Examination of Witnesses (Question Numbers
160-179)
MR RAPHAEL
WITTENBERG AND
PROFESSOR CAROL
JAGGER
5 NOVEMBER 2009
Q160 Dr Stoate: Do we know much about
things like time bombs, things like obesity, epidemics, alcohol-related
illness, because those are clearly changing in society? Do we
know much about the future effects of those?
Professor Jagger: Obesity does
not have a huge effect on mortality; it has a much greater effect
on disability. The obesity rates are rising, though I understand
that in children they have started not to increase as much recently.
That will certainly have an impact on dependency but it will not
reduce life expectancy particularly.
Q161 Dr Stoate: I do not actually
agree with that because evidence I have seen is that obesity reduces
life by about nine years. We are now likely to see people predeceasing
their parents with conditions such as diabetes and heart disease
as a direct result of obesity.
Professor Jagger: That has not
been the case in America, partly because people with obesity are
more closely monitored than anything. Certainly at older ages
it is not true. It might increase premature mortality somewhat
but by the time you get to 65 some degree of overweight may be
protective.
Q162 Dr Stoate: You are presumably
talking about the over-65s. It is estimated that one quarter of
smokers, for example, do not reach 65 so I suppose you do not
look at those so much.
Professor Jagger: No, I am not
looking at those so much. What I know most about is the older
population.
Q163 Dr Stoate: Do you have any possible
projections of things like pandemics such as pandemic flu? Have
you done any modelling on how that might affect prevalency?
Professor Jagger: No, not to my
knowledge is there any modelling on that at all and I do not think
we have the data, to be honest.
Q164 Mr Scott: Could you tell us
what the Government could do, particularly through public health
interventions, to reduce the need for long-term care services
in the future?
Professor Jagger: I would say
concentrate more on alleviating the disabling effects of disease
rather than reducing mortality from disease. A measure of the
efficacy of many clinical trials is mortality rather than disability
so we do not really have a good feel for how some of these treatments
like statins are improving daily life for older people. We know
that they are reducing mortality and they are reducing secondary
strokes or coronary events but we do not know how much they are
improving daily life.
Q165 Mr Scott: Do you think that
is something we should certainly look into in greater detail?
Professor Jagger: Yes, it would
be useful to be able to have some idea of how much treatments
that are coming in are reducing disability and allowing people
to remain independent longer. Also, we have to make sure that
treatments are getting to everybody who could benefit because
there is good evidence that certainly women and the very old are
not getting treatments that they should.
Q166 Mr Scott: What about intermediate
care?
Professor Jagger: Yes, obviously
it would be helpful if people were allowed to develop services
which would benefit them more than having formal services that
everybody had to fit into. I certainly think that would be helpful,
yes.
Q167 Sandra Gidley: It surprised
me that you said women were not accessing or receiving treatments.
Generally they access health services better than men and there
is a lot of evidence for that. Are you actually saying that they
are accessing maybe primary care but then being denied treatment
and there is sexism in the system or does something go wrong when
they get older?
Professor Jagger: It is particularly
the evidence for statins because coronary heart disease is not
as well diagnosed in women as it is in men.
Q168 Sandra Gidley: Apart from statins
is there any other evidence?
Professor Jagger: No, I do not
think so.
Q169 Sandra Gidley: You made quite
a sweeping statement there.
Professor Jagger: I did but it
was in a particular treatment so I am saying that there are people
who do not get treatments that they would benefit from and women
and statins is one example.
Q170 Sandra Gidley: To be clear,
one example is women and statins; that is just one example and
not a generic situation.
Professor Jagger: That is the
case.
Q171 Dr Naysmith: Mr Wittenberg,
we have heard quite a lot about statistics and the demographic
aspects from Professor Jagger. Can you tell us what other factors,
in addition to the ones we have just been talking about, are likely
to affect future long-term care expenditure? What are likely to
be the pressures on expenditure for long-term care?
Mr Wittenberg: Looking at the
pressures on long-term care expenditure, I imagine one wants to
concentrate it in the first place on the demand side. Clearly
what is actually spent will also be a function of what money is
made available, so I assume it is mainly the demand side that
you are asking about.
Q172 Dr Naysmith: Yes.
Mr Wittenberg: The demand side
is affected by the numbers of disabled people in the future. Other
issues to be looked at in the modelling I have been involved in,
for example, are the household composition of older people, particularly
the proportion projected to live alone. Very closely linked up
with that are issues around the supply of informal care, that
is how many older people will have a surviving spouse who might
provide care or surviving adult children, for example, who might
be able and willing and living near enough to provide care. The
whole social side in a sense around household composition and
informal care is very important. Whereas the expectations around
the quality and types of care and the quantity of care is another
big issue, that is clearly a speculative one. There is a view
that expectations of future cohorts may be higher but I am not
aware of one particular measurement of that. Economic factors
may be relevant as well, issues around the wealth and the pensioner
income of future cohorts of older people in two senses: they clearly
would affect the means test, since we have a means-tested system;
obviously future incomes and savings affect the numbers eligible
for publicly funded care but may also affect overall demand if
people's preferences for care in any way related to economic considerations.
Q173 Dr Naysmith: These are fairly
diverse things we are talking about. How easy is it to estimate
them and bring them into models of future provision? Some of them
depend on all sorts of things over which we have no control.
Mr Wittenberg: I agree; some of
these factors are difficult to look at and it means there is a
range of uncertainty around the estimates. You remember that the
Royal Commission talked about a funnel of doubt and had a diagram
opening up a wedge of different projections; that was a very good
phrase in a sense to have used. I should also have mentioned earlier
the unit costs of care which are another area of uncertainty.
As far as the household and informal care areas are concerned,
projections of household type are produced from time to time by
CLG, which are available and one of my colleagues at LSE, Linda
Pickard, has looked into the area of projections of informal care.
Again, one has to make assumptions. Her base case assumption really
is that the propensity to provide informal care is constant, that
is to say that if at a given age, gender, educational attainment
level X% provide informal care to their parents, then one way
of looking at it is to say "Let's assume X% remains constant
over time". Of course it may not do. So there are ways of
looking at building up scenarios in some of these issues but of
course the future is uncertain and with informal care being dependent
on employment-related issues and geography, where people live,
which in turn may be related to employment, makes it a very difficult
area.
Q174 Dr Naysmith: I imagine quite
a lot of informal care is actually people who are caring because
they cannot get any help from anybody else to do the caring. Is
that not the case and if there was better provision there would
be less informal care?
Mr Wittenberg: The issues of the
linkages between formal and informal care is another complex area.
For example, we have looked at data from the General Household
Survey and certainly it is the case that after controlling for
people's age and disability, taking that into account, people
living alone are more likely to get care than, say, a married
person living with their spouse or a married couple getting help
from adult children. Yes, it is possible in theory to imagine
a system that was carer blind and I think that Denmark has such
a system. If there were more care, in theory that could be done
but it would clearly use resources and the question then is where
one wants to concentrate resources.
Q175 Dr Taylor: Continuing that line,
may I try to tie you down to some estimated figures? From the
modelling work you have done, can you tell us how many older people
require long-term care at present? Is that known?
Mr Wittenberg: I can tell you
about the numbers who receive long-term care at present and I
can tell you something about the numbers of disabled older people
in the community.
Q176 Dr Taylor: The number receiving.
Mr Wittenberg: The numbers of
older people receiving are probably roughly 300,000 in care homes;
a bit of uncertainty because we do not have hard data on either
the NHS funded group or the privately funded group but it would
be of the order of 300,000, which is less than 4% of the older
population.
Q177 Dr Taylor: But you do not know
the number struggling at home with informal help and somehow managing.
Mr Wittenberg: We have some estimates
of the numbers of older people receiving informal care and I think
that in our work we found roughly 1.75 million out of two million
disabled older people in private households, excluding the care
home group, receive informal care. This is obviously dependent
on survey information extrapolated from the General Household
Survey on particular definitions of disability and informal care.
It looks as though a very considerable proportion of older people
who are disabled receive informal care and it is mainly from a
spouse or an adult child.
Q178 Dr Taylor: I find that 300,000
a much smaller number than I expected. Does the modelling give
any idea how this is going to grow in the next ten years or so?
Mr Wittenberg: Yes. May I just
explain that we have been working with various models at the PSSRU.
The aggregate model certainly looks separately at the growth in
the numbers in care homes and the numbers in the community. However,
the only way of doing this is to make assumptions about future
patterns of care. One way of looking at it is to say "Let's
assume that the balance between residential and home care and
indeed the balance between formal and informal care is constant"
but clearly this is a policy variable and, as you know, there
has been a longstanding policy to promote care in the community
rather than in care homes. Taking that into account, it clearly
depends on the success of the policy and the wishes of future
cohorts of older people. So it is not possible to give a categorical
answer.
Q179 Dr Taylor: So you are saying
that the ratio at the moment is 1.75 million to 300,000.
Mr Wittenberg: The 300,000 in
care homes and roughly 1.75 million receive informal care. What
I have not given you yet is the formal care in their own homes.
The latest data is that about 650,000 are receiving publicly funded
home-based care, day care et cetera. An estimated 150,000 severely
disabled are receiving private home care, but again one has to
be rather cautious about the private care numbers as to whether
they are quite right or not. There may be people in both but that
would suggest something like 800,000 disabled older people in
the community receiving either publicly or privately funded home
care. Of course a lot of them may receive informal care as well;
there will be an overlap.
| 
