Part 6: Health and well-being of older people
6.1
In this Part, we:
- discuss why our work programme has focused on older people;
- list our reports, since 2007, that have focused on older people;
- discuss what our work has told us about older people's health and well-being; and
- indicate areas of potential future interest.
Why our work programme has focused on older people
6.2
The structure of New Zealand's population is changing, but the main change is that it is ageing. In 2006, there were two children for every older person. In 2023 – only nine years from now – we could have more people aged 65 or older (older people) than we have children under 15. The 2013 census found that females outnumbered males in all age groups from 25 to 29 years onwards, and 64% of people aged at least 85 years were female. There were 607,032 older people (14% of the total population) and 73,000 of this group were aged at least 85 years.
6.3
One way or another, many public resources will be committed to responding to our ageing population. We expect that governments will spend more on superannuation, healthcare, and social support care (such as home-based support services and aged residential care). Spending on other services might decrease.21
6.4
Maintaining and improving older people's health and welfare is important for everybody. Individuals' health and well-being in older age is affected by current behaviours and practices, but is also affected by their health at younger ages. For example:
- Prenatal nutritional deficits and impaired growth during pregnancy and infancy represent a significant risk factor for type-two diabetes, heart disease, stroke, osteoporosis, and high blood pressure in later life.
- Non-communicable diseases are of long duration and potentially slow progression. The four most common of these diseases (cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes) all share the same risk factors, which are tobacco use, physical inactivity, harmful use of alcohol, and unhealthy diets.22
6.5
Improving the health and well-being of children and younger adults will produce benefits for those individuals in older age. Society also benefits because healthier older people can participate more fully in the business and affairs of the wider community.
Our reports
6.6
Since 2007, we have published a range of reports that fully or partly focused on the health and well-being of older people. We decided to bring together the findings from our work to get an overview of how public entities have been meeting the needs of older people. Figure 13 lists our reports by year along with the relevant follow-up reports.
Figure 13
Reports of performance audits and follow-up reports, by year of publication
| Year | Title | |
|---|---|---|
| 2007 | Ministry of Health and district health boards: Effectiveness of the "Get Checked" diabetes programme | |
| 2010 | Effectiveness of the Get Checked diabetes programme, which aimed to help DHBs make further improvements in implementing the programme | |
| 2008 | The Accident Compensation Corporation's leadership in the implementation of the national falls prevention strategy | |
| 2010 | Performance audits from 2008: Follow-up report, which included an article on ACC's progress in responding to the Auditor-General's recommendations | |
| 2009 | Effectiveness of arrangements to check the standard of services provided by rest homes | |
| 2012 | Effectiveness of arrangements to check the standard of rest home services: Follow-up report | |
| 2010 | District health boards: Availability and accessibility of after-hours services | |
| 2014 | Forthcoming – an article following up on progress in responding to the Auditor-General's recommendations | |
| 2011 | Progress in delivering publicly funded scheduled services to patients | |
| 2013 | Delivering scheduled services to patients: Progress in responding to the Auditor-General's recommendations | |
| 2011 | Home-based support services for older people | |
| 2014 | Forthcoming – an article following up on progress in responding to the Auditor-General's recommendations | |
| 2013 | Using the United Nations' Madrid indicators to better understand our ageing population* | |
* Many of the Madrid indicators are health related, but there are also indicators for other sectors, such as social development, justice, and transport.
What we have learned about older people's health and well-being
6.7
Our work using the United Nations' Madrid indicators shows that, as a group, older people generally experience good health and well-being, and mortality rates from common non-communicable diseases are improving. However, not all older people experience improvements uniformly. Women, Pākehā, and people on higher incomes often (but not always) benefited more than men, non-Pākehā, and people on lower incomes.
6.8
There are some relatively small groups of vulnerable older people, such as those in residential care and those receiving home-based support. We found that progress in introducing systems that will collect reliable data about the quality of these services is slow.23
6.9
We also found that public entities use different definitions of elder abuse, neglect, and exploitation, and that no single agency collects data on this subject. Therefore, little is known about the extent of this issue and no one can really know whether current prevention programmes are effective.
Improvements in health and well-being
6.10
Most older people (90% in 2010) were satisfied or very satisfied with their quality of life. In 2011/12, only 5% had experienced any recent psychological distress. An increasing proportion assess their own health as good to excellent.
6.11
Mortality rates for older people24 are decreasing for non-communicable diseases (especially circulatory diseases), though mortality rates from external causes (accidents, injuries, and poisoning) have increased. Disability rates for older people are decreasing.25 Seven per cent of older disabled people needed daily help with a range of everyday tasks.
6.12
In 2011/12, about 7% of people aged 65-74 years and 4% of people aged at least 75 years reported that cost was a barrier to accessing primary health services.26
6.13
Access to elective (or scheduled) surgery has improved for older people faster than for younger age groups.27
Areas where progress has been slow or has worsened
6.14
Obesity rates have doubled for people aged 65-74 years between 2002/03 and 2011/12, and overweight (but not obese) rates have increased slightly, too. Obesity is linked to diabetes, the rate of which is increasing.
6.15
Older people are disproportionally affected by falls. There has been a national focus since 2001 on reducing the incidence and harm of falls, but the rate of falls for every 100,000 population, aged at least 60 years, increased from 37 in 2000 to 53 in 2009.28
6.16
Findings for some of the Madrid indicators showed that outcomes for health and disability services for older Māori, Pacific, and, increasingly, Asian ethnicities were worse than for Pākehā.
6.17
In 2008/09, about 9% of older people were believed to be receiving home-based support services from the health and disability sector (excluding services funded by the Ministry of Social Development and ACC). Some older people living in the community are potentially more vulnerable than others. In 2006, a higher proportion of older disabled people lived alone (one-third) than disabled people in other age groups (one-quarter).
Other areas for improvement
Lack of data
6.18
A high proportion of older people live in the community and may receive support from whānau, family, friends, neighbours, churches, charities, and state agencies. Reliable trend data on the number of older people receiving home-based support services is not collected by the Ministry of Health. Reliable data on the number of older people receiving home-based support services should be available once interRAI29 is fully implemented.
6.19
Also, an estimated 31,305 older people were living in residential care in 2013. We found that the Ministry and DHBs do not have reliable information about the quality of residential and home-based support services received by older people. Progress in implementing our recommendations about this has been slow and depends on the successful implementation of interRAI.
6.20
It is not yet clear how and when the data collected from interRAI will be used to improve nationwide equity of access, improve quality, and evaluate the effectiveness of policy settings for aged residential care and home-based support services.30
Elder abuse
6.21
Our Madrid indicators work showed that public entities use different definitions of elder abuse, neglect, and exploitation (abuse), and that no single agency collects data on this subject. The size and scope of the problem and the main risk factors are unknown and it is difficult to evaluate the effectiveness and efficiency of current prevention programmes and legislation.
6.22
However, some data is available and it indicates that the size of the problem is larger than might be generally understood. Data about reported cases of abuse comes mainly from Age Concern, which received an average of 3.6 reports per calendar day from 1 July 2010 to 30 June 2012 (an average of 1,314 each year).31 Using a low prevalence range from other countries of 2%-5%32 and 2013 census data, we estimate that 12,141-30,352 older people might have experienced abuse in 2013. In 2011, we reported that nine out of 20 (45%) DHBs had yet to involve Age Concern's Elder Abuse and Neglect Prevention co-ordinators to empower older people to complain about abuse.
6.23
Older people report a higher rate of victimisation than the narrower definition of abuse. The 2008 New Zealand Crime Survey found that 20% of people aged at least 60 years had been victims of a crime or felt they were at risk of being a victim. Fifteen per cent of retired people had been victims, or felt they were at risk of being a victim.
Areas of potential future interest
6.24
There are many uncertainties about the effects of a changing population structure on individuals and on society as a whole. Having the right kind of data available is important in managing for those uncertainties and preparing for the future. Accurate, relevant data can be used to identify improvements or adverse consequences as the result of changes in society and in government policy, and helps support accountability and transparent decision-making.
6.25
We expect the public entities involved in improving the health and well-being of older people to be clear about the intervention logic for policy and programmes, and collect relevant data to identify the effectiveness and efficiency of actions taken. We expect interventions to be based on a good understanding of how to change people's behaviour for the better, and incentives to be focused on promoting progress towards achieving the desired outcomes.
6.26
We will continue to monitor the progress made by the Ministry and DHBs in improving their knowledge of the quantity and quality of home-based support and rest home services through the introduction of interRAI and how that data is used to make improvements.
6.27
Allied to this, we expect public entities to work with service providers to understand the size and scope of the elder abuse problem and the main risk factors involved, and evaluate the effectiveness and efficiency of current prevention programmes and legislation.
21: The Treasury has considered the effect of New Zealand's ageing population on the country's financial sustainability in its 2013 report Affording Our Future: Statement on New Zealand's Long-term Fiscal Position. Our report on the Treasury's Statement is available at our website: www.oag.govt.nz.
22: Health Committee (2013), Inquiry into improving child health outcomes and preventing child abuse with a focus from preconception until three years of age: Volume 1, pages 45-46, New Zealand House of Representatives, www.parliament.nz.
23: In 2011 and 2013, we described how the reporting on progress towards achieving the objectives of the Health of Older People Strategy (2002) was not complete, reliable, or comparable. Data collected was not analysed to provide a national report on progress.
24: The available data is for people 60 and over, not 65 and over, and is from 2000 to 2009.
25: From data available to 2006.
26: This data was collected for the first time in 2011/12. The results were lower than for younger adults.
27: The Ministry of Health data that we used was extracted from the National Minimum Data Set (surgery only) on 4 February 2013 for data up to 2011/12. The 2012/13 data was extracted on 12 August 2013.
28: The Health Quality and Safety Commission has introduced a programme to reduce the incidence and harm from falls in hospital and residential care settings.
29: The interRAI Organization is a collaborative network of researchers in more than 30 countries, committed to improving care for persons who are disabled or medically complex. In practice, the term "interRAI" is used to refer to the organisation's clinical assessment tool. Data collected by health professionals using the tool is stored in an information technology system.
30: The New Zealand Health Survey asks respondents questions about their experience with general practitioners, practice nurses, after-hours doctors, emergency department doctors, and medical specialists, but not home-based support services.
31: Data reported to public entities, such as the Health and Disability Commissioner, the Ministry of Health and district health boards, the New Zealand Police, or the Financial Intelligence Unit, is not included in Age Concern's data.
32: These rates were used in Ferrino, April (2013), Improving the quality of age-related residential care through the regulatory process, page 55, Ian Axford (New Zealand) Fellowships in Public Policy, www.fulbright.org.nz.