Stiff Upper Lip?

The British, I’ve argued previously, are ahead of us in health care for older people. They have more robust geriatric and palliative care programs than we do. They screen for frailty in older people and have a strategy for addressing the needs of those found to be frail. They devote a larger fraction of their resources to primary care (as opposed to specialty care) than we do, which benefits the aging. And data from the Commonwealth Fund consistently show that even though the UK spends a smaller percentage of its GDP and much less per capita on health care than does the US, health outcomes are typically at least as good and often better. In the fund’s most recent report, for example, the US does well in cancer care but has higher mortality from ischemic heart disease and higher rates of diabetic complications than the UK: death rate from IHD was 128/100,000 in the US compared to 98/100,000 in the UK and amputations in diabetics occurred in 17.1/100,000 in the US compared to 5.1/1000 in the UK. So the report published this month called “Health and Care of Older People in England 2017” was of great interest.

The basic demographic reality in England is the same as in the United States: the population is aging and the oldest old, those over age 85, are the fastest growing subset of the older cohort. And the economic reality in England may well foreshadow its American counterpart: over the last several years, the UK has been in the grip of belt-tightening fever, as government spending on both medical care and social services has been cut or its rate of growth slowed. The net effect is that gains in life expectancy leveled off by 2011, but more alarming, disability-free life expectancy at age 65 has been falling since 2011. Between 2005 and 2011, older women gained a full half year of good health and men gained 0.3 years. Since then, most of those gains have been lost.

Another result is that over a single year, there has been an 18 percent increase in the number of people who do not get the basic help with their activities of daily life that they need.

The authors of the study conclude that the “massive reduction in publicly funded social care has had a severe impact on older people, families, and carers.” Five years of cutbacks have led to a 26 percent increase in the number of older people with unmet needs for care and support. And this is in a country where there is a lower rate of obesity and fewer chronic diseases per person than in the US.

What’s particularly interesting is that the UK has for years devoted far more resources to social support for older people than has the US. The possibility that the mediocre or downright poor health outcomes for Americans (despite a per capital medical expenditure of more than double that of other developed countries) is attributable to lack of spending on social services was first raised by Elizabeth Bradley at Yale. She found intriguing evidence that the added dollars lavished on physician care, hospital care, and diagnostic tests, among other outlays, were not nearly as valuable as the money spent on supporting caregivers and home care. And a recent RAND study, “Are Better Health Outcomes Related to Social Expenditures?” which was commissioned to challenge Bradley’s findings, instead confirmed them. Moreover, this analysis concluded that public social expenditures (as opposed to the private ones that are favored in the US) have a particularly strong relationship with health outcomes. It also found that certain social expenditures such as spending on old age care, translate into better health outcomes throughout the life cycle (ie support middle aged caregivers and they and their children are healthier). Finally, the study concluded that the role of social expenditures is magnified in countries with a high degree of income inequality—such as the US.

The US is on the brink of rolling back government programs. Presumably, what little support is currently provided to older people and their families is a candidate for the chopping block. The British experience shows us what sort of improvements in health and well-being are achievable for older people--and also what happens when social programs are cut. Caveat emptor!

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I stumbled on it purely by accident. I was looking for a picture to illustrate "diversity" for a talk I am preparing, and I seemed to remember that the World Health Organization had some beautiful photos in its earlier reports. Maybe what I liked best about those photos is that they capture the beauty and the humanity of their subjects without insisting that everyone smile for the camera. As it turns out, I didn't find what I was looking for but I discovered that on the very day I was searching, the WHO released a brand new report. It doesn’t have a very snazzy title—it’s called World Report on Ageing and Health—but it’s a remarkable and inspiring document. 

Not surprisingly, none of the major US newspapers breathed a word about its release. Maybe the reporters just haven’t had time to go over it: it is, after all, 260 pages. Or maybe they figure that what’s happening in the rest of the world isn’t terribly germane to the US. Perhaps--and I suspect this is the real reason--the media don't want to think about aging. In fact, the report is brimming with fascinating observations and interesting insights, many of which are relevant to the United States both in terms of our own aging population and in terms of national security. There is so much in here worth commenting on, that I think I will devote more than one blog post to the report. Let me begin by sharing some of the most astonishing things I learned in the first half of the report.

The report begins by suggesting that rather than thinking about expenditures on older people as pure costs, they should be seen as investments. It points to a study done in the UK a few years ago which calculated that if you put everything that the government spends on old people in one column (pensions, health care, other social welfare programs) and you put the contributions of older people in another column (taxes, consumer spending, work), you come up with a positive balance. At least in England, the net contribution of older people amounts to 40 billion pounds per year.

One of the most startling differences between this new report and its predecessor is that today's version defines healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age. iI like that. All health care systems in all countries, the authors argue, should have as their single goal fostering the functional ability of older people by supporting and maintaining their intrinsic capacities and by enabling those with diminished functional capacity to do the things most important to them. This is a marked improvement, in my view, from the last major WHO report, Active Ageing, which came out in 2002, that talked about "optimizing opportunities for health." Then, health was the ultimate objective; now, health and healthcare are means to an end and that end has to do with the ability to function in society.

The description of what health in older age looks like in different countries is both intriguing and sobering. My attention was drawn to a single chart showing the percent of the population age 65-74 and the percent age 75 and older with limitations in one or more activities of daily living, by country. Only a handful of countries were listed. But the gap between the worst off and the best off was shocking—as was the revelation of who occupied the extremes. In first place is Switzerland, with fewer than 10% of the 65-74 year olds suffering a limitation in function and fewer than 20% of those over 75. In last place is Russia, with 60% of the younger old and 80% (that’s not a typo) of the older old reporting at least one ADL deficit. I haven’t quite figured out how this relates to Putin’s policy in Ukraine and Syria, but I suspect there’s a connection. There's something very rotten in the state of Russia.

On a more optimistic note, the chapter on “Health Systems” gives some uplifting examples of countries that have introduced novel approaches to improving the well-being of their older populations. Ghana is making an effort to harness its well-established system of community health workers to meet the needs of older people. And Brazil has begun integrating aging into its national family health strategy: it is using multidisciplinary teams comprised of physicians, nurses, and physical therapists, psychologists, nutritionists, occupational therapists, and others to work in community centers and to go into patients’ homes to deliver care.

More to follow…