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Does an "ageing population" make it harder to afford our NHS? A look behind the rhetoric

Jeremy Hunt claims the "ageing population" poses a challenge "as serious as global warming". New UKIP leader Paul Nuttall says the "ageing population" will force us to see the NHS as merely a "monolithic hangover from days gone by". OurNHS thought it was time to examine such claims - and finds they distort a much more interesting reality...

Image: Wikimedia

In every population every individual is ageing. To say that a population is ageing means that the average age of the population is rising.

This might be because people are living longer.

Or it might be because fewer people are dying young so that more people live to be old, though when they do become old they don’t live any longer than old people always have.

Or because relatively fewer young people are being born or migrating compared to those currently maturing into old age.

In other words, this ‘demographic ageing’ is nothing to do with changes in longevity but arises because of changes in birth rate and immigration now or in the past. This could arise either because of a fall in the birth rate or in immigration or because of increases in birth rate 65-90 years ago.

Demographic ageing

Demographic ageing undoubtedly increases health and social care costs. Around the turn of the 20th century there was a sharp fall in infant mortality. Prior to that people had had large families but many of the children had died. Later on in the 20th century, when people realised their children were going to survive, they started to have smaller families. But for about a generation there were large families most of whom survived.

This began to cause demographic ageing as this generation reached old age in the last third of the 20th century. Society was ill-prepared - the large number of single women created by the slaughter of men in the First World War had led to an expectation that there would always be a single daughter around to look after elderly parents. But by the time this generation reached old age they had fewer children, and fewer daughters who had not found another role in life as women became more educated and economically active.

By the end of the 20th century, the men who had been too young for the First World War came into old age, followed by the first generation of men to have lived their entire adult lives in peacetime. This added to the demographic ageing but without the same gender gap.

Demographic ageing eased off in the first decade of the 21st century but in 2011 those conceived on VE night turned 65. In 2016 they turned 70. This ageing of the post war baby boom, though less intense than the ageing that occurred at the end of the last century, is now the driver of demographic ageing.

There is no doubt that demographic ageing increases health and social care costs by adding to the proportion of the population who are part of a group with higher than average need.

Increasing life expectancy

However demographic ageing is no longer the only factor in the ageing of the population. Life expectancy is also increasing.

The ‘increased life expectancy’ aspect of ‘an ageing population’ does not necessarily increase health and social care need. A lot depends on how healthy we are in old age.

We know that at the moment disability (and hence health care costs) occur as follows:

The fear is that increasing life expectancy does not delay the onset of disability, it simply makes it last longer. For every extra year of life there is an extra life of woe. We live longer, but the extra time is spent taking longer to die:

If such fears were realised, there would be a huge increase in disease burden for the individual (and hence health and social costs for the population) as a result of an increased life expectancy

Another possibility however is that all that happens is that disability and death are both delayed. For every extra year of life woe is delayed by a year but there is no change in the amount of woe. We live longer and the extra time is spent living – we spend no extra time on dying:

In such a case there would be no increase in the disease burden incurred by the individual. At a population level the health and social care costs will be delayed and the proportion of the population incurring them at any one time may therefore be reduced.

An intermediate possibility is that disability may arise at the same time but may develop more slowly. Woe increases with the extra years but not by as much. We live longer and the extra time is partly spent enjoying more life and partly spent taking more time to die:  

In this case there will be some increase in the disease burden incurred by the individual and some increase in the health and social care costs incurred by the population, but it will not be anything like as great as in the first scenario.

The most optimistic scenario however is that we will live longer and we will spend less of that time ill. For each extra year of life there will be fewer years of woe. We will live longer and die quicker. My preferred mode of death is to be shot by a jealous lover at the age of 104: 

If this scenario is correct then the lifetime disease burden on the individual becomes less as life expectancy increases – we have the double benefit of living longer and suffering less. Health and social care costs for the population are both diminished and delayed – again a double benefit.

The theoretical basis for the nightmare scenario (longer life more disease) is that as people avoid the causes of premature death – infections, accidents, heart disease, violence, famine – they come to live long enough to suffer from chronic diseases and as a result to suffer a greater and longer disease burden.

It is certainly true that people have to die of something and that diseases that are commoner in older people, such as cancer, increase in incidence as diseases that kill a lot of young people decline. But the theoretical basis for the delayed disease scenario (longer life, same amount of disease) is that there is no particular reason to suppose that these diseases will cause a greater burden.

Most people make most use of health care in the year before their death. This is true whenever that death is. Therefore if most people die when they are old that is when most health care costs will occur. It has nothing to do with age – it is related to proximity to death.

The optimistic scenario (longer life less disease) was first put forward by Fries and became known as the compression of morbidity scenario. Fries believed that if death from disease were avoided people would eventually die of old age. He believed there was a genetically programmed natural average age of death which increased by a few months each generation, having been three score and ten in biblical times and now being four score and five. ) Death from old age is, Fries argued, quick. Hence if more people survive to reach this maximum age the total amount of morbidity or illness would be reduced.

An alternative view of the ‘compression of morbidity’ scenario sees ageing as a harmonious deterioration of organ systems which diminishes resilience and increases the probability of death. Old age brings “frailty” – a term used here with the particular meaning that people are fully healthy and fit but are less likely to recover from factors which disturb that health and fitness. Improving population health delays people experiencing the disease that will kill them. The older they are when they encounter that disease the less resilience they will have and the shorter their death will be. On this basis the compression of morbidity consists of somebody living on, fit and well, into old age until they die suddenly of a disease or injury which a younger person would have recovered from.

In a theoretical population with no migration and a fertility rate that maintained a constant population the proportion of the population experiencing the need for health and social care associated with the disability and dependency of old age would be given by the formula:

Life expectancy minus healthy life expectancy / Life expectancy

In other words, an increase in life expectancy will reduce the proportion of people needing health and social care, provided healthy life expectancy keeps pace.

For example:

Life expectancy

Healthy life expectancy

Proportion needing care

70

65

7.1%

80

75

6.25%

90

85

5.5%

 The increasing 20 years life expectancy (from 70 to 90) with an unchanged gap between healthy life expectancy and life expectancy (5 years) has reduced the population burden by 1.6 percentage points out of 7.1 percentage points, a reduction of 22.5%

However changing healthy life expectancy affects the figures even more spectacularly:

Life expectancy

Healthy life expectancy

Proportion needing care

75

65

13.3%

75

68

9.3%

75

70

6.7%

 An extra 5 years of healthy life expectancy with constant life expectancy of 75 reduces the population burden by half.

If compression of morbidity occurs these two effects would operate together reinforcing each other:

Life expectancy

Healthy life expectancy

Proportion needing care

75

65

13.3%

80

75

6.25%

90

87

3.3%

 It must be emphasised that these are theoretical figures which address only the non-demographic component of an ageing population. The increases in need due to demographic ageing also need to be taken into account.

There is real evidence to support the compression of morbidity theory. The gap between healthy life expectancy and life expectancy is lowest in areas with the highest life expectancy. People in such areas not only live longer but they experience less sickness in that longer life.

What does this mean in terms of money?

The analysis above suggests that the burden of an ageing population falls most heavily on those areas with the lowest life expectancy.

It also suggests that currently, the money is going to completely the wrong areas.

Currently, health and local government resources are allocated based on the assumption that the burden falls most heavily on areas with the largest old population. This neglects the fact that in deprived areas people become sick sooner and are dependent for longer within that shorter life.

On the whole, the areas with the largest elderly population will be those where people live longer and have correspondingly shorter gaps between healthy life expectancy and life expectancy (although there are also areas which have high elderly populations merely because they are popular areas for retirement).

Demographic ageing increases health care costs but ageing due to an increasing life expectancy reduces them. We are experiencing both of these processes at the moment. The balance between them can be improved promoting healthy ageing – which I will turn to in my next article. Older people should not be abandoned to a life of dependency, low expectations and frailty. But short term financial pressures worsen the problem – and the failure to understand the difference between demographic and non-demographic ageing current resource allocation processes seriously misallocate resources to the unfair benefit of affluent areas and the unfair disbenefit of deprived areas. 


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