In this section, older people are defined as those aged 65 years or over, unless stated otherwise.

Inequality
Mortality data by social class are limited in older people, because occupation is not recorded at all on the death certificates of men or women over the age of 75 years and is recorded for married women only if the woman has been in paid work for the majority of her life. Thus, alternative measures of social classification, such as housing tenure, are needed to describe socioeconomic differences in mortality in older people. Compared to the national average, the mortality rates in people aged 60 to 74 who had been living in local authority rented accommodation showed a 16 per cent excess, whereas rates for people who had been living in owner occupied accommodation showed a 13-14 per cent deficit412. Although data are available on fewer specific causes of death than in younger cohorts, patterns seem to be similar after the age of 65 years. The most pronounced differences between socioeconomic groups are for lung cancer and respiratory disease, coronary heart disease and stroke, all of which show higher rates as disadvantage increases 30,412,413. Life expectancy at age 65 years is 2.6 years greater in men (2 years greater in women) from social classes I and II compared to men from classes IV and V31.

Prevention of morbidity and disability rather than mortality may be a more relevant focus in older people. Available data, which are fewer than those for younger age groups, suggest that older people experiencing disadvantage tend to have poor health. Respiratory function is lower and blood pressure higher in people from lower socioeconomic groups37. Older people from lower socioeconomic groups have higher rates of total tooth loss than those from higher socioeconomic groups414. Long standing illness prevalence is greater in unskilled manual groups of men over the age of 65 years than in men from professional groups, 72 per cent and 53 per cent respectively. However, there is no corresponding difference for women28.

The following sections set out specific inequalities in the health and socioeconomic determinants of health in older people, and summarise the evidence which we have concluded indicates areas for future policy development to reduce these inequalities. These areas are: promoting the material well-being of older people; improving the quality of their homes; promoting the maintenance of mobility, independence and social contacts; and improving health and social services. The sections on each also indicate the benefit which may result from such policies. The inequalities, evidence and benefit in relation to most of these policies have been discussed in earlier parts of this report. They are raised again in brief here, with particular regard to their relevance for older people. As the majority of older people are women, and the ratio of women to men increases with age, some areas are discussed again in the section on gender.

Promoting material well-being

Inequality
Older people are more likely to be living in poverty, whether this is defined as below half-average income or the receipt of means-tested benefits65. This is particularly true for older women. There are three times as many female as male recipients of Income Support77.

Evidence
The poorest pensioners, who rely most on benefit, have experienced a relative deterioration in their income. This is the result of cutting the link between increases in earnings and annual rises in pensions and benefits in the 1980s. Current levels of pensions are not generous compared to other European Union countries79. Older people are at risk of fuel poverty96,97, and may face extra costs in purchasing social and health care. Disabled pensioner households are more likely to be reliant on state benefits than non-disabled pensioner households415.

Around one million state retirement pensioners do not take up the means-tested benefits to which they are entitled, losing on average £16 per week86,87. A number of factors may operate, including lack of knowledge of entitlement, a perception of being stigmatised by the receipt of benefit, and physical or other difficulties in the processes of claiming. Possible ways of overcoming some of these problems are the establishment of new organisations or agencies: a separate pensioners' agency88; a citizens' bank88; or a welfare counsellor in primary care89. Schemes such as welfare counselling in primary care could also raise awareness of other entitlements, for instance free dentures. Fear of cost is thought to deter some poor older people from seeking services and aids which would, in fact, be free to them416-419.

Benefit
Measures which increase the income of poor older people are likely to improve their living standards, such as promoting better nutrition and heating, and so lead to improvements in health.

27. We RECOMMEND policies which will promote the material well being of older people. Specifically:

we recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits among entitled groups (recommendation 3.3).

Improving the quality of homes

Inequality
Properties in poor condition are disproportionately occupied by single older people, and tend to be older, privately rented properties209. Older women are particularly likely to live alone420,421.

Evidence
Unmodernised homes have high heating costs. Cold housing leads directly to hypothermia and may contribute to the excess of winter deaths seen in older people208,215. It also leads to fuel poverty96,97. Schemes which aim to improve insulation and heating efficiency are the most direct way of addressing this problem. Poor housing design contributes to major accidents in older people and seemingly minor accidents which may have grave consequences208. Home visits for the assessment and modification of hazards can reduce falls in older people422.

Benefit
Removal of hazards in the home is likely to lead to reduced death and injury from accidents. Improvements in home design may allow older disabled people to be cared for at home, with improvements in their quality of life.

28. We RECOMMEND the quality of homes in which older people live be improved. Specifically:

we recommend policies to improve insulation and heating systems in new and existing buildings in order to further reduce the prevalence of fuel poverty (recommendation 12.1).

We recommend amending housing and licensing conditions and housing regulations on space and amenity to reduce accidents in the home, including measures to promote the installation of smoke detectors in existing homes (recommendation 12.2).

Promoting the maintenance of mobility, independence, and social contacts

Inequality
Lack of access to transport is experienced disproportionately by older people229, limiting their access to goods, services, opportunities and social contacts423,424. This is particularly a problem for older women40,282 and older people who are disabled425. Older people are more likely to fear becoming victims of crime than younger people. This restricts their opportunities to leave their homes, particularly at night220.

Evidence
High traffic volumes result in feelings of insecurity234 and decrease walking as well as the use of other transport426,427. The use of public transport is partly determined by price238,239. There are over 10 million older people who are eligible for concessionary fares. Concessionary fare schemes vary from place to place258 and in places are very limited. Furthermore, uptake of concessions is lower in areas of low population density, and only 39 per cent in rural areas259.

Benefit
Greater opportunity for travel through the availability of affordable and effective public transport should remove a barrier to health-promoting opportunities. For example improved access to community based leisure facilities, which might include the facilities of health promoting schools, should allow increased opportunity for older people to enjoy physical and social activity. Increased exercise is important in preserving muscle tone. This decreases the risk of falling and thus injury, and reduces the disability caused by osteoarthritis.

29. We RECOMMEND policies which will promote the maintenance of mobility, independence, and social contacts. Specifically:

we recommend the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in (recommendation 13).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands (recommendation 18).

Improving services

Inequality
Poor older people may be less likely to receive some health care services428,429, or may have poorer health outcome after receiving these services428. For instance severe visual problems are more likely to remain unrecognised and untreated in older people from low socioeconomic groups430,431.

Evidence
Functional capacity relies on sight, hearing, mobility and continence. Older people from low socioeconomic groups have higher rates of ill health and disability than those from more affluent groups. Health and social services can ameliorate the experience of poor health and disability in old age, and should be accessible and distributed on the basis of need. However, levels of domiciliary support are insufficient to counter an increasing trend for more older people to enter residential care425.

Although data are sparse, user fees - for instance for sight tests or dentures - may deter poor older people from seeking services416-419. Where demand for services exceeds supply, such as for social services support - home cleaning, shopping, bathing and meals - user fees may disadvantage those below average income, even if the poorest groups are protected through means-testing. Furthermore, poorer older people are less able to bear the additional costs of disability, such as the additional laundry costs associated with incontinence. Whenever a significant private sector exists, for instance in chiropody, poorer older people are likely to have decreased access428.

There has been considerable discussion on whether "ageism" exists within health services428,432. Ageism in this context means the withholding of beneficial care, on the basis of the person's age. The Inquiry has not considered inequalities in health (or health care) by age group to be within its terms of reference. However, we consider that services should be provided on the basis of need, and that age alone should not be a reason for withholding a service.

Benefit
By definition, services distributed in relation to need will result in health gain, which will be greatest in those most in need.

30. We RECOMMEND the further development of health and social services for older people, so that these services are accessible and distributed according to need.

Monitoring inequalities

Inequalities in health that are demonstrable earlier in life persist throughout the lifespan into old age428. However, there is a lack of routinely collected reliable data on social class or other markers of socioeconomic status in people after the age of retirement. This leads to particular problems in monitoring inequalities in health and its determinants in older people.

We recommend a review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level (recommendation 1.2).