Select Committee on Science and Technology First Report



7.1.  Physical health is perhaps the most important factor to be considered in assessing the quality of life of older people, but it is only part of a wider picture. In this chapter we assess the role of the Department of Health, and the guidance it gives to the National Health Service. We next consider the involvement of other government departments, and how they coordinate their work. In this context, we look at the importance of a cross-departmental assessment of the cost-effectiveness of different approaches. Lastly we consider the role of older people in clinical trials, and the importance of longitudinal studies of ageing.

The National Service Framework for Older People

7.2.  In March 2001 the Department of Health published the National Service Framework (NSF) for Older People. This is the main policy document of the Government, the Department and the NHS for dealing with the health of older people. The Department is to be applauded for recognising the need to make headway in what is still a relatively neglected area, and for attempting to move older people's services higher up the agenda.

7.3.  We set out on page 72 the NSF for Older People, with the eight standards to be achieved.

7.4.  At the time of the Wanless Report,[121] in addition to the NSFs for Older People and for Children, there were five disease-based NSFs governing coronary heart disease (CHD), cancer, renal disease, mental health services and diabetes. The review considered these disease-based NSFs in some detail,[122] and welcomed the Government's intention to extend the NSF approach to other diseases.[123] We accept that the disease-based NSFs have much to commend them. However, the NSF for Older People is not addressed only to clinicians; it is addressed to a much wider range of managers and clinicians in health, social care services and the independent sector, all of them crucial in developing an integrated service for older people. This is as it should be, but in broadening the aims, the hard edged evidence-based interventions and measurable health outcomes have been sacrificed to somewhat woollier objectives. The NSF is written in terms which are not sufficiently precise for it to be easy to verify whether or not a standard has been achieved.


NSF for Older People: Standards

7.5.  Most of the standards are however accompanied by "milestones" which were to be achieved by April 2005. By way of example, we set out in Box 5 the milestones for Standard Four of the NSF.


Milestones for Standard Four of the NSF for Older People

The achievement of these milestones is unquantified. Progress is in practice assessed by asking a Trust or Primary Care Trust whether the standard is achieved, without specifying in detail what the criteria for success should be. It is all too easy for hospitals to claim that a standard has been met without any significant change having been made in clinical practice.

7.6.  In this respect the NSF for Older People may be contrasted with the NSF for CHD. There will for example be less room for argument as to whether a standard requiring "people with symptoms of a possible heart attack [to] receive help from an individual equipped with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help" has or has not been achieved. In November 2004 DoH stated: "Since February 2000, nearly 700 [automatic external defibrilators] have been placed at 110 locations across England and more than 6,000 volunteers have been trained in Basic Life Support skills. Current evidence suggests that 57 lives have been saved as a direct result of the work of the programme." We would have hoped that the NSF for Older People might have included milestones in similar terms, for example in relation to thrombolyic therapy for acute stroke, target increases in hip replacements per thousand population of those aged over 75, or the percentage of acute stroke cases among older people admitted directly to a specialist stroke unit under a specialist consultant and team. There could be numerous other specific milestones.

7.7.  DoH witnesses were enthusiastic about the NSF for Older People. Mr Craig Muir, the Director of the Older People and Disability Division, listed a number of the specific milestones: "the introduction of integrated stroke services, the numbers of people treated for intermediate care, integrated falls services, protocols for dementia …rooting out age discrimination…" (Q 153). Although Mr Muir did not say so in so many words, the implication was that these had either been achieved, or were well on the way to being achieved. Certainly, in the case of stroke, Professor Fentem agreed that "Standard Five of the NSF for Older People has had its effect" (Q 290). We acknowledge that NSF standards have been helpful in raising awareness of the styles of desirable service, and in focusing the planning effort across the statutory and voluntary sectors. We are less convinced of their impact in improving health outcomes.

7.8.  In support of the view that the NSF milestones were being met, Mr Muir cited a report to the Secretary of State from Professor Ian Philp, the National Director for Older People's Health, entitled Better Health in Old Age (Q 154). This was published by DoH only a few days before the departmental witnesses gave evidence to us on 9 November 2004. The report, which was accompanied by a "Resource Document", sets out the eight standards of the NSF which we have quoted in paragraph 7.2. It does not however consider whether or not they have been achieved, but describes "the progress that has been made since the NSF was published", and identifies "the major challenges and how these are being addressed". It sets out a series of case studies—there are more in the Resource Document—in which a number of persons describe the positive outcomes of their individual treatment at particular hospitals. These are good illustrative examples of the kinds of care that services should aspire to provide, but they do not supply hard evidence that the treatment of older people's conditions is improving.

7.9.  The report does set out a number of matters where there have been significant improvements. Most of these are a consequence of the very welcome injection of funds into the NHS. Mr Muir told us that the report "does show a very strong improvement in a whole range of things. Also it shows areas where there is still a little way further to go, but the overall picture is one of dramatic increases, for example, the number of integrated stroke units increased from 45% to 90% … The number of people receiving intermediate treatment increased to 330,000 from just over 100,000, I think, over the period, so a quite substantial improvement". (Q 154) These are indeed welcome developments, and there are others listed in the report, such as increases in the numbers of consultants in old-age psychiatry and in old-age medicine. But it is impossible to tell to what extent these changes are simply a consequence of increased funding, and to what extent they follow from a clear and targeted application of scientific advances to the treatment of older people. We suspect that the answer is, more the former than the latter, particularly since no reference is made within the NSF for Older People to harnessing the developing insights from scientific research on age-related disorders.

7.10.  The report concludes by stating as a fact: "Health in old age is improving and should continue to improve". This may well be true; we hope it is. But the evidence given for this is a table headed Summary of Progress (paragraph 3.1 of the report) showing increases in life expectancy at age 65, and decreases in the mortality rate from CHD, stroke, cancer and (in common with several other European countries) suicide. Since the table is contrasting figures for 1993 with those for 2002 and 2003, it is hard to see how they can be used to support the view that the NSF had, at the date of Professor Philp's report, played a significant part in this improvement.

7.11.  Moreover, what is relevant is not an increased life expectancy, but an increased healthy life expectancy. It was Professor Sally Davies, the Department's own Director of Research and Development, who first drew our attention to the fact that HLE, far from keeping pace with LE, was lagging further and further behind (Q 139). We have seen no scientific evidence to support the proposition that health in old age is actually improving; what we have however seen is evidence that, whether or not their health is improving, older people perceive the last years of their lives as increasingly being years of poor health.[124]

7.12.  Some of the disease-based NSFs deal with diseases prevalent in old age: CHD in particular, and to a lesser extent cancer and diabetes. Achievement of the milestones for those NSFs will therefore give an indication of the extent to which, in the case of those diseases, targets for older people have been achieved. We nevertheless believe that if there is to be a meaningful NSF dealing specifically with the health of older people, it must include targets making it possible to verify where progress has been made, and where further effort should be concentrated.

7.13.  The Department of Health must set out clear and measurable standards for assessing the health of older people, with particular emphasis on the care and treatment of those diseases prevalent in old age. Claims that those standards have been met should not be made unless they are supported by hard evidence.

The importance of joined-up government

7.14.  We have referred in this report to the involvement of many government departments in improving the quality of life of older people including (in addition to DoH) DTI and OST, DfT, ODPM, the Department for Education and Skills (DfES), and the Department for Culture, Media and Sport (DCMS).

7.15.  If the quality of life of older people is to improve, there must be effective cooperation between all these departments. This was recognised in 1998, when the Prime Minister established an Inter-ministerial Group on Older People. In 2001 this was replaced by a Ministerial Sub-Committee on Older People (DA(OP)), a sub-committee of the Cabinet Domestic Affairs Committee.[125] The sub-committee's chairman is the Secretary of State for Work and Pensions. Until the general election the Secretary of State for Health was the only other departmental Cabinet minister member, but the Secretary of State for Trade and Industry has now been added. The sub-committee's terms of reference are "To develop and monitor the delivery of policy affecting older people; and report as necessary to the Ministerial Committee on Domestic Affairs."[126] We would have been interested to be told about the mechanism for ensuring implementation of the Committee's decisions.

7.16.  Until the general election there was a second, and more senior, Cabinet Committee, MISC 29, which had as its terms of reference "To oversee and drive forward policy on the ageing society." In this committee the Secretaries of State for Health and for Work and Pensions were only two of nine Cabinet-rank ministers. We understand that this Committee was set up to deal with major projects concerning older people, and that at the date of this Report it is not proposed to appoint again a similar Cabinet Committee.

7.17.  It was a Secretary of State for Social Services, Alistair Darling MP, who in April 2000 was appointed by the Prime Minister as the first "Government Champion of Older People". That role was subsequently held by Alan Johnson MP, who until May this year was Secretary of State for Work and Pensions, and who, as we have said, chaired DA(OP). The choice for this task of the Secretary of State for Work and Pensions was re-affirmed in Opportunity Age, published by the Department for Work and Pensions (DWP) in March 2005.[127] Since the general election, the current Secretary of State for Work and Pensions, David Blunkett MP, has been appointed both as "Government Champion of Older People" and as chairman of DA(OP).

7.18.  Given the choice of DWP as the coordinating department, and given that officials were in the course of preparing Opportunity Age while we were taking evidence for this report, we find it regrettable that they chose not to submit written evidence to us. In reply to our call for evidence, they explained that they felt they had nothing to contribute, and that other departments were better placed to offer evidence. It is true that many of the matters we are considering are the specific responsibilities of other departments, such as DoH, DfT, DTI and OST, all of which gave us written evidence, and oral evidence through their ministers and officials. But evidence from DWP on the coordination of departmental responsibilities would have been valuable.

7.19.  Opportunity Age confirms that "at least seven different government departments have responsibility for major services directed to older people".[128] The paper is designed to bring together in one document all these responsibilities, including those of DfT and ODPM to which we referred in Chapter 5, those of DoH, and the responsibilities of the DTI and OST for research. We recognise that the economic aspects of old age, and pensions in particular, are at least as important as the medical and scientific aspects. If however the minister chosen to lead the Government's strategy for older people is to continue to be the Secretary of State for Work and Pensions, we believe that there are some matters which must remain the specific responsibility of other ministers and departments. We deal with these matters in Chapter 8.

7.20.  We welcome the appointment of a "Government champion of older people". We believe that this must be a single minister of Cabinet rank who, whatever his or her title and departmental responsibilities, has full responsibility for bringing together and implementing all aspects of government policy relating to older people.

7.21.  Although cooperation between departments leaves something to be desired, their cooperation with charities active in the ageing field seems to be good. Dr James Goodwin (for Help the Aged) and Dr Ian Nowell (for Age Concern England) both told us that they had positive experiences of working closely with DoH and DWP, and that they had found them to be very responsive. There was however more difficulty over their research plans and their strategic levels of spending (QQ 498-499).


7.22.  For any individual suffering from some particular disease or condition, its rapid diagnosis, treatment and cure are plainly highly desirable. Even more desirable would be to avoid the disease or condition altogether. But although, for the individual, prevention must always be better than cure, from a financial perspective this will not always be true. It is arguable that there comes a point at which too much money can be spent on the prevention of a condition which in any case has only a small chance of materialising. At that point, not only would the money not be well spent, but the portrayal of a risk factor as a disease might cause unnecessary fear of an unlikely consequence.[129] Despite this, we believe that an emphasis on prevention must normally be right.

7.23.  At first sight, it seems plain that the resources of the NHS will also benefit if a lesser amount of money spent on prevention can save a larger of money which would have to be spent on treatment. In Chapter 4 we have given an example of this in relation to the positioning of scanners in stroke units. Other examples were given us. Professor Peter Weissberg took the view that "the major focus … in terms of research has necessarily to be on the prevention of … vascular disease in middle age, because … if we could prevent the development of atherosclerosis in middle age then the consequences of vascular disease would be very much less in the elderly, and they would die of other things, in effect, because the organs involved are pretty robust." (Q 275)

7.24.  We have however also been warned by Sir John Grimley Evans against adopting too simplistic an approach to the question of cost-effectiveness. There are two main reasons why, solely from the point of view of healthcare costs, prevention may not be cheaper than cure. The first is that the cumulative lifetime costs of prevention may exceed the cost of treatment in terms both of economics and fiscal accountancy. The second reason is the problem of competing morbidity: "One might avoid sudden death from a heart attack in one's fifties (cheap) only to survive a stroke in one's sixties (pretty expensive) or suffer Alzheimer's disease in one's seventies (very expensive)".[130]

7.25.  In those cases where prevention and cure are both the responsibility of the NHS, it will be the NHS which is best placed to assess the long-term benefit of spending more money now on prevention to achieve a subsequent saving in the cost of treatment. But the NHS will not always be in the best position to judge. Money spent by the NHS now on prevention may result in savings—but not to the NHS—in long-term expenditure on care. Conversely, money saved to the NHS by avoiding treatment may result from expenditure on prevention elsewhere. Falls are a good example. We have already given[131] the startling figures for the frequency of falls among older people. Guidelines issued in November 2004 by the National Institute for Health and Clinical Excellence (NICE) are based on evidence showing that "falls are a major cause of disability and the leading cause of mortality resulting from injury in people aged over 75 in the UK. In 1999, there were 647,721 A&E attendances and 204,424 admissions to hospital for fall-related injuries in the UK population aged 60 years or over. The associated cost of these falls to the NHS and Personal Social Services was £908.9 million and 63% of these costs were incurred from falls in those aged 75 years and over".[132] However, savings in the costs to the NHS and personal social services would probably result mainly from expenditure outside the NHS, for example by local authorities.

7.26.  Professor Weissberg explained it in this way:

"Again, we have all put forward economic arguments and mentioned "Is there a saving, ultimately, to be made?" The answer is yes, there is, but not to today's budget in that hospital. That is the way, I am afraid, the NHS looks at it; they are looking at this year's budget in this hospital: 'If I keep a heart failure patient out of that bed somebody else's patient is going to fill it.' So the bed is still filled, the work is still there, but in terms of future cost to the NHS there is a large saving, but we do not seem to have the flexibility to build that into the system." (Q 285)

7.27.  That flexibility is vital. Government departments must look at the wider picture, and not assess it from the perspective of narrow departmental self-interest. It also seems to us plain that, where there is a possibility of saving even a fraction of these very large sums, an assessment of the cost- effectiveness of prevention must be a priority. Sadly, what we have discovered is that this question has not been addressed. In a document which looked at the most clinically and cost-effective interventions and rehabilitation programmes for the prevention of further falls, NICE stated that "a systematic review of the published literature up to August 2003 found no published cost effectiveness analyses of strategies for falls prevention in the elderly".[133]

7.28.  The initiation of studies of the cost-effectiveness of spending resources on prevention rather than treatment must be an important consideration for the Minister with overall responsibility for coordinating policy relating to older people.

7.29.  There must be effective supervision to ensure that it is the overall cost to the taxpayer which is considered, and not the cost to the budget of an individual department, to the NHS or to local government.

Clinical records

7.30.  We were told by the Academy of Medical Sciences that the UK is strong in research into the fields of epidemiology, demography and population genetics, but that the potential for large-scale research of this kind has not been realised. The registration and record systems of the NHS could be an extremely useful resource for researchers, but the quality of data generated by the NHS is relatively poor. It has never matched the enormous research potential demonstrated by United States patient databases such as Medicare. Work in this area is inhibited by a confusing regulatory framework and a great deal of bureaucracy.[134]

7.31.  The Department of Health and the NHS should consult with the scientific community as to how the data generated by the NHS could be improved, the regulatory framework simplified, and the bureaucracy reduced.

Clinical trials

7.32.  Diseases associated with ageing are common targets for the development of new drugs and therapies, and older people often receive treatments for conditions which may strike regardless of age. Yet older people are commonly excluded from clinical trials; Professor Crome told us that this was why there were very few conditions for which we had a good evidence base of what treatments were required for the over-80s (Q 33). Reasons for such exclusion are not always explicitly stated, but when declared they may include the problems of co-morbidity, and the fact that an older person may already be taking other medications. Such exclusions make little sense scientifically. If a drug or therapy is to be used to treat an older person, who in all probability will have something else wrong with them and will be taking other medication, then the drug or therapy should be evaluated in these circumstances. Furthermore, from what is known already about the changes in physiology and metabolism that accompany ageing, the biological actions of a drug or therapy may be different in older people, and this needs to be assessed. The fact that older people may represent an intrinsically more variable target group is no justification for excluding them from clinical trials. The current position is like the man who searches for his lost keys under the streetlamp because "that way I can see what I'm doing", when in truth he knows he dropped them in the forest.

7.33.  Two reasons are commonly given for the exclusion of older people from clinical trials.[135] The first is the alleged difficulty of obtaining their informed consent to participation. We do not believe that, except perhaps in the case of the oldest old, this in practice causes a problem. The second is that the bodies of older people metabolise drugs differently, which may distort research findings. It is precisely because this does "distort"—or, more accurately, influence—research findings that older people should be included in the trials. Only in this way will the effects of drugs on older people be reflected in the outcomes of trials. Since older people are increasingly the major users of drugs, it is most important that the pharmaceutical industry should as a matter of course include them in trials. The Medicines and Healthcare Products Regulatory Agency (MHRA) should ensure that this is done.

7.34.  Professor Sally Davies explained that it was a concern of the Department of Health that trials should be open to people of all ages (Q 149). We commend this approach.

7.35.  The Department of Health and the research councils should take steps to ensure that older people are not routinely excluded from clinical trials, and that positive steps are taken to include them in the testing of medicines to be used to treat conditions prevalent among older people. The Medicines and Healthcare Products Regulatory Agency should ensure that the pharmaceutical industry does likewise.

Longitudinal Studies of Ageing

7.36.  We mentioned in Chapter 2 the importance of conducting longitudinal studies of ageing; this was also stressed by the Foresight Ageing Population Panel.[136] Longitudinal studies present obvious logistical challenges, and funding must be provided to support the necessary infrastructure over much longer periods of time than are required for cross-sectional surveys. Within the UK there have already been important longitudinal studies on scientific aspects of ageing such as the MRC Cognitive Functions and Ageing Study (CFAS) and the English Longitudinal Study of Ageing (ELSA). However, the range of questions that have been addressed remains limited, and each of these studies has experienced problems of continuity with its funding.


7.37.  CFAS is a large-scale epidemiological study of ageing with a special focus on cognitive and physical decline in later years. It is based on interviews with a random sample of persons aged 65 or over in six centres in England and Wales: Cambridgeshire, Gwynedd, Liverpool, Newcastle, Nottingham and Oxford. Three waves of interviewing were completed between 1990 and 2005.

7.38.  The broad aims of the study are:


7.39.  ELSA is based on a sample taken from the 1998 and 2001 survey years of the Health Survey for England. Eligible members of the sample were individuals born on or before 29 February 1952, and who therefore were aged 50 or over at the time of the start of the ELSA fieldwork. The 12,000 members of the sample completed questionnaires and were interviewed to provide data on such matters as health (including measurement of walking speed), housing, work, social participation, income, assets and pensions. A principal purpose of the survey is to examine the interrelationship between these different areas of life.

7.40.  The data from all these interviews were published by the Institute for Fiscal Studies in December 2003 as the 2002 English Longitudinal Study of Ageing. A second wave of interviews of the same sample (as near as possible) took place in spring 2004, and subsequent interviews will take place every two years.

7.41.  The value of such a survey is not confined to England. ELSA was designed to be compatible with the US Health and Retirement Study (HRS), and half the funding for ELSA over the first five years has come from the US National Institute on Aging, the remainder being funded by nine Government Departments.[137] ELSA and HRS have become models for the Survey of Health and Retirement in Europe (SHARE) which is planned in several European countries to yield comparable data.


7.42.  The strength of CFAS comes from its focus on detailed assessment of cognitive performance. It has included measures on other factors, including socioeconomic variables, but these have not been a major focus of enquiry. In the case of ELSA, its strength lies in the in-depth questioning on socio-economic matters such as work and retirement, social activity, physical and cognitive function, housing and social environment. However only one brief chapter deals with health problems, and therein lies its weakness. Whether the weaknesses of studies like CFAS or ELSA would best be addressed by extending their scope or by funding a network of interlinked longitudinal studies of ageing is a matter beyond the remit of this inquiry. Nevertheless, we have been made aware of the considerable importance of conducting longitudinal research on scientific aspects of ageing and of the major difficulties that investigators have encountered in securing the long-term infrastructure support that is needed to underpin such research.

7.43.  The Government should make additional funding available through the Department of Health and the research councils to implement joined-up programmes of longitudinal research on scientific aspects of ageing.

121   Final Report of the Review by Derek Wanless, Securing our Future Health: Taking a Long-Term View, April 2002. Back

122   Paragraphs 2.32 to 2.61. Back

123   Paragraph 2.33. Back

124   Paragraphs 2.18 to 2.21 Back

125   Since the general election, the name has been changed to "Sub-Committee on Ageing Policy". Back

126   Prior to the general election, the terms of reference were "To co-ordinate the Government's policies affecting older people; and to report as necessary to the Committee on Domestic Affairs." Back

127   Cm 6466, paragraph 5.5. Back

128   Paragraph 5.3. Back

129   Iona Heath, British Medical Journal, 23 April 2005. Back

130   p 358. Back

131   Paragraph 4.27. Back

132   Scuffham and Chaplin, Incidence and Cost of Unintentional Falls of Older People in the United Kingdom. Back

133   Clinical practice guideline for the assessment and prevention of falls in older people, January 2005. Back

134   p 192. Back

135   Ferguson, Selecting Participants when Testing New Drugs: the Implications of Age and Gender Discrimination, Medico-Legal Society, April 2003. Back

136   The Age Shift - Priorities for Action, December 2000, page 25. Back

137   DfES, Defra, DoH, DTI, DWP, ODPM, Treasury, Inland Revenue, ONS. Back

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