House of Lords - Ready for Ageing? - Select Committee on Public Service and Demographic Change

Ready for Ageing? - Select Committee on Public Service and Demographic Change Contents

Ready for Ageing?

Report

Introduction

1. The UK population is ageing rapidly, but we have concluded that the Government and our society are woefully underprepared. Longer lives can be a great benefit, but there has been a collective failure to address the implications and without urgent action this great boon could turn into a series of miserable crises.

2. The Committee focused on the implications of an ageing population for individuals and public policy in the near future, the decade 2020-2030. Key projections about ageing include:

· 51% more people aged 65 and over in England[1] in 2030 compared to 2010

· 101% more people aged 85 and over in England in 2030 compared to 2010[2]

· 10.7 million people in Great Britain can currently expect inadequate retirement incomes[3]

· over 50% more people with three or more long-term conditions in England by 2018 compared to 2008[4]

· over 80% more people aged 65 and over with dementia (moderate or severe cognitive impairment) in England and Wales by 2030 compared to 2010.[5]

3. Longer lives represent progress, and the changes do not mean a great economic or general fiscal crisis.[6] Moreover the contribution to our society made by older people, which is already impressive, will be even greater as a result: 30% of people aged over 60 volunteer regularly through formal organisations.[7] However, as well as opportunities, the changes create major challenges for individuals, for employers, for our welfare services, and for the Government and all political parties. Others have looked at aspects of these changes, but the Committee's approach was holistic: surveying the landscape to highlight key issues for our society and encourage public debate.

4. To make a success of these demographic shifts, major changes are needed in our attitudes to ageing. Many people will want or need to work for longer, and employers should facilitate this. Many people are not saving enough to provide the income they will expect in later life, and the Government must work to improve defined contribution pensions, which are seriously inadequate for many. People need help to make better use of the wealth tied up in their own property to support their longer lives.[8]

5. The National Health Service will have to transform to deal with very large increases in demand for and costs of health and social care. Overall, the quality of healthcare for older people is not good enough now, and older people should be concerned about the quality of care that they may receive in the near future. England has an inappropriate model of health and social care to cope with a changing pattern of ill health from an ageing population. Further fundamental reform to the NHS in the next few years would be undesirable, but radical changes to the way that health and social care is delivered are needed to provide appropriate care for the population overall and particularly for older people, and to address future demand.[9]

6. Social care and its funding are already in crisis, and this will become worse as demand markedly increases. The split between healthcare and social care is unsustainable and will remain so unless the two are integrated. Sufficient provision of suitable housing, often with linked support, will be essential to sustain independent living by older people.[10]

7. An ageing society affects everyone: these issues require open debate and leadership by the Government and all political parties. The challenges are by no means insuperable, but no Government so far has had a vision and coherent strategy; the current Government are no exception and are not doing enough to ensure our country is ready for ageing.[11]

How will we support ourselves through later life?

8. Living for longer is to be celebrated. But our society needs to review how to pay for the risks and costs associated with lives that may be 10 or more years longer than previously: people can outlive their pensions and savings, suffer ill health and need social care. The Government cannot carry all these risks and costs, but there is much the Government can do to help people prepare: to make it attractive and possible to work for longer, to address the major deficiencies in our pensions system, to make it easier to harness the value in people's homes to support some of the costs and risks of later years, and to help people understand those costs and risks. The Government should help people be better informed about healthy life expectancies, pension projections, the likelihood of needing social care and its cost, and how best to use their own assets, so that individuals and families can analyse their own situations and make their own informed choices (see Annexes 3 and 6).

LATER WORKING

9. By 2030, men aged 65 in the UK will expect to live another 23 years, to 88, and women another 26 years, to 91.[12] As people live longer they will need enough income to support a good quality of life; it would be naive to think that this can simply come from taxpayer-funded sources. But many are not saving enough to pay for a decent standard of living over a much longer retirement. People should therefore be enabled to extend their working lives if they wish to do so, as a vital part of the response to increased longevity.[13]

10. Working for longer would increase income from work, potentially increase savings, and reduce the time of dependence on those savings. Working for longer can often improve health and brings social and intellectual benefits. More people working for longer also help sustain economic growth and improve the country's fiscal position. Employing older workers can benefit employers by using the experience and knowledge of people who still have much to contribute.

11. Making working for longer possible will require changes to attitudes, as well as policy and practice (more fully explored in Annex 5):

· The Government and employers need to work to end 'cliff-edge' retirement, by enabling more people to work part-time and to wind down work and take up pensions flexibly. It should be beneficial to defer taking state and private pensions. Employers need to be much more positive about employing older people. The Government should publicly reject the 'lump of labour fallacy' that wrongly argues this will disadvantage the young.

· We must abandon the idea of a fixed retirement age implicit in many pension structures, employment practices, and tax and benefit thresholds: people should decide for themselves how and when they retire. Incentives in the tax, benefit and pensions systems to retire early should be reviewed.

· Employers should help older people adapt, re-skill, and move to more suitable roles and hours when they want to do so, and should support those with caring responsibilities for older people to work part-time or flexibly.

· The Government should, with employers, help support those in manual or low-skilled jobs, who might need to work longer but have most difficulty in doing so. Welfare to work policies should also address the needs of older people.

· Age is no longer a good indicator of people's needs or income, so the Government should review whether age alone is a sensible determinant for tax liability, access to services or benefits.

REFORMING PENSIONS AND SAVINGS

12. The UK has a worrying under-saving problem.[14] The Pensions Commission chaired by Lord Turner of Ecchinswell began a period of reform and when complete, this will represent progress. State pensions will be linked to earnings (at a minimum), preventing further erosion; pensions auto-enrolment will extend private pension coverage to many who are currently not covered; and the single-tier state pension will rationalise state provision and make it more generous for those with intermittent employment histories (see Annex 8). The Committee welcomes these positive steps.

13. But despite this, the current system of state and private pension provision is not adequate as many people, young and old, expect far more pension than they will get. While the poorest will be protected at a basic level by state provision, and the richest can afford to save enough in private schemes, there is a substantial gap for much of the rest of the population.

14. Under the current defined contribution pensions system, the individual does not know what income the pension will provide and therefore what he or she is saving for. Defined contribution pensions now dominate private pension provision, with risks and uncertainties, and are inadequate for many, especially women.

15. The Committee has concluded:

· The Government were right to raise the state pension age, but they are now adopting a timetable of increases slower than that recommended by the Turner Commission and will have to revisit this with rising healthy life expectancy. Those who work beyond state pension age should clearly benefit if they defer taking their pension.

· Auto-enrolment is a big step forward for people who would otherwise not be saving for a pension. However, while helpful, auto-enrolment alone will not solve the problem of under-saving. The scale of pension saving encouraged by this scheme, eventually 8% of an individual's earnings, will still result in a pension significantly below many people's expectations unless people save considerably more in addition.

· But saving more is made less likely as the current defined contribution pensions system is not fit for purpose for anyone who is not rich, or who moves in and out of work due to bad health or the need to care for others.

· The Committee urges the Government, pensions industry and employers to tackle the lack of certainty in defined contribution pensions and address their serious defects to make it clearer what people can expect to get from their pension as a result of the savings they make.

USING THE VALUE IN OUR HOMES

16. Many older people have seen the value of their homes increase considerably but have not viewed this as a partial solution to some of the challenges of living longer. The Committee considers that it is reasonable to expect those who have benefited in this way to support their own longer lives. People need to be able to use their assets to help pay for the cost of their social care, and to release money to adapt their homes and to support their incomes. Some schemes exist, but are little used.

17. People with housing equity should be enabled to release it simply, without excessive charges or risk. The Government should work with the financial services industry to ensure such mechanisms are available, and to improve confidence in them. We explore this in Annex 7.

Living independently and well

18. Older people are diverse; most enjoy life and want to live independently, in their own home for as long as possible. But eventually almost all of us will need healthcare, and two thirds of men and 84% of women currently aged 65 will need some social care before they die.[15]

INCREASING PRESSURES ON HEALTH AND SOCIAL CARE

19. The NHS is facing a major increase in demand and cost consequent on ageing and will have to transform to deal with this. Because of this rising demand, without radical changes in the way that health and social care serve the population, needs will remain unmet and cost pressures will rise inexorably.

20. A rapidly ageing society means many more older people living for more years, often with one or more chronic long-term health conditions; a consequence of this and other pressures is a large increase in health and social care costs. Predicted increases in demand for health and social care from 2010 to 2030 for people aged 65 and over in England and Wales include:

· people with diabetes: up by over 45%

· people with arthritis, coronary heart disease, stroke: each up by over 50%

· people with dementia (moderate or severe cognitive impairment): up by over 80% to 1.96 million

· people with moderate or severe need for social care: up by 90%.[16]

21. The treatment and care of people with long-term conditions accounted for 70% of the total health and social care spend in England in 2010, so the large increases in the number of older people with long-term conditions will create significant extra costs.[17]

22. The Nuffield Trust has recently estimated that under the current healthcare system, the NHS in England will see a funding shortfall of £54 billion by 2021/22 if NHS funding remains constant in real terms, if no productivity gains are made, and if trends continue in current hospital utilisation by people with chronic conditions and in healthcare costs.[18] If the English NHS achieves unprecedented productivity gains of 4% a year in every year from 2010/11 to 2014/15, they predicted that this funding gap would be reduced to a potential shortfall of £34 billion. For comparison, the total budget for the English NHS in 2010/11 was £107 billion.[19] If the system did not change and a shortfall on this scale materialised, it would have particularly serious consequences for older people, who are the biggest consumers of NHS spending (see Annex 10).[20] The Committee has concluded that the current healthcare system is not delivering good enough healthcare for older people and is inefficient; there is an urgent need to change the current system to provide better healthcare more efficiently and this should help with the predicted funding shortfall.

23. At the same time, public expenditure on social care and continuing healthcare for older people may have to rise to £12.7 billion in real terms by 2022 (an increase of 37% from £9.3 billion in 2010), just to keep pace with expected demographic and unit cost pressures (see Annex 10).[21]

24. Social care funding is already in crisis, and this will become worse as demand markedly increases. Many people needing social care now are not getting it as eligibility thresholds are tightened because of reduced local authority funding (see Annex 10). The Government's response to the proposals made by the Commission on Funding of Care and Support (the Dilnot Commission) is welcome and necessary but in our view will not be sufficient because it will largely benefit higher income groups by protecting them from depleting their housing assets rather than address the current funding crisis (see Annex 11). It does not bring extra funding into the system to tackle the current funding crisis or address the problem of expanding need in the coming decades—although we acknowledge that this was not the task given to the Commission.

25. There should be a sharing of responsibility for social care between individuals and the state. The implementation of the Dilnot Commission proposals makes this sharing explicit and puts a limit on individual risk. But many people do not have families who can provide care, nor the money to buy it, and cannot cope without care—and this situation will worsen as demand rises (see Annex 10). If the neglect of social care continues and these people are not properly supported in the community, they will end up with more severe needs, or will suffer crises and go into hospital, driving up healthcare costs.

CARE AT HOME—WHENEVER POSSIBLE

26. The Committee received expert evidence that a new system of health and social care is needed to:

· be more focused on prevention, early diagnosis, intervention, and managing long-term conditions to prevent degeneration, with much less use of acute hospitals (see Annex 12)

· be centred on the individual person, with patients engaged in decisions about their care and supported to manage their own conditions in their own homes so that they can be prevented from deteriorating

· have the home as the hub of care and support, including emotional, psychological and practical support for patients and caregivers

· ensure older people only go into hospitals or care homes if essential, although they must have access to good specialist and diagnostic facilities to ensure early interventions for reversible conditions and prevent decline into chronic ill health.

27. A remarkable shift in NHS services will be needed to deliver this. Older people with long-term conditions need good, joined-up primary care, community care and social care, with effective out-of-hours services. Such services make it possible to minimise hospital stays. Time in hospital is often not what older people want or need, and is expensive.

28. This shift in NHS services would help move demand, and funding, from acute and emergency services (which consume nearly half of the NHS's budget[22]). This should allow more investment in services which prevent older people from going into hospital. Some of this released funding should flow into improving social care. It is obvious that if more older people could be treated in the community rather than admitted to hospital, expenditure on hospitals could be reduced. Improving the quality of hospital-based treatments through specialisation and rationalisation would also raise standards.

29. To meet the needs of the population, and to achieve this shift in services, the health and social care system needs to work well 24 hours a day, seven days a week. The Committee was heartened by the Secretary of State for Health's commitment to a 24/7 NHS, and calls on him within 12 months to set out how this will be made real. For this to have value, there will also have to be 24/7 community-based healthcare and social care.

30. The inter-dependent nature of health and social care means that the structural and budgetary split between them is not sustainable: healthcare and social care must be commissioned and funded jointly, so that professionals can work together more effectively and resources can be used more efficiently. The Government and all political parties will need to rethink this issue. We note the Government's commitment to introduce a national minimum eligibility threshold for social care from 2015: we consider that the consequence of this must be that the Government will address the public funding needed to make it possible, but we consider that health and social care integration is the longer-term solution for social care funding. The health and social care systems also have to plan more systematically for changing long-term needs, so the Government should consider introducing a 10-year spending envelope for the NHS and publicly-funded social care.

31. The Government need to develop a new basis for health and social care for our ageing population and create a vision so that other decision-makers can work to bring it about. Ministers told us the Government do not believe in top-down command and control, and that the decentralisation of budgets and responsibilities to over 200 clinical commissioning groups and new Health and Wellbeing Boards would drive the necessary changes. The Committee has concluded that organic, bottom-up change has benefits, but that it will not by itself bring about the major changes to health and social care services that an ageing population will need (see Annex 12). The Government must set out the framework for radically transformed healthcare to care for our ageing population before the general election in 2015. All political parties should be expected to issue position papers on the future of health and social care within 18 months, and address these issues explicitly in their manifestos for the 2015 election.

32. Our older population should be concerned about the quality of care that they may receive in the near future, because the current system is in trouble now. It will require substantial changes to address both present needs and future demand, and this challenge is combined with an impending funding crisis. Nothing like enough is being done to face up to these challenges.

PERSONALISED CARE

33. The local delivery of health and social care does not serve older people well: services operate independently of each other and are peppered with negative incentives. The Committee congratulates heroic professionals such as those in Torbay and the North West London Integrated Care Pilots who are striving to make this poor system function.

34. The Government must act now to challenge the barriers that make it difficult for professionals to deliver the kind of personal, integrated care that our older population wants, such as by doing away with restrictions on sharing data between care professionals, and encouraging less risk-averse attitudes. This will require support for a transparent, good quality market in privately provided social care (see Annex 14). The Committee heard exciting examples of how person-centred commissioning, a single point of contact for care, pooled budgets, new payment systems and new technology can bring improvement. A culture that facilitates experimentation is needed, so that local authorities and clinical commissioning groups are pushed to innovate to find the best local solutions.

35. Publicly funded care alone has never met all the needs of older people who are frail, vulnerable, ill or isolated. As our society ages, more informal care from family and friends will be required, and more volunteers. The number of disabled older people in households receiving informal care in England will need approximately to double over the next 20 years so the Committee calls for employers to make it easier for employees to provide informal care (see Annex 5), and for the Government to promote how crucial this is.[23]

36. Older people contribute greatly to society, including through volunteering and informal care. Increasing lifespans offer a great opportunity for older people to play an even greater role in public life (see Annex 15). We recognise the very valuable work already done by a number of charities to support older people. Central and local government should work together with the third sector to increase volunteering especially by older people to support older people.

HOUSING AND WIDER PUBLIC SERVICES

37. A better health and social care system to support people to stay living independently needs adequate housing and support in the home. The work done by housing adaptation and repair charities is commendable, but needs to become universal. The housing market is delivering much less specialist housing for older people than is needed. Central and local government, housing associations and house builders need urgently to plan how to ensure that the housing needs of the older population are better addressed and to give as much priority to promoting an adequate market and social housing for older people as is given to housing for younger people (see Annex 16).

38. Other services such as urban planning, banking and product design will need to adjust to an older population and an older consumer base, and will have an important role in preventing the social isolation of older citizens. Older people must be involved in their design (see Annex 17).

Fairness

39. There are likely to be considerable increases in public and private spending over the next two decades on services that are particularly important to older people: healthcare, pensions and social care. This is not a bad thing; over time, an increasingly affluent society (as, on the whole, we expect to become) is likely to want to spend more on improving the lives of its citizens, and an older society is likely to want to spend more on the priorities of older people. This increased spending can only be financed by individuals directly, or through taxes, social insurance, or cuts elsewhere: it must be financed fairly.

40. The welfare state has largely meant people paying in when they are young and drawing out when they are older; this should continue. But we have to be wary of shunting too many costs onto younger and future generations. In particular, the property boom has led to a very large transfer of wealth to older, better-off homeowners, which has increased housing costs substantially for younger generations. Younger generations will benefit from being part of a richer society in many ways in the future, but they will also have to service large public and personal debts and may often have poorer pensions (see Annex 7).

41. It does not seem fair to expect today's younger taxpayers—especially those not born to better-off parents—to pay more for the increased costs of an older society while asset-rich older people (and their children) are protected. For this reason too, an effective equity release market to unlock the housing assets held by older people is important.

42. Fairness within generations is also important: people's later lives are affected by their socio-economic background, and men's and women's experiences of older age are markedly different. Older women are the primary users of health and social care and particularly lose out when it comes to pensions (see Annex 7). These divergences must be taken into account.

43. There is a potential for inequalities in our society to increase considerably as the population ages because of inequalities in health, savings and pensions, with a growing divergence between those for whom longer life is comfortable and those for whom living longer involves greater exposure to risks while they have few assets to draw upon.

Are the Government ready for ageing?

44. The Cabinet has not assessed the implications of an ageing society holistically, and has left it to Departments who have looked, in varying degrees, at the implications for their own policies and costs. The Government have not looked at ageing from the point of view of the public nor considered how policies may need to change to equip people better to address longer lives.

45. The ageing of the population is inevitable, and affects us all. The major changes this Report proposes may take a decade to bring about, and should inform the priorities for the next spending review. The Government must make the case to the public as to why changes are needed. If a government tries to move some age-related benefits onto different eligibility criteria without setting out a vision for our old age and committing to make major improvements in some areas, significant opposition would be inevitable. Our society is intelligent and pragmatic and is capable of understanding the arguments for change.

46. The Government should set out their analysis of the issues and challenges, and their vision for public services in an ageing society, in a White Paper to be published well before the next general election. There needs to be cross-party understanding of the importance of these choices, and an effort to seek as much consensus as possible. Progress will not be made if the solutions chosen by the Government change with each administration. So the Government elected in 2015 should, within six months, establish two commissions based on cross-party consultations: one to work with employers and financial services providers to examine how to improve pensions, savings and equity release, and one to analyse how the health and social care system and its funding should be changed to serve the needs of our ageing population. Both commissions should be required to report within 12 months and to make clear recommendations for urgent implementation. We also conclude that when political parties are working on their manifestos, they ought to consider the wider implications of the ageing society for the balance of responsibilities between individuals and the Government.

Principal conclusions and recommendations

47. The Government and employers need to work to end 'cliff-edge' retirement, by enabling more people to work part-time and to wind down work and take up pensions flexibly. It should be beneficial to defer taking state and private pensions. Employers need to be much more positive about employing older people. The Government should publicly reject the 'lump of labour fallacy' that wrongly argues this will disadvantage the young (paragraph 11).

48. The Committee urges the Government, pensions industry and employers to tackle the lack of certainty in defined contribution pensions and address their serious defects to make it clearer what people can expect to get from their pension as a result of the savings they make (paragraph 15).

49. People with housing equity should be enabled to release it simply, without excessive charges or risk. The Government should work with the financial services industry to ensure such mechanisms are available, and to improve confidence in them (paragraph 17).

50. The NHS is facing a major increase in demand and cost consequent on ageing and will have to transform to deal with this. Because of this rising demand, without radical changes in the way that health and social care serve the population, needs will remain unmet and cost pressures will rise inexorably (paragraph 19).

51. To meet the needs of the population, and to achieve this shift in services, the health and social care system needs to work well 24 hours a day, seven days a week (paragraph 29).

52. The inter-dependent nature of health and social care means that the structural and budgetary split between them is not sustainable: healthcare and social care must be commissioned and funded jointly, so that professionals can work together more effectively and resources can be used more efficiently. The Government and all political parties will need to rethink this issue (paragraph 30).

53. The Government must set out the framework for radically transformed healthcare to care for our ageing population before the general election in 2015. All political parties should be expected to issue position papers on the future of health and social care within 18 months, and address these issues explicitly in their manifestos for the 2015 election (paragraph 31).

54. Central and local government, housing associations and house builders need urgently to plan how to ensure that the housing needs of the older population are better addressed and to give as much priority to promoting an adequate market and social housing for older people as is given to housing for younger people (paragraph 37).

55. The Government should set out their analysis of the issues and challenges, and their vision for public services in an ageing society, in a White Paper to be published well before the next general election (paragraph 46).

56. The Government elected in 2015 should, within six months, establish two commissions based on cross-party consultations: one to work with employers and financial services providers to examine how to improve pensions, savings and equity release, and one to analyse how the health and social care system and its funding should be changed to serve the needs of our ageing population. Both commissions should be required to report within 12 months and to make clear recommendations for urgent implementation. We also conclude that when political parties are working on their manifestos, they ought to consider the wider implications of the ageing society for the balance of responsibilities between individuals and the Government (paragraph 46).

1 Due to the effects of devolution, our focus is primarily on England, although many of the issues that we have highlighted may apply throughout the United Kingdom: see Annex 1. Back

2 Central Government (Department of Health (DoH), Department for Work and Pensions (DWP) and Department for Communities and Local Government (DCLG)), written evidence. See Annex 2. Back

3 Department for Work and Pensions, Estimates of the number of people facing inadequate retirement incomes, July 2012. Back

4 The King's Fund, supplementary written evidence. Back

5 Professor Carol Jagger, Newcastle University. Back

6 See Annex 4. Back

7 See Annex 3. Back

8 See Annexes 3, 5, 8, 7 for each point. Back

9 See Annexes 9 and 10, 12 to 14, 13, 12 to 14 for each point. Back

10 See Annexes 9 and 10, 12, 16 for each point. Back

11 See Annexes 7 and 18. Back

12 Office for National Statistics (ONS), Pension Trends - Chapter 2: Population change, February 2012, data for figure 2.5. Back