THE EMPOWERMENT OF ELDERLY PEOPLE

PETER LLOYD* University of Sussex

ABSTRACT: Governments and their agents adopt a managerial approach to the delivery of social services. Professionals, voluntary workers, friends and kin all, in their own way and in pursuit of their own interests, promote the dependency of elderly people. Elderly people themselves, however, strive to retain control over their own lives, to maintain their independence. This contradiction or power struggle cannot be resolved; but it can be mitigated through overt recognition of it and the reflection upon patterns of interaction between the elderly person and those providing services and care.

COMMUNITY CARE: FROM IDEAL TO POLICY

The care of frail elderly people is now conceived, in Britain as in most industrial countries, as a social problem. For the individual, coping with increasing frailty has not changed much in recent decades-indeed advances in medicine and technology have probably alleviated many of the symptoms. But, collectively, care is now seen as responsibility of the welfare state-as a problem widely aired in professional and academic journals, promoted in the media and accepted as a cause for concern by the government. The change in attitude has not, however, been generated by the elderly people themselves. For decades voluntary organizations such as Age Concern and Help the Aged have campaigned on their behalf; it is only within the past three years that an Association of Retired Persons has existed in Britain to generate activity by the elderly people themselves. The crisis has arisen from the realization that the costs to the welfare state-through the National Health Service and Social Services-of care and support for elderly people are rising to an alarming proportion of the budget, much of this being attributed to residential care.

*Direct all correspondence to: Peter Lloyd, School of Social Sciences, University of Sussex, Brighton, East Sussex BNI 9QN, UK.

JOURNAL OF AGING STUDIES, Volume 5, Number 2, pages 125-135 Copyright @ 1991 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.

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The problem is expressed in terms of the increasing numbers in the population who are past the age of retirement-65 years for men, 60 for women. With increasing longevity far more people are living into their 80s. Thus, not only are there more elderly people, but they are older; and it is assumed that the periods for which they are extremely dependent will be correspondingly longer. This aging of the population is taking place at a time of low birth rates; so not only do elderly people constitute a larger proportion of the total population, but the ratio of working population to dependents-old and young-narrows.

As the number of elderly people grows, that of close kin who might be responsible for their care declines. The present cohort of elderly persons born in the twentieth century does not have the large number of siblings common to the Victorian families of their own parents. They in turn have had fewer children on whom they might depend. Their daughters are now working and reluctant or unable to forgo income and career to care for a parent; with one third of marriages now ending in divorce many daughters are no longer in stable households which can accommodate an elderly dependent; and with increasing longevity children are frequently retired and becoming frail themselves as the needs of a parent demand their attention.

The solution to this equation-more dependent elderly people, fewer carers-is seen to lie in community care. For two decades at least the phrase has heralded the answer to the social problem. In the English language the term has strongly positive connotations. The community is the small local neighborhood with a dense network of cozy and warm interpersonal relationships, and copious mutual support. In stark contrast are the geriatric wards of hospitals, now vilified as inhuman and impersonal in their treatment of long stay patients. But community care is widely interpreted. For some it denotes care in the community; elderly people (or the mentally impaired for that matter too) are moved into small units of accommodation within residential areas. Here, it is assumed, they will interact with their neighbors, fit into the community; in practice the establishment of such a “home” frequently precipitates protest from these neighbors who deem the tone of their street to be threatened. More widely accepted and promoted is care by the community. The emphasis today is upon enabling aging persons to continue to live in their own homes for as long as possible with the assistance of mechanical aids such as grab rails, stair lifts etc. alarm services and the help of a wide range of helpers-close kin and neighbors, workers from statutory services and voluntary agencies all contributing to an interlocking jigsaw of supportive activities. Such an idyllic picture of care can hardly fail to win widespread support.

The concept of community care is, however, expressed differently within rival and competing discourses. In one, a liberal discourse, the bureaucracy of the welfare state is accepted and the focus is upon control over and participation in its activities; elderly people are entitZed to services and should have greater voice in expressing their needs and ensuring that appropriate services are delivered with efficiency. In another discourse, a conservative one, the emphasis is on independence from the welfare state, which in its attentiveness stimulates over-dependence; we should learn to do more for ourselves. The traditional family and its caring role is extolled. Rather than control over the state apparatus, the focus is upon choice between state services and those offered both by the private and the voluntary sectors. Not far below the surface in this discourse is the assumption that the cost of community care is lower-lower, that is, for the state;

The Empowerment of Elderly People 127

for the increased costs to informal and voluntary carers is usually excluded from the account. Where these are totalled it is seen that community care is in fact a more expensive policy. Indeed by its very success are its costs further increased, for by improving the quality of life of elderly people it is assumed, with good evidence, that they will live even longer (Buie 1988). Opposition to community care comes from those who argue that, with declining state expenditure on welfare services and the unreality of the expectations of greater altruistic support from neighbors, the burden of care will fall, where it is usually fallen in the past, on daughters who receive minimal external support in their ascribed role.

While community care has been a buzz word for a long time, it is only recently that the government has taken it on board as an explicit policy. In 1986, the Audit Commission, a body which monitors the many activities of statutory local authorities, published a report Making a Reality of Community Care. One of the main targets of its criticisms was the fragmentation of service provision.

“For community care to operate these agencies must work together. But there are many reasons why they do not, including the lack of positive incentives, bureaucratic barriers, perceived threats to jobs, and professional standing and the time required for interminable meetings” (1986, p. 3).

The report, while admitting that poverty of care reflected a lack of funding, also emphasized that many elderly people were being cared for in institutional settings when “community care” could be provided at almost half the cost. What was needed was rationalization and collaboration. The government quickly responded by asking Sir Roy Griffiths to provide a blue print for action; Sir Roy, a Deputy Chairman of one of Britain’s largest grocery supermarket chains, had just completed a report on the management restructuring of the National Health Service which the government was in the process of implementing (though not without considerable opposition from much of the medical profession).

The Griffiths Report, advocating that the major responsibility for a community care program should lie with the social services departments within the local authorities- the County and Borough councils-was published when the Conservative Government appeared to be determined to reduce the powers of these local government bodies, silencing them as political opponents and curtailing their allegedly extravagant spending. The Report received such a tepid response that many felt that it would be shelved indefinitely. However, eighteen months later, in November 1989, the Government published its White Paper Caringfor People setting out its own proposals very closely in line with the recommendations of the Griffiths Report (Departments of Health and Social Security, Welsh and Scottish Offices 1989).

The essence of the proposals is that there should be a single assessment of the needs of each elderly person

“to determine the best available way to help the individual” (para 3.2.3) “All agencies and professions involved with the individual.. .should be brought

into the assessment procedure.” (para 3.2.5). “Assessments should take account of the wishes of the individual and his or her

carer.. _. .and where possible should include their active participation.” (para 3.2.6)

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A package of care will be designed which reflects the individual’s needs and the

availability of services in the locality; this package will be organized and managed by

a nominated “case manager” who will often, though not necessarily, be an employee

if the Social Services department. The White Paper assumes a much closer co-ordination between social service, health and other statutory agencies and voluntary organizations

than has previously existed within local Joint Planning Committees and the like. It

also stresses the role of the private sector. Nevertheless,

“the statutory sector will continue to play an important role in backing up, developing, and monitoring private and voluntary care facilities, and providing services where this remains the best way of meeting care needs” (para 3.4.3.).

Overall the policy is intended to

“enable people to live as normal a life as possible in their own homes.. .to achieve

maximum possible independence. _. .(and). .help them to achieve their full

potential.....to give people a greater individual say in how they live their lives and

the services they need to help them to do so.” (para 1.8)

The key components of community care should be to respond flexibly to individual

needs, to give consumers a range of options, to foster independence (with no more

intervention than is necessary) and to concentrate on those with greatest needs.

The White Paper was greeted with widespread support for its principles (though the

private residential sector was less enthusiastic) and local authorities began to plan both

the procedures for assessment and care package formulation and the mechanisms for

inter-departmental collaboration and financial management, in order that the policy

should begin to be implemented in April 1991. Disappointment was expressed in many

quarters that funding for community care services was not “ring fenced” or protected.

However, the state of the economy led the government, in mid-1990, to announce a

year’s postponement. The financing of local government through property rating-the

Rates-was replaced in 1990 by the Community Charge, which had become known

as the Poll Tax because all make equal contributions. Most poor households were

paying, in toto, much more than previously. The implementation of Community Care

threatened to force these local tax rates even higher.

Criticisms of the policy have focused on its paternalistic approach as exemplified

indeed by its title “Caring for People.” As the Briefing Paper of the National Council

for Voluntary Organisations argues, there is no sense of entitlement to services “and a lack of vision about what community care should look like” (1990, p. 2)-how might

one judge the adequacy of services provided? The White Paper gives no right to assessment and is silent on redress for consumers in the form of requests for second opinions or appeals against the decisions of the “care manager.” Great power is invested

in the professionals in allocating available resources-they are destined for those in greatest need. The bland statements of the White Paper give little indication of the way in which policy will be implemented in daily practice--they are markedly managerial

in their tone.

The Empowerment of Elderly People

CONSENSUS OR CONFLICT

The ongoing discussions and debates about the implementation of community care

policies take contrasting forms which we might term the consensus and conflict

discourses. The consensus discourse assumes that all those who are involved in the assessment

of the needs of the elderly person and in assembling the package of care and support

services are people of good will, seeing as their prime objective the best and correct

solution. They work together in partnership-a much used term in this discourse.

Technical difficulties, when they occur, can be resolved through amicable discussion. Distinctions are drawn between “good”and “bad’lpractice; the latter arises largely from

individual failings and is to be remedied, therefore, by training and education. Typical

is a handbook published by the Centre for Policy on Ageing, Community Life: a code of practice for community care, (Sir Roy Griffiths, in his Foreword, welcomes its

publication). The handbook provides a lengthy check list of items to be noted in the

establishment of “good practice”-access to information, monitoring, appeals

procedures. Throughout, the recipients of care are referred to as consumers;

“We trust that the enduring message of Community Life is an ambition to find this

consumer oriented attitude in every facet of community care, whether provided by

public, voluntary or private agencies” (1990, p. 42).

The contrary discourse stresses structural contradictions and conflicts of individual

interest, oppositions which are present in any social situation. The NCVO critique of

the White Paper articulates the former well. A bottom-up approach which stresses the

right of elderly individuals or consumers to services, to express their needs and have

a say in the selection of services offered, to control their delivery and to protest when

things go wrong is incompatable with the top-down approach with management

assessing needs and deciding who is most needy, allocating accordingly scarce resources,

rationed by a limitation on funding, and adopting a professional stance before the

dependent recipient of services.

The ethos of the voluntary organizations is to display initiative in seeking out un-

met needs, filling gaps which the statutory services are unable or unwilling to close.

Their independence is challenged by the proposals that state agencies should contract-

out many of their services; Abrams (1980) has, using the terminology of incorporation,

colonization and domination, classified a range of modes whereby the voluntary

organization becomes subject to state control (see also Lloyd 1990). In the same way

the responsibilities imposed on informal helpers-more distant kin or neighbors for

example-are incompatible with their altruistic motives.

Although the statutory agencies are collectively grouped within “the management” and at this level assumed to have a common interest and ideology, interdepartmental rivalry is, as Gillian Dalley shows in her own article below, rife. Each department has

its own accustomed way of expressing a problem, its own set of practiced remedies;

each fears the expansionist designs of the other onto its own closely guarded territory.

Collaborative partnership may well prove to be an unattainable ideal.

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These contradictions are manifest in innumerable conflicts of individual interest. Overriding all is the independence and control sought by the elderly individual which conflicts with the creation of dependency by all those offering care and support. Family members wish to show their love, neighbors their altruism; the elderly recipient wishes to establish a reciprocal relationship to mask the dependency so created. Individuals struggle with conflicting demands. The daughter’s desire to care for a parent clashes with her responsibilities to her husband and children and with her career aspirations. The social worker’s genuine desire to meet the needs of her client in the best possible way may be incompatible with her departmental duty to work within budgetry constraints, to abide by policy decisions.

As plans to implement community care policies proceed apace, more people are wondering whether the original conceptions were but a pipe dream; can they really work in practice?

One set of questions challenges the assumptions upon which community care rests- that there is a potential for greater support within the family and the informal sector of friends and neighbors both to meet the needs of elderly people and to relieve the state of some of its responsibilities. The pessimists argue that the limits of support have already been reached; optimists such as Bulmer (1987, p. 70), hold that with a little

stimulation and initiative a greater level can be achieved. Phillipson (1990) has recently cited a number of studies which show that the elderly no longer wish to live with, or be dependent upon their children. Beliefs that receipt of statutory services constituted a stigmatizing charity are being replaced by assertions of their entitlement as a due

return for the payment of taxes and national insurance contributions. The altruism of neighbors and friends is, as Patricia Thornton shows below, threatened by the imposition of payment and fixed schedules; it may be very difficult to sustain the supply

of voluntary workers. Another set of questions raises issues of power. In situations of structural

contradiction and conflict of interests there is an implicit power struggle. While it is certainly possible to view any situation as an exhibition of consensus and partnership, in the search for the perfect situation a more realistic view takes cognizance of the contradictions and conflicts, both latent and manifest, out of which are created an imperfect, though hopefully workable, solution.

The White Paper continually refers to the independence of, and the choices to be offered to, its elderly consumer. But how much power will they be able to exercise over their lives? Will community care become a euphemism for a somewhat more benign but still dependency-creating paternalism?

Asymmetrical Relationships

Most of the literature on elderly people posits a dependency approach. Elderly people are construed as a problem; the White Paper, as we have seen, is entitled Caring for People (my emphasis); and virtually all social work texts echo the same themes. The social anthropological literature is however very different. The authors follow the classic dictum of their founding father, Bronislaw Malinowski, in seeing it as their task to “grasp the native’s point of view, his relation to life, to realise his vision of his world” (1922, p. 25). Their studies of communities of elderly people focus upon their struggles

The Empowerment of Elderly People 131

to maintain control over their lives, to assert their independence, to preserve a progressive continuity in their “careers” rather than admit that the rest of the way is down hill. Thus Barbara Myerhoff, in her Number our Days (1978) describes how a Jewish Community Centre provides its members with a locus in which they can place their past experience. Janice Smithers (1985) writing of “St. Regis”, a hotel for the aged in Los Angeles, shows how the residents exchange much informal help but in a very surreptitious way-for any outward sign of a failure to cope with independent living would lose them their tenancy and they would be consigned to a geriatric hospital. She found, as did Jean Collins in her own study cited in her article below, that reciprocity is an important element of the relationships of elderly people-without it they lose self respect and acknowledge their dependence. In her studies of clubs, amplifying the descriptions given in her article below, Dorothy Jerrome (1986) has vividly described how the more capable and dominant members sanction the behavior of those who seem less able to cope effectively by referring to them by such terms as “a poor thing” for someone who cannot cope, “old dears” for those in receipt of care.

But elderly people inevitably come to need the support of others, usually (though not necessarily always) younger than themselves. We cannot therefore look at them in isolation from the rest of society. As Maria Vesperi (1985, p. 76) has argued, we must see how they mobilize their resources not only to adjust to their own increasing frailty, to the changes in the world about them, but also to the expectations of others with whom they must interact. These interactions take the form of protracted negotiations in which each party begins with their own construction of the situation, strives to establish shared understanding and in so doing to preserve their own status and reputation (Finch 1989, Ch 6).

Nowhere is this negotiation of role and expectations more poignant than within the family; the relationships between elderly people and their children is, as Doris Francis (1984) has described, fraught with ambiguity. She studied two Jewish communities- one in Leeds, England, the other in Cleveland, Ohio-which shared a common experience of migration from Eastern Europe. The elderly members of the former seemed more fortunate in that they had, in most cases, cared for their own parents and so had a model; they tended too be of the same social (working) class as their children. The Cleveland children were more upwardly mobile; and while the parents were undoubtedly proud of their children’s achievements, including them as it were to their own curriculum vitae at a time when they themselves had little new to add, they felt estranged from the life style of the children and felt more nervous of intruding upon them. In a slightly different vein Clare Ungerson (1987) has looked at the way in which women (as they mostly are) have become carers of their parents and how they made sense of their position-positions which were complex, contradictory and replete with tension. Obligations to care were expressed variously in terms of love and duty; but these clashed with obligations to other family members, to husband and own children, and to oneself with the possible damage to career prospects.

The striving for independence and for reciprocity in informal relationships is incompatible with the altruism expressed by volunteer workers-expressed to boost both their own self respect and that accorded to them by their communities. Community care policies have rested on assumptions that there is a reservoir of voluntary help waiting to be tapped. But increasingly it is being shown-as the articles in this issue

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indicate-that elderly people often resent offers of unpaid “charitable” help. Again, as some have suggested, volunteers may be offended either by the challenge to their altruism or by the payment of a token fee which falls far below the market rate for the job. (The contracting-out of services by statutory bodies to voluntary agencies tends to create a category of welfare workers who are underpaid, lacking formal rights of employment etc.).

Social workers have obligations both to their clients/consumers and to their employers; “whose side are we on?” IS their familiar plea. With financial stringency the dilemma becomes more acute. Kent Social Services Department has carried out much of the experimentation into one model of community care practice upon which the White Paper was substantially based. According to a recent report (Cervi 1990) it is determined to push ahead in spite of government delays in implementing the policy. But targeting and rationing are the order of the day. Staff can care for only the very highly dependent-those with moderate or low dependency are told to seek help from the voluntary or private sectors. A care manager has about f40 to spend on services for each client-about 8 hours of care; yet f 120 worth would be a more realistic figure. Many social workers resign, being unable to reconcile this budgeting role with that of counsellor. As Which, the magazine of Britain’s Association for Consumer Research, pithily puts it,

“The danger here is that the person who should be gunning for the elderly person is also the one who rations the services they get” (1990, p. 535).

Community care assumes that professionals from a variety of departments will co- ordinate their efforts in providing a package of services appropriate to each elderly person. But as Gillian Dalley shows in her article below, the professionals do not speak with one voice. Each group has its own ideology and preferred modes of action, though these may be modified to meet the exigencies of each specific case.

Thus in innumerable everyday situations the elderly person is negotiating a relationship and a probably course of action with a family member, a voluntary worker or a professional social welfare worker. In each interaction we see a struggle, a conflict of interests. Maria Vesperi (1985, pp. 50-62) has given us two delightful vignettes; in each we see the social worker initiating the interview with a set list of questions about the elderly person’s attributes, fitting the perceived needs into a pattern and thus into a (pre-determined?) remedy (e.g., admission to a day care center). The respondents strive, mostly in vain, to express a somewhat different set of needs and expectations and as an obvious failure to leads to verbal stumbling, answers which are “irrelevant” and so on, respondents are characterized as senile and therefore incapable of sharing in decisions about their future.

RESTORING SYMMETRY

For many years the debate about community care has revolved largely around the interweaving of a plurality of care systems-statutory, private, voluntary and informal-to create a “community” responsibility. The cared-for person was still regarded as a dependent, passive client. In the past few years the focus has altered,

The Empowerment of Elderly People 133

partly through a greater emphasis on participation, itself due in some measure to the managerial approach to all services currently being promoted by the Conservative government. The elderly person has thus become a consumer of services actively making choices (constrained though they may be in practice) between alternative modes of care provision. For the middle class person, able to afford services from the private sector, choice is a reality; for the working class person it means protest against inappropriate or insufficient provision by the statutory services.

Almost inevitably, elderly people are in a weak position. With increasing frailty of body and mind their needs escalate; but their resources decline-savings are used up, pension levels fall behind inflation rates, one’s peers and age-mates predecease one. Services are provided by others-statutory service employees, volunteers, friends, and close kin. The statutory services, underfunded, are rationing their allocation of services, the altruism of volunteers is threatened, family members have many other competing commitments. Many writers have challenged the homogeneity with which elderly people have been portrayed. Clare Wenger’s typology graphically presented below links patterns of one major resource, that of the social network, with the timing and content of the need for service provision.

Dependency is thus unavoidable; but the distinction between client and consumer is a real one. The degree to which elderly people are enabled to feel in control of their lives, solving their own problems, making choices for themselves, seems likely to promote happiness and a feeling of well being which is reflected in both health and longevity (Buie 1988). Much depends here on the way in which elderly people actually experience the provision of services and care. The range of situations is wide; Maria Vesperi has, as cited above, described the interaction between a social worker and elderly male clients; Dorothy Jerrome has described clubs run by volunteers. Since we have been looking specifically at the provisions outlined in the White Paper let us imagine two scenarios-one illustrating a stereotypically bad practice, the other an idealistically good practice-to contrast the ways in which an elderly person experiences the construction of a package of services and care.

First the “bad practice:” Our elderly person is referred to the social services department by her neighbor or family without consulting her; they feel that she is becoming too great a burden for them. The initiative is passed to the social workers; they summon the elderly person, together with family, informal carers, to an assessment meeting in their offices in an inaccessible part of the town at a time to suit their schedules. Arriving there the elderly person and her party first wait in a draughty waiting room before being ushered into an office. Professionals sit on one side of the table behind their files; the visitors sit across the table but the elderly person is given a low easy chair from which she can hardly see across the table; “you’ll be more comfortable there, Alice dear,” referring to her by her Christian name as though she were a child. The professionals introduce themselves in a mumbling way; the visitors are unsure who they are, what they do; they are ignorant of the form of the meeting or of the services to be offered. The professionals have a very clear idea of the agenda. Rapidly the needs and attributes of the elderly person are listed in their own terminology; together they are deemed to place her in a well defined category for which an appropriate package is available-a home help, meals on wheels etc.-designed to be cost effective and to meet local availability. Interjections by the visitors are brushed aside; their ignorance

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is demonstrated by their incorrect designation of services; the elderly person begins to

feel that she is not going to get what she really wants but before she can collect her

thoughts the discussion has moved on. The professionals, clearly accustomed to meeting together in this way, conduct their business and expeditiously as possible; they visibly

demonstrate their control as they write in their files. When one of the visitors asks if

rather more services could not be provided, she is reminded that there are many more

elderly people “out there whose needs are much greater”, thus eliciting feelings or guilt. Thus, in initiating action, in their control over information and agenda, in their

definition of the problem and thus of its solution and through the countless ways, in

speech and body language, in which they assert their superiority, they induce in their

clients a sense of complete lack of control yet a gratitude that they have been given as much as they have; to protest might well mean being branded as a troublemaker

with consequent loss of services.

In contrast an ideal situation: Our elderly person has decided that the time has come for her to have some external help. She has armed herself with a package of leaflets

and booklets from her local Age Concern office and has discussed their contents (and

the quality of the local delivery of such services) with peers at her club. A meeting is arranged at her home; she makes tea for her visitors before describing her problems in her own words. Those present, social worker, health visitor, voluntary agency helper,

daughter, friend and neighbor offer, in turn, possible services. The result may fall short of wildest expectations but the process has at least demonstrated the control exercised

by the elderly person. (It might be argued here that many an elderly person will already

have become so frail as to be unable to exercise such control; here an advocate-

daughter, friend but not professional-could assume the dominant role). The experience of control is enhanced both by a belief that the statutory services are received as a right

(and therefore to be demanded) rather than as “charity” and by the introduction of reciprocity into informal caring relationships (small gift exchanges, token payments,

a service rended in return).

As community care continues to move from being an utopian dream into the realms

of policy making and practice so do the issues surrounding its implementation become more poignant. Demands for care and services escalate not only because the number

of elderly persons is increasing but also because they are becoming more vocal in demanding help. The threatened rise in public expenditure is met by the government in calls for more voluntary activity and family support-so that in some circles, “community care” is seen as a euphemism for “care by the daughter.” But increasingly

studies are showing that elderly people do not want to be a burden to their children;

they would prefer to continue to live in their own homes, and here too they do not want to impose on their neighbors; they seek state services as a right. The greater the demands on the state, the more severe will be the rationing in the allocation of services.

The rationing process, however, implies clientage which runs counter to the consumer oriented approach explicit both in government statements and in criticisms of them.

Humanity requires that we enable elderly people to exercise their independence and control over their lives; the management of service and care provision continues to maintain them in a dependent status and to exacerbate their experience of this dependency.

The Empowerment of Elderly People 135

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