Welcome to the Equalities and Ageing digest, part of the transition and legacy work of the Equalities Board team. Each month from April to October we will take a look at a topic of interest to older people and look at it from an equalities perspective. We aim to show how different forms of discrimination can cross over and create a deeper experience of inequality.
We know from supporting the Equalities Board that age, experience and history can create collective wisdom. So this digest also aims to highlight how marginalised communities respond to discrimination and inequality.
We make a PDF of each issue of the digest and a PDF of a simpler summary that is also in our monthly bulletin.
Published most recent first - scroll down for Digest #2 - Housing, Inequality and Ageing, and Digest #1 - Covid-19 Unequal Impacts
Equalities and Ageing Digest #3
Health, Social Care, Inequalities and Ageing
In our latest inequalities and ageing topical digest we look at health and social care. The GM Older People’s Network has made nine recommendations for ensuring that health and social care provision is age friendly. These recommendations are about ensuring that everyone has good access to health and social care services as we age. However, some people already have less access to these services than others, and enjoy less good health than other people because of social inequality.
In our first Equalities Digest #1 – Covid-19 Unequal Impacts, we looked specifically at how the virus was affecting people from different social groups differently. We wrote our digest in the early days of lockdown. These differences have become more and more apparent since then. Even before Covid-19 it was evident that poverty causes poor health. Now Independent Sage, a group of scientific advisers set up to offer independent analysis of the Covid-19 situation, has reported on the different impact of the pandemic on BAME communities. The report argues that structural racism is likely to have an effect on infection and rates of death due to systematic inequality affecting all aspects of life for people from BAME communities. For example, in our digest on housing and inequality we mentioned the connections between poverty, housing and health.
Health inequalities have been known about for a long time. They are defined as “avoidable, unfair and systematic differences in health between different groups of people”. They can involve a variety of factors, including differences in access to health and care, differences in quality of care, risks arising from behaviours, genetic risks for specific conditions. However, a major factor, which can affect and be affected by all these others, is what is known as “broader [or wider] determinants of health”. This term refers to the impact that wider social factors such as the economy, work, education and the environment can have. These factors have more influence on staying healthy than access to healthcare has. The variation in these factors results in individuals having different resources to meet their needs, and deal with change.
In 2020 the Marmot Review update found that life expectancy had not increased since the original report in 2010. The report concluded that: “Health is closely linked to the conditions in which people are born, grow, live, work and age, and inequities in power, money and resources – the social determinants of health.” It found that differences between life expectancy in the poorest and richest areas of England had increased. The gap in healthy life expectancy is even wider – people in poorer areas on average spend nearly one third of their lives in poor health, compared with only one sixth for people in the richest areas. Now Greater Manchester aims to become the first Marmot City Region. The GM Health and Social Care partnership will tackle social inequality to reduce health inequality across the region.
Most of the existing evidence about health inequality relates to economic inequality - there is a need for more research about health inequalities for BAME and LGBT communities and disabled people. The available evidence shows older people from marginalised communities are doubly affected. As well as being affected by social factors, they may be doubly disadvantaged in accessing health care because of age and discrimination. Disabled people may face additional discrimination from policies to deliberately “ration” healthcare according to assessments about quality of life. This has happened during the Covid-19 pandemic, when NICE issued guidance to doctors about how to choose whether someone should be given critical care support.
Inequality means that some marginalised groups, most notably homeless people and people with learning disabilities, also have significantly shorter life expectancies.
Inequality may also be a direct cause of ill health. Minority stress is the additional stress that members of marginalised groups experience due to prejudice and discrimination. For example, minority stress caused by racism affects mental health within BAME communities, in addition to social inequalities and other factors.
There have been concerns about the funding and quality of social care for some time. There is increasing demand for social care, but a short supply of good quality care that is affordable. This impacts everyone growing older, but particularly those ageing on lower incomes, and for disabled people growing older and their carers. The neglect of social care and care home residents has been highlighted by the pandemic crisis, and led to increased calls for reform. However, the Coronavirus Act included a provision to allow local authorities to suspend some rights in the Social Care Act 2014, and eight local authorities have so far done this.
Culture, language and communication can be a barrier to accessing the right social care, as well as health care. This can be a particular issue for people from some BAME and refugee communities, D/deaf people and people with learning disability or autism. It can result in poorer care, and increased isolation. Research into health and social care for older people from BAME communities in Greater Manchester found unfair treatment resulting in a lack of dignity for people. Overall, however, we found it much more difficult to find publicly available reports on inequalities in social care than in health care, suggesting that there is a need for more research into this. Ensuring equality in providing care services is important to make sure everyone gets better care – and it can be more cost-efficient, too.
Ways Forward for Social Care
Research and development of person-centred, community based approaches to providing health and social care are offering creative and effective new models for services. Personalised care, which takes account of people’s identities and preferences, is essential for meeting individuals’ particular care needs. It takes a holistic approach and can ensure that people have more independence and wellbeing within strong, resilient communities. Community capacity building approaches, such a s community navigators, peer support, and shared lives, support personalised care planning. They can save the NHS and social care systems more money than they cost. Co-production, with its core values of equality, diversity, accessibility and reciprocity, can help in developing better social care. It has a role to play in the care system itself, and also in community capacity building. It is now built in to social care planning since it was included in the guidance for Local Authorities on implementing the Care Act 2014. There are now many new community-based models of care.
Equalities and Ageing Digest #2
Housing, Inequality and Ageing
The picture of housing
The quality of housing makes patterns of social inequality highly visible. In fiction and non-fiction writing, descriptions of housing are often used to tell readers about the context of poverty, inequality and diversity of the story or article. Sometimes this language is a kind of code specifically about race. On TV the introductions to Coronation Street and Emmerdale tell viewers not just where the stories are set, but also give clues about class and the types of community in the stories.
Our second Equalities and Ageing briefing looks at equalities issues in relation to housing for older people. The Greater Manchester Older People’s Network (GMOPN) Insights and Recommendations report has made three recommendations about appropriate housing for older people. They say that housing must be of good quality, must be part of and contribute to inclusive neighbourhoods, and should adapt to people’s change needs as they age.
Black and ethnic minority communities experience housing deprivation at much higher rates than white British community. They are more likely to live in lower quality housing because of current inequality, and because of historic discrimination and economic disadvantage. This has resulted in communities living in clusters of deprived and often inadequate housing. Increasing numbers of older people are living in private rented sector housing, which is often inadequate, and not adapted to their needs. BAME communities are more likely to be in the private rented sector, where more housing is of poorer quality housing and there is less security of tenure.
Some BAME communities have higher rates of living in multigenerational housing. Although this may be a cultural preference, the lack of appropriate family housing makes these communities more likely to live in inadequate housing as multigenerational living may not always be by choice. Those who have arrived in the UK more recently are much more likely to live in inadequate housing, and this disproportionately affects BAME communities – as the Grenfell Tower fire revealed.
Disabled people, both newly disabled in older age and those who age with impairments or chronic illness, are also disproportionately likely to be poorly housed. Poor quality housing causes or exacerbates many chronic health conditions. Due to the lack of accessible housing older disabled people remain trapped in inappropriate housing as their impairments worsen. In addition, application and assessment processes are often difficult to access.
Unequal housing also creates unequal risk of COVID-19 infection - poor quality housing can cause and exacerbate conditions which place people at higher risk of severe illness, and crowded housing with little access to outdoor space increases the chances of being infected.
For older LGBT people housing safety is also about being free to be who you are, and having your identity valued and respected. Many older LGBT people find themselves going “back into the closet” when they enter a care home, for fear of discrimination from staff or other residents.
Homelessness is also related to inequality, as it is both an unequal experience and a more common experience for people from marginalised communities. BAME families form a disproportionately high percentage of homeless household cases, and BAME people more likely to be in the uncounted / non statutory “hidden homeless” population. Almost one in five LGBT people have experienced homelessness during their lives. The figures are higher for trans people, LBT (lesbian, bisexual or trans) women, disabled, and poor LGBT people, demonstrating the effect of intersectional discrimination. Homelessness is implicated in poorer outcomes in later life, and can cause long term health problems and a shorter life expectancy.
Housing is an important factor in creating and sustaining safe, accessible, inclusive neighbourhoods.
Appropriate housing is well located. For disabled people of all ages, neighbourhoods have to be safe and accessible in order to live independently, be able to meet with friends and family, get to shops and services, and be free from harassment. The Equalities Board “Ageing Equally?” research projects found that hate crime is a major concern for a number of marginalised communities, including people with enduring mental ill health and recent migrants.
Safety is a key consideration for older LGBT people, one-third of whom do not feel safe in the areas where they live, according to Houseproud. This figure rises to nearly two-thirds for trans people. Where over 80% of general survey respondents felt they belonged in their neighbourhood, only just over 40% of LGBT Houseproud survey recipients answered the same way.
BAME communities have experienced unequal effects of poor planning and regeneration. Gentrification of estates has led to dispossession and breaking up communities, impacting on the resilience of individuals and communities, and increasing the risk of social isolation for older people.
The increase in private renting among older people has implications for loneliness and social isolation, particularly for those with more fragile social networks and at higher risk of isolation. There are many reasons for this, including lack of secure tenure forcing people to move and undermining their local social relationships, and being unable to have pets. Some local AfA projects found it easier to connect with tenants in social housing, underlining the likelihood of social isolation for people in private rented accommodation. The cost of private rented housing is at an all time high, albeit there are sizeable regional variations in cost, with implications for financial exclusion for the 10% of private renters who are older people. Fresh research into the financial effects of coronavirus particularly on younger older people raises concerns that this could be an even bigger problem in the future.
For many people safety and security is a home that you don’t have to leave as you age. Government policy can have a big impact for working age older people on benefits affected by the Bedroom Tax. Those affected may struggle to find alternate housing appropriate for growing older, due to the lack of accessible housing currently available and planned.
The lack of accessible housing negatively affects individuals’ mental wellbeing, forcing people to remain in unsuitable accommodation, and also undermines the creation of inclusive neighbourhoods and safer social spaces. Poorer disabled people, who are likely to disproportionately include disabled people from BAME communities, are less able to navigate the systems to get the housing they need.
Solutions and responses
There is a long history of BME-led housing organisations, which have sprung from community initiatives to meet housing need that is not well-understood by mainstream service providers. Work will soon start on the first LGBT-specific extra care home, in Manchester. Self-organised community-led housing may also be an option for those with capacity and access to economic and social support. In some areas, local authorities are supporting co-housing for seniors and other community housing schemes specifically for older people. Equalities initiatives within existing housing schemes address the needs of minority community residents, such as LGBT people with dementia. In addition, national and local organisations, and tenants and residents associations are calling for more and better quality social housing, and Age UK has produced this guide for older private renters.
In the same way that Coronavirus has highlighted health inequalities, it has shown up housing inequality, with issues of overcrowding, affordability of housing on benefits, and homelessness becoming important in public policy discussions. “Building back better” means looking at a fairer housing system for all, that will meet people’s lifetime needs.
Equalities and Ageing Digest #1
Covid-19 Unequal Impacts
A common way to understand inequality is to think about people being in different boats on the same sea. But this image doesn’t allow us to understand the intersection of different experiences and identities, or how individual or collective capacities for resilience may affect the experience of inequality. The Equalities Board has always focused on the intersection of ageing and inequality, but also other experiences of intersectionality.
We see this coronavirus crisis as a complex landscape, through which all of us are travelling on different roads, and which we are therefore experiencing and meeting in different ways. The differences in our journeys are due in part to the nature of the landscape, in part to the nature of the road beneath our feet, and in part due to our personal capacity for keeping going. Some of us are walking on a smooth road through a challenging mountainous area; others are picking their way along a pitted, unclear path that is nevertheless flat and direct; others are confidently navigating a moderately challenging journey through delightful scenery. You get the picture.
The coronavirus has pushed the inequality in the UK into the spotlight. The first six health workers to die, and the London bus drivers who have died were all Black or Asian. Disabled people’s rights were reduced in the Coronavirus Act. People who are homeless, overcrowded, or not safe at home were instantly placed in greater danger by the lockdown. It is clear that the coronavirus crisis is as much social as medical and has laid bare historic inequalities.
In this brief overview, we look at four key aspects of the Covid-19 crisis, and some of the evidence that they have disproportionate impacts for marginalised and minority communities. We also highlight some of the creative ways that marginalised communities have responded: to defend their rights, take care of themselves and the wider community, and raise awareness of the dangers of discrimination.
There has been much coverage of the higher rates of deaths among BAME communities, and the higher risks of infection and severe disease outcome. Certain working conditions carry higher risk of infection. Low-paid customer service and manual jobs often cannot be done from home and BAME people are more highly represented in these jobs. Jobs in transport are similar. Women and BAME people are more likely to be key workers, in caring, cleaning and shopworker roles, and therefore at higher risk of infection.
Higher density living situations increase the risk of catching the virus and BAME people are more likely to be living in higher density households, sometimes with several generations of one family living together, and in more crowded urban and inner city areas. People are also at higher risk of infection in prison, in mental health institutions, in homeless accommodation, and in immigration detention. BAME communities are more highly represented in all of these places.
Certain pre-existing health conditions make people more ‘vulnerable’ to more severe illness. These conditions include heart disease, high blood pressure, diabetes, auto-immune disease and lung diseases. Black and South Asian people are more likely to experience many of these conditions, due to health inequalities and a complex mix of social factors, including poverty. Some people with HIV / AIDS who have a high viral load or low CD4 count may be at higher risk. African people and gay and bisexual men are more likely to have HIV / AIDS. The LGBT community may also be more severely affected, due to higher rates of smoking, cancer or HIV, and barriers to healthcare.
Even among the general population there are higher rates of serious illness because GP surgeries are closed and we can’t go out. People who were already struggling to access healthcare, either because it is less available to them, or because of historic discrimination, are therefore even more at risk of serious illness. This includes LGBT people and BAME people. There are also reports that this affects people in care homes. Historic cultural barriers may also mean older men are at higher risk.
Unequal impact of social distancing and lockdown
Social distancing and lockdown rules affect people in marginalised groups in different ways. Poverty has been exacerbated by the lockdown – food banks are seeing a 300% increase indemand, and 1.5 million people have gone a day without food since the lockdown began. Incidences of domestic violence have increased – women and members of the LGBT community are at higher risk. The imposition of lockdown measures have created additional barriers for disabled people – reducing access to online shopping for those not categorised as ‘vulnerable’, and increasing isolation and exacerbating historic disadvantage for many others.
Unfair effects of government policy
People in marginalised and minority communities have also experienced more severe “knock-on” effects from the government’s policies to tackle coronavirus. The economic impact of the lockdown has been felt more severely by people on zero hours contracts, for example in the hospitality sector or other service industries, who in turn are more likely to be members of BAME communities, and be those with lower qualifications. Many of these people are ‘younger older’ people, and are likely to face greater difficulty in finding new employment.
The government’s hastily drafted Corona Virus Act 2020 has a number of human rights implications for disabled people and those with mental health conditions. The Act includes a change to require only one doctor’s decision to detain someone under the mental health act, weakening the rights of people with mental health conditions, which potentially impacts BAME communities more. The Act also allows for ‘easements’ to the Care Act 2-14, suspending the duty of local authorities to assess disabled adults and meet their care needs, replacing this with the ‘power’ to decide on care needs without assessment. At the time of writing eight local authorities had ‘switched on’ this option.
Increase in discrimination
From the early days of the pandemic in the UK, there have been incidents of direct discrimination and racism against Chinese people, while long-term discrimination against BAME communities is implicated in their higher risks of severe disease outcomes from Covid-19 infection. The labelling of older people and people with certain underlying health conditions as ‘vulnerable’ is deepening ageism and ableism. By ‘othering’ these groups of people it sets them apart from the mainstream population and portrays them as lesser members of society.
Marginalised communities have responded proactively to this multiple assault of the virus, the effects of measures to tackle it and government policy, and direct discrimination, in diverse creative ways. These responses have had benefits for others beyond these communities’ members.
The disabled community has a history of legal activism to fight discrimination and gain legal rights. Disabled people quickly mounted a successful legal campaign to change the NICE guidance issued to doctors to use “frailty scores” to decide who would be prioritised for intensive and life saving treatment. Building on their history of self advocacy, people with learning disabilities have responded to the blanket application of advance ‘Do Not Resuscitate’ orders with statements about the value of their lives. [insert link to PDF]
In many areas, the Muslim community responded to the emergency even before the statutory sector and mainstream voluntary sector organisations, as was seen after the 2015 floods in Rochdale and other places in the north west. This reflects the strong bonding capital that can be found in many minority ethnic communities, which can enable a community to meet its own needs and then reach out to others.
The LGBT community is historically experienced in meeting members’ health and support needs, famously during the early crisis days of the HIV pandemic. Early in the coronavirus pandemic the Queercare mutual aid group’s guidelines were used as a model for mutual aid organising across the country.
There is long experience in BAME communities of monitoring inequality and discrimination. A group called Charity So White has been monitoring the inequalities affecting BAME people, and quickly began offering practical recommendations for the voluntary sector to ensure that the root cause of discrimination and inequality are tackled.
A wider response
Equalities and human rights organisations have been raising awareness of these unequal impacts since the crisis began. They argue that we must both design equality and human rights in to Coronavirus response plans and also ensure that any emergency powers do not breach human rights. Now the Women and Equalities Committee of the UK Parliament has launched an inquiry into these issues.