Healthy Living: Increasing Healthy Life Expectancy And Driving Innovation In An Ageing Society
We want Scotland to be a place where everyone can live long and healthy lives. Our ambition is to raise both the life expectancy and, critically, the number of years that all of Scotland's people spend in good health. To do this, we must reduce the unjust and avoidable inequalities that exist between those in our most deprived communities and those in our wealthiest. Some of these inequalities have been exacerbated by COVID-19 and we must therefore rebuild in a way that delivers a world-class public health system to improve the health and wellbeing of our population.
At the same time, creating a Scotland where more people are living for longer, will require us to create an inclusive and innovative society that not only supports our older population to live healthy lives but ensures they have opportunities to participate, contribute and thrive.
This chapter sets out the demographic context around longevity in Scotland, alongside a summary of what actions are already being taken and where more work is needed.
What does the evidence tell us?
Like many advanced economies around the world, the age structure of Scotland's population is changing. Since the 1950s, our life expectancy has increased dramatically. We are living longer. We are having fewer children. Given modern patterns of migration, this means the numbers of older people as a proportion of our population are rising. Major achievements in public health and science over time have brought us to this position, though Scotland still has a lower average life expectancy than the rest of the UK or in Western Europe.[29,30] The long-term effects of living longer and having fewer children means that the age structure of Scotland's population is changing. This will have major implications for our future.
As Figure 11 shows, National Records of Scotland projects that the proportion of the population of pensionable age people in Scotland will increase. By mid-2043, it is projected that 22.9% of the population will be of pensionable age, compared to 19.0% in mid-2018. As the proportion of Scotland's pensionable age population grows, the proportions of both Scotland's working age and child population are projected to fall.[31,32]
To see this age-structural shift from another angle, projected population estimates show that, over the next 25 years, the number of people of pensionable age per 1,000 working age people is expected to rise significantly in Scotland. These estimates factor in the anticipated changes in the state pension age.
Scotland's age-structural shift is also projected to contain increasing numbers of people aged in, what demographers refer to as, the 'oldest old' age categories. For example, the NRS projects that the number of people aged 90 and over in Scotland will double between 2019 and 2043 from 41,927 to 83,335.
It is important to acknowledge that these population projections are based upon assumptions and therefore have limitations. Over the next 25 years, many social and economic factors, such as COVID-19, can and will influence population change. However, projection data does show a window into Scotland's potential future.These measures of projected longevity across our lifespans and increasing dependency ratios, are tools to inform our understanding of a sustainable future for Scotland as a country in 2040, in 2060, and beyond.
These projected age-structural shifts of the upcoming decades are part of a wider historical context where, since the 1950s, life expectancy in Scotland has risen dramatically. Figure 13 demonstrates this upwards trajectory over the past seven decades.
Figure 13: Male and Female Life Expectancy in Scotland: 1950-52, 1980-82, and 2017-2019.
|Life Expectancy (Scotland)||Born in 1950-52||Born in 1980-82||Born in 2017-2019|
|Male||64.4 years||69.1 years||77.1 years|
|Female||68.7 years||75.3 years||81.1 years|
These long-term trends reflect the continuous advances of public health, housing, and scientific developments since the Second World War. Over decades people in Scotland have had more time to enjoy being active, to have a fulfilling and well-earned retirement, and to prolong their contributions to society as they grow older.
However, life expectancy and healthy life expectancy trends in Scotland have not improved since around 2012. A similar stalling in trends has been seen across the rest of the UK and some other countries including the USA. This has meant that life expectancy has actually been decreasing for the Scottish population living in the most deprived 40% of areas. The best available evidence indicates that this is largely due to economic factors impacting on the whole population, but particularly on those living in the most deprived circumstances. These life expectancy trends are very unusual and indicate the urgency of addressing their underlying causes – the social and economic circumstances such as poverty, housing, and education that together influence health throughout the life.
Without focusing on this, life expectancy and healthy life expectancy cannot be assumed to improve in the future.
Much of our challenge to support longer, healthier lives for our population must be focused around tackling premature mortalities, preventable illnesses, and widening health inequalities.
Unjust and avoidable differences in health among population groups are widespread. In 2017-19, comparisons of people who live in our most and least deprived areas of Scotland show a difference of 10.0 years in life expectancy for females and 13.3 years for males. This rises dramatically for healthy life expectancy (the years that people can expect to live in good health) where the gap is 21.5 years for females and 25.1 years for males. These gaps – broadly determined by the conditions in which we are born, grow, live, work and age - have been increasing. And there is evidence that death rates are increasing in the most deprived areas whilst falling in the least deprived areas – meaning that the gap is getting wider.
Working Age Population and the Economy
For Scotland, how our population is ageing is important not only in the context of having sufficient numbers of people of working age to fulfil business requirements for workers and the overall health of the economy, but also for the Fiscal Framework agreement with the UK, where Scotland's budget is dependent on its tax performance relative to the rest of the UK.
Despite the many benefits of an age diverse workforce these older and ageing demographics can impact on Scotland's labour market performance as inactivity due to poor health is more common among older ages. For example, although "long-term sick" as a reason for inactivity accounts for 6.6% of the inactive population of 16-24 year olds, this rises to 38.4% of inactive 50-64 year olds.
Although Scotland's unemployment rate tends to track the UK rate quite closely, over the past 4 years Scotland has consistently had a higher rate of inactivity (the proportion of people aged 16-64 not active in the labour market) than the UK, with latest figures showing Scotland's inactivity rate at 21.8% compared to 20.8% for the UK.
Scotland's higher inactivity rate has been driven by a greater proportion of inactive people citing poor health and retirement as the reason in Scotland than the UK. This has arguably acted to keep Scotland's employment rate lower than it otherwise would have been.
These age profiles and subsequent pools of available labour supply vary significantly by region in Scotland with rural and remote areas tending to have older populations that are set to continue ageing. Some of these areas, particularly those located in the West coast (e.g. Argyll and Bute, Western Isles), are expected to experience overall population decline in future years and typically don't benefit from migration trends in the way that Scotland's major cities do.
Increasing healthy life expectancy for all
We want Scotland to be a place where everyone can live long and healthy lives. We also want to create an inclusive and innovative society that not only supports our older population to live healthy lives but ensures they have opportunities to participate, contribute and thrive. In order to do this, there is still much work to be done.
In 2018, the leading causes of death in Scotland in 2018 were:
- Ischaemic heart disease: 6,615 deaths (11.3%)
- Dementia including Alzheimer's disease: 6,484 deaths (11.1%)
- Lung Cancer: 3,980 deaths (6.8%)
- Cerebrovascular disease (including stroke): 3,831 deaths (6.5%)
- Chronic lower respiratory diseases (e.g. bronchitis and emphysema): 3,469 deaths (5.9%)
In 2018, we published our Public Health Priorities and major action plans that are enabling us to tackle some of the most significant challenges we face. Our cross-government action to create a world-class public health system is focused directly on stopping the stalling of life expectancy improvement, improving healthy life expectancy, and tackling health inequalities.
To address these challenges, our major action plans include:
Our Framework for supporting people through Recovery and Rehabilitation during and after the COVID-19 Pandemic sets out our vision for the provision of rehabilitation and recovery services across Scotland, for people whose health and wellbeing has been affected by the COVID-19 pandemic.
Our Diet and Healthy Weight Delivery Plan includes population-level approaches to encourage healthier choices, including progressing legislation to restrict the promotion and marketing of foods that typically have little or no nutritional value, where they are sold to the public. This sits alongside tailored and targeted approaches to help people eat well and have a healthy weight.
Our Active Scotland Delivery Plan sets out the wide range of actions we and our partners are taking to encourage and support people in Scotland to be more active more often – these include our National Walking Strategy, supporting women and girls to take part in sport, and record investment in active travel.
Our Alcohol and Drug Treatment Strategy and our Rights, Respect, and Recovery Action Plan, are committed to preventing and reducing drugs and alcohol harm in Scotland, whilst ensuring that effective interventions and high quality treatment and support services are available when required.
Our Tobacco Control Action Plan sets out how we will reach our goal of creating a tobacco-free generation by 2034.
Our Mental Health Strategy 2017-2027 sets our ten year plan to prevent and treat mental health problems with the same commitment as we do with physical health problems.
Our Suicide Prevention Action Plan has a commitment to reduce the rate of suicide by 20% by 2022 (from a 2017 baseline) and supporting local partners and, in particular NHS staff, in supporting those in crisis.
Our Health Literacy Action Plan aims to provide individuals, families and employers the skills and knowledge to maintain good health.
At its heart, our Public Health Reform Programme sees an interconnected system between our health, our public services, our economy, and our communities. Together through a whole-systems approach, we aim to create a sustainable public health system that is not only able to address the nation's current health challenges, but is also equipped to respond to the complex future challenges of the twenty first century – one of which is an ageing society.
Challenges and opportunities for Scotland's changing population:
A changing population brings with it new opportunities and new challenges. Population projections show that, like many other Western European nations, Scotland has an ageing society. As a greater proportion of our population are projected to become of pensionable age, there are major implications.
Almost every area and every region of Scotland will feel the implications of our age-structural shifts. This includes:
- Public finance
- Health and care systems
- Our working lives
- Education, skills, and learning
Looking into the future, we need to find ways to drive innovation to meet the needs and to maximise the opportunities for a Scottish population in 10, 20, and 50 years' time. For the Scottish Government, this means careful thought and strategic engagement about our changing needs as a population.
Ageing is a significant driver of public service expenditure. An ageing population puts increasing pressures on public expenditure, in particular pensions, health and social care. As the Scottish population is ageing and the proportion of the working age population decreases, this means that public services and welfare payments for all need to be funded on a smaller active economy. While these changes are gradual and not necessarily significant over short periods of time, policy interventions are required early in order to maintain the affordability of health care and the pension system over the long-term.
Health and social care:
An ageing population, with an increasing number of our 'oldest old' citizens, has the potential to transform our population's health and care needs. In order to address these, careful long-term systems planning is needed. While many older people will enjoy better health than their predecessors did at an equivalent age, they will still have significant health needs living with potentially multiple conditions, and the overall impact will be a steadily increasing demand for health and social care.
On the one hand, we must ensure that we are able to manage and mitigate the levels of demand from an ageing population on our health and care services. First and foremost, extending the number of years that our population spends living in good health is vital. If people in Scotland live longer, but not healthier lives, then more people will spend a greater proportion of their lives in some kind of ill-health. An outcome of this would be increasing demand on health and care services for a longer period of time across the lifespan.
Long-term planning must also consider the gradually changing nature of demand on health and care services that may manifest as our population changes. Population ageing is likely to increase the prevalence of age-related conditions in Scotland. Chronic conditions which affect the heart, along with the musculoskeletal and circulatory systems are all more prevalent with age. The same is true of certain mental health conditions such as dementia. A changing burden of disease – towards increasing prevalence of chronic and degenerative conditions – means that there are likely to be changing needs for primary, secondary, and community care.
Current and future workforce planning efforts will need to be attentive to the profound disruption to models of service delivery caused by COVID-19. Work is underway in the Scottish Government to understand how the landscape of health and social care services has been impacted by COVID-19 and to draw on lessons learned from the domestic and international response to the pandemic. This intelligence will inform workforce planning that balances short-term challenges and the long-term health and social care needs of our changing population.
In December 2019, we published the first Integrated National Health and Social Care Workforce Plan in the UK. Developed in partnership with COSLA, the Integrated Plan sets out how health and social care services will meet growing demand to ensure the right numbers of staff, with the right skills, across health and social care services.
The Independent Review of Adult Social Care published its report on 3 February 2021. The report sets out how adult social care can most effectively be reformed to deliver a sustainable national approach to adult social care that delivers high quality care and support to people who need it and improves support for their families, unpaid carers and the workforce.
To face the long-term challenges of an ageing society, innovation must also be at the heart of health and care systems planning. This is why the Scottish Government's innovation pathway is working to support the introduction of new innovative health technologies into NHS Scotland and the social care sector rapidly, with Scotland's ageing society viewed as an area of priority. Such innovations in public health (such as medical devices, diagnostic tests, pathway interventions and digital technologies, including robotics and artificial intelligence) can bring improvements in healthcare outcomes, quality, safety, and result in cost savings for NHS Scotland. Benefits for patients can also include faster diagnosis, a decline in preventable deaths, more effective and appropriate treatment, smoother pathways and easier methods of treatment.
We are taking a step-wise approach to embedding genomics medicine in NHS Scotland, ensuring the service has a capacity and resource needed. We included a commitment in the Programme for Government 2018/19 to continue the development of genomic medicine through the enhancement of NHS Scotland genetic capabilities for the diagnosis of rare diseases. In September 2020, we signalled out support for the UK Government Genomics UK: the future of healthcare Strategy, committing to publishing our own response to the strategy in the form of an Action Plan.
We work closely with the NHS Scotland National Planning Board to support strategic planning of NHS Scotland services in the medium to long-term, part of which involves taking account of new and emerging areas of health technologies and innovation. One area of particular focus for the Board recently has been the expansion of Robotic Assisted Surgery (RAS) across NHS Scotland.
In 2020, we pledged to establish a Scottish Health and Industry Partnership to work with industry and academics to strengthen the research and development stages to help bring such technologies into NHS Scotland and social care sectors at pace.
The prospect of longer life also presents numerous opportunities to reframe how we work and learn over the course of lifespan. Over time, as people live longer, more can be done to support longer and fuller working lives, and to remove the barriers which can force older people to leave working life before they may wish to. Such ways to increase these 'longevity dividends' may include addressing negative attitudes towards older workers, encouraging entrepreneurship or civic participation in later life, or providing mechanisms for continuous learning across the lifespan.
Harnessing such demographic dividends will require joined-up collaboration to combine demographic opportunities with other shifts in society. For instance, combining shifts in demography with changing economic trends – e.g. providing pathways for skills development in emerging sectors of Scotland's economy.
As part of this conversation on doing right by our older population, in 2019 we published A Fairer Scotland for Older People: framework for action. This plan engages with how we can remove barriers experienced by older people, tackle inequality and allow people to flourish in later life.
Housing also represents an important piece of the interconnected demographic challenge. It is vital that we have a housing system that is dynamic and resilient enough to meet people's changing needs, including an ageing population. As more of the Scottish population grows older, we must think about our different housing options and promote greater accessibility to allow our people to live well and independently at home and to reduce unnecessary hospital admissions.
Our Housing 2040 Routemap together with the National Planning Framework are central to the way in which we plan for and deliver the right homes in the right places to ensure that we meet housing needs, support people to live independent lives and support regeneration and growth alongside the infrastructure required. We will invest over £2.8 billion in direct capital grant funding, over 5 years, to deliver more affordable and social homes, continuing to ensure the right types of homes in the right places reflecting and supporting Local Housing Strategies and regional development priorities. As part of planning reform we will provide more clarity on future housing land required (for consultation and scrutiny) in the draft National Planning Framework, due in 2022, and will frame this within a new spatial strategy that aligns with our investment programme and principles National Planning Framework 4 will also need to fulfil a statutory obligation to set out how it will support homes for older people and disabled people, as a result of the Planning (Scotland) Act 2019.
Housing to 2040's long-term vision will help to deliver a housing system that is dynamic and resilient enough to deliver the homes we need in the right places and of a quality and type to meet people's changing household needs, including those created by an ageing population.
Community and Social Connectedness
As we live longer lives, there are also opportunities to enhance our quality of life. Social isolation and a lack of community connectedness are issues which can often be felt most by our oldest citizens.
As part of this conversation, in 2018 we published A Connected Scotland: our strategy for tackling social isolation and loneliness and building stronger social connections. It recognises social isolation and loneliness as a major public issues that can have significant impacts on the physical and wellbeing of older people.
Together, these issues only scratch the surface of the complex combination of challenges and opportunities that we can address in the face of population ageing. One of the actions for this paper is for Scottish Government to consider establishing a Demographic Commission to further open up these conversations with experts and partners.
|7||We will continue to invest in improving population health and reducing health inequalities to ensure that people are supported to live longer healthier lives||Scottish Government|
|8||We must consider the changing nature of demand of an older population and adjust our healthcare provision accordingly||Scottish Government and Health Boards|
|9||We will consider innovation and technological tools to support our future ageing population||Scottish Government|
|10||We will explore opportunities to help people live longer and fuller working lives and remove barriers which force older people to leave the workforce before they wish to||Scottish Government with employers|
|11||We will ensure our housing options allow our population to live independently at home for longer||Scottish Government and Local Authorities|
|12||We will ensure the quality of life for our older people is enhanced to combat social isolation||Scottish Government, local government and partners|