• Accessibility
• Email alerts
• RSS feeds
• Contact us

Ageing: Science, Technology and Healthy Living Contents

---

Chapter 2: Trends and challenges

Demography of ageing

11.The population of older age groups is growing more rapidly than younger age groups. This trend is expected to continue. Between 2018 and 2035 the population aged 80 and over is expected to increase by around 51%, compared with an increase of almost 29% for 65–79-year olds and a small decrease for 20–34-year olds (due to falling birth rates) (see Figure 1).

Figure 1: Expected percentage change in population by age group (2018 to 2035)

Source: Office for National Statistics (2019) Principal projection—UK population in age groups: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/tablea21principalprojectionukpopulationinagegroups [accessed 28 September 2020]

12.This means that the proportion of the population that is older is expected to increase. In 2018, the population aged over 80 was 3.3 million, equating to 4.9% of the total population. By 2035, that population is projected to be 5.0 million (7% of the population), 7.6 million by 2065 (10% of the population) and 8.8 million by 2080 (11% of the population) (see Figure 2).

Figure 2: Projected UK population by age group (based on 2018 data)

Source: Office for National Statistics (2019) Principal projection—UK population in age groups: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/tablea21principalprojectionukpopulationinagegroups [accessed 28 September 2020]

13.Demographic changes will not be even across the country. Professor Chris Whitty, Chief Medical Officer for England and Chief Scientific Adviser for the Department of Health and Social Care, explained that the demographic profile of cities is expected to remain relatively constant, with people arriving “at about 18 and tend[ing] to leave, classically, after their second child”, meaning that the population of rural areas will get older relatively faster.13 People in older age groups will therefore be “highly concentrated … in places where delivery of service is more difficult than it is in cities.”14

Life expectancy and mortality

14.Life expectancy is a “population based statistical measure of the average number of years a person has before death.”15 Life expectancy at birth16 in the UK in 2017–19 was 83.1 years for women and 79.4 years for men.17 These values represent a slight increase from the period 2016–18 of 6.3 weeks for males and 7.3 weeks for females. Since the start of the 20th century, life expectancy has increased by over 30 years; in 1901 life expectancy in England and Wales was 48.5 years for males and 52.4 years for females.18

15.Although life expectancy has continued to rise, since 2011 the rate of annual life expectancy increases in the UK has slowed compared with the previous decade.19 Between the periods 2002–04 and 2009–11, life expectancy at birth in the UK increased by an average of 16.7 weeks for males and 12.7 weeks for females each year; between the periods 2010–12 and 2017–19, the rate of improvements decreased to an average of 6.3 weeks for males and 4.2 weeks for females per year (see Figure 3).

Figure 3: Annual change in life expectancy at birth in weeks, for males and females in the UK, between the periods 2002–04 and 2017–19

Source: Office for National Statistics (2020) National life tables, UK: 2017 to 2019: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2017to2019 [accessed 28 September 2020]

16.Reasons for this slowdown are under investigation. On 25 February 2020, the UCL Institute of Health Equity published the report Health Equity in England: The Marmot Review 10 Years On (“Marmot 2020”)20, a follow-up to a 2010 report by the same authors (the “Marmot Review”).21 The report found that the slowing of life expectancy improvements since 2011 “cannot for the most part be attributed to severe winters”, as “more than 80 percent of the slowdown, between 2011 and 2019, results from influences other than winter-associated mortality.” Some studies have linked the slowdown to austerity policies and their impact on public services.22 Marmot 2020 was “reluctant to attribute the slowdown in health improvement to years of austerity because of difficulty in establishing cause and effect”, but said that “the link is entirely plausible, given what has happened to the determinants of health” over this period.23

17.Life expectancy is not even across the UK. There is a strong link between life expectancy and deprivation, resulting in a gap in life expectancy between the most and least deprived areas (see Figure 4). In England in 2016–18, males in the least deprived areas could expect to live on average 9.5 years longer than males in the most deprived areas, while for females the gap was 7.7 years.24 This gap has widened since 2013–15, when it was 9.2 years for males and 7.2 years for females.25 This is in part a consequence of different rates of improvement of life expectancy by levels of deprivation; for example, Marmot 2020 found that in the most deprived 10% of neighbourhoods female life expectancy declined between 2010–12 and 2016–18, while in the six least deprived deciles female life expectancy increased by around 0.5 years.26

Figure 4: Life expectancy for males and females in England by national deciles of area deprivation (1 = most deprived, 10 = least deprived)

Source: Office for National Statistics (2020) Health state life expectancies by national deprivation deciles, England: 2016 to 2018: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2016to2018 [accessed 28 September 2020]

18.As with the slowdown in life expectancy improvements, reasons for widening differences in life expectancy are unclear. Marmot 2020 noted that it was impossible to establish precise reasons at this stage, but that “the health situation is somewhat similar to other countries that have experienced political, social and economic disruption and widening social and economic inequalities.” The report also noted that “in some of the key social determinants, inequalities are widening in England”.27

19.The most common cause of death in 2017 in England was heart disease for males (13.6% of deaths) and dementia and Alzheimer’s disease for females (16.6% of deaths) (see Table 1).28 The mortality rate from dementia and Alzheimer’s disease has been rising steadily in both sexes since 2006, which may in part be due to better diagnosis and recording. Conversely, mortality rates from heart disease have been falling; this was the biggest cause of increased life expectancy between 2001 and 2016. However, the rising mortality from dementia offset gains in life expectancy between 2011 and 2016 by 0.2 years in males and 0.3 years in females.29

Table 1: Leading causes of death in 2017 for males and females in England

Rank	Cause	% of all deaths (males)	Cause	% of all deaths (females)
1	Heart disease	13.6%	Dementia and Alzheimer’s disease	16.6%
2	Dementia and Alzheimer’s disease	8.9%	Heart disease	8.1%
3	Lung cancer	6.2%	Stroke	6.7%
4	Chronic lower respiratory diseases	6.1%	Chronic lower respiratory diseases	5.9%
5	Stroke	5.2%	Influenza and pneumonia	5.5%
6	Influenza and pneumonia	4.7%	Lung cancer	5.1%
7	Prostate cancer	4.1%	Breast cancer	3.7%
8	Colorectal and anal cancer	3.1%	Colorectal and anal cancer	2.5%
9	Leukaemia and lymphomas	2.6%	Leukaemia and lymphomas	1.9%
10	Cirrhosis and other diseases of liver	2.0%	Kidney disease and other diseases of the urinary system	1.8%

Source: Public Health England (2019) Health Profile for England: 2019, Chapter 2: Trends in Mortality: https://www.gov.uk/government/publications/health-profile-for-england-2019 [accessed 28 September 2020]

Healthy life expectancy

Definitions

20.Healthy life expectancy is defined by the Office for National Statistics as “an estimate of the number of years lived in “Very good” or “Good” general health, based on how individuals perceive their general health.”30 For the period 2016–18 males in the UK had a healthy life expectancy of 63.1 years; for females it was 63.6 years. Males will then on average live a further 16.2 years in poorer health, equating to 20.5% of their lifespan. Females can expect to live a further 19.4 years (23.3% of their lifespan) in poorer health.31

21.Another similar measure is disability-free life expectancy, “an estimate of the number of years lived without a long-lasting physical or mental health condition that limits daily activities.”32 Disability-free life expectancy was slightly lower than healthy life expectancy for men (62.6) and women (61.6) for the period 2016–18.

22.Our evidence suggested that collecting information on both self-perceived health and more objective measures of disability is important. Professor Whitty told us that “there is no objective measure of health” and it is “very useful” to ask people whether they feel healthy. He explained:

“You can have a very good life and have multiple disabilities, and some people can have no disabilities objectively but feel that they have a rotten life and indeed feel that their health is impaired. That is particularly true with some mental health issues.”33

However, Professor Michael Marmot, Director of the University College London Institute of Health Equity, noted that cultural differences can result in different perceptions of health, and so subjective measures of healthy life expectancy are not directly comparable between countries.34

23.The Ageing Society Grand Challenge mission of five extra years of healthy, independent life by 2035 is based on disability-free life expectancy at birth for the period 2033–35, compared with the UK 2014–16 baseline of 62.5 years for males and 62.1 years for females.35 There was consensus across our evidence that improving healthy life expectancy—and reducing the gap between healthy life expectancy and life expectancy—is a greater priority than improving life expectancy itself.

Trends

24.Increases in healthy life expectancy at birth have generally not kept pace with increases in life expectancy. In 2009–11 in the UK, males could expect to live to 62.7 in good health, compared with 63.1 in the period 2016–18. Over the same period, life expectancy increased by twice the amount (0.8 years), meaning the proportion of life spent in good health for males has decreased from 79.9% to 79.5%.36 For females, healthy life expectancy at birth decreased by 0.2 years between 2009–11 and 2016–18, while life expectancy increased by 0.6 years, resulting in a decrease in the proportion of life spent in good health from 77.4% to 76.7% (see Figure 5). However, healthy life expectancy at age 65 has increased at a faster rate than life expectancy since 2009–11 in England and Wales for both females and males, and in Northern Ireland for females.

Figure 5: Change in life expectancy and healthy life expectancy between 2009–11 and 2016–18, for males and females, in the UK

Source: Office for National Statistics (2019) Health state life expectancies, UK: 2016 to 2018: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/healthstatelifeexpectanciesuk/2016to2018 [accessed 28 September 2020]

25.Inequalities in healthy life expectancy are greater than for life expectancy. In England for the period 2016–18, men in the least deprived decile could expect to live in good health to 70.6, whereas men in the most deprived decile could expect to reach only 52.3 in good health. This difference of 18.3 years is almost twice the difference in life expectancy between the most and least deprived deciles (9.5 years).37 For women, the difference in healthy life expectancy at birth was 18.9 years, more than twice the difference in life expectancy (7.7 years).38 Figure 6 shows the life expectancy and healthy life expectancy of males and females by level of deprivation.

Figure 6: Life expectancy and healthy life expectancy of males and females in the UK, by national deciles of area deprivation (1 = most deprived, 10 = least deprived), 2016–18

Source: Office for National Statistics (2020) Health state life expectancies by national deprivation deciles, England: 2016 to 2018: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2016to2018 [accessed 28 September 2020]

26.Inequalities also exist in healthy life expectancy between different ethnic groups, which exceed inequalities in life expectancy in those groups. Professor Whitty told us that there are “clear patterns … in both mortality and healthy life expectancy in ethnicity”, but these “co-locate to a large degree with deprivation”.39 People from ethnic minorities are more likely to live in poverty in older age; 29% of Asian or Asian British people and 33% of Black or Black British people over the age of 65 live in poverty, compared with 14% of White people.40 The Government told us that inequalities exist across a range of dimensions, including “ethnicity, gender, sexuality and having a disability”, and that the “underlying causes of these inequalities often cluster together, with people experiencing ‘multiple disadvantage’.”41

27.Other factors which may account for the differences in healthy life expectancy (and disability-free life expectancy) by ethnicity include: a higher prevalence of chronic disabling conditions in some groups (for example, Indian, Pakistani and Bangladeshi populations have a higher prevalence of cardiovascular disease than other groups); whether large numbers of the group are recent immigrants, and the reasons for such immigration (e.g. for work or fleeing a crisis); and differences in behaviours amongst groups (e.g. prevalence of smoking or levels of physical inactivity). 42

International comparisons

28.Professor Whitty told us that the UK is “pretty well mid table” compared with EU and other OECD countries, for both healthy life expectancy and life expectancy, though he noted that different countries calculate healthy life expectancy in different ways.43 For male life expectancy, the UK (79.5) ranked higher than the EU average (78.3) in 2017 (see Figure 7), though its position in the ranking has shifted downwards since 2006 (6th to 10th highest). For females the UK ranked lower than the EU average life expectancy in 2017 (83.1 and 83.5 respectively), and had the same ranking (17th) as in 2006.44

Figure 7: Life expectancy at birth for males and females in EU countries, 2017

Source: Public Health England, Health Profile for England: 2019, Chapter 1: Population, deaths, life expectancy and health life expectancy (September 2019): https://www.gov.uk/government/publications/health-profile-for-england-2019 [accessed 2 November 2020]

29.On improvements in life expectancy, Marmot 2020 found that “the UK has seen low rates of life expectancy increases compared with most European and other high-income countries.”45 As of 2016 data, the rate of improvement in life expectancy in the UK was slower than the EU rate for both sexes, although four of the other five largest EU states also experienced a reduced rate of improvement.46 In a 2016 analysis of 20 countries, females in the UK had the lowest rate of improvement in life expectancy, followed by those in the USA. For males, the UK had the second-lowest rate of improvement, after the USA.47

30.Life expectancy in the UK continues to rise, but since 2011 it has risen at a slower rate. Healthy life expectancy is not keeping pace with increases in life expectancy, resulting in a growing period of poor health towards the end of life. Inequalities in healthy life expectancy are stark, with people in the least deprived groups living more than 18 years longer in good health than those in the most deprived groups.

31.We recommend that the Government, along with NHS England, Public Health England, and other agencies, prioritise reducing health inequalities. In its response to this report we request that the Government sets out a plan for reducing health inequalities over the next Parliament.

Age-related diseases

32.We heard that ageing is the primary risk factor for a wide range of diseases, often referred to as age-related diseases.48 Age-related diseases include cardiovascular disease, diabetes, hypertension, neurological diseases, cancer and arthritis.49 In 2017, the leading cause of morbidity in England for males aged 70 and over was low back pain, followed by age-related hearing loss50 and diabetes.51 For females aged 70 and over, the two leading causes were also low back pain and age-related hearing loss, followed by chronic obstructive pulmonary disease.52

33.Alongside physical conditions, mental health conditions are a leading cause of years lived with disability.53 The most common mental health conditions in England are depression and anxiety, with nearly half of adults over the age of 55 saying they have experienced depression, and a similar number for anxiety.54 Dr Chris Blackmore, Lecturer in Mental Health at the University of Sheffield, told us that data from the Adult Psychiatric Morbidity Survey show that “older people suffer much lower rates of mental disorder than their younger counterparts in their lifespan”, which might suggest that “there is something protective about older adulthood”.55 However, he highlighted that living alone, which is more prevalent for older people, “seems to double your chance of experiencing a common mental health issue”.56

34.We heard that loneliness is a risk factor for mental health and physical health conditions. Dr Blackmore told us:

“The research shows that being chronically lonely puts you at much greater risk of many physical and mental health conditions. For example, you are twice as likely to develop frailty or dementia. You are nearly three times as likely if you are chronically lonely to be physically inactive, which puts you at greater risk of developing other health conditions such as diabetes, heart disease and having a stroke, and you are more than three times more likely to suffer depression.”57

35.While the Centre for Ageing Better told us that “overall, older people are no more likely to report feeling lonely than younger people”,58 the NHS and Age UK have suggested that older people may be particularly vulnerable to loneliness, due to factors such as increased frailty, disability, and the deaths of spouses and friends.59

Frailty

36.Alongside an enhanced prevalence of age-related diseases, older people are more likely to experience frailty, which can exacerbate their response to conditions and other stressors. Professor Simon Conroy, Professor of Geriatric Medicine at the University of Leicester, explained:

“Frailty describes a decline in function across multiple organ systems, linked to ageing but progressing at different rates in different people. It is characterised by vulnerability to poor outcomes in individuals exposed to an apparently innocuous stressor, such as a minor infection.”60

37.The British Geriatrics Society states that, as of 2014, around 10% of people over the age of 65 had frailty, increasing to between a quarter and a half of people aged 85 or over.61 Professor Conroy told us that frailty “predicts the risk of falls, delirium, disability, [hospital] readmission and care home admission.”62

Multimorbidity

38.Multimorbidity is the state of having two or more long-term conditions.63 A study by the Health Foundation using data from 2014 found that one in four people sampled had two or more conditions (see Figure 8). They estimated that this equated to around 14.2 million people in England as of September 2018.64 One in 12 people had four or more conditions, equivalent to 4.7 million people in England. The most common conditions included hypertension, a painful condition, depression or anxiety, and hearing loss.65

Figure 8: Estimated percentage of people in England with 0, 1, 2, 3 or 4+ conditions, 2014. Based on analysis by the Health Foundation of data from the Clinical Practice Research Datalink.

Source: The Health Foundation (2018), Understanding the health care needs of people with multiple health conditions: https://www.health.org.uk/sites/default/files/upload/publications/2018/Understanding%20the%20health%20care%20needs%20of%20people%20with%20multiple%20health%20conditions.pdf [accessed 2 November 2020]

39.Multimorbidity is more common in older age groups. Professor Marcus Richards, Programme Leader at the MRC Unit for Lifelong Health and Ageing at University College London, told us that “the risk of multimorbidity strongly increases with age”.66 The Government told us that “multimorbidity is now the norm among older people in the UK”.67 A 2012 study based on patient data from 314 medical practices in Scotland (covering over 1.7 million patients) found that, by age 50, half of the population had at least one condition and by age 65 most people had multimorbidity.68

40.Evidence suggests that the prevalence of multimorbidity is increasing and will continue to do so. The number of patients admitted to hospital as an emergency in England with three or more conditions increased between 2006–07 and 2015–16 (see Figure 9). In 2006–07, one in 10 patients admitted to hospital as an emergency in England had five or more conditions; by 2015–16, it was one in three.69 A 2018 study projected that, between 2015 and 2035, the proportion of people with four or more conditions is expected almost to double, and for two-thirds of those people one of the conditions will be related to mental or cognitive health.70

Figure 9: Trends in emergency hospital admissions in England by number of conditions, compared with 2006–07 baseline. Based on analysis by the Health Foundation of Hospital Episodes Statistics data.

Source: The Health Foundation, Emergency Hospital Admissions in England: Which May be Avoidable and How? (November 2018): https://www.health.org.uk/publications/emergency-hospital-admissions-in-england-which-may-be-avoidable-and-how?gclid=Cj0KCQjwsYb0BRCOARIsAHbLPhFdZyal4uj2ZwmY4gx7ZC9UX4fyF76BVc2adG4pzg63WJGUMHXy4KQaAsTbEALw_wcB [accessed 2 November 2020]

41.Data from longitudinal studies can indicate the incidence of multimorbidity in cohorts of people and how they have changed over time. Professor Richards explained some of the trends seen in the 1946 birth cohort:71

“on average, at age 60 to 64, people had two conditions. Only about 15% were disorder-free, about 20% had four or more disorders, and about 10% had five or more disorders: the most common were hypertension, obesity, raised cholesterol and diabetes or impaired fasting glucose. There is a small cluster with a very high probability of those conditions; another key factor was that they were in the poorest health in their mid-30s.”72

Professor Richards noted that this finding was particularly surprising as, like in most cohort studies, “there is a retention of the more socially advantaged and the healthier, and a selective dropout over time of people who are less healthy”.73

42.We heard that the onset of multimorbidity is occurring earlier in life in more recent cohorts. Professor Richards told us:

“One of the key differences across the cohorts is in the growth of obesity … Since 1946, every generation has been heavier than the previous one, and people are becoming overweight at an earlier stage. In the 1946 generation, people reached overweight around the mid-40s. In the cohort of people born in 1970, that has dropped down to about 35. That means that people are living longer with these conditions, which will almost certainly impact on coronary heart disease, diabetes and arthritis, and that is projected to cost the NHS about £23 billion per year.”74

43.Professor James Nazroo, Professor of Sociology at the University of Manchester, concurred, explaining that in the English Longitudinal Study of Ageing:

“something like two-fifths of the 50-and-older population are classified as multimorbidity in their diagnosis. This is increasing to about 50% in more recent cohorts. Something like 15% of the 50-and-older population have more than one body system involved in disease. This is increasing to about 20% in more recent cohorts”.75

44.There is evidence that certain morbidities tend to cluster together, and the prevalence of certain conditions can affect the likelihood of others. For example, the Health Foundation found that if a person had hypertension they would have, on average, an additional 2.1 conditions, while people with depression or anxiety typically had a further 2.0 conditions (see Figure 10). The report found that “82% of people with cancer, 92% with cardiovascular disease, 92% with chronic obstructive pulmonary disease (COPD), and 70% with a mental health condition had at least one additional condition”, meaning that for people with those conditions multimorbidity “is now the norm”.

Figure 10: Common conditions and the average number of additional conditions, 2014. Based on analysis by the Health Foundation of data from the Clinical Practice Research Datalink.

Source: The Health Foundation , Understanding the health care needs of people with multiple health conditions (November 2018): https://www.health.org.uk/sites/default/files/upload/publications/2018/Understanding%20the%20health%20care%20needs%20of%20people%20with%20multiple%20health%20conditions.pdf [accessed 2 November 2020]

45.There is evidence that patterns in, and clustering of, multimorbidities are linked to socioeconomic deprivation. The 2012 analysis of medical practice data in Scotland found that the onset of multimorbidity occurred “10–15 years earlier in people living in the most deprived areas compared with the most affluent”.76 Of people in the least deprived decile, 19.5% had multimorbidity, compared with 24.5% of people in the most deprived decile. They noted that, while in general the presence of a mental health condition increased as the number of physical conditions increased, this relationship was stronger for people in the most deprived deciles (11% of whom had physical and mental health co-morbidities) compared with the least deprived decile (5.9%).

46.A 2018 report by the Academy of Medical Sciences argued that further evidence is needed on the clustering of multimorbidities, including how they change over time and whether particular clusters of conditions are more prevalent in particular communities or subgroups of the population, as with some individual chronic conditions.77 The report noted that much of the research into multimorbidity clusters has been “largely descriptive and has not extended to the investigation of common causal factors or pathological processes” of clustering conditions.78

47.Multimorbidity—the state of having two or more long-term conditions—is more common in old age. There is evidence that the rate of multimorbidity is increasing, so it will become an increasing issue for the NHS. The environmental and biological factors driving the development of multimorbidity are not fully understood.

Coordination of healthcare for older people

48.With the rising prevalence of multimorbidity, particularly among older people, a major challenge is the coordination of care and treatment for people who have multiple conditions. Several witnesses told us that in the current system healthcare is provided on a condition-by-condition basis. Professor Miles Witham, Professor of Trials for Older People at Newcastle University, explained:

“Historically the NHS was designed, or has evolved, to deal with single problems in single-organ systems. It has evolved to deal with episodic care. It is less good and less well designed to deal with chronic care. It is particularly poorly equipped to deal with multiple problems affecting a single person.”79

49.Dr Maggie Keeble, a GP and co-founder of the British Geriatric Society’s GeriGPs Group, explained that most long-term monitoring of conditions happens within primary care. However, because GPs and district nurses often have particular interest areas, face-to-face reviews are usually “disease specific” and conducted by different clinicians depending on the condition. This means that “patients with multiple conditions will need to see a number of different people within the practice for a certain disease review.”80

50.We heard that patients may not be able to see the same clinicians each time they visit. The Northern Health Science Alliance told us that treating people in “condition silos” means that “there is no health professional who can address the needs of that person (as opposed to their conditions).”81 Dr Keeble told us: “Increasingly patients are unable to see the same clinician for interval problems”; this “lack of continuity results in increased investigations and referrals.”82 In 2013, the then-Secretary of State for Health proposed that vulnerable older people being treated in the NHS should have a named primary care clinician to oversee their care outside of hospital.83 However, this proposal does not appear to have been implemented.

51.Dr Keeble also thought there is a “lack of coordination between reviews for different conditions”.84 This means that often multiple sets of blood tests and face-to-face appointments are needed for a single patient. Analysis by the Health Foundation found that the average number of appointments attended in England is considerably higher for a person with multimorbidity:

“patients with 4+ conditions had an average of 8.9 outpatient visits across 2.8 different medical specialties. Over the study period,85 they visited their general practice 24.6 times (or once a month on average) and were prescribed 20.6 different medications. This compares with the 2.8 outpatient visits, 8.8 visits to the general practice, and 5.6 different medications for patients with one condition.”86

The report found that those with multiple conditions did not on average spend significantly longer with their GP on each visit, despite having more complex needs.

52.This lack of coordination across the health system places a burden on people with multimorbidity, and can be confusing for them.87 A 2018 report by the Richmond Group of Charities on multimorbidity noted that “as a result of having to engage with a fragmented and siloed system, people living with multiple conditions are often in contact with multiple health professionals, and are more likely to report care coordination problems”. It found that “patients with three or more long-term conditions are 25–40 per cent more likely to report care coordination problems than those with a single condition.”88 The report noted that people with multiple conditions are likely to be particularly vulnerable to adverse consequences arising during transitions in care, which are “further complicated by poor communication and inadequate data flow across the health and care system.”89

53.A particular care coordination challenge is that patients with multimorbidity can end up following several different, possibly contradictory, care pathways. Professor Whitty told us that “we do not have the science of properly linking up different diseases, which may well have a common pathway”, meaning that a person with multiple conditions may attend “six different clinics and follow six different NICE [National Institute for Health and Care Excellence] pathways.”90 The Health Foundation explained that “specialists in outpatient departments are not set up to provide joined-up treatment”, and so “those specialists might be treating the patient according to condition-specific guidelines, rather than considering what other conditions the patient has and coordinating their advice and treatment.”91 The Richmond Group of Charities argued that “existing clinical guidelines and quality standards are not based on, and do not reflect, the lived experiences of people with multiple health conditions”, and while “efforts are currently underway to increase the applicability of NICE clinical guidelines and quality standards to people living with multimorbidity”, the uptake of updated guidelines is currently uncertain.92

54.Dr Keeble told us that condition-specific pathways are a particular challenge when treating people who also have frailty. She explained that it is important that clinicians adopt a “Frailty Sensitive Approach” to care, ensuring that “individual’s wishes and preferences are discussed with them”. However, she told us:

“At the moment all systems are disease orientated, protocol driven and pathway aligned. We need to shift the focus to being person orientated, choice driven and priorities aligned. We are living in a system which is entirely based on clinical algorithms and pathways which does not support a personalised approach to care. Adopting a Frailty Sensitive Approach means departing from guidelines and accepting uncertainty and risk.”93

55.Professor Russell Foster, Professor of Circadian Neuroscience at the University of Oxford, gave an example of how a lack of coordination between departments can result in additional negative health outcomes for older people.94 He explained that older people are frequently prescribed sleeping tablets for insomnia, which can also cause daytime sleepiness, which may in turn contribute to increased falls in older people. A more co-ordinated approach to care for people with multi-morbidities would aim to avoid such indirect adverse effects.

56.We heard several suggestions for how care for older patients with multimorbidity could be better coordinated. Several witnesses suggested that GPs need access to more training in how to provide holistic care to older patients and those with multimorbidity, given that most care takes place in primary care settings rather than hospitals. The British Geriatrics Society told us:

“General practice is the cornerstone of the NHS … However the GP contractual system has historically incentivised recognising and responding to individual conditions and very few GPs have had specific training in caring for older people living with frailty.”95

57.We heard that better coordination between primary and secondary care will be vital for ensuring more coordinated care for older patients and those with multimorbidity. Dr Keeble told us that “there remains very poor coordination between Primary and Secondary Care with very limited sharing of information”.96 The British Geriatrics Society agreed, telling us that healthcare professionals working in different settings often use different IT systems, “making seemingly simple things like sharing patient records difficult”.97

58.NHS England and NHS Improvement told us that they have been “introducing improvements in coordination and collaboration across primary and secondary care”, including via the “New GP contract”, which “paves the way for thousands of pharmacists and pharmacy technicians to … create new multidisciplinary teams across primary care in England over the next four years”.98

59.Another suggestion for improving care was better and more regular use of Comprehensive Geriatric Assessments (CGAs). According to the British Geriatrics Society, CGAs consist of a “multidimensional holistic assessment of an older person [which] considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant).” 99 NHS England and NHS Improvement told us that the aim of CGAs is to “develop a coordinated, integrated plan for treatment and long-term support and reduce impact and extend healthy life.”100

60.Once in place, interventions are arranged in support of the CGA. Birmingham Health Partners wrote, “we know CGA works; [they] reduce the time people spend in hospitals, and increase their chances of being alive, and living in their own home.”101 CGAs are mentioned in the NHS Long Term Plan as a method for reducing avoidable hospital admissions.102

61.However, we heard that CGAs are mostly undertaken in hospital settings, by geriatricians, and the extent to which they are used in primary care settings is not known.103 Dr Keeble told us:

“Until very recently the CGA has been the domain of Geriatricians. GPs were not and many are still not aware of or use it … Short appointments and home visiting only when requested by the patient or carer as a result of a deterioration doesn’t allow for the time required to undertake a lengthy intervention in a planned proactive manner.”104

62.Birmingham Health Partners thought that application of CGAs outside of hospitals is “hampered by the resource requirement to deliver it—we need more geriatricians, and more therapists trained to deliver CGA”.105 Dr Keeble agreed:

“Training of medical students and for GPs doesn’t to my knowledge include training on the use of CGA … Another barrier to completion of a CGA is a lack of integrated computer systems enabling the compilation of information already held by different professionals working in different parts of the system. Primary, secondary, community and social care usually work of different systems which differ again from emergency and out of hours services.”106

However, we heard that once the resources and expertise to conduct CGAs are in place, it is a “cheap intervention.”107

63.We also heard that it is important that multidisciplinary teams are involved in compiling a CGA. Dr Keeble told us: “The elements of the CGA can be compiled by a single individual but it is more efficient and likely to be more detailed if contributed to by all members of a multidisciplinary team including social workers.”108 However, we heard from both Dr Keeble and the British Geriatrics Society that social workers are often not involved in these discussions, as health care and social care are highly “siloed”.109

64.Finally, witnesses told us that there is a need for more geriatricians, in both hospital and community settings. The British Geriatrics Society told us that:

“More geriatricians are always needed—the 2018–19 [Royal College of Physicians of London] census found that 72% of Higher Specialty Trainees and 59% of consultants in geriatric medicine reported that a gap in the rota occurred daily or weekly … However, while we will always need hospital-based doctors, the NHS is moving towards a model of providing more care in the community and this is often preferred by patients. As such, we need more geriatricians to work in the community as well as in a hospital setting.”110

65.NHS England and NHS Improvement told us: “Geriatricians should be a part of the local population health team”, and “The role of oversight should be that of the local system.”111

66.Care pathways are not well coordinated or integrated for older people, particularly those with multimorbidity. Patients often have to see multiple doctors, with multiple specialisms, with little coordination between specialists to reduce the burden on patients.

67.We recommend that, as was proposed in 2013, the NHS ensures that all older patients have a designated clinician. This clinician would have oversight of the patient’s care as a whole, and should coordinate activity across multidisciplinary teams, which should include members from across the health and social care sectors. The clinician could be from either primary or secondary care, depending on the patient’s needs.

68.We recommend that designated clinicians for older people ensure that Comprehensive Geriatric Assessments are used regularly for older patients, particularly for those with multimorbidity. The Government should ensure that training in how to conduct Comprehensive Geriatric Assessments is a core part of medical training, and that training is provided on an ongoing basis, in particular to GPs.

Polypharmacy

69.The treatment of conditions in silos, via multiple appointments with different clinicians, has led to increased polypharmacy (the prescription of multiple drugs). Professor Sir Munir Pirmohamed, Professor of Molecular and Clinical Pharmacology at the University of Liverpool and President-elect of the British Pharmacological Society, told us that polypharmacy is a “major problem”.112 According to the British Pharmacological Society, “over 1 million people in the UK take eight or more medicines per day”.113

70.Polypharmacy creates several problems. First, it is burdensome for patients and can lead to confusion and frustration. Professor Witham explained:

“If you are a patient and you are having to attend appointments in six clinics, take 20 medications a day and undertake multiple, different self-care behaviours that have been recommended by your physicians, the number of hours in a month that that takes is truly enormous. A study in 2015 suggested that if you have six conditions and you adhere to all the guidelines, you will be looking after yourself—self-care appointments—for 80 hours a month. That is not uncommon and is a huge burden.”114

71.Polypharmacy heightens the risk of adverse drug reactions. Research suggests that older adults are more susceptible to adverse drug reactions than younger adults, and polypharmacy can compound this.115 Dr Keeble explained:

“As people age, they are more likely to suffer adverse effects from medication prescribed for a number of conditions. The causes of this are multiple: older people may have liver and kidney problems meaning drugs are not excreted as efficiently causing a build-up in the system. They may lose weight over time meaning that the amount of drug available to the body increases.”116

72.Professor Pirmohamed told us that drug-drug interactions are usually considered binary—”one drug, a victim, interacting with a perpetrator”—but:

“Actually, when you have 15 drugs, there are three, four or five-way interactions going on, together with your renal and hepatic functions, which compounds the problem and leads to the adverse drug reactions that are common in this age group and often not picked up in routine clinical care.”117

These side effects may cause patients to stop taking some of the drugs, leading to a “vicious cycle”.118

73.Adverse drug reactions are a significant cause of hospital admissions. Professor Pirmohamed told us that “of the general population coming into hospital, 6.5% of patients are admitted because of adverse drug reactions, and 15% of patients develop adverse drug reactions while in hospital” equating to 8,000 hospital beds in use by patients with adverse drug reactions.119

74.Polypharmacy can increase the risk of other negative health outcomes. Professor Witham explained:

“typically, over half the number of people we see in a falls clinic will be on a medication that we know contributes to their risk of falls. Typically half of people in hospital who have delirium, a confusional state, have medications that are contributing to that delirium state. We know that that is a very dangerous state. It makes dementia more likely and means that people are likely to stay longer in hospital.”120

75.Polypharmacy is costly for the NHS. The British Pharmacological Society told us that “total NHS expenditure on drugs was estimated to be £17.4 billion in 2016/17 and is growing at an average of around 5% per year.”121 Professor Pirmohamed said that a recent report commissioned by NHS England estimated that the cost to the NHS of medication errors (including adverse drug reactions) is £1.6 billion per year.122

76.We heard that solving the problems of polypharmacy will require “regular structured medication reviews”, and a coordinated approach across different specialisms.123 Professor Pirmohamed told us that while the current system of medicine reviews conducted by pharmacists can help reduce some of the issues of polypharmacy, “when you have a very complicated patient with seven diseases and on 15 drugs, deciding which one to stop and having that conversation with the patient is quite complicated”.124 He told us that multidisciplinary teams covering “care of the elderly, clinical pharmacology, pharmacy and general practice” would be required to solve the problems of polypharmacy, but “we do not have a model of care like that at the moment”.125

77.We heard that more effective medicine reviews will require greater involvement and awareness by pharmacists. Dr Keeble told us that “Clinical pharmacists are becoming more common in the system”, but “there is a range in expertise with some colleagues being very aware of older people’s needs and others being less well informed”.126 She added that there tends to be “insufficient interaction, coordination and communication” between pharmacists working in different care settings, which results in errors.127

78.We were told that there is also a need for more pharmacologists (scientists who study drugs and how they affect the body) in the UK.128 Dr Lauren Walker of the University of Liverpool and Chair of the Specialty Training Registrars Committee at the British Pharmacological Society, explained that clinical pharmacologists are not single-organ specialists; their job “is to look at medicines across all therapeutic areas”. She said that:

“super-specialisation” has “changed the way that we manage many diseases … but the cost of that is that we are less familiar with prescribing in somebody else’s specialty, and we end up with five different prescribers all prescribing in their area of expertise but with limited knowledge of how that affects the others.”129

79.In December 2018 the Secretary of State for Health and Social Care launched a review into overprescribing, to be led by Chief Pharmaceutical Officer Dr Keith Ridge.130 The aims of the review included “addressing ‘problematic polypharmacy’”, “creating a more efficient handover between primary and secondary care”, and “improving management of non-reviewed repeat prescriptions”.131 We heard that this review is due to report to the Secretary of State in late 2020.132 We also heard from NHS England and NHS Improvement that in 2019 the English Deprescribing Network was launched, to “promote appropriate prescribing to avoid severe and avoidable harm from medicines.”133

80.Medicine reviews are a core component of Comprehensive Geriatric Assessments, and if these are used more widely, with the involvement of multidisciplinary teams, the incidence of polypharmacy and the risk of adverse drug reactions should reduce.

81.We recommend that the review into overprescribing—which is due to report to the Secretary of State for Health and Social Care in late 2020—should be published as soon as possible.

NHS Long Term Plan

82.We asked witnesses whether the NHS Long Term Plan, which sets out the key ambitions for the service between 2019 and 2029, adequately addresses the changes required to provide better care and support for older people, particularly those with multimorbidity.134 Responses were positive but cautious. The British Geriatrics Society told us that some of the commitments under the “Ageing Well” component of the plan, such as “enhanced health in care homes, anticipatory care and urgent community care, have the potential to transform services for older people in England.”135

83.The British Geriatrics Society saw “much promise” in the development of Primary Care Networks—which will bring general practices together to work at scale—telling us: “The introduction of [Primary Care Networks] and joined-up working with community services marks a turning point in aligning and delivering services that support older people to lead happy, healthy, and independent lives.”136

84.However, they warned that the commitments made in the plan should not be “watered down”.137 For example, they raised concerns that the scope of the Ageing Well component had been widened to include more care groups since publication of the plan. They told us that: “We do not believe that this would be in the best interest of older people and recommend that the Ageing Well programme is firmly focused on older people.”138

85.Dr Keeble told us that the plan is “laudable in its aims to improve primary and community services with a focus on community based care with anticipatory care and personalised care and support planning at its heart”.139 However, there “needs to be an appropriate allocation of funds in community services” to support the implementation of this part of the plan and this is “yet to be seen”.140 The British Geriatrics Society agreed about the importance of the community-based care components: “We would like to see greater pace around the urgent community response component as well as clarity about recurrent funding to allow recruitment of staff to reach the required community capacity.”141

86.Dr Keeble expressed concern about a lack of focus in the plan on healthy ageing activities and public health communication. The message that “the onset of frailty is not predetermined and can be either prevented, reversed or reduced if appropriate measures are taken” should be “promoted at all ages”, including in schools. She suggested that the Government sends a strong message that “people will end up spending far less on their health and social care needs if they adopt an age positive lifestyle.”142

---

• A-Z index
• Glossary
• Contact us
• Freedom of Information
• Jobs
• Using this website
• Copyright