An ageing population demands a new conversation about care - Fliss Murtagh
The parliamentary defeat of assisted dying legislation was narrow. A majority of just 16 MPs rejected a bill that would have permitted assisted dying in limited circumstances. Yet public support remains strong.
This support is accompanied by growing public concern about a health and social care system under pressure, struggling to meet the needs of people in later life and a population whose health needs are changing rapidly.
An ‘ageing population’ is about more than growing numbers of older people. It is also about their health and care needs. In 1954, 11 per cent of the UK population was aged 65 or over. Today it is almost 20 per cent, projected to reach 25 per cent by 2050. Life expectancy has increased dramatically with many people now living well into their late eighties.
But longer lives do not necessarily mean healthier lives. Between 2012-14 and 2022-24, healthy life expectancy in the UK fell by around two years. Across most of the country, healthy life expectancy is below the state pension age and, in some areas, below 55 years. The gap in health life expectancy between the most and least deprived areas has widened to almost 20 years.
Among 21 of the world's wealthiest nations, the UK is one of only five where healthy life expectancy declined between 2011 and 2021. During that period, the UK fell from 14th to 20th place. Only the US now has a lower healthy life expectancy.
Growing numbers of people are living longer with multiple long-term conditions, frailty and complex care needs. Many older people are increasingly concentrated in coastal and rural communities, presenting further challenges for a health system still largely designed around urban populations and acute treatment.
As healthy life expectancy falls, healthcare spending continues to rise. In real terms, healthcare spending has increased from around £16.5bn 70 years ago to approximately £225bn today. Only part of this growth reflects greater need. Increasingly, resources are directed towards more intensive and more expensive interventions.
Yet these interventions are not always what patients want. For those who are older, with multiple health conditions, better quality of life and wellbeing is often the priority.
In England, 43 per cent of deaths occur in hospitals, the most expensive setting in the healthcare system. Around one-third of acute hospital beds are occupied by people in the last year of life. Many older people receive fragmented care from multiple specialists, despite living with several interconnected conditions. Too often, healthcare remains organised around diseases rather than people.
There are not currently enough generalists or ‘hospitalists’ or palliative care specialists who can better manage their patient’s journey back into the community, who are skilled at difficult conversations, listening to what their patients really want, who recognise that hospital is not the last place that people want to be towards the end of their lives.
Our health and social services are not currently meeting the needs of older people or their families and, on current trends, the prognosis is not looking good. As acute hospitals absorb an increasing share of NHS spending, fewer resources are available for GPs, district nurses, hospices and community services. Charitable providers, especially hospices and community palliative care teams, report major financial and workforce challenges and are reducing beds and workforce, leaving gaps in care. Into those gaps some 1,500 Britons a day are quitting their jobs to become unpaid carers according to Carers UK, at a cost to themselves and to the economy estimated at £37bn a year.
Families consistently describe a fragmented system, repeating their story to multiple professionals and being passed between disconnected services. If their unpaid labour had to be replaced by health and social carers, this would represent more than £28bn annually. Yet as the population ages, the pool of family carers is likely to shrink. Alarmingly, one in ten carers say they would be unwilling to provide care again under similar circumstances. Their experience must improve if future caring capacity is to be sustained.
Palliative care is part of the answer. Despite strong evidence that specialist palliative care improves quality of life and can reduce healthcare costs, only a minority of those who could benefit currently receive it. Expanding access to and resources for specialist palliative care would yield substantial savings to the NHS. Reducing costs would support investment in care as well as cure, which is not currently the norm. Meeting future demand requires investment in community services, workforce development, data-driven planning and recognition of the full care workforce.
But structural reform alone will not be enough. We need earlier conversations between clinicians, patients and families, better planning and greater openness about uncertainty, hoping for the best while planning for worse.
Professor Fliss Murtagh is Professor of Palliative Care and Director of the Wolfson Palliative Care Research Centre.