I'd like them to welcome our first speaker, who is Laurel Hicks, and Laurel is a research fellow at the Oxford Institute of Population Ageing, and she's got over two decades worth of experience in working in this field. Her particular interests, acute and long term integrated care service delivery models and financing. So three public sector and private sector models are both very, very important areas for us to consider.
If we're thinking about old age psychiatry, I must say particularly intrigued that she's also worked in the office of the president and in America. So I think that sounds sounds great. And I'm imagining all sorts of the West Wing in all its glory. And what you might think of that. See, that probably probably just have to talk to you over coffee to find out about that.
But you're very welcome. So thank you. I'm interested that you started the introduction by saying, you know, I really like what I do. It's really interesting. And I think that that's an important message because I got into ageing in 1983 and I really like what I do. I've done I've been able to do some really interesting things in the field. And so I you know, to the extent that this is this is the talk about opportunities, career opportunities, this is this is a good one.
So as Charlotte said, I I'm a research fellow here and I've had academic appointments here in Australia and in the U.S. and about half of my time I've been in academia and half the time I've been in public policy and which is, I think, a little bit more common in the U.S. than it is here and in Australia, because what happens, at least in my field, which is health policy, is that when a president comes in that has as part of his,
you know, what he wants to accomplish during his time as health reform, then all the people who have been sort of hiding away and think tanks and universities, we all come out and we work for the president and try and do, you know, try and work our magic. And then when it fails, which is what happened when I worked for President Clinton as the health reform effort failed. And then we all go back and to think tanks and academia and so forth.
So with that, the other thing is that I would like to slightly change my topic from challenges to challenges and opportunities, because I think that this field is wide open with with opportunities, not challenges. Always seems a little little heavy to me. First, I'd like to describe some of the demographic measures that are commonly used and then link them to specific policy,
challenge public policy challenges. And I'm going to do this in both sort of a theoretical way because, you know, I think you need some grounding in people's beliefs and values in order to think about public policy. But I'd also like to give a really a very concrete example, both from my interest, but which sort of links into some of the some of the the future speakers.
And I'm going to touch on three public policy areas just really, really lightly, sort of once over lightly of that are that are common in this area.
It's the future financing of health care and the implications of an ageing population on that, a future financing of pensions, also a big a big public policy area and then labour force participation, both older people moving in and out of the workforce, but also the the labour force issues around having sufficient numbers of people to take care of older people.
So the care sector and as a sort of an overarching theme or concern, I'd like to I'd like for us to think about all of this in the context of all of this social contract, this generational contract between workers and older people, and how public policy is about figuring out ways to share the burden and and and and our nation's resources. I mean, I think that's really the what all of this is about ultimately. So let's start with the first measure of demographic change, life expectancy at age 65.
So hooray. Right. Fantastic, we've in the last 30 years, men live five years longer, women live four years longer. So now life expectancy is about 83 for men and 86 for women. Hooray. Right. And it's so interesting that so much of this is is not couched in hooray. I mean, I think this is amazing that we've made this sort of progress. And this is just in the last 30 years, you know, beyond a lot of the sort of issues of the past.
But but again, you know, it doesn't always get met with that sort of response. So let's dig a little deeper, a little. Let's look at a maybe a slightly more meaningful measure of demographic change. And that's that all of those extra years that we added, they're not always healthy years, and that's where the public policy challenges come in. So instead of Harare, it's more like Umrah.
We've half of those years, half of those extra years actually aren't aren't lived and in good health, mental or physical health. So a lot of policy challenges around that. They that after age 65, health care costs go up, social care costs go up. Well, actually, the I think it is important to say that actually what we're doing is delaying those costs more than than sort of having them go up the scare. Again, the scarcity of labour in the care sector really important.
And so the big public policy challenge, the big goal of public policy is to increase that the share of those extra years that are lived and a healthy a healthy way. Third measure of demographic change is life expectancy after pensionable age and pensionable age being a slightly more meaningful term than age 65. Obviously, age 65 is kind of a social construct or a public policy constructed age. It's no reason why 65 is when people retire.
So pension pensionable age is a little bit more fluid and a little bit more meaningful. So the challenges, when you think of it in the context of how many years are you going to live after you stop working, has a lot of implications for the cost of pension systems. And I think this next point at the bottom is that ageing ageing is in a lot of ministers portfolios, unlike other issues, say maybe education, which is fairly concentrated in one portfolio age ageing crosses a lot of boundaries.
And so I think it's really important to while most of the challenges fall in health, labour and pensions, that the ageing population will show up in an awful lot of portfolios in Westminster.
Now, the those extra years, I think it's also really important to think about in in a public policy way, is it not all of those years are are healthy and not everybody has the same sort of experience in terms of their and in terms of their physical health after retirement is kind of a harsh way of putting it. But death is death is not democratic.
And so the physical health of someone and probably in our our sort of cohort, which would be a high grade occupation, the physical health of one of us at 70 is is approximately equal on average to the physical health of someone who's 62 and at a low grade occupation. In fact, in Australia, the differential between white, Anglo, older people and the Aboriginal population is is so endemic that the the eligibility to that eligibility age for benefits is actually 55 for Aboriginals instead of 65.
They've just systematically, you know, said you can have benefits 10 years earlier than everybody else. These inequalities come from a lifetime of advantages, different differences and advantages and disadvantages from birth and death. And so sort of a really big public policy goal or a challenge is how do you redistribute resources at the end of life to make up for a lifetime of differences? That's a really, really big picture sort of public policy goal.
The fourth measure, which you probably hear about a fair amount is this old age dependency ratio. And I think that, you know, again, this sort of harkens back to that, you know, the earlier comment that I made about the generational contact and sharing the burden and resources.
How do you how do you how do you work that out? And so what you see here is that this old age dependency ratio, which is basically a ratio of working people to people who are retired today, you've got 25 working people support a way. Excuse me. Anyway, the ratio is 20, 25, whereas it's going to go up 70 percent in 50 years. So a lot more burden on the working people to support support old age.
So part of this is is really how to how to look at the pension systems and the and Labour labour regulations and labour practises to to either discourage or encourage people to be part of the workforce, to stay in the workforce and into older age. So this is a fourth measure, this old age dependency ratio that you see, that you see quite a lot.
And I actually think that as a measure, it's, you know, again, it's it's it's it's really attached to this sort of burden of of ageing sort of discussion, you know, again, talking about this in terms of a burden instead of hurray, we've got lots more people living, living to longer ages. It's the burden of workers and and who they need to support. So it's sort of a sort of an alarmist way of describing demographic change.
And the other piece of this is that you need you really need to think about the other way. It's not all about economic formal employment. It's it's about some of the non-economic transfers that occur in society, grandparents taking care of their grandchildren, other sort of meaningful and productive activities that older people are involved in. I'm sure the AMA will be talking or perhaps we'll be talking about that in the context of the Alzheimer's Association and the sort of volunteer efforts.
So this this this burden, I don't think I think it's more meaningful if you measure it, not just in economic terms. Now, there's also the public policy discussions are. Influenced by two things. First of all, it's sort of what's on offer, what are the what are the different policy changes and how how are they different options, how they play out, what their what their impact is in terms of efficiency and effectiveness in targeting and and so forth.
But but the other thing that we that I'd like to sort of gloss over kind of quickly is that there are beliefs that undergird these discussions and and and and policy paradigms that do sort of drive the way people think about the public policy options. Not today. The sort of more popular policy paradigm is this active ageing paradigm where it says here from the World Health Organisation's definition, it's the process of, you know, optimising opportunities. Right.
It's it's a much more holistic that that ageing is more than just working and being economically productive. It's about it's about enhancing quality of life. And it's probably one of the terms that you've heard or will hear is quality adjusted life years. You know, it's more than just about the economics of it. And this that policy, that active ageing paradigm has replaced the earlier paradigm, which is productive ageing.
Like how how how much do you bring in terms of production to the to the the discussion here now the example of this sort of active ageing versus productive ageing paradigm played out in, you know, over the last 60 years or so in the context of the labour shortages or just the labour dynamics in in the UK.
So one of the you know, I think that one of the things that raises the question of whether or not old age is as socially constructed and and and here the example that seems quite relevant is in the 1950s, what happened is there was there was a lot of labour shortages. And so the the there were a lot of government appeals to older people to, quote, not sink into premature old age.
In other words, they're saying, please, we need you to stay in the labour market because there's a lot of shortages in the 1950s, by the 1970s, with rising unemployment, you know, the the reverse happened and there were all these appeals to people to retire, to free up good jobs for younger people. And that's probably a slightly more familiar refrain to to you all is this idea that the job release schemes get out, make opportunities available to to younger people.
So so the you know, what's interesting is that, you know, your experience with older age seems to be at least somewhat constructed by the needs of the environment. Do you do you want me to work or do you not want me to work? And the and the active ageing paradigm sort of says, let's create choices. So people who do want to work that the opportunities are there.
People who don't want to work, they'll they won't fall into a situation where they you know, where they're impoverished and without resources and so forth. So creating meaningful, meaningful activities for people outside of retirement and supporting them, but not treating them as a homogenous group. The eight, the elderly. Interestingly, you might you might have a different perspective on that as we start the day.
Perhaps by the end of the day, you'll realise how heterogeneous older people really are. Now, the the other thing that will be discussed and a bit more later in the in the day is this notion that also that active ageing cuts across a lot of interrelated policy areas. And I had sort of talked about health policy and social care policy and pension policy and and so forth. But the but the the important point is that if we really want to.
Increase those extra years in terms increase the sort of good physical and mental health and those extra years that you really need to look across quite a few boundaries. A lot of policy boundaries to to to achieve that.
And I'm going to elaborate that on that. And in the next couple of slides, and this is sort of a topic sort of near and dear to my heart is how hospitals and GP practises and nursing homes and community care, how those things work together, how the acute and the long term care systems work together. Now, why do we know why is there a push for this? Besides just demographics, the chronic health conditions are becoming much more prevalent amongst amongst the young and and the old.
So all these, you know, heart disease and stroke, cancer and so forth are all much more prevalent.
But what's really interesting about chronic disease, as opposed to the more acute types of diseases, is that these disabling conditions are are much more the outcomes of those conditions are much more dependent on the, you know, sort of what's what's around them said things like vulnerability in terms of frailty, social isolation, mental mental illness and lots of other social advantages really exacerbate chronic care conditions.
And so you can't really separately treat the chronic condition without looking at the context that it's occurring. And so it's, again, this sort of the need for a more holistic view when you're looking at when you're looking at chronic conditions. And a lot has been written about about acute and long term care and how they don't work well together, how people are are are left in hospital beds because it's hard to discharge them to care homes. Why people aren't getting the sort of care they need.
Some of the acute services they need in a care home wind up in hospitals, you know, that sort of thing. And and, you know, again, thinking about that active ageing paradigm, is it ultimately this journey, patient journey? What a lot of people now are talking talking about in the context of person centredness is that patients should be actively involved in their decisions and in their journey. And then how? As a chronic condition, as a person with a chronic condition, how how this will play out.
This is especially true, I think, in the end of life care. And and too often and these are some quotes that I had read from the from the UK press about how the NHS operates, that it revolves that care that revolves around buildings or historical practise instead of people. And that's the sort of sort of thing that really bumps up against the idea of active ageing and that patients often fit their needs and lives around services on offer rather than experiencing flexible and responsive systems.
So these are the sort of sort of things that I you know, I pulled out of the press about how the NHS works and how it's in conflict with integrating health and social care and doing this around the needs of of the older person. Now, new developing new care models, innovation and so forth has dominated for decades the policy discourse and in and the UK.
And I think it's quite interesting that the UK has taken this sort of let a hundred flowers bloom approach because they realise that local context, the talents of the strengths and weaknesses of local communities really matter a lot and trying to form and form new systems and that we really we really haven't figured out quite,
quite how to do this. And so built into a lot of the efforts and particularly a relatively new effort in the UK, the innovation pioneers built into that as a process for evaluating the outcomes and then communicating what works and what doesn't. The communications strategy is very much a part of of, you know, these new, you know, hundred hundred flowers blooming around the U.K. But all of this, of course, the the devil is in the details.
That's my that's always been my favourite term in the context of health reform. You might have these great ideas, but operationally, how they play out is really is really important here. So, of course, near and dear to my heart financing, how do you sort out the money? And and there's been a lot of discussion about pooling budgets, bringing together the acute or the health and the social care budget at the level at the level of the community.
Quite a lot of counties are trying to do this because they see, you know, two different systems with two different pots of money that are that are funded in really different ways, whether they're local council taxes or coming from coming from the bigger central government. So, you know, getting the money right does involve as a first step, putting the putting the money that a person is eligible for together into a single pot and trying to figure out what to do with that.
But it's also really important to to get the right incentives built in to the way the money flows out. And and ultimately, what you're trying to do is to provide for people the the right services and the least restrictive excuse me, least restrictive setting. So it's sort of like the downward substitution of care where you can take care of someone in the community.
You should do that instead of having them go to a care home where you can take care of somebody in a rehab unit instead of in a in a more acute setting, you should try and do that and to align the incentives, the financial incentives in such a way that you can that you can achieve those those sorts of goals.
And and it's really important that the financing system doesn't reward activities that may increase the incomes of the people, that you're not rewarded for providing more services, but instead you're rewarded for providing better outcomes. So one of the ways of doing this is, is through a capitated system. And, you know, I could spend the whole day talking to you about the sort of the technical difficulties of upsetting capitation rates.
But so that's sort of the first the first level to me is getting getting the money straight. The second is is getting in place those mechanisms that help you integrate care and those involved care management and and also involve information systems. And there's a lot again, this is another hundred flowers bloom sort of thing.
There's a lot of care systems, our care management systems and information systems that are there to support and to to help to help bring together the care needs in a sort of person centred way. But the couple of really important lessons to learn from from decades of experience in these areas is that it's really hard to try and fund those mechanisms to try and pay for those mechanisms.
With savings, you really need to build into your reform money to buy an information system rather than saying we'll pay for it with the savings we get out of becoming more efficient and more effective providers. So that's kind of like one key lesson from decades of experience in and looking at care management systems. The other the sort of third key lesson that that I would sort of put forth to the UK in terms of trying to get get it right,
get it like a really practical level. Get this, pulling the system of acute and social health and social care together. First of all, not everybody needs care management. Not everybody to to have a case conference on someone whose needs are very simple is is a waste of resources.
What you. You really need to do is try and target people with complex needs, people whose needs cross boundaries, cross settings, a few of the groups of people who integrated care works best for or are frail elderly people who are eligible for nursing homes but are in care homes. But you're trying to keep who you're trying to keep in the community. HIV AIDS populations there needs cross a lot of boundaries. And and those are sort of groups that would be targeted to this.
In the U.K., there's been a lot of focus on specific diseases and creating care pathways for specific diseases and and sort of standardising the way the way care receives its prescriptive. But it can be, you know, the checklist. You know, if anybody's read the Atul Gawande checklist book, you know, it sort of speaks to that sort of thinking. The problem, of course, is what happens when you have multiple conditions. So which pathway do you take or how do you how do you merge pathways?
Because often people do have more than more than one condition. And and in terms of getting it right, I also think, again, going back to the aligning the financial incentives, but also getting providers to be thinking about outcomes, not to be thinking about the process so much, but say, how am I going to keep someone out of the hospital? How am I going to keep a nursing home patient out of the hospital?
What what's the best way to do that and how to get the money sort of lined up to to achieve that sort of that sort of goal? And then this is the kind of the piece for you all is where did doctors fit into this this new these new care models? This is sort of the fourth lesson, the take home lesson from some of my experiences looking at these issues in Australia, but in particular some of the efforts that have been that have been done in the
in the U.S. And I spent quite a lot of time following a model in the U.S. years, quite a few years ago. But a model that's actually expanded quite a lot. And it's really, really important that doctors behave differently in these sorts of models. And in the U.K., this is probably less of an issue than in the U.S. I think doctors in general just are.
In fact, what's really interesting is that us this is in some of its more recent efforts, is trying to replicate what the UK already does, but to do it without having socialised medicine. So the culture change, this whole notion of working in a multidisciplinary in a multidisciplinary team is really, really critical to the active ageing, integrated care.
All of these all of these sort of big pictures that you're trying to achieve involves a lot of behaviour change and and working together in teams and respecting the that when you're sitting around the table. And one of actually one of the great example in this this model in San Francisco's Chinatown is that they would have at the time, the care conference table.
They would have the doctors and the nurses and the therapists, but they would also have someone who represented the transportation people, the people who brought brought the older people into this day health centre. And of course, this is San Francisco's Chinatown.
And some of these older people were quite small and would live and walk up like would live on a fourth floor, walk up and and and some of the transportation drivers would literally pick them up, pick up the elderly and take them down the stairs and put them in the transport to bring them into the day health centre. And those transportation workers, those drivers could tell you a lot about that person just by picking them up.
So here you are at a case conference and they'd say and, you know, transportation, what can you say about Mrs. X? And they they could actually have really meaningful input into she seemed more or she seemed less or, you know, when I looked at her house and it wasn't clean and it was always clean before and so forth. So so as the doctor sort of valuing the input of other disciplines is a really critical piece, a really critical lesson here.
And again, I I'm going to I'm sort of sort of going to leave you with with a quote from from a paper. This is from this is 1994 and it is in the US. So or it's based on us doctors. But I think it's worth it's worth you know, just pulling out as a closing words is that, you know, a lot of physicians are uncomfortable not being the the pre-eminent or the dominant voice at the table. And that I'm sorry, but extra different is not paid to their rank, which is what we wrote.
And I do think that this is much more of a US phenomenon than here. But the notion of of them being able to be members of a multidisciplinary team and to not be and to not and to have the sort of characteristics that that requires in terms of controlling resources and and and and letting the sort of financial incentives be part of the way they they make decisions as there is is really critical in terms of forming these teams.
Those sort of characteristics are really are really key and things that you should kind of keep in the back of your head as you're as you're making decisions about moving into this area. So that turn it over fact. Sure. Thank you. I think it's very interesting what you're saying about integrated care and the role of the multidisciplinary team, because I think that's something that in psychiatry, especially old age psychiatry, we really hold dear to the core of our practise.
So I think in terms of psychiatry, the and the integration agenda, I hope that we're slightly ahead of the curve compared to some of the more traditional specialities. I think what your total is very nicely onto Chris talk. Who's coming next? So you talked about integrated care and the need for services to be flexible and responsive.
And I think you also with your sort of speaking about the finances and the other elements, touched on how political this area is and how there are so many people who have got a stake in deciding how integration should happen and what is the best thing.