On Sunday, Baroness Greengross had a letter published in the Sunday Times (22 January) which highlighted one of our recommendations, i.e. if we are going to encourage more younger people into a savings habit, perhaps we should look to introducing a savings rule of thumb similar to the “five-a-day” healthy eating message.

Additionally, this week we heard that the new Chief Executive of the ABI is interested in another of our recommendations, i.e. the idea of greater pension flexibility (for example, allowing younger people to draw down their pensions when they need to). Saga have backed this call.

As a relevant aside, there is an interesting and recently posted TED lecture by Daniel Goldstein which talks about how we can nudge people to save. Take a look.

Perhaps they have all been reading the ILC-UK report?

David Sinclair

1. Resuscitating Retirement Saving http://www.ilcuk.org.uk/index.php/publications/publication_details/resuscitating_retirement_saving_how_to_help_todays_young_people_plan_for_la

The Wall St Journal [2] recently commented on the dramatic response of the new unelected Italian Government to Italy’s economic crisis, the centrepiece of which is a significant increase in retirement age. This year, Italy’s retirement age of 65 years will be extended to include women, but only in the public sector. For women in the private sector, the age will rise steadily from the current 60 years to 65 and eventually higher. The revised statutory retirement age (SRA) as of 2013, is 66 years and three months (13 months higher than Germany). By 2046 Italy’s SRA will be 69 years and 7 months.

Due to legacy programs from previous decades more than half a million Italians will spend half their lives receiving pensions. Some half a million Italians began receiving public pensions before turning 50 years old, and 240,000 did so before turning 45. The pensions in question represent an outlay of €9.5 billion a year, more than those of people who work until 65. But their real cost is even higher as beneficiaries of schemes begun in the 1970s and 1980s spend 48% of their average life span receiving public money, the total cost of the legacy schemes to €149 billion. In 2009, 23.8 million Italians were receiving pensions, amounting to €253 billion or 16.7% of gross domestic product that year.

Elsewhere, the Washington Post [3] reports on a poll, conducted during the first days of the new government, which finds that 93% of Italians polled said reducing the public debt was either an “extremely” or “very important” goal for the government to tackle and only 2% said it was “not too important” or “not at all important.” Despite apparently prioritising cutting the country’s public debt, few Italians are willing to make personal sacrifices, like retiring at age 67 instead of 65. Indeed, only around a quarter of Italians favor reforming labor laws to make it easier to fire workers, or raising the retirement age — considered critical to curb Italy’s public spending and boost economic growth.

Italy is in a serious position because it has one of the highest older to younger population ratios in the world. In 2010 20.2% of the population was 65 years and over. [4]. Moreover Italians are healthier than most other nationals and live longer. Male life expectancy at 65 is the 4th highest in Europe, mortality rates from all causes of death are the 2nd lowest and Italian smoking and alcohol consumption rates are lower than the EU average [5]. While total Italian health expenditure per capita, public and private, was €2463 in 2008, very close to EU average, total health expenditure as a share of GDP was 9.1% (the EU average was 8.3 %). Thus with a population of 60 million, comparable to Germany France and the UK, and higher health costs, the combination of longevity and physically healthier people has very significant implications for their economy. Just looking at one condition associated with old age gives a very good indication of what Italy is facing. In 2006 the prevalence of dementia in the Italian population aged 30 years was 1.7%, the 2nd highest in Europe. This dementia incidence is expected to increase, piling even more pressure onto a creaking health system.

The rest of Europe and the world can only watch and see if this experiment in using increases in retirement age as a proxy for austerity is successful, or if as many commentators suspect the ensuing social stresses will prove so huge that they overwhelm Italy’s already delicate democratic institutions.

Peter Barnett

1. Retirement Age. An ILC Global Alliance Circular, March 2011
2. Italy’s Baby Retirees Leave Costly Legacy. Wall St Journal, 28th Oct. 2011 & Italy Pledges Fast Change To Raise Retirement age: Christopher Emsden, WSJ, 15th Nov. 2012
3. Cutting debt a top priority for Italians, but few want to raise retirement age, ease labor law. Washington Post, 23rd Nov. 2011
4. The World Factbook. CIA 2001 ISBN 1574883461
5. Health at a Glance: Europe 2010. Eurostat – OECD, European Union, Dec 2010

As is often the case poor nutrition and hydration has once again hit the headlines this week, but unfortunately not to support the NPSA’s excellent campaign. The Daily Mail asked the Office of National Statistics to provide figures for the number of deaths in both NHS and privately run hospitals where malnutrition and dehydration was reported as a ‘direct cause’ or a ‘contributory factor’.

The figures show that in 2010, 1,316 deaths, an increase of 24 on the previous year, were linked to or directly caused by dehydration and malnutrition. These figures are higher than in 2000, when 862 deaths were recorded. There is no doubt that these figures will be shocking to many. The prospect of any deaths being related to the basic requirements to human life of food and drink is appalling. The article notes that a further 812 patients died with dehydration and another 301 with malnutrition, although this did not directly cause their death.

However, these figures only tell us part of the story and raise the question of whether increased awareness of nutrition and hydration issues in hospitals has led to better recording, or if we are failing in our efforts to address the fundamentals of care. In some circumstances patients at end of life refuse food and drink making care a difficulty. Patients with Alzheimer’s or advanced forms of cancer can really struggle to eat and drink. More importantly the figures also do not take into account the large numbers of people experiencing malnutrition and dehydration in their own home.

As a result we do not get a full picture of what is really happening. It is likely that the figure is in fact a gross underestimate of the extent of malnutrition and hydration.

Those living unnecessarily with malnutrition/dehydration who remain at risk of preventable illness and death need our support. The figures on dehydration are less clear; there are no exact figures on the hydration status of the general UK population, but research into malnutrition suggests 1 in 10 people aged over 65 are malnourished and living in their own homes (ENHA, BAPEN, ILC-UK; 2006). Hydration and nutrition are individual issues and must be treated as such, but are in turn inextricably linked, both to each other and the overall health of the individual. Integrated care is key to ensuring the best possible care opportunities are met for all.

Clearly, anything that highlights the importance of hydration and nutrition can only be a good thing, but we need to then follow the numbers up with demonstrations of what good policy and practice can and do achieve. There are many examples of areas where local solutions have transformed the patient experience (as seen in Cornwall, Dorset, West Midlands and Harrogate, to name a few) and where national policy makers should be taking note to ensure this issue remains a priority area.

Clear, firm and relevant national nutrition and hydration policies need to be put in place to ensure that all patients have universal access to the most appropriate care for their needs. Many organisations are already able and willing to support this development are stuck waiting for policy makers to take this step. Developing policy around integrated care would be one step towards the whole person approach which is sorely needed. Policy makers need to learn from the positive outcomes in successful areas and better understand the basic need to enshrine good nutrition and hydration practices in care.

Find out more at: http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-news/nutrition-and-hydration-week

Lisa Wilson

Social care is currently in crisis and is letting people down. Across England eligibility thresholds are being restricted, charges are increasing and services squeezed.

Currently around 800,000 older people in need of care and support don’t get any formal help. This shocking figure shows just how serious the crisis has become.

For those people able to access services, the support they receive is too often inadequate or poor quality leaving them without the care they need to live safely and with dignity.

Without urgent action this crisis will continue.

So last week Age UK launched its Care in Crisis campaign and petition urging the Government to grasp this opportunity for far-reaching and sustainable reform of the care system.

So what exactly are the issues?

• The system does not provide support for those that need it: In 2011-12, nearly 80% of local authorities have set their eligibility threshold for adult social care at ‘substantial’ and a further 3% set their threshold at ‘critical’, meaning that hundreds of thousands of people who don’t meet these criteria are missing out.
• The system is unfair: there is a postcode lottery for care. Eligibility varies depending on where you live and there is no portability if you move between local authorities.
  The system makes it impossible to plan ahead to meet future care needs: people do not know what to expect from the state or understand what they are personally responsible for. Without any idea of how much it could cost, no-one is able to plan ahead.
• The system often leaves people with undignified care: too often, there are stories of people being left unfed, unclean and ignored. Older people regularly tell us they feel invisible and what they want and need is not taken into account.
  The system is complex and difficult to understand: information and advice is poor and the current legal framework surrounding care is complex and confusing. Too often services do not join up.
• The system is under-resourced: there is not enough money available to provide good quality care. This situation is likely to get worse while local authorities seek to balance their budgets by cutting social care at a time when demand for services is only going to increase. From 2010 – 11 to 2011 – 12 older people’s social care expenditure was cut in real terms by £331 million (4.5%), this is despite the government providing additional money for care in the 2010 Comprehensive Spending Review.

These are not challenges for the faint-hearted. We need to fundamentally redesign the system to make it reliable, fair and sustainable. A few tweaks here and there are not going to solve the problem or give people confidence in future services.

So we are calling on this Government to be the one to achieve successful reform where all others have failed. Key to success will be political consensus on the way forward, an understanding of the nature and scale of the problem, and a willingness to invest.

And what do we want care to look like in future? Age UK has set out seven key building blocks for reform. In the future we want all older people to confidently say:

1. I receive the care and support I need and there’s no chance I’ll be left without it
2. I receive high quality care and support
3. The care and support I receive enables me to live safely and with self-respect
4. I am able to plan in advance before I need care
5. I am able to pay for my care in a fair and transparent way
6. I find the system clear and easy to understand
7. If I have a family member or friend who acts as a carer they have the support they need and are not expected to sacrifice health, career, social life or future economic security

Age UK’s Care in Crisis campaign has kicked off with a call to sign our petition. We’re aiming for 100,000 signatures in support of care reform – an important indicator to David Cameron and his Government that thousands of people care about care.

I know when I’m old that I will want to be able to say those seven things about care. I’m banking on the care system being there to support me and my family. Is that what you want as well? Sign our petition at www.ageuk.org.uk.

Elizabeth Feltoe

This growth in numbers of older prisoners is also partially attributable to the impact of new technologies such as DNA profiling in securing convictions for old, unsolved crimes. A number of older prisoners are currently doing time for crimes committed decades before.

Dying Inside makes the point that owing to general poor health and lifestyle differences, prisoners experience accelerated ageing. This group has comparative health levels with those up to ten years older. Consequently, ‘ageing’ prisoners are often grouped as those aged over 50. Despite the growth in numbers of this group and the additional needs as a result of poor health and the ageing process, there is no national strategy for older prisoners.

The programme also explores how prisons should respond and cope with the demand for space and the need for better facilities for older prisoners with increasingly complex needs. In Dying Inside, we hear the view from a couple of prisoners that as such a long period has passed since their crime was committed, and they are no longer physically fit, that they should no longer be considered a threat and therefore do not need to be imprisoned.

On the face of it, this could seem like an idea with potential. Use of home arrest and electronic tagging as an alternative to custodial sentences would remove a section of the prison population with greater needs (and therefore higher costs to the Prison Service). Additionally this could help to alleviate the unequal ‘double punishment’ reported of older prisoners carrying out their sentences as well as coping with inadequate facilities and care provision.

However, the equality argument runs both ways and the penal system has to remain retributive, with equal treatment given to all who pass through it. It should be noted that 40% of male prisoners aged over 50 have been convicted of sex offences [2]. As such, leniency and community sentences may not be appropriate for this considerable portion of the population, considering both public and offender safety issues.

This does not resolve the issue of older prisoners who are also dealing with potentially complex health problems during their incarceration. If we are to ensure that ageism is not taking place behind prison walls, it is vital that appropriate care is provided and older prisoners do not suffer doubly.

Jessica Watson

[1] Dying Inside, BBC Radio 4 This programme is available on iPlayer.

[2] Bromley Briefings: Prison Factfile July 2010

But despite all these positive developments, some worrying signals remain. The reality, as highlighted by ECDC, is that perhaps we are becoming complacent about immunisation. For example, there were several significant outbreaks of measles, an extremely serious potentially life-threatening disease in adults, in EU countries during 2009. This was a clear marker that Europe was on track to miss its target of eliminating measles by 2010. Outside Europe a quick “Google news” search highlights measles outbreaks in Canada, the United States and New Zealand.

So even in the developed world, let alone the developing world, these diseases are by no means defeated. OECD included influenza in its 2010 Health at a Glance: Europe 2010 report [2] and noted that the highest influenza morbidity and mortality occurs among the elderly and those with chronic conditions (e.g. 85-90% of people who die from influenza in France and Germany are over 65 years of age). In their report, ECDC noted that in the 2008/9 influenza season a severe outcome was associated with increased age and the presence of at least one underlying medical condition. If sustained, these changes in risk patterns for severe influenza may result in a change in thinking about who should be offered immunisation in terms of age and risk profile.

In the USA, vaccination against chickenpox/shingles has become routine and cases have dropped by 80%. US researchers found that the Zoster vaccine reduced the occurrence of shingles by about 50% among persons age 60 years and older. The vaccine is most effective for those age 60–69 years (64%) and effectiveness declines with increasing age. Despite these outcomes this vaccine is not used in the UK to prevent shingles, apart from those at risk in a health work setting. In January 2010, the government advisers on vaccines recommended the vaccine to those aged 70 to 79 [3]. The UK Department of Health calculates that up to four million people might be immunised and further progress with a UK vaccination programme is dependent on negotiating a “fair price”.

Over the last few years, ILC-UK has been studying and developing the case for adult immunisation both in the UK and internationally. In 2009 an ILC Global Alliance paper [4] found there is a gap between recommendations for vaccination among older persons and actual vaccination rates in Europe. At the same time an ILC Global Alliance immunisation policy brief [5] noted that as well as children, older persons require immunisation as well. Vaccines can prevent the onset and/or consequences of serious, often deadly, diseases including influenza; pneumococcal disease; chickenpox and shingles (varicella and herpes zoster); and measles, mumps and rubella (MMR).

In the interim, if anything the pace seems to have slowed in terms of investment in education and immunisation practice for older people and so it may be time to revisit this issue and reinforce the message. It appears that, along with other health programmes, immunisation is suffering from recession-induced health cuts. An important policy question for us here in the UK is if a shingles vaccination programme were in place, has a ‘value’ been calculated for the ensuing reduction in suffering and economic and social cost, which would be borne by those who would otherwise develop symptoms.

Let us know about vaccination policy in your country:
• what is happening with vaccination where you are;
• are you satisfied that not only are the appropriate policies in place;
• that they are being correctly implemented and monitored?

Peter Barnett

[1] Annual epidemiological report – Reporting on 2009 surveillance data and 2010 epidemic intelligence data ECDC Surveillance report 2011
[2] Health at a Glance: Europe 2010 OECD, European Union Dec 2010
[3] BBC News Sunday, 31 January 2010
[4] Life Course Vaccination. Impact of Life Course Vaccination on an Ageing Population. Alliance for Health & the Future at the ILC. Policy Brief Volume 4 Number 1, Nov. 2009
[5] Immunizations—Not Just For Kids, Harrison Bloom, M.D. ILC Global Alliance Policy brief. Oct 2009

Over the next few months (kindly supported by the Nominet Trust) we will be exploring the role of behavioural economics in relation to the continuing digital exclusion faced by many older people.

The latest (November 2011) Internet Access Quarterly Update [1] highlights the scale of the challenge ahead. By the third quarter of 2011, 8.43 million adults had never used the Internet. While 98.6% of 16 to 24 are Internet users, just 27% of those aged over 75 have ever used the internet.

And whilst many highlight increases in online activities by older people, progress is actually very slow. Between the first and third quarter of 2011, the percentage of 65 to 74 year olds who have ever used the internet grew from just 57.1% to 58.7%. This growth amounted to just under 40,000 fewer people in this age group who had never used the internet.

We learnt more about internet usage and age in the ONS report, Internet Access – Households and Individuals [2], published in late August last year.

The statistics revealed that:
• Older people haven’t caught the social networking bug. Whilst it is a popular activity for 91% of 16 to 24 year old internet users, only 18% of over 65s participated in social networking.
• 5.7 million households have no internet access
• We have seen significant growth in mobile internet access which may be creating a new digital divide. 71% of 16-24 year olds use mobile internet compared with just 8% of those aged 65 plus.
• There remains a significant gender gap in internet use. Men aged over 75 are almost twice as likely to have ever used the internet as women of same age (21.6% cf 35.2%)

Our piece of work will attempt to take a new approach to explore what we can do to get people online. Put simply, should we compel, educate, or nudge people online?

We know that 32 million people (66% adults) have purchased goods over the internet. But we seem to buy different things online as we age. The most popular internet purchases for over 65s are travel related. Perhaps this emphasises the importance of compulsion. Buying travel tickets can be very difficult if you don’t do it online.

At the same time, older people are more likely than other ages to confess to lacking skills. Those aged over 65 are twice as likely than 16-24 year olds (29% compared with 15%) to claim they don’t have the skills to protect personal data online. 23% of those aged 65 plus claim their computer skills are not proficient to protect themselves from viruses (compared with 14% of 16 to 24 year olds). So perhaps the key remains in education. But if so, how can we deliver it in a cost-effective way when funding for adult learning is thinly stretched?
Or are there other approaches we can learn from behavioural economics. Can we find new and innovative ways to nudge people online?

Our view is that this shouldn’t be an issue we ignore. So should we force, educate or nudge people online? What do you think?

David Sinclair

[1] Internet Access Quarterly – Office of National Statistics
http://www.ons.gov.uk/ons/rel/rdit2/internet-access-quarterly-update/2011-q3/art-internet-access-q3.html

[2] Internet Access – Households and Individuals, 2011
http://www.ons.gov.uk/ons/rel/rdit2/internet-access—households-and-individuals/2011/stb-internet-access-2011.html

Cacciopo argues that within the world of retirees, those feelings of social isolation are lowest and wellbeing is highest among those who remain socially active, healthy and who continue to interact with friends and former co-workers. How can the remainder, who sometimes feel extremely isolated, come to share in a similar enduring social capital substitute which may go some way to replacing that of the long gone ‘village’ type community?

Importantly Cacciopo reminds us that rather than constituting a societal burden, the higher proportion of older adults in our societies has the potential to become a unique and valuable resource on which to build mutually beneficial intergenerational connections. He argues that longer lifespans and intergenerational interdependencies offer families, communities and societies a sound way forward, as do policies that promote not only longer, but also healthier and more productive lives.

Plainly human wellbeing, unlike health, is very much a product of reality: where you have been, where you are now and your perceptions of both, including the comparison of your own lot versus your neighbours and peers. In modern times our awareness of our neighbours situation, experiences and predicaments have been greatly increased by technology. Social networking, once the domain of family and local community influence, has gone global and online, 24 hours a day. The downside is that individuals are exposed to, and therefore have to cope with and manage, fewer personal social connections in the traditional sense. Committed, enduring social identities, often few in number, are being replaced by many more, shorter-term collaborations resulting in a weakening of social bonds. Technology is, and will continue to be, a strong driver for economic and social change. For many of us communication is increasing, at least in quantity if not in quality but some, possibly amidst a cacophony of noise, are experiencing increased isolation.

Is there a solution? In an increasingly globalized world, what is required is a human-centred global perspective that recognises the central and essential contribution of social identity to human economic welfare and social capital. Recently, Steve Jobs, the pioneer of IT for personal use, sadly passed away. Amidst the many valedictory comments was a mention of his 2005 Stanford University Speech [2] in which he famously said ‘Don’t let the noise of others’ opinions drown out your own inner voice… have the courage to follow your heart and intuition. Policy makers need to foster and encourage mutual support without discouraging entrepreneurship.

In the UK David Cameron would argue that in its simplest form that is what his ‘Big Society’ is all about; employing a more local approach to social action, rights and responsibilities; enabling communities to feeling empowered enough to solve problems in their neighbourhood and having the freedom to influence and discuss topics that matter to them. In our communities, we can get through this economic downturn if everyone, of all ages, works positively alongside one another. We either swim together and fulfil our hopes and dreams – or drown sadly alone!

Peter Barnett

[1] Lonely planet, John T Cacioppo, RSA Journal, Autumn 2011
[2] Commencement address delivered by Steve Jobs, CEO of Apple Computer, At Stanford University on June 12, 2005

Yet the question of whether employees aged above state pension should be exempt from NICs is an increasingly contentious issue. The exemption is arguably a form of subsidy for older workers, which impacts on employment opportunities for young people. Given that people are living much longer than anticipated by the architects of the National Insurance system, and in many cases are physically able to work significantly beyond state pension age, it may be that NICs should be paid by all employees, irrespective of age, reflecting the fact that we will be receiving the state pension for a much longer period of time.

A survey recently commissioned by ILC-UK, with the support of Aviva, suggests however that there is strong opposition to people above state pension age, yet still in work, paying NICs as well as income tax – two-thirds of people would oppose the change. Remarkably, opposition seems to be strongest among young people. It should be noted that survey respondents aged 16-24 were the least likely to oppose the idea, although 6 in 10 of this age group nevertheless argued against the proposal. Furthermore, the 25-34 age group were the most likely to oppose the proposal: 74 per cent argued against the idea (compared to 67 per cent, 68 per cent, 70 per cent and 64 per cent, respectively, for the 35-44, 45-54, 55-64 and 65+ age groups).

The above figures suggest another remarkable finding, that is, that the 65+ age group are the most likely to support the proposal. 1 in 3 people aged 65 or over agree that workers aged above state pension age should pay NICs; only 1 in 5 of the 25-34 age group support the proposal.

What explains these results? We can speculate that the high level of support, relative to other age groups, among the over-65s is due to the fact that most of this age group have already retired from work – and so believe that those among them still getting an income from employment should not be exempt from any tax. They will, after all, be far more worried about the economic prospects of their own children and grandchildren, than their fellow over-65s.

The results for the 25-34 age group are perhaps more difficult to explain. While there may be a degree of ignorance about how the tax system works among young people, this would not explain why the 16-24 age group is among the most likely to support the proposal. A lifecourse-based explanation may be helpful. Firstly, National Insurance is based, fundamentally, on a contract between the generations. Secondly, people aged 25-34 are far more likely to be in work than those aged 16-24. It may be that it is among the young, as they embark upon their careers that support for the intergenerational contract is strongest. They are engaging meaningfully with the tax system for the first time, and develop an appreciation of the intergenerational contract that necessitates why they are paying NICs as well as income tax. While opposition to the proposal is also evident among older age groups, it dissipates to some extent as the financial burdens of family-formation and home-ownership kick in, meaning we become more selfish as generations.

Just a thought. Intergenerational attitudes to the intergenerational contract is an issue we know relatively little about; more research would be very much welcome.

Craig Berry

The survey results are presented in full in the ILC-UK report ‘Gradual Retirement and Pensions Policy’. Click here to download a copy.

The argument for future-focussed medical training is that for the most part, current medical training is “geared up to a world where it’s all about young people”[2], whereas the future healthcare needs of an ageing population will require a greater amount of attention and care to be given to older people. In particular, treatment for older people with more than one chronic disease will become the norm. As such, training for future healthcare professionals needs to adapt to the demographic they will be treating once qualified, and the common issues for that group.

There has been an historic reluctance to focus on ageing in medicine, and it is an issue often left solely to geriatricians. The Economist Intelligence Unit report suggests the inclusion of specialised education in ageing health during doctors and nurses’ training. Perhaps there is also an argument for the despecialisation of geriatric medicine alongside this improved education for other medical streams. If the majority of patients to be treated are going to be ageing, why should the majority of the staff treating them not be trained in ageing health? Having old age-specific medicine as part of the mainstream of a traditional medical education more closely reflects the needs of future patient demographics.

It need not be the case to throw out the wealth of knowledge and experience of the geriatric field, but rather to ensure a full understanding of ageing health by all medical professionals regardless of field or specialism. In this way we can ensure that our medical staff are fully prepared for the patient demographic challenges that lie ahead.

Jessica Watson

[1] A new vision for old age – Rethinking health policy for Europe’s ageing population, The Economist Intelligence Unit http://www.businessresearch.eiu.com/sites/default/files/downloads/A%20new%20vision%20for%20old%20age_0.pdf
[2] Professor David Oliver, quoted in A new vision for old age, p.8