Globally, we are facing a significant shift in the age profile of the population. As a consequence of past successes in public health, more people are living longer – much longer. Globally , life expectancy has more than doubled since the start of the 20th century and is now above 70 years (WHO, n.d.) . In the 1950s, the global average was 46 years, compared to 71 years in 2015 (Roser et al., Reference Roser, Ortiz-Ospina and Ritchie2019). Advances in medical care over the past 20 years – tackling the big killers such as heart disease and stroke and improving survival rates for people with cancer – have also added further years to our (later) lives. Add to this the rapidly changing age profile of the population as a result of baby booms after both World Wars and throughout the 1960s combined with historically low birth rates in recent decades, and the economic consequences for health and social care as well as pensions can look daunting to even the most optimistic Minister of Finance.
The fact is that ageing is one of the most important issues we face – it presents us with ethical, financial, social, political, economic and environmental issues – and yet a lot of people just do not want to talk about it – including policymakers. It is widely presented as an impending disaster. Media coverage refers to a ‘tsunami’ of older people, the pension ‘timebomb’ or the ‘burden’ older people put on the health system. The response to the coronavirus pandemic has also at times stoked this fear of ageing and the older generation. All those over 70 have been labelled as vulnerable, dependent and needy despite huge variations in their health and resilience. There have been egregious examples of ageism with some health care providers introducing ‘do not resuscitate’ (DNR) orders or rationing of ventilators based on age. Some economists have pointed out the costs of saving lives has been disproportionate (particularly if you calculate the indirect costs of the lockdown and economic downturn). This has been portrayed as young people making a ‘sacrifice’ for the older generation stoking an intergenerational conflict.
Is it all doom and gloom? What actions do we need to take to create a more positive future for us all? In my new book ‘The Age of Ageing Better? A manifesto for our future’ Dixon, 2020 , I tackle head on this negative view of the age shift and suggest that if we take actions across key areas of society, we can create not only longer lives, but healthier and more fulfilling lives. The coronavirus pandemic means it is more important than ever to properly address issues around ageing and ask ourselves what future do we want.
1. The economics of the age shift
The first thing we need to do is acknowledge the age shift is happening. It is upon us and upon us now. These shifts in the age profile of the population should not have taken us by surprise. And to see the opportunities as well as the challenges.
The majority of countries across the world are in the midst of an age shift. As we have seen life expectancy increase, we have also seen the median age increase as these people live longer. But this is not a new problem, in fact the General Assembly convened the first World Assembly on Ageing in 1982 – some 38 years ago now – to guide thinking and the formulation of policies and programmes on ageing. Yet it seems that for so long, policymakers have largely ignored this issue but now is the time to properly address it to ensure that health and social care can better meet the needs of an ageing population.
The predominant viewpoint of economists is that an ageing population means an increased burden on public finances as, to put it crudely, more older people means more money needs to be spent on health and social care and pensions while there is a decreasing number of people in the workforce to fund this – which is an unsustainable balance.
The measure used to support these conclusions is the increases in the old age dependency ratio which compares the number of people over a certain age (usually 65) to the number under this age. Measurements done this way essentially count everyone over 65 as economically ‘dependent’, i.e. not working or contributing productively to the economy, and assumes that everyone below 65 is working, paying taxes and contributing to the economy. But we know that this is a poor measure as not everyone of working age is working and not everyone over 65 is economically inactive. For example, in the UK in July 2019, 29% of 18 to 24-year-olds were economically inactive and 11% of over 65s were in work, equivalent to 1.3 million people (ONS, 2019).
This also fails to take into account the contribution over 65s may make in terms of voluntary or unpaid work or care. If we take the UK, during 2016/17, the contribution made by over 65s through volunteering account for £2.7 billion (Iparraguirre, Reference Iparraguirre2017), while unpaid care for adult relatives or spouses has been estimated at £59.5 billion and grandparents are providing childcare worth £6.6 billion (ONS, 2018). The support that grandparents can offer enables many women who may not otherwise have returned to work the opportunity to return to paid employment. It is also worth noting that the over 50s have a far greater spending power than those in younger age groups – this age group held an estimated 76% of all the financial wealth held by UK households in Q2 2015, the equivalent to just under £800 billion (cebr.com, 2015). So this myth that older people are dependent and economically inactive is false. Older people contribute greatly to the economy via their spending power, as well as through paid and unpaid work.
We must change our perspective and see the age shift as a potential opportunity. We must take urgent action to enable more people to live healthier for longer, so they can continue to be economically and socially active, contributing directly and indirectly to society.
2. Health and ageing
Secondly, we need to understand that ill health is not an inevitable consequence of ageing. If we are to address the sustainability of health care, we need to focus on prevention and tackle health inequalities.
Pressures on health care services and the rising expenditure on health care are often blamed on the increase in the number of older people. Will the age shift result in the collapse of public health systems?
Historically, there have been several scapegoats for the rise in health spending – doctors wasting resources, public expectations, drugs and expensive treatments, and the ageing population. Demographic changes account for just 1% of the increase in health care expenditure in the UK compared to a historic 4% above inflation rise. Numerous different analyses point to technology as the main culprit – the ability to treat a wider range of diseases and disorders (Appleby, Reference Appleby2013). Falsely blaming higher levels of spending on the ageing population detracts from the important but difficult decisions about what treatments and how much medicine we want to pay for.
On average, health care spending per capita is higher for someone aged over 65 than it is for someone aged 30. Most projections of future health spending assume that the average cost of someone aged 65 today will be the same in the future. But for every extra year we live, we do not necessarily add another year of high-cost health care. We are generally staying healthier for longer and therefore the cost of care shifts to older ages. A wide range of studies have also confirmed that age is a much less significant determinant of health care expenditure than proximity to death Seshamani & Gray 2004.
So what if we took a radically different approach. Instead of a focus on extending life at all costs and spending ever increasing amounts on staving off the inevitable, we focused on supporting people to have a good (but perhaps earlier) death. Instead of investing more and more in innovations to identify and treat diseases, we invested more in taking action to prevent disease and disability and delay the onset of chronic conditions.
We must move away from this notion that as we age ill health is inevitable. Much of the health problems we see in old age are caused by a lifetime of cumulative exposure to risk factors – stress, smoking, alcohol, air pollution, poor diet, etc. We know that most diseases are caused by a combination of genetics, lifestyle and environmental factors. As we age, naturally through wear and tear, our bodies are more susceptible to illness – a process called senescence, and it refers to the decline in organ and cell function. Telomeres are the end sections of DNA, at the end of our chromosomes, and telomeres shorten as we age. This shortening is one of the biological pathways towards disease. While this does happen naturally, exposure to environmental stressors such as pollution, smoking, poor diet and alcohol, as well as chronic stress and poor sleep quality, are associated with telomere shortening. Chronological age is therefore a poor indicator of health.
The reality is that we ‘age’ differently depending on the socio-economic disadvantages we have faced – people from poorer backgrounds experience disease or disability much earlier in life, while those who are wealthier on average can remain fit and healthy into their 70s and beyond. This means that the poorest in our society are spending more of their later life in ill health. We need to address these inequalities and make sure that a healthier later life is not the preserve of the rich. We need a radical approach to prevention to reduce the incidence of chronic diseases. This will require tackling the main causes of ill health – smoking, alcohol consumption, lack of physical activity and obesity through better regulation of the tobacco, alcohol and food industry.
3. Changing the world around us
Thirdly we need to recognise that our environment has a huge impact not only on our health but on whether we are able to live a full life despite disability or limitations to our health. This is why it is critical that the response is cross-sectoral. It requires action from all parts of government and all sectors of society.
Many people as a result of the coronavirus pandemic have been confined to their homes – resulting in less physical activity, increasing the risk from damp and cold homes, and increasing social isolation (particularly for those who are digitally excluded) which can have an impact on people's mental and physical health. It is critical that we look to improve the environments in which people live to get people moving, tackle the poor quality of housing and close the digital divide. This means more green spaces for people to exercise, more walkable environments and better support for active travel such as better cycle lanes. It means enforcement against private landlords, information and funding for low-income home owners to tackle some of the worst housing conditions in our poorest communities. And it means making the Internet affordable and accessible to more people, supporting them to develop skills and confidence, and to offer off-line alternatives for those who are not digitally engaged.
For those whose health impacts their ‘intrinsic capacity’, it is vital that the environment is designed to enable them to remain as active and independent as possible, to maximise their ‘functional ability’ – to use the language of the World Health Organisation's definition of healthy ageing. This means designing transport and planning towns and cities and so that everyone, regardless of age or mobility, can get out and about. It means designing new houses to be accessible and adaptable as well as retrofitting and adapting existing homes, which evidence shows improves wellbeing, reduces hospital admissions and prevents or delays moves into residential care Centre for Ageing Better Reference Centre for Ageing Better2017. It means offering greater flexibility and supporting those with health conditions and caring responsibilities to continue working.
The coronavirus pandemic has impacted all of us and made us view our homes, communities and workplaces in a different light. It has shone a spotlight on issues around ageing and the inequalities in experiences of later life. This should be the wake-up call needed to take ageing seriously and make those policy changes to improve all our later lives. I can see a positive future, The Age of Ageing Better; we just need positive policy action to create this future.
