Introduction

The focus of this chapter is on the tertiary level of health promotion – action to promote health in the context of long-term or incurable illness. It is in these circumstances that the link between care and health takes a qualitative turn, and that the importance of care for health is at its most stark. As discussed in Chapter Three, the circumstances in which an increasing number of older people live during the last stage of life before death involve long-term illness and increased dependency on others, and because these illnesses are associated with the end of life they take on greater significance. In high-income countries, at no other time in history has death been so closely associated with old age, and demographic trends show that this association is strengthening in most other parts of the world. The concentration of mortality in old age has profound implications for the way that the care of older people with long-term health problems is perceived. Because of demographic trends and because the much-hoped-for compression of morbidity has not yet occurred, the need for care is increasing rather than decreasing (OECD 2005) and socioeconomic inequalities are reflected in differing levels of long-term illness. Poorer people are likely to suffer from more severe long-term health conditions in old age and to have their health problems occur earlier.

This chapter discusses older people's need for care and analyses policy responses to this. It considers the provision of unpaid care by families and friends as well as paid care by care workers, and critically examines the relationship between these two spheres of care. The intention is not to attempt a comprehensive account of care policies but to highlight key debates in order to pursue the analysis of how the overarching policy aims of cost containment and promotion of active ageing are played out in the context of dependence in old age.

Dependence on others: the need for care

A recurring theme within this text has been that an over-simplistic portrayal of global demographic trends has generated a particular view of rising dependency levels as a global economic problem.