Institutional ageism

The NHS was famously set up to look after people from cradle to
grave. It was designed to give people of all ages a service which
was – for the most part – free at the point of use. However, the
initial sense of security which it offered to young and old alike
has been somewhat eroded by fears that older people are not always
able to access services on the basis of clinical need alone and on
equal terms with younger people.

The King’s Fund has been engaged for some time in looking at age
discrimination in health and social care.1 A King’s Fund
survey of senior managers working in health and social services in
2001 found that three out of four believed age discrimination
existed in some form in services in their area.2 There
have also been concerns that access to some forms of treatment has
been based on age rather than clinical need. In social care, cost
ceilings for older people’s services have frequently been lower
than those for younger adults, and residential care has too often
been seen as the best option on cost criteria rather than on the
basis of individual needs and preferences.

Given these growing concerns, it was particularly welcome that the
National Service Framework for Older People set rooting out age
discrimination as standard one, stating: “NHS services will be
provided, regardless of age, on the basis of clinical need alone.
Social care services will not use age in their eligibility criteria
or polices, to restrict access to available

Scrutiny groups have been set up across the country to look at
possible age discrimination. Their membership includes staff from
health and social care organisations, voluntary organisations and
individual older people. Their initial audits of policies revealed
few examples of blatant age discrimination, but they highlighted
awareness of subtler forms of age discrimination. This is not
surprising as organisations do not usually intend to discriminate,
and when they do so it is more often a reflection of ageist
attitudes than deliberate policy. Identifying age discrimination is
a new challenge and organisations may not know what to look for. It
may take time for people to develop skills in this area.

The King’s Fund has produced a guide to help those involved with
auditing age discrimination at a local
level.4 It offers advice on how to
gather and assess evidence of age discrimination and how to make
change happen. The guide asserts that older people themselves have
a central role in highlighting age discrimination. However, the
ways in which this might be done are not necessarily self-evident.
Enthusiasts who rushed in with questionnaires about age
discrimination tended to find that the answers were not necessarily
very helpful. It is worth reflecting on why this is so.

One of the main reasons may be that ageism and age discrimination
are not particularly well understood or recognised, at least in
comparison to discrimination on other grounds such as race, gender
and disability. Also, it is not easy to formulate questions which
capture the subtlety of age discrimination. Older people themselves
may not know for certain whether they are being discriminated
against, or whether such discrimination is based on age. If they
find services unsatisfactory or feel that waits for admission are
too lengthy, they may have no way of knowing whether their
experiences might have been different if they were younger, or
whether the services are simply not good enough for anyone of any
age. It is even more difficult for an individual to know whether
decisions about suitability for treatment are being made on an
age-related basis or on evidence-based clinical grounds. If a
treatment is simply not offered or a referral to a specialist is
not made because of some arbitrary age criterion, an individual
older person would probably have no way of knowing that this was so
as it is unlikely that such age discrimination would ever be

However, while direct questions may not hit the mark, older people
do have a great deal to say about access to services and the
quality of those services. They and the health and social care
staff who look after them can make an enormous contribution to
putting together the pieces of the jigsaw and enabling a judgement
on whether the picture shows age discrimination. Scrutiny groups
would do well to use a range of methods as no single approach can
reveal all aspects of the picture. Statistical data needs to be
complemented by older people’s experiences in order to understand
the combined impact of policy and practice and to see the impact of
both direct and indirect discrimination.

Older people may wish to give their views in a variety of ways. In
addition to the direct involvement of older people on scrutiny
groups, much can be done locally to seek the views of older people
through focus groups or discovery interviews. It is also useful to
go out to groups and voluntary organisations where older people are
meeting. Teleconferencing and telephone interviews offer
interesting options for seeking frail older people’s views.

Information about older people’s experiences can also be gleaned
from material that is collected for other purposes such as data
about complaints and untoward incidents. Direct observation may
reveal ageist attitudes, or poor environments for care. Research
projects can also bring to light unfair resource allocation, skill
mix, facilities or other variables that may adversely affect older
people’s treatment and care.

Older people can often highlight ageism from their personal
experiences. There are often bitter complaints about condescending
forms of address, such as “dear” or the inappropriate assumption
that all older people are happy to be addressed by first names. For
many people, the practice of distinguishing – as many organisations
do – between services for “adults” and services for “older people”
is offensive. Older people are adults and unless they are
recognised as such, discrimination is almost inevitable.

In many health and social care organisations, tackling age
discrimination is still accorded a relatively low priority, in
spite of the National Service Framework, particularly as there are
so many urgent and more politically sensitive “must-dos”. In
addition, staff and older people may themselves have ageist
attitudes, of which they may not be aware, and this can get in the
way of change. Most important of all, there is often a real fear of
the resource implications of eradicating age discrimination.
However, this cannot be allowed to act as a barrier to incremental
change to put right what is shown to be unfair and unjust.

The King’s Fund has identified a number of principles to work
towards the eradication of age discrimination. The principles
combine the need for urgent action with a longer term strategic
overview. This approach was described by one scrutiny group member
as “think big, start small.” It is essential to empower front-line
staff to make changes which counter age discrimination. Some will
be ready, willing and able to do this and others may need training
to increase their awareness and understanding of age

If health and social care services are to command the trust of the
whole population, all forms of discrimination and unfairness must
be challenged, and action must be taken to provide a needs-related
service that properly reflects diverse circumstances and
preferences. Tackling age discrimination is a cornerstone of this
approach – and one from which we may all expect to benefit.

Ros Levenson is a visiting fellow at the King’s


1 E Roberts, Age Discrimination in Health and Social Care – a
Briefing Note (available at www.king, 2000

2 E Roberts, J Robinson and L Seymour, Old Habits Die Hard –
Tackling Age Discrimination in Health and Social Care, King’s Fund,

3 Department of Health, National Service Framework for Older
People, 2001

4 R Levenson, Auditing Age Discrimination – a Practical Approach
to Promoting Age Equality in Health and Social Care, King’s Fund,
Price £15 (voluntary organisations £7.50), 2003.
To order visit the King’s Fund bookshop website on,
or telephone 020 7307 2591.   

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