Does an ageing population lead to increased healthcare costs?

In every population every individual is ageing. To say that we have an ageing population means that the average age of the population is rising or that the proportion of the population above a specified age is increasing.

This might be because people are living longer.

It might be because fewer people are dying young so that more people live to be old, but when they do become old they don’t live any longer than old people always have. Or it might be because the average age of death hasn’t changed but the number of young people being born or migrating in is not keeping pace with the number of people who are maturing into old age. This demographic ageing is nothing to do with changes in longevity but arises because of changes in birth rate or immigration now or in the past. This could arise either because of a fall in the birth rate or in immigration or because a large cohort of the population is coming into old age or into a more advanced stage of old age because of increases in birth rate 65-90 years ago.

DEMOGRAPHIC AGEING

Demographic ageing undoubtedly increases health and social care costs. Around the turn of the 19th/ 20th centuries there were sharp falls in infant mortality. Prior to that people had had large families but many of the children had died. Later on in the 20th century, when people realised their children were going to survive, they started to have smaller families. But for about a generation there were large families most of whom survived.

This began to cause demographic ageing as this generation reached old age in the last third of the 20th century. At first it affected a disproportionate number of women because a large proportion of the men had been killed in the First World War. Society was ill-prepared for it because the large number of single women created by the slaughter of men in the First World War had led to an expectation that there would always be a single daughter around to look after elderly parents but by the time this generation reached old age they had fewer children, fewer unmarried daughters, and fewer daughters who had not found another role in life as women were now educated and economically active.

Towards the end of the 20th century we began to see the coming into old age of the men who had been too young for the First World War and around the turn of the century the coming into old age of the first generation of men to have lived their entire adult lives in peacetime. This added to the demographic ageing but without the same gender gap.

Demographic ageing eased off in the first decade of the 21st century but in 2011 those conceived on VE night became 65. In 2016 they became 70. In 2036 they will become 90. This ageing of the post war baby boom is now the driver of demographic ageing. It is not as intense a process as the ageing that occurred at the end of the previous century.

There is however no doubt that demographic ageing increases health and social care costs by adding to the proportion of the population who are part of a group with higher than average need.

INCREASING LIFE EXPECTANCY

However demographic ageing is no longer the only factor in the ageing of the population. Life expectancy is also increasing.

That component of an ageing population which is due to increasing life expectancy does not necessarily increase health and social care need. A lot depends on how healthy we are in old age.

Let us assume that at the moment disability (and hence health care costs) occur as follows:-

The fear is that increasing life expectancy does not delay the onset of disability, it simply makes it last longer. For every extra year of life there is an extra life of woe. We live longer, but the extra time is spent taking longer to die.

In this case there will be a huge increase in disease burden for the individual (and hence health and social costs for the population) as a result of an increased life expectancy

Another possibility however is that all that happens is that disability and death are both delayed. For every extra year of life woe is delayed by a year but there is no change in the amount of woe. We live longer and the extra time is spent living – we spend no extra time on dying.

In this case there will be no increase in the disease burden incurred by the individual. At a population level the health and social care costs will be delayed and the proportion of the population incurring them at any one time may therefore be reduced.

An intermediate possibility is that disability may arise at the same time but may develop more slowly. Woe increases with the extra years but not by as much. We live longer and the extra time is partly spent enjoying more life and partly spent taking more time to die.

In this case there will be some increase in the disease burden incurred by the individual and some increase in the health and social care costs incurred by the population, but it will not be anything like as great as in the first scenario.

The most optimistic scenario however is that we will live longer and we will spend less of that time ill. For each extra year of life there will be fewer years of woe. We will live longer and die quicker. My preferred mode of death is to be shot by a jealous lover at the age of 104.

If this scenario is correct then the lifetime disease burden on the individual becomes less as life expectancy increases – we have the double benefit of living longer and suffering less. Health and social care costs for the population are both diminished and delayed – again a double benefit.

The theoretical basis for the nightmare scenario (longer life more disease) is that as people avoid the causes of premature death – infections, accidents, heart disease, violence, famine – they come to live long enough to suffer from chronic diseases and as a result to suffer a greater and longer disease burden.

It is certainly true that people have to die of something and that diseases that are commoner in older people, such as cancer, increase in incidence as diseases that kill a lot of young people decline. But the theoretical basis for the delayed disease scenario (longer life, same amount of disease) is that there is no particular reason to suppose that these diseases will cause a greater burden. Most people make most use of health care in the year before their death. This is true whenever that death is. Therefore if most people die when they are old that is when most health care costs will occur. It has nothing to do with age – it is related to proximity to death.

The optimistic scenario (longer life less disease) was first put forward by Fries and became known as the compression of morbidity scenario. Fries believed that if death from disease were avoided people would eventually die of old age. He believed there was a natural age of death which varied for each individual but was normally distributed around an age that increased by a few months each generation, having been three score and ten in biblical times and now being four score and five. This was genetically programmed, probably in the part of the chromosome known as the telomere. We would not be able to increase this maximum longevity, apart from the few months by which it naturally increased each generation, until we were able to genetically re-engineer the telomere, at which time massive extensions of longevity would occur. Until then all increases in life expectancy would be achieved by increasing the proportion of the population who survive to the maximum longevity. Death from old age is, Fries argued, quick. Hence if more people survive to reach this maximum age the total amount of morbidity would be reduced.

An alternative theoretical perspective, without the concept of a maximum longevity, but still with the perspective of compressed morbidity, views ageing as a harmonious deterioration of organ systems which diminishes resilience and increases the probability of death. Old age brings “frailty” – a term used here with the particular meaning that people are fully healthy and fit but are less likely to recover from factors which disturb that health and fitness. Improving population health delays people experiencing the disease that will kill them. The older they are when they encounter that disease the less resilience they will have and the shorter their death will be. On this basis the compression of morbidity consists of somebody living on, fit and well, into old age until they die suddenly of a disease or injury which a younger person would have recovered from.

In a theoretical population with no migration and a fertility rate that maintained a constant population the proportion of the population experiencing the need for health and social care associated with the disability and dependency of old age would be given by the formula:

Life expectancy minus healthy life expectancy

Life expectancy

As life expectancy appears in the denominator of this equation then an increase in life expectancy will in itself reduce the proportion, provided it is matched by an increase in healthy life expectancy so that the numerator doesn’t increase.

For example:

The increasing 20 years life expectancy (from 70 to 90) with an unchanged gap between healthy life expectancy and life expectancy (5 years) has reduced the population burden by 1.6 percentage points out of 7.1 percentage points, a reduction of 22.5%

However changing healthy life expectancy affects the figures even more spectacularly:

An extra 5 years of healthy life expectancy with constant life expectancy of 75 reduces the population burden by half.

If compression of morbidity occurs these two effects would operate together reinforcing each other:

It must be emphasised that these are theoretical figures which address only the non-demographic component of an ageing population. The increases in need due to demographic ageing also need to be taken into account.

There is real evidence to support the compression of morbidity theory. The gap between healthy life expectancy and life expectancy is lowest in areas with the highest life expectancy. People in such areas not only live longer but they experience less sickness in that longer life.

THE IMPLICATIONS OF THE ABOVE ANALYSIS FOR RESOURCE ALLOCATION

The above analysis suggests that the burden of an ageing population will fall most heavily on those areas with the lowest life expectancy. Resource allocation for both health and local government currently assumes that the burden of an elderly population falls most heavily on areas with the largest chronologically old population. This neglects the fact that in deprived areas people become sick sooner and are dependent for longer within that shorter life. Current resource allocation policies therefore direct the resources available to deal with an elderly population to the wrong areas. Apart from areas which have high elderly populations because they are popular areas for retirement, the areas with the largest chronologically elderly population will be those where people live longer and have correspondingly shorter gaps between healthy life expectancy and life expectancy.

A striking example of the difference between chronological age and dependency is given by the difference between two alternative formulations of the dependency ratio.

If the dependency ratio is formulated as

People over the age of 65

People of working age

it is at its highest ever and will inexorably continue to rise.

If however it is formulated as

People within 15 years of life expectancy

People in work

it is at its lowest ever and not likely to increase significantly in the near future.

This is partly because as life expectancy increases the age at which people enter the numerator of the second ratio also increases. It is also because of increasing female participation in the workforce and increasing participation in the workforce by people over the age of 65.

WHAT CAN WE LEARN FROM CENTENARIANS AND POPULATIONS WHERE AGEING WELL IS NORMAL?

There are a number of populations in the world where it is much more common for people to live to over 100 and to remain healthy well into old age – Okinawa, Sardinia, some Seventh Day Adventist communities in California, Georgia, and some remote valleys in Ecuador and in Pakistan. These communities have been the subject of study as have centenarians in a number of different countries.

About two thirds of centenarians demonstrate compression of morbidity, remaining fit and active well into their 90s so these groups definitely demonstrate a desirable characteristic. About 30% of the chance of living to be over 100 seems to be genetic but about 70% seems to be environmental. The best documented environmental factors are a healthy diet, exercise (and especially remaining active into old age), social support networks with a strong marriage and good friendships, a strong sense of personal identity with a goal to life, and some element of continuing challenge.

CAN WE PROMOTE HEALTHY AGEING?

One strategy to reduce health and social care spending is to promote healthy ageing. Can we do this?

A healthy ageing strategy must

• encourage people to live the kind of healthy life described in the preceding section, especially to remain active into old age, to maintain friendships and a purpose to life, and to continue with healthy lifestyles, such as healthy diets.
• ensure that people are not encouraged to accept that they suffer from old age when in fact they suffer from treatable illness.
• make it easier for old people to remain active and involved
• support people in staying independent when old age does begin to affect them

The Role of Healthy Lifestyles

The idea that it is too late to worry about good health when you are old is simply wrong. The drive to maintain healthy lifestyles must continue throughout life.

The Role of Expectations and Age Discrimination in the NHS

When I was 58 I began to develop some trouble with my ankle. I found it difficult to walk uphill. I commented to my wife that I felt like an old man when I walked up hill. I was fine when I walked on the flat or swam. However I did have two episodes where the ankle became swollen and painful.

I went to see a physiotherapist. She told me that there was restricted movement in the ankle probably as a result of an old injury in my twenties. She gave me exercises to carry out. Most importantly she advised me to force the ankle to bend when I was walking uphill.

I carried out the exercises. The ankle got a lot better. It still isn’t right. I still have to force it when walking uphill, and I still walk more slowly uphill than I would like. But my life is in no way restricted.

Imagine that I had had the idea that life ends somewhere in your 60s and that by your late 50s you are coming to the end of your life. Many people have that idea, especially in poorer areas. Being 58, I would just have accepted that I couldn’t walk uphill. I would have stopped walking uphill. I would therefore have walked a lot less. I would have become less fit. I would fairly soon have stopped walking. A downward spiral would have gathered pace, all of it as a result of one eminently treatable and not very disabling start.

Suppose that the health professional I had gone to see had said “Oh, it’s just your age”. I would have been a bit distressed that I was wearing out so quickly. I would have felt upset to abandon my ambition to be shot by a jealous lover at 104. But I would undoubtedly have resignedly accepted reality. Except that it wouldn’t actually have been reality. Although it would rapidly have become so as I accepted it as such.

An immense amount of harm and premature ageing is caused by people accepting treatable illnesses as old age and restricting their lives instead of tackling the problem. Often people do this because of a culture that tells them that life ends in your 60s and you are lucky if you reach your three score and ten. We have to fight that attitude and substitute for it a culture which says that you shouldn’t even consider being old until you have reached four score and five and even then think twice about it.

However people often abandon their active lives because the NHS has told them that a treatable condition is “just your age”. This is something we have to root out and bring to an end. It is essential that we take steps to stop this error being made. It is a common error that has devastating effects and that we have to stop.

Experiential training of front line staff can assist with shifting cultural thinking.

The Role of Well Being

Of the five factors which the studies of centenarians and of long lived populations showed to be most strongly associated with a long healthy life, three are elements of well being – social support networks with a strong marriage and good friendships, a strong sense of personal identity with a goal to life, and some element of continuing challenge. A fourth – exercise – is well known to be a factor which promotes a sense of well being.

From an ageing well standpoint it is important that old people are encouraged to retain a place in the world and a goal in life. It is also important that old people maintain social networks, friendships and leisure activities.

From a standpoint of preparation for ageing it is important that these aspects of mental well being play an important part in health improvement programmes.

Iatrogenic Ageing

Iatrogenic ageing is ageing which is produced by failures of health care.

The point made above about misdiagnosing treatable conditions as due to old age is one example.

Another is failure to recognise that there is clear evidence that physical activity is a highly effective treatment for frailty, and is indeed probably the only really effective treatment available. Advising people to reduce physical activity when they become frail, in some misguided attempt to protect them from risk, is seriously wrong.

A third form of iatrogenic ageing was described by Doctors in Unite in section 13 of its evidence to the House of Lords Select Committee on Long Term Sustainability of the NHS:-

1. The burden on the NHS is increased by the failure of social care systems to provide effective crisis intervention leading to people presenting to the NHS. This is well recognised.
2. Equally important but less well recognised is that the burden on social care is increased by failures of the NHS to intervene early to prevent the development of dependency – a process which is increasingly coming to be called iatrogenic ageing.
3. The following is a scenario which will be played out in a number of places in the country today and every day.
4. An old person who lives alone falls or feels unwell and is unable to look after themselves. They need no more than some temporary support but, being unable to arrange any form of crisis care, they or their neighbours or their out of hours GP, sends them to hospital.
5. The hospital admits them to a busy ward with overworked staff.
6. Their nutrition and hydration are neglected by busy staff and nobody has time to mobilise and walk them.
7. As a result they lose mobility.
8. Lacking mobility they are unable to be sent home.
9. After a period of time the hospital starts to say that they have no medical need and to demand that the social care system finds them a place in a care home so that they no longer “block a bed”. However there are no community social care facilities available as they are either closed down or full. The patient remains in the hospital bed and other acutely unwell patients have to be kept in A&E or in corridors.
10. Failing to invest in crisis intervention and intermediate care options to keep people out of hospitals, in staff to pay attention to the nutrition and hydration of people in hospital and in staff to mobilise old people in hospital, is stripping the lead off the roof to make buckets to catch the rain.
11. When people start to become dependent they will initially want to support themselves at home. Support for this will slow the increasing dependency. Inadequate support will turn the home into a lonely place as constraining as any institution. Domiciliary support has been cut to this point already. Like failing to invest in hydration, nutrition and mobilisation in hospital, it is a false economy, stripping the lead off the roof to make buckets to catch the rain.
12. When people do become unable to maintain a satisfactory lifestyle at home they need to be cared for in a dynamic vibrant community (what Nye Bevan, referring to the service that private hotels in the first half of the 20th century provided to those old people who could afford them, described as “the private hotels for the working class”). As one of our members put it “one of the most awful things we see is an old, vulnerable and helpless person stranded in their own home, visited by professional carers four times a day, unable to get out of bed and completely at the mercy of whoever has the number for the key safe. What a terrible existence. I am going into a care home with a lot of other raucous old ladies. I don’t want to moulder away unnoticed in my own home.”
13. Unfortunately year by year pressures on the unit cost of care homes means that they often have to reduce the features which make them a vibrant community. There is some reason to believe that social pressures which focus on looking after people rather than on promoting their independence add to this pressure, as do CQC inspection regimes which have that same mindset. There is a place, albeit probably a limited one, for co-residency, where groups with different needs live together in mutual support. We are concerned by the uncomprehending way in which the CQC approached such a situation at Botton Village in Yorkshire.
14. We need vibrant communities of old people and we need effective domiciliary care which delays the point at which people need to enter them. We are in grave danger, if current funding approaches continue, of having neither of these. If we do not have them the burden will fall on the NHS. We will once again have stripped the lead off the roof to make buckets to catch the rain.

CONCLUSION

Demographic ageing increases health care costs but ageing due to an increasing life expectancy reduces them. We are experiencing both of these processes at the moment. The balance between them can be improved by processes of healthy ageing including addressing the problem of iatrogenic ageing. Short term financial pressures undermine this and worsen the problem – stripping the lead off the roof to make buckets to catch the rain. Because of the failure to understand the difference between demographic and non-demographic ageing current resource allocation processes seriously misallocate resources to the unfair benefit of affluent areas and the unfair disbenefit of deprived areas.