Healthy ageing: what can England learn from Japan and Sweden about meeting the challenge of an ageing society?

Introduction

Demographic ageing is one of the most important challenges facing developed countries in the 21st century. How England can respond to these challenges, particularly in terms of its health and care system, is the focus of this report.  

In Britain, already close to 20% of the population are aged over 65, and this will rise to over a quarter of the population by the 2070s. The growth in life expectancy that’s been achieved over successive decades is something that should be celebrated. The ‘problems’ that it presents are, of course, good problems to have, but without parallel improvements in health or embracing the opportunities of long lives, such demographic change will pose profound challenges to many aspects of our society. The workforce will shrink relative to the overall size of the population, meaning there will be more people needing public services and fewer people available both to deliver them and to raise the tax revenue needed to pay for them. Indeed, these dynamics are already starting to become visible.   

These public sector and economic challenges will be compounded by political ones. How we navigate the politics of migration that will accompany these changing demographic realities, for example, will be crucial. Questions about what’s fair to ask of different generations have also raised their heads already in British politics, and will continue to do so.  

Learning from other countries that are experiencing similar trends will help meet these challenges. Here we share findings from Japan and Sweden about how they are dealing with demographic ageing, and make recommendations on what lessons England can take from them.  

Background on England, Sweden and Japan

Why we chose to look at Sweden and Japan

We chose our comparator nations for this project using the International Longevity Centre’s (ILC) Healthy Ageing and Prevention index.

The Healthy Ageing and Prevention Index is an online interactive tool that ranks 153 countries on six longevity indicators: life span, health span, work span, income, environmental performance and happiness. It also measures countries’ adaptability to longevity, with two waves of data (2019 and 2022) allowing progress to be tracked over time. Data is obtained from various sources, including the United Nations, the World Health Organization, the World Bank, and the Yale Environmental Performance Index.

We chose Japan as a comparator nation for England¹ because it is older: it is the country with the world’s largest share of older adults. As such, it is already in some senses living our demographic future. It is also the top ranked country in the Healthy Ageing and Prevention Index when it comes to two indicators (life span and health span), though overall its performance is more mixed.

We chose Sweden as a second comparator because it is better: in terms of the Healthy Ageing and Prevention Index, it is ranked 3rd overall out of 153 countries ranked, whereas England is 14th. It is in the top 10 for 4 of the 6 indicators covered by the Index. Sweden may therefore represent a best practice that England can aspire to. While Switzerland and Iceland score higher than Sweden overall, these are less useful as comparators to England. Iceland has a much smaller population and, although healthy aging is affected by more factors than the structure and performance of a healthcare system, Switzerland has a very different health care system to the UK.

England, Japan and Sweden all have a substantial portion of their population aged 65 or older –though Sweden and Japan are further advanced in this regard. As previously mentioned, Japan is the most striking case, with almost one third (30%) of its population aged 65 or older. In Sweden, 21% of the population is aged 65 or above, compared with 19% in the UK. (All figures from 2024.)

Full profiles of how each nation performs on the Healthy Ageing and Prevention index are presented below.

Healthy Ageing and Prevention Index profiles for the United Kingdom, Sweden and Japan (2022)²

Understanding the health care systems in Japan and Sweden 

Sweden and Japan both have universal health care systems, but through markedly different models. Similar to in the UK, Sweden’s health care system is tax funded. Public funding makes up 86% of total health spending, with out-of-pocket payments (which are capped) making up 13%, and voluntary health insurance just 1%. In terms of funding level, Sweden spends the most per capita on health of our three countries, with the UK in second and Japan spending the least.  

By contrast, the Japanese system operates through mandatory health insurance, where employees and employers both pay into a fund, subsidised by government. Those who don’t have a formal employer – for example, self-employed people or students – access insurance through their local municipality Out-of-pocket payments are usually set at 30% for each service, though lower co-payments are available for older people, children and those on lower incomes.  

Delivery of health and long-term care also differs between the two countries – Sweden operates a decentralised system, while Japan operates a more hybrid model. Sweden’s system is made up of 21 regions providing hospital and primary care, and 290 municipalities providing social care. These municipalities are responsible for care and support for older people, long-term care, home support and services for people with disabilities. Social care in Sweden is largely tax-funded with residents paying small, capped payments – about £210 a month³ for home care or daytime activity assistance. Co-ordination between health and social care has been strengthened through the 2018 Care Co-ordination Act.

Meanwhile, Japan’s system means that all insurance providers operate under a single national fee schedule – a government-set pricing system that determines costs for all medical services, procedures and pharmaceuticals. This ensures uniform costs and access regardless of insurance provider or location. Most hospitals and clinics in Japan are privately owned, and unlike the UK and Sweden, there is no official GP system. Instead, clinics have specialised departments that people can self-refer to. This market model means it is more difficult to categorically class Japan’s system as centralised or decentralised. While it is centrally regulated through the fee schedule, the many insurance providers and privately-owned hospitals, and the role of municipalities, mean that it also has local, decentralised elements.  

Municipalities in Japan also manage long-term care through the long-term care insurance (LTCI) model, which covers home-based, community and institutional care for those over 65, or disabled people over the age of 40. The LTCI is funded through mandatory insurance contributions, national and local government funding and user co-payments (which are between 10% and 30% of costs depending on income). While the model does provide broad coverage, integration between medical and long-term care remains limited, with workforce shortages and service gaps evident, particularly in rural areas. 

While both health systems are different, they both have significant areas of strength. Sweden’s decentralised system is combined with high public investment and strict health policies, giving patients statutory rights like a maximum waiting time of 90 days for treatment or referrals (compared to England’s target of 18 weeks). Sweden’s use of health care data is also world-class – clinical quality registries collect patient-level data on diseases or procedures to monitor outcomes, reduce variation in care and improve health care quality overall.  

Japan’s system shows strengths in prevention and community care, with nationwide Tokutei-Kenshin health checks encouraging healthy lifestyle changes for people over the age of 40. About 30 million people – just under 25% of the total population – participate in this programme each year (though the number of people who adhere to health advice remains lower, which is common in many preventive programmes globally).  

Lessons from our roundtables 

In order to see what the UK could learn from these two systems, we held a series of workshops over the summer of 2025 with experts and policy makers from Sweden and Japan. Attendees included representatives from government, the voluntary, community and social enterprise (VCSE) sector, practitioners and academics, enabling us to get a wide variety of perspectives. The sessions covered both the successes that Japan and Sweden have had, as well as the challenges they’ve faced, before thinking about what both of those things might mean for England.  

Below are some key lessons for the English system that we took away from those discussions. 

Lesson 1: Meeting the challenge of an ageing society needs to be a national mission 

The concept of an ageing population is something that has been part of the national conversation in Japan going back decades.  

This national conversation began in 1989/90, when the fertility rate fell to 1.57. This kicked off a wave of policy making and media interest, dubbed the ‘1.57 shock’ (Tsuya, 2017). Since then, there has been a succession of policy programmes aimed both at increasing fertility, beginning with the 1994 Angel Plan (which have largely failed to reverse trends), and reforms to the way in which care and social services for older people are delivered and funded (which have been much more successful). This includes the creation of the current system, established in 2000, which involves a mix of social insurance, taxation and co-payments.  

In our roundtable, it was clear that the historical legacy of all this policy work on the concept of an ageing society has been important. While there remain significant problems that Japan continues to struggle with, it has created a broad-based understanding of the issue of demographic ageing – and we heard that this has encouraged policy-makers to think about it not as a discrete challenge, but as a new reality with implications across health, employment, immigration, social cohesion and a host of other areas. As such, one of our key takeaways from our conversations with Japanese colleagues was that they have succeeded in making an ageing society something that the entire public sector is concerned with. What’s more, the media interest in fertility rates means that the public is also part of the national conversation around these issues, increasing the opportunity for legitimacy and democratic consent to be brought into the policy making process.  

In Sweden, we found different dynamics but a similar sense of mission. Despite being a high performing system (as discussed above), in our conversation we found no hint of complacency about the work being done, particularly in the health and social care spaces. Instead, what we found was what one expert called ‘the Swedish passion for equality’ shining through strongly – a desire that, we heard, drove system leaders to ensure that a healthy and dignified older age was something that was available to all. 

Sweden has, compared to England, a relatively localised and decentralised system of health and social care delivery – and as such there is a potential for inequalities to develop according to geography. Ensuring that this doesn’t happen was a major theme of our conversation⁴, as was ensuring that services were accessible to everyone regardless of income or ability to pay. As with Japan, the drive for equality and access seemed to bring people working in service design and delivery together, helping break down silos between different types of public service professionals.  

In both countries, but particularly in Sweden, we saw that meeting the challenge of an ageing population was being interpreted as a challenge around building prevention into services and wider society. Sweden has a legal framework that puts prevention into the responsibilities of those providing public services, and numerous prevention initiatives that exist around ageing were brought to our attention during our conversations. These included offering ‘health meetings’ for older people to discuss their health behaviours, and then in the more acute space, ensuring that people don’t stay too long in hospital by making the social care system (municipalities) bear the cost of patients who remain in a hospital bed after a doctor has said they are fit enough to leave.  

Lesson 2: Successful policy programmes build on existing culture, but are bold enough to change and challenge it 

Much of the work taking place in Sweden and Japan to respond to their ageing societies is highly culturally specific.  

For example, we heard a lot about how employers in Japan are thought of as part of the public health system and are used to run preventive interventions for older members of staff, including things like exercise classes. This seemed to draw on a different kind of relationship that exists in Japan between employers and employees than exists in the UK. Similarly, we heard about public exercise classes co-ordinated by radio broadcast designed to keep older adults active that have a long history in Japan dating back to the 1920s.  

As well as working around the cultural norms that already exist, we also heard about ways in which these countries were responsive to cultural change. The Japanese social care system came into its current form in 2000, prior to which there was no publicly funded social care available in the country at all. The assumption to that point had been that families could provide the care, but this model had started to break down with high rates of older people ending up in hospital for lengthy stays. Japan also wanted to ensure that younger women – who had traditionally been expected to be caregivers for older relatives – were able to join the workforce. The creation of a new model responded to this changing cultural reality.  

However, as well as responding to cultural attitudes as they already exist, another lesson we took from our conversation with Japanese experts is that successful policy development also involves being prepared, at times, to take on policy ‘taboos’.  

Japan has historically taken on very low levels of immigration compared to other similarly wealthy countries.  However, in recent times there has been a major political discussion about increasing migration to fill gaps in the labour market. During our workshop, the need for immigration particularly to fill roles in the social care sector was also discussed repeatedly.  

Case study: community gathering places in Japan

Community gathering places (CGPs) for older adults are one of Japan’s key policies for improving healthy life expectancy. CGPs arrange community activities ranging from exercise classes to hobby groups, with the aim of improving health and cognition, preventing frailty and fostering social connection. Activities are usually free or very cheap.

In our roundtable, CGPs were pointed to as a key example of the kind of preventive, community-based initiatives that Japanese policy makers view as key to both tackling the health effects of ageing and preventing loneliness and social isolation. Evidence suggests that CGPs have been reasonably successful in these aims.

Lesson 3: There are no silver bullets when it comes to an ageing population

Over the course of our discussions with Japanese and Swedish experts, we heard much that we could learn from in terms of meeting the challenges associated with an ageing population. However, what was also apparent was that on some challenges, there are no silver bullets available. Questions around issues such as: funding for social care, meeting demand caused by a growing share of the population experiencing multiple long-term conditions, dealing with workforce shortages – all of these seemed just as salient in high performing systems as it is in the UK.  

In Japan, financial pressures have led co-payments to rise steadily over time for people accessing some health services. In Sweden, we heard a lot about the challenges caused by workforce shortages in social care and an over-reliance on informal carers.

Even in areas where our countries of interest are widely assumed to be surging ahead, we found a more complex picture. There is a media narrative that Japan is able to deal with its demographic difficulties to plug gaps in its workforce and care for older adults. But from our conversations, it seemed that most of the technology that is being used in health and social care were broadly tools that are already available and being used in settings in the UK.

For its part, Sweden is regarded as a leader in the health data space, and we heard about impressive work that was being facilitated by good data collection, enabling large population health studies that built up detailed pictures of population need. However once again, we heard that this was no silver bullet, and significant challenges existed around sharing data between different parts of the state so that health and social care services could be integrated and prevention initiatives targeted.

What we took from these conversations then was that on these big questions, there are no easy answers and no ‘drag-and-drop’ solutions that we can take from other countries. In particular, the financial challenges that come from having a shrinking working age population and a growing cohort of people with substantial health and care needs are not things that are easily resolved, and no country seems to have found answers that are both financially sustainable and politically viable to this point.

Where are we in England? 

To discuss the findings described above and their applicability to our system, we convened a second special roundtable of experts, representing the NHS, public health, social care, charities and government.  

As discussed above, lessons cannot readily be parachuted into one country from another because of different cultures, geographies, histories and politics. However, some of the principles and approaches in Japan and Sweden – and other countries that came up in the discussion – could be considered and potentially adapted for England.  

During this roundtable, a number of key themes emerged. These included:   

• The importance of prevention.

• Differing models of care in the community.

• Attitudes to ageing and older people .

• Use of technology and data .

• Workforce as a driver of change .

• Variation and inequalities: differences within countries .

• The need for social care reform.  

The importance of prevention  

Prevention was a theme that was striped throughout the discussion, with a sense that both Japan and Sweden are ‘better at it’ than England⁵.   

A key recognition was that what happens to people in older age is, in many cases, determined by people’s condition much earlier in life.  As one participant noted: ‘Our population enters middle age and older age with health in a much more parlous state [than in Sweden or Japan].’⁶  

One clear priority for improvement was population-level approaches to cardiovascular health. One participant talked about heart health and the importance of ‘reaching people in their 30s and 40s and making a real difference at this point’.  

Sweden’s data collection and use of registries, which were felt to be world-class across the board, were specifically felt to be important here. As one participant put it: ‘these are so much better than what we have here. Evidence from cardiac registry is that it has massively improved cardiac-related mortality rates.’ 

Beyond heart health, our group also highlighted the potential for prevention around brain health, and the importance of physical activity and tackling loneliness. It was also noted that muscular-skeletal conditions were a major contributor to healthy life expectancy. It was noted that ‘these conditions are treatable, but we don’t have a good track record of doing that’.   

The overall goal should be to ‘reduce demand rather than work out how to meet it; push things down the life course and reduce the disability level.’ It was noted, for example, that obesity is a big part of musculoskeletal health.   

Intervention at an earlier stage in people’s lives to improve, heart, brain and musculoskeletal health would also have important benefits in helping prevent and limit two other conditions which were also discussed at length: frailty and dementia. It was observed that, while we need a better understanding of frailty and its causes, ‘we do know you can reduce many of the risk factors for mild frailty… and you can reduce the pace of progression.’   

As well as tackling the causes of heart and brain health that contribute to dementia, the importance of getting an early diagnosis was also discussed. Diagnosis ‘unlocks the care options that people need'. Without it, 'there is lots of evidence that people are more likely to fall, get infections, [and] end up in A&E’⁷.   

Participants noted that there was a real opportunity to adopt a more preventive approach to frailty and dementia in the upcoming Modern Service Framework for Frailty and Dementia, which is due to be published in 2026.   

Differing models of care in the community 

As well as taking a more preventive approach earlier in life, the roundtable also discussed how we should organise care for people once they reach later life. Here again, it was felt we could learn from Japan and Sweden, which were thought to take a more holistic approach to support, recognising the psychosocial and economic factors of ill health. This was illustrated by a concern about poor co-ordination of care, meaning older people were ‘having to retell their stories so many times’ to different professionals.  

Part of the problem, it was argued, is a lack of community geriatricians, who by training take a more holistic view and can help knit together services (although we didn’t find evidence that there are necessarily more of these professionals in Sweden or Japan). This is compounded by not enough professionals prioritising ‘quality of life rather than extension of life’.   

Co-ordination was also thought to be impeded by the way health and care is organised in England, with a ‘very hospital-centric approach’ dominating, leading to overlong stays in hospital before people are discharged back into the community. Tackling that, it was argued, required both a ‘mindset shift’ and a ‘neighbourhood health’ approach, as envisaged by the current government’s intended shift from ‘hospital to community’. It was felt that we had much to learn from ‘highly devolved systems like Sweden that have embedded community approach and [a] preventative lens’.   

The discussion of community went far beyond simply how we organise formal health and care services, however, and suggested we don’t always need to look as far away as Sweden and Japan for inspiration. One participant spoke of being impressed by a recent visit to Greater Manchester where health services were working with volunteers to better connect with different communities to try and increase screening rates for conditions like bowel cancer.   

One participant wondered whether there was an opportunity to ‘join the dots’ between planned  neighbourhood health ‘hubs’ and the Pride in Place Strategy, which aims to help build ‘stronger communities, [and] create thriving places and empower local people’.  

There was a concern, however, that community services such as lunch clubs and day centres struggled for funding and many had been closed. There was a concern about a possible tension between a ‘community-first’ approach and a ‘home-first’ approach which ‘risks shutting older people behind front door’. It was observed that people’s strong desire to be independent at home could easily turn into isolation. A better understanding how other countries approach the idea of promoting independence was suggested.   

One participant noted the importance of the role of local government in ‘cross-place approaches to strengthening community’. These were intended to promote looking to your community as a place to get care and support, with formal services there in a complimentary role.

This led to an important discussion about the need for an honest conversation about the relative responsibilities of the state, employer, local community, family and individual.  

Attitudes to ageing and older people  

A key issue affecting the ability of older people to live independent lives in their communities is how they – and the ageing process – are viewed by wider society.   

It was felt in our discussion that older people were more engaged in communal activity in Japan than in England. Part of the reason for this, it was suggested, is that England does not create third spaces for older people to access and spend time in in the way that Japan does. It was also noted that in Japan it is very common to co-locate children’s nurseries with older people’s services, whereas this approach remains rare in the UK.   

Some of this might be due to cultural factors. The perception among our attendees in England was that in countries like Japan there is more emphasis on people coming together in communities than in England, and also that there is a greater sense of respect for age and a ‘life of value’. 

It is also critical to remember that older people need to be involved in the design of their environment and the support they receive. ‘Older people want to choose, they want to co-produce’, said one participant. A key element of this, as noted in the section above, was the desire to ‘age in place’: ‘Older people don’t want to go somewhere else for their care.’   

Participants also felt that it was important that in England we make more effort to understand older people’s own priorities for care and support, which are often basic needs like continence and mobility.  

Finally, participants noted that there are important cultural differences between countries that might affect what lessons are possible to take. The UK (and Sweden) have higher foreign-born populations than Japan, which might mean we need to look in addition to countries with greater diversity in order to draw harder conclusions.   

Workforce as a driver of change  

The health and care workforce could drive change in two very different ways, our roundtable attendees thought. First, the difficulty in recruiting sufficient staff – a worldwide problem – could drive advances in working practice and use of technology. It was noted, for example, that Japan had sought to introduce technology in nursing homes in recognition of recruitment difficulties. It was expected that the reality of there not being an unlimited supply of staff would be recognised in the upcoming NHS workforce plan. However, there might also be particular groups of staff – for example geriatricians – where the numbers would need to increase.   

Second, it was also felt there was an opportunity to use better training and co-ordination of staff to drive improvements. There was a particular concern that England has a ‘cultural blind spot’ in that health and care professionals don’t recognise that, for many, their major client group is in fact older people. This is important because it affects the service older people received – it was noted, for example, that there are differences in how older people present with disease compared to younger people. Examples of this include pneumonia, where ‘classic’ symptoms of the condition are often not present in older adults (Joshi, 2024).    

Linked to this was a need to ‘reach beyond the specialists’ and equip the entire workforce with the skills and knowledge to work with older people, particularly around long-term conditions, frailty and dementia. One participant, for example, argued for mandatory dementia training for all health and care professionals, arguing that it is good for patients, good for families and improves retention of care workers because they feel they have the skills they need to make a difference.   

Variation and inequalities: differences within countries  

The roundtable noted that while it was usual to talk about differences between countries, there were also very wide differences within countries.   

In England, a key issue is that the concentration of older people varies between different parts of the country. In some areas – for example Norfolk – a quarter of the population is aged over 65. Cities like London have much younger populations. This presents current and future challenges, particularly around workforce recruitment.  

There is also variation in services between different parts of the country. ‘Some places are quite frailty-attuned and others less so’, said one participant. Access to geriatricians also varies between areas.   

However, it was not just geography that determined older people’s experience of ageing. A fundamental issue is that the UK is a more economically unequal than Japan or Sweden. As a result, ‘If you are in a poor area you come to older age, or age with disability, at so much younger an age’. It was also noted that access to social care services is also unequal because care homes are often subsidised by self-funders and, as a result, they tend to be in wealthier areas.   

The need for social care reform  

The issue of social care access also came up frequently during the roundtable. It was noted by participants that Britain is an outlier in terms of how many people are excluded from the publicly funded social care system and forced to either pay for themselves, rely on family and friends or go without care entirely. Both Japan and Sweden have social care systems that offer far more support to people who have a social care need, irrespective of their level of income and assets.⁸

‘Both Japan and Sweden offer strong state services that are there for people when they need them’, said one participant. Another participant noted that some people were facing care home costs of £1,750 a week for their relatives and: ‘At that price, people take terrible decisions about care, often to remain at home’. A clinician at the roundtable recognised that patients discharged from hospital might receive free care at home for a short period but would stop it when it became chargeable. The risk was that they then ended up back in hospital as a result: ‘The default place of safety where people fall into is acute hospitals’.  

The Casey Commission⁹, currently underway, was recognised as the vehicle that had the potential to recommend fundamental change to England’s social care system.   

Recommendations 

The context of every individual country is different, and lifting approaches or policies entirely from one place and trying to implement them in another is rarely wholly successful. However, both Japan and Sweden do offer lessons about how to approach the challenge of an ageing society that we can learn from in England.  

Here we make a series of recommendations that would help England move to become a high performing nation in terms of performance around healthy ageing. Where possible, we situate these recommendations within the government’s established framework of the 10 Year Health Plan, and, particularly, in the context of the government’s proposed ‘three shifts’ from analogue to digital, from hospital to community and from treatment to prevention.  

While these cover wide ground, they are not a comprehensive, but rather reflect the specific issues raised at our roundtables.  Our recommendations are: 

• Create a national strategy for addressing an ageing population.

• Deliver on the shifts to prevention and moving care closer to home. 

• Develop a workforce suitable for an ageing society, with a strong focus on community care.

• Tackle variation and inequality in ageing.

• Create a more universal social care system. 

Create a national strategy for addressing an ageing population  

Meeting the challenge of an ageing society requires a real sense of national mission around the issue, as shown in Japan and Sweden. This is lacking at present in England. It is now 13 years since the House of Lords Committee on Public Services and Demographic Change argued that the UK was ‘woefully underprepared for ageing’ and it is hard to see where there has been a step-change in the government response since then. The fertility rate is now 1.41, significantly lower than Japan’s ‘1.57 shock’ moment, and yet we haven’t so far reacted accordingly.  

To address this, the government should commit to producing a national strategy around the challenges of an ageing society and how it plans to meet them. This needs to be implemented with a co-ordinated, cross-departmental approach that recognises that action is needed not just in health and care but in critical areas such as benefits, employment, housing and pensions. It also needs to tackle the negative stereotypes and assumptions about ageing that limit the contribution older people can and do make to society. Prime ministerial support and co-ordination will be needed to ensure this is effective and that it has the political space needed to take on sticky issues and policy taboos, as discussed above. The government’s Health Mission could provide the architecture for how to do this in practice – and bundling into the mission a challenge as important and broad-ranging as demographic ageing could be the impetus needed to get the mission running with the energy and focus that was first envisioned.  

Deliver on the shifts to prevention and moving care closer to home

As was argued in the Chief Medical Officer’s annual report in 2023, the key to dealing with the health impacts of an ageing society is to push the age at which people develop disease and disability as far down the life course as is possible. This means that, at its heart, the challenge of an ageing society is a challenge of prevention. This needs to be recognised within the framework of the government’s proposed ‘shift’ to prevention, with the concept of healthy ageing placed at the heart of initiatives aimed at making that shift a reality.  

Prevention cannot start in older age but rather must be a continued approach over people’s lifetimes. Yet England is failing in this. The latest Health Survey for England data shows that 27% of adults participate in less than 30 minutes of moderate or vigorous physical activity a week. By contrast we heard in Japan how there was a strong focus on exercise, which dates back to the 1920s. While measures cannot simply be lifted from one country to another, the government needs to speed up measures to get the country moving.   

While the government’s 10 Year Health Plan promises on prevention, it has not been backed with concrete policies, for instance introducing a minimum unit pricing for alcohol. Some of the caution appears to stem from fear of action being labelled as ‘the nanny state’. Yet polling suggests that in fact the public supports measures such as reducing the amount of fat, sugar and salt in foods and restricting the advertising of unhealthy products. The government should be bolder and initiate a conversation with the public about how much of a ‘nanny state’ it really wants.  

The shift from hospital to community is particularly important for older people, especially those at risk of frailty. One third of hospitalised older adults experience ‘pyjama paralysis’ – muscle weakening, loss of mobility and changes in cognitive function.  The President of the Royal College of Emergency Medicine, Adrian Boyle, put it graphically when he said hospitals can be ‘lobster traps’ for older people – easy to get into but hard to get out of. NHS spending priorities therefore need to shift from secondary and acute care to primary and community. To do that, NHS leaders and the government must align all policies – investment, workforce, financial architecture and performance management policies – to that vision. Retaining focus on hospital performance – for example waiting times and elective care targets – will simply reinforce the status quo.  

Moving care from hospitals to community is not simply about where older people’s medical interventions happen. Much more fundamentally, it is about the infrastructure, services and connections that exist within local areas that can enable older people (in fact, people of all ages) to live healthy, happy and purposeful lives, surrounded by friends and neighbours, and supported by services and organisations that allow them to remain active and independent. Local authorities require the resources to be able to carry out this role effectively and it is critical both that government ensures local authority spending power is sufficient for them to carry out this role, and that local authorities in turn provide the support that the voluntary and community sector needs.  

Develop a workforce suitable for an ageing society, with a strong focus on community care 

Of course, as well as social care and services provided by VCSE organisations, quality care for older people, as we can see from the examples of Japan and Sweden, means good quality health care available to people in their communities. One of the issues in delivering this in England is the low status attached to working in primary and community services. This is leading to workforce issues in areas like community gerontology and district nursing, professions that are crucial to meeting the challenge of an ageing society.   

To tackle this, training for both practitioners and managers should focus as much on primary and community care as it currently does on hospitals, with system and national leaders having expertise in, and experience of, community and primary care. More broadly, there must be a strong focus on ensuring that existing staff have the right skills and capabilities to support older people, and are enabled and authorised to deliver the three shifts outlined in the 10 Year Health Plan. Retention of staff is critical and will require a focus on staff health, wellbeing and morale, and on the leadership and management that creates the conditions to support it.  

The government should consider carefully the implications of tightly restricting immigration on its ambition to deliver better care for patients and the public. We heard that in Japan, despite immigration being a controversial subject, national policy recognised – albeit at quite a low scale – its potential importance to filling gaps in the health and care workforce. In England, future workforce planning must also be realistic about the prospects for recruitment of British citizens. The government needs to build an immigration policy that helps meet workforce demands in the short and medium  term, while also thinking about the changes to training and delivery models of care in the long term that can limit the need for overseas recruitment.  

Tackle variation and inequality in ageing 

The challenge of an ageing society will not be distributed equally. There are some areas of the country, like London, where internal migration patterns will mean that the population ages incredibly slowly, if at all. By contrast, there are already other parts of the country where significant ageing has already occurred.   

As these dynamics deepen and develop, they will create significant challenges in terms of ensuring that resources, both in terms of money and workforce, are flowing to the areas where need is greatest. The government needs to ensure that plans and strategies are in place for this, and that technology is used where appropriate to allow professionals working in any part of the country to offer their skills to areas with high demand.  

Deprivation is a key driver of premature ageing and mortality. As the Chief Medical Officer’s report observed in 2023: ‘inequality in the rate of biological ageing is largely preventable and is affected by the social and economic environments that people live and work in’. Tackling these health inequalities and improving health for the groups who typically experience the worst outcomes requires a consistent and coherent focus on population health at a local, regional and national level. The shift towards a more preventative approach to health and towards care being delivered closer to people’s homes are key steps in this.  

Create a more universal social care system

 Britain is an outlier in terms of how many people are excluded from the publicly funded social care system and forced to either pay for themselves, rely on family and friends or go without care entirely. Both Japan and Sweden have social care systems that offer far more support to people who have a social care need, irrespective of their level of income and assets. Though it is hard to find ‘smoking gun’ evidence about the benefits to the health care system of this more universal approach, it seems likely that – as one clinician observed in our England roundtable – lack of publicly-funded social care causes people to make greater use of ‘free’ NHS services such as GPs and accident and emergency.  

The government set up the Casey Commission to explore reform of adult social care but on the current timetable its conclusions will not be available until 2028. The government should encourage the Commission to move faster, particularly in its interim recommendations, which are due this year. It should also set out that its vision of a ‘national care service’ includes a universal eligibility for publicly funded social care.  

Final word  

Demographic ageing is a policy challenge that often feels as if it’s in the background, relegated behind concerns that feel more pressing. That isn’t to say that governments never seek to challenge it – we have had ministers launch initiatives like the Ageing Society Grand Challenge before. However, it is clear that what we have done thus far hasn’t made the progress that was hoped for, and that we need to think again about how to best achieve impact. 

As we anticipated, we found few ‘drag and drop’ reforms that could simply be transferred from Sweden or Japan and would work perfectly in England. We did however find a number of key themes and lessons that could help England navigate its ageing journey, and we have set these out throughout the report.  

We also found something less tangible but equally as important. It was striking in the roundtables focused on Japan and Sweden, and indeed in the one on England, that no one was satisfied with the system they had. Even in areas where countries appeared to perform well according to the data, there was a tendency to see the remaining defects and imperfections and a strong desire to remedy them. 

This may be no bad thing, however. Nurturing a culture in which complacency is seen as an enemy may not be a bad approach to responding to the changes of an ageing society.