The fact that people now live longer has been a source of concern for some years now. At the same time, many older people say they are happy and report high levels of well-being, while research is beginning to suggest that the proportion of old people with poor health may be reducing. So should this phenomenon be a cause for celebration rather than concern? Professor David Oliver, President-elect of the British Geriatrics Society, looks at the evidence and calls for a fundamental shift in approach and priorities.
When the NHS was founded in 1948, 48 per centof the population died before their 65th birthday. It is now only 14 per cent, with the “oldest old” the fastest growing demographic. Already, life expectancy at 65 in England is around 17 years for men and 19 for women. By 2030, a 65 year-old man will expect to live on average to 88 and a woman till 91. That’s a long time in the traditional “post-retirement” phase.
We should avoid using sensationalist and catastrophising language, which foments ageist attitudes (well-evidenced in the 2009 Centre for Policy on Ageing Reviews on age discrimination in health and care) around the “grey tsunami”, “ticking time-bomb” or “burden” of ageing. Ageing should instead be a cause for celebration.
Better housing, diet, workplace safety, safer childbirth, higher wealth and better universal welfare have played their part in this success story. So has public health; for instance in reducing smoking or mass vaccination and screening programmes or in reducing the spread of infectious diseases; what we might call “primary prevention” across the life course.
Although there are still huge inequalities both in absolute life expectancy and disability free life expectancy between different groups of older people. Many of the differences are explicable through preventable lifestyle factors such as obesity, exercise, diet, smoking, alcohol or social engagement.
The management in primary care, of long-term conditions and risk factors such as diabetes and hypertension has also played a part. So has interventional treatment for conditions such as stroke, heart disease, lung disease and infection, so that people now survive what were former mid-life killers. And of course, we should all celebrate our increased chance of surviving and thriving in older age.
Embrace the challenges
So policy-makers should naturally embrace the “challenges”, rather than the “threat”, of ageing populations. These include retirement age, affordability of pensions, the role of unpaid family caregivers, already estimated at 6 million in the UK and with demand set to outstrip supply, and the need, with birth-rates low, to have sufficient workforce to care for our most vulnerable older people.
Crucially, the core business of health and care systems will increasingly be the care of older people with frailty, dementia, complex co-morbidities and a degree of disability or dependence.
We haven’t quite up caught up with this reality in attitudes, skills, knowledge and system priorities. We need to get with the programme and make systems “age proof and fit for purpose”.
Happy in old age
It is important at this stage to make it clear that most older people are not unhappy, isolated, in poor health and dependent. Major cohort studies such as the English Longitudinal Study of Ageing, Newcastle Over-85 Study, or surveys such as the Census, General Household Survey, Health Survey for England provide the evidence. Self-reported happiness peaks in the 70s and 80s.
Two thirds of UK residents over 75 rate their health as “good” or “very good” and around half say they don’t live with life-limiting long-term conditions. Only one in five report feeling lonely. The evidence suggests that, if anything, the proportion of older people with poor health or disability is not increasing and may be reducing; all excellent news.
BUT…. and there is a big “BUT” coming, with an increasing proportion of society being older, there are challenges we can’t duck or postpone.
Long term Conditions
With increasing age, people are likely to live with multiple long-term conditions. (Over 75 at least three is the norm – many conditions specifically age-related). Frailty is also more prevalent. Older people who are frail fatigue easily, have slow walking speed and weaker muscles and poor homeostatic or functional reserve. This means they can often present to services with problems such as acute confusion “delirium”, falls, immobility, incontinence or a non-specific “failure to thrive”, sometimes disgracefully labelled as “acopia” or “social admissions” to hospital.
Dementia already affects 800,000 people in the UK with this figure set to double over the next two decades. And although most older people are not disabled, most disability is in older people. We would never know this because we have “normalised” disability as part of ageing; whether poor mobility, sensory or cognitive impairment. Loss of mobility or independence is a particular problem in older people who become acutely unwell.
Prescribed medications also increase with age: for instance with over 75s being on a median of 5 medications and 10% being on ten or more. Older people are more likely to rely on informal or formal care, including the 380,000 or so UK residents in nursing and residential homes, three times the hospital population.
Finally the older you are, the more likely you are to interact with multiple services, multiple professionals and suffer multiple transitions.
Shift in approach
To move towards models of care and support which reflect these realities, we need a shift of approach and priorities. This includes:
- moving far more towards prevention across the life course and mature life course
- a focus on people (with multiple long term conditions) rather than single disease entities
- a growing recognition of the importance of frailty and dementia, and of the need to support and educate informal carers.
- it requires our institutions such as acute hospitals to be fit for the people who actually use them (generally the old and frail) and a workforce with the right skills, training and values (in the right setting) for this challenge
- it also requires care which is more integrated and focussed around delivering person-centred co-ordinated care
There are many examples of local services around the UK which are already delivering solutions to these wicked problems, despite austerity and despite political reorganisation. We need to stop obsessing about “innovation” when we already know what good looks like and get on with spread, adoption and implementation. So what are the biggest things policy makers could do?
- Acknowledge that our services are underfunded relative to many OECD comparators and bridge the gap.
- Ensure the resource is re-allocated to focus more on prevention and community support.
- Scrap the nonsensical distinction based on an accident of history between what is counted as “social” versus “health” and make permissions far easier for joint working, merged organisations and pooled funds.
- Ensure that we select and train staff who have an interest and skills in the care of the old.
- Please, please put an end to short-term, non-recurring monies which hamper 5-10 year planning and lead to serial “projectiles”, “pilotitis” and parallel running of numerous similar services.
If we always do what we’ve always done, we will always get what we’ve always got. Population ageing means that this is not an option. If we transform our approach, it is potentially “win/win” for public services and for older people and their families.
Professor David Oliver is a visiting fellow of the Kings Fund and is president-elect of the British Geriatrics Society.