That the Grand Committee takes note of the Report from the Science and Technology Committee Ageing: Science, Technology and Healthy Living (1st Report, Session 2019-21, HL Paper 183).
My Lords, it is a great privilege to open this important debate on the Science and Technology Committee report Ageing: Science, Technology and Healthy Living. I thank the Minister for making time to respond to the debate. I am hoping that, being new in the post, he might have a more positive response to the conclusion of the report than the one we got from the Government.
It is a compliment to the committee and its report that so many notable noble Lords are taking part in the debate. I thank them all and look forward to their contributions. I sincerely thank all the committee members. I could not ask for a more committed, passionate, understanding, gentle, malleable and only occasionally challenging committee—or maybe not. I thank them all for their hard work and tolerance.
The committee was fortunate to have talented, hard-working committee staff: our clerk, Dr Simon Cran-McGreehin, policy analyst Dr Amy Creese, and committee operations officer Cerise Burnett-Stuart. I thank them for their hard work in running the committee and producing the report. The committee was well advised and supported by our specialist adviser, Professor Janet Lord, professor of immune cell biology and director of the Institute of Inflammation and Ageing at the University of Birmingham. On behalf of the committee, I thank her for all the help and advice she gave us.
We started our inquiry in July 2019 but had to delay concluding evidence sessions and publication because of the pandemic. It has already become clear that those who are old, who suffer from multiple comorbidities and who are socially deprived will pay the highest penalty as a result of Covid-19, compared to the young and healthy.
The background to our inquiry was a government publication in November 2017 naming an “Ageing Society”, as one of four “Grand Challenges” of the industrial strategy. It committed to
“harness the power of innovation to help meet the needs of an ageing society.”
In 2018, the Government announced that the mission of the ageing society grand challenge was to:
“Ensure that people can enjoy at least 5 extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest.”
The aim of our inquiry was to understand to what extent developments in science and technology related to ageing will be important to reaching the goal of the Government’s grand challenge of an ageing society.
We also considered how current public health policies and co-ordination of healthcare for older people may contribute to years spent in poor health. Demographic projections suggest that, by 2035, 7% of people—some 5 million of the population—will be aged over 80. Life expectancy continues to rise, but the rate of rise is slowing. There is a strong link between deprivation and life expectancy. Males in the least deprived areas live nine and a half years longer than those in the most deprived areas. For females, the gap is 7.7 years. A more important measure than life expectancy is healthy life expectancy. The average age of healthy life expectancy in England is 63 years, with males spending a further 16 years—20% of their lifespan—and females 19.4 years, which is 23.3% of their lifespan, in poor health.
My Lords, when I first came to this House, the doorkeepers told me that this was the best elderly daycare centre in London and that it would give me another 10 years of life expectancy, so this is an apt report for your Lordships’ House. I join my former colleagues on the Science and Technology Committee in thanking the noble Lord, Lord Patel, for his chairmanship of this important inquiry and echo his thanks to the staff, who supported us splendidly.
It is clear that improvements in healthy life expectancy have stalled. On average, about 20% of our lives is spent in poor health. The gap in life expectancy between the rich and the poor has widened even further.
I want to pursue three areas this afternoon. The first is to touch on technological support for older people to help to improve the quality of their lives. The second is to focus on the root causes of increases in years of ill health and disability—the root cause is indubitably poverty and deprivation—and to explore what the Government’s levelling-up agenda must do to tackle them. The third is the importance of integration of action across all policy areas nationally and locally and how the recent changes in responsibilities for prevention of ill health will work out.
I have some lasting impressions of the committee’s work. First, the foundations for healthy old age are laid down from our youth onwards. We need to focus on how people can be healthier throughout their entire life course and not try to put a sticking plaster on the situation once old age is reached. Secondly, there is a pronounced societal difference in healthy life expectancy, which is highly correlated with deprivation and ethnicity. The difference in healthy life expectation between the least and most deprived is nearly 20 years. Poverty and deprivation are the root cause of unhealthy ageing. That is totally unacceptable in a civilised society. However, perhaps my most abiding memory was that we convened a panel of elderly people to help our deliberations only to find that Select Committee members were generally older than the elderly people.
My Lords, I also thank the noble Lord, Lord Patel. I joined the Science and Technology Select Committee just in time for the inquiry that led to this report, so was able to appreciate the consummate ease with which he chaired the complex scoping exercise and then of course the inquiry itself. I add my thanks to the clerks for their hard work and dedication. My remarks today will focus on the impact of the Covid pandemic on the fundamentals of the Government’s two-tier grand challenge strategy to, first, increase healthy independent living by five years by 2035 and, secondly, narrow the gap between the richest and the poorest.
Like all developed countries, the population of the UK is ageing. The report tells us that we will see a 51% increase in people aged over 80 to about 5 million from 2018 to 2035, and all the while the working-age population remains static. It was against that backdrop that in 2017 the Government named our ageing society as one of the four grand challenges in the now sadly abandoned industrial strategy. Between 1980 and 2018, life expectancy at birth rose to 79.3 years for males and 82.9 years for females. However, healthy life expectancy—the number of years for which a person is expected to live in good health without disability—has not improved at the same rate; it stands at 63.1 years for males and 63.6 years for females.
It will come as no surprise, given the heavy mortality rate due to Covid last year, that the ONS reports that, for the first time in four decades, life expectancy for men in the UK has fallen. Life expectancy for women remains unchanged. Are the Government assessing the impact that long Covid may have on healthy life expectancy? On the last page of their response to the report, the Government seem to imply that the ageing society grand challenge will no longer be identifiable as such in the more nebulous plan for growth, under the “build back better” soundbite that replaces the more solid industrial strategy. I hope that the Minister can offer reassurance that this will not be the case, and in particular that R&D funding into the science of ageing and support for SMEs at the cutting edge of technological innovation to aid independent living will be protected from any cuts to the promised £22 billion per annum investment in R&D. I would appreciate it if he could refrain from listing the Government’s historic support, as was the case in their response to the report, and instead tell us their future plans.
I thank the noble Lord, Lord Patel, for the opportunity to consider how we might enhance the prospect of a long and healthy life. Accordingly, I declare an interest as founder and CEO of Neuro-Bio Ltd, a biotech company developing an innovative treatment for dementia, specifically Alzheimer’s disease. As the noble Lord correctly predicted, I will focus most of my comments on that subject.
Alzheimer’s is a neurological condition characterised by memory loss, disorientation and general cognitive impairment. It is a disease typically, though not exclusively, of older people. One in six over the age of 80 have dementia, a condition that affects as many as 70% of residents in care homes. The spectre of Alzheimer’s is one of the cruellest potential scenarios awaiting us in later life. While heart disease and cancer are serious, often disabling and sometimes terminal, you can still reminisce over old photographs and spend meaningful and precious time with your grandchildren. These life-enhancing moments are gradually closed off to an individual with dementia.
Despite hearing from witnesses from both Alzheimer’s Research UK and the Alzheimer’s Society, there seems to be no substantive discussion in the report of the very real threats that Alzheimer’s currently poses to enjoying a healthy older age. It is cited as the most common cause of death for women, then flagged in relation to air pollution and reported as mitigated by cognitive reserve. That is three mentions of one of the most important issues related to ageing and its potential alleviation by science.
The Alzheimer’s Society’s website reports facts and figures that are truly concerning. First, there is the societal impact of dementia as one of the main causes of disability later in life. There are currently around 850,000 sufferers in the UK; this figure is projected to rise to 1.6 million by 2040. This year, 209,600 people are expected to be diagnosed with dementia; that is one person every three minutes.
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Viscount Ridley (Con)
My Lords, it is an honour to follow that eloquent speech from the noble Baroness, Lady Greenfield, and her strictures are well made. I begin by commending the noble Lord, Lord Patel, not only on securing this debate but on steering the committee through a vital and largely virtual piece of work. He did so with charm, wisdom and not a little fierceness when necessary.
The main issue that our report grapples with, as others have said, is the gap between health span and lifespan. We are spending longer living, but even longer dying. We would all like to live lives of perfect health until, one day, we drop dead, but it does not happen that way and the gap is not closing. I am horrified to hear the statistics from the noble Lord, Lord Patel, and that, as a 63 year-old, my health span is coming to an end. By largely or partly exterminating the quick killers, such as smallpox and heart attacks, we have left ourselves with slower killers, such as cancer and Alzheimer’s.
The first thing to say is that this is a problem born of success. The defeat of premature mortality is a spectacular triumph of modern medicine and we should not forget that. In my lifetime, global life expectancy has increased by about five hours per day; it has gone from 49 to 71. Let us not be so keen to complain about the failure to defeat the morbidities of old age that we forget to celebrate these unprecedented achievements. I am not wholly convinced that better leadership and accountability by government on the grand challenge would necessarily have made a big difference in the last few years.
As the noble Lord, Lord Patel, said, the central issue with which we grappled was how to close the gaps between health span and lifespan and between rich and poor. There are four possible ways to do it: we can teach young people not to get into unhealthy habits, such as obesity and lack of exercise, which will make them unwell in old age; we can learn to treat people’s illnesses better when they get ill in old age; we can diagnose illnesses better and earlier, as the noble Baroness said; or we can do research into the underlying mechanisms of ageing in the hope of finding preventive therapies. Today, I argue that, from what I heard in the inquiry, the first and second suggestions are unlikely to work very well; the third and fourth may be much more important.
I am a little cynical about public health advice to the young as a cure for old age. In the report, we say that
“a life-course approach to healthy ageing is to be commended”
and that
“There are advantages to adopting healthy lifestyles earlier in life.”
My Lords, it is an honour to follow the noble Viscount, Lord Ridley. I am pleased to accept his advice that, before we address the challenges, we should celebrate the achievements of medical science. If he will excuse me, I will take some time to reflect on some of his other advice, and I will certainly not introduce him to my sons until I have worked out what the implications might be.
It was a privilege and an education to have been a member of the Science and Technology Select Committee while it was carrying out this inquiry under the expert chairmanship of the noble Lord, Lord Patel. I associate myself with his words of recognition and thanks to the committee staff and our expert adviser, and I thank him for his impressively comprehensive introduction of a complex report in an accessible way. I do that principally because I will use it as reason for concentrating on one aspect of the report, which was raised both by my noble friend Lady Young of Old Scone and the noble Baroness, Lady Sheehan—the impact of inequalities. Over the months during which we took evidence, we found that inequality was the most significant challenge.
Our committee heard evidence from many witnesses to support the finding set out in the first conclusion of our report, which is that inequalities in healthy life expectancy remain stark. People in the most deprived groups on average spend almost 20 years longer in poor health than those in the least deprived groups. There are also shockingly large differences in healthy life expectancy among ethnic groups. The evidence that we received more than justified our recommendation that the Government prioritise reducing health inequalities and our request that they set out a plan for reducing health inequalities over the next Parliament—a request with which they respectfully declined fully to engage. There is hope yet. The Government, via the Minister, have been invited three times to engage with this issue, so it will be interesting to hear his response.
My Lords, it was a privilege to have been a member of this House’s Science and Technology Select Committee under the excellent chairmanship of the noble Lord, Lord Patel. I too thank him for his leadership in our inquiry on ageing and the production of our report. Our report highlighted that people are living longer but, regrettably, many of the extra years are spent in poor health and in difficult conditions. Today I will focus on the role of engineering and technology in improving the situation and how it can enable people to live independently in their homes for longer in old age.
Our committee concluded that technologies and related services have an increasing role in helping people to live healthily and independently in old age. This was referred to by the noble Baroness, Lady Young of Old Scone. These include assistive technologies, which can compensate for declining ability and help individuals to cope better with their environment, making it possible to extend independent living. They also include medical technologies, which can improve health and capability.
I will first address assistive technologies that can provide the ability for independent living, which is especially important. Remaining in one’s own home and community is vital to many older people and can contribute to an improved sense of health and well-being. To this end, there is considerable potential for smart homes, with technologies in the home such as sensor networks, motion sensors, infra-red cameras and even robots.
Today’s internet of things makes the possibilities of the smart home much more easily attainable. Wireless monitoring devices can be placed around the home to monitor the individual’s daily activities. Monitoring could be done directly, by devices that monitor gait, breathing or speech, for example, or indirectly, by devices that monitor the use of the fridge or utilities such as electricity and water, for example. Data can be accessed by formal and informal carers, who can make real-time care decisions to help the elderly person.
The Science and Technology Committee’s report on ageing was written before I joined the Committee. I have no hesitation in declaring that it is an excellent report. It is lengthy and comprehensive and it contains numerous important recommendations.
The report has disposed of the optimistic belief that citizens of affluent societies can look forward with equanimity to the prospect of increased longevity. However, in comparison to the experience of Britons 100 years ago, the average lifespan has already increased markedly. A century ago, average life expectancy at birth for men was 48 years, whereas for women it was 54. By 2015, life expectancy for a man was 79 years and for a woman it was 83 years. It should be noted, however, that it can be misleading to compare average lifespan statistics then and now. The earlier figures are affected by a higher frequency of infant mortality and death in childbirth, both of which have been radically reduced.
The process of increasing longevity has slowed and there is little prospect of further significant increases at the top end of the range. Nevertheless, there remains considerable scope for reducing the incidence of premature death associated with social deprivation. The prospects of a morbid senescence, in which people suffer from the ailments of old age, have increased disproportionately. Both the duration of that period of affliction and the incidence of the associated ailments have increased markedly. Although it should be possible to delay the onset of the diseases of senescence and to mitigate their effects, they will not be eliminated. As the report observes, few of these ailments are liable to be eliminated by natural selection, since they occur mainly after the age of reproduction.
The report also revealed the wide differences in health and longevity among individuals in different socioeconomic circumstances. The expected duration of a healthy period in life—the health span—for those in the most affluent areas is 18 years longer than for those in the most deprived areas. Those in poverty suffer more from the ailments of old age. If there is a realistic prospect of increasing longevity on average and of reducing ailments, it must be by addressing these inequalities.
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Inequalities in healthy life expectancy are even starker than those for life expectancy. The difference of 18.3 years in healthy life expectancy between the least deprived and most deprived is striking, with 70.6 and 52.3 years of healthy life respectively. Prioritising reducing health inequalities will have huge gains for health and for the economy.
Data from deaths from 2003 to 2018 show that that one-third of the deaths in England are attributable to social inequality. The King’s Fund report of September 2021 says that the Government have
“failed to make significant progress in reducing inequalities”.
While there is clear understanding of the lifestyle and environmental factors throughout life that correlate with good health, interventions in public health do not seem to be effective. Public health interventions need to find ways to motivate and to facilitate change to a healthier lifestyle, particularly for those living in deprivation and suffering the worst health. A child in year 6 from one of the most deprived areas is twice as likely to be obese compared to a child from a well-off area.
Ageing is a major risk factor for a wide range of diseases. Older people often have more than one health problem, often referred to as multimorbidity. Some 14 million people in England have two or more health conditions and 4.7 million have more than four health conditions. The health system currently fails these people for lack of co-ordination of care, with polypharmacy and overprescribing adding to their misery and making them sicker. The report indicated ways of reducing overprescribing, particularly in older patents with multi- morbidity.
I am pleased to see that the report on overprescribing from the Chief Pharmaceutical Officer confirms our views, with one in five admissions to hospital of the over-65s and 6.5% of all hospital admissions related to overprescribing. The Government did not accept our recommendations to help reduce the problem. When will the Government publish their response to the Chief Pharmaceutical Officer’s report and the implementation plan?
From a biological perspective, ageing is the result of an accumulation of a wide variety of molecular and cellular damage over time that leads to decreased physical and cognitive function, increasing the risk of illness and death. A recent animal study suggests that an ageing immune system may play a critical role in diseases related to age. The timing of these changes is not fixed, hence a person’s biological and chronological age can be out of step. Genetics, lifestyle and environmental factors may all have a role. Ways to measure how well a person is ageing will help science to develop understanding of the biological effects of ageing and how they can be modulated.
Understanding the biological pathways that lead to multisystem ageing will help us to discover new diagnostics and technology. Cellular senescence and deregulated nutrient sensing are two good examples of hallmarks of ageing. Understanding biological processes opens up the potential for developing new therapeutic interventions that could reduce or even reverse biological ageing and decrease the risk of developing disease. For example, targeting senescent cells which cause inflammatory changes in tissues leading to disease may allow us to develop senotherapeutics. Some repurposed drugs have already shown promise in mitigating age-related tissue damage.
Despite my enthusiasm for speaking more about the science related to ageing, there are several eloquent speakers taking part in today’s debate who have greater knowledge than I do and can—and I hope will—say more. The recent government report Life Sciences Vision identifies two key areas for research that relate to ageing. The first is improving translational capabilities in neurodegeneration and dementia. No doubt my noble friend Lady Greenfield may have more to say on that. The second is research into better understanding of ageing-related pathways. It is suggested that funding should come from partnership with industry. What plans do the Government have to implement those proposals? Our report recommended increased funding for ageing-related research and better co-ordination. I am pleased that UKRI has taken some recent initiatives in funding such research, but who will provide the necessary co-ordination, for which our report indicated a need?
I now come to the ageing society grand challenge and the mission of extending healthy life by five years by 2035. Our single conclusion in the report was that the Government are not on target to deliver on it, with lack of leadership and lack of a clear plan being major barriers. Different government departments had a role, but no one had responsibility for leadership or co-ordination. I hope that the Minister can confirm that the Government are still committed to the ageing society grand challenge of extending healthy life expectancy by five years. If that is the case, who will lead on it? When will the Government publish a detailed plan with timelines to achieve it? Who will independently monitor progress and will Parliament be able to review progress on a regular basis?
Any plans to extend healthy life expectancy cannot succeed without also addressing inequalities in health outcomes. The Government had said that they would publish their response following the end of consultation on the prevention Green Paper to address health inequalities. When will they publish their response? The Government are to publish the levelling-up White Paper by the end of the year. Will the White Paper address the issues related to inequalities in health and the means of reducing them?
In conclusion, research to better understand the biology of ageing, developing technologies, diagnostics and treatment for age-related diseases and keeping people healthy longer are the themes that our report tried to address and to suggest possible solutions to. Although the Government’s initial response was disappointing, there are now some positive signs and promise of more, so I remain hopeful.
I end with a plea to the Minister. I know that he will have a long brief to read out in response to today’s debate. My plea to him is to leave some time to answer the questions raised by noble Lords today and not just read the brief. If he does that, he will make himself very popular. I beg to move.
I will raise three issues directly with the Minister. The first is the role of technology in enabling healthier ageing. There are many technologies, such as digitally based products and services such as fall trackers, medication monitors and digital befrienders, and other newer technologies such as robots and digital surveillance programs, all of which could help to support older people, improve their quality of life and allow them to maintain a more independent existence. But provision is low and the poorer and more deprived simply do not get access to such help. That gradient will increase with new technologies becoming more and more available. That has to change. What plans does the Minister have to accelerate not only the pace of technological development but, more importantly, the uptake of those technologies?
Secondly and most importantly, let us not be in any doubt that the root causes of unhealthy ageing are deprivation, unemployment, poor education and housing, lack of opportunity and unhealthy diet and lifestyles, including smoking and alcohol. Tackling these root causes sounds just the thing for the Prime Minister’s levelling-up agenda. Sustained action is needed over a lengthy period, with co-ordinated efforts between national and local government.
Cutting the income of the poorest by removing the £20-a-week universal credit payment does not fit that bill, nor does a spending review and Budget in the next few weeks that has been trailed as the ultimate austerity measure by the Chancellor, who seems increasingly out of love with his boss’s objectives. We are facing another version of the TB-GBs—I will leave your Lordships to fill in whatever acronym you would like for the new Chancellor versus Prime Minister tension. We need not a focus politically on the red wall seats and town centre tart-ups but a sustained attack on inequality and lack of opportunity wherever it occurs.
It is only three years since the Government set themselves the target of five extra years of healthy life by 2035, but that target is already being airbrushed out. Its future is unclear from the Government’s response. Can the Minister confirm whether, in his view, the ageing society grand challenge will survive the proposed review that will be undertaken and whether the five extra years will still be a target? If the target has gone within three years of being established, how confident can the Minister be that the sustained approach required to tackle poverty and deprivation will not be as ephemeral? We no doubt await the White Paper on levelling up later this year, but it would be good to get a feel from the Minister now.
My third point is about the importance of integration of action to promote healthy living across all departments and many policy areas, such as work and education, transport and housing, air quality, local environment quality et cetera. Public Health England, which was responsible for co-ordination on prevention and health promotion, has gone and the Office for Health Improvement and Disparities was launched only at the beginning of this month. I understand that there is to be a cross-government ministerial board on prevention to drive forward a co-ordinated government approach on the wider determinants of health. How often has this ministerial board met and what has it done so far?
The local effort is to be driven by local directors of public health. I will pay a small tribute to those incredibly important people. They are currently up to the neck in Covid and before the pandemic were definitely below the salt for esteem and resources in local authorities. Can the Minister tell the Committee in detail how the Government will ensure that local directors of public health will be given the position, authority and resources to do this co-ordination job across many policy areas on a local level?
We hear much about the pressure on the NHS these days. Much of that pressure is due to those substantial years of poor health that, on average, many people experience. The Government need to see the challenge of healthy ageing as an issue of economics and of health service sustainability, but above all as an issue of equity.
I turn to the second tier of the grand challenge: narrowing the gap between the richest and the poorest, which stands at nine and a half years for life expectancy and, distressingly, almost 20 years for healthy life expectancy. That will have been exacerbated by the country’s recent experience of those who bore the heaviest toll in lives lost during the pandemic. Covid hit the poorest hardest and, within that, hit people from ethnic minorities even harder. The report’s first recommendation is that the Government, along with NHS England and the erstwhile Public Health England, “prioritise reducing health inequalities” between the least deprived and most deprived areas, and asks that they set out a plan to do so over the next Parliament. In response, the Government in effect say that we will get the report due course when they come forward with proposals in response to the prevention Green Paper. What is the progress to date on that response?
My final remarks will focus on obesity, which is closely linked to deprivation. Food loaded with cheap harmful additives is leading to an increased number of lives lost and points to a failure by successive Governments to act on the prevention agenda by promoting healthier diets and a more mobile lifestyle. Frankly, it is a disgrace that poorer people have little choice but to buy food that is poor in nutrition and positively harmful to their health.
The experience of the pandemic illustrates starkly that the Government have not curbed the appetite of the food and drink industry to maximise profits at the expense of the health of their customers. Cheap and addictive additives such as sugar, salt and hydrogenated fats in heavily processed foods—to boost flavour and shelf life—have wreaked immeasurable harm on the population at large. Will the emphasis that the Government propose to place on prevention include tackling the food and drink industry’s role in increasing obesity? Will they, for example, extend the sugar tax to foods and drinks that are high in added cheap sugar? Trans fats, a form of processed hydrogenated cooking fats, have been identified as one of the most dangerous food additives. Are the Government rethinking their reluctance to introduce curbs on their use, if not their total ban?
Our report points to the damage that a lack of movement does to our bodies, let alone a lack of physical exercise. The sedentary lifestyle of a couch potato is one that will lead to an end of life riddled with multiple morbidities and a carrier bag full of drugs to treat symptoms of each disease, as well as drugs to counteract side effects. The Government have failed to provide central oversight of the volume or interactivity of these drugs. GP oversight is proving inadequate, to the detriment of the patient and NHS finances. I hope that the Minister will give us greater cause for confidence than the Government’s written response.
Secondly, there is the economic factor. The total cost of care for people with dementia in the UK is £34.7 billion. This is set to rise sharply over the next two decades to £94.1 billion by 2040.
Thirdly, there is the impact on carers, in addition to the financial and mental health repercussions of perhaps giving up a job to care for a loved one. On more than one occasion, I have heard this daily existence described as a living death.
Since these problems are not raised in the report, it is unsurprising that there are no recommendations specifically to resolve them. I want to make a few suggestions for brief consideration here. The only successful way to combat Alzheimer’s disease will be to devise an effective treatment. In turn, this is dependent on gaining insight into the underlying brain processes. Further research, both basic and translational, is thus essential.
However, dementia research is desperately underfunded. For every individual living with the condition, the annual cost to the UK economy is more than £30,000, yet only £90 per patient is spent on research. Five times fewer researchers choose to work on dementia than on cancer. Yet if we could come up with a means of delaying the onset by five years, the number of deaths from the condition would be halved, saving 30,000 lives a year.
Admittedly, various recommendations in the report are concerned with drug development in a more general sense in relation to older people. However, sadly and strangely, no specific issue is raised in relation to improved therapies for Alzheimer’s disease. An obvious and predictable recommendation would be to make more funds available for research, be they from public, private or philanthropic sectors.
Just as important, but much less obvious, is the question of how such resources should then be deployed. Currently, the majority of funding is directed at just one strategy to combat the histological marker in the brain—amyloid—as it is a frequent feature of Alzheimer brains. However, drugs designed to antagonise amyloid at best only slow down the progression of the disease. There is increasing doubt that it is the primary cause of the neurodegenerative process. The report could have highlighted the lack of success of current treatments and thus argued the case for promoting initiatives pursuing innovative lines of inquiry. In this way, we could truly understand the degenerative mechanism in order to intervene with a successful pharmaceutical strategy.
The hunt for an anti-Alzheimer’s drug that actually works is far from straightforward. As yet, there is a no accepted narrative for how and why neuronal loss starts, nor for—of equal importance—how it is perpetuated for decades before the classic profile of cognitive impairment presents. Unless and until we understand what is happening in the brain for this period, we will only ever be able to deal with downstream symptoms, such as amyloid accumulation, rather than halting cell loss by intercepting the driver of the disease.
The second reason for failure to date is the lengthy time window of 10 to 20 years between the onset of cell loss and the eventual presentation of cognitive impairment. Any treatment initiated at this late stage is comparable to closing the stable door after the horse has bolted, as the pernicious cycle of cell loss would have been under way for decades. Analogous to the measurement of cholesterol for detecting cardiovascular problems, we need a routine blood test, say, that would enable easy screening to determine whether the degenerative process was already in train, even though the person may feel perfectly fine at the moment. Imagine if we had a blood biomarker indicating early on that degeneration had already started, well before the behavioural symptoms of Alzheimer’s were apparent. Imagine if we had a drug that stabilised cell loss and halted neurodegeneration. If such a drug were taken before the symptoms became apparent, those symptoms may never arise—not a cure in the literal sense, but effectively just that.
What is stopping us developing such a biomarker and such a drug? We need to facilitate more innovative lines of research and challenge existing dogma. Admittedly, there will be false dawns and blind alleys. There will be risks to take and cynicism to overcome, but that is the only way we will ever develop an effective treatment for Alzheimer’s disease. The American physicist and philosopher Thomas Kuhn famously argued that science does not evolve gradually towards truth but has a paradigm; that is, it has an accepted approach that remains constant until anomalies start to accumulate, and accumulate to such an extent that it is finally accepted that established thinking cannot explain the phenomenon in question. A completely new theory must then be conceived—a paradigm shift. If we are to understand and tackle this devastating condition successfully, we are long overdue for such a shift in our thinking.
Alzheimer’s disease is not an inevitable consequence of ageing, but it is a disease of old age. In my view, the report has missed a golden opportunity to draw attention to its current impact and future threat. Most importantly, it has missed the opportunity to promote new strategies to consign dementia to being a disease of the past. Only when this happens will we be able to have justified confidence in an old age that is not only able-bodied but clear-minded.
But we lament that
“We heard differing views on whether young people tend to engage with the issue of healthy ageing”,
which is a bit of a euphemism, yet we recommended
“regulatory and fiscal measures, actively to encourage people to adopt lifestyles that support healthy ageing”.
That would all be great, but do we really think that we can tell the young that they must drink in moderation now to prepare for a sedate old age, free of illness, or that they will believe that we can deliver that promise? After all, lots of us adhere to Hunter S Thompson’s advice, even in middle and old age:
“Life should not be a journey to the grave with the intention of arriving safely in a pretty and well preserved body, but rather to skid in broadside in a cloud of smoke, thoroughly used up, totally worn out, and loudly proclaiming ‘Wow! What a Ride!’”
We sort of admit in this report that solving the problem of the gap between health span and lifespan through public health advice is not working but say that we should do more of it.
On treating people’s illnesses better, we rightly focused on multimorbidity. One doctor treats one symptom, another treats another and the fact that the patient has five things wrong with him at the same time either is ignored or, worse, leads to multiple medications that interfere with each other. “Polypharmacy” was a word that I learned during this inquiry.
I like to think that we can reform healthcare in such a way as to do better at this, but it will be a Sisyphean task, because the rise of multimorbidity is, to some extent, an inevitable consequence of defeating premature mortality. Someone with multiple organs failing at once is simply expressing their biological sell-by date. It is an interesting fact that when supercentenarians—people older than 110—die, they generally just fade away with no particular cause. The machine just stops. Even cancer cells struggle to keep going in their elderly bodies.
By the way, an even more interesting fact is that, while the number of people reaching 100 goes up and up all the time, the number reaching 115 remains extremely small and has hardly changed in decades. There really is a sell-by date on human life. Jeanne Calment, who is the only person to get past 119 and supposedly died at the age of 122 in the 1990s, had probably swapped her birth certificate with her mother’s, we now think. There is currently one 117 year-old and one 118 year-old woman alive in the world and no man older than 113, I think. For those worried about pensions, it is a good thing that we just ain’t going to live to 150—not without genetic engineering, at least.
That leaves diagnosis and research. I genuinely think that the best thing we can do for the elderly and the best way to help to close the gap of social inequality is to diagnose people’s ailments sooner. It disappoints me that this country does not seem as keen on early diagnosis as other countries sometimes are. As for research, like the noble Baroness, Lady Greenfield, I am convinced that Britain, with its terrific bioscience expertise, has a great opportunity to make a huge contribution to the underlying science of ageing. Therein we might find a way to treat people either with senolytic drugs or with telomerase to give them the bodies of 40 year-olds in their 80s, followed by a sudden death at 110. That seems a noble goal, which the Government should heartily embrace. In his reply, will the Minister tell us what the Government are doing to support ambitious research into both the mechanisms of ageing and the value of early diagnosis?
Our relatively short paragraphs on inequality disguise the scale of the evidence that we received of the all-pervasiveness of its effects on longevity and healthy living and the degree to which it repeatedly raised its head in our evidence sessions. In our report, the word “inequalities” is used 77 times.
We conducted our inquiry largely over the course of the pandemic, during which there has been a growing awareness of the degree to which poverty and the underfunding of public health have been associated with a large and unequal mortality caused by Covid-19 across the whole UK. However, before the pandemic, in many communities both life expectancy and, in particular, healthy life expectancy had begun to decline after a period of improvement. Hitherto, this decline in longevity was explained by growing unemployment or the replacement of long-term secure jobs by largely insecure and low-wage employment because of de- industrialisation and changes in the economy of the UK in the latter part of last century. Largely, these trends resulted in greater loss of good economic opportunities and jobs in the north as opposed to London and the south-east, where the burgeoning service economy and education opportunities gave young people, including some from poorer areas, a better chance to succeed in that changing environment.
However, during the period of austerity, these long-term changes were worsened by a deliberate decision to reduce social support, welfare payments and funding to local government and public services. By 2018-19, one in five people in the UK, including many in work, was living in poverty and many still are—in fact, those numbers are increasing. Like the changes in the economy, these austerity cuts had a greater impact in the poorest communities, making the effects of the loss of secure employment worse. Poverty and reduced funding of this nature were reflected in increased unhealthy and harmful behaviours, such as poor nutrition, alcohol use and smoking, and less provision of or use of preventive healthcare and, consequently, increased mortality.
Pedantically—and I hear this said regularly—it is correct that healthcare spending was affected less by austerity than other sectors. There has been an annual 1% to 3% increase since 2010, but it has been insufficient to keep up with the increasing demands of an ageing population. This imbalance has led to longer waiting times for primary and specialist care and, once again, the most significant effects have been in deprived areas. The real-term cuts in public health spending have also been larger in the north and north-east, where life expectancy lags.
To make matters worse, helping people to stop smoking and health checks, which affect diseases with substantial contribution to mortality inequalities, had greater than average funding cuts. To arrest and reverse this trend of falling life expectancy, we need economic and social policies that specifically address inequalities, supported by greater investment in public health and healthcare in the communities with the lowest healthy life expectancies.
Despite the terms of the Government’s response to the committee’s recommendations, thus far the post-Covid “build back better” agenda does not explicitly address equity. The levelling-up funding plans to address these regional inequities, particularly in the so-called left-behind districts, appear to be focused on investment and infrastructure. At best there has been a limited specific focus on areas such as child poverty, public health or high-skilled education.
An awareness of place is crucial to tackling inequity. It is regrettable that place-based improvement in northern cities, for example, remains limited to local action facilitated by devolution in cities such as Manchester, and community resilience, well-being and regeneration initiatives. Without additional resources for education, employment and health, these positive steps will prove insufficient to address this issue. To reverse the decline in longevity in many of our communities, health equity needs to be a key outcome of policy.
The date set for the publication of the spending review, 27 October, is the opportunity for the Government to provide at least some certainty on these important areas of spending and investment, including those identified in this report. It could also be the foundation for at least the outline of a coherent plan for reducing health inequalities over the next Parliament, as recommended in this report.
However, although such smart homes can promote independent living and safety, there are two important issues. The first is privacy: how would an elderly person react to being constantly monitored in their home? The second is the possible risk that such technologies, by making the elderly person more capable of being on their own, could even promote further loneliness and social isolation. Impressive as these new technologies and services are, there is a need for more research to understand whether they would be acceptable to the user and whether they would in fact make a real difference to older people’s lives.
There is also the important issue of digital service provision for older people. We heard evidence suggesting that only around 60% of one-person households, where the person is over 65, have broadband. This widespread lack of broadband connection is likely to become less of an issue with the advent of 5G. Nevertheless, we recommended that the Government ensure internet access for all homes so that older people can access services to help them to live independently and in better health. Lifelong digital skills training is needed, so that when people enter old age they will have the ability to use the available technologies to their benefit. The Government’s recent introduction of a new entitlement for adults with few or no digital skills to undertake specified digital qualifications, up to level 1, is to be welcomed.
I will now address medical technologies. Our committee received evidence that wearable and implantable medical devices have an increasingly important future for the ageing population. Miniaturised devices applied to the skin or implanted into the body can allow precise and timely interventions to improve healthcare while reducing the number of medical appointments. For example, people with diabetes can use implanted technology to monitor blood glucose levels and deliver insulin. Devices monitoring other important health indicators, such as blood pressure and skin temperature, are also envisaged. More futuristic are exciting engineering developments in the field of microrobotics that may enable very local drug delivery or other treatments, such as microsurgery, within the body. There are also non-invasive surgical techniques, “robotic” implants, ingestible robots, in-body sensors for monitoring purposes, implanted drug delivery systems such as insulin pumps, and many others.
In the light of the evidence that we received, our committee concluded that the use of wearable and implantable technologies for monitoring health conditions and administering treatments is likely to become increasingly common. Such technologies have the potential to provide more precise and timely treatment and could well contribute to better health and greater independence in old age.
Our committee recommended that the Government support the deployment of technologies that contribute to healthier and independent living. Our universities and industries are world leaders in science and engineering and are consequently well-placed to undertake the necessary R&D. UKRI is making significant investment in early-stage technologies to support the ageing society grand challenge through the healthy ageing challenge. It is to be hoped that the forthcoming spending review and Autumn Budget will continue to support and indeed increase this UKRI funding that is so vital for our ageing population.
My final remarks relate to the mission of the ageing society grand challenge announced by the Government in 2018. This was eloquently addressed by the noble Lord, Lord Patel, in his opening speech and by the noble Baroness, Lady Young of Old Scone. The Government’s mission was to
“ensure that people can enjoy at least 5 extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest.”
Technology can undoubtedly contribute to independence and social connectedness in old age. However, even with the rapid engineering advances that we are seeing, it seems unlikely that technology can add five years of healthy and independent living by 2035. Moreover, there is a risk of new technologies actually widening the health inequalities gap in old age, due to barriers to uptake being more prevalent in disadvantaged groups. We heard from several witnesses that technologies and services may heighten inequalities if products are not affordable and accessible to deprived groups. The Government will need to take the necessary steps to make these new technology tools ubiquitous and beneficial for the whole population in old age. Can the Minister comment on this and indicate how the challenge will be met to avoid the inequalities gap potentially increasing?
The statistics of disease and mortality recorded 100 years ago are dramatically different from the modern statistics. The Office for National Statistics has a web page titled “Causes of Death over 100 Years”, which shows the top causes of death by age and sex from 1915 to 2015. The incidence of mortality through infectious diseases has been radically reduced over that period. Until after the Second World War, infections were generally the leading cause of death for young and middle-aged males and females. During the second half of the 20th century, polio, diphtheria, tetanus, whooping cough, measles, mumps and rubella were all virtually wiped out, largely as a consequence of childhood immunisation. Meanwhile, from 1945 onwards, heart conditions became a leading cause of death for middle to older-aged males, followed by cancer. A similar trend, occurring at older ages, has been seen in women during that period, while younger to middle-aged women have more frequently died of breast cancer.
The committee’s report remarks that modern medicine is still dominated by the objectives of defeating single diseases and single ailments. To be more appropriate to treating an ageing population, it should be addressing what is described as multimorbidity, which is the state of having two or more long-term medical conditions. Coronary disease, hypertension—or high blood pressure —diabetes, dementia and strokes are all highly correlated in the aged cohorts; that is to say, they occur together, but they are being treated as if they were isolated ailments.
The experience of death and the social attitudes towards it have changed markedly over time. In predominantly rural communities, the realities of birth and death, witnessed in both the animal and the human populations, are liable to be part of everyday experience. These experiences are curtailed in urban populations.
In late Victorian times, the decline in premature mortality was accompanied by a curious side-effect, which was the ritualisation of death. This can be witnessed by visiting the cemeteries that date from then that accommodate lavish funereal monuments. In London, the Brompton, Highgate and Abney cemeteries are prime examples. Later, when cremation became an acceptable means of disposing of bodies, the memorialisation of the dead was much diminished. The incidence of mortality per head has been much reduced by the increased longevity that we have witnessed in the past 100 years. Nowadays, death is marginalised. It is no longer ever-present in our consciousness. I suggest that this marginalisation has had some deleterious consequences.
Although we are aware that the population has aged, we have been unwilling to face the consequences. Our provision of care for the elderly has not adapted to these circumstances and it has become seriously inadequate. We are frequently surprised and resentful when relatives die. Many appear to believe that death occurs only through medical negligence or malpractice. Doctors are fearful of being blamed for the death of relatives and they seek to indemnify themselves against complaints by asking relatives to assent to “do not resuscitate” orders.
The report is replete with recommendations of what should be done to reduce the impact of the diseases of senescence. It emphasises the well-known circumstances that undermine health in later life. Foremost among these are smoking, alcohol consumption and obesity, but only the first of these has been consistently targeted by public health campaigns. Much less has been done to address alcohol consumption, obesity and the lack of physical exercise. It is notoriously difficult to change human behaviour merely by exhortation and there has been political resistance to the interference of what has been described as the “nanny state”.
The recommendations of the committee’s report are too numerous to recite, but some of them are striking and should be remarked on. The report declares that the piecemeal approach to the problems of ageing needs to be replaced by a co-ordinated approach that addresses the complex and interrelated problems. Patients are often prescribed a multiplicity of drugs, with little attention given to the potential for their damaging interactions or to the harm caused to a patient by a pharmacological overload. It has been recommended that ageing people should be assigned to a designated clinician who has a complete oversight of their care.
The report calls for further research into the processes and problems of ageing and asserts that not much is fully understood yet. It calls for fuller and more enduring longitudinal studies. However, cross-sectional studies are needed that would highlight the disparities in health that are attributable to the inequalities in our society. The Covid pandemic has revealed the health hazards associated with social and economic deprivation and the stark differences in health and mortality between ethnic groups. Surely the most effective means of promoting good health in an ageing population is by striving to achieve a just and equitable society.