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Healthcare Braced for the Agonies of Old Age
The Scotsman
October 11, 2004
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Scotland's ageing population is often portrayed as a potential timebomb; in reality it is one of the 20th-century's biggest success stories. A baby boy born in 2003 can expect to live ten years longer than one born in 1953.
But an ageing population represents a huge challenge for an already-stretched health service and health economists fear that without radical change, the NHS could become a victim of its own success. In the decade since 1992, the cost of prescriptions to the NHS has risen from £2.6bn to £7bn and we are now consuming an average of 12.5 prescriptions per person per year compared with 8.6 in 1992. Azeem Majeed, Professor of Primary Care and Public Health at University College London, says: "The biggest increase is for drugs to combat diseases associated with ageing. Spending on drugs to treat high blood pressure, high cholesterol and diabetes is increasing at a rate of more than 20 per cent a year. By 2019, 81,300 Scots, 35 per cent of those over 65, are predicted to be living with dementia."
Prof Majeed has projected that by 2031, there will be a 14 per cent rise in GP consultations, 15 per cent rise in outpatient referrals and a 22 per cent rise in hospital admissions. "A much greater proportion of cases will be among older age groups," he predicts. "For doctors, [nurses and therapists] it will mean more work, more complicated cases and an increased requirement for their services."
For a health service already experiencing budgetary pressures, the additional demand could be crippling. The average 18-year-old consumes around £250 worth of medical care a year, the average 80-year-old almost ten times that amount. But with fewer taxpayers to meet increased demand, some fear ageism will become more commonplace.
At present, health authorities in Scotland have their budget based on the size and make-up of the population. Health care costs rise with age - 60 per cent of a person's health care costs occur in the year before death - so health authorities with an older population are allocated higher levels of funding.
Dr Andrew Walker, a leading health economist based at Glasgow University's Robertson Centre for Biostatistics, says it is easy to over dramatise the effects of demographic change on the NHS: "We need to take a step back. The frequency of disease is age related and the demographics do not look great for the NHS, but it is not old age per se which costs the NHS money, it is the year before death. If people were previously dying at 70 they would have incurred the cost then. If you keep them alive for another ten years, those extra ten years are not expensive in themselves because most of their costs are still incurred in the year before they die. And whatever happens, there won't be a 'big bang'. Demographic change happens gradually and we will have time to prepare."
Dr Walker says he is not arguing there will be no extra costs to the NHS - if more people suffer from chronic diseases and live longer, costs are bound to rise. But he argues old age does not necessarily equal ill health or high costs: "If we can keep people who will soon be our elderly population healthy, we can alleviate some of the costs."
It's a big 'if'. The biggest unknown factor in terms of how demography will affect economics is the likely health of the ageing population. The Wanless Report into the NHS suggests the effect of an ageing population will be to "postpone rather than increase health service costs". But Scotland has one of the worst health records in Europe.
Prof Robert Wright, Chair of Economics at Stirling University, says: "Are we going to become much healthier in the next 30 years? Even if you take the most optimistic projections and assume the costs of looking after the 65-75 age group is neutral, you will still going to see an increase in people over 80, the frail elderly - and the frail elderly are expensive to take care of. That is just a fact."
Evidence from the Scottish Household Survey suggests most people in Scotland are not active enough to maintain good health in old age and the latest report commissioned by the Executive says the cost to the NHS of caring for elderly patients is expected to rise by 82 per cent to £579m by 2019.
Dr Walker believes we need to address the thorny issue of ageism in the NHS head-on: "We need to ask is there any evidence for ageism in the NHS and could, under any circumstances, ageism be an acceptable priority setting policy?"
Research by the London School of Economics shows a person's health has a value to others in society that varies with age. "Studies have asked people to choose between two patients who both needed treatment... identical in all respects except age," says Dr Walker. "One scenario was a five-year-old and a 70-year-old; 94 per cent of people chose to treat the five-year-old. When it was a 35-year-old and 60-year-old, 81 per cent chose the 35-year-old."
A more extreme study undertaken in Sweden asked people to choose between saving a 30 year-old and a 70-year-old. The stakes were then raised and the choice was between a 30 year-old and two 70-year-olds, and so on. The trade-off they finally reached was one 30 year-old equalled nine 70-year-olds.
The concept of a national policy based on ageism is one most people would find deeply offensive yet we tacitly endorse ageist principles in healthcare. "It's relatively rare to hear of older people portrayed as a positive group within the context of the NHS," says Dr Walker. "We see the elderly as users of resources rather than contributors".
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