Late-life dependency and the social care crisis
As winter and the flu season approach, health and social care services are bracing themselves for what has become the inevitable surge in older people falling ill. Simon Stevens, chief executive of NHS England has already warned that Britain may well experience the same heavy burden of flu cases that Australia and New Zealand are just coming out of. But it isn’t just hospitals that will feel the effect – when an older person who lives alone is admitted to hospital, they may not be able to be discharged as quickly as both sides might like because of delays in organising a package of care. Add to this mix a cold winter and/or fuel poverty, and England and Wales might be in line for another record year for excess winter deaths.
However the crisis in social care provision is not just a winter phenomenon. Part of the problem is the greater numbers of old, and particularly very old, people due to the larger post-war birth cohorts and the steady increase in life expectancy over the last decades. What is most surprising is that there has not been more notice taken of these trends which have been visible for many years. Perhaps it is because some have equated longer life expectancy with a healthier population and, indeed, anecdotally there is a belief that today’s older adults are fitter and healthier than previous generations. But our recent research suggests this is not true.
Living longer but with more care needs
Over the last 20 years, men’s life expectancy at age 65 has increased by 4.7 years and women’s by 4.1 years. However, not all of these extra years are ones spent independent. Indeed we have seen from the Office for National Statistics that trends in healthy life expectancy and disability-free life expectancy are not keeping pace with gains in life expectancy with a resulting increase in the years with ill-health and disability. But it is difficult to equate these measures with the amount of care that older people may need.
Our recent research is the first to be able to show that only about a third (36%) of the increase in men’s life expectancy was spent independent whilst for women it was only 5%. Most of the gain in women’s life expectancy (58%) was with low level dependency, requiring care less than daily. More worryingly 20-30% of the increase in life expectancy at age 65 over the last 20 years has been years requiring 24hr care. So the social care crisis is not just an issue of more older people but also that those older people are requiring significant amounts of care for longer than their counterparts 20 years ago.
Against this trend of more years with significant care needs, a much greater proportion of highly dependent older people are now receiving care in their own homes rather than in care homes. Our research suggested that if these rates of dependency and care home residence remain, an extra 71,000 care home places for older adults with medium (daily care) and high (24 hr care) dependency will be required for older adults by 2025. As this is against the current climate of care homes closing due to lack of sustainability, it paints a bleak picture.
Addressing a complex problem
Solutions will be required at a number of levels. Our research suggests that alongside extra funding, there should also be a focus on maintaining independence and low level dependency for longer.
Social care is a national issue but is presently devolved down to local authorities. This has meant that increasingly cash-strapped local authorities have to balance between providing care for their older population with their other responsibilities of education, public health, and infrastructure. The result is that care home providers are tending to build homes in more affluent areas where there are greater numbers of self-funders of care and where the care homes are therefore more likely to be viable in the longer term. Our results suggest that men aged 65 will, on average, spend 1.3 years requiring 24 hr care and women 1.9 years. If the state cannot provide the funding for this through taxation or other means, then long-term care insurance products need to be developed, thus allowing individuals to pool their risk and therefore balance out the individual variability in the years requiring care. Our estimates of years requiring different levels of care levels should reduce some of the uncertainty around this.
Secondly, we need to convince older people and their families that much of ageing is malleable. There is good evidence from around the world that functional decline can be halted and even reversed if treated early. The majority of the increase in women’s life expectancy over the last 20 years has been in years with low dependency, requiring help with shopping, laundry and other household tasks, many of which require mobility and upper body strength. Both of these can be improved with regular exercises, or, in the longer term, with aids or adaptations. However this requires a positive action in the minds of older adults, their families, and their healthcare providers, that these are important functions to maintain and their loss should not necessarily be viewed as inevitable or irremediable.
Back in the 1990s, the then government stipulated that general practitioners in the UK should offer each of their over 75 year olds an annual health check. Since this was implemented prior to evaluation, with little guidance on the factors to be assessed, and certainly no recommended scales or measures, it was hardly surprising that it failed. It was, however, a missed opportunity to begin to capture regular physical and cognitive function which could identify, and therefore begin to treat, early functional loss. A similar system in Denmark underwent evaluation in two areas and after showing improved outcomes (in both reduced functional decline and mortality) was then rolled out to the whole of Denmark. It is perhaps time to revisit the idea of annual health checks for older people with agreed outcome measures which could massively enhance the data already collected in general practice.
These are not ‘either-or’ solutions, neither are they the only ones. What is certain is that solutions should be agreed and acted upon soon.
This was first published on the British Politics and Policy blog.