‘The tragedy of old age is not that one is old, but that one is young’
Men and women in the developed world typically live longer now than they did throughout history, an increase from about 25 years 2,000 years ago to around 80 at the beginning of the twenty-first century. The increase has been mainly due to the advances in medicine and biology which have given us vaccines and antibiotics, and the development of sanitation systems, as well as better lifestyles and better nutrition. All of these have been successful in preventing infectious and parasitic diseases causing premature deaths. But we now need to understand the implications of the increase in age of the population.
At present just 11 per cent of the world’s population are over 60, but in developed countries they will be one third of the population by 2050. In rich countries one in three individuals will be pensioners and one in 10 over 80. In some countries in the West the over 65s are the fastest growing age group. Those over 80 in the world are expected to increase to 4 per cent by 2050, four times more than now. Current estimates are that 700,000 of those in the UK at present around 25 years old will live to be a hundred. Moreover, half of babies being born now will reach a hundred thanks to higher living standards. But our bodies are still wearing out. Children will be outnumbered by those over 75 in what some call the Zimmer-frame society. How will society adapt?
A majority view is that an increase in numbers of older people would make no difference to safety, security, standards of living, health or access to jobs and education. But one third of the public think life would be worsened by an increase in the older population because it would have negative economic effects. It is worth noting that by 2050 it is estimated that more than one third of voters in the UK will be over 65, and since the old vote more than the young, they could wield much power and vote for much costly support in their old age.
David Willetts, the current science and education minister, has argued that the baby boom of 1945–65 produced the biggest, richest generation that Britain has ever known. Today, at the peak of their power and wealth, baby boomers, he claims, run our country; by virtue of their sheer demographic power, they have fashioned the world around them in a way that meets all of their housing, healthcare and financial needs at the expense of their children. Social, cultural and economic provision has been made for this reigning section of society, whilst the needs of the next generation have taken a back seat. But it is the old who will have the greatest impact.
Some analyses suggest that improvements in health and longevity have resulted in enormous gains in economic welfare. One estimate of the economic impact of post-1970 gains in life expectancy suggested that they might have added as much as 50 per cent to the GDP of the US. Even so, there are profound economic problems to be tackled.
The Economist has called the economic effect of an ageing population a slow-burning fuse. It claims that age-related spending by a country like the UK will in the future be more serious than the recent recession. The elderly require money for pensions, health and care. The age-related spending by the government in the UK is already about £7 billion, less than 1 per cent of GDP, but it clearly needs to rise. Already there are billions of pounds of benefits for the old which are not claimed. The last years of life can cost tens of thousands of pounds and this increases with advanced age. In many cases the cost of the last year of life is more than all that has been spent in earlier years. Forcing older workers to retire cost the UK in 2009 an estimated £3.5 billion in lost economic output. Pension plans, social security schemes and notions of the length of working lives will need to undergo major reformulation.
The small increases over time in average life expectancy that lead to very large increases in the size of a population are prompting many arguments. Reproductive practices might have to change in order to keep the population from becoming too large. In regard to the escalating costs of looking after the old, one group in the US has suggested there should be cuts to protect the young. It has been argued that any technological advances in life extension must be equitably distributed and not restricted to a privileged few. There are suggestions that the UK will become a giant residential home, with the young looking after the old. With family ties weakened by increased mobility and rising divorce, in the future the elderly will be less likely to be married or co-habiting, and more will live alone; and since they do not want to leave their homes it will hard for the young to find one to buy.
Such concerns were presented by Jeremy Lawrence, writing in the Independent, who described the ageing population as the greatest threat to human society: ‘No invading army, volcanic eruption or yet undreamt of plague can rival ageing in the breadth or depth of its impact on society… The impact of this transformation will be felt in every area of life, including economic growth, labour markets, taxation, the transfer of property, health, family composition, housing and migration. And the “demographic agequake” is already under way.’
The countries with the oldest populations—that is with the highest percentage over 65—are Monaco, then Italy and then Japan. The median age of the world population will, in the next 40 years, go from 28 to 38. The United States is on the brink of a longevity revolution. The elderly comprise 12 per cent of the US population, and their number is projected to almost double between 2005 and 2030, from 37 million to 70 million. By 2030, the proportion of the US population aged 65 and older will double to about 71 million older adults, or one in every five Americans. The far-reaching implications of the increasing number of older Americans and their growing diversity will include unprecedented demands on public health, ageing services and the nation’s healthcare. Although there may be unjustifiably pessimistic views of what is before us, an ageing population does present severe problems. But there are also great advantages.
An analysis of the consequences of increasing life expectancy must include the economic implications of changed population age structures, especially changes in the ratio of those in the labour force to those outside it, mainly children and elderly, which is known as the support ratio. In the early stages in which life expectancies rise, the proportion of the population within the labour force age range rises significantly, providing a substantial boost to economic growth. However, as people live longer those extra years will have to be financed, and there are only a limited number of ways to do this. These include working longer, increasing social security or other taxes, increasing immigration, and reducing consumption.
In order to reap the economic benefits of longer lives, some of the extra years of life will probably have to be spent working productively. In the UK one in five over the age of 55 can expect to work till they are 70 and even older. This is because of their limited finance. At 55 many still have a mortgage and less than £2,000 in savings. There is considerable variation in the EU about attitudes to the extension of working life—9 out of 10 in the Netherlands, Denmark, and Finland are positive, but in Greece, Portugal, Spain and Hungary they are not at all keen. It may be sensible to compensate younger people for working when they are older by allowing them to work fewer hours per week over the whole course of their lives.
The number of people supporting pensioners is decreasing, and it will go from four workers for each pensioner at present to two workers for every pensioner in 2050. A major problem of the ageing of societies is that people are having fewer children. The current global average is 2.6 children per woman, while in rich countries it is 1.6. One reason is that women are having babies later in life. This means that in some rich countries the population is beginning to decrease. In ageing countries, the economy can shrink as more retire and there are fewer young to take their place, and the older workers may be less productive. Japan has a very low ratio of workers to pensioners, just three to one, and by 2050 the number will probably halve. Such changes can reduce economic growth significantly. In some countries immigration is filling this labour gap; another solution is to encourage people to have more children, as has been done in France and Japan. There is also the problem of finding enough young adults for the armed forces.
Pensions raise serious economic issues. The official retirement age for most developed countries has remained the same even though the population is ageing. Many have even retired before the official retirement age. Retirement pensions are the largest component of age-related spending, and the cost of state pensions in rich countries will probably double by 2050 and reach more than 15 per cent of GDP. Payments to the pensions of retired civil servants in the UK which are based on final salary are very expensive—the pensions can be as large as two thirds of final salary. Each one-year increase in longevity increases costs £1.3 billion a year.
Part of the problem is that men can now look forward to between 14 and 24 years in retirement, much more than anticipated. Older workers also want a less onerous workload. The UK government’s decision to abolish the compulsory retirement age, currently 65, wll increase the number of the workforce. Retiring later will help financially, but will not the young then be deprived of senior appointments? It is estimated that unless urgent action is taken there will be a £6 billion hole in the funding of social care within 20 years. Free care at home could cost the state more than £1 billion. A very big financial hole is being opened up.
The Big Question: ‘Is the world’s population the wrong age?’ In some countries there are too many old people, while in others the population is very young. While the developed world is facing up to the challenges of an increasing number of elderly citizens, some developing countries are facing the strain of populations in which a third of the people are under the age of 15. Neither situation is ideal, but the challenge is to find ways of adapting to cope with the economic demands of differing population ages.
According to a UK survey, most individuals approaching old age had not yet thought about how they would be cared for. I myself am guilty of this. At least 13 million, according to the government, are not saving enough to retire on a decent income. Some 70,000 people have to sell their homes each year to cover the cost of long term care. When asked about the supposed worries they would have when 75, about half those aged 45 to 75 were rightly worried about money for long-term care. At 65, the government says, a woman can expect to face average care costs of £40,400 and a man, who will not live as long, £22,300. Those with severe health problems such as disability and Alzheimer’s disease and and other forms of dementia are by law entitled to free NHS care, but ageing illnesses makes self-support increasingly difficult. Plans for nearly half a million needy elderly to remain in their own homes would cost £670 million a year, and in current economic circumstances such figures are vulnerable.
The health of the elderly remains a major issue. Health spending on the elderly in the EU is about one third of the total health budget. In the UK more than 40 per cent of the NHS budget is currently spent on people aged over 65. The estimated number of people in the UK living with the effects of stroke, which mostly strikes people over the age of 60, will rise significantly, and the number of people with dementia will increase to around a million in 2025 imposing a major burden on social services and families. The cost of looking after them has been predicted to increase to £35 billion. The number living with coronary heart disease, osteoporosis, osteoarthritis and age-related macular degeneration of their sight will all increase dramatically. Treatment of all these illnesses is, to put it mildly, expensive. Currently those over 65 consume one third of all drugs but are only 14 per cent of the population. The NHS will face increasing demand for its services to the old. To go further and increase the quality of services will require an additional 3 or 4 per cent increase each year.
According to the Institute of Medicine report in 2008, the elderly in the US account for more than one third of all hospital stays and of prescriptions, and more than a fourth of all office visits to physicians. The average 75-year-old American has three or more illnesses and takes at least four medications. Delivering optimal geriatric care has become a costly medical and ethical priority. Medical and nursing schools are, it is claimed, training far too few doctors and nurses on how to care for the elderly. At the same time, other workers, such as nurses’ aides and home health workers, remain under-trained and underpaid, the experts say. The number of doctors specialising in geriatrics has been falling. The US government has recently announced a new initiative to assist with housing costs for elderly and disabled people.
Despite the best efforts of any government, the cost of the elderly is going to leave a gap in funding. Spending on care for the elderly will have to double over the next 20 years to cope with a surge in the numbers of sick and disabled old people. It was previously believed that the amount of time that pensioners spent being sick or disabled would remain constant or even shrink with the help of medical advances, but this is unlikely. Instead, many of the extra years will be spent being unwell and in need of care. Increases in the number of years of good health have not kept pace with improvements in total life expectancy. The number of sick elderly people, or those with disabilities, will increase by around two thirds over the next 20 years. The costs are frightening.
Around 700,000 people in the UK spend more than 50 hours a week caring for a relative, according to Carers UK. A lack of facilities means one million family members already take time off work to care for aged or disabled relatives, while another six million take some ad-hoc responsibility for caring. By 2033 the number of people aged 85 and over is projected to more than double again to reach 3.2 million, and to account for 5 per cent of the total population, and so the number of carers needed will have to soar as well. Britain faces a care time-bomb within seven years, with the number of elderly needing full-time help outstripping the number of carers. Free personal care at home is available in Scotland but not in the rest of the UK.
Public transport systems, especially fixed-route bus services, face important challenges in meeting the needs of the elderly for convenient transport. There is a need for wider pavements to make the roads and streets safer for older pedestrians. This could include dedicated pathways for electric wheelchairs, improved access points to public transit and commercial areas, along with special ramps or expanded parking spots for the ageing population. Yet more costs.
In China, meanwhile, an enormous population is also ageing rapidly. By 2050 about one quarter of all Chinese will be aged over 65. This is one of the consequences of the country’s ‘one couple, one child’ family planning policy made 30 years ago. This puts China in a difficult situation. With a population of 1.3 billion—the world’s largest—and one that is set to peak at 1.5 billion in 2026, the authorities cannot afford to relax their tough birth control policies. But without more younger people, who is going to support the hundreds of millions of elderly? The percentage of elderly is projected to triple from 8 per cent to 24 per cent between 2006 and 2050—to about 320 million old people. It is almost certain now that China’s generation of only children will find themselves as adults trying to support two retired parents and four ageing, and possibly ailing, grandparents. Officials are already talking anxiously about the 4-2-1 phenomenon. How are those costs to be borne?
In Japan in 1950 there were 97 centenarians and in 2008 there were 36,726. Reaching a hundred is no longer the miracle it used to be. It has one of the oldest populations; there are just 3.4 people working for each one over 65, and by 2050 the number will be just 1.3, worryingly few. Can the pension books be managed as fewer children are being born? Japan has the world’s fastest-ageing population and is very short of care for the elderly. It was estimated that 100,000 new carers will be needed by 2010; as the recession has caused much unemployment and 3 million are jobless, an attempt is being made to train many of these as carers for the old.
What of the future? The charity Age UK has an agenda for later life. Age UK is in partnership with over 300 local Age UK organisations and the overall budget is around £400 million, of which about £250 million involves these local organisations. They get about £50 million from insurance, about another £50 million from their shops selling clothes and mobility devices like stair lifts, and around a final £50 million from donations. I spoke to their chief executive, Tom Wright:
Age UK has a very simple vision, which is a world in which older people flourish. Our purpose is to help to improve the lives of people in later life. We believe that an ageing society is one of the biggest challenges globally, but there is also an enormous opportunity as an ageing society brings with it decades of wealth, experience and knowledge which at the moment is not always fully appreciated. That is the challenge for us, being the largest organisation focusing on later life in the UK, and we have set out to deal with it. There are five important areas: money matters, wellbeing, care at home, work and education, and finally leisure.
At present the most important is care. Living in your home is an area the government have not fully got to grips with. We campaign on all these issues and it is based on sound research and we have several hundred forums with older people around the country where we continually get feedback on issues that are affecting older people, day in, day out. And then we employ some of the experts in the different disciplines which allows us to go to the government and business with the best knowledge about the issues and to work with them to develop solutions.
Many of the issues are interrelated but care and wellbeing is a very significant one. Wellbeing affects health and evidence from the research we do shows that activity helps in later life and prevents cognitive decline and depression, and can lead to less care having to be given. The new government has picked up on many of the manifestos and ambitions that we have sent to them. Before the election we laid out for all the parties what the key priorities are, and many of these have been retained by the new government. All the indications are that it includes getting rid of compulsory retirement at the age of 65. There will also be prevention of erosion of state pensions. They are putting forward a care commission to look at these issues.
We do not focus on the illnesses like dementia and cancer that affect later life, but on the quality of life. We do work on cognitive decline and how mental abilities change. There is a study by the University of Edinburgh on a cohort of 1,000 in Scotland starting in 1947 from the age of 11. We do a lot of work on incontinence, which is an area that others are less likely to focus on, particularly infections of the bladder which are key contributors to incontinence. The tests for incontinence are not sufficiently given, and incontinence is also linked to dementia. We are concentrating on improving later life rather than extending life. We do not take a strong position on euthanasia one way or another.
There is a sense that the old are put in a box labelled ‘old’ or ‘aged’ and there are many cases in medicine where the old do not get the necessary care because the condition is claimed to be age-related. A person going to a doctor, for example, and saying that he has a bad knee, the doctor would say that’s because you are old, and the person would say that his other knee is fine. With regard to care in the community, younger people get much higher budgets than older people. There is at times a lack of respect for the experience and knowledge of the old.
Another important issue is that there are over 2 million older people living in poverty. And many would be pulled out of poverty if they took the benefits they were entitled to. This is partly due to the complexity of the process and the forms that need filling in. Half of those over 75 live alone and do not have someone to help them with this. We would like auto-enrolment which means that the government would automatically give you your entitlement. It is a complex area.