The demographic context in which we work is changing inexorably. Although Ireland has one of the youngest age profiles in Europe, we, like all other EU members, are seeing rising numbers of older people as a proportion of the population. This is happening for a variety of reasons. Clearly, improved diet, healthcare and housing conditions have all played a part. Across much of Europe, the change from the old patterns of heavy industry has had an effect. We’ve also seen the gradual impact of health promotion in reducing smoking, for example, and eliminating it in public places. It’s equally the case that there is a strong correlation between prosperity and longevity. Life expectancy is notably lower in poorer communities, and despite the recent recession, the overall trajectory has been towards increased prosperity throughout the Union.
The rise in the number of older people has an inevitable impact on public services. We’ve seen great concern about the cost to the State of funding pensions and the fact that the increase generally has to be funded by a smaller workforce. This is often leading to increases in pension age and where the pension age for women was previously lower than that for men, there is now a tendency to increase it on equality grounds, although in truth, the State is probably happy to do so to help to contain the cost. There is also a greater emphasis on the use of occupational pension schemes, which are sometimes made compulsory, to also limit the cost to the State.
In addition to the impact on pensions, many older people also have to access benefits as their income from pensions is not enough.
Healthcare is another area where the impact is being felt. In the UK, for example, two-thirds of hospital admissions are people over the age of 65. Many have multiple chronic conditions, such as heart disease and dementia.
In fact, the change in the patient population has been so acute that a study undertaken by the health research institution, the King’s Fund, put the average age of a patient at over 80. Age also impacts on how long people stay in hospital. In Ireland, the average length of stay is 3.9 Days for inpatients aged 0-64 but 9.8 Days for inpatients aged 65+.
These changes have fundamentally changed the role of acute hospitals. Originally designed to deal with younger people who were inpatients for brief spells, they are increasingly dealing with older people who have conditions which are now treatable, but who often face challenges in returning to their communities. Thus the occurrence of so-called delayed discharge which can contribute to a shortage of hospital beds and queues of patients waiting outside hospitals in ambulances or on trolleys in emergency departments for beds to come free. Many older people enjoy good health, but the growing age of our population brings with it problems of chronic illness and dementia which pose huge challenges to our health services.
The pattern of health provision across Europe varies from almost wholly state provided to mainly insurance funded. The role of Parliamentary or public services Ombudsmen varies accordingly, but for those who have all, or a significant element of, health care within remit, it often constitutes a major part of their workload.
Another impact of the changing demographic is in social care. The traditional pattern of family support is in decline. Many people rely on care provided or paid for by local authorities or the state to enable them to remain in their own homes or to live in older peoples’ facilities. The availability of this care can have a critical impact on the quality of life of older people who rely upon it.
The next area I wish to highlight today is housing. For those older people who become less mobile, there is often a need to either have property adapted, with the addition of items such as stair-lifts, showers to replace baths, downstairs bathrooms and level access or to move to a more suitable home. Access to funding for adaptations is one route to address these needs. Social rented housing providers, whether municipalities or housing associations, can also help by adapting properties for their tenants or by helping people to move to accessible housing.
Finally, transport can become an issue for older people whose mobility is reduced, and assistance with the purchase of adapted vehicles, tax-breaks or grants can all be used to address this.
Given that older people can often be heavily reliant on public services, it is not a great surprise that they can form a very significant part of the Ombudsman’s caseload. It’s easy to think of older people as being in some way disadvantaged, yet some of the most effective complainants can be retired professionals, with access to the Internet, time on their hands, and an unwillingness to take no for an answer! Such complainants know the system, are articulate and are in no need of any special support.
On the other hand, older people with dementia may be entirely unable to make a complaint without an advocate, whether that person is a professional or voluntary advocate, or a friend or family member. Where Ombudsmen keep records of complainants, older people can be disproportionately represented.
Many of the issues raised by older people complaining to an Ombudsman are the same as those raised by other complainants. There are however, specific issues faced by older people which can show evidence of discrimination.
My predecessor, Emily O’Reilly, was particularly concerned about a scheme which offered grants to disabled drivers. The scheme was not available to older people above the age of 65. Her report highlighted the blatant discrimination underpinning this approach. As a result, the Government withdrew the scheme and committed to developing a non-discriminatory replacement. For many colleagues here today, your remit includes upholding human rights, and such discrimination will be seen in that context. For those of us working in countries with separate human rights agencies, there is nonetheless the requirement that we should take breaches of human rights into account when determining whether there is evidence of maladministration. I would like to commend to you the work of the Northern Ireland Ombudsman who has used IOI funding and other support to develop a human rights toolkit which will prove of benefit to other Ombudsmen in identifying and addressing human rights issues.
Other issues which arise are often particularly relevant to older people. These include competence, the capacity to make decisions about their own lives. It is important that there is a proper framework to ensure that others can act in their best interests when they are no longer able to do so themselves.
Dignity and respect are also features of many complaints, where there are instances of neglect or simply a failure to see older people as individuals. In my work as an Ombudsman, I have seen an instance where an older person who was a lifelong vegetarian was given dinners with meat because she was no longer able to object, to the great concern of her family. I have also seen cases where financial decisions have been taken which were clearly not in the best interests of the individual.
There is also often concern about isolation. Ultimately, simply maintaining people is not enough. Services should be designed which respect the individual and seek to maximise the quality of life and continued engagement with communities.
I want to illustrate some of these points by drawing on two investigations undertaken by my office. The first considered end of life care, and resulted in a report entitled “A Good Death.” The second is coming to a conclusion now, and will be published shortly. It is an own initiative investigation into how complaints are managed in public hospitals.
It is said that there are two certainties in life, death and taxes. Providing support to enable people to die in a dignified way, in a setting of their choice, without pain and in the company of their loved ones is a challenge faced by all societies. My Office worked with the Irish Hospice Federation in preparing the report, which is based on complaints we considered over the years.
The themes which emerge are predictable. Foremost is poor communication. This can be about a failure to properly convey a diagnosis or prognosis, leaving patients and families without a clear understanding of what the likely outcome will be. It can suggest a lack of compassion, and cause people to miss an opportunity to plan for their last precious time with their loved one. Excessive use of technical language, and not checking whether the message has been absorbed in traumatic circumstances are other features. Saying it once may not be enough, and using clear language is essential.
Other issues frequently raised are about location. Many people want to die at home, but are not supported to allow them to do so. When people do die in hospital, we found incidents where a private room was not provided and relatives could not spend the final hours nor grieve in private.
Both at home and in hospital pain relief was not always promptly and effectively delivered leading to great distress for the individual and their loved ones who had to live with the knowledge of the distress. Ombudsmen also report instances where people do not have proper care for their basic needs.
This report demonstrated how we as Ombudsmen can respond to tackle such issues. Firstly, it was developed in conjunction with an advocacy body to ensure that the Office was responding to the requirements of the group concerned. Secondly, it sought to identify trends in services so that systemic problems could be tackled. Thirdly, it gave examples of good practice as well as bad to show the way forward. Fourthly, it engaged with service providers to set out an action plan to tackle the deficiencies identified and which will be monitored to ensure that the required steps are being taken and are proving effective.
The second report is entitled “Learning to Get Better”. It is due to be published on 27th May. It was designed to discover why there were relatively few complaints about public hospital services in Ireland compared to other jurisdictions. Because many hospital patients are older people, many of the issues are particularly relevant to them.
We decided to undertake this as an own-initiative investigation. We used a variety of approaches. We met with representative groups, advocacy groups, professional regulators and health service providers. We invited members of the public to tell us about their experiences of complaining, both good and bad. We held focus groups for complainants. We visited a representative sample of hospitals, considered case files, interviewed staff and looked for evidence of information about how to complain.
In summary then – Ombudsmen have a key role in ensuring that older people receive the public services to which they are entitled. We need to make it easy for them to complain to us including using outreach and being aware of the role of advocates. We need to adopt a rights-based approach when considering complaints and be alert to any discrimination. Where people are unable or reluctant to complain, we need to be prepared to use our own-initiative powers to ensure that problems are addressed. We need to consider instances of systemic failure and to ensure public service providers correct them, and we need to be alert to problems in legislation and use our access to Parliaments to raise awareness of them and propose changes.
Finally, I just want to use a recent practical example. Like many Ombudsmen, we provide outreach services to make it easy for people to come to us with complaints. Our outreach includes a specific presence at shows for older people, and regular surgeries outside Dublin at Citizens’ Information Centres.
Mr D called into our surgery at the Cork Citizen Information Centre. He was looking to have his Non-Contributory State Pension back-dated. He was approved for the pension in 2014 but believed he was entitled to have it back-dated to 2010.
He called in a number of times and talked to the staff from my office. They helped him to put his complaint and it was then considered by a member of staff in my Assessment Unit.
In fairness the staff in the Government Department dealing with pensions were extremely helpful. They agreed that Mr D was entitled to have his pension back dated to 2010 and he received approximately €15,000 in back money.
So while we have an important job to do in supervising administration and addressing systemic weaknesses, often, solving individual problems can put a smile on the face of the older people we help!