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A new international approach
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In the context of global ageing societies, there are few challenges to the underlying assumption that policies should promote functional health and independence in older people and contain the costs of care. This important book offers such a challenge. It provides a critical analysis of the limitations of contemporary policies and calls for a fuller understanding of the relationship between health and care throughout the life-course. Located within the tradition of the feminist ethic of care, the book provides a fresh insight into global policy debates and the impact that these have on people’s experiences of ageing. Including international evidence on health inequalities, health promotion and health care, this book will be of interest to a range of social scientists, particularly specialists in gerontology and social policy.

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In this chapter, the tertiary level of health promotion is the focus and the link between health and care is seen most clearly. It is argued that at this point in history, the association between old age and death is at its strongest and that this has implications for how both ageing and death are perceived. In the context of long-term illness and at the end of life the need for care increases but socioeconomic inequalities are evident in older people’s access. Both formal and informal (family) care provision and the relationship between these two are discussed in different contexts. The conceptualisation of care in policies is critically examined and it is argued that in long-term care the inadequacy of policy agendas is starkly apparent, as seen in the reduction of the human need for care to managerialist agendas.

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The concluding chapter identifies the key issues that have arisen throughout the text and discusses the value of the ethics of care as an explanatory framework. It reflects on how the presentation of demographic trends has fed into the policy process to produce a policy agenda that is disadvantageous to older people. It is argued that the overarching policy priorities of promoting healthy and active ageing and containing the cost of care need to be challenged as a the basis for health and care policies in ageing societies.

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The debates and controversies surrounding the personalisation agenda that have already been identified in this text are clearly evident in the context of services for older people. The development of any policy can be understood as a battle of ideas in which there will be winners and losers (Colebatch, 2005). In this case, as Needham (2011b) has pointed out, the personalisation agenda has gained enormous popularity in the field of social care policy, having now become effectively ‘the only game in town’. However, the ambiguous nature of the concept effectively means that the battle of ideas is still continuing. On the one hand, personalisation is characterised as a revolution in social care, a wholesale cultural shift in the perceptions about how people who need support should be able to exercise control over how it is given. On the other, it is more prosaically seen in terms of the levels of implementation of personal budgets (PBs) and direct payments (DPs) to individual service users, which redistributes responsibility from the state to individuals. Since services for older people constitute more than half of social services expenditure (HSCIC, 2012), it is unsurprising that much attention is being paid to the implementation of personalisation in this sphere, although older service users appear to be less enthusiastic than others about PBs and DPs (Glendinning et al, 2008; Hatton and Waters, 2011). The pressure on councils to increase their uptake raises questions about whether older people are also under pressure to accept PBs or DPs, thus undermining the claims to increased choice and control that are made for them.

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The introduction sets out the main aims of the book, highlighting the complex relationship between ageing, health and care. It provides an overview of the theoretical orientation of the book, setting out the challenge to contemporary policy priorities for ageing societies and the importance of an ethic of care for this challenge. It also provides an outline of the organisation of the book.

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This chapter sets the scene for the subsequent discussion through a focus on global data on life expectancy, morbidity and mortality and a critical analysis of the production and presentation of these data. It provides a discussion of how the data have shaped ideas about ageing, health and care and have influenced global policy agendas. Key points explored include inequalities in health, dependency ratios and the compression of morbidity thesis. It is argued that there is a need for a better understanding of dependency and life expectancy and that, equally necessary, is a better understanding of the ethical complexities of inequalities in health and the extension of life expectancy.

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This chapter focuses on different ways of conceptualising health, care and the lifecourse. It discusses the critiques of biomedicine that have influenced thinking among gerontologists concerning the medicalisation of old age and analyses the concept of salutogenesis. The discussion of care is focused on the key points of a feminist ethic of care. Debates concerning the dichotomy between the Third and Fourth Ages are discussed. The complexity of the concepts of health and care highlighted in this chapter stand in contrast to the over-simplistic conceptualisations identified in the previous chapter as influential on policy-making.

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This chapter focuses on policies as continuous processes, characterised by conflicts of interest and the unequal exercise of power. It is argued that the presentation of demographic trends as a problem to be grappled with by policy-makers coincides with neo-liberal economic agendas to the detriment of older people. The impact of global-level liberalisation of markets and production on health and care policies is considered and a critical analysis is developed of the actions of global actors, including the World Bank, in shaping policies of direct relevance to the health and care of older people. The outputs of the UN and the World Health Organisation are also critically examined for their roles in the policy process and the impact these have on health and age-related inequalities. In this chapter the influence of the capabilities approach on policy-making for health is discussed and the relevance of age to equity in resource distribution is considered.

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This chapter is about secondary level prevention: that is, the restoration of health and alleviation of illness symptoms. It is argued that it is at the level that there is greatest commercial potential for health providers. Gross inequalities in access to health care at a global level are considered in relation to the migration of health workers from low- and middle-income countries to high-income countries. Examples of age-related inequalities and age discrimination considered include the neglect and abuse of older people within healthcare systems and the inadequate attention given to health conditions that affect older people disproportionately. Health care systems are increasingly attuned to the rise in chronic and non-communicable diseases (NCDs) but the imperative to contain costs impedes effective development. It is argued that there is a need for a better understanding of older people’s experiences of living with chronic illness and of the importance of age to illness experience.

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