Interview

The tide is not rising

Has the ‘demographic time bomb’ gone off? Hospital specialist Linda Patterson spoke to healthmatters about ageing, the NHS and the evolution of geriatric medicine

The population is ageing, and the costs of health care for old frail people are rising. How will the NHS and social services cope with the demands of an ageing society?

In fact, our society is not ageing rapidly. Since 1981 there has been no increase in the proportion of the population aged 65 and over, now about 16 per cent of the total. This age group will probably rise to 17 per cent by 2011. The projected rate of increase among those aged 60 or more during the 1990s is 0.08 per cent per year, about a quarter of that projected for those under 60, while the number of those aged 65 to 74 is likely to fall by half a million. The population of women aged 75 to 84 seems likely to fall by 0.6 per cent per year in the first decade of this century. We are living through a pause in the process of demographic ageing, and probably face only a modest increase in the size of the older population in the first quarter of the 21st century, with a projected increase among those aged 60 and over from 20 per cent to 24 per cent.

Sweden experienced change on this scale in the middle of the 20th century, and became one of the most stable and successful societies in Europe. The real ageing of British society occurred during the middle decades of the last century and was accommodated without hugely damaging effects on social structures or the economy. Projected increases in the proportion of older people in the population at the beginning of the next century are not new, and they will be significantly less than increases in under-developed countries, which will experience the greatest problems of service provision. Anxieties about the ageing of the British population and the effect of demography on provision of health and social services are less to do with the absolute numbers of older people than with heightened expectations about the type, length and costs of such care – and perhaps a moral panic about ageing and mortality themselves.

The older population is an important resource for the whole community. Changing marriage and fertility patterns over the last 50 years have resulted in the expansion of the social networks of older people. In 1977 one third of those aged 75 or over had no children, but by the early 1990s this had fallen to nearer a sixth. More is demanded of older people by their children and grandchildren, and more support is offered to them, contrary to the myth that children neglect and abandon their ageing parents. The result is that older people provide over a third of the so-called informal care of ill and disabled people, act as a major source of childcare for the increasing proportion of working mothers and provide the backbone of voluntary support in the health service and in voluntary organisations that contribute on a broad scale to health and social care. The relationship between older people and their children, friends and neighbours is not one of simple dependency of young on old, but a complex exchange relationship which shifts only gradually – and only sometimes – towards the younger becoming the predominant givers.

The major contribution of older people to family and local economies can occur because we are not only adding years to life, but also life to years. Life expectancy for women is currently 79 years, and 74 for men, with projected figures of 83 for women and 78 for men by the year 2021. Instead of the pandemic of disability and dementia implied in apocalyptic interpretations of demographic change, most of the gain in life expectancy seems to be occurring without disability. A woman of 65 with over 17 years life expectancy will remain fit and active for nine or ten years, and a man of the same age, with a life expectancy of nearly 14 years, for seven or eight years. American studies of cohorts of older people during the 1980s showed that the decline in disabling conditions was most pronounced for disorders of the heart and circulation. In these studies the probability that a person aged 85 or over remained free of disabilities increased by nearly 30 percent during the 1980s. The impact of improving health can be seen in the recent review of the 1991 census and seven other national surveys of older people (see box).

But disability and frailty are widespread…

True, a very significant minority of older people will continue to have major, disabling problems that require medical, nursing and social support if anything like normal life is to be maintained, and the prevalence of major neurological and musculoskeletal causes of disability, like stroke, the dementias, Parkinson’s disease, osteoarthritis and fractured neck of femur, is likely to rise.

This disabled and frail subsection of the older population deserves better services than it gets. The relative deprivation that this group experiences is the combined effect of the complexity of disability itself, low expectations among older people and poor quality care – especially in general practice, where I think age barriers to treatment operate most powerfully. Our health services can be very good, and the near unique British experience of developing geriatric medicine as a discipline means that multidisciplinary assessment and rehabilitation are widely available. But there are still some problems in hospital medicine, like delays in investigation and treatment because older patients are given low status, even when their needs are greatest and their capacity to benefit from treatment very high. Logically they should be at the front of the treatment queue, not the back.

Why does this unevenness in services persist?

My impression is that it is partly fear that creates these barriers – the feeling that ‘I don’t want to get like that’ – and partly that frailty is complex in its causes and effects, and takes time and skill to unravel. The current cohort of older people is as a whole not very assertive, nor very articulate. Staff in the NHS work more and more intensively, time is a scarce commodity, and the front-line staff are often the least experienced professionals. Having said that, the expertise of geriatric medicine has diffused into other aspects of hospital care, perhaps more in medicine than in surgery, and there is no reason to think that this will stop.

Why is the NHS good in parts for older people?

In geriatric medicine we have developed team working and inter-agency collaboration, with respect for different professional roles and a real commitment to building a consensus on clinical care. These styles were introduced in the 1950s and 60s by the pioneers of geriatric medicine, and taken further by their disciples in medicine and nursing in the 70s and 80s. The pioneers and their disciples were very effective, in that geriatric medicine lost its Cinderella status, gained an academic base without losing a broad perspective, and was no longer a career failure for professionals. The third, rising generation of professionals faces three new challenges that might halt this progress. The first is the NHS preoccupation with throughput, which penalises a specialist service that needs time to be effective, especially with rehabilitation, but also with acute care. The second is the change in the pattern of clinical activity in hospital medicine due to shortening junior doctors’ hours of work, and the third is the shrinkage of general medicine – the ‘Jack (or Janet) of all trades’ bit of hospital care – in favour of specialisation.

The reduction in junior doctors’ hours means that there are not enough junior medical staff to continue to run a specialist geriatric service 24 hours a day. Other specialist teams have to provide clinical care for older patients, and geriatricians also have to take their turn at medicine for younger adults. This merging of disciplines affects senior staff too, so that in some places the geriatricians make up the majority of general physicians, especially where the general physicians have decided to become gastroenterologists or whatever. There is a risk here that the skills of geriatric medicine – in multidisciplinary assessment and rehabilitation – will be diluted, both in the training of future specialists in medicine for older people, and in the practice of existing services. Of course you can overstate this risk – when I am on call for general medicine 70 per cent of the patients that I admit are aged 65 years or older. We also have to consider the argument that separate services for older people perpetuate prejudice against them, sometimes deny older patients access to other specialist services, like cardiology, and strengthen rather than weaken the view that geriatricians are not ‘real’ doctors.

How might this loss of skills be avoided?

The glory days of expanding geriatric medicine in hospital settings may be over, but there is still one arena where it may play a big part – in the community, particularly with the integration of general practice, community nursing and social care. These professional groups need to learn about multi-disciplinary working, collaboration between agencies and complex problem solving with older people. There is a debate at the moment about whether geriatric medicine should be a community-based or hospital-based specialism. I think this misses the point. Primary care groups and trusts will need a lot of input from geriatric medicine if they are going to cope with the needs of older, frail patients in their localities. The orientation of geriatric medicine must be towards the community, wherever its base may be.