Healthy Life Expectancy
2.17. We believe that increases in life expectancy
are truly to be welcomed only if the "added years" are
years of relative good health. We therefore also looked at figures
which indicate to what extent healthy life expectancy (HLE) has
kept pace with LE. We immediately came up against a problem of
definition. As with all statistics relating to future projections,
there is a margin of error in the figures for life expectancy.
But while there is no possibility of error in determining when
life begins and ends, good and bad health are far from being absolutes.
They are often a matter of impression, and the line between the
two is not a sharp one.
2.18. The ONS gave us the following information
about methods of estimating HLE in the UK:
BOX 2
Methods of Estimating Healthy Life Expectancy

2.19. Professor Sally Davies, the Director of
Research and Development at the Department of Health, told us
that figures obtained in this way, far from supporting the proposition
that HLE is increasing at a faster rate than LE (as one might
have hoped), or at least keeping pace with it, is in fact growing
more slowly, so that there is a corresponding increase in what
might be termed "unhealthy life expectancy" (Q 139).
She subsequently drew our attention to the following graph, which
strikingly illustrates this:
FIGURE 2
Life Expectancy and Healthy Life Expectancy

2.20. If this apparent increase in unhealthy
life expectancy is a true reflection of the facts, it is a matter
of considerable concern. We wondered however if this might simply
be a reflection of the inaccuracy of self-assessment of so vague
a concept as ill-health, and we asked the ONS whether this was
a reliable method of calculation. They told us:
"A morbidity measure based on self-assessed
health provides valuable information on the relevance of illness
to the individual. A comparison of evidence by Ilder and Benyamini
established that simple measures of self-rated health consistently
predict subsequent morbidity, health care use and mortality, after
controlling for risk factors and diagnosed conditions. While self-assessed
health status is recognised as a valid measure of population health,
concerns remain about the reliability of subjective assessments
in general. These are known to vary systematically across population
sub-groups (by ethnicity and social class) and over time. They
reflect difference in ill-health, behaviour, expectations and
cultural norms for health.
We know little about the sources of health perceptions,
and what people are telling us when they report 'good', 'fairly
good' or 'not good' health, or what is the underlying mechanism
which consistently links perceived health status with other health-related
outcomes. However self-perceived health has been repeatedly shown
to be predictive of health outcomes. The most dramatic influence
is seen in the association between self-rated health and subsequent
mortality."
2.21. As an explanation of the apparent widening
of the gap between LE and HLE, the ONS had this to say:
"There are several theories behind the increase
in reported ill-health. It is possible to separate these ideas
into the following six broad categories:
- People have become more sensitive about health
or have adopted higher expectations about their health and/or
functioning. The result is that conditions that would not earlier
have been regarded as problems are now considered to impact on
daily living. Any changes in morbidity over time may reflect people's
expectations of good health as well as changes in incidence or
duration.
- Economic incentives are persuading people more
readily to consider or present themselves as ill. Workers are
suspected of having target incomes, below which they are more
inclined to work and it is suggested that rising real income has
promoted more ill-health time, or higher incidence of injuries.
- Improvements in survey methods have led to the
discovery of a growing proportion of health problems.
- Diseases, especially chronic diseases, are being
detected earlier. The prevalence of those diseases has risen because
the point at which sickness is said to have begun is now earlier.
People examined or screened and found sick, the 'earlier patients',
add to the prevalence of disease. In the case of diabetes, for
example, earlier detection allows progress of the disease to be
arrested and permits the sufferer to carry out ordinary activities
despite to continued presence of the disease.
- People with ill-health are living longer. Illnesses
and injuries that, in former times, were resolved in death are
now more often resolved in management of the disease.
- The last century has seen a substitution in health
risks. On the whole, illnesses with a short course and higher
incidence, such as infectious diseases, have been replaced by
diseases with a long course and low incidence, for example chronic
conditions. This leads to an expansion in morbidity prevalence
values, even when incidence remains the same over time.
Each hypothesis provides a plausible explanation
for increase in the prevalence of ill-health. Untangling the differential
trends in incidence, duration and prevalence of ill-health is
only possible using longitudinal data. Many of the issues related
to observed increases in ill-health rates in cross-sectional surveys
will be addressed in the future using results from the English
Longitudinal Study of Ageing."
2.22. These are all possible explanations for
a perceived increase in "unhealthy life expectancy".
However we have received no specific evidence showing whether
the increase is wholly perceived, or a reflection of a true increase
in years of ill-health in later life, or (as seems more likely)
a combination of the two. In the case of a perceived increase,
we do not know to what extent each of the reasons suggested by
the ONS is actually responsible for the increase. If there is
a true increase in ill-health, no explanation for this has been
suggested to us.
2.23. It appears to us that questions based on
self-assessment of such a vague concept as health, while they
may enable comparisons to be made with replies to the same questions
from different groups or different areas, are simply not sufficiently
reliable to provide an effective objective measure of health in
old age. Moreover, the questions asked often differ. While the
GHS and 1991 Census asked for health to be classed as "good,
fairly good, or not good", Department of Health (DoH) surveys
have adopted criteria recommended in 1996 by the WHO, and have
asked whether health is classed as "very good, good, fair,
bad or very bad". Nor can international comparisons usefully
be made, since other countries rely on yet other criteria. For
example, the United States, Canada and Australia ask whether health
is perceived as "excellent, very good, good, fair or poor";
in those countries, those who perceive their health to be "fair"
are in the fourth category rather than the third.[18]
2.24. Ms Susan Lonsdale, Acting Head of the DoH
Policy Research Programme, equated healthy life expectancy with
disability-free life expectancy (Q 140), but other witnesses
drew a clear distinction between the two. Sir John Grimley Evans,
Emeritus Professor of Clinical Geratology at Oxford University,
told us:
"Most geratologists have since [1984] focused
on disability rather than morbidity as the crucial transition,
because it is disability and its associated loss of autonomy that
older people fear, and which in turn leads to dependency with
its cost implications for the health and social services. Moreover,
much of modern medicine as applied to older people does not 'cure'
disease but relieves its symptoms and other effects and, in the
best case, prolongs survival. People may still have the 'disease'
in a medical sense but it does not affect their quality of life.
Such effects ought surely to register as success in prolonging
disability-free life expectancy, rather than as failure in extending
the duration of (irrelevant) 'disease'
I would urge the
Committee to focus on disability-free life expectancy rather than
healthy life expectancy as a measure of the well-being of an ageing
population."[19]
2.25. Sir John explained that it was generally
accepted that the prevalence of disability in later life had fallen
in the United States since the 1980s,[20]
but that as far as the UK was concerned "the informed view
is that we simply do not know what is happening, but there is
certainly no evidence that disability levels in later life are
falling as in the USA". Evidence that we received during
our visit to the United States National Institute on Aging was
to the same effect; Dr John Haaga, deputy associate director of
the Behavioral and Social Research Program, suggested that in
the United States, unlike the UK, HLE had been rising at the same
rate as LE over previous years.[21]
2.26. In Sir John's view, what had happened in
the United States could be made to happen here through appropriate
health, social and educational policy. It was therefore highly
desirable that disability free life expectancy in the general
population should be monitored. This would not only assess the
effectiveness of relevant government policy, but would also provide
a more secure basis for recognising current shortfalls and predicting
future needs for health and social services. Sir John thought
that the ONS would be the most appropriate body to oversee the
repeated standardised surveys necessary, and that it could draw
on the extensive experience in the United States in the assessment
of disability.
2.27. Although disability is easier to define,
and hence to determine, than ill-health, it is still far from
being an absolute. For example, research in the Netherlands has
shown that in 85-year olds there can be a marked discrepancy between
having an intrinsic capacity to perform an activity of daily living
and the translation of this capacity into actually doing it; the
factors underlying such a discrepancy may need to be taken into
account in measuring "disability".[22]
Here too, different countries have different definitions as to
what constitutes disability. Australia takes disability to be
one or more of 17 defined conditions, Japan takes disability to
be confinement to bed, France includes as disabled all those in
retirement homes, while in the UK disability is self-reported
as a long-standing limitation on activities in any way.[23]
2.28. Despite this, we accept and endorse the
view that it is easier to assess disability accurately than it
is ill-health, and that disability is less susceptible to changes
in people's perceptions of themselves over time. We believe that
it is important for all concerned with this question to know more
accurately how the health of older people is changing over time;
what the trends are; the direction in which and speed with which
they are changing; and what the forecasts are for the future.
2.29. We conclude that there is considerable
uncertainty about whether healthy lifespan is increasing faster
or slower than lifespan. The uncertainty comes from the variability
in individual health trajectories through life, and the difficulty
in applying objective measures of health and quality of life across
different age groups. We believe that freedom from disability
provides a more easily ascertainable objective measure of the
quality of life.
2.30. Further research should be undertaken
to validate and apply appropriate measures to monitor the trends
in healthy lifespan. We recommend that funds should be made available
to the Office for National Statistics to enable it to carry out
over a number of years the surveys needed to assess disability-free
life expectancy.
2.31. If the information provided by such a survey
does ultimately show that there is a real increase in the number
of years that older people experience ill-health, it will then
be possible to look for the causes of that increase, and to attempt
to find a remedy. If this is achieved, it will of course improve
the quality of life not only of the people concerned, but also
of those caring for them. But it will have a further benefit.
Some 38% of NHS expenditure is spent on the 16% of the population
currently over 65, and a major part of that on the last five years
of their lives, whatever the age of death. Anything that can be
done to increase the years during which older people are in good
health and free from disabilities will therefore additionally
free resources which can be used to improve treatment and care
of older people.
2.32. For the present, the fact remains that,
on any measure, there are a number of years, of the order of
eight in the case of men and eleven in the case of women, during
which older people regard themselves as not being in general good
health, or as having a limiting long-standing illness or disability.
Such evidence as there is suggests that this period of perceived
ill-health is not decreasing, and may well even be increasing.
Perceived ill-health will on its own adversely affect the quality
of life of older people, and their sense of well-being.
2.33. The Royal College of Physicians in Edinburgh[24]
warned that "Disability may be postponed but it cannot be
eliminated". We accept this obvious truth. We accept also
that the adverse effects of disability cannot be eliminated. We
believe however that it should be possible to increase disability-free
years and, if and when disability does supervene, greatly to reduce
the adverse effects.
OTHER FACTORS AFFECTING QUALITY
OF LIFE
2.34. Older people wish to feel that they are
"active providers within the community"(Q 41),[25]
that they are a useful part of society, and that they are not
a burden on others. This is more likely to be achieved by people
who live in their own homes, and who are sufficiently mobile to
have access to family, friends and shops. Reasonably good health
is undoubtedly a major contributing factor, but it is not the
only one. There are ways of ensuring that, although health worsens,
quality of life does not, or not at least to the same extent.
Technological advances are at the forefront of such measures.
2.35. The focus of this report is therefore to
make recommendations which may, first, help to increase HLE, and
secondly which may, if and when health does deteriorate, ensure
that the quality if life is adversely affected as little as possible.
Sir John Grimley Evans summed this up as "Live longer, die
faster".[26]
The Need for Longitudinal Studies
of Ageing
2.36. The figures obtained from sources such
as the Census and the General Household Survey are based on samples
taken at a given time, and provide useful snapshots of the position
at that time for that sample. Longitudinal studies, on the other
hand, aim to follow the changing fortunes of individuals over
the years, and thus provide continuing patterns of data, albeit
based on smaller samples, from which it may be easier to discern
the factors that are responsible for underlying trends. We consider
this further in Chapter 7.[27]
3 House of Lords Select Committee on Economic Affairs,
4th Report (2002-03): Aspects of the Economics of an Ageing Population
(HL 179-I). Back
4
Census 2001: First Results on Population for England and Wales,
September 2002. Back
5
Health Statistics Quarterly 25, Spring 2005, table 5.1. Back
6
Clare Griffiths and Justine Fitzpatrick, Geographical Inequalities
in Life Expectancy in the United Kingdom 1995-1997, Health Statistics
Quarterly 09, Spring 2001. Back
7
Life Expectancy at Birth by Health and Local Authorities in the
United Kingdom, 1998-2000, Table 2, Health Statistics Quarterly
13, Spring 2002. Back
8
Life Expectancy at Birth by Local Authorities in the United Kingdom,
1991-1993 and 2001-2003, Health Statistics Quarterly 24, Winter
2004. Back
9
These were the criteria used at the time of the study referred
to. From 2001 they have been replaced by the National Statistics
Socio-economic Classification. Back
10
Lin Hattersley, Trends in Life Expectancy by Social Class - an
update, Health Statistics Quarterly 02, Summer 1999. Back
11
Angela Donkin, Peter Goldblatt and Kevin Lynch, Inequalities
in Life Expectancy by Social Class 1972-1999, Health Statistics
Quarterly 15, Autumn 2002. Back
12
Paragraph 3.49. Back
13
Office for National Statistics. Back
14
Office for National Statistics, Focus on Older People 2004,
May 2004. Back
15
Paragraphs 3.42 to 3.45. Back
16
Older Americans 2004, Federal Interagency Forum on Aging-Related
Statistics. Back
17
UN World Population Prospects 1950-2050, 2002 revision. Back
18
OECD: Perceived health status, July 2004. Back
19
p 356. Back
20
Note of the Seminar, Appendix 4, paragraph 21; Manton KG, Gu X
(2001). Changes in the prevalence of chronic disability in the
United States black and nonblack population above age 65 from
1982 to 1999. Proc Natl Acad Sci USA; 98: 6354-6359. Back
21
Appendix 5, paragraph 33. Back
22
A. Bootsma-van der Wiel et al, Disability in the Oldest Old: "Can
Do" or "Do Do"? (2001) Journal
of the American Geriatrics Society, Vol 49, Page 909. Back
23
International Health Comparisons, National Audit Office,
2003, quoting from OECD Health Data 2002. Back
24
p 391. Back
25
From the evidence of Professor Christopher Phillipson, p 23. Back
26
Note of the Seminar, Appendix 4, paragraph 21. Back
27
Paragraphs 7.36 - 7.43. Back