This is the full version. The shortened version is on the NHSE website.
Many have written on the error of the unending hyperbole of “ageing tsunami” or “the ageing population spells doom for health and social care”, and why our wrong narrative on this matters and does harm. This view takes us in the wrong direction and may be harmful in a number of subtle ways.
This blog will focus on framing a response, building on the previous blog in this series. I will set out some thoughts on what to do about it. I wont cover heath and social care delivery systems for an ageing population. These are important but only a small part of answer. The blog will focus on the broader issues.
2. The “problem”
The term “problem” is used advisedly.
We broadly know the drivers of the population health problem and why it matters. It is true that illness is correlated with age, there are more older people, thus many assume there is more illness is directly associated with the ageing process.
Baby boomers are now getting older and reaching the age where the impact of policy decisions and individual decisions 30 years ago are beginning to catch up with them. Many argue that recent austerity polities and cutbacks in the social safety net are making the problem worse. The recent Civitas report on the implications of the UK’s rapidly increasing population sets out some of the macro challenges of changing demography across a wide range of areas.
The population is growing. There ARE more people in absolute terms in the population many of these are getting to the stage in their lives where loss of function, or the flip side of this illness, is more common. There is continued inequality between groups, for example the age of onset of multiple illness in those in the poorest groups is 15y earlier than those in the most affluent. ONS data would suggest that 22% of people in the most affluent decile have disability aged 55, compared to 34% in the least affluent, or a 20 year difference in onset age. We aren’t getting healthier. Historic improvements in life expectancy have ground to a halt. Improvement in healthy life expectancy are also stalling.
We have neglected the demand management part of health and social care. We have neglected demand management functions and focused on specialist care at the expense of generalist models. This is obviously exacerbated by ongoing changes to the way health and social care is funded. Many would also suggest that the knock on impact of social policy well beyond the NHS is also having a very direct impact on the health and well being of our population.
Of note to the NHS, new models of care or the integration of health and social care don’t look set to achieve giant financial saving on the basis of the evidence so far. It may lead to more efficient use of the same £ envelope, this is a good thing. It will only do so if we focus on culture and frontline, not structural integration. Similarly, we wont solve the social care cost crisis till either funding settlement is sorted (seems unlikely) or we sort out the demand that’s driving it. That comes from downstream consequences of poorly folk and certainly less than perfect well being. Wanless told us this 12 years ago. Everyone ignored it. It seems unlikely we will solve the NHS problem till we solve the problem of demand management (degradation of primary and social care) and drivers of demand (poorly folk again). Wanless told us this 15 years ago. Everyone ignored it.)
These are not problems of ageing per se. They are problems of our failure to prevent and promote the best possible well being.
WHO are increasingly vocal on Ageing and Health and have recently published a global strategy, with a new definition of healthy ageing:
“The process of developing and maintaining functional ability than enables well being in older age”, or more bluntly enabling people to do what they believe is valuable and wide enough to encompass wider social processes welfare reform, poverty, employment, spatial planning and housing, amongst other areas.
This definition requires a very broad response. Single sector responses will not be sufficient.
Only last week the HMG Industrial Strategy identified ageing as one of the grand challenges facing the country, usefully locating the concept in a framework of the economy and well outside of health & social care.
3. Towards solutions – A social policy on ageing – wider than health and care framework
Often we see ageing as a “problem for health and social care” and thus approach solutions with this in mind. We need a social approach, ageing is a social issue, not clinical one.
The aim of better ageing might legitimately be expressed as to delay the onset of loss of function or independence often associated with “ageing” but more correctly associated will illnesses. Prof Walker’s article sets out a wide range of specific areas of and provides an excellent route map that pushes us away from a medical model towards a social model. The MICRA Golden Generation report highlighted the multi factorial nature of the aspects of the solution and underscored the need to address social, economic and community aspects in our response as well as biological, physiology and psychology.
Perspective – whole of society or health and social care system looking outward (or inaward)
Decision point one is whether the “answer” is whether “ageing” response is health care system looking out or we start with a societal paradigm. Only a small chunk of the necessary response to the problem lies within the health and social care sector.
Arguably even the WHO framework is a little “health system looking out”, rather than a truly social model of ageing. Lynch recently warned of the dangers of medicalising the solution, in the context of health inequalities. The same principle applies here. This is a societal issue not a health and social care issue. That isn’t to say there aren’t changes that might helpfully be made in the way health and social care is delivered.
A life course approach to ageing is not an “older people” issue
A life course strategy obviously commences from pre birth, and all life stages; and obviously incorporates social policies with a wide range of focus. Ageing is a life course issue, it starts from birth (or before) and what happens early in life has been proven many times to fundamentally affect life course trajectory. Just as if we wait till we are 65 to sort out our pension – it will be too late, if we see “ageing” as only a problem of “the elderly” it will be too late and any return may be marginal compared to a whole life course.
An asset based approach.
There’s obviously a need to a focus on an asset based model, at both individual and community or city level. These are flip sides of the same coin and the approach should be focused on increasing the ability of communities to be resilient and thus changing the threshold at which individuals in that community become “dependant”. Focusing on asset based approaches has the benefit of moving us away from the narrative of the older population are a “burden”, and towards older people being the solution.
4. An organising framework
The Five Ways to Well Being is as good as any framework to hang a practical response around. It can and should be applied at multiple levels, from individual to city and larger. To remind you – connect, be active, take notice, keep learning, give.
The WHO strategy has identified ten priorities for a decade of healthy ageing. Five abilities are considered particularly important, and might set a framework for a strategy.
• Basic needs
• Learn grow and continue to make decisions
• Be mobile
• Build and maintain relationships
• To contribute
A comprehensive strategy should as a minimum cover five strategic objectives:
• Long term commitment to action on Healthy Ageing;
• developing age-friendly environments;
• aligning health systems to the needs of older populations;
• developing sustainable and equitable systems for providing long-term care (home, communities, institutions); and
• improving measurement, monitoring and research on Healthy Ageing.
5. There is no single thing. If only there was one thing to do. Some specifics
What interventions should we implement please? There isn’t a single silver bullet. Nor is there a single policy lever or intervention. The answer is as much about culture change, places and policy environment as it is about what a wide range of services do.
A few thoughts on specific areas of intervention follow. This isn’t in any way comprehensive. It borrows heavily from the2016 Foresight Review on the ageing populationwhich considered longer working lives, skills, housing, health and the family.
a. Age Friendly places are important
The WHO Age Friendly framework has many merits that are applicable across many policy areas.
Specifically, Creating age-friendly environments in Europe. A tool for local policy-makers and planners (2016). A coherent societal response to better ageing must encompass domains of physical and outdoor environment, transport and mobility, housing, social participation, social inclusion and non discrimination, civic engagement, employment, communication and information, community and health services. It must also focus on economic wellbeing, quality of work, retirement processes and social and cultural engagement.
b. Working lives. Work is good for us, at all ages, and has personal and economic productivity benefits.
The numbers working beyond state pension ages have risen significantly in recent years and this is projected to continue. Keeping people well so as to maximise wellbeing is important economic issue, there are obvious economic losses for those who retire early on account of illness. Many have quantified these, and the loss is many £billions.
As more than half of over 60s have 2 or more long term conditions, this makes prevention and delaying and treating those conditions a quality of life AND an economic issue. Supporting the ageing population to lead fuller and longer working lives will require an examination of the factors that are causing employment rates at older ages to vary across the population. Those who have involuntary retirement and unplanned retirement acquire disability quicker, we know there is socioeconomic difference in the early retirement rate, obviously feeding into wider inequalities in outcomes.
The Centre for Better Ageing recently highlighted that almost a third of 50-64 year olds in the UK are not in work – some 3.6 million people, and suggested a number of challenges and solutions to enable people over 50 to avoid the unemployment trap from improved health through to lifelong learning and reskilling. There is also a need for employers to consider adaptations to the workplace including addressing negative attitudes to older workers and health needs, improving workplace design, encouraging access to new technologies, and adaptation of human resources policies and working practices.
c. Lifelong learning
Learning boosts mental capital, which in turn increases individual resilience in later life. The benefits of learning in later life and whether include reskilling for new roles, brain health, reducing social isolation. However 4 in 10 of of 55 to 64 year olds have undertaken no formal training or education since leaving school. Improving participation in learning could enhance later life working and productivity and build mental capital and resilience.
Employers should develop opportunities to enable people learning new skills in older age, this should enable people to keep up to date and to develop new skills suitable for ability. This may be through formal apprenticeships or through other means.
The current model of education and skills development focuses education at the beginning of a person’s lifetime. As working lives lengthen, and the workplace undergoes major changes, job-related training will become almost as important to people in mid-life as at the beginning of their career. This will require the UK to move towards a model where training and re-skilling opportunities are available throughout people’s careers.
The principle challenges to improving learning opportunities frim adulthood into later like may be cost and who is responsible for paying. Others include attitudes (amongst learning providers, employers and older people) and personal circumstances, such as lack of time, work and family commitments.
The University of the Third Age – U3A – is an under utilised resource. This movement has a role in democratising lifelong learning in a way where traditional education providers may not see a business case to do so.
d. Moving regularly to maintain strength, improve fitness and slow or preventing frailty. And thus avoid the need for care
Major physical and mental health risks and substantial health and social care costs are the products of inactivity. McNally et al recently set out an agenda for avoiding unnecessary social care. The same principle applies to avoiding unnecessary health care.
It’s a simple thing, coined by many as a miracle cure or magic bullet. It’s called “regular exercise”.
McNally makes a clear distinction between ageing and physical decline, and states clearly that the sometimes drastic loss of ability that many older people experience is not an inevitable part of ageing. Disease can speed that decline and loss of ability. Exercise can significantly delay or prevent disease AND can slow the rate of decline.
There are plenty of examples of this in action, including working with Local Care Homes. A national programme of physical exercise is urgently required and would be expected to have a significant impact providing that it was tailored to specific populations.
e. Ensuring housing and family policy and supply keeps up with demographic and social changes.
Suitable housing can significantly improve life in older age, while unsuitable housing can be the source of multiple problems and costs.
Demand for housing that meets the needs of older people will increase as the population ages. Adapting existing housing stock to meet this demand is critical as even by 2050 the majority of housing will have been built before 2000. Ensuring new housing can adapt to people’s changing needs as they age will also be important, reducing demand on health and care services and enabling people to work flexibly and for longer.
Thinking ‘beyond the building’ to include the neighbourhood and community to enable social activity and to access services are particularly important.
Housing can be a financial asset, providing financial security, and can also represent a significant financial burden if individuals still have large mortgages or rent when they enter retirement. Home ownership rates currently vary widely across regions, socio-economic groups and birth cohorts.
The impact of long run trends in house prices locking many out of ownership may have many impacts we don’t yet understand.
f. Health and care systems
I may write a more detailed blog on this soon.
We are seeing rapid shift away from acute illness towards chronic conditions, multi-morbidities, cognitive impairments and long-term frailty.
Families and communities will play an increasing role in providing care services. As will person centred care and a delivery system with far greater weight on generalist care and design around multiple morbidities.
As I’ve written rather a lot, if the health care system doesn’t improve it’s game re prevention we won’t make a great deal of progress.
The number of people aged 65 and over who need unpaid care is projected to grow significantly. We will need to find ways of supporting unpaid carers to balance other competing responsibilities, particularly work, will help meet the increasing demand for unpaid carers.
73% of disabled people over 65 receive some care from a spouse or other family members. The ageing population, alongside a major increase in the diversity of family types, is likely to change the role of families, and challenge policies that rely on them.
There is limited understanding of the impacts the trend in lone parent households will have, especially on the future provision of unpaid care.
6. Moving it on
The business case for ageing well.
Its easy to delay the investing in future gains if we haven’t enough capacity today, furthermore often what we are judged on is small, visible and often high profile. This may not be what makes the most difference, especially in a long term perspective.
I don’t know how many times in my career I’ve heard the “must sort out prevention and social care” line. First time I really heard in earnest was Wanless 20 years ago, I’ve heard it many times since. Each time we seem to get led astray by the rather pressing immediate pressures. This is understandable, but we will never solve the structural problem with more money for more care. More care might indeed be harmful, more care certainly brings us closer to the point of diminishing marginal return, whilst we ignore upstream.
There isn’t a neat business model to describe the gains. Mehta and many others have tried to quantify the substantial future savings by attending to the issues of healthy ageing now. Some come at these from a clinical perspective, some come from a social model perspective. Neither is invalid.
Framing this in the language of short term ROI is also troublesome. The obvious issues are invest now / payback later, agency x invests / agency y sees return, framing in the context of new financial investments rarely changes mainstream thinking – we must change the shape of existing resource commitments, focusing on ROI for “new” things locks in poor value investments already in the system. If we make the point of the exercise only about ROI, and “saving” then we may miss the point. People hide behind the line of “we must have a better business case before we act”. I have commented on this before.
7. Five reasons why don’t we react, or why is our reaction slow and sub optimal.
In the absence of any other push it may take institutions decades to catch up with the demographic and epidemiological shift.
There are five reasons why our response may be slow, each of these reasons is redressable.
1. Firstly, there is deeply ingrained ageism, a short term focus in both financial and political thinking, a narrative that old people “represents a ‘burden’” that is significantly amplified by the mass media, especially the print media. Secondly, the UK’s presently dominant neo-liberal political-economic anti-welfare state paradigm that priorities individual entrepreneurial freedom, private property rights, free markets, and free trade, combined with liberal-inspired austerity politics is making matters much worse, for example by increasing poverty and inequality. Austerity policies since 2010 have exposed, rather than protected, some of the poorest groups while preserving those in the middle and upper sections of the income distribution.
2. Secondly there is seemingly unending faith in the power of “medicine” to “cure” the downstream consequences of the above factors.
3. Thirdly it is arguably too big an issue to be “owned” by one single institution, it is arguably too diffuse. We should try to avoid setting up new infrastructures, trying to avoid cumbersome central programmes. The problem an the answer should be owned at multiple levels across any place, avoiding organisational centric solutions. It anything the “central bit” is the thinking and strategy, doing must be across all organisations.
4. Fourthly, there isn’t a burning platform; the issue is not seen as mission critical to the business – there isn’t a “business case” clearly written and articulated on it. Whilst its easy to say ‘yes we agree to move resource differentially’ the rubber will hit the road when it becomes about cold hard folding cash around.
5. Finally, we don’t yet have the right public facing narrative that avoids focusing on “burdens”.
8. Ageing is inevitable but also malleable.
A coherent response to ageing must be a societal one, it cant be sector specific, and cannot be addressed in silos. It should start from birth, and be a long term approach. It is definitely not an illness to be treated. Thus we SHOULDN’T assume a medical model should be dominant. Work and productivity is arguably the most important area of focus.
However, most domestic policy areas will be affected by the ageing population. Undoubtedly this is one of the ‘grand challenges’ facing the UK, and most other countries. It’s a big issue in every sense of the word. This leads to the rabbit / headlights conundrum. Start somewhere, set the right conditions for success and pick 3 or 4 big (but not too big) initiatives to get the ball rolling.
Ageing is a health and social care thing, a health and wellbeing thing and an economic thing. It matters to, and is impacted by many other policy areas. Single sector approaches arelikely to to sub optimal.