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?
Firstly the needs of the population simply don't fit the general purposes of health and care services and over several decades neither has provided compelling evidence of pro-active ownership...
Secondly, the scale of need remains contentious and the funding responsibility a nightmare.
Thirdly whilst the more recent regulatory developments have brought greater alignment to people in care as opposed to the compliance of systems around their care there is still a lack of tracking individual experiences and outcomes.
Even if these three issues were nailed there would still be a problem in staffing. Presently the ablest professional nurses are typically involved in regulation or commissioning not actually assessment and care planning and care providers with registered nursing beds simply have to recruit any available nurse with a live professional accreditation even if their experience is not primarily age care. This is not a criticism of the many excellent nurses employed by the various agencies but just a reflection of lack of strategic leadership and inadequate policy.
So from my perspective what needs to be done?
1) Clarity of needs by an observatory
2) A new Commission is created for the leadership of policy and practice of care homes. Supported with a structured national funding and licensing care facilities enabling stimulation of market both development and management. Block contracts to provide stability of supply and an ability for providers to invest with confidence
3) Assessment of needs, care plans and ongoing maintenance led by professional nurses with a defined case-load employed by the NHS. The shortage of professional nurses now and the costs of nurse training mean that the professional role of the nurses has to be developed and defined
4) Care providers to provide care facilities and care staff to national standards developed by the new commission this reducing the perpetual reinvention of the wheel and facilitates providers large and small. Care staff to be licensed practitioners with defined competencies
5) Regulation to be a mix of compliance with licensing standards and dynamic performance increasingly through monitoring of data for example medicines management and personal experience and outcomes measures.
6) Understanding what funding has to address both in terms of hotel and care services the contribution of the state and the individual can be modeled to a predictable cost that the treasury could understand and sanction. A significant reduction of NHS bed use could significantly contribute as indeed could local authority monies presently spent on care homes. Furthermore, with greater clarity of rights and responsibilities new insurance proposals might find favour.
The achievement of this sort of model is beyond current strategic vision and debate but increasingly there is an understanding that more of the same will simply yield more of the same. Both the NHS and social care are becoming overwhelmed at the very least consolidating and developing the responsibility for over 400,000 beds to a new commission could reduce the distractions to effective health and social care. Tne first step must be agreeing on the population needs, which is why I propose an Observatory as a politically neutral but proven approach to developing sustainable policy