Evidence submitted by the International
Longevity Centre-UK (WP 30)
1. THE ILC-UK
The International Longevity Centre-UK (ILC-UK)
is a think-tank which aims to help decision makers in the public,
private and voluntary sectors understand the implications of an
ageing population. It provides evidence to facilitate new policy
solutions and promotes awareness of these issues in the public
domain. Further information can be found at www.ilcuk.org.uk
2. SCOPE OF
SUBMISSION
This submission considers the following issues
raised by the Select Committee call for evidence:
"In considering future demand, how should
the effects of the following be taken into account:
— Recent policy announcements, including
Commissioning a patient-led NHS.
How will the ability to meet demands be affected
by:
To what extent can and should the demand be
met, for both clinical and managerial staff, by:
— changing the roles and improving
the skills of existing staff;
— the recruitment of new staff in England."
3. THE IMPLICATIONS
OF POPULATION
AGEING FOR
HEALTHCARE SERVICES
3.1 The Committee will be well aware of
demographic trends in the UK: low birth rates and increasing life-expectancy
are reshaping our population. There were 19.8 million people aged
50 and over in the United Kingdom in 2002, a 24% increase from
16.0 million in 1961. The number is projected to increase by a
further 37% by 2031, when there will be close to 27 million people
aged 50 and over. More importantly the "oldest old"
over 85 are projected to rise from over 1.7% of the population
in 1994 to over 5% in 2055 (ONS 2005).
2. THE IMPORTANCE
OF NEW
WORKING PRACTICES
2.1 Greater longevity poses new challenges
to human resources in health at two levels. Firstly, as people
age, they are more likely to suffer from multiple chronic conditions,
often occurring at the same time. Secondly, the health and social
care workforce itself will experience population ageing.
2.2 The management of chronic illness is
at odds with the traditional acute, medically dominated, hospital-based
model of care (McKee et al 2005). The focus of service
delivery must therefore change to encompass settings outside the
hospital and recognise the value of care solutions based in the
community, for example:
— Geriatric assessment, conducted by
a multidisciplinary team, including risk assessment for malnutrition.
— Prevention (eg housing adaptations,
information).
— Rehabilitation, manifested particularly
in the creation of intermediary care facilities that allow older
persons a transition between (expensive) hospital beds and the
community setting.
— Integrated care, which spans across
all components of the health care system (primary, secondary and
tertiary care) as well as social care.
2.3 The integration of health and social
care services is recognised as a key lever to providing efficient,
patient-centred care to ageing populations. Integrated care may
also confer significant economic benefits to health care systems,
as it relieves the burden of care from acute hospitals and moves
it into the community. Multi-disciplinary approaches (eg stroke
unit teams) to managing chronic conditions have been shown to
result in better patient outcomes (Wait S, and Harding E, 2005.)
2.4 Figure 2 above represents a somewhat
simplistic projection of the 2003 age-specific risk of living
in residential settings and applies it to future demographics.
However, other studies have also concluded that population ageing
is expected to lead to considerable future increases in the numbers
of people requiring residential and nursing care, particularly
due to the likely rise in chronic diseases such as dementia (Warburton,
1994; Wittenburg et al, 2004). Such figures are, at least,
a strong signal for the need for greater investment in preventative
initiatives.
2.5 Demand is expected to increase for those
who work on the interface between health and social care, such
as home-care workers, nurses, community health nurses and physiotherapists
(Dubois, McKee and Nolte 2006). There is evidence from several
care settings that nurse-led clinics achieve better results than
traditional physician-led care (vrijhoet et al, 2000).
Nurse-led diabetes management clinics, for example, represent
a shift towards enhancing the role of nurses as the primary provider
and coordinator of care as well as moving the nexus of care into
the primary care setting (Renders et al 2001).
2.6 These new models of integrated, holistic
and community orientated care render the traditional boundaries
between professions obsolete and call for a change to the current
hierarchy of professions within health and social care (Wait,
Harding 2006). Thus attitudinal changes will be necessary alongside
new strategies in human resource management.
2.7 Despite ambitious new policy guidance,
significant gaps between policy and implementation exist (Lewichsenring
2003.) Increased decentralisation of services and local resource
constraints often create cumulative hurdles to achieving integrated
care. As a result, many people with chronic illnesses end up "falling
through the net" as available services fail to meet their
needs (Wait, Harding 2005). Indeed, a significant risk is that
people may delay access to physicians and thus have delayed diagnosis
if access to care is limited. These issues need to be urgently
addresses by health service planners.
3. THE IMPLICATIONS
OF AN
AGEING WORKFORCE
3.1 The ways in which the health care workforce
is recruited, trained, rewarded, regulated and managed have often
failed to keep pace with the changing demands facing health care
systems, and workforce ageing represents a new challenge for the
UK (Dubois, McKee and Nolte 2006).
3.2 Whilst population ageing increases the
demands on healthcare systems, it also restricts the population
of working age available to provide care. The UK—as with
many European countries—is seeing the greying of their nursing
workforce. In the UK, one nurse in five is over 50, and nearly
half are over 40. Some 40% of consultants over 50 are expected
to retire in the next 10-15 years. Recruitment of younger nurses
is a major concern, between 1988 and 1998 the proportion of nurses
aged under 30 fell from 30% to 15%. Only 19% of the UK consultant
workforce was under the age of 40 in 2002. Furthermore about 40%
of those over 50 are likely to retire during the next 10-15 years
(Dubois, McKee and Nolte 2006).
3.3 Although aggressive policies for boosting
supply have been implemented in the UK, such as training new doctors,
nurses and recruiting and training foreign clinicians, the time
lag needed to fully train health professionals is at least 10
years. Severe imbalances between supply and demand of health care
labour are both inevitable and imminent (Dubois et al,
2005). Previous policies such as restrictions on training and
intake for medical positions are partly responsible for the likely
future shortages in human resource (Dubois, McKee and Nolte 2006).
3.4 Attempts to reverse the trend towards
early retirement the workforce have yet to make any real impact
in boosting participation rates. The proportion of physicians
working beyond the age of 60 years has fallen in most European
countries since the mid 1990s (Dubois, McKee and Nolte 2006),
and nursing professions show similar trends. Effective policies
are likely to be those that recognise issues of low renumeration,
the physical demands of many healthcare professions, and the growing
burden of family demands such as informal care.
We urge the committee to:
— Strongly advocate sustainable policies
to recruit and train new medical staff over the long term.
— Consider how the existing healthcare
workforce can be better retained, and in the case of those near
retirement age, promote flexible and advantageous arrangements
to encourage the extension of working life.
4. ENSURING THE
CORRECT BALANCE
OF SKILLS:
GERIATRIC MEDICINE
4.1 Population ageing, and the corresponding
shift in patterns of disability and disease, demand that healthcare
systems aspire to a balance of skills relevant to user needs.
About 40% of the NHS budget— £10 billion—and
around 50% of the social service budget—£5 billion—was
spent on people over the age of 65 in 2001 (Department of Health,
2001). Two thirds of acute hospital beds in the same year were
occupied by people over the age of 65. We can expect these trends
to increase over the next decades.
4.2 Comprehensive geriatric assessment and
rehabilitation are of proven benefit in the management of frail
older people in hospital and the community, resulting in improved
mortality, functional status and reduced discharges to nursing
homes (Stuck et al 2003). "Standard practice"
may sometimes need to be adapted for older persons, for example
the course of presentation of many diseases may be delayed in
older persons, due to weaker pain sensitivity and cognitive impairment
(Derejcek, 2004). Many symptoms may be masked by the presence
of other morbidities.
4.3 The United Kingdom was one of the pioneer
countries to recognise and develop the clinical discipline of
geriatric medicine, which is now one of the largest specialties
in medicine (British Geriatric Society 2005). However, a recent
survey of medical school teaching by the British Geriatric Society
(BGS) revealed that it was still possible for medical undergraduates
to bypass geriatric medicine training entirely. There was not
sufficient evidence from the survey to show whether there was
any teaching about impairments, disability and functional status.
4.4 The role of geriatricians has also changed.
Over the last 10 years, geriatricians have become increasingly
responsible for the acute intake in hospitals at the expense of
their role in the management of chronic, frail older patients.
Closure of academic departments of geriatric medicine is a further
concern (BGS 2005).
4.5 Given that the over 65s represent the
majority of health service users and that this trend is likely
to increase in future, we must:
— Ensure that undergraduate and postgraduate
clinical training includes factors such as co-morbidity and chronicity
of conditions.
— Where training is being undertaken,
ensure that geriatric medicine modules include adequate exposure
to community-based settings and principles of integrated care,
and are not overly dominated by clinical, hospital-based practice.
— Ensure that all clinicians, not just
geriatricians, are trained in how to manage older persons' conditions
in a holistic and multidisciplinary approach.
— Ensure that social care workers are
trained to meet the complex needs of older persons, particularly
dependent adults disabled by co-morbidities.
5. CONFRONTING
AGE DISCRIMINATION
IN HEALTHCARE
Age discrimination is an "action which adversely affects the older person because oftheir chronological age alone." (National Service Framework for Older People, 2001).
| | |
| |
|
"Age discrimination happens when someone makes or sees
a distinction because of another person's age and uses this as
a basis for prejudice against, or unfair treatment of that person"
(Department of Health 2001).
5.1 Population ageing, coupled a growing recognition
that discrimination against older people is unacceptable, demands
that healthcare services revise ageist practices and ensure the
most equitable, efficient provision of care possible.
5.2 Older people are recognised as the largest consumers
of health care services, and as such are often viewed as a "burden"
on crippling publicly-funded health care systems (Wait, 2005 b).
The media encourages a "catastrophic" view of health
care system sustainability by constantly reminding us of the financial
drain that older people pose on our scarce health care resources.
There is a tremendous need to dispel the myth of the "expensive
older patient", a problem possibly exacerbated by resource
constraints, and to recognise the limited role that ageing plays
in explaining exploding health care expenditure (ibid). There
is now a rich wealth of literature indicating that high levels
of resource use are predominantly a function of dying and not
of old age—high use of services occurs principally in the
12 or 18 months prior to an individual's death (ibid).
5.3 The depiction of older people as frail and dependent
(Henwood, 1990), condescending terms such as "little old
lady" (Bytheway, 1995), are echoed in health services' own
jargon, most notably in the concept of old people as "bed
blockers" (Roberts, 2002). The fact that older patients may
be "blocking" precious hospital beds because of a lack
of available community-based facilities may be overlooked. As
is stated by Roberts, "the label `bed blocker' tempts [medical]
staff to apportion blame to individual patients although the problem
is caused by a system failure." (Roberts, 2002). Most importantly,
age discrimination may occur because we are all going to become
old—reflecting our own fears of old age and what it implies
for our health and well-being (Wait, 2005).
5.4 Nonetheless, such discrimination results in multiple
barriers in access, financing, planning and delivery of care for
older people (Roberts 20 02; Wait 2005). For example:
— Symptoms in older people may be dismissed as a
natural manifestation of ageing, resulting in compromised health
outcomes. For example, a survey in one PCT in Haringey found that
there was a tendency amongst clinical staff to re-label mental
health problems as dementia as soon as they hit the age of 65
(Office of Public Management 2004).
— Reduced choice being offered to older patients,
denial of surgical procedures or expensive but effective treatment,
and delayed admission to intensive care units.
— Explicit age barriers to treatment, for example,
in various aspects of cardiovascular care.
— Inadequate information and little referral to
self-help or patient groups designed to improve availability of
information and promote patient rights.
— Older people may be excluded from clinical trials
(Wait, 2005).
5.5 Most restrictions in access to services are dictated,
not by explicit protocols but by historically-inherited practices
and staff behaviour. Commissioners of health services may have
lower expectations of what older people need compared to younger
people. Medical staff may alter their communication, transmission
of information and expectations of outcomes with older patients
if they feel a social distance from them (Robinson, 2002). Quality
of care offered to older people may be lower, be it in terms of
longer waiting times, less attentiveness to detail, less choice
being offered in treatment options (Ellis 2002).
5.6 Surveys of medical staff reveal little awareness
of systematic ageist policies but point instead to ad hoc ageist
behaviors and practices. For example, clinical staff may assess
the needs of older and younger people differently, for example
by only asking younger persons whether they have a social life.
We urge the select committee to advise in favour of:
— Continued and enhanced training for the healthcare
workforce to challenge and raise awareness of ageist and arbitrary
barriers to care for older people. Dedicated training of all clinical
and managerial staff may help dispel false assumptions and slowly
change behaviours.
— Continued support, promotion and policy development
and of the National Service Framework for Older People at the
highest level.
6. THE IMPORTANCE
OF RECOGNISING
THE INFORMAL
CARE WORKFORCE
6.1 Discussions on the healthcare workforce have tended
to omit reference to the 6 million informal carers in the UK,
some 10% of the total population, or approximately 12% of the
adult population (Carers UK 2005). This is a burden likely increase
in future. The 2001 Census and the General Household Survey revealed
that the number of carers providing support for 20 hours or more
every week increased from 1.5 million in 1990 to 1.9 million in
2001. Those with very heavy care burdens (defined as over 50 hours
of care per week) increased to 1.25 million (Carers UK 2005).
6.2 Their contribution to services is immense and remains
largely unrecognised. Yet policy-makers cannot take the presence
of informal carers for granted. Family structures in the UK are
changing, as are expectations of the role of children 6.3 towards
their parents. Women form the majority of carers (Carers UK 2005)
yet this role is under pressure from changing lifestyle ambitions
such as career demands—boosting workforce participation
is, incidentally, a stated government objective.
6.3 The growing age gaps between generations caused by
women waiting longer to have children also has many implications
for care. There is a fear of the "women in the middle"
scenario: whilst 20 year generations create 45 year old women
helped by 65 year old mothers to support 20-25 year old children
today, 30 year generations will create 50 year old women caring
for both 80 year old mothers and adolescent children (Harper S,
2003), with a likelihood of increased workforce participation
caused by various factors, not least less advantageous pension
arrangements.
We urge the committee to:
— Recognise that informal care is the bedrock of
our formal healthcare services and public support will achieve
significantly positive outcomes for health and wellbeing.
— Recommend that training, community care support,
better information and empowerment for carers in healthcare provision
forms part of a wider strategy to prepare our healthcare system
for future need.
7. SUMMARY RECOMMENDATIONS
In summary, we urge the Select Committee to:
— Advocate long-term sustainable policies to recruit
and retain staff in both medical and social care services.
— Recommend continued and enhanced workforce training
to cope with the changes in service demands associated with population
ageing, such as a greater emphasis on community-based, integrated
care and co-morbidities.
— Recommend continued and enhanced training for
the healthcare workforce to challenge and raise awareness of ageist
and arbitrary barriers to care for older people.
— Recognise that informal care is the bedrock of
our formal healthcare services and public support for carers will
achieve significantly positive outcomes for health and wellbeing
and our formal healthcare services.
Ed Harding
International Longevity Centre—UK
March 2006
| 
