to be independent. Older peoplein this study confirmed that keepingphysically active, eating well andmaintaining interests and relationshipshelped them maintain theirindependence.

The study identified a number of areaswhere individuals felt they lackedinformation critical to taking action tomaintain their independence, forexample, on where to go to get help, whattheir entitlements were, and how toaccess them. They had a number ofsuggestions for improving the situation:


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■ Having readily available, up-to-dateinformation on all entitlements. Forexample, health agencies would provideinformation on income/welfareentitlements as well as on healthservices.

■ Ensuring that GPs have full knowledgeof the entitlements and servicesavailable.

■ Making information available through awide range of avenues – posters,pamphlets, 0800 numbers, regulartelevision campaigns, local newspapers,better funding of Citizens AdviceBureaux, local Age Concern councils andother groups – the campaign needs tobe ongoing and constantly updated.

■ Producing information in a consistentform e.g. an older people’s brand, nota Department of Work and Income,HFA or IRD brand – maybe Age Concerncould continue work in this area.

■ Clarifying the layout of the governmentagencies section of the telephone book- the names of agencies do notnecessarily relate to their function.

■ Reinstating local services such as visitsby IRD to rural areas.

■ Providing more help for older peoplewith new technology e.g. banking andtelephone systems.

Money worries also constrainedindependence, both as a result of the“worry” factor and because not havingenough money meant some people wereunwilling or unable to undertakeactivities that are important tomaintaining independence. Paying fortransport and house maintenance ormoving to more suitableaccommodation are two examples.

The older people in this study did notdiscuss the challenge of saving for older

age to any great extent but thegovernment has recognised thischallenge through the establishment ofthe Retirement Commissioner. However,this study did provide an insight to thelack of incentives to save for retirement,and also the incentives to disguisesavings or not to divest assets. Severalolder people discussed the lack of goodproducts to protect the value of savingsand to enable release of home equity.Others expressed resentment at the lowlevel of publicly funded support forservices for older people with modestsavings. They were particularly resentfulat the erosion of their personal assets topay for long-term care. There is alsoevidence of retirement plannersspecifically advocating the setting up oftrusts to avoid the divestment of assetswhen needing long-term care96.

To encourage people who can save fortheir own retirement to do so, theimportance of risk management andgaining some direct benefits from thosesavings needs to be acknowledged.

The literature review, interviews, focusgroup discussions and letters confirmedthe importance of families as carers ofolder people with disabilities or poorhealth. These sources also agree that thesupport provided to carers is patchy andinsufficient. A more explicit strategy tosupport carers, and acknowledge theirrights to time off, training and othersupports, will enhance the capacity offamilies to care. It is also likely toimprove the quality of care.

96 St John, S., 1999. “Retirement policy issues that we are not talking about” Paper to the NZAssociation of Economists Annual Conference, Rotorua

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Self help, community groupsand voluntary organisations

Self-help, community groups andvoluntary organisations provide a widerange of services for older people,including:

• transport to appointments, social eventsand for shopping

• home visiting

• social and recreational opportunities

• support for people with disabilities orwho have had illnesses

• home maintenance

However, the provision of such servicesis uneven and depends on the availabilityof people able and willing to provide theservice. Key gaps in some areas are helpwith transport, shopping and managingfinances.

This study confirms that mostcommunity groups and voluntaryagencies rely on even small grants orcontracts from government or quasigovernment organisations to keep going.It also revealed that the lack of integratedand reliable funding means that theviability of many small organisations isprecarious. Both paid and unpaid co-ordinators spend a disproportionateamount of their time applying for fundsand meeting accountabilityrequirements. Few are able to plan aheadwith any certainty.

Private sector firmsand non-profit businesses

The older people in this studyappreciated private firms who wereresponsive to their needs. They citedlocal firms that delivered goods free ormade special arrangements for oldercustomers, or who sponsored local

events through cash payments or byproviding goods and services.

However, participants also identified anumber of areas where private serviceshave not been responsive to the needs ofolder people. The two mentioned mostoften were the new technologies,particularly automated banking andtelephone systems, and the reduction inface to face contact. It is not easy forpeople with loss of dexterity, hearing,sight or response times to use many ofthe new technologies, and many wereconcerned about or mistrusting of thesedevelopments. While some older peoplewere prepared to travel to find a familiarperson with whom they could dobusiness, most simply did not have thischoice and many expressed regret at theloss of branch offices that providedfamiliarity, personal recognition andtrusted advice.

Some older people also discussed theinappropriateness of many products forolder people. Examples includedtoothbrush handles that are too slim forpeople with arthritis to hold, and thesmall print on many products.Participants suggested that private firmsshould consider providing aids such assmoke alarms and telephones with lowfrequency rings, as well as cheaper legalfees for older people wanting to movehouse. As one man said: “If they wantour pittance make the products suitablefor our use.”

A number of contributors suggested thatgreater representation of older workersamongst staff would enhanceunderstanding of the needs of olderclients. Older people and key informants


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agreed that encouraging positiveattitudes to older workers and havingfamily friendly workplaces thatacknowledge the care needs of olderrelatives, not just children, are importantin supporting the independence of olderpeople.

Private sector firms and non-profitbusinesses could also do more to portrayolder people in advertisements in apositive way and provide greatersponsorship for activities that includeolder people.

Local government

This study did not review localgovernment policies to any great extent.However two trends were evident. Firstly,older people were generally positiveabout and appreciative of theimprovements being made at the locallevel to make amenities suitable forpeople with impaired mobility or otherdisabilities. They acknowledged thebenefits to their independence. On theother hand, in many areas, localauthorities are reducing theirinvolvement in services that have beenimportant to the wellbeing of olderpeople, such as libraries and pensionerhousing, or are introducing user charges.Pressure to constrain rates increases,which many older people would support,is leading to councils to pull back onsocial support provision. Thecommitment of councils to providingsocial services appears to varyconsiderably.

Local authority policy will be critical tothe independence of older people in thefuture. Local authorities have a limited

range of funding sources available tothem. The most common, rates and usercharges, are not sensitive to affordabilityconcerns and can fall heavily on olderpeople. Local authorities could do moreto publicise rates relief schemes for olderpeople.

The risk for older people, if localauthorities have greater responsibility inthe future for funding services such astransport, is not that the local authoritywill be unwilling to provide the servicesbut that they, and other residents, will beunable to pay. This may increase thedisparities in transport and amenityprovision in different areas of thecountry. Transport is of great importanceto older people. If they do not providetransport systems themselves, localauthorities at least need to work withprivate providers to ensure that transportis available, accessible and affordable forolder people.

Local authorities can also assist theindependence of older people byendorsing supported housing initiatives,either their own or those of communitygroups. Local authorities that providelow cost or pensioner housing couldenhance the quality of this service byhaving a paid or subsidised warden orlive-in support person in each housingcomplex.

Local authorities may also considerstrengthening building codes to ensurethat buildings are user-friendly for olderpeople and keeping a register oftradespeople and community groupswilling to offer special rates for olderpeople.

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Local authority commitment to olderpeople can be reflected in a number ofways: involving older people in policy-making; supporting social services suchas resource and community centres,library services and recreation amenities;and continued attention to ensuring thatpublic areas are safe and convenient.

Central government

Government plays a key role in providingfor older people, both livingindependently and in residential care.Government expenditure on olderpeople is substantial, particularly in theareas of income support, health anddisability services. As the populationages, government expenditure in theseareas is predicted to rise. The cost of NZShas been projected to increase from 5.3%of GDP in 1996/97 to 10.7% in 2051, andthe cost of health and disability care torise from 5.9% to 11% of GDP over thesame period97.

Income

Under NZS policy, older people areguaranteed an inflation-adjustedpension, and this policy is expected tocontinue. This pension is supplementaryto any other income or assets they ortheir partner receives, and is set at a levelto provide a modest income for day today expenses.

NZS is not designed to provide for all ofthe additional costs of illness anddisability that occur with increasingfrequency as people age, but vary fromindividual to individual. Currently, thesupplementary assistance available to

meet additional costs, the DisabilityAllowance, Community Services Card,Accommodation Supplement, andSpecial Needs Grants, are all targeted ona slightly different basis to people withlow levels of additional income.Assistance with the costs of residentialcare is more tightly targeted and notavailable to people with more thanmodest assets. These policies are not wellintegrated together, nor are they wellintegrated with other subsidies in thehealth and disability sector.

Over the medium term, the work of theRetirement Commissioner in promotingprivate savings can be reinforced throughdeveloping policies that leave anincentive for people who can to save, sothat they share the costs of old age withgovernment. As raised earlier, olderpeople considered the risks of theirsavings eroding due to high additionalcosts to be unfair. The OECD argues thatthe need for governments to contain thecosts of an ageing population requiresnot just shifting costs to privateindividuals, but doing so within aframework that enables older people tohave adequate and equitable access tohealth and care services, lifelong learningand income security. Policy thereforeneeds to ensure that those who do savedo not then have their savings exposed toan uninsurable risk should they requiresubstantial amounts of care.

Government support for thedevelopment of feasible and attractivepolicies that enable older people torelease equity from their homes either

97 cited as general conclusions of government modelling work in “A wake-up call: The ISI report onRetirement Savings”, Investment Savings and Insurance Association of New Zealand Inc, June 1998


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for living, for home maintenance or tobuy aids such as mobility scooters, couldhelp older people make the best use oftheir assets. Similarly, the promotion ofprogrammes to assist older people withmanaging their finances and establishingEnduring Powers of Attorney couldreduce levels of dependency.

Health and disability support provision

As discussed above, the most criticalissues that emerged for centralgovernment in this area were the need toimprove the co-ordination of health,disability and welfare services for olderpeople, and the need for acomprehensive strategy to train, support,and relieve carers. Older peoplethemselves made a number ofsuggestions for improvement:

Partnership and co-ordination

■ Having funding agencies and ministrieswork together more to co-fundinitiatives.

■ Co-ordinating health and welfareservices better so that individuals’needs are met more quickly.

■ Encouraging health and welfare agenciesand community groups to talk to eachother and sort out their strategies andprovisions, perhaps through protocols.

■ Giving greater recognition to thevoluntary contribution of older peopleand community groups through morerespectful and genuine partnerships,and provision of stable funding.

■ Streamlining application andaccountability procedures for smallgroups and groups receiving smallgrants.

The Older People’s Health Forum98 andAge Concern New Zealand haverecommended the development of anintegrated strategy for older people. Intheir view, this should include a separatepolicy and planning unit within theMinistry of Health for services for olderpeople, rather than the current splitbetween disability support services,mental health services, and personalhealth services. The lack of integration offunding for acute medical or personalhealth needs with funding for mentalhealth or disability support has beenidentified as a barrier to maximisingindependence at home. Extra costs forDSS result from delays in surgery.Integration contains the promise of costeffectiveness as well as improving thequality of life for older people. Integratedapproaches are needed not just betweenhealth and disability services, but alsowith income supplements, such as fordisability or housing, and with voluntaryand community services.

It may be possible to manage fiscal riskand improve the health status of olderpeople by generating more goodwill withfamilies and community organisationswho are partners in care provision. Thiscould also lead to more flexible andresponsive opportunities beingestablished at a local level. Older people,older carers and family members allsought more generous support for familycarers both directly and through theprovision of support services.

The government may consider othersuggestions made by older people,

98 Older People’s Health Forum, 1998

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including making expenses associatedwith care fully tax deductible, andfunding early intervention for ailmentssuch as cataracts and hip replacements.Early intervention would not onlyimprove older people’s quality of life andability to remain independent but alsosave costs of home support and hospitalcare at a later stage. Subsidised care inrest homes for people who have been illwould allow older people to move out ofhospital more quickly but to still receivethe support they need before they arewell enough to return home. Olderpeople also sought greater flexibility inthe provision of home care services.

Housing

There is little focus in current policy onthe costs that flow to the governmentfrom premature entry into residentialcare by older people who live ininappropriate housing. Nor is muchknown about the cost-effectiveness ofinterventions that assist the supply ofgroup housing and public housing, or letpeople spread the costs of housingmodifications that enable them to stay athome.

The biggest policy challenge in housing isto find ways to ensure older people withlimited means can access a wider rangeof housing choices. In particular, theyneed more choices that provide fordegrees of supported or assisted livingthan currently exist at an affordable pricefor them. A lack of research means it isimpossible to know to what extent this“supply gap” is a persistent problem, or atemporary lag.

The different subsidy regimes and serviceboundaries for care provided in homes

and for care provided in residentialsettings also appear to be a barrier tooptimising living arrangements. As in thestate of Oregon, the best results bothfiscally and in terms of older people’sindependence may be achieved throughcreating seamless subsidy streams forcare, and on the same basis at home as ininstitutions.

Well-maintained and safe homes providehealth and quality of life benefits to olderpeople. There are a number of voluntaryand private sector initiatives that assistolder people to maintain and modifytheir homes, however there are barriers,in particular accessing finance. Policyaddressing this area, perhaps using homeequity as collateral for loans, could becost effective through the resultant healthbenefits.

Transport

Poor transport and limited localamenities can have immediatedetrimental effects on the standard ofliving of older people, and flow onto thepublic sector as premature needs foracute health services, home-basedservices and residential care. A “handsoff” approach to these policy areas mayexpose central government to excessiverisk. The links between public transport,local amenities, and health need to bebetter understood.

Forms of publicly accessible transportwill need to be available if older NewZealanders are to live independently. Thelack of public transport and the high costof taxis emerged as critical issues forcorrespondents, focus groupsparticipants and key informants in thisstudy. While sheer numbers of older


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people and their increased concentrationin certain areas may generate enoughdemand to ensure public transport isnot just viable but regularly available,we cannot be sure this will always bethe case.

The proposals in Better Transport, BetterRoads will effectively place responsibilityfor subsidising transport at the regionalauthority level. It would be useful toconsult with regional councils as to howthey plan to meet the needs of olderpeople should these proposals come intoeffect.

Work

As an employer, government could takethe lead in providing work opportunitiesfor older workers and exploringopportunities for leave provisions to carefor older relatives.

Changes that make it easier for olderpeople to work, and support them whenthey do, are likely to be good for theeconomy as well. The ageing of thepopulation means that New Zealand, likemany other OECD countries, may haveits growth constrained if it doesn’t makeprovision for more older, skilled workersto remain in the workforce. This is likelyto mean having flexible approaches totraining and retirement, and being ableto make different choices around hoursof work.

Cross-sectoral issuesCo-ordination and partnership

The desire for greater co-ordinationbetween health and welfare agencies anda stronger partnership with communitygroups has already been discussed. Manyparticipants in the research were also

frustrated by the division ofresponsibilities between centralgovernment agencies as a whole, andbetween central and local government.For example, one group identified healthand well-being benefits from a recreationand home-visiting programme, but theywere not eligible for any health funding.Others talked of the frustration of tryingto obtain services for clients whenfunding came from different sources.One key informant with considerableexperience in applying for grantscommented:

“Government talks co-operation andintegration but doesn’t do it. If youmake a funding application you haveto be very careful. If you ask for thewrong thing, you miss out. They needto co-fund things – they and we have tobe able to be flexible, to respond to need.”

Older people themselves were aware thatgovernment on its own cannot achievesuccessful ageing. They were quick toacknowledge the part that individualsmust play in maintaining their ownhealth and well-being. At some pointthough, most older people do need somesupport, and while this may be fundedeither through central or localgovernment, it has to be delivered locally.As one person commented:

“Much of supporting independence hasto happen locally. It is about peoplestaying in touch, going out and beingpart of the community.”

This requires co-operation at all levelsand supports the argument for acoherent strategy on ageing. This would

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provide an opportunity to build apositive, longer-term approach to theageing of the population that wasbroadly regarded as sustainable and fair.Flexibility and partnership may wellprove to be the best way to manage thefiscal risks, and risks of social discord, ofan ageing society.

Research

This report and others have identifiedthat problems such as poor housing,inadequate support for family carers, andpoor transport infrastructure cantranslate into higher costs in other areas,particularly health and ACC. There is ascarcity of research investigating the linksbetween policies and independence forolder people.

We see a need for policy-orientedresearch that cuts across departmentaland local and central governmentboundaries, and a commitment toprogramme experimentation andevaluation.

Addressing Maori issues

While Maori generally have a positiveview of ageing and accord older peoplestatus and respect, the economicsituation of older Maori people is oftenpoor. With high levels of unemployment,younger Maori are not well placed tocare financially for older family membersor to plan for their own future needs.The expected increase in the number ofolder Maori people has policy andresource implications, particularly in theprovision of health services and housing.While several positive initiatives arealready in place, they need to beaugmented and supported by long-term

strategies and adequate resources.Developing policies and servicesappropriate to the status of Maori astangata whenua is an ongoing challenge.

Building a long termconsensus on critical issues

Governments in the future will facesignificant risks if population ageingresults in fiscal costs that are notsustainable, and the population is thendivided between the young and agrowing voting block of alienated olderpeople. A long-term commitment acrosspolitical parties will enhance the abilityof future governments, ensuringmaximum independence for olderpeople at a sustainable cost.

The two most expensive items ofgovernment expenditure on olderpeople, NZS and health and disabilitycare, are contested across politicalboundaries. The consequence of this isan uncertain environment for olderpeople, and for younger people planningfor their old age. It can be argued that theuncertain policy environment alsodetrimentally affects savings levels andprivate, voluntary and local governmentprovision of new services, such asalternative housing options.

The independence of older people, and asustainable environment for managingan ageing population, would be greatlyassisted by a “de-politicisation” of at leastsome core elements of these majorpolicies.

As discussed above, improvedresponsiveness will benefit more thanjust older people. For example, accessiblepublic transport in urban areas and rural


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communities is of concern for othergroups in the community. Having a senseof belonging and participating in thecommunity applies to unemployedpeople and parents of young families asmuch as to older people. Similarly,housing designs or modifications thatsuit older people will also suit manyfamilies with young children and peoplewith disabilities. Well-designed urbanareas and good security systems benefitall citizens. The same is true of havinggovernment, local authority andcommercial services that are easilyaccessible, customer-focused and “user-friendly”. In many instances, therefore,improving policies and services for olderpeople are a good investment, which willbring improvements to society as awhole. As a member of Grey Power said:

“If they live long enough, everybodygets old. While we are concerned withour own generation, we also considerourselves to be intergenerational aswhat is done for current policy will setthe scene for future generations.”

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Thorns, D. (1993). Tenure and wealthaccumulation: implications for housingpolicy. In P. Koopman-Boyden, (Ed.)New Zealand’s ageing society: Theimplications, Daphne Brassell AssociatedPress.


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Tilson, D. & Fahey, C. (1990).Introduction. In D. T. Tilson (Ed.), Agingin place: Supporting the frail elderly inresidential environments, Glenview Ill:Scott, Foresman.

Victoria Government (1997). Positiveageing newsletter of the aged care branch,Vol. 1, No 2, November 1997,Department of Human Services.

Viney, L., Benjamin, Y. & Preston, C.(1988). Promoting independence in theelderly: The role of psychological, socialand physical constraints, ClinicalGerontologist, Vol.8 (2), 3-17,

White, A. M. & Groves, M. (1997).Interdependence and the agedstereotype, Australian Journal on Ageing,Vol. 16, No 2, 83-89, May.

Wolinsky, F., Stump, T., Callahan, C. &Johnson, R. (1996). Consistency andchange in functional status among olderadults over time, Journal of Aging andHealth, Vol.8 No. 2, May, 155-182.

Yoon, G. (1996). Psychosocial factors forsuccessful ageing, Australian Journal onAgeing, Vol.15, No.2, May, 69-72.

http://www.sprc.unsw.edu.au/papers/dp75.htm (22/09/98) Dawning of a newage? The extent, causes and consequencesof ageing in Australia - paper presentedat the International seminar on ageingand the elderly in the context ofeconomic and social developmentin Asia.

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The terms of reference set out in therequest for proposals were for theresearch to:

• be positive, focusing on ways ofimproving older people’s ability tomaintain their independence andproviding empirical evidence of factorswhich can contribute toward this goal;

• gather and analyse New Zealand dataconcerning these factors;

• empirically investigate the identifiedfactors and provide evidence on theimpact and importance of the factors inassisting the maintenance ofindependence of older people;

• empirically investigate factors identifiedas barriers to older people maintainingtheir independence, and makerecommendations on how to removethese barriers;

• fill a gap in the New Zealand researchon maintenance of independence ofolder people, and not simply replicateprevious research;

• make recommendations for policy,service delivery and future research thatarise from the research, including anyinformation about the potential costsand potential savings to the Crown thatwould arise from the implementation ofany such recommendations.

APPENDIX I: TERMS OFREFERENCE


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Research Design

Information was gathered in four mainways:

1. A literature review to identify relevantfactors and the effectiveness ofinterventions. This included a review ofexisting New Zealand statistical andeconomic data.

2. Interviews with key informants workingwith older people or having expertise inthis area.

3. Focus group discussions with olderpeople in a range of situations.

4. Invitations to older people to contributeindividual stories to the study.

Literature review

The literature review discusses both NewZealand and overseas literature underfive main headings:

1. Factors that maintain the health ofolder people.

2. Environmental factors that help olderpeople maintain their independence.

3. Factors which make it more probablethat an older person who is ill or has adisability can live independently.

4. Personal services and other initiativesthat enable people to stay livingindependently.

5. Policy issues that are relevant to thegoal of maximising “ageing in place”.

The review also highlights barriers thatrestrict older people’s independence andexamines literature on the incentivesolder people have to invest inindependent living. The review usescensus data to identify significant trendsin the proportion of people living athome. It compares the circumstances of

men and women, and people in differentethnic, income and age groups. It alsodiscusses data on health expenditure oninstitutional and home-based care ofolder people.

Interviews with key informants

Interviews were completed withinformants working with older people orhaving expertise in this area. Theseincluded:

1. Lanuola Asiasiga, Pacific HealthResearch Unit, Whitireia CommunityPolytechnic

2. Sister Rae Boyle, Community TeamManager, Wesleycare Services for OlderPeople, Wellington

3. Janferie Bryce-Chapman, Age Concern,North Shore

4. Megan Courtney, Senior Policy Analyst,Waitakere City Council

5. David Dobson, Chairman, SeniorNet,Wellington

6. Pat Hanley, CCS, Wellington

7. Christabel Gibson, Ohariu Branch,University of the Third Age, Wellington

8. Sue Hine, Project Leader, RelationshipServices, Wellington

9. Gemma Kennedy, Clinical Coordinator,Taihape Rural Health Centre

10. Rihia Kenny and Charlene Williams, OraToa Health Centre, TakapuwahiaMarae, Porirua

11. Heather Maranui, Past President,Wairarapa Organisation for OlderPersons

12. Beverley Park and Shirley Marshall,Social Workers, Psychogeriatric Unit,Porirua Hospital, Wellington

13. Prof. David Richmond, AucklandMedical School, University of Auckland

14. Don Robertson, Grey PowerNew Zealand

APPENDIX II:METHODOLOGY

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15. Margaret Sander, Senior Social Worker,Elder Care Services, Capital CoastHealth

16. Verna Schofield, Lecturer in SocialWork, Victoria University of Wellington

17. Rebecca Thompson and JonathanMosen, RNZFB, Wellington

18. Betty Tierney, Coordinator, Older andBolder Group, Taihape

19. Di Valentine, Member, Board of GoodHealth Wanganui

The interview schedule which formedthe basis for most of these discussions isincluded as Appendix III.

Information was also gathered bytelephone and mail from governmentand local government officials and:

1. Chrissy Dallen, Total Mobility Services,Wellington Regional Council

2. Mrs D. Featherstone, CommitteeMember, Nelson Arthritis Association

3. Bruce Penny, Manager, Elder CareCanterbury Project

4. Hugh Simonsen, Abbeyfield Society,Nelson

5. Evan Thomas, Age Concern, Kapiti

Focus group discussionswith older people

Eight discussions were held with groupsof older people. Participants were invitedto discuss both the factors that help olderpeople maintain their independence andany barriers to achieving this. They werealso asked to make suggestions forimproving both policy and servicedelivery and in particular to identifyinterventions that they consider wouldbe cost effective.

The interview schedule which formedthe basis for these discussions is includedas Appendix III.

The focus groups included:

• Members of Older and Bolder, Taihape

• Residents of the Kapiti RetirementVillage, Paraparaumu

• Members of the Friendship Centre,Miramar, Wellington

• Members of the Salvation ArmyFriendship Club, Wellington

• A group of older Otaki people

• A group of volunteers at the BrooklynResource Centre, Wellington

• A group of older New Plymouth people

• A group of older Taranaki Maori people.

Fifty-one older people took part in thediscussions. Their ages ranged from themid-50s to the 90s. As might be expected,women outnumbered men - 36 womentook part in the discussions comparedwith 15 men. The discussions generallylasted about one hour and werefacilitated by one of the research teamwhile another took notes.

Invitations to older peopleto contribute individual storiesto the study

Information about the research was sentto 30 community newspapers fromKaitaia to Invercargill and included inthe information kit sent out by theSenior Citizens Unit. The research wasalso publicised through the newslettersof Age Concern and Grey Power and theRural Bulletin. Readers were invited towrite to the researchers identifying thefactors that have either helped themmaintain their independence or hinderedthem from doing so. The press release isincluded as Appendix IV.


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Seventy-three letters were received fromolder people and caregivers, along with anumber of emails, faxes and telephonecalls. A number of people includedadditional information with their lettersand six family members described theircondition in considerable detail. Of the73 letters, 18 came from men and 55from women. A third of respondents(26) did not give their age and three ofthis group wrote on behalf of someoneelse. Three were in their 50s, six in their60s, 17 in their 70s and 15 in their 80s.Five people in their 90s wrote in.

An item about the research was includedin a Local Government New Zealandnewsletter. It sought examples of localgovernment initiatives or innovativeprojects in providing services for olderpeople. Only one response was received;it described initiatives common to manylocal authorities, including supportingSeniorNet.

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Introduction

As part of its commitment to theInternational Year of Older Persons, thegovernment has commissioned researchinto factors that may improve the abilityof older people to remain independentand contributing to the community.Information is being gathered through aliterature review, interviews with keyinformants, focus group discussions witholder people and stories contributed byolder people and family members. Theresearch will contribute to governmentpolicy and help the government andother groups provide better services forolder people.

While we will list the people we havetalked to in the back of the report, wewill not identify comments individuallywithin the report. We will give you theopportunity to comment on the notes wemake from our conversation if youwould like this.

As background, could you tell me a bitabout your experience in this area, forexample, how long you have beeninvolved and in what capacity.

1. What do you see as the key factors thathelp older people to remainindependent – in your area of interest/overall? - Prompt as to why /examples ifnecessary

2. What do you see as the main barriers toolder people remaining independent – inyour area of interest/overall? - Promptfor why / examples where necessary

3. What can or should be done to increasethe independence of older people? Wehave a list, ranging from individuals tocentral government. Let’s begin with:

■ by individuals themselves?

■ by partners and other familymembers?

■ by members of the community?

■ by private firms and non-government organisations?

■ by local government?

■ by central government?

4. Are there different issues for people ondifferent incomes?

5. What do you think would be the singlemost cost-effective initiative thegovernment could take to increase olderpeople’s independence? Have you anyideas on how it could be funded or toensure it was good value for money?

6. Is there anything else you want to addabout helping older people remainindependent?

7. Is there anyone else we should talk to onthis subject?

APPENDIX III: KEY INFORMANTINTERVIEW SCHEDULE


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Introduction:

Welcome to this discussion. Thanks fortaking the time to join us to talk aboutwhat helps older people be independent.My name is _____________ and this is___________________. We’re doingsome research for the Senior CitizensUnit and the Social Policy Agency whichare both part of the Department ofSocial Welfare. They are doing this studybecause this is the International Year ofOlder Persons. They want to know:

• what (has) helped you stay independent?

• what has been hard for you? and

• what changes or improvements wouldmost help older people be independent?

We’re having discussions like this withseveral groups around the country. Wewant to talk to as wide a range of peopleas possible. We know you will all havehad different experiences and points ofview and that’s fine. We’re interested inwhatever comments you have. Thediscussion is confidential – no nameswill be included in the report.

The government plans to use theinformation to develop new policiesitself and encourage others to makechanges. Of course, we can’t guaranteethat they will pick up on all yoursuggestions.

Record number, gender of participants;age range

1. Can I begin by asking each of you whathas helped you to stay livingindependently?

2. Likely topics – facilitator or assistant towrite up – add new topics as required

Keeping healthy

Having positive attitude

Being valued as individuals

Having interests and skills

Personal safety

Change/technology

Family attitudes and behaviour

Appropriate housing

Enough money

Transport / being able to get around

Home support services

Health services

3. What has been hardest for you? – writeup/record as separate list.

Keeping healthy

Having positive attitudes

Being valued as an individual

Having interests and skills

Personal safety

Change/technology

Family attitudes and behaviour

Appropriate housing

Enough money

Transport / being able to get around

Home support services

Health services

APPENDIX IV: FOCUSGROUP DISCUSSION GUIDE

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4. Let’s follow up on some of the thingsyou’ve talked about as being difficult.With X (go through list), what do youthink would have a made a difference,so that you can/could have stayedindependent longer?

Possible prompts: attitudes, knowledge,social opportunities, responsiveness bybusiness/agencies, money, planning,informal/ formal services.

5. Finally, can each of you say what youthink would be the single most effectivechange the government could make tohelp older people stay independent?

6. Is there anything else you’d like to saywhile we’re here? Have we missedanything?

Thank you very much for coming.


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Helping Older PeopleRemain Independent ContributingMembers of Society

1999 is the International Year of OlderPersons. To mark this event, theGovernment wants to find out whathelps older people remain independentcontributing members of society.

The Government has asked us, as agroup of independent researchers, tocarry out the study which will help theGovernment and other groups providebetter services for older people. Aspart of the study we want to collectexamples of:

• barriers that make it harder for peopleto remain independent

• initiatives that help older people remainin the community and participate fullyin society

We know that a lot of things affectpeople’s ability to be independent.Changes in health are obviouslyimportant, but having suitable housing,help with looking after the home, andgood social, community and transportnetworks can also make a difference.We know that while older people do facebarriers, many individuals andcommunities have found creative andinnovative ways to enhance theindependence of older people.

Please tell us what helped you, a familymember, or an older member of yourcommunity, remain independent. Whathelped the most? What would have madea difference? Your stories will be totallyconfidential.

We will not print your name or anyinformation that will identify you in ourreport or pass your personal details on tothe Government or any agency.

Please send information to:Alison GrayGray Matter Research LtdPO Box 28 063WellingtonPhone/Fax 04 475 9406Email: [email protected]

We would love to hear from you.

APPENDIX V:PRESS RELEASE

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1. Attitudes to ageing

The Task Force recommendedestablishing flexible approaches toworking life, education, care giving andretirement, prohibiting compulsoryretirement and communicating positiveand diverse images of old age.

2. Planning and preparation

The Task Force supported anenvironment where people can plan andmanage their own futures. This wouldrequire the integration of governmentpolicies and services, more educationabout life planning, and opportunitiesfor lifelong education, spiritual growth,fitness at all ages as well as improvedaccess to community and health services.

3. Managing resources

The issue here is to raise skill levels inNew Zealand and increase understandingof the ways in which paid and unpaidwork is connected to overall wellbeing.The Task Force recommended freeing upworkers for voluntary activity, careerplanning and skill acquisition throughlife, greater use of mentoring schemes inbusiness and involving all ages in schoolsand creative endeavours.

4. Policy developmentand service delivery

The Task Force had four majorrecommendations in this area. They werestrengthening the policy vote for seniorcitizens, strengthening research and data

APPENDIX VI: A SUMMARYOF THE RECOMMENDATIONSOF THE PRIME MINISTERIALTASK FORCE ON POSITIVEAGEING

analysis on positive ageing and olderpeople, rationalising funding ofgovernment community services forolder people, and greater consistency inthe delivery of health care to olderpeople.

5. Experiencing positive ageing

The Task Force recommended a numberof actions to achieve greater appreciationof diversity, and strongerintergenerational and voluntarycommitments. These included resolvingTreaty grievances, creating more culturaland educational opportunities andexpanding programmes that assist peopleto stay in their own homes. Townplanning, housing, transport and localamenities should integrate the needs ofdifferent age groups, the status ofvolunteer workers and unpaid carersimproved, and government-communitypartnerships strengthened.


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II

III


ACKNOWLEDGEMENTS

We would like to thank all the older people who contributed to this

report, through letters, discussion groups and interviews. We

appreciated their time, good humour and passion. Thank you, too, to

the key informants who gave generously of their time.

Huia-ngarangi Lambie ran two discussion groups in Taranaki and Liz

Mortland and Betty Tierney of the Taihape Rural Education Activities

Programme were welcoming and informative hosts. A number of

individuals helped arrange groups of older people for us to meet with

and we are grateful for and appreciative of their efforts.

We also want to acknowledge the support of Sue Bidrose of the

Research Unit, Ministry of Social Policy and Jenni Nana, of the

Senior Citizens Unit.

We hope all the contributors find the finished report interesting

and satisfying.

Máire Dwyer

Alison Gray

Margery Renwick


IV

V


PART I: INTRODUCTION .............................................................1Introduction ................................................................................................................... 1

The context ..................................................................................................................... 1

The research project ....................................................................................................... 2

Literature review .............................................................................................................3

Empirical research ..........................................................................................................4

Suggestions for change ...................................................................................................4

PART II: SUMMARY OF RELEVANT LITERATURE ...................................5Factors that maintain the health of older people ..........................................................5

Environmental factors that help older people maintaintheir independence ........................................................................................................ 7

Factors which make it more probable that an older personwho is ill or has a disability can live independently ......................................................9

Personal services, and other initiatives that enable peopleto stay living independently ......................................................................................... 11

PART III: RESEARCH REPORT...................................................... 14Introduction .................................................................................................................. 14

Personal factors that affect the independence ofolder people .................................................................................................................. 15

Environmental factors that affect the independenceof older people .............................................................................................................. 30

Services that help maintain the independence of older people .................................. 44

Summarising the issues for Maori ............................................................................... 56

PART IV: SUGGESTIONS FOR CHANGE ........................................... 58Critical support issues for older people ....................................................................... 58

Service and support - issues and gaps ......................................................................... 59

Sector roles in the maintenance of independence in old age ..................................... 63

Cross-sectoral issues ..................................................................................................... 70

BIBLIOGRAPHY...................................................................... 73APPENDIX I: TERMS OF REFERENCE.............................................. 81APPENDIX II: METHODOLOGY..................................................... 82APPENDIX III: KEY INFORMANT INTERVIEW SCHEDULE ....................... 85APPENDIX IV: FOCUS GROUP DISCUSSION GUIDE .............................. 86APPENDIX V: PRESS RELEASE .................................................... 88APPENDIX VI: A SUMMARY OF THE RECOMMENDATIONS OFTHE PRIME MINISTERIAL TASK FORCE ON POSITIVE AGEING ................. 89

TABLE OF CONTENTS


VI

Documents

Factors affecting the ability of older people to live ... · PDF fileFA CTO RS AFFECTING THE ABILITY OF OLDER PEOPLE TO LIVE INDEPENDENTLY ... FA CTO RS AFFECTING THE ABILITY OF OLDER