The burden of triumph: meeting health and social care needs
Authors: Andrew Dilnot
Journal: The Lancet (2017)

Life is getting longer. Death is not defeated, but it takes longer to win than it used to. The increases seen for most people in life expectancy are surely a matter for great rejoicing. References to the burden of ageing seem to have missed the crucial point that living is something that most people at most times want to prolong, and on average people are able to do that for longer than ever before1Office for National StatisticsHow has life expectancy changed over time?.http://visual.ons.gov.uk/how-has-life-expectancy-changed-over-time/Date: 2015Google Scholar, 2Kontis V Bennett JE Mathers CD Li G Foreman K Ezzati M Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble.Lancet. 2017; 389: 1323-1335Summary Full Text Full Text PDF PubMed Scopus (662) Google Scholar This increased life expectancy is a triumph of a century or more of improved incomes, lifestyles, and medical technology and intervention. However, it does mean that there are more older people, and the amount of care they need is increasing too. In The Lancet, the study by Andrew Kingston and colleagues3Kingston A Wohland P Wittenberg R et al.the Cognitive Function and Ageing Studies collaborationIs late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS).Lancet. 2017; (published online Aug 15.)http://dx.doi.org/10.1016/S0140-6736(17)31575-1PubMed Google Scholar looks at the interval need (a measure of dependency) being met by carers, as a way of assessing intensity of demand from patients. They use data from the two Cognitive Function and Ageing Studies and include four states of dependency in their analysis: high dependency (24-h care), medium dependency (daily care), low dependency (less than daily), and independent. Kingston and colleagues found that in England, UK, in the 20 years from 1991 to 2011, life expectancy at age 65 years increased substantially, for men and women, and that the numbers of individuals in residential care homes have decreased. These findings seem welcome, as does the increase in the numbers of individuals who are leading independent lives. For men, most of their gain in life expectancy at age 65 years was spent independently (36·3%) or with low dependency (36·3%). By contrast, women had most of their gain in life expectancy with low dependency (58·0%), with 4·8% independent. Using this evidence as the basis for their projections to 2035, Kingston and colleagues estimate the future demands for social care, projecting an increase of 41% in the number of people aged 65 years or older who will be independent, increases in the numbers with low (56·5%), medium (66·6%), or high (61·5%) dependency, and an increase in the number of residential care home places needed for those with medium (89·3%) or high (84·5%) dependency. These projected changes are very large, and although there is uncertainty about such projections, their broad outline seems likely to be accurate. Such changes are to be expected in many countries in the next 20 years and demand attention and action.4Muir T Measuring social protection for long-term care. OECD Health Working Papers, No. 93. OECD Publishing, Paris2017Crossref Google Scholar Expenditure on the care of older people will need to increase substantially and quickly. It will be important to ensure that this expenditure is managed efficiently, and in particular that the boundary between health care and social care is well handled. In England, for example, there is substantial difficulty in so-called delayed discharges, where patients remain in (more expensive) hospital care, despite being fit to leave, because it has not been possible to arrange social care for them, which is less expensive and also more appropriate. Although the overall amount of care needed will increase substantially, this increase does not mean that every individual will need large amounts of care.5National Archives. Fairer care funding: the report of the commission on funding of care and support. 2011. http://webarchive.nationalarchives.gov.uk/20130221130239/https://www.wp.dh.gov.uk/carecommission/files/2011/07/Fairer-Care-Funding-Report.pdf (accessed June 19, 2017).Google Scholar On average, as Kingston and colleagues showed in their study, high dependency will last for only about a year. But for a minority it will last for much longer, and the fear of that is a powerful one. What role does the state have in financing this care? The community as a whole will be expected to pay for those who cannot pay for care themselves. But is there a case for going further, reflecting in social care the attitude to health care seen in many health-care systems of developed countries, to provide some or complete support for all who need it?6Barr N Long-term care: a suitable case for social insurance.Soc Policy Adm. 2010; 44: 359-374Crossref Scopus (71) Google Scholar There are two arguments that might be put forward. First, there is a fairness argument. In universal health-care systems, such as the UK's National Health Service, the financial burden of health care does not fall on those unlucky enough to need it. Money is raised through a progressive tax system, and used to provide health care free at the point of use. If it is right to act in this way in the case of, for example, someone with cancer, why is it right to expect someone with dementia or acute arthritis, who cannot look after themselves, to bear the financial burden of their own care? Second, there is a market failure argument. In the case of health care, in the absence of universal state provision the alternative is private insurance, which is available in most countries, and is seen at large scale in, for example, the USA. But this alternative is not feasible in the case of social care. The uncertainties surrounding the possible cost of social care provision are so great that private insurers do not and will not make such cover available. Therefore, in the absence of state activity, individuals cannot pool their risk, so that although most of them will not face high and extended costs, they are all left facing that possible worst case scenario. This scenario is terrifying for individuals, and very inefficient. If the private sector cannot pool the risk, the case for the state taking that responsibility, at least in part by providing social insurance, is very strong. These arguments do not suggest that individuals should not pay towards their own care, just that they will want to share the risk, tackling at least some of it together, and finding the right form of tax or charge is vital. Failing to address coherently change on the scale that we face in many countries worldwide would be a tragedy. Longer lives are to be celebrated. Effective provision of the additional care needed should be a happy challenge, not a burden to be ignored. I was from 2010 to 2011 the chair of the UK Government's commission on the funding of care and support. I declare no other competing interests. Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations. Full-Text PDF Open Access