CJ/Designed for Life/Dependencies & Expectations v1
Dependencies & Expectations
Aim:
To look at changes in the patterns of dependencies and expectations over the next 20-30 years.
Methodology
This paper presents some of the trends which may impact on the pattern of dependencies and expectations for future health care services. Because of the timescale available to undertake this piece of work, the author does not claim to provide a detailed discussion of dependencies and expectations. Instead, the paper provides an overview, using evidence from already known literature and a search of relevant and well respected sites and sources of information.
Introduction
The future dependencies and expectations of a population are difficult to predict. Studies into future scenarios in healthcare have however highlighted several areas where there is a high level of certainty, that they will impact on the need and demand for health and health care services 1:
· An ageing society and ageing workforce;
· Increasing life expectancy;
· Changing family forms and an increase in single-person households;
· New disease threats linked to an ageing society, environmental change, growing antibiotic resistance and modern living;
· Growing health awareness and consumerism;
· Growing ubiquity and power of ICTs;
· An increased understanding and medical exploitation of genomics and other biomolecular fields;
· Continuing and increasing politicisation of health and social care.
Dependencies
Dependency has been described as the need for human help (or care) beyond that customarily required by a healthy adult 2.
Demographic Changes
Population changes give rise to significant economic, health and social issues 3. The demand for health and health care services can be influenced by the following demographic factors:
· Increasing life expectancy
· Ageing population
· Changing household structures
Increasing life expectancy
Life expectancy has increased dramatically in recent years, particularly for men. By 2020, life expectancy for men in Wales is predicted to be 84 years and 87 years for women 4.
Ageing Population
The population of North Wales is predicted to change between now and 2023. In 2023, young people will account for a smaller percentage of the total population than in 2005, while older people will account for a higher proportion.
An ageing population has implications for future health and health care services in North Wales. Increasing age is often associated with increasing frailty, disability and loss of independence 5. 70% of disabled adults are aged 60 years and over 6. The prevalence of chronic diseases is also higher in older people. More people aged over 65 years report at least one chronic condition than any other age; the number of conditions also increases with age 7.
As a consequence of poorer health in older age, dependency on health and health care services is greater among the older population 4.
· Older people are major users of health and social services, accounting for 41% of all hospital admissions in 2003/04.
· Older people are more likely to use GP services.
· Older people often have multiple chronic pathologies, requiring multiple medications, which if poorly managed can lead to avoidable admission and readmission.
· As well as being the main users of acute hospital services, older people tend to experience a longer length of stay.
Although increasing age is associated with poorer health, evidence at an international and British level suggests that older people have been getting healthier 8, therefore the impact of an ageing society is difficult to predict.
Some researchers claim that as disability increases with old age, an increase in the number of older people will therefore result in more disabled people and more demand on services. This is known as the ‘expansion of morbidity’ theory. Evidence of this can already be seen in the 12% increase in hospital admissions in Wales amongst people aged 75 years and over between 1997 and 2003 4.
Others claim that if people are living longer and remain healthy for longer then the overall degree of disability in the population will remain unchanged. This is known as the ‘compression of morbidity’ theory 4.
A New Zealand study found a third theory of ‘dynamic equilibrium’ in older age. Although an ageing population is likely to lead to an increase in demand for services, the financial cost will be offset by a shift from major to moderate limitations for older people, with a reduction in the average levels of support required for that group 4.
The Policy Futures for UK Health 2000 Report highlights the following policy implications of an ageing society 10:
· Increasing importance of broad policy objectives towards maintaining and promoting the health of older people, which includes participation in work, leisure activities, maintaining personal and social networks and housing, amongst other factors.
· An increase in disability illness, in particular in the chronic conditions associated with ageing, such as dementia, musculoskeletal diseases, cardiovascular diseases and sensory impairment. Systems will need to address treatment and care of increasing numbers of people with these problems.
· Significant resource implications for the health service, local authority social services and for individuals who contribute towards the costs of long term care.
An ageing society will also have implications for service provision 10:
· A broad range of service needs in order to maintain health and wellbeing of older people including housing; medical care; transport and support links.
· A shift in health service resources towards older people particularly in relation to the treatment and long-term care of those with chronic diseases.
· Continuing difficulties of assigning responsibility, ensuring adequate monitoring systems and providing effective, fair and appropriate treatment for older people, both in terms of funding in relation to health and social care, which originates from different sources, and in service provision, which is carried out by different organisations such as acute hospitals, community hospitals and social services.
Future dependencies of older people
A document by the Foresight Ageing Population Panel 11 identifies some opportunities and challenges for healthcare and the older person in 2020.
· New interventions and preventative strategies will emerge as genetic knowledge burgeons with the completion of the human genome. Enhanced understanding of the genetics of ageing and disease will identify those who may be predisposed or at risk to certain conditions and improve drug targeting.
· Sensors, IT and remote care technologies have the potential to sustain functional independence and well being among older people in their homes.
· Demand for medical interventions in older people will grow in response to growing evidence of their effectiveness. Many health preventative strategies are also proving their worth among older people, so health education messages should be targeted more towards older people.
· Social and healthcare systems will need to cater for increased social polarisation and diversity among future cohorts of older people.
· Older people will demand to be included to a greater extend in clinical trials and screening programmes.
· Changing family and neighbourhood structures are likely to limit the future availability of informal, family carers.
· Training and development of healthcare professionals should reflect the importance of the growing older population.
· Older individuals will increasingly be asked to take charge of their health through responsible and appropriate lifestyles. Genetic knowledge will provide the basis for effective preventative strategies. As health information becomes widely available, there will be more opportunities for effective self-care and treatment.
Key messages· Life expectancy is predicted to increase by 2020.
· Older people are major users of health and social services.
· North Wales’s ageing population could increase dependency on health and health care services over the next 20-30 years.
Although some predict an ageing population will have significant consequences for health and health care services, others argue that such predictions are not as straightforward.
· Estimates of future mortality carry considerable uncertainty. Issues around individual choice such as diet, smoking or drugs have the potential to slow down or even reverse mortality improvements 12.
· Recent projections show that taking account of the increased fitness of successive cohorts of older people in the UK reduces the population burden of disability by about threefold, from 3.5 million to 1 million affected by 2051 13.
· Future technologies will make older people less dependent on traditional forms of care 14.
Changing household structures
Changes in family structures are likely to impact on the availability of informal care. Factors such as increased numbers of single parent families, divorce rates, geographical mobility and diminishing neighbourhood networks may reduce the number of informal carers, causing individuals to depend on formal care services 3.
The Policy Futures for UK Health Report predict an increasing older dependency ratio, 308 per 1,000 people by 2015 10.
Key message· Demographic, family and social changes may lead to a reduction in informal care provision, leading to increased dependency on formal health and health care services.
Chronic Diseases
It has been highlighted that people with chronic conditions are more likely to use secondary care. It has been stated that ‘people with any long-term problem are about twice as likely to be intensive users…[of inpatient service]…than those without’ 15.
Changes in the incidence and prevalence of chronic conditions will impact on the need for services.
Circulatory diseases
Circulatory disease is the main cause of death in North Wales. The mortality rate for circulatory diseases for people aged 85 years and over in North Wales increased between 1998 and 2003 16.
Coronary Heart Disease (CHD) is the biggest killer in Wales. It is a common chronic condition that is largely preventable through diet, exercise and avoidance of smoking.
Over the last 20 years, CHD incidence and mortality rates have halved in the UK but CHD admissions have doubled 17.
Poole-Wilson predicts that while the death rate in younger age groups from cardiovascular diseases will diminish, the total number of persons with CHD in the overall population will increase. He argues that the decline in the occurrence of these conditions in the young is offset by an increase in the occurrence in the older population. As a consequence, cardiovascular disease will continue to be a major entity in the delivery of healthcare, but the patients being treated will be in the older population 18.
An increase in the incidence of CHD could lead to increased dependency on the following services:
· Cardiology· Pharmacy
· Patient education services
· Smoking cessation services
· Dietary services
· Exercise rehabilitation services
· Specialist support e.g. specialist nursing teams
Key message
· The decline in the occurrence of CHD in younger people is offset by an increase in the occurrence in an ageing population.
Diabetes
Around 75,000 people in Wales are currently diagnosed with diabetes and in addition many thousands may have Type II diabetes without yet knowing it.
According the Welsh Health Survey 2003/04, 5% of the population in North Wales, and Wales, are currently being treated for diabetes.
· The incidence of diabetes is increasing in all age groups.
· Type I diabetes is increasing in children, particularly under 5s.
· Type II diabetes is increasing across all population groups.
· The prevalence of diabetes increases with age. One in 20 aged over 65 in the UK have diabetes and one in five aged over 85 years 19.
People with diabetes are twice as likely to be admitted to hospital as the general population and, once admitted, are likely to have a length of stay that is twice the average. People with diabetes occupy one in ten beds. The presence of diabetes increases NHS costs more than five-fold. People with diabetes are five times more likely to need hospital admission 19.
About 9% of acute sector costs are spent on diabetes and the management of its complications 19.
An increase in the number of people with diabetes in the next 20-30 years, may lead to increased dependency on the following services.
· Podiatry services· Ophthalmology
· Pharmacy services
· Dietary services
· Primary care services
· Cardiology
· Renal services / Nephrologists
· Patient education services
· Smoking cessation services
Key messages
· The incidence of diabetes is increasing in all age groups.
· The prevalence of diabetes increases with age.
· People with diabetes are more likely to be admitted to hospital.
Respiratory Disease
Respiratory disease is one of the most common causes of ill health and a leading cause of hospitalisation and death; diseases include pneumonia, asthma and COPD 17.
According the Welsh Health Survey 2003/04, 13% of adults were currently being treated for a respiratory disease and 9% for asthma.
Prevalence of COPD is around 10% of the population in the UK 17.
During 2001/02, 5% of all general medical and elderly medical emergency admissions in Wales were for COPD 20.
Smoking is a major cause of all respiratory diseases. Pneumonia is more common amongst smokers and is more likely to be fatal. At least 80% of COPD deaths can be attributed to smoking 21.
Influenza is a common and highly contagious respiratory disease. For most of the population, influenza is relatively harmless although those with pre-existing respiratory disease are at increased risk of serious complications and even death.
Influenza is responsible for a significantly large amount of hospital admissions during the winter 17.
Key message· An ageing population could result in more people being dependant on services for respiratory conditions which older people are at greater risk of, including, COPD, influenza & pneumonia.
Rheumatology
Musculoskeletal conditions are a major cause of chronic disability and one of the most common reasons for referral to secondary care 22. Most interventions for musculoskeletal disorders are concerned with relieving pain, particularly following orthopaedic surgery; therefore they are largely secondary and tertiary interventions 17.
A study in the Netherlands found musculoskeletal disorders were ranked as having the greatest impairment on quality of life of all chronic conditions and diseases 23. Osteoarthritis was ranked as the worst within musculoskeletal disorders followed by back impairments.