Ready for Ageing? No!

By Deborah Gale

The Select Committee of Public Service and Demographic Change, an adjunct of the House Of Lords, was formed in May 2012. They solicited evidence based inputs from experts and then published their Ready for Ageing? report on the 14 March 2013.  The answer to the question posed then, as now, remains the same. No, we most certainly are not.

However, the degree of un–readiness has been dissected here and I was encouraged to see that the select committee had female representation with five women out of the twelve members. That said, the message from the House Of Lords; that fundamental reform was undesirable at the same time that radical change was necessary, sounded confused instead of constructive. Merely highlighting the collective failure of past and present governments to address the growing implications of population ageing by requesting yet another White Paper feels like a hand wringing, delaying tactic. The 2011 Dilnot Commission on Long Term Care, another grim governmental review which was specifically focused on long term elderly care, was also starkly critical of the seriousness of this issue but we have barely moved on since then.

Once again, the Ready for Ageing? report raises the right issues in exhaustive detail but the combination of a lack of political will and initiative to address the realities of a rapidly accelerating, ageing population remains obvious. It is as if no one in a decision–making capacity has taken this on board. Is it because the scale of the problem is, as yet, unrecognizable and that there aren’t any personal consequences for this massive, predictable risk?

While firmly in the policy stream and the thrall of the media, the fact remains that ageing terrifies every one of us. A weak stance is borne out in this 105 page report. Progress surrounding approaches to ageing issues will eventually demand a serious ideological, socio–cultural shift. This will require a new narrative with new words, definitions and ways to define and appreciate our thirty–year longevity bonus. We are nowhere near ready for this either.

REPORT OVERVIEW

Preparing this report, the committee issued a call for evidence to some 93 experts across central and local government, think tanks, academics, the NHS, several builders and providers of retirement homes as well as volunteer groups from the third sector. Notably, witnesses from the private sector were limited to BT and The Saga Group. The questions posed to these experts were purposely broad with respect to how British culture perceives age, what people’s expectations were regarding work, savings, retirement and independence, what their attitudes were about the scope and responsibilities of public service along with how they thought the public purse ought to be allocated.  Questions also included a call to action for addressing present and future deficiencies within the existing systems and concluded by asking the experts what was required to stimulate a national debate on population ageing and its attendant challenges. 

Given this scenario, the impact on public services will be immense. The delineation between health care and social care and how each will be delivered requires disentangling with surgical precision. Right now the concerns and condemnation regularly voiced in the media surround inappropriate levels of care for the current older population. Crucially, we not only have a situation where present needs are unmet but are looking at a future where unknown levels of demand are also unlikely to be met. This is occurring at the same time that the global financial crisis has contributed to a significant spending crisis. The report makes clear that the not yet old have every reason to be concerned, even if they have decided they aren’t ready and don’t want to tick the “old” box yet. That is why stimulating a national debate and moving beyond the impasse and inertia is at the crux of this overarching issue. Following a review of the key areas of the report, I suggest a potential, immediate, albeit short–term solution to moving ageing up on the agenda.

DEMOGRAPHIC SNAPSHOT

Depending on your point of view, ageing projections make for celebratory or sobering reading. Longevity equals human progress but also represents a challenge when longer life spans with reduced health and less wealth are anticipated. Between 2010 and 2030, a 51% increase in the over 65’s and a 101% increase in the over 85’s is forecasted. Simultaneously, this illuminates several critical issues: the under–saving problem and the inadequacy of retirement incomes, the deterioration in wellness when the number of people with three or more long term conditions is growing, along with estimates that the number of over 65’s with moderate to severe cognitive impairment will rise 80% over the next 15 years.

At the same time, the divergences between the rich and poor as well as men and women; women being the primary users of social care in later life, are markedly different. The difference is also seen and predicted in the outcomes for those facing a comfortable longer life vs those with greater exposure to multiple risk factors, who also have significantly fewer assets to draw upon in later life.

HEALTH CARE/ SOCIAL CARE CONUNDRUM

As was previously detailed by the Dilnot Commission, the structural and budgetary split between health and social care is unsustainable. The Dilnot report made clear that individuals must plan for the likely costs of their own long term care and also encouraged private investment and pension sectors to enter this specific market and provide options. Clearly, the current model is inappropriate and unable to cope with the unpredictable but changing patterns of ill health that are to be expected from a longer living, aged population. We see on a daily basis that the lack of quality care for older people in both the private and the public sector has a domino effect. Health care needs not satisfied by a 7 minute visit to their GP eventually accelerate to a crisis situation, usually requiring a visit to A&E or hospital. This results in significant increases in health care costs and generally negative outcomes. Studies reveal that older people who are admitted to hospital for more than three days are more likely to die there. Modern medicine does disease not decline.

The call for patient centred treatment would radically change service provision in the NHS and make care at home the new hub and minimize hospitalizations. Putting this system in place, whenever possible, is the real goal. This, however, would require a radical shift in NHS service provision by front–loading health care towards prevention and early intervention.  In this way, reversible conditions could be caught earlier and prevented from contributing to further declines from the chronic ill health that is seen to accompany advancing age.  However, in order to achieve a truly 24/7 NHS, it has to work in conjunction with a 24/7 community based health and social care system which does not yet exist. The report proposed the introduction of a 10 year spending envelope for the NHS and publicly funded social care to make this viable. This, however, would require stewardship which does exist either, particularly after the decision to decentralize responsibilities to 200 clinical commissioning groups. Presently, an organic, bottoms–up solution would not be sufficient given the scope of unmet need.

In the meantime, the absence of preventative strategies, excessive waste and a lack of integration of services was detailed and the report highlights the benefits of making hospital admissions for older people restricted to essential procedures and used only as a last resort.

PROBLEM WITH PREVENTION STRATEGIES

Medical care typically treats symptoms and single manifestations of illness whereas prevention is very complex. Multiple factors from genetics, to individual diet and exercise choices and/or social circumstances must be considered. The requirements for any prevention program necessarily expand to require management of multiple funding streams with a commensurate increase in complexity. For example, a single decision by NICE as to how the NHS would cover end–stage renal disease is easier to achieve than a community based program to tackle high blood pressure through diet, physical activity and smoking cessation. Prevention initiatives remain outside the purview of traditional health policy because of these requirements for massive coordination between entities with different agendas. Unfortunately, policy makers are not into deferred gratification. Any demonstration of the effectiveness of any initiative must be seen to be of immediate benefit. Those benefits must then be seen to accrue directly and immediately to the taxpayers making the investment.

Another example of how the introduction of prevention strategies may become even trickier is in a situation evolving right now. There are medical advances in the pipe line that could reduce the likelihood of someone developing dementia but other medical breakthroughs might allow that individual to survive a disease, only to find themselves in a further disabled state and subjected to the related escalation in their costs of care.

The unpredictability of who benefits from prevention activities makes it a hard sell. If the public can be persuaded of the payoffs resulting from a change in lifestyle and feel confident that a change in social conditions is actually possible, available and won’t be too difficult, change in attitudes regarding the power of prevention is also realistic.

PENSIONS AND SAVINGS

In the past, people only had to try to predict how many years they would need a pension. At the time, longevity risk and care costs were born by the state. This risk was moved to employers for a time and now the pendulum has swung the other way so that individual workers and the already retired are required to bear this risk. In the current climate, this is politically and practically unsustainable and yet, to date, no major financial services provider offers any product with pre–funded insurance against social care costs. Likewise, the possible creation of social impact bonds as a new funding mechanism while oft discussed, has still not come to fruition. Even though the recently introduced Lord Turner reforms  do represent some progress by linking state pensions to earnings, the introduction of auto enrolment and single tier state pensions that do not penalize people with intermittent employment history, the a state of political denial remains. 

Furthermore, evidence of chronic under–savings only serves to underpin the need to change pensions and employment practices, across the board. Longer lives and under saving deficits are unable to be met by taxpayer funded sources. Looking at existing schemes, the report also calls for an end to both defined contribution and cliff edge retirement as unfit for purpose given their unclear payouts.

All of the above underscores the core disconnect. People’s expectations in terms of pension provision remains far greater than reality and the squeezed middle, once again, faces the biggest challenge.

CHANGING ATTITUDES?

While the least exacting, I found this part of the review made for the most compulsive reading.  It is abundantly evident that it is not only governments but individuals and markets who also fail spectacularly in preparing for ageing. Procrastination is simply human nature. While no one knows their ageing fate, people misjudge and deny the likelihood of having to face adverse life events from the ageing process. And it is not just the older people, even younger people underestimate their own longevity expectations by about six years. There is also a great misconception about who is responsible for looking after older people in need and people excel at shying away from complexity when they have a poor understanding of the risks involved.

The report calls for the government to help people be better informed. This runs the gamut from healthy lifestyles and longevity expectations, pension projections, the likelihood of needing social care and the costs of that care and the best use of personal assets. It is anticipated that by making people begin to understand the costs of care and realizing that they may have personal responsibility for some portion of their own care needs, they can begin to take some interest in analyzing their own situations and be in a position to make better informed decisions. This is a big ask.

POSSIBLE WAY FORWARD?

It is impossible not to notice the parallels between education and ageing. Ageing is a lifelong process and it is clear that education should also be perceived to be one. Research indicates education is a key predictor of health outcomes and it appears that re–skilling in later life for post–traditional retirement employment will become the new normal. Ever since Michael Gove was appointed Secretary of State for Education after the formation of the Coalition Government in 2010 he has been on the hot seat, particularly for his latest overhaul of secondary school curriculum for GCSE’s and A levels. One month ago, at the NAHT, (National Association of Head Teachers) in Birmingham, he was mercilessly heckled and they passed a vote of no confidence in his policies. Gove was ruffled but patently undeterred.

His enemies sited the short term–ism of targets and the constant churn of change in curriculum without proper consultation. They view the negative rhetoric from government as damaging to the morale of schools and the piecemeal approach to standards as having no visible aim. While there is no argument about the importance of raising standards and making UK education the best in the world, Gove’s tactics have not been appreciated to date.

This essay has highlighted the limitations of this and past government’s response to population ageing. These challenges are not dissimilar to those facing education and given that they are inextricably intertwined, I propose that Gove’s purview be enlarged and expand his role as a new Secretary of State for Ageing AND Education. I feel that substantive, positive change in our approach to ageing has been stalled. It will only be possible to inch forward if the tops down view to managing these complementary life course processes are combined, potentially with synergistic consequences.

CONCLUSION

In the final analysis, health care and population health differs from education and so is not a pure return on investment formula. The health care policy priority must be driven by quality of life and health status across the life course of the entire population.  That said, in the same way as education, ageing is everyone’s issue. However, it is not an issue that is impossible to overcome but political gamesmanship and short–termist thinking makes a coherent policy response that much more difficult. In the existing climate and given current market conditions, the baby boomers represent the cohort who will be responsible for driving change, either as they watch their own ageing parents or when they seriously consider their own care needs. The boomers do represent the cohort with the most “skin in the game” now but that perception has to change too. Unfortunately, with longevity gains, many boomers appear to be sprinting in their attempts to run away from death. They might say they don’t want to live longer but they really don’t want to die either.

The reality is, living with a long term conditions including cognitive decline is more likely than not and we are at a critical crossroad now in terms of figuring out how we will pay for it. Engaging British society to participate in the national debate is the way forward.   It makes sense that this gets firmly imbedded in the public psyche as everyone’s problem and getting everyone on board must happen, now.

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Deborah Gale is a Research Fellow with BioCentre. Deborah’s undergraduate degree was in home economics and social work, followed  by an MBA from the University of Santa Clara and an international treasury career in Silicon Valley. She is an Apple Computer veteran, serial expat and mother of five daughters. She returned to academia for an MA in Public Policy and Ageing at King’s College in London. This fired her interest in the demographic transition currently underway and in the potential to optimise the influence of the baby boomers, now navigating the lengthening transition between midlife and old age. She tweets @debgale

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