Thursday 16th February sees the Greater Manchester Ageing Conference, held by the GM Ageing Hub, of which MICRA, the Manchester Institute for Collaborative Research on Ageing, is a part . To celebrate the conference, and to highlight the policy implications of living in an ageing society, MICRA have teamed up with Policy@Manchester to deliver a week of  highly relevant age-related blogs.

The health and social care system faces new challenges in caring for the UK’s steadily ageing population. Here Professor Martin Vernon, National Clinical Director for Older People and Person Centred Integrated Care at NHS England, explains the factors which must be considered in order to support older populations who remain fit to lead fuller and longer working lives.

• Life expectancy from birth in England has increased by over five years since 1990 to 81.3 years, with gains being greater for men than women
• Frailty should be considered in health and social care policymaking
• Decline in mortality has not been matched by decline in morbidity leading to more people living longer with disease
• Proactively identifying people with multi-morbidity is important
• System leaders must ensure that policy and planning reflect the scale and impact of population ageing on employment, housing, transport and family life while also taking a whole-community approach

I have lived, studied and worked in Greater Manchester (GM) for most of the last 30 years. The conurbation has changed almost beyond recognition, and so has its health and social care system.  But we are facing new challenges and the words of French author Jules Renard (1864-1910) seem particularly apt when considering how to tackle the needs of our population.

The relentless expansion of an ageing population is not the demographic ‘time-bomb’ I learned of as a student. It is a steadily rising population tide driven by reductions in fertility and successful survival into later life. Life expectancy from birth in England has increased by over five years since 1990 to 81.3 years.

It’s about Frailty

Why is this so important now? The answer lies in frailty, characterised by gradually lost resilience with increased vulnerability to unexpected rise in dependency after a comparatively minor stress event such as an acute illness. Its presence is significantly associated with poor health outcomes including unplanned hospital or care home admission and death.

Put simply, the more health problems a person has, the more likely they are to get into difficulty. In people aged 60 and over the prevalence of frailty is 1 in 7, but this rises to two thirds of those aged over 90

As we continuously optimise public services we must have due regard both to the needs of older people who remain fit, and systematic identification of those with declining resilience. This provides a triple aim of keeping fit older people healthy and active, delaying the onset of poor quality ageing and meeting the needs of those who are not ageing well through to the end of their life.

Inequalities in ageing

So while celebrating successful ageing we must not be led into complacency. There is marked inequality between least and most socioeconomically deprived areas with men living on average up to 8 years less in the most deprived areas including the North West.

Decline in mortality has also coincided with more people living longer with disease.  One in four of us have two or more long-term conditions (multi-morbidity) rising to two thirds of those aged 65 or over, making it the norm not the exception. This matters because it is associated with reduced quality of life, higher risk of death and higher utilisation of unplanned health care.

Moving towards proactive identification

Proactively identifying people with multi-morbidity is important. Recognising when care has become burdensome can facilitate a recurrent process of tailoring care to better meet the needs of the individual. To do this it must be understood that not all older people are frail and not all frail people are old. Routinely identifying those most likely to benefit from tailoring their care among a population of older people presents us with a challenge.

In 2016 the validation of the electronic frailty index (eFI) created the first opportunity to do just this. The eFI routinely identifies frailty by degree at population level using routine health care data already collected and coded within general practice. This permits identification of populations of people aged 65 or above who are fit, living with mild, moderate or severe frailty. This is important. Compared to the 50% of the population aged 65 or over who are fit, people with mild frailty (35%) are twice as likely within one year to be admitted to a hospital or care home in an unplanned way or to die. For people with severe frailty (3%) these risks are quadrupled.

The utility of the eFI lies in our ability to stratify populations by anticipated future need, providing an opportunity to proactively target interventions for individuals most likely to benefit. Using the eFI to trigger care tailoring in line with NICE Guidance  and falls risk assessment guided by  the recently published system wide consensus statement provides two meaningful and potentially high impact interventions we can get on with straight away. To this end NHS England has now agreed with General Practitioners to begin nation-wide routine frailty identification in primary care from April 2017.

A different future

In setting the pace of change we must also not lose sight of the fact that the UK population is ageing fast: as plans for devolution in GM were announced the average population age exceeded 40 for the first time.

In the next twenty years one in seven of us will be aged over 75 and we will be living in a different society where more people are in older age groups than ever before. This has implications for how we approach both our own old age and that of our family members. While pursuing equitable and sustainable high quality health and social care for the entire population, system leaders must take care to ensure that policy and planning reflect the scale and impact of population ageing on employment, housing, transport and family life.

To give one example, social isolation is associated with increased all cause mortality and while addressing the needs of people who are already firmly on the health and social care radar, we must also ensure that efforts are made to address social isolation for those people who are at risk but not necessarily in direct line of sight.

A Manchester perspective

The 2015 memorandum of understanding for Greater Manchester Health and Social Care Devolution sets clear objectives including improvement in the health and wellbeing of all GM residents from early to old age, recognising that this can only be achieved by focusing on prevention of ill health and promotion of wellbeing.

Accelerating closure of the health inequalities gap within GM, and between GM and the rest of the UK, is key to improving health outcomes from some of the worst to some of the best in the country. Moving care closer to home and integrating the organisation and delivery of health and social care cross the conurbation AND around the person are key enablers in meeting these objectives. Setting the right direction of travel by ensuring frailty and multi-morbidity are key system priorities will be crucially important if we are to maintain focus.

Considering the whole life course

The 2016 Foresight report encourages us to develop whole life course policies, taking into account the growing interdependencies between generations. Lone parent families have grown by over 10% to 3 million in the last decade and in the next 20 years there will be 1.4 million more households headed by someone aged 85 or over. Increasingly families have multiple generations alive simultaneously creating opportunities for cross generational caring but also increasing pressure on individuals to care for their dependents for longer periods of time.

We have much to do. We must support older populations who remain fit to lead fuller, longer working lives. We must be mindful of how we best facilitate neighbourhoods, communities and families to meet the demands created by emerging care needs of older people. Going forwards we require health and care systems invested in proactive community based approaches to ageing well, while ensuring acute and long-term care systems are optimally configured to meet the needs of older people with moderate and severe frailty.

Responding positively to the challenges of an ageing population requires us to take a clear and consistent approach to defining the scale and scope of the needs of the population at various stages in the advancing later life course. Understanding frailty as a progressive long-term condition is crucially important to achieving this.