4. MORTALITY, LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY
- The annual number of deaths in Scotland in 2009 (53,856) was the lowest ever recorded.
- Reduced mortality in relation to the "3 big killers" collectively has been notable.
- Life expectancy at birth in Scotland stands at 75 for men and 80 for women.
- Healthy life expectancy is increasing but not at the same rate as life expectancy.
- Health inequalities in Scotland result in significant variation in mortality, life expectancy and healthy life expectancy, with deprivation being a key determining factor.
4.1 Reduced mortality has been an important factor in Scotland's population growth in recent years. This section looks at the related issues of mortality, life expectancy and healthy life expectancy in Scotland, and the implications of a population with increasing numbers of people living longer lives. There are, of course, clear links to the previous section which looked at ageing and the changing age balance in the population, as the implications of an ageing population are often articulated in terms of the implications of increasing numbers of older people.
Mortality trends in Scotland
4.2 Mortality, a key determinant of population change as one factor in natural change, has been decreasing in Scotland in recent years (see Figure 9). The number of deaths recorded in 2009 (53,856) was the lowest recorded since civil registration began in 1855, and represented a drop of 3.3 per cent on the previous year. There has been a downward trend in annual deaths since the 1990s, following a period of relative stability since the 1950s. Linked to the overall reduction in mortality, the average age at death has been increasing in Scotland, meaning that people have been living longer.
Figure 9: Deaths in Scotland (1951 - 2009) (thousands)
4.3 More than half of all deaths in Scotland in 2009 were as a result of the "3 big killers" of cancer, heart disease and stroke. There has, though, been a notable reduction in mortality in relation to the 3 big killers collectively (reducing from 41,000 in 1980-82 (average over 3 years) to 28,000 in 2009), with such deaths now accounting for 53% of all deaths, down from 65% in 1980. However, this overall reduction masks the fact that the mortality rate for cancer has in fact increased over the period, while the rates for heart disease and stroke have fallen.
4.4 Despite these improvements, Scotland fares poorly against the rest of the UK in relation to mortality. Calculations of standardised mortality ratios 22 for Scotland and the UK, show Scotland to have a figure significantly higher than that of England (about one sixth higher). In relation to Europe, Scotland's crude death rate (deaths per 1000 population) is higher than all other EU15 countries ( GROS, 2010).
Life expectancy and healthy life expectancy trends in Scotland
4.5 Life expectancy has been increasing in Scotland over recent decades. Figures for 1980 give life expectancy of 69 and 75 years for men and women respectively; for 2008 the figures now stand at 75.3 and 80.0 years respectively (Scottish Government, 2010). As with mortality, there is a persisting gap between life expectancy in Scotland and other countries in Europe; men in Scotland can expect to live 4 years fewer than men in the best performing EU countries, with women living almost 5 years fewer ( GROS, 2009). Scotland also lags behind England which has life expectancy of 77.5 years for men and 81.7 years for women; comparative figures for Scotland stand at 74.8 years and 79.7 years ( ONS, 2010). There is no sign of the gap narrowing between Scotland and UK or Scotland and EU15 life expectancies.
4.6 Healthy life expectancy in Scotland has also been increasing, but not at the same rate as life expectancy and the gap between life expectancy and healthy life expectancy has, for men, actually been widening. The latest data indicates healthy life expectancy in Scotland to be 68.1 years for men and 70.8 years for women (Scottish Government, 2010). When looked at in conjunction with life expectancy, men and women can currently expect to spend around 7 years and 9 years respectively in poor health (Scottish Government, 2010). While HLE has increased in Scotland, the gap between life expectancy and HLE has not closed; comparisons with 1980 data shows the gap between life expectancy and HLE has remained unchanged for women and has in fact increased for men (from 6 years to 7 years) (Scottish Government, 2010) 23. So, although people in Scotland are spending more years in good health (in line with the population target), the number of years spent in poor health has not decreased.
Health inequalities in Scotland
4.7 Despite the improvements in mortality, life expectancy and healthy life expectancy, it should be noted that the all Scotland figures mask significant intra-country variation. On a geographic basis, men and women in rural Scotland (remote and accessible) can expect to live longer than those in large urban areas (around 3.5 years and 2 years more for men and women respectively) ( GROS, 2010). Gender differences have already been noted; in addition socio-economic status, ethnicity and disability are all identified factors, and are reflected in the geographic variation apparent across Scotland. For example, the standardised mortality ratio in Scotland ranges from 27 per cent higher than the Scottish average (in Glasgow City, with some of the highest levels of deprivation in Scotland) to 23 per cent lower than the Scottish average (in East Dunbartonshire) ( GROS, 2010). In relation to life expectancy, Glasgow City has the lowest male life expectancy at 71.1 years ( GROS, 2010i); at the other end of the scale, East Dunbartonshire has male life expectancy of 78.3 years 24. This geographic variation is illustrated in Figure 10 which shows the life expectancy at birth for males and females in local authority areas in Scotland. A similar pattern is evident for women, although the gap between highest and lowest life expectancy is not quite as great.
Figure 10: Life expectancy in Scotland (2006-8) (males and females)
Note: The figure above shows life expectancy based on 95% confidence intervals. Life expectancy at birth is an estimate which is subject to a margin of error. The accuracy of results can be indicated by calculating a confidence interval which provides a range within the true value underlying the expectancy would lie (with 95% probability).
4.8 Differentials in healthy life expectancy are even more marked. Analysis based on deprivation quintiles shows that HLE for males in the least deprived quintile is 15.8 years more than in the most deprived quintile. A similar pattern was evident for women with a 15.2 year differential. In relation to years spent in poor health, the differential was greatest for women. Men in the least deprived quintile spent 6.2 years in poor health, compared to 10.1 years for those in the most deprived quintile; the comparative figures or women were 6.2 and 14.2 years ( GROS, 2010ii).
Implications of increasing life expectancy
4.9 While there are implications - both positive and negative - across all policy areas (including, eg, housing and transport) related to increased numbers of older people in the population as a result of increased life expectancy (see Section 3, Population Ageing), this section concentrates on the areas of health and social care, and caring. These are particularly key, given the persisting gap between life expectancy and HLE.
Implications of increased numbers of older people for health and social care in Scotland
4.10 The increasing numbers of older people have implications across a range of policy areas, but a key area (particularly given the increasing number of years that people spend in poor health) is that of health and social care. Figures from the Scottish Health Survey ( SHeS) for 2008 show that self-assessed health declines with age. For example, 61% of men aged 65-74 and 55% of men aged 75 and over rate their health as good or very good compared to 76% of all men. Similarly, 12% of 65-74 year old men and 17% of those 75 and over rate their general health as bad or very bad compared to 7% of all men. A similar pattern is evident for women. The same survey shows the percentage of people (men and women) with a long term condition (limiting or non-limiting) to increase steadily with age. One particular condition with a clear age dimension is dementia. Figures included in Scotland's National Dementia Strategy (Scottish Government, 2010) indicate that while 1.5% of the 65-69 age group are affected, this increases to around one in 3 for those over 90, and the number of people with dementia in Scotland is expected to double over the next 25 years.
4.11 In line with the findings on self reported health, research shows that use of health care services, and health care costs, increases with age, and that, thus, greater numbers of older people in the population will place increasing demands on health services. However, evidence suggests that "proximity to death" rather than age per se is an important determinant of health care use and costs, with health care costs increasing significantly in the final year prior to death 25. Taking this into account will tend to moderate the projected increase in health care expenditure due to the ageing of the population. Achieving improvements in HLE (ie, reducing the numbers of years spent in poor health) will, though, be an important factor in age related health expenditure in the future if the point at which people start making increased demands on health services is delayed. Indeed, in relation to geographic variation, the greater proportion of older people in rural areas suggests higher demand for age-related health and social care services; however, this may be off-set to some extent by more favourable HLE in rural areas. Borders, Orkney, Grampian, Shetland and Highland Health Board areas all score particularly well in relation to HLE26.
4.12 In relation to care services, Scotland is currently unique in the UK in having a policy of free personal and nursing care ( FPNC) for the elderly. The number benefiting from this policy has increased steadily since its introduction in 2002. Over 50,000 older people across Scotland currently benefit from the policy. The latest figures (2008-09) show that around 44,600 people receive personal care services at home without charge. In addition, around 9,500 self funders in care homes receive flat rate payments towards the cost of delivering personal care. Of these people, around 6,200 also receive flat rate payments towards the cost of nursing care. The number of self funders receiving FPC payments in a care home increased by 15% between 2003-4 and 2008-9, while those receiving FPC in the community increased by 35% over the same period. The numbers receiving FNC payments increased by 17%.
4.13 In Scotland, the current economic situation and the resulting pressure on public finances has raised concern about the affordability of policies such as free personal and nursing care for the elderly. The previous UK Administration produced a green paper on the provision of care services, Shaping the Future of Care, highlighting the costs associated with increased demand for care services from an ageing population and the need for a fundamental review of how such services are provided and funded. The coalition government are taking forward three strands of work on social care; (1) the work of the Law Commission 27 on creating a modern statute for social care; (2) work within the Department of Health to articulate their vision of a more personalised and preventative service; and, (3) the independent Commission into the Funding of Care and Support 28. There is strong recognition by all UK political parties that projected costs of social care cannot be met under the current financial arrangements and the independent Commission have been asked to explore all possible options for the future funding of care. The current review of long term care in Scotland, Reshaping Care, is examining issues in relation to the planning and provision of services in Scotland. In general, improvements in data in this area would allow improved Scottish projections relating to the likely needs of the ageing population in Scotland, and consideration of the options of how such services might be provided and funded in the future. However, the UK Government's reserved authority over welfare benefits and taxation restrict the policy levers available to Scottish Ministers to look at options for reforms to the way that social care is funded or paid for.
Implications of increased numbers of older people for caring
4.14 Caring is a key issue in relation to older people in Scotland, with clear links to the broader area of health and social care. Not only do older people represent a significant proportion of those in receipt of care, but they are also important providers of unpaid care. Findings from the Scottish Household Survey ( SHS) (Harkins & Duddleston, 2008) show that a significant proportion of those providing care are older people: a third of those caring for someone within the household are retired, and retired people make up 40% of those acting as sole carers for someone within their household. Census data (2001) shows a similar pattern with the incidence of caring increasing with age; in addition census data also shows the number of hours spent caring also increasing with age. As expected, a high proportion of those in receipt of care are also aged over 65. Numbers in both of these categories (carers and the cared for) are likely to increase as the numbers in the older age groups increase.
4.15 Many elderly people receiving care receive a combination of paid and unpaid care, but the contribution of unpaid carers is crucial to their families, to society and to the economy. Scotland's carers strategy, Caring Together (Scottish Government, 2010), sets out the available evidence base pointing to current and future savings across health and social care arising from effective carer support 29.
4.16 In relation to the introduction of free personal and nursing care for the elderly in Scotland there was concern that the policy would lead to a reduction in provision of unpaid care. However, early research by Bell and Bowes based on analysis of British Household Panel Survey data indicates that this has not been the case. An evaluation of the policy commissioned by the Scottish Government explored this issue further and found that people were continuing to provide care but they were doing so in different ways, providing "non-personal" as opposed to "personal" care. Bell and Bowes found that attitudes to caring for elderly relatives were linked to education and income, with those better educated and on higher incomes indicating less willingness to provide care (possibly because of the greater opportunity costs involved), although a greater likelihood to provide financial help. "Baby boomers" as a group were found to be less likely to believe people should care for elderly parents; this may have implications for publicly funded care if the behaviour of this group proves to be in line with their currently expressed beliefs. The Scottish Government carers strategy is, though, clear that assumptions should not be made about whether people want to or choose to be carers, or about the time that people may be able to give to caring
4.17 Across caring, older people make a valuable contribution to society, and increased life expectancy (combined with the persisting gap with HLE) is a major factor that suggests that the demand for carers will increase in the coming years 30. Currently older people/retired people are important providers of unpaid care, but raising the retirement age and encouraging labour market participation amongst older people may have implications for the availability of such people to carry out caring activities (and, conversely, the wish to provide care for others may result in people leaving the workforce 31).
Positive implications of increasing numbers of older people
4.18 As previously noted the increasing numbers of older people in the population present opportunities as well as challenges, and it is important to recognise the positive contribution that older people make to society in a wide range of areas. The positive economic impacts of changing demographics in Scotland have already been noted, as have the contribution that older people make through caring. In addition to caring for older relatives and others with social care needs, it is also worth restating that grandparents (many of whom will fall into older age groups and/or be retired) are also important providers of childcare (see para 3.17). Thus, this may be seen as one version of the "sandwich generation" where people are caring for relatives in generations above and below them at the same time, with older people potentially caring for elderly relatives and providing childcare for younger relatives at the same time. Volunteering is another area where the positive contribution of older people to society and to the economy in Scotland can be seen. The Scottish Household Survey shows that over a quarter (27%) of those in the permanently retired group are involved in volunteering. Further, just under a third of 60 to 74 year olds (28% of men and 33% of women) volunteer in some capacity. Thus retired older people provide a rich source of volunteers across a range of sectors, with this potential pool of volunteers increasing as the numbers in these age groups increase in coming years, although, again, the raising of the pension age may impact on this available pool.
4.19 The Scottish Government has adopted a positive approach to the increasing numbers of older people in the population, and the 2007 action plan, All Our Futures: Planning for a Scotland with an Ageing Population, set a broad vision for responding to Scotland's changing demography, with activity across the range of policy areas, eg, health, housing, learning etc. The Action Plan highlighted the positive contribution made by older people and how the potential of this group could be maximised, stressing the importance of building on the contribution that older people make to the workforce, to volunteering and caring, and of facilitating links between generations and supporting the participation of older people in all aspects of civic life.
Current issues for policy makers
4.20 The increased number of older people in Scotland's population is a key issue for policy makers. Significant current and future issues include:
- The provision, cost and funding of care services, generally and in the light of Scotland's rural geography.
- The need to achieve accurate projections relating to demand for care services and the likely costs of such services, and to better understand the interaction between different health and social care services, to allow for effective planning.
- Consideration of the opportunities that may be available to influence demand for health and care services by focusing on different types of service provision, where a greater focus on "upstream" interventions and anticipatory care, for example, may reduce the need for more intensive support and interventions later on.
Current policy activity in relation to older people
4.21 Current policy activity in this area falls within 2 broad (interlinked) strands: activity responding to the increasing number of older people in Scotland's population, and activity that aims to promote increased HLE (and thus supporting progress towards the population growth target). Of course, some policy work can be seen to be responding to the increasing numbers of older people in the population and aiming to increase HLE. One example here would be the NHSScotland Quality Strategy which makes specific reference to responding to the challenges of demographic change and supporting people to live longer, healthier lives.
Responding to the increasing number of older people in Scotland
4.22 Work has continued since publication of the action plan, All Our Futures, and important initiatives have been seen across a range of areas. Current policies and initiatives relevant to older people include:
- Free Personal and Nursing Care: This policy introduced free care services to people over 65 who are assessed as having appropriate needs.
- Development of Telecare: The National Telecare Development Programme makes funds available to Health and Social Care Partnerships to provide technology based equipment to allow older people to live independently in their own home.
- Long Term Conditions Collaborative: This programme is working to deliver improvements in patient centred services and changes in the way care is provided for people with long term conditions.
- Scotland's National Dementia Strategy: This 2010 strategy aims to ensure that people with dementia and their families and carers can access services that provide support, care and treatment in a way that meets their personal needs.
- Care Information Scotland: This is a telephone and web service (launched in 2010) providing information about care services for older people living in Scotland.
- Concessionary Travel Scheme: Over 60s in Scotland qualify for free travel on local (and some long distance) bus services.
- Caring Together: This 2010 strategy recognises carers as equal partners in providing care and sets out a series of actions for ensuring that carers are properly supported to manage their caring responsibilities with confidence and good health and to have a life of their own outside caring.
- Older People's Consultative Forum: This forum of older people's organisations was established to increase participation in the policy process in relation to issues relevant to older people.
4.23 Although All Our Futures emphasised the importance of cross-policy action in relation to older people, it is perhaps not surprising that many of the key policies and initiatives noted above have concentrated on the health and social care areas.
4.24 In relation to current policy considerations, Reshaping Care for Older People is a major programme of work designed to engage all interests in reshaping care and support services to ensure that policy objectives are met in ways that are sustainable, given current demographic and financial pressures. The programme initially involved 8 primary work streams looking at different aspects of care for older people, reporting to a Ministerial Strategic Group. It has now entered a period of public engagement with a view to encouraging wide national debate on how care is delivered for older people in Scotland. The publication, towards the end of the year, of plans for the future delivery of care will be informed by views from across Scotland. These plans will also support better integration of data routinely collected by separate agencies in health, housing and social care, to allow improved Scottish projections relating to the likely needs of the ageing population in Scotland, and consideration of the options of how such services might be provided and funded in the future.
4.25 It should be noted that other key polices relevant to older people - retirement age and pensions, age discrimination etc - are reserved matters dealt with by the UK government where significant changes have been proposed (or announced) since May 2010.
Improving healthy life expectancy
4.26 A range of policies - some more health specific and others cutting across a range of policy areas - are designed to improve the health of Scotland's population and further increase life expectancy and HLE, and can be seen to be tackling some of the social, environmental and behavioural determinants of health which contribute to health inequalities in Scotland:
- Early Years Framework (2008): Research points to early years intervention potentially having the greatest impact on outcomes in later life, as recognised in this policy framework. The framework is based on partnership working, and aims to give children the best start in life with an emphasis on early intervention and prevention across the full range of policy areas including education, health and social care.
- Achieving Our Potential (2008): This policy framework aims to tackle poverty and inequality, with their links to health and well-being.
- Equally Well (2008): This report of the Ministerial Task Force on Health Inequalities responds to the variation in health and HLE across Scotland and set out a series of recommendations to tackle health inequalities.
- Towards a Mentally Flourishing Scotland (2009): This action plan aimed to promote good mental health in Scotland, a major component of health and well-being.
- Healthy Eating, Active Living (2008): This Action Plan included a range of initiatives (targeting all age groups) intended to improve diet and physical activity levels and reduce obesity and health inequalities.
- Preventing Overweight and Obesity in Scotland: A Route Map towards Healthy Weight (2010): This is a long term strategy for obesity prevention setting out actions in 4 categories: energy consumption, energy expenditure, early years and working lives.
- Smoking, Alcohol and Drugs Strategies: Scotland's Future is Smoke Free: Smoking Prevention Action Plan (2008), Changing Scotland's Relationship with Alcohol: A Framework for Action (2009), and The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem (2008) all aim to tackle behaviours which contribute significantly to ill-health in Scotland
Current/future evidence needs relating to mortality, life expectancy and older people
4.27 As people live longer and the numbers of older people in the population increase, the importance of increased life expectancy (and healthy life expectancy) for public services is widely recognised and this is reflected in the analytical attention being paid to this issue. The main source of statistical data in this area is GROS which produces census data and related mid year estimates and projections. These data provide information on population numbers for different age bands. In addition, the Scottish Government regularly publish statistics on Community Care Services 32 including Free Personal Care, NHS Scotland ( ISD) publish health information relating to older people, the large national surveys in Scotland ( SHS, SHeS) provide valuable information on older people in Scotland (including good quality health-related information in particular) 33, and a range of one-off projects add to knowledge on health behaviours and older people. The current Scottish Government Reshaping Care programme also includes important analytical work which will inform policy thinking in relation to the changing demands for and costs of care in the future. Scottish Government led work is also continuing in relation to establishing a "client-based" dataset in relation to care home and home care statistics, with the possibility of future linking with ISD health data. The Scottish Longitudinal Study 34 provides a further possible source of information on the characteristics of older people in Scotland.
4.28 There are, though, limitations to the data available on older people in Scotland. For example, information on the views and experiences of older people is less readily available, as this group may be excluded from surveys which have upper age limits or which exclude those living in residential accommodation. Where older people are included in surveys, the numbers involved (particularly at Scotland level in a UK survey) may be too small for detailed analysis, or the topics covered may not properly capture the experience of older people. In addition, where information is available it may be spread across a number sources (in the same way as would be the case for other age-groups within the population).
4.29 In relation to addressing perceived information gaps in relation to older people in Scotland, work was carried out in 2008 looking at the possibility of establishing a longitudinal study of ageing in Scotland 35, similar to the studies already running in a number of other countries, including England. Such a study would allow for the collection of data on a range of issues (health, housing, family and household formation, family finances etc) which would assist with the forecasting of need and the planning of services for the increasing numbers of older people. The scoping work highlighted particular information gaps (eg in relation to labour market participation, transitions into retirement, views and experiences of older people in receipt of care (paid and unpaid) which such a study might address but also highlighted the value of providing the possibility of exploring links across particular issues (eg, health and employment). Following the scoping study, the preferred option amongst policy makers was to further explore how data needs might be met through making better use of existing data sources, including further investigation of the applicability of English data from the English Longitudinal Study of Ageing in a Scottish context. It is clearly important, though, that any data solution adopted ensures the availability of good quality information in this crucial policy area to feed into projections and support sophisticated and reliable modelling work, and ensure the development of appropriate and informed policies.