Consultant Physician and Professor in medicine for older people
What we are currently seeing is a compression of morbidity – you see what is called the ‘rectilinearisation of the survival curves’ - which means that most people are surviving childhood, and surviving mid-life. For instance, a woman born in England today has a 50% chance of living to 100. An awful lot of that advance is to do with three things. Firstly, is that we have better social conditions, a better diet, and we have better housing. Secondly, it is due to a much lower infant mortality rate. And thirdly, it is the success of medical science in treating conditions of midlife and in the prevention of conditions of midlife. If you look at heart disease or stroke, we are now able to not only prevent heart disease by management of cholesterol and blood pressure, but also when they do have a heart attack, the majority of people can be saved by things like urgent angioplasty, whereas before there would have been a very high mortality.
What is interesting though is even in the UK, we still have 15-20 year variations in life expectancy depending on poverty. If you look at Glasgow, for example, it has the 10 most health deprived wards in terms of life expectancy, and high rates of poverty.
I think in terms of what I’ve mentioned so far – preventative medicine and better medical interventions – we’ll see a gradual increase in life expectancy from these. In terms of a radical extension, this will depend where we go with genetic screening and gene therapy. Both in terms of how we develop the technology and whether it will be seen as morally permissible. Now that we know what genes code for a lot of diseases, it wouldn’t be beyond the bounds to be screening for say, breast cancer predisposition, and doing some gene therapy and modifying people’s risk that way. But it really does all depend firstly on the technology and whether it’s morally permitted by society.
It is a cliché, but when people talk about adding life to years instead of years to life, you do need to think about what quality of life we would have. Because unless that increase in life expectancy is accompanied by people not becoming immobile, not becoming disabled, or visually impaired – it wouldn’t be worthwhile. In England right now, there are about 700,000 people with dementia and there will be about 1.4m people with it in the next 20 years. Now surviving longer at the expense at most people having these diseases wouldn’t be worthwhile, and I don’t think it’s what most people would want.
Is it inherently selfish? That gets into the question of social gerontology - are all these old people depriving young people of resources, of the chance to flourish? And unless this expansion was accompanied by people working into older age, the dependency ratio would be skewed, with far more older people dependent on a few young. It would be selfish without older people having that longer period spent contributing, especially if it was a generalised behaviour – much as if everyone flew around in private jets, it wouldn’t be very good for the environment.
It is true that some of the language – like when people use the term “demographic timebomb” – isn’t particularly helpful. It portrays an ageing population and older people as a threat to society.
There are a few assumptions there that need to be challenged. There’s the assumption that we will have no economic growth, or that people will continue to retire at 65, or that we won’t have any advances in our technology. So, it’s by no means certain that it will just be inevitable – people were making similar predictions 30 years ago. However it is interesting that none of the parties are making commitments for a funded social care because they all think it’s unaffordable.
But this does get into intergenerational conflicts. It’s not helpful for older people to be labelled as a problem; it’s no more helpful than labelling “hoodies” or immigrants a problem.
My view as a citizen is that having children through artificial means is not a right. IVF is a medical treatment – the same way plastic surgery is a medical treatment, it’s a choice. Doctors have a moral responsibility not to carry out a treatment that’s futile or hazardous – so if, for instance, the risk to baby or mother was particularly high. Secondly, if it’s a public resource, we do have to consider that rationing and priorities are a reality and we do have to think is it a wise use of public resource to carry out a treatment with a very low chance of success?
Apart from that, I think it’s all very well to frame it in terms of autonomy and personal choice, but it’s a bit like getting in a car drunk – it’s not just your personal choice, it affects others too, and you do have to think of the welfare of the unborn child. If you are electing to have a baby if you are already 55 or 60, it is a bit vainglorious and selfish. Having said that, nobody castigates men in their 70’s for having children through natural means, so there is an interesting question about if that is as reprehensible. But I certainly do not think IVF for over-50’s should be seen as a public good and I don’t think doctors should do it just because someone pays them to do it, without thinking of the risks benefits and the welfare of the child.
First of all, I think that kind of language is sensationalist. We know from British household surveys that many older people have a good quality of life, are not socially isolated, and live to an old age in good health. So it’s not the case that everybody’s miserable. Nor is it the case that if you look at satisfaction surveys that everybody who uses social care is institutionalised or neglected.
Having said that, what we haven’t woken up to yet is that society itself is ageist and that the services we have reflect that. We haven’t woken up yet to the fact that the main users of these services are older people – that’s who comes through the doors of hospitals, who goes to see their GP, who ends up needing nursing home care. And particularly it’s older people who have long-term medical conditions, or a disability. We have a situation in society where we don’t really want to talk about it.
And I think there is a mismatch between reality and what’s represented – so on the one hand you have people like the 97 year old who runs the marathon every year, or the 100-year-old who still works as a plumber, or the 80 year-old skydiver. So you have what you might call ‘elite’ old people.
On the other hand, you have the likes of Menzies Campbell, who was leader of Liberal Democrats at 62 being represented as doddery and incompetent because of his age, or Madonna being caricatured as being on stage with a catheter bag and zimmer frame. The reality is that there are large numbers of older people who do have one or two disabilities or medical conditions but still lead worthwhile and meaningful lives. And I think in society, we’re so youth-obsessed, we fetishise youth, and no one wants to talk about old people in this way. For example, a health correspondent on a national newspaper, when I asked how to get attention to conditions like osteoporosis or dementia, he said to me that I’d have to find a young person with it. And it’s only when some-one like Terry Pratchett, who is relatively young, came out as having dementia that there was much publicity for it. People can be very keen to work with autistic children, but you don’t see these people wanting to do the same work with very old people with dementia.
And I do think these attitudes are reflected by in our services – in the health service, doctors have tended to prioritise high-tech cutting edge curative treatments, when much of healthcare today, as the population ages, is involved in maintenance, treating long-term conditions and improving quality of life – or even giving someone a good death. In health and social care you get patronising attitudes, old people do get talked about over their heads as if they weren’t there, we use condescending language, we assume that old people can’t take any risks, that they can’t make any decisions for themselves. I think those attitudes do give rise to undignified care for some people.
The retirement age is a construct of the 20th century. If you consider that in 1900, there were only around 1 million people over 65 in England and Wales – there’s around 8.9 million now. So the way retirement was structured was partly a product of the conditions at the time. There are currently certain walks of life, such as acting, or theatre director, football manager, or politician, where people work well into their 70s or 80s and are still productive – for example Sir Bobby Robson, or Tony Benn or Shirley Williams. Judges also work well into their old age and use that life experience to their advantage in the courts.
So there is something wrong about people being taken out of the game at this specific age. There’s no evidence that older people can’t learn IT skills, or can’t be trained in new skills, and there’s no evidence that they’ll take more time off sick than younger people. Often in a workplace environment, they’ve got the people skills and they’ve got the wisdom, that younger people lack – and they can mentor and coach, and pass these skills onto younger people. The same goes for outside the workplace, for example in the family. Someone who’s ‘been there and done that’ and raised a family can help younger mums who are perhaps struggling.
I do think that older people already do make a contribution and we shouldn’t make assumptions about people’s value based on their age alone.
For a start, when it comes to delivering health and social care, we need to have professionals who are trained an equipped to work with older people. If you ask many doctors when they first start out if they want to work with older people, they’re likely to say no. But the reality is that will be their job. They need the training, the skills and the knowledge to work with older people and this will help transform attitudes - our systems need to be fit for purpose.
In terms of wider society, it would be good if we could get more older people into schools, to share their experiences, and at the same time, as these things work the other way round, meet young people - just as there’s a distaste for old people, there’s a suspicion of teenagers – of “hoodies”. So getting those groups together in an educational setting would help. And in the media - because it’s so important - it would help to have more positive examples of ageing. It’s disgraceful when you see examples like the woman from Countryfile being sacked for her age and then being replaced with younger women. It’s the same story in the mainstream news.
So we need more role models for successful ageing - not just the odd heart-warming story at the end of the news about an 85-year old going skydiving - because at the moment, we tend to shut older people away from the public eye. It would also help if the media stop using language like demographic timebomb and, well meaning as it may seem, newspapers to stop talking about ‘dignity’ for the elderly, as it is as meaningless as talking about the black community as one amorphous blob. We can’t talk about old people as all being victims of abuse or neglect, or as helpless.