THE change in his elderly patient, says GP Dr Adrian Hayter, is remarkable. “She’s been living with gradual dementia for the past five years,” he says. “And her condition is sadly worsening. But when she talks about her grandchildren, how she sees and plays with them every week, her eyes light up. Her speech becomes clearer, she’s more animated, you see instantly how it really sparks something within her. And that benefit to her psychological capacity has a huge impact on her overall health.”
Of course stimulation has long been known as a way to maintain capacity, whether that’s cognitive, physical or psychological. But, says Dr Hayter, connecting people of different ages, like his patient talking about her grandchildren, can enhance those benefits even further.
“Intergenerational activity can and does play a valuable role in healthcare,” he adds. “And it doesn’t just benefit older people, but everyone involved.”
Dr Hayter sees those benefits every day, both as partner at Runnymede Medical Practice in Surrey and in his wider role as the NHS’s national clinical director for older people and personalised care. And an intergenerational approach, he says, has a huge impact on he calls the cornerstones of living as healthily and happily as we can into old age.
“The World Health Organisation has identified six domains of ‘intrinsic capacity’ which are vital to healthy ageing,” he explains. “Cognitive, mobility, nutritional, sight, hearing and psychological. All of these keep us part of the world around us, and the concept of activity and connection between different generations is a huge part of that.”
Bringing young and old together can, he says, especially boost everyone’s psychological capacity. “Things like, say, music – intergenerational music making – enables those interactions, it’s social, it brings people together to share an experience. That concept of intergenerational activity is weaved into all the domains of intrinsic capacity, makes us healthier and happier as we get older, and therefore brings huge benefits to wider society.
Dr Hayter is, unsurprisingly, a keen advocate for Intergenerational England, an organisation dedicated to bridging the divide between generations by fostering all-age collaboration across diverse organisations and sectors such as health, housing, transport, education, and employment.
Health is an excellent place to start, he says. In particular, he believes intergenerational approach is a fundamental component of the United Nations Decade of Healthy Ageing, which runs until 2030 and is a global collaboration to improve the lives of older people, their families and the communities in which they live.
“There are so many presumptions about older people and their capacity, and that has shaped their healthcare and imposed restrictions on how they access it,” he says. “In my 30 years as a GP I have observed what has fundamentally been ageism, the healthcare inequality agenda that puts up barriers to people getting certain services because they’ve been assessed according to their age, rather than their individual needs.”
Dr Hayter cites the example of a patient in her late 90s who suffered a stroke and then calmly drove to his surgery. “We treated this lady by looking at her overall health situation,” he recalls. “She had excellent cognitive ability, a good social life and strong interactions with other people. We created her care plan with her, asking ‘What matters to you? What’s important to you?’ Between us we decided on thrombophlebitis treatment which gave her a quality life for nearly another 10 years.”
Such personalisation of care is key to combatting ageism, says Dr Hayter. “Decisions around implementing such interventions such as rehabilitation, physiotherapy and other plans have tended to be made according to a broad metric of how old someone is,” he says. “Younger people have tended to be offered them as a matter of course, while people above a certain age haven’t. That is fundamentally ageist.”
This discrimination was, he adds, particularly in evidence during the first wave of the pandemic when doctors tended to base their care decisions exclusively on an NHS metric called the Clinical Frailty Score. “As hospitals became overwhelmed, if you had a CFS score of XYZ which rated you “severe”, you automatically wouldn’t get access to certain treatment,” says Dr Hayter. “That’s an example of ageism that we need to be cognitive of and it can crop up in any kind of situation in healthcare. We have to take a much more open view of age and a holistic view of what suits the individual patient. It’s easier to do this in general practice, where we know our patients. It’s more difficult in a hospital setting where the doctor doesn’t know the patient, but the NHS is striving to provide more personalised care that looks just beyond someone’s age. Healthcare shouldn’t be a ‘one-size-fits all’ solution based on assumptions around how many years someone has lived.”
That means applying Intergenerational England’s central tenet of giving equal weight to everyone’s experience, knowledge and opinions, regardless of their age. “We shouldn’t be making these calls in isolation as professionals,” adds Dr Hayter. “They should be informed by medical scientific evidence along with a holistic view that includes patients contributing to the conversation, and being heard.
“That goes beyond just talking to a patient when they’re in front of you. It’s about having their wishes communicated really well, having them written down. That’s where general practice can work better by sharing records, distributing a care and support plan that portrays those wishes that can be taken into account even when a patient is unconscious.”
Giving genuine, sincere respect to the opinions of older patients opens up the education of younger people – leading to a truly cross-generational approach. Intergenerational England’s ambition reaches beyond teaming the old with the young: it provides spaces for every generation to learn from every other generation – something Dr Hayter fully endorses. “It’s a double win,” he says. “I am part of a trip to Lourdes every year and there are many older people on the trip, but 17-and-18-year-old schoolchildren come along as volunteers, and every single time that’s a hugely transformative experience for those young people. That’s not just in terms of exposing them to the concept of caring, giving them skills or the understanding of what an older person’s needs might be, but in connecting them as people, seeing that their older companions have lived lives, have a wealth of knowledge and experience, and are interesting personalities. Again, everyone gets so much out of that cross-generational initiative, mentally, physically and emotionally. In the end, it’s not about one generation looking after another. It’s parity, a two-way street, a literal equal opportunity.”
So how can barriers be broken down to ensure this cross-generational approach happens and works? “Much of the work I do is around policy and how we translate evidence of these intergenerational benefits into action,” says Dr Hayter. “That’s looking at the way we design hospitals to meet the needs of all individuals, through to how we deliver particular services, the investments we make to support that, and in my area of course, how intergenerational approaches can help older people. I’m hopeful of change – the new government seems much more signed to that agenda. The chief medical officer Sir Chris Witty wrote a great article last year called Helping An Ageing Society, which focused people’s minds on how we might want to think about living as we age, how we need to spend our resources and the effect on communities.
“My role also means I lead on clinical policy – thinking about different pathways of care, new drug treatments and other therapies. Sir Chris said the priority is to gather evidence around what is out there, what needs to change and how it can change, thinking not just about the care and support of older people but ensuring people of all younger generations live a healthier whole life course. We can feed this into the intergenerational approach, and direct this evidence in terms of policy change to force investment and transform the way we deliver healthcare in a sensible way for everyone of all ages.”
This would better reflect the World Health Organisation’s concept of integrated care for older people. Its ICOPE guidelines offer recommendations based on the best available evidence for strategies in preventing, slowing or reversing declines in the physical and mental capacities of older people – and Dr Hayter says the UK can learn from the international community.
“We do well in the world rankings in terms of longevity of life, but could do better I think for quality of life. In terms of intergenerational activity we can learn from some south-east Asian countries around how families and different generations live and work together in different settings. In Singapore, for instance, they are really putting initiatives into action, such as intergenerational reminiscence, which encourages people to look back on their lives and celebrate them. They also lead on intergenerational initiatives around dementia – a lot of which is not well evidence-based so we need to look at the research there and learn from that. Scandinavia, too, has a very multigenerational approach and a wealth of intergenerational activity. We now have the opportunity in the UK to study that and see what we can learn.
“Greater research into these and our own intergenerational activities could transform the way we do things. Studies and trials around intergenerational initiatives – such as music making and other activities – and not just understanding their impact on cognitive capacity, psychological well-being but being able to see the quantitative and qualitative biological evidence of those benefits could completely change how we deliver health services, and how we can create a better society for everyone of all ages.”