At the end of last year, the Chief Medical Officer (CMO) for England, Professor Sir Chris Whitty, published his annual report for 2023, Health in an Ageing Society.
This detailed and important study focuses on England’s rapidly ageing population. The report does not aim to advise on how to extend life span further. Instead, it provides a much-needed call to action on the steps that need to be taken now if we are to successfully meet the myriad health, care and societal challenges that will accompany the expected rise in the number of older adults. The lengthy report analyses the current position and presents a number of recommendations aimed at maximising independence and minimising the time in ill health for older people in England.
The key takeaway from the report is that whilst death is an unavoidable fact of life, many of the numerous illnesses that impede the freedoms and well-being of older adults are far from inevitable. The report concludes that it is entirely plausible, and likely to have a substantial impact, to take action now in order to lessen the duration of older age that is spent grappling with illness and disability.
An ageing demographic
The number of older adults residing in England has substantially increased since the inception of the NHS. In 1948, there were 1.5 million individuals aged 75 years and older in England and Wales, constituting 3% of the population. At the most recent Census in 2021, this figure had more than tripled to 5.2 million people, representing 9% of the population in England and Wales. This demographic shift is expected to persist and escalate, with the most rapid growth anticipated in the 85 years and older age group. In mid-2016, 1.6 million individuals aged 85 years and above accounted for 2% of the total population. Projections indicate that by mid-2041, this number is expected to double to 3.2 million (4% of the population), and by 2066, to treble to 5.1 million (7% of the total UK population). Conversely, the population aged 16 to 64 years is projected to experience only a 2% increase over the next 25 years and a 5% increase by 2066.
Despite this significant rise in life expectancy, healthy life expectancy has not kept pace. Consequently, there is an expanding period of ill health and frailty in the latter stages of individuals' lives. Recent data from the Office for National Statistics (ONS) indicates that the average UK man spends the final 16 years of life in poor health, while for the average UK woman, this period extends to the last 19 years. Disparities in healthy life expectancy are considerable across various regions and among different socioeconomic groups, highlighting substantial health inequalities among older individuals.
The geography of older age in the UK
The demographic landscape of older age in the UK is already significantly imbalanced, with a notable shift away from major urban centres, and this trend is expected to intensify. A substantial portion of the population relocates from cities before reaching old age. Consequently, metropolitan areas will largely experience only gradual ageing. In contrast, certain regions, especially rural, semi-rural, and coastal regions, will witness a much more rapid ageing process.
Simultaneously, these rural areas are likely to face a decline in the proportion of working-age individuals who are available to provide care. Many of the regions also lack adequate healthcare services, with less accessible transportation links and insufficient infrastructure tailored to the needs of older adults, including housing.
Biological versus chronological ageing
The term ‘ageing’ can be used in two quite different ways:
■ Chronological ageing refers to a person’s age in years.
■ Biological ageing refers to the biological changes that take place throughout our lives in our bodies associated with older age. These occur at different rates in different people.
We obviously cannot change how we age chronologically. However, our biological age can be influenced by many factors, both within and outside of our control, to change how, and how fast, our bodies age.
The CMO’s report identifies three broad sectors of society who are able to make a difference to the pace and extent of biological change.
(1) Individuals
The initial category comprises individuals themselves. Engaging in more physical activity, adopting a healthy diet, quitting smoking, and moderating alcohol consumption are all measures that individuals can adopt to positively influence and postpone or mitigate the repercussions of diseases later in life. The report meticulously examines the impact of each of these measures.
(2) Government
The second category is the state. Both local and national governments have the capability to intervene in delaying diseases for the entire population, ideally before the onset of illnesses. This is referred to as primary prevention. The benefits of primary prevention are most evident in older age. The prevention of smoking serves as an illustrative example of the practical implementation of this type of intervention. Given that two-thirds of smokers start smoking before the age of 18, and 83% before the age of 20, the most effective time to prevent smoking is in childhood. The best way to prevent harm in older individuals is to ensure they never smoke in the first place. If implemented, Rishi Sunak's recently announced legislation to prohibit the sale of cigarettes to anyone under 14 is likely to have a substantial impact on health issues and disabilities in older age.
(3) Health and care practitioners
The third category encompasses the NHS and healthcare practitioners who can identify and address early-stage diseases and risk factors, such as hypertension or atrial fibrillation, significantly delaying the onset of major diseases. This is referred to as secondary prevention and encompasses screening and early clinical diagnosis to enhance the effectiveness of treatment and minimise the condition’s impact on the quality of life. The CMO acknowledges that detecting diseases at an early stage, when treatment options are cheap, efficient, and less invasive, is crucial for improving health outcomes. National screening programmes play a pivotal role in achieving this goal, identifying diseases early before individuals develop serious symptoms. Examples include screening for cardiovascular disease (CVD) and national screening programs for various forms of cancer, including breast, bowel, and lung cancer.
The importance of managing cognitive and mental health in older age
The report emphasises the significance of preserving cognitive well-being (the ability to think, learn, and remember) and mental well-being (psychological or emotional health) in older age. Dementia, such as Alzheimer's disease, stands out as the primary contributor to diminished cognitive health among older adults. Depression is the most common mental health condition among individuals aged 65 years and above. Whilst both conditions are expected to increase as the population ages, they are not unavoidable aspects of ageing, and there are positive steps individuals can take to uphold their mental and cognitive well-being for longer. The challenge is that older adults encounter limited access to talking therapies compared to other age groups and may discover a lack of specialised support in their locality.
The increase in multimorbidity
As we age, the likelihood of developing multiple chronic diseases at the same time, known as multimorbidity, increases. The CMO warns that the medical profession has traditionally focused on single diseases or organ systems and is not as well-equipped to address the challenges posed by rising multimorbidity. Older adults may find themselves navigating multiple specialist clinics, care pathways, and medications (polypharmacy), hindering their ability to maintain independence and quality of life. The report states that the current approach of further sub-specialising training and clinical care is inadequate and that a radical re-think is needed. In particular, it advocates that doctors and care professionals must retain generalist skills alongside their specialist expertise to effectively respond to the growing prevalence of multimorbidity in the population.
So what’s to be done? The recommendations.
The statistics underpinning this report are obviously concerning. There is no doubt that we are getting older as a society and that this collective ageing brings with it many social, health and care challenges. However, the report is also quite optimistic as it makes it clear that there is an opportunity to improve the health of older people, provided we act now. With these aims in mind, the report makes the following recommendations:
1. Ageing is increasingly concentrated in specific regions of England, requiring national attention and resource allocation, especially in peripheral, rural, and coastal areas. Planning for the future ageing population is crucial, necessitating housing, transport, and healthcare services adjustments.
2. The primary responsibility for preventing early ageing lies with central and local governments. Creating environments that promote lifelong exercise and addressing factors like smoking, air pollution, and obesity are key to delaying age-related health issues.
3. Public health and medicine should focus on delaying disease to minimise disability in old age. Emphasising secondary prevention, particularly within the NHS, through screening programmes is essential.
4. The medical profession must adapt to the increasing prevalence of multimorbidity. Maintaining generalist skills among doctors and streamlining healthcare services to reduce the need for multiple clinic visits for the same set of diseases is crucial.
5. Recognising and addressing the health and care needs of older adults requires systematic data collection and sharing among organisations, including the NHS, the Office for National Statistics, and central and local governments.
6. It is important to address the current gaps in research multimorbidity, frailty, and mental health by eliminating exclusion criteria based on age or comorbidities.
If we are to achieve the two objectives that the CMO has identified are needed to maintain independence – namely, keeping people as healthy as possible for as long as possible, and modifying the environment to support them in achieving this – this will require skill and dedication from many professions, as well as very significant resources from central and local government.
The information contained in this article does not represent a complete analysis of the topics presented and is provided for information purposes only. It is not intended as legal advice and no responsibility can be accepted by Altea Insurance for any reliance placed upon it. Legal advice should always be obtained before applying any information to particular circumstances.
