HC 1048-III Health CommitteeWritten evidence from Age UK (PH 80)


As our population is ageing any meaningful public health programme will have to fully incorporate the needs of those in later life. There is strong evidence that public health and prevention activities deliver clear benefits throughout the whole life course.

Changing demographics must be reflected in the organisation of public health through its structures, funding and incentives.

Health and Wellbeing Boards must have representation from across all sectors of the community.

The Public Health Outcomes Framework must reflect outcomes that are meaningful for later life. Indicators must not in their design or data collection discriminate against older people.

Arrangements for funding must not act as a disincentive to improve the health of the older population.

1. Background

1.1 The population is ageing. There are now more people in the UK aged over 60 than there are under 18. Over 10 million people in the UK aged 65 and above of whom 1.3 million people aged 85 or over.

1.2 It is important to be aware of the sheer diversity within this large group of people which affects their public health needs. The group generally referred to as “older people” encompasses several age-cohorts ranging from baby-boomers to centenarians. Older people are not just diverse in age; they are also diverse in other respects such as ethnicity, faith, sexual orientation, and whether they live in a rural or urban area. All these factors will affect their health needs and concerns and should be reflected in public health interventions.

1.3 Public Health has traditionally focussed on early intervention which often means initiatives aimed at early life. This is, of course, ideal as it can provide long-term benefits. However as the recent Public Health White Paper acknowledged, this does not preclude the need to continue to improve health along the life course.

1.4 Although healthy life expectancy at 65 is rising, it is not keeping pace with the overall increase in life expectancy. We are living longer, but we are not living healthier for longer. Poor health and wellbeing has serious impact on older people’s overall quality of life, preventing people from participating in the activities they enjoy and limiting their ability to live independently.

1.5 It is not just imperative that we act, but there is also growing evidence that it is effective. Many of the chronic conditions which blight the lives of older people can be either prevented or the onset delayed. There is good evidence that it is never too late to improve health and wellbeing if people are given the right information, support and services and that the environment is conducive. Even when there is no longer the prospect of extending life expectancy, there is still every possibility of improving quality of life and wellbeing. Both are legitimate outcomes for public health.

1.6 Many aspects of healthy living apply to all ages; a prime example of this is physical activity. A CMO report from 2004 stated the benefits of being physically active in later life:

Preventing cardio-vascular disease, diabetes and obesity.

Maintaining mobility and independent living.

Training to increase muscle strength which is important for daily living.

Strength, balance and coordination training to reduce the risk of falls.

Preventing depression and aiding recovery.

Improve cognitive function and reducing risk of cognitive impairment.

1.7 In addition to promoting healthy lifestyles throughout life, there is a need to address specific health problems that are particularly prevalent in older populations. Limiting long-term conditions are particularly prevalent in older age groups. Social isolation in later life must now be recognised as an important public health issue.

1.8 Falls are a major cause of injury among older people. About a third of all people aged over 65 fall each year. Falls represent over half of hospital admissions for accidental injury at a total cost of about £2.3 billion a year. Yet, there is good evidence of effective action that can prevent falls and falls injury such as NICE guidance. The recent Audit of Falls and Bone Health in Older People by the Royal College of Physicians has revealed enormous scope for improvement in this area.

1.9 The public health community is largely concerned about the obesity epidemic but there is scant recognition that malnutrition is serious and prevalent among older people living in the community. Malnourished individuals are less likely to recover from illness or injury, more susceptible to infection, experience increased ill health and have an increased risk of mortality. In addition, they have longer stays in hospital and are more likely to be readmitted. Age UK estimates that around 1 million older people—around 1:10 of people over 65—are malnourished.

2. The Creation of Public Health England (PHE)

2.1 While many public health problems are best solved locally, there remains a clear leadership role for central government in providing the right drivers for local change and removing any obstacles.

2.2 Some issues that have implications for public health need to be addressed nationally such as banning advertising of certain products. There is a clear role for PHE to spot emerging health trends including health inequalities between groups of people and between different parts of the country.

2.3 There is a role for a central body like the PHE to:

take responsibility for collecting and disseminating good practice and evidence for effective public health interventions;

identify and fund research in public health; and

to identify and address needs of small groups of disadvantaged people who are geographically dispersed and would therefore not register on the horizon of local authorities e.g. Gypsy Travellers.

2.4 Furthermore, PHE will be in a position to identify the health impact of government decisions for example around welfare benefits and to recommend that guidance from government is issued for example in relation to reducing speed limits.

2.5 As a result, in addition to its role in providing support and guidance to local public health organisation, it is essential that Public Health England has cross-governmental membership including representation from Departments for Work and Pensions, Communities and Local Government, and Transport.

3. The Future Role of Local Government in Public Health

3.1 We welcome the transfer of health improvement responsibilities to local government as it presents an opportunity to address the complex needs of older people in a holistic way. However, the transfer of the responsibility for health improvement to local government should not simply move functions from PCTs to local government. For this to work, all the levers for change must be aligned across NHS acute and primary care, mental health services, and public health.

3.2 Local authorities are in a better position to address many of the wider determinants of health, driving the creation of healthy neighbourhoods that allow people of all ages to thrive by providing the right support and infrastructure services, for example:

Provision of public toilets in combination with medical treatment and access to continence products will help make life for people with bladder problems less limiting and allow them to remain active and engaged.

Local transport and retail planning which makes food shopping easier as well as the provision of meals and other services that help people with shopping and cooking helps reduce the risk of malnutrition.

Decent housing and support to escape fuel poverty will have an impact on respiratory diseases and ultimately on winter deaths.

3.3 The increasing decentralisation of powers to local government should result in communities that meet the needs of everyone in later life. However while the new powers are welcome, Government must address the risk of unintended consequences:

The whole community needs to be represented in shaping the neighbourhood and services that they rely on. This is particularly important for those who are most isolated and excluded. Older people are a diverse group, and engaging all sections of the community is not achieved just by making things “accessible”. There needs to be an assertive drive to reach into communities where there is deprivation, or which are disenfranchised for whatever reason, and to actively target and work with them.

There needs to be reassurance that people will have the tools to maintain accountability. With more powers for local government and more organisations involved in running services, older people need access to data and information that will allow them to challenge decision-makers if they are not receiving quality services.

3.4 Localism needs to have its limits, and there has been little opportunity for debate on where the boundaries should lie. The Government should review the impact of these proposed changes regularly, to understand how the powers for local government and communities are being executed and the effect they have on public health and community empowerment.

3.5 Health and Wellbeing Boards will have as important role to play in embedding health improvement into the work of local agencies. However, there is a need to ensure that the public and service users are fully engaged in the public health agenda. Health and Wellbeing Boards will have a duty of patient and public involvement. It is vital that they have representation from groups stemming from different sections of the local community. Voluntary and community groups have knowledge about, and access to, seldom-heard groups and can make a valuable contribution to the assessment and analysis of public health needs.

3.6 It will be essential to make sure the needs of disadvantaged group are identified if we are to achieve a real reduction in health inequalities. Joint Strategic Needs Assessments and Health and Wellbeing Strategies must reflect the needs of all sectors of the community.

3.7 Health and Wellbeing Boards must ensure that all aspects of public health, including the wider determinants of health, are incorporated into their plans. They must also ensure the full engagement of those whose responsibility lies in related areas of services such as planning, environment, and transport.

4. Structure and Purpose of the Public Health Outcomes Framework

4.1 The Public Health Outcomes Framework must reflect the reality of an ageing population. It is essential that it effectively factors older people into the benefits it sets out to achieve. The Framework must incorporate what is important to older people and the full set of outcomes and indicators must reflect later life proportionately.

4.2 It is essential that the outcome measures and underpinning indicators serve the whole population, including people in later life. All indicators should be disaggregated by age unless it clearly does not make sense to do so.

4.3 We are particularly concerned about the proposed indicators for Domain 5: “Healthy Life Expectancy and preventable mortality” in the draft Outcomes Framework. The proposed indicators exclude deaths in people over the age of 75 from cardiovascular disease, cancer, liver disease and chronic respiratory disease.

4.4 We are deeply concerned that limiting these vital indicators by age will compound ageist practice and send a message that older people do not matter. We fully understand that mortality is higher for older ages and that it is not meaningful to make comparisons of mortality between different age groups. As an alternative to the proposed indicators, we suggest that data is collected and reported (separately) for additional age bands “75–84” and “85 and over”.

4.5 The manner in which indicators are measured must not discriminate against older people either. For example, assessment and outcomes measures must include people living in institutions such as care homes and prisons whose residents are often excluded from health surveys. Most older people live in their own homes but nearly 400,000 people over 65 live in care homes. Care home residents are among those people in the poorest health.

4.6 We can only assess and reduce health inequalities if we measure all groups in the population. All data relating to indicators should be collected and disaggregated according to protected equality characteristics as a matter of course. Progress against indicators should also be routinely reported by population groups. We need to ensure that headline progress does not obscure persistent failure to make improvement in relation to specific groups.

5. Arrangements for Funding Public Health Services

5.1 The recent consultation paper, Healthy lives, healthy people: consultation on the funding and commissioning routes for public health set out a proposal for a target allocation of funding to each local authority.

5.2 We suggest that the allocation is developed to reflect the five “life stages” identified in the Public Health White Paper: “Starting Well”, “Developing Well”, “Living Well”, “Working Well”, and “Ageing Well”. There would be an allocation to reflect the needs of the local population in each of these strands. The total grant for a local authority would then be the combination of all these strands. For example, using this method local authorities with particularly high existing and projected needs due to an ageing population would be able to better focus on the promotion of “Ageing Well” activities and initiatives, whereas other local authorities with a relative high proportion of young families might dedicate more resources to “Starting Well” or “Developing Well”.

5.3 It should be an essential condition for the grant that money is spent on activities that directly contribute to improving health and wellbeing.

5.4 There is a need for clarification for how public health funding relates to other local government funding such as Supporting People and Disabled Facilities Grant.

6. The Health Premium

6.1 It is clear that the Health Premium will be a key driver for activity, especially during the coming years of reduced public budgets. It is therefore particularly important that the Premium is not attached to outcomes in a manner that would, perversely, increase health inequalities.

6.2 The Health Premium must not in its design or allocation discriminate against public health activities that will benefit older people. This makes it imperative that the Health Premium is designed and allocated in a manner that incentivises outcomes that will have an impact on health and wellbeing in later life as well as in earlier life equally.

6.3 As a result, we suggest that indicators that benefit the whole population should be selected in the first round. For example physical activity which has enormous potential to improve physical and mental health throughout the life course. We also know that there is room for improvement across the whole life course as only a minority of older adults are active at the recommended level.

6.4 The development of the Public Health Outcomes Framework and the Premium provides a good opportunity to incentivise activity in areas that have previously been neglected by public health. For example, we would suggest a mental health indicator is selected—such as self-reported wellbeing—as mental health is often the poor relation in public health.

6.5 The Public Health White Paper has taken into account the findings of the Marmot Review. The Review concluded that health inequalities stem from social inequalities, and that action on health inequalities requires action across all the social determinants of health. The findings of the report should be reflected in the allocation of the Health Premium. It would be of huge benefit to incentivise local authorities to improve the local environment through attaching a Premium to a healthy locality measure and to improvements in housing. These are both areas which are already within local authority responsibility.

6.6 In order to ensure that the Premium does not inadvertently increase inequalities, there should be a requirement for recipients to report on improvement against each equality strand (or to justify objectively otherwise). For example, if unemployment becomes one of the incentivised indicators, recipient authorities would need to demonstrate decreased unemployment rate not just in the general population but also in specific subgroups such as Black and Minority Ethnic groups or older workers.

6.7 We also suggest that outcomes resulting in cost savings in the NHS in the short term, such as alcohol related hospital admissions, are not given additional financial incentives. Similarly, any indicators that are based on the Quality and Outcomes Framework for GPs should not have a Health Premium attached as they are per definition incentivised.

June 2011

Prepared 28th November 2011