Health systems are still not prepared for an ageing population
Today’s post is by Francesca Colombo, Head of the OECD Health Division
That population is ageing across the world is well known. As fertility rates drop and life expectancy improves, a bigger share of the population is greying. At least one in four people will be aged over 65 by 2050 in about two-thirds of OECD countries. The share of those aged over 80 years will more than double, from 4% in 2010 to 10% in 2050. In Japan, Spain and Germany, this trend will be even more pronounced, with the proportion of the over-80s expected to triple, rising from 5% to 15% in Spain and Germany, and from 6% to 16% in Japan. The speed of ageing will be even more dramatic in some emerging economies. China, for example has taken only 40 years to increase life expectancy from 40 to 70 years, something that took Germany 80 years.
Such a demographic shift has an impact on societies and economies. The size of the workforce will shrink, putting pressure on governments to reform labour markets, pension entitlements and retirement age thresholds, so that older people can remain productive and employed longer. We’re already seen employment rates of older people improving over the past decade in many G20 countries. Rising education levels and skills will help more people work for longer periods of time, although differences in opportunities throughout individual life-course trajectories will affect their ability to remain fit for work as they grow older. The experience individuals gain through education and work will help to raise productivity and keep economies growing as populations age.
In the face of the speed of population ageing, though, our health systems are still too slow at reforming and remain ill-prepared for the consequences of greying societies.
The health care delivery model prevailing today has not kept pace with the changing epidemiology and health needs of the population. The focus often remains on building new hospitals, buying expensive new equipment and upgrading acute service delivery structures. The management of care processes remains to a large extent focussed around episodic care needs. However, population ageing requires a different approach, involving a shift from acute, episodic and hospital centric care to the management of chronic conditions, the delivery of continuity of care across different care settings and providers, and a strong role for primary care professionals such as general practitioners.
A main challenge will be the management of complex combinations on chronic conditions. In many OECD countries, more than half of individuals aged over 65 have more than one chronic condition, and from age 75, many people will have three or more. Health and social care systems are still grappling with how to manage the diversity and uniqueness of this complex combination of diseases and care needs in an effective way, in relation to how to organise care teams, how to identify the right measurement metrics, or how to equip health professionals with the skills they need to address changing population structures and epidemiological profiles.
A compelling example of how health systems struggle to respond adequately to the rising complexity of population ageing is dementia. Dementia affects a growing number of people worldwide – currently estimated at 47 million but expected to rise to 76 million by 2030. In the OECD, France, Italy, Switzerland, Spain, Sweden and Norway have the highest prevalence rate, with 6.3% to 6.5% of the population aged 60 years and over now estimated to live with dementia. For a person affected by dementia, the outlook is pretty grim. For a start, there is no cure as yet nor disease-modifying treatment. Several clinical trials have failed miserably in the past. There is hope that international processes – started with the G7 Summit in London in December 2013, continued with G7 Legacy Events during 2014 and ending with an international Health Ministerial Conference hosted by the WHO with the support of the UK government and the OECD in Geneva in March 2015, will bear some fruit.
But beyond changing incentives for public investment in research and encouraging private investment to finding a cure, the lives of people living with dementia remains poor in most countries. This must change through training doctors and caregivers, and equipping them with better tools to assess the needs of people with dementia; facilitating improved care co-ordination, particularly across health and social care services; and encouraging a better focus on measuring outcomes for people with dementia (such as quality of life, safety of services and medical products, effectiveness and responsiveness), as well as for the many families and friends who look after people with dementia. OECD work has shown 10 basic features that would make a differences, ranging from minimising the risk developing dementia to unleashing the potential of technology to support people with dementia, and helping people die with dignity.
Underpinning some of the difficulties of health systems in addressing population ageing is a failure to understand and monitor adequately the care processes through the data we have today. In an era of ‘big data’, health systems remain poor at using the massive amount of administrative, clinical, population-based, and biological data that are routinely generated from the millions of contacts individuals have with different parts of the health system. Most often, such contacts remain unrecorded; or records are paper -based, not standardised, nor shared across the care pathway. To improve care for old patients with complex care need, we need these data to be stored and linked so as to display a more granular picture of the quality of the care delivered to patients, especially those affected by chronic or multiple chronic conditions. Addressing weaknesses in the governance of this data infrastructure, including through generating better outcome measures to monitor care delivery and through enabling a privacy respectful use of personal health data, will be key priorities for the future.