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Our society is ageing, and the scale of our demographic challenge is immense. To choose just one of several striking projections, between now and 2050, the number of people over the age of eighty will triple to around eight million.

At some time in our lives, all of us will be faced with decisions to make about older people’s care, be it our own, or a loved one’s, whether it is in a professional, personal, or voluntary capacity. How will we make such decisions?

At some time in our lives, all of us will be faced with decisions to make about older people’s care

On reflection, the question is not so much about adult social care policies, but the complexity of choosing between different aspects of 'care' which often look very different from conventional models of state provision. The pertinent questions become: Who do we trust to help us make these decisions? What are the risks in making one choice as opposed to another? Should physical safety be prioritised above wellbeing and quality of life?

We explore many questions of this nature in our recently released evidence review: Improving Decision-Making In the Care and Support of Older People: Exploring the Decision Ecology’.

Early this year, the Joseph Rowntree Foundation, as part of their Risk, Trust and Relationships in an Ageing Society programme of work, put out a call for a review of the evidence surrounding risk and trust in an ageing society. The RSA's proposal was accepted, along with a contrasting but complementary proposal from a team at Brunel Institute for Ageing Studies. We focussed our evidence review using decision-making as a lens through which to explore the broader issues. The team from Brunel took a different approach, reviewing contrasting bodies of literature from disciplines including psychology, political philosophy and gerontology.

On Wednesday last week, the two evidence reviews were published at a launch event at Brunel University.  I presented our review, and in preparing what I had to say, I found myself pleasantly surprised by the piece of work we produced.

The process of compiling the review involved several members of Staff from Social Brain and Connected Communities and was not the smoothest or easiest of processes. In all honesty, while we were fascinated by the content and relevance of the work, by the time the final draft was signed off, the process felt so protracted that I think we were all relieved to move on to other things.

So, when I came to talk to an interested audience about what we found, it was rewarding to discover that I felt confident in the value of the overall message of our evidence review. (More generally, it definitely helps to have a gap between completing a piece of work and launching it, which gives you time to appreciate the document as something you have produced, while being free from the gruelling process that produced it.)

The Decision Ecology

Our report paints a picture of the ‘decision ecology’. Jonathan Rowson coined this term to capture the complex social context in which decisions are made, including the diverse range of actors including the older person, their family, friends, neighbours, professional carers, health providers, volunteers, acquaintances and the community at large.

At the heart of this ecology is a triad, consisting of the older person, their informal carers and supporters (such as friends and family) and their formal carers (professionals and practitioners). Like any threesome, this triad is unstable, and the balance of decision-making power tends to be weighted towards the professionals and practitioners.

The insider knowledge that family members have about their older relatives is all too easily sidelined or overlooked, and professional ‘expertise’ takes pole position. The danger is that important personal preferences can be neglected, and decisions made to favour institutional or administrative convenience.

The insights of the Social Brain perspective tell us that the traditional view of decisions being made on the grounds of logic and rationale is at best inadequate. Decisions are still implicitly framed as individual, conscious and rational, but they rarely are. In reality they are influenced by affective, unconscious and social factors, including our cultural biases, negative stereotypes and risk aversion. Because of this, we need to think very carefully about whose perspective (or decisions) should be given precedence, and on what basis.

To make good decisions, it is vital that we build trust. There are various tools and strategies that can help us do this, and taking seriously and making space for personal narratives is one of them. The stories we hear and tell can change attitudes and be emancipatory and empowering. This emphasis on the unrecognised relevance of narrative was a key part of the report.

Challenging declinist stereotypes of ageing is part of our responsibility, along with being reflexively critical about our attitudes to risk.

Most importantly, we need to do everything we can to enable genuine partnerships between care providers, care recipients and their families and supporters. The responsibility for decision-making should be shared as equally as possible, and efforts made to include and respect everyone involved. Challenging declinist stereotypes of ageing is part of our responsibility in this, along with being reflexively critical about our attitudes to risk.

At some point in your life, perhaps quite soon, you will be playing a part in this decision ecology- it is worth reflecting now on what kind of part you want to play. You could do worse than start by reading our evidence review!


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