National Care Service - adult social care: equality evidence review

3. Age

The Equality Act 2010 defines the protected characteristic of age in terms of persons of a particular age, or those belonging to a particular age group^[12]. This section brings together data and evidence on adult social care and age. Evidence is presented here in relation to the experiences of people who access social care, unpaid carers, and social care workers.

3.1 People who access social care

Although people of all ages access social care, patterns of use vary by age group. Further information can be found in People who Access Social Care and Unpaid Carers in Scotland.

There is a clear relationship between long-term health conditions or disability and increasing age. In 2020, the Scottish Health Survey found that the prevalence of any long-term condition increased with age, from 32% among those aged 16-44, to 68% among those aged 75 and over^[13]. The proportion of individuals who have two or more medical conditions simultaneously (referred to as ‘multimorbidity’) has risen across high income countries, including the UK^[14], partly reflecting increases in life expectancy across recent decades. Projections suggest that this trend is set to continue^[15]. A recent cross-sectional study which linked national health and social care data to explore multimorbidity and social care use in those aged over 65, found that the vast majority (93.3%) of those receiving social care had multimorbidity^[16]. While these trends reflect the ageing profile of populations, it is important to note that multimorbidity is not restricted to older people. Further information about multimorbidity can be found in Scotland’s Health and Demographic Profile.

Long-term health conditions, disability, and age are all associated with increased likelihood of needing care and support and the likelihood of needing social care increases with age; in 2020/21, consistent with previous years, more than three quarters (77%) of people receiving social care support and services in Scotland were aged 65 and older. Furthermore, almost half (463.5 per 1,000 social care clients) of the people receiving social care support were in the ‘elderly and frail’^[17] client group. Between 2017-18 and 2020-21, there has been an overall increase in the number of people receiving social care in Scotland across all age groups^[18]. There is also some evidence from England to suggest that the number of younger adults who require social care support has increased over the last five years, with further increases projected over the next five years^[19].

There are variations in assessed support needs between age groups. In 2020/21, personal care was identified as a support need for around 56% of people aged 65 and over whose needs were assessed, whereas personal care was identified as a support need for just under a third of people aged 18-64 whose needs were assessed. The vast majority of assessed support needs for people aged 65 and over were for personal care and equipment and temporary adaptations. For people aged 18-64 whose needs were assessed, there was a much wider range of assessed support needs, including: personal care; domestic care; housing support, social, educational and recreational; equipment and temporary adaptations; and ‘respite’^{[20] [21]}.

There are substantial age related variations within the population aged 65 and over, as service provision generally increases with age. The proportion of the population receiving home care increases from a rate of 25 people per 1,000 population for ages 65-74, to 87 people per 1,000 population for ages 75-84, and 255 people per 1,000 population for ages 85 and over. Many people aged 65 and over in receipt of home care receive a relatively small amount of support, with around a third of this group receiving between 4 and 10 hours per week, and just over a third receiving 10 or more hours per week. In contrast, around half of people aged 18 to 64 receiving home care support received 10 or more hours per week^[22].

The vast majority of people reported to have a community alarm or telecare are aged 65 and over, with the highest rates in the oldest age groups. For people aged 65-74, the community alarm/telecare rate per 1,000 population is 30, rising to 112 for the 75-84 age group, and 315 for those aged 85 and over^[23]. Additionally, people in the older age groups are more likely to have both a community alarm or telecare and home care. Just over one third (37.3%) of people aged 65-74 with an alarm or telecare also receive home care, and this proportion rises to nearly half (47.1%) of people aged 85 and over. This differential may reflect the higher prevalence of long term conditions, including frailty and dementia, and more complex needs associated with these conditions in older age groups, as well as potentially reducing informal support networks being available as people get older^[24].

Older adults are also much more likely to receive social care support in residential and nursing homes than younger adults. The majority (90.8%) of long stay care home residents are aged 65 and over, with more than half of this group aged 85 and over^[25].

People aged 65 and over who receive social care support are also much less likely to have a direct payment (Self-directed Support^[26] Option 1) than those aged 18-64, and much more likely to have their support chosen and arranged by the local authority (Self-directed Support Option 3)^[27]. Research by the ALLIANCE and Self Directed Support Scotland (SDSS) highlighted particular barriers to accessing information about Self-directed Support for older people, and suggested actions to address these barriers, including: increasing professional knowledge and awareness; streamlining and signposting; and ensuring people can access information in a range of formats^[28].

The majority of people who receive social care services report being satisfied with them. Analysis of Health and Care Experience Survey data found that, when asked to rate their help, care or support services (excluding care/help received from friends and family), 62% of respondents rated services ‘good’ or ‘excellent’ in 2021-22, while 17% rated services ‘poor’ or ‘very poor’. Males^[29] were proportionally more likely than females to rate their quality of care as positive, at 64% and 61% respectively. Similarly, people aged 65 and over were proportionally more likely to rate their quality of care as positive compared to the national figure, at 68% and 59% respectively. The oldest age cohort was 9 percentage points more likely to rate their services positively compared to the youngest age cohort (aged 17-24) in 2021-22 (68% and 59% respectively)^[30].

3.2 Unpaid carers

People of all ages are unpaid carers, however caring may be experienced differently across the life course. For example, young carers may be balancing caring with education, working age carers may be balancing caring with work and childcare, and older people may be balancing caring with needs associated with their own health and ageing.

It is difficult to accurately ascertain the number of unpaid carers as data sources are self-reported and some people may not identify themselves as unpaid carers. However, the Scottish Health Survey provides robust data on the prevalence on unpaid care within the adult population. In 2020, the Survey found that almost one in five adults (19%) reported that they provided regular unpaid care, with women more likely to do so than men (23% and 14% respectively). Caring prevalence also varied by age, increasing from 12% of those aged 16-44 to 28% of those aged 45-64, before decreasing to 14% - 18% among those aged 65 and over. A similar pattern was found for women, however, for men there was no clear pattern by age^[31].

The Carers Census provides data about unpaid carers who are being supported by their local carers services^[32]. In 2020-21, there were 31,760 individual carers reported to be supported by those local services that responded to the Carers Census and around a quarter of this group were people aged 65 and over. Adults aged between 18 and 64 made up a further 62% of unpaid carers being supported by local services, and a further 14% of this group were aged under 18 years^[33].

The Carers Census also provides data about the number of hours spent caring and suggest that caring intensity increases with age. In 2020-21, two thirds of young carers spent less than 19 hours a week providing unpaid care, compared to 11% of adult carers. This may reflect differences in the capacity for, and the appropriateness of, higher levels of caring between adult carers and young carers^[34]. However, it should be noted that this data only includes those unpaid carers who are being supported by local services and may not reflect the experiences of the wider population of unpaid carers.

The Carers Census also suggests that adult carers and young carers were impacted differently by their caring roles. In 2020-21, adult carers were more likely than young carers to experience impacts on their health (56% compared to 27%), finance (34% compared to 20%) and future plans (43% compared to 19%). Young carers were more likely to experience an impact on their emotional well-being due to their caring role than adult carers (89% compared to 74%). However, the impacts of providing care varied depending on the average number of hours of care provided per week; the more hours of care per week provided by carers, the more likely people were to experience impacts on their health, employment and living environment^[35].

UK-wide polling carried out by Carers UK found that unpaid carers aged over 65 were particularly worried about negative health implications of caring, specifically managing the stress and responsibility associated with being a carer and the negative impact on their own physical and mental health. The Carers UK report also highlights difficulties in juggling work and care for working age carers, and the impact of unpaid care on people’s ability to also undertake paid work, leading to many people giving up work to care^[36].

There is well established research about the impact of caring on young carers^[37]. Being a young carer tends to be associated with poorer health and well-being, which is likely to have implications for other areas of young carers’ lives, such as education and employment. Those providing more hours of care appear to have worse self-reported health, however, it is not possible to say the extent to which this is directly related to caring responsibilities. Other factors such as deprivation, gender and support networks are also likely to have an impact. Research suggests that young carers may face challenges in participating in social or leisure activities and may feel isolated as a result. However, it is also important to note that young carers can be positive about their caring role and feel that it brings benefits^[38].

Young carers can face challenges in balancing their caring responsibilities and education and employment requirements and opportunities. Caring responsibilities may influence education and employment choices, and flexibility is an important factor in enabling young carers to balance different commitments. The negative impact of combining caring and education may have potentially significant enduring consequences for workforce participation, and geographic and social mobility, with the risk of compounding deprivation and inequalities^[39].

Young carers are a diverse group of all ages and backgrounds and live in all areas of Scotland. However, analysis of data from Scotland’s Census in 2011 shows that caring is more common in some groups of young people than others. The data suggests that as children become older, more of them regularly provide a few hours of caring per week. The majority of young carers and young adult carers are female. A higher proportion of young people in the most deprived areas report providing care and they provide the most hours of care. Young carers in rural areas may face additional challenges due to the more dispersed nature of services and facilities^[40].

3.3 Social care workers

Scottish Social Services Council (SSSC) data show that the social care workforce (not including Personal Assistants), is older than the general workforce. The average age of social care workers varies between services and sectors; public sector services tend to have the oldest workforces (average age 51), while the private sector has the youngest (average age 42)^[41].

There is no national data collected on personal assistants, however there is some data on those who recently received the Scottish Government pandemic thank you payment for social care workers^[42], which suggests that this group may also be older than the general workforce. Almost half (47%) of the Personal Assistants who received the thank you payment were aged 51 and over, though this may not be representative of the Personal Assistant population as a whole^[43].