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Age-related dependency needs policy and long-term planning

Current estimates put UK life expectancy at age 65 at just under 86 years for women and just over 83 years for men. And the number of people aged over 85 in the UK is predicted to more than double in the next 23 years to more than 3.4 million.

These numbers represent a success story for modern medicine, public health and broader societal and economic conditions. Though there are major inequalities in healthy life expectancy at 65, and living with an increasing number of long-term conditions is becoming the norm for many older people, most reach their mid-70s without those conditions being life limiting or causing impairments in essential activities of daily living. Levels of self-reported wellbeing remain high well into older age.

This is positive news, and while we should avoid the ageist language of catastrophe – ‘grey tsunami’, ‘ticking demographic time bomb’, etc – we mustn’t duck the reality of planning future health provision and services to meet the needs of this ageing population. If we live long enough, most of us will need care and support in some form.

A rapid rise in the overall numbers living with dementia and frailty – when people live with lower reserve and resilience – is inevitable. Against this backdrop, there’s considerable interest in whether people who live longer will spend more years in a state of poor health or dependence, or whether so-called ‘compression of morbidity’ into the last phase of life is possible.

A recent Lancet paper gives an interesting perspective. Researchers looked at elements of dependency including continence, cognition and self-reported activities of daily living in two cohorts of people aged over 65 – one cohort recruited in 1991 and the other in 2011.

The bottom line finding from this research is that the men and women studied in 2011 were living, on average, an additional 2.4 and 3 years respectively with substantial care needs. Even with a radical shift towards healthy active ageing, it’s unlikely that a hypothetical 2031 cohort would show anything but an increase in the total number of older people living with dependency.

What are the implications of this for public policy? The study found that a smaller proportion of the 2011 cohort were in long-term residential care, despite the greater years lived with dependency. Some people have care needs so high that 24 hour residential support is necessary. The paper’s authors suggested that perhaps an increase in care home capacity would be required to match the increase in population dependency. Though this expansion might not be necessary if we invested in alternative kinds of support.

Currently, most support comes from informal family caregivers. Of six million people in the UK caring for an elderly relative, around two million are themselves aged over 65 and half a million are over 80. Many of these carers have their own health concerns that may be adversely affected by their caring role and few receive statutory help, despite government rhetoric about providing more support. There have been some aspirations in government policy and legislation around carer support, but funding hasn’t been made available to support it. The House of Lords Ready for ageing?report suggested that within the next decade, demographic demand for unpaid care will outstrip supply. What are we doing about it?

There is a need for more age-friendly housing and to provide more support in people’s homes. Yet we have failed to invest in the former and sustained funding cuts mean that last year 400,000 fewer people over 65 were in receipt of social care than in 2010. There is also a crisis in the health and social care workforce, compounded by the impact of Brexit on recruitment and retention, and of austerity on wages and morale.

Sadly, from Lord Sutherland’s Royal Commission on Long Term Care through the present day, we have had report after report – including one from the Barker Commission – all ducked by government of the day. In 2011, the Dilnot Commission on long-term care funding pointed out that social care is the one public service where risk isn’t shared and where some people will be hit for huge personal costs. As Dilnot pointed out in his response to the Lancet paper, there is no real appetite in the private insurance market for long-term care insurance.

We need the kind of public–personal partnership the Dilnot and Barker commissions recommended, but the febrile reaction to the Conservative manifesto promise to use the value of people’s estates to pay for their care – immediately branded a ‘dementia tax’ – or to Labour’s 2010 so-called ‘death tax’ shows how far we are from a mature public debate on social care funding.

Of course, we could aim to reduce some late-life dependency by investing in prevention and wellbeing: through exercise, reducing social isolation, preventing or delaying long-term conditions, or through secondary prevention – by helping people to live better with those conditions – we might reduce some of the need for care. Yet, the policy response to date has been to cut public health funding and the proportion of NHS funds going to primary care.

We could do far more to help older people recovering from episodes of illness or injury to regain their independence through investing in intermediate care rehabilitation or reablement and so reduce their reliance on formal or informal care. In reality, we only have around half the beds and places we need currently to do this, with capacity falling and response times increasing.

A final, intriguing suggestion to me from Professor Clive Bowman (an honorary visiting professor at the School of Health Sciences – City, University of London) was that we should set up a public health observatory of age-related dependence, its prevalence and duration to be tracked over time which could then be used to inform this crucial area of public policy.

The findings from the Lancet paper pinpoint the urgency with which we need to tackle the demographic challenge of age-related dependency. But is anyone listening?

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