Is the NHS "a victim of its own success"?

Published: 14th Mar 2013

As a nation, we are entering a Silver Age. Courtesy of modern medicine, more of us are living longer. At one level, this is a huge achievement.

But it will also ask questions of how we organise our society. Today's newspapers, drawing on a new report into the health of the UK's ageing population, warn of a "demographic timebomb", with an older and sicker population exerting an ever larger strain on public resources.

In its publication 'Ready for Ageing?', a House of Lords Committee advises that "without urgent action this great boon could turn into a series of miserable crises". The NHS is helping people to extend their life expectancy, but this has only resulted in increased pressure on its services.

Fewer diseases are fatal, and the health service must treat people who present with complex, chronic illnesses - whether it's diabetes or dementia. Meanwhile our social care system, which attends to those people who can no longer look after themselves, is struggling to meet demand.

Our society is growing older...

The 'Ready for Ageing?' report provides a range of statistics on life-expectancy. Perhaps most notably it suggests that, compared to 2010, in 2030 there will be 51% more people aged 65 and over in England. Meanwhile, the number of people aged 85 plus will double.

These figures originate with the Office for National Statistics (ONS), which has generated population projections from 2010 data. The increase in the geriatric population is partly due to an increase in life expectancy. By 2030, it will be 88 years for men (78 years now) and just over 91 years for women (82 years now).

However, it can also be explained by a spike in the birth rate back in the 1950s. It is this 'baby boomer' generation that is now approaching old age.

Speaking on Radio 4's Today programme, Lord Filkin, Chair of the House of Lords Committee that compiled the report, said that an ageing popultion was "probably the biggest challenge the NHS has ever faced".

He said that the evidence was "overwhelming". So is it?

To start with, there's some evidence of pressure on hospital wards. The charity Age UK, using Department of Health (DH) statistics, claim that during September and October 2011 more than 128,000 hospital bed days were lost as a result of the delayed discharge of people who could have been cared for in the community if the necessary support had been available - an increase of 13,000 bed days compared to the same period in 2010.

Meanwhile, Dr Foster Intelligence, which analyses healthcare data in conjunction with the Department of Health, estimated that 29% of hospital beds are occupied by people whose admission might have been avoided if their care had been better managed. Although not all of these people will be aged over 65, 50% of avoidable admissions involve those over 75 years old.

Primary Care Trusts (PCT) data shows that those aged 65 and over are the biggest consumers of NHS resources and that they're responsible for more than half of PCT spending (Table 6 of the Revenue Allocations Exposition Book).

The NHS is increasingly subsidising the social care system. Additional funding for social care (worth £3.8 billion over the next four years) has been made available through the NHS. Furthermore, the NHS also pays the bill for some nursing home residents, or for people who need intensive medical treatment as part of their social care. 

Older, but healthier?

An ageing population doesn't necessarily mean a population that's more disease-ridden, and therefore more burdensome. After all, if life expectancy is on the rise, doesn't that mean we're getting healthier?

Any prediction about the size of a future population will involve us making a number of assumptions about life expectancy. 

An estimate of 'period' life expectancy is calculated on the basis of existing age-specific mortality rates. In other words, it's taken as a given that someone of a certain age is in the future likely to die at the same age that they would now. 

On the other hand, we can generate an estimate of 'cohort' life expectancy. This takes account of the fact that the health of a population is subject to change. The House of Lords Committee on Public Service and Demographic Change has applied this method in its calculatations of life expectancy, explaining that "it provides a more useful description of the length of life that individuals might expect". 

However, just because somebody's life is extended doesn't mean that they'll spend their extra years in good health.

The 2004 Wanless Report generated life expectancy estimates on the basis of three different scenarios: that of "solid progress" (a population's general health improves gradually); "fully engaged" (it advances dramatically); and "slow uptake" (it flatlines or deteriorates).

The House of Lords Committee notes that all of the evidence it received suggests a "substantial increase" in the number of people with disabilities up to 2030. Its report warns of a 45% increase in the number of people with diabetes, a 50% increase in the incidence of arthritis, coronary heart disease and stroke and an overwhelming 80% increase in cases of dementia.

This set of numbers was supplied by Professor Carol Jagger from Newcastle University, who in fact assumes no change in the prevalence of disability, merely an increase in the size of the older population. It is, as it were, an optimistic scenario.

What about the Government's plans to reform social care?

Lord Filkin insisted that, while the Government has taken steps to protect people from the excessive costs of social care (which, unlike the NHS, is not a free service for most people), its reforms - based on the recommendations of the economist Andrew Dilnot - wouldn't help the vast majority of people who weren't being adequately cared for at the moment.

Crucially, the plan to introduce a £75,000 cap on care fees "didn't bring any significant new money into the social care system".

As we've discussed previously, many local councils, dealing with cuts to their budget, have rationed their social care provision. According to a recent survey, 83% of local authorities only support people with "critical" or "severe" needs. This means that anybody who's assessed as having "moderate" needs is, effectively, left to fend for themselves. There have been several attempts to estimate the size of this "unmet" need.

More often than not, the people neglected by the social care system will end up in hospital. Take a simple example: if there's no one there to help you out of bed and down the stairs, you're more likely to break your hip and spend time on a hospital ward.

The report from the House of Lords Committee concludes that the Government and society at large are "woefully underprepared" for the demands imposed by an ageing population. It recommends that, when it comes to the management of our health and social care system, "all political parties will need to rethink this issue".

The Coalition has signalled its intent to maintain a distinction between the NHS and the social care service provided by local authorities. Under its plans, healthcare will continue to be free at the point of use and a service provided at public expense while social care will mainly be financed through private contributions (either by direct payments or via an insurance policy).

At the same time, the Labour party has outlined its vision for "whole person care" and the integration of our health and social care systems. This approach is more in line with the House of Lords Committee's recommendation that "healthcare and social care must be commissioned and funded jointly".  

This report also makes clear that an ageing population has a lot to offer the rest of society. But if the Silver Age is to be one to celebrate, we need to ensure that we are enabling an older generation to spend more years living in health, and contributing to the public good.


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