The Sunday Long Read
We live in an ageing world, with people living longer, but having fewer children. This is certainly true of the UK. And East Anglia is one of its most rapidly ageing regions. In North Norfolk, the oldest district in England, the average age of the population is 14 years above the national average, and a third of the population is over 65. And a similar picture is evident across Suffolk and East Essex. How well are we preparing for an ageing society?
Good news, but…
In many ways the ageing of society is good news. In the past, retirement was relatively short, much of it in poor health. People now spend decades in retirement, and for many that can be a healthy and rewarding life stage. Despite the popular images, the majority are not poor; four out of five people do not end their lives in residential care; and only one person in ten has dementia in their early 80s.
But the pattern is not uniform across the country. Increasingly, the young and the old are living in different areas. When they can, young people follow employment opportunities and social attractions into the cities. Then, in middle age or at retirement, they move to more rural and coastal communities where the quality of life appeals more. So in urban areas only 17% of people are over 65, while the figure in rural areas is much higher at 25%. And the disparity is set to increase over the next 20 years.
For those in reasonable health, life in rural and seaside communities has many attractions, but as they grow older, the inadequacies of services, including health, begin to bite.
The response: better late than never
Although the ageing trend has been evident for decades, social attitudes and public policy have been slow to adapting to this reality. Now, late in the day, a range of agencies are responding. They are recognising that it is possible for older people to lead good active lives into their 80s and beyond, but only if public policy pays proper attention.
It is to address this that the Chief Medical Officer, Chris Whitty, has just published a review of Health in an Ageing Society. It coincides with a major conference on The State of Ageing Research convened by UK Research and Innovation (UKRI – the main government research funding body) which is currently funding over 240 healthy ageing projects. And it takes place during the World Health Organisation’s worldwide Decade of Healthy Ageing programme.
The shared focus of all these initiatives is on the quality of life: extending healthy lifespan, rather than just living longer. Delaying the onset of disease is good for individuals, and also for public services. And we know that how long you spend in ill health at the end of life varies enormously, by where you live, your social class, and your ethnicity.
So what do we learn from the Whitty report and the UKRI research?
It’s not just about health
Health matters. Whatever their age, people in poor health have a poorer quality of life, and as we grow older, health matters more. However, many other factors are also important, and often impact on our health. They include the design and availability of housing in the right places; access to transport, to green spaces, opportunities to engage with other people, to exercise and eat well. When we get these right, people are better able to remain independent, and in good physical and mental health.
By comparison with much medical research and intervention, these interventions can often be relatively cheap and easy. But they are not always simple: people in rural areas are close to fresh air, but exercise can be impossible if the only place to walk is a main road with no footpath.
We have been looking at the wrong people
Older people are by far the biggest users of health services, but those services have often failed to reflect this. In the early days of the NHS, the economic and social priority was often seen as keeping the (male) family breadwinner healthy and productive. So research and treatment models continued to be built around men in mid life. And while drug trials have slowly begun to recognise that women and men may respond differently to treatment, the same cannot be said for older people. Older people are often excluded from drug trials, and wider research, by arbitrary age limits, despite the fact that they are overwhelmingly the largest users of health services.
There is a similar issue for ethnic minorities, many of whom suffer earlier, and differently, from some health conditions. Many of these issues are under-researched, but we know they are real. At the conference, Whitty pointed out that we know that members of ethnic minorities typically experience arthritis 10 years earlier than their white British neighbours, but we don’t know why.
People are complicated
One result of the focus on mid-life men is concentration on single conditions. Traditionally, and still for the middle aged, a health problem is usually a single disease. But as the chart shows, as people age they are much more likely to have several conditions at the same time (“multimorbidity”). This is much more common among the poorest, and has a major impact on quality of life. But there is a shortage of research into how those conditions, and the relevant treatments, interact. We simply don’t know whether they cluster in particular ways.
So older people with several conditions often find themselves being treated by several separate doctors, in different places. If the patient is lucky, their GP may be able to coordinate, ensuring that different treatments and drug regimes do not conflict. But this doesn’t always happen. So a patient may be treated in Norwich for one condition and in Cambridge for another, with the patient and the GP in the dark about what is happening and why.
The same issue arises in the development of drugs. There are commercial and practical incentives to produce drugs for single conditions. Drug trials are easier to organise like that, the clustering of conditions is not well understood, and why develop one drug when you can sell three?
So, one clear priority is to expand the number of generalists in the health services: people who can look at a patient in the round.
Where you live matters
In general, public services are poorer, and more difficult to access, in rural and coastal areas, where the concentration of older people is greatest. In cities, not only are there more doctors, but there is better public transport to get to see them. Most people lose the ability to drive much sooner than they lose other kinds of independence. But living in a rural area without a car or reliable bus services is usually impractical, however healthy you are.
Environmental design also matters. Planners do not always allow for people with less mobility, and when they do, sometimes a solution to one problem can aggravate another. For example, the provision of a ramp or grab rails to get into the house can enable people to remain independent much longer. However, an alarmingly high proportion of burglaries happen in such houses: what is an aid for the resident can conspicuously identify a vulnerable victim. Different services need to work more closely together to tackle such issues.
There is too great a focus on tertiary care
It is always easiest to gather public and political support for research and treatment of the big and well-known conditions. Dramatic medical breakthroughs make good headlines, but they can often be very expensive. Unchecked, the capacity of the tertiary (hospital) system to absorb money is unlimited, but sometimes the same money spent on prevention, in primary and secondary care, would reduce demand for expensive hospital treatment, and benefit far more people.
Whitty points out that many of the biggest calls on the NHS budget are the result of poor public health: conditions which result from poor diet and exercise, like smoking, obesity and diabetes. But public health has always been the Cinderella of the health service. And the quality of life of many older people is severely damaged by relatively minor issues. By comparison with cancer, mild incontinence may seem relatively trivial, but the lack of accessible public toilets, and the lack of medical attention to the problem, can leave some people trapped in their homes, while the problem turns from a minor into a major one.
Research focus is improving
The Whitty report and the UKRI conference both noted positive changes in the research landscape. They welcomed the fact that research projects are increasingly interdisciplinary. The teams working on the 240 healthy ageing projects funded by UKRI included medical specialists, sociologists, epidemiologists, sports scientists, designers and technologists, taken out of their traditional silos to work together on integrated policies and strategies.
They also note a welcome involvement of patients and older people more generally in the design of research. This is helping to better identify what are the real concerns of patients, and what their experience is actually like. One benefit of this, highlighted by Whitty, has been a growing understanding of the problem of over-treatment. Doctors are trained to keep people alive, and when the focus of medicine was on people in mid-life, unpleasant treatments might seem entirely appropriate. But in later life a point comes when many patients will decide that the time has come to stop treatment and make a dignified exit.
Preparing for an ageing society: what needs doing?
The messages from this work are clear:
- Don’t wait for people to fall ill: expand the provision of preventative medicine and screening services.
- Focus more strongly on stopping people getting ill, rather than treating them when it happens. We can ease many of the most debilitating conditions of later life by early intervention.
- Do everything possible to create the conditions for people to remain active and engaged in the community, to eat healthily and exercise.
- Promote more research into multimorbidity.
- Encourage the development of more medical generalists.
- Seek strategies to improve services in the places with high concentrations of older people.
- Give more priority in research funding to older people, and especially older people from ethnic minority groups.
- Encourage interdisciplinary research, and research which actively considers older people, and does not have arbitrary upper age limits.
- Seek better understanding of how social care can deliver good quality of life.
Above all, plan better, and longer term. Its good that we are beginning to think about these issues, but there is still a long way to go.