Website of the Department of Health

Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 21 May 2008: Prevention Speech: Old Age is the New Middle Age

Thank you very much for inviting me to speak here today. I’d like in particular, to thank the King’s Fund for hosting this event.

For over one hundred years, the King’s Fund has championed the health needs of people in London – raising money for voluntary hospitals and acting as a guardian of excellence.

And over the last twenty to thirty years, it has of course, led the way in health and social care research, in particular, in the arena of public health. 

This is therefore the perfect venue for our discussion today.

Preventative Healthcare: A Brief History

The issue of preventative healthcare is not new. The most profound improvements in health of the 19th and early 20th century were led by public health initiatives. Providing better housing reduced  the levels of tuberculosis. Improved sanitation quelled outbreaks of cholera and typhoid.

In 1839, William Farr, the prominent sanitary reformer declared that: “A park in the East End would diminish the annual deaths by several thousands, and add several years to the lives of the entire population.” Victoria Park, just a few miles east of where we are today, was to become the first publicly owned park in London, and a vital resource for residents in the slums of Bethnal Green.

But public health efforts were patchy, untargeted and motivated by the goodwill of philanthropists and the campaigning of radical reformers, rather than by government. 

Such interventions gave way eventually to the national health service free at the point of need, that made 20th century advances in medicine available to everyone irrespective of their income.

But this does not mean that the NHS was set up simply as an infrastructure to treat ill health. Its aim has always stretched well beyond diagnosis and treatment. The 1944 White Paper, which led to the creation of the NHS, said and I quote: “Much of present custom and habit still centres on the idea that the doctor and the hospital and the clinic are the means of mending ill health rather than the increasing of good health.” The intention from the very beginning was to prevent poor health and in many respects, it has lived up to this ambition.

The principle of free access to primary care, so that no citizen had to wait until they were so ill that the fact that they couldn’t afford to see a doctor ceased to be a consideration, is fundamentally one of prevention.

Mass immunisation schemes, pioneered by the NHS in the 50s and 60s all but eradicated childhood diseases such as polio and diphtheria. Child health screening and universal access to antenatal care led to dramatic reductions in infant mortality and improved maternal health.

This year, we celebrate the 20th anniversary of the introduction of screening for breast cancer, which saves 1,400 lives and cervical cancer, which saves 4,500 women’s lives each year.

Technological advances have vastly improved our understanding of disease and its causes, so we can detect disease much earlier and predict its onslaught more effectively. And critically, we have a better understanding of the correlation between poor lifestyle and poor health. To prevent is not just to predict, diagnose and treat. It is also about promoting good health. This needs to be our key focus as we put greater emphasis on prevention.

Shortly, we will publish the final report of the NHS Next Stage Review, which has been led by my ministerial colleague Lord Darzi. It will set out how we can make the NHS – world class in so many respects – world class in all respects. And in particular, how we can remorselessly focus on promoting good health as well as preventing and treating bad health.

Obesity, smoking, alcohol, the link between poor health and deprivation, and the challenge of supporting an ageing population with increasingly complex health and care needs – these are the modern health variation of Beveridge’s five giants. They threaten to undermine the astonishing achievements of the last 60 years.

There are fewer smokers in this country than there have ever been. But smoking still remains the single biggest preventable cause of early death and disease.

It could soon be joined by obesity. Nearly a quarter of adults and almost a sixth of all children are obese. As the Foresight report graphically illustrated if we take no action, by 2050, that figure will rise to over half of all adults and a quarter of all children. And if obesity isn’t tackled, we will have to confront for the first time, the prospect of the life expectancy of today’s children being the same or even lower than that of their parents.

Alcohol-related deaths are rising – they have more than doubled since 1991 and now claim nearly 9000 lives every year.

The fifth giant – an ageing population - is one we should be pleased about, but demographic change brings a whole host of new challenges. In 1948, when the NHS was established, over 65s made up less than ten per cent of the population. They now make up around sixteen per cent. For the first time in our history, there are more pensioners than children, and centenarians are the fastest growing age group.

Promotion of Health in Childhood

So how do we deal with these new and very different health problems? Early intervention is crucial. Promoting good health must begin in the early years. The success of immunisation programmes and child health screening programmes is indisputable.  In the1960s, measles was seen as a fact of childhood, now, thanks to mass immunisation schemes, it is a rarity.

But if we want to tackle obesity, if we want to reduce the prevalence of smoking and drinking in later life, then good health habits need to be ingrained early on. Health promotion isn’t just about what happens in doctor’s surgeries and hospitals, as you all know full well – it’s about what happens in homes, schools and communities.

Health visitors have played a vital role in delivering trusted advice to new parents on all aspects of the health and wellbeing of their child, continuing a fine tradition of public health nursing that dates back over 100 years. This is a tradition that we need to preserve and develop.

The Child Health Promotion Programme, led by health professionals, enables health workers to target advice and support on those who need it most.  So as early as 12 weeks into pregnancy, mothers who are already overweight or obese are identified and advised on healthy weight gain, which will aid their baby’s development and safe delivery.

And the Family Nurse Partnership programme provides direct help to new parents facing acute and multiple problems. It has already proved successful in promoting breast-feeding and other healthy behaviours in families who need intensive support.

Children’s Centres are providing families with convenient access to a range of services – including childcare, health and employment advice. The majority of primary and secondary schools are now involved in the healthy schools programme – increasing participation in sports both in and out of school, as well as providing healthier food as well as comprehensive advice on all aspects of healthy lifestyles – such as diet, exercise and the risk of smoking and alcohol use. 

All of these initiatives are necessary but they are not sufficient.

The Middle Years: Interventions and Screening

The benefits of health promotion don’t disappear when young people reach their late teens and early 20s. They are important at every stage of life.

Middle age is often the time when our ingrained habits catch up with us – the awkward period as one commentator put it “where father time catches up with mother nature.” Or, as somebody else once said, when your broad mind and narrow waist swap places. Health problems caused by years of heavy drinking or smoking start to manifest themselves in this period and the need for early detection becomes even more important.

In January, the Prime Minister set out plans for a vascular screening programme that will enable doctors and other clinicians to identify more people at risk of heart disease, diabetes, stroke or kidney disease – conditions affecting over 4 million people. Offering those at risk advice on how to change their lifestyle or the benefits of preventative medication can substantially reduce the risks of these life-threatening conditions.

In addition, by providing men aged 65 with a simple ultrasound test to detect early abdominal aortic aneurysms, we could save more than 1,600 lives each year.

 So early detection is a crucial element of the preventative agenda, particularly in middle age.  But what more can we do for those who are in good health but struggle to maintain a healthy lifestyle as they work longer hours, frequently juggling employment responsibilities with childcare and other caring duties.

Lifestyles that are simultaneously hectic and sedentary can lead to weight-gain, drinking problems, fitness loss and debilitating conditions such as back pain. A forty year old man who is in apparent good health, but has smoked for 25 years and rarely exercises is not going to find it easy to change the habits of a lifetime. Deteriorating health is more likely to lead him to his GP, rather than a new-found enthusiasm to protect his health for the future.

Tackling this will require a much broader coalition. Promoting good health is not the sole responsibility of the health service. It should be ingrained in, education, transport services and town planning. Employers can play a huge role by providing opportunities for employees to take time off to exercise, giving on-site health advice and providing basic provisions such as changing rooms and shower facilities. Working with the Department of Health, the Royal Mail has developed a health trainer scheme, to offer practical advice and support to staff. And its online health check and assessment centre is enabling 180,000 employees to regularly monitor their health and wellbeing. Their sick absence has reduced dramatically.

Few of us manage our recommended weekly quota of exercise. Yet if employers were to encourage their staff to jog, cycle or walk even part of their way to work each day, we would increase the number of people getting enough exercise from three out of ten to seven out of ten.

Old age: can it be the new middle age?

So we need early intervention, we need better screening, we need a stronger message, but the need for health promotion doesn’t end in middle age. Our perspective on ageing is changing. We have children later, we work and stay active for longer and of course, life expectancy has improved.

Today’s 65 year old man can expect to live until he is 81 and a woman can expect to live to 84. Some of them will spend much of that time in good health. We see nothing unusual in a US presidential candidate who is in his 70s or the adventurer who climbs Everest in their 60s. Or indeed the pensioner who uses their free bus pass to travel from John O’ Groats to Land’s End.

For many people today, their 60s and 70s really is the new middle age. But for others, it’s a time of recurrent health problems leading to misery and isolation. One in four older people suffer from depression. Alcoholism and drug use amongst the over 65s have increased, with suicide rates, which have fallen for all age groups, are for this age group at an all time high.

Health and social care services need to adapt to the changing and diverse needs of today’s older people –those in good health and those who need extra support.

Cicero said: “Advice in old age is foolish; for what can be more absurd than to increase our provisions for the road the nearer we approach to our journey's end?” Well he was wrong. There are significant benefits to promoting health and wellbeing among older people.
Even those who’ve smoked all their adult lives and don’t give up until they are in their 70s are still likely to reduce their chances of suffering from heart disease or cancer. Five years after quitting, the risk of a stroke will be the same as that of a non smoker. Within ten years, the risk of heart disease will also fall. Cessation also leads to reductions in the risk of hip fractures, cataracts and rheumatoid arthritis. Six out of ten over 60s who use NHS Stop Smoking Services quit compared to four out of ten of the under 35s. 70 year olds who take regular exercise and don’t smoke are nearly 20 per cent more likely to reach their 90s than those who continue to smoke and lead sedentary lifestyles.

You have been kind enough to host the Prime Minister and last week, I launched a major public consultation with the Prime Minister about how we should fund adult social care. We know that the current system is not working – it is neither fair nor sustainable. In particular, too many elderly people lose their independence unnecessarily, because they can’t access the low level support they need. Those who have very old relatives will be familiar with the pattern  – the loss of a husband or wife can lead to isolation, housing difficulties and financial problems. A trip or fall leads to a lengthy hospital stay, loss of confidence, and eventually to multiple care needs that can only be met in a residential home.

I believe we can do much more to promote good health in old age and help more people to maintain their independence and quality of life. The National Service Framework for Older People, published in 2001 made clear that we would improve access to low-level, preventative care services for older people. But progress has been patchy and inconsistent and many older people still struggle to access basic services.  They don’t know where to go to access the care and support they need to maintain a fulfilling, independent life for as long as possible. We need to explore what needs to happen nationally to support the National Service Framework – particularly around improving access to intermediate care and rehabilitation services.

But we need to do more to prevent the circumstances that lead to older people losing their independence in the first place. Falls are responsible for 2 million hospital bed days per year and are the cause of approximately 40 per cent of all long term admissions to care homes. Fractured hips cost the NHS and social care services £1.8 billion every year.

Fifty per cent of all falls among older people are second falls, so that indicates very starkly that in too many instances, once an older person has experienced a fall, they don’t get the rehabilitation they need.

Primary care trusts who work with social care services to prevent falls among older people enable more of them to stay in their own homes for longer as well as reducing hospital admissions and other potential costs. Strength and balance training, good podiatry services, better lighting in homes small things  such as handrails can all help to reduce falls substantially.

The Partnerships for Older People Projects (POPPs), which I saw in action in Dorset, are promoting the health and wellbeing of older people through innovative services delivered jointly by health and social care professionals. By engaging older people in what services would help them most, POPPS is enabling more older people to maintain their independence for longer. In Southwark, for instance, they are providing specialist services for elderly people returning home after a stay in hospital. Health and social care workers identify services that are normally delivered in hospital to older patients recovering after treatment that can be delivered as effectively in the home. They work with older people to identify other support they may need to remain independent. This gives older people longer to recover from a spell of illness and instead of being pushed into a care home – they have the time they need to reflect on what care and support they will require in the future.

Older people are already entitled to a range of preventative services, including flu vaccinations and eye care. Bowel cancer screening is becoming available to the over 60s and by 2012, breast cancer screening will be extended to women in their early 70s.

But again we need to do more. Building on these existing entitlements and to the Abdominal Aortic Aneurysm screening programme I mentioned earlier, my intention is to develop a prevention package to improve the support we give to older people – in particular, to enable more of them to maintain their independence and lead active, sociable lives for longer.

So in addition, we will encourage PCTs and social care services to work together more effectively to improve fall services and provide more comprehensive support for older people returning home from hospital after a fall or illness. In particular, we want to see PCTs using their powers as commissioners of services to give older people a say in what these services should look like and how best their needs can be met.

We will work with all interested parties to review the provision of low level podiatry services, to ensure that more older people – not just those with acute needs - can access services such as nail-cutting, which are essential to maintaining mobility and independence.

Last week marked the beginning of a £31 million programme to test the potential of technologies such as telecare and telehealth to help those with complex health and social care needs manage their own conditions at home. We will also set up an expert learning group to consider how best telecare and telehealth schemes can be implemented across the country.

And additionally, we will consider how to revitalise fall services, how to make them a higher priority for PCTs and we’ll also encourage better commissioning and integration.

We will look at how we can improve hearing services for older people –  we’ve already come a long way in reducing waiting times for the assessment and treating of hearing loss, but we can do more. In particular, we want to reduce the waiting times for the fitting of hearing aids.

Conclusion

Increased life expectancy and rising expectations mean that for many older people, the age milestones of the past such as 60 and 70 are no longer this kind of  curtain that gently nudges them off centre stage and into the wings, or to paraphrase T.S. Eliot, a prompt to “stand still and stagnate”.

Our aim must be to make quality of life stretch right to the end of life. Promoting health and wellbeing throughout life, coupled with preventative health interventions, will, I believe, not only improve life expectancy, but also healthy life expectancy.

And then for us (and indeed, the NHS), life really will begin at 60.