Work and Pensions Committee
Oral evidence: Pensioner poverty: challenges and mitigations, HC 465
Wednesday 30 April 2025
Ordered by the House of Commons to be published on 30 April 2025.
Members present: Debbie Abrahams (Chair); Johanna Baxter; Steve Darling; Gill German; Amanda Hack; Danny Kruger; Frank McNally; John Milne; David Pinto-Duschinsky.
Questions 156 - 211
Witnesses
I: Professor Sir Michael Marmot, Director of the UCL Institute of Health Equity.
II: Dr David Attwood, GP Partner at Pathfields Medical Group.
III: Dr Ruth Law, Honorary Secretary, British Geriatric Society; David Finch, Assistant Director of the Healthy Lives Team, Health Foundation; and Toby North, Head of Public Affairs, Marie Curie.
Written evidence from witnesses:
British Geriatrics Society (PPCM0058)
The Health Foundation (PPCM0059)
Marie Curie (PPCM0011)
Witness: Professor Sir Michael Marmot.
Q156 Chair: A very warm welcome—and it is warm—to the sixth session for the pensioner poverty inquiry. It is a pleasure to welcome Professor Sir Michael Marmot to the Committee. Sir Michael, would you like to introduce yourself? We have a few minutes to go through the list of things that you have been involved in.
Professor Sir Michael Marmot: I am Michael Marmot. I am Director of the Institute of Health Equity at UCL, University College London. I chaired the World Health Organisation Commission on Social Determinants of Health, which we published in 2008. Gordon Brown was Prime Minister then; do you remember him? He invited me to conduct a strategic review of health inequalities, asking the question, “How could we apply the findings and recommendations of your global commission to one country, England?” It became known as the Marmot review, as these things do, “Fair Society, Healthy Lives”, which we published in February 2010. I don’t think there was a causal connection with Labour losing the next election, at least I hope not. The Conservative-led coalition Government issued a public health White Paper and said it was the Government’s response to my review. I thought, “This cross-party thing is a doddle”. It was commissioned by a Labour Government and a Conservative-led coalition Government has adopted it. I was very pleased.
In the event, the policies of austerity were not conducive to improving health and reducing health inequalities, so my 2020 report, “The Marmot Review 10 Years On”, documented the fact that health had stopped improving pretty much. Health inequalities had got bigger and health for the poorest people had got worse. Life expectancy had gone down. Then three years of the pandemic and life expectancy fell. We went through a 14-year period from 2009 to 2023 where life expectancy did not improve at all. Health inequalities got bigger and life expectancy for the poorest people declined and self-reported health got worse. So, that is where we are.
Q157 Chair: Thank you, Sir Michael. That is wonderful. We all have questions for you, and this is around the pensioner poverty inquiry in particular. I will kick off. From your huge knowledge, how does poverty in earlier life affect pensioner poverty and being poor in retirement? How does it also affect health over the life course?
Professor Sir Michael Marmot: What we know is that, in general, rich parents have rich children when they grow up; poor parents have poor children when they grow up; middle income parents have middle income children when they grow up, and that is true in every country in general. However, the magnitude of that effect varies and one way of looking at that mobility—forgive my citing technical numbers—is to ask, at the current rate of social mobility, how many generations would it take for someone in the 10th centile of income to get to the median. In Denmark, it would take two generations. In Finland, Norway, or Sweden, it would take three generations. The average for OECD countries, the rich country club, is 4.5 generations. In the UK and the United States, it is five generations. In Brazil, it is nine. We are heading to Brazil, not to Denmark.
Why these big differences? There are two explanations. The first is the magnitude of income inequality. What the data show is, the bigger the income inequality, the more income of adult children resembles that of their parents, the less social mobility. The second is investment in early childhood. Again, citing OECD figures, the average investment in early childhood is about $6,000 per child aged nought to five per year. Norway spends 12,000; the other Nordic countries, nine, 10; France, 9,000. We are about average. We were below average, but the latest figures suggest it is about six. The US is 3,000, Brazil lower than that. What we are doing by having less social mobility is we are guaranteeing a lifetime of low income.
Chair: Including pensioners.
Professor Sir Michael Marmot: That will feed right through the life course. Given that, we know that socioeconomic circumstances predict ill health right up through the oldest age. For example, in the US there were data suggesting the black/white differences reversed at older age. Blacks have a higher mortality than whites, but that reversed at older age, and that led to people speculating on some kind of survivor effect: if you can get to older age as a Black man or woman, then you must be really hardy to survive all that. We do not see that in Britain when we look at socioeconomic differences. We see that the poorer you are, the worse your survival and the higher your mortality, right up to the oldest age. It goes right through the life course.
Q158 Chair: You mentioned the Marmot review that you published in 2010 and then the follow-up in 2020. In “Fair Society, Healthy Lives” you made a recommendation about a minimum income for healthy living. What role do you think our social security system has to ensure that?
Professor Sir Michael Marmot: We probably said it in my review. Certainly, my general view of the evidence is that work is far preferable to non-work if that is possible for people, but it has to be reasonable work. We said back in my 2010 review that the experiment of getting, for example, single mothers into low-paid, insecure, poor-quality work was a failure. That was not a social success. Trying to get the most disadvantaged, deprived people into the work that I have just characterised is not a social success by any means. It has to be well-paid, decent quality work. We know the majority of people below the minimum income threshold are in households where at least one adult is working, so that is of working age. Work has to be the way out of poverty, so work has to pay.
For people who cannot work, then the state has a vital role to play. We know that, for working-age people, the Joseph Rowntree Foundation and the Trussell Trust have calculated the cost of meeting essentials, and Universal Credit pays about 70% of the minimum income for healthy living. I was just looking at figures for pensioners, and with pension credit top-up—let’s take a married couple—it is around £17,400. The estimate is that, before housing costs, a pensioner couple would need about £22,000. The amount of money they get with the pension credit is about £4,500 less before housing costs than the minimum needed to have a healthy life. Then you have to add housing costs on top. The welfare system has a vital role to play, but it should not be consigning people to incomes below what is needed to have a healthy life.
Q159 Amanda Hack: Thank you. I could listen to you all day. It has been fascinating so far.
Professor Sir Michael Marmot: You had better stop me, otherwise you might.
Q160 Amanda Hack: We did public health in Leicestershire and even in Leicestershire life expectancy has plateaued, but healthy life expectancy has actually taken a dive. In your work, you did put a cause for optimism through that, particularly lessons from the Marmot city regions like Greater Manchester. What do you think would be needed to roll out more Marmot Places in the UK?
Professor Sir Michael Marmot: On your mention of optimism, commonly I get asked, “The world is going to hell. Are you depressed and pessimistic?” and I say no. I was in Liverpool last Wednesday when they declared themselves a Marmot city. I was in Cardiff yesterday where they reconfirmed that they are going to make Wales a Marmot nation. We launched three Scottish Marmot Places in February, and I went to Newcastle on the way back and they launched Newcastle as a Marmot city. I couldn’t be more upbeat. Yes, I have heard about that chap in the White House, but I cannot affect what goes on in the White House. I could not be more excited by what is going on in community after community. It would be quite helpful if Government came in behind them.
I know you want to ask me about money. I am not good on money, but what is interesting is that none of the communities that have invited us in have said, “Oh, the cuts to local government funding have been brutal”—they have been brutal—“and that is an excuse for us not to do anything”; they’re saying, “We are going to do the best we can with the resources we have.”
I am sorry if this is a circuitous answer to your question, but when I was in Liverpool I said we need the Chancellor to reduce child poverty, but what you can do locally is break the link between child poverty and poorer outcomes. By the way, when I talk about child poverty, everything I say about childhood applies to the rest of us. If we have less poverty, we will have less pensioner poverty. If we have better social conditions, better amenities, and housing, that will apply through the life course. When I said we need the Chancellor to reduce child poverty, what you can do is break the link between child poverty and poorer outcomes. The Citizens Advice Bureau said, “No, we are reducing poverty. We make sure people get the full benefits to which they are entitled. We help people of working age get into work. We are in the business of reducing poverty, not just breaking the link”. The fact that Wales has taken this on nationally, the fact that Scotland has taken this on nationally—and there is another country that has slipped my mind—it would be quite good if England took this on nationally and comes in behind the initiatives that are happening locally because they are exciting.
The key questions that I ask myself all the time are, “Does it work? Are we making a difference?” These are not vaccine trials, so we do not have a proper counterfactual. I cannot give you a Lancet publication that I have written to show it works in Coventry. I don’t really know what would have happened had they not been a Marmot city, but I can tell you that there are indicators moving in the right direction. It is not evidence that I would call pukka evidence, but the indicators are good.
Improving housing will be good for pensioners. Improving conditions for young people, reducing the number of 18 to 24-year-olds not in employment, education or training—it is slightly circuitous but if there are fewer young people on the streets making trouble, then for pensioners who are afraid to go out because of fear of crime, that will improve their lot. It is a bit circuitous, but in other words they are improving communities, and the indicators are moving in a good direction, with all the caveats that I mentioned.
I think it would be extremely helpful to say we have learnt from these Marmot Places how important cross-sector action is. This is not just for health and social care. This is for employment, environment, housing, and income. It is for all the key sectors. It is easier to get that cross-sector action at city level. It is a bit easier to do it in Wales and Scotland. It is harder, because of scale, to do it in Westminster, but that is what is needed.
Amanda Hack: Thank you. That has been extremely helpful.
Q161 Johanna Baxter: What resources might be needed to help to roll out Marmot Places across the rest of the United Kingdom?
Professor Sir Michael Marmot: I am not the Chancellor, but I can tell you what happened, and I am sure you know that. Central Government support to local government went down by 59% over the decade because of the increase in council tax. The total spend by local government went down by 34% over the decade from 2010. The more deprived the area, the steeper the reduction.
I plotted life expectancy for every local authority in England in 2010-12 and the subsequent reduction in local government spending power. The shorter the life expectancy, the steeper the subsequent reduction in local government spending power. We have to change that. That is regressive. That looks like a policy designed to increase health inequalities. That is what it looks like. I cannot believe that that was the purpose of the people who designed that policy. I don’t believe that for a moment, but that is what it looks like. That is the effect. That has to change.
We need a more equitable settlement at local government. I try not to be political, but when a former Prime Minister said, “Do you know what Labour was doing? It was putting money into deprived areas. We are going to move it out of deprived areas into wealthier areas”, the effect is that life expectancy goes down in deprived areas and health gets worse. That has to change. I cannot tell you how much it will cost and, as I said, I am not the Chancellor. I always argue from a health point of view, but from a health point of view I would like a more equitable, less regressive settlement to local government.
Q162 Johanna Baxter: Thank you. I note that that same need exists in Scotland as well because the same approach has been taken with respect to local government funding there.
Moving on to the next question, your review called for an ambitious national health inequalities strategy. What do you think that should have as its objective for older people?
Professor Sir Michael Marmot: My overall approach would be to put equity of health and wellbeing at the heart of all government policy. As you can imagine, I got asked, “What do you think about winter fuel payments? What do you think about the two-child credit?” You can guess the questions that journalists wanted to ask me. My response in a way to it all is, “Put equity of health and wellbeing at the heart of all government policy”, whatever it is you are deciding.
I know we do not do that when we decide to support Ukraine. It is right that we support Ukraine; I am not against it. We don’t do that, and we don’t ask about cost-benefit analysis either when we support Ukraine. We only ask about cost-benefit analysis if we do not want to do something. “Oh, you want to spend more on supporting older people? What is the cost-benefit analysis for that?” In my experience, you get asked that when they do not want to do it. If they do want to do it, they do not ask the cost-benefit analysis. I am not against trying to do that analysis. We need to know if we are going to spend a pound are we better off to spend it here or there, and that is a reasonable question.
Overall, put equity of health and wellbeing at the heart of all Government policy. You may decide that is not the No. 1 that you are going to do as a Government because you have other priorities, but that is what I would like to see.
Q163 Amanda Hack: I want to focus on the 10-year health plan. Specifically, in my constituency we have most of the Leicestershire coalfields. What we see in our health data is very much an increase of COPD but also an increase of cardiovascular disease. What should we prioritise when looking at the five-year plan for older people? In my constituency it would be that, but how would we do that more broadly?
Professor Sir Michael Marmot: I am in a slightly difficult place here because when people talk about prevention they usually mean healthy lifestyle, not smoking, doing something, and I am fully supportive of all those things, of course. However, for me, prevention has to be on the social determinants of health. It has to be about housing. It has to be about being able to afford to heat your dwelling.
We did a report early last year, in from the cold. We said one third of households in the United Kingdom are either below the minimum income threshold and in dwellings that are not up to energy conservation level C. That, of course, includes pensioners. It will damage children’s lungs and their mental health, and it will cause excess winter mortality in older people. I am not against doing something about lifestyle, smoking, diet and all those things—of course, it is important—but I want to do something about housing and having enough money to live on.
I am sure you know the figures that social isolation is as deadly for people 50 and over as smoking. On social isolation, you might ask what Government can do—well, local government, the voluntary and community sector, supported by central Government. I talked about the fear of crime. We know, going back decades, that when public transport was made free at the point of use for older people, they went to visit their grandchildren. They got on the bus. You can do things. I can remember when I recommended in a report subsidising transport for older people, before it had happened, this economist haranguing me, saying, “What are you doing wanting to waste public money on old codgers like me?” It is quite good if older people can go to visit their grandchildren because they can catch the bus and we make it easier to get on the bus, so there is not a step up if you are a bit disabled.
There is a great deal that you can do to support the lives of older people. I would like to see in the five-year plan, the first five years of the 10-year plan, an absolute commitment to action on the social determinants of health.
Q164 Amanda Hack: That is fascinating. The data says that the impact of social isolation is like smoking 50 cigarettes. You mentioned in your response to Jo that you have been asked all these questions, but what health impacts have you seen from the change of the eligibility to winter fuel payment? Have you researched that yet?
Professor Sir Michael Marmot: I cannot quote you any figures yet. When the war in Ukraine broke out, we had been saying that fuel poverty was around 10% or 15%. It looked like it was going to be two thirds. You have to put the cut in subsidy to winter fuel payments in that context.
There is another point, as the Chair knows. We talk about proportionate universalism, which is a way of trying to combine the typical means-tested benefit approach with a more universal approach. If two thirds of households are facing fuel poverty in winter, some means-tested benefits will not work. Proportionate universalism I think is entirely consistent with some kind of tapering. You do not say, “You get a benefit. You are eligible for pension credits. We will give you the benefit and you get some other things, but everybody else, forget it”.
Given that the figures are that if you are on the level of income that the pension credit tops you up to, that is not enough money to have a healthy life. If you are between the amount of money you need for a healthy life and the level of income that the pension credit tops you up to, to say, “You are not going to get a winter fuel payment. We know you will suffer but we are not going to give it to you”, surely there must be a way to grade that.
Q165 John Milne: As you know, the pension age is being pushed up steadily over a period of years and it is going up again next year from 66 to 67. That is fine for people, like MPs, who can work long past senility, but not for everyone. What mitigations or measures do you think the Government could take to help those people who will be left out with a gap between their last job and their first pension?
Professor Sir Michael Marmot: In figure 1 in my Marmot review from 2010, for medium super output areas for neighbourhood level of deprivation, we had two graphs, life expectancy and disability-free life expectancy. We drew two horizontal lines on that graph: 65 and 67. Because of the social gradient, back in 2010, we said if you advance pension age from 65 to 67, two thirds of the population, the more deprived two thirds, will not have disability-free life expectancy as long as 67.
If the effect is to move people off pensions on to disability benefits, that will have little social value and will not save much money. I don’t know the figures for what proportion of the 2.8 million people, or whatever it is, in receipt of disability benefits are in that 65 to 67 band. I do not know those figures, but they must be available. We predicted that you would get an increase in disability because people could not work that long.
If you look at the life expectancy figures, it is not as dramatic as for the disability-free life expectancy, but what we are doing is saying, “You work all your life, but we are not going to give you a pension for very long if you are relatively deprived”. You just don’t get it. You can work but then you have this much shorter period where you get a pension because of your shorter life expectancy.
Going back to Adair Turner’s report, he said there are three possibilities for dealing with the problem: you work longer, you are poorer as a pensioner, or you pay more as a working-age person, so we can solve it one way or another. The problem with working longer is the inequality dimension because poorer people work longer and then enjoy a pension for less of their lives. That is a social decision that we have to make as a society.
Q166 John Milne: Do you have any specific recommendations or mitigations beyond not doing it?
Professor Sir Michael Marmot: Everything that I recommend in terms of action on the social determinants of health is trying to mitigate that. We are trying to prolong people’s healthy lives. We want them to have longer lives and more of those lives spent in good health. That is the holy grail; that is what we are trying to do. The evidence is that has to be possible. If you go back to the 1960s and look at the social gradient in life expectancy, and if we were having this kind of meeting we would say, “Well, what can you do about this? We have always had these inequalities”.
The life expectancy of the best-off people in the early 1960s is now no better than that of, not quite the worst off, but those near the bottom. We have improved things dramatically for the poorest people. It is possible to make these changes relatively quickly. We can do it; it is not that it is impossible. It takes a while, but we can do it. That is what the evidence shows.
We need to look a bit more Nordic. I am so used to making presentations where I say, “God, this has gone badly, that has gone badly,” but I was invited by the Norwegian Prime Minister to do a review of health inequalities in Norway, and I am presenting the report to the Norwegian Ministers saying, “Actually, you are doing pretty well here and you are doing pretty well there, and that looks good”. They want to do even better because they still have health inequalities, but they are narrower than ours and they look a good deal better. Action needs to be taken on these social determinants of health, which will mitigate that problem.
Q167 Gill German: I could not be more delighted for you to join us today; welcome, Sir Marmot. I want to talk to you about cliff edges in the social security system, and you have touched on this in one of your previous answers. We have heard concerns that there are people who are a few pounds above the threshold, and that means that they miss out on thousands of pounds of passported benefits. For example, for somebody with a small occupational pension, it means that they would not be eligible for pension credit. My mum is one of these people; she had a job in retail, she has a very modest pension, and it means that she is not eligible for an awful lot. I wondered what change you think the Government should take to this. You have mentioned tapering; do you think that is a way forward?
Professor Sir Michael Marmot: Tapering is a way forward. I have been thinking about it more below pension age of getting people in to work. As you said, some of us keep working beyond pension age because we are privileged to have fulfilling work that is life enhancing and the like. Thinking about fulfilling work, a colleague of mine in the US was an originator of the Experience Corps and getting pensioners essentially to mentor teenagers. Very fulfilling for both sides. These teenagers from deprived backgrounds had an older person who cared about them who they could talk to, and who related to them and had time for them—so, thinking creatively about what a creative role for older people could be. I do not know about your mum being in loco grandmother—forgive my Latin—to be somebody’s grandma, somebody’s mentor.
We can say, “Well, you’re on the scrapheap, and we’ll give you a bit of money until you die and that’s it”, or we can think more creatively about a social role for older people where they can use their wisdom, experience and humanity in a positive way that is fulfilling all around. Forgive me if that sounds a bit airy-fairy but that is the way I would like to be thinking about it.
Q168 Gill German: Thank you. Mum with five grandchildren of her own may find that she is a little overstretched on that front, but I take your point that there is huge benefit to be had. I have spent my life working with children and young people, and absolutely, that dual benefit is something we need to be exploring, so thank you for that, and for your thoughts on tapering earlier as well.
I have been working with local benefit advice agencies to try to increase the take-up of pension credit for those who are eligible because many are not aware of the process of what to do. I know that we have seen some success with that nationally, which is positive. Your 2010 report referred to the patchy provision in short term funding of advice work generally to support benefit take-up, and that is something I hear on the ground as well when I work with my local agencies. What sort of change would you like to see here? I suspect your comments on local Government previously may come in and I am totally in agreement with them, but I am interested to hear your views.
Professor Sir Michael Marmot: I have to put in a plug for the voluntary community sector. I used to think either Government should do it, or individuals should do it or the private sector, and that was it. Then I realised that the voluntary community sector are not just filling in the gaps. I quoted Citizen’s Advice Bureau a few minutes ago; it has an absolutely vital role to play, particularly in this issue of pension take-up.
In Liverpool, the doctors write prescriptions to the CAB. A patient comes, and the doctor says, “You need to see the CAB”—it is a kind of social prescribing—and they go off to the Citizen’s Advice Bureau. We need to recognise the vital role that the voluntary community sector has.
In the few minutes you kindly gave us outside we were talking about pension credits. I will not try to reproduce the conversation—“How does this work?” “No, we think it—” “No, how does it work?” We were the experts standing outside the room trying to make sure we knew how the pension credit system worked. I do not want to embarrass my colleagues, but then we thought, “If we can’t figure it out—”, and I am sitting there looking at my iPad. The voluntary community sector has an absolutely vital role in helping people.
Gill German: That joined-up working is certainly something I support as well, so thank you for that.
Chair: That concludes our questions to you, Michael. Thank you so much for joining us today.
Examination of witness
Witness: Dr David Attwood
Q169 Chair: Welcome to our second witness to this evidence session for the Pensioner Poverty Inquiry. It is a pleasure to welcome Dr David Attwood. David, would you like to introduce yourself?
Dr Attwood: Hello everyone. My name is David Attwood. I am a GP partner at Pathfields Medical Group, which is a 30,000 GP surgery in Plymouth, a rural, coastal, deprived city. I am also the associate medical director for Livewell, which is the community services arm of the health providers in our patch. Thanks for having me.
Chair: Thank you for joining us. I will hand over to Steve Darling.
Q170 Steve Darling: Thank you. It was good to have a brief chat with you outside this room, and thank you for trekking up here. Clearly Plymouth is very urban; equally, there is that level of rurality. It would be helpful if you could unpack that pensioner poverty and that dichotomy that may well exist between urban and rural pensioner poverty.
Dr Attwood: The key thing is drawing it back to: what do we want as a society? I would argue that we want our older population to live longer, healthier, and more independent lives. To do this, when we think about people’s natural lifespan, the human body should enjoy a normal lifespan whereby your health does not impact on your independence. That is a normal lifespan. What we see particularly in deprived areas is that people do not age normally. They seem to show signs of almost accelerated ageing—more rapid ageing than an age-matched counterpart in a more affluent area—with cumulative loss of health, and it eventually impacts on independence.
Many of us in this room can be authentic citizens here because we probably know family and friends who are on this journey. It might start as a slowing up in life where you walk a bit slower, the weekly shop takes a couple of hours instead of one hour. As things advance and your health deteriorates, your independence is affected. You might become housebound or in a care home, needing carers to support with personal care. We have a medical diagnosis that describes this accelerated ageing and loss of independence; it is the medical diagnosis of frailty, and it exists on a spectrum: mild, moderate, and severe. I will use that word quite a lot, and I am keen to point out from the get-go that I use it as a medical diagnosis, not as an adjective. It is incredibly pejorative and discriminatory as an adjective.
Why am I talking about frailty and how does this relate to poverty? The outcomes for frailty are grim, both for the individual and their loved ones, and also for the wider NHS. We know that the one-year mortality for frailty rivals that of some of the most aggressive cancers in the UK, and we know that, in terms of hospitalisation, 50% of hospital beds are occupied by over-75s. Three in four of them will have the medical diagnosis of frailty. If you are over 75 and hospitalised and you are not frail, your chance of dying in that hospital bed on that very admission is 1 in 50. For mild frailty it doubles to 1 in 25. For moderate it is 1 in 17. For older people with severe frailty, there is a 1 in 5 chance of dying in that hospital bed on that very admission.
If you are lucky enough to escape hospital there is a 1 in 7 chance of being readmitted 28 days later to revisit those same statistics. We know that two in five over-75s are in their last year of life, and we know that a third will spend more than a month of that precious last year stranded in a hospital bed, often not by choice. This is not the same as saying that hospitals are bad and they are to be avoided at all costs, and I certainly would not want the Committee to go ahead with that. If my mother has a broken hip, I would like her to go into hospital. What we would like to do is maximise the benefits and minimise the risks of our older population from a hospital admission.
The costs of frailty to society and Government have never been fully calculated, but let me give you a few numbers to play with. We know that the Department of Health and Social Care’s annual budget for the last financial year was £188.5 billion. We know that all 42 integrated care systems in England are in deficit, with a combined total of £1.5 billion. We know that just under half of that total spend goes on workforce, and we know that workload and workforce match, and when it comes to frailty and workload, it accounts for 39% of total hospital bed occupancy, 58% of total ambulance callouts, 25% of primary care workload, I would estimate based on lived experience, and it would dominate the adult social care budget. The cost is unfathomably massive.
While we are thinking about that cost, let’s spare a thought today for all the individuals and their loved ones who are in hospital right now powering those tragic statistics. This is happening in the 21st century. The good thing is that everyone in this room can be authentic citizens here, because we will know friends and loved ones who are either on this journey at the moment or powering some of these statistics in the past. That is why frailty matters. If we want to achieve our goal of having a society of healthy ageing, where everyone has the opportunity to enjoy a normal lifespan of health and independence, we need to absolutely make frailty rare. We need to do this by preventing the development of frailty and halting, delaying, or reversing established frailty.
When it comes to causes of these things and things that we can target, deprivation is absolutely front and centre stage. Poverty is a big contributor to the development of frailty. I will not repeat what Sir Michael Marmot said. I agree with everything he says about wider determinants of health. The only thing I will echo is that people from a deprived background face a cumulative disadvantage throughout life because of inequality. They will consult with their GPs much more frequently; they will use healthcare much more frequently. The funding for NHS spend does not accurately reflect inequality and deprivation, and that does need addressing.
The other thing I would say is that there are other factors despite deprivation that are associated with the development of frailty. It is more common in deprived communities, but it can occur in more affluent areas. There are things like loneliness, social isolation, bereavements, loss of loved one, physical inactivity, mental health, chronic pain; then there are individual factors: smoking, alcohol, nutritional choices. There will be other factors as well that I have submitted.
An area I am quite interested in is: what is it about the individual that takes all of those factors and makes decisions based on that? For example, if you are from a deprived background and you are an older pensioner and you have a cigarette on your desk, people will say, “That is my only luxury in life. I will continue smoking. I will spend my tiny budget on this habit”. Others will say, “D’you know what? Maybe I could escape nicotine addiction, maybe I could focus a bit more on my health and some of the budget could be used elsewhere in the household”. Those individuals’ choices are areas that are ripe for intervention. It is called behavioural change theory, and people from the health, social and voluntary sector are trained to manage behavioural change theory.
To bring it back to where we are, in summary I would say we would like to have a society where we see healthy ageing. To do that we need to make frailty rare by preventing it and reversing, delaying, and preventing progression of established frailty. If we target all of the determinants, we will have a healthy older society.
Q171 Steve Darling: Thank you. I did ask at the beginning whether there is a dichotomy between rural and urban, because in your introduction you did talk about your patch covering rural and urban. Is there any of that, or is it mostly just that inner-city Plymouth is a challenge?
Dr Attwood: It is a good question, Steve, and if I am honest we are mostly inner city, so I cannot comment so much on rural areas. What I will say is that rural areas face their own individual demographics and challenges. It is a much wider population, and I suspect other factors will be at play.
Q172 Steve Darling: I am sure colleagues would have found your focus on frailty helpful. The impact on the health service and social care is probably a bit of a given from what you were describing, but Professor Marmot was highlighting the opportunities of the voluntary sector. Can you unpack that a bit? Not too far away, my constituents in Torbay have an active, ageing well approach in the voluntary sector. Is that part of your world in Plymouth? Where are there other opportunities?
I know that Plymouth Argyle could be doing stuff with over-55-year-olds to be more active. Can you unpick that bit of your world of how there could be this broader approach, rather than just thinking it is health and social care’s problem?
Dr Attwood: Steve, I am delighted that you have said that. I certainly would not want to leave this room without you thinking that I value our voluntary and community sector. We would not be where we are without them today. They are fabulous.
In terms of where we are with things, in our patch we have implemented a command-and-control older people’s hub with an integrated neighbourhood team, and it brings professionals from health, social and the voluntary community and social enterprise sector together as one big, shared team. This shared team works on a shared IT solution, and it delivers a single, shared, biopsychosocial assessment that targets all of the things that will lead to the development of frailty or allow frailty to progress if unchecked. The shared health, social, VCSE teams, shared IT solutions, and shared single assessment are based on a comprehensive geriatric assessment. That is a bit of a mouthful, so we call it CGA for short. Those three things together I believe improve outcomes for older people. We have data for that now.
Also, working together, we leverage the benefits of continuity. Continuity has been independently associated with better health outcomes. We have four ingredients. The fifth ingredient is that our teams are loaded with advanced digital tech so that we can better identify individuals with frailty, and we can pinpoint ones within frailty that are at higher risk of progression, so we can send teams out to target them for holistic interventions that can improve patient outcomes, prevent delay and reverse frailty. Those are the five winning ingredients. Will you permit me to talk a bit more about health outcomes and what we have found?
Q173 Steve Darling: We have lots of question, but if you can be brief, I am sure it will be helpful.
Dr Attwood: In a sentence, we have published a mixture of data showing the outcomes: older people may be living longer despite being in a deprived practice. They may be living healthier with a reduction in frailty prevalence and severity, and we are also seeing reductions in healthcare utilisation. The 25% reduction in A&E admissions in over 75s comparing this year with 2019—so, pre-pandemic—and a sustained 41% reduction in unplanned care home admissions over the same period.
Q174 Frank McNally: David, I appreciate your contribution this morning. You have touched on the challenges and the consequences linked to frailty. Certainly, in Scotland we have seen the failure of an effective, joined-up approach to addressing some of these challenges—particularly the challenges linked to health and social care—where the Healthcare Improvement Scotland report last year highlighted that at least 10% of Scots over the age of 65 are recognised as frail, but 42% are recognised as being pre-frail, so obviously at significant risk.
We know that by 2035 the over-65 population will be more than 30% of the population in Scotland, so we can see the potential difficulties coming towards us. You touched on this in your response to Steve, which focused on the evaluation of the work you have been doing and its impact on older patients, but you also mentioned some of the key outcomes. Do you want to expand on that at all?
Dr Attwood: The key thing that we have been focusing on is maintaining that razor-like focus on a healthy older population, because that is the only thing that matters. Healthy people will have happier lives—and that has got to be the purpose of the NHS—and will naturally use healthcare less.
My favourite graph this year—if you could put such a word in a sentence—was a time series graph looking at frailty prevalence in our over-70s population. Since 2021 we have seen progressive year-on-year reductions in people with moderate to severe frailty. Although we have had growth in our older population, that growth is driven by people who are fit and well and have mild frailty; so, Frank, there is hope for you guys in Scotland, there truly is, if we get the balance right and we maintain that razor-like focus on health.
When you think about it in terms of triangulating the statistics it kind of makes sense. If you focus on health, you should see less frailty; you should see more fit and well people who are ageing well. If you focus on health, you are less likely to need to use the hospital. We are seeing that in our older population as well, but we are also seeing improved survival. We have published—and it has been independently peer reviewed and was presented at the British Geriatric Society autumn meeting last year—the data on 429 residents in care homes showing an absolute two-year survival advantage of 39.6%. Our older people are living longer but healthier as a result.
I did not have the chance to submit it, but I will submit it retrospectively to the group. I would also like to credit a colleague—Dave Spencer, who is in Devon ICB—with analysing this data. He has produced a graph, hot off the press yesterday, looking at deprivation on the vertical axis and mortality per 100,000 along the horizontal axis. You can easily imagine, the more deprived you are, the higher the mortality will be.
Our surgery is one of the most highly deprived surgeries in the Devon area and we have an under-75 mortality that is comparable to some of the most affluent areas. Most of the deaths occurred in the 55-to-75-year bracket. It is preliminary data and needs a bit more unpacking, but the ICB are excited by this data because it seems like we might be beating deprivation, which is quite nice.
Q175 Frank McNally: Expanding on that, you have cited a whole range of welcome outcomes from the work you are doing. Do you see any particular challenges around upscaling, to take the work you are doing beyond the areas you are covering? One final question is around the priorities of Government. Ultimately, we are keen to get a sense of whether there are any areas where you think the Government should be prioritising in terms of improving healthy ageing for people in later life.
Dr Attwood: In terms of upscaling the formula, the five winning ingredients are shared teams in health, social and VCSE, shared IT, shared single assessment, continuity and—my mind has gone blank—the fifth one I referred to earlier. They are all scalable. It requires time. There is a certain methodology to do this, but this is all eminently scalable. We have been doing this now for six years, so it takes a little while to see the data emerge, and I would urge Government to be patient, but to know that it will work. Hold your nerve, Frank. When you go back to Scotland and have a chat with the various folk there, tell the team to hold their nerve.
The biggest challenge we face is all the chaos that is taking place outwith our community. It is difficult to keep this model going because of a variety of national and local policy drivers. I would say that, in terms of things that could be done to help to embed this, our focus is on health and independence and the wider determinants of that. It would be lovely to have a long-term plan for healthy communities that is put out by all parties, and all Government Departments should be signed up to this and engaged with all stakeholders. It is not about health. It moves wildly beyond that into all Departments, because we all have a role to play in developing a healthy society.
That long-term plan needs to follow a natural life course approach of children and young people, working-age adults, and older people because those groups have slightly different and more nuanced needs. When it comes to doing that plan it should address two NHS cultural issues head-on. The first is our enthusiasm in the NHS—I don’t know what other Departments are like—for developing plans, which is not matched with an enthusiasm for executing the plans. We have a proliferation of plans and little in the way of absolute change. I would like to see the last plan as a living document that every Government can update in the light of the latest information. We adhere to that plan; we implement that plan.
The next thing is that the NHS was set up in 1948 to offer high-quality healthcare for free, for all, and forever. The 21st-century NHS is subtly different. It feels sometimes like a national hospital-centric service where policy is being driven by getting people out of hospital at all costs because hospital beds drive NHS spend. That policy has often led to penny rich, pound poor strategies focusing on discharge and avoiding admissions at all costs, which is not the same as a razor-like focus on health.
We all service our cars proactively and regularly to keep them healthy, so that they will last us longer and not cost us loads of money when they are 10 years old. We need to adopt the same pattern with the NHS and go back to focusing on high-quality health for all, for free, and forever. When it comes to that, we do need to think about deprivation and we need to ensure that the funding moves from sickness to prevention, hospital to community, analogue to digital and, as a fourth, I would say, affluent to deprived, because it does not accurately reflect the challenges of deprived communities. Other things to—
Q176 Chair: Final thoughts, if that is all right, David.
Dr Attwood: My final thoughts are: I would like to hope within this evidence that we have shown that primary care general practice, working with wider health, social and VCSE colleagues, can deliver. The challenges that we are facing, particularly in general practice at the moment, are ones of the National Insurance pension contributions. In my surgery we are looking at £120,000-worth of extra increase in NI contributions. On top of that we have the top-ups of our staff to minimum wage.
We used to be a real living wage employer; we are no longer. We cannot afford it. When we top up those staff, we have to uplift the other staff who manage them, so that the salary increment can be the same, so everybody needs uplifting. We will also have the increased costs of goods, because all the other private sector things like heating will all go up, because they are all paying their NI contributions and that cost will be passed on to the end user, which is me.
When you are in a situation where you are faced with a fixed budget you have two options: you can go bust or take a pay cut, or you can cut output. With the situation we are in now, with £125,000 of increased NI contributions, and the rest that I have outlined, that realistically means that the extra money that is going into general practice is coming straight back out and boomeranging back to the Treasury.
In real terms, the GPs who are leaving for good reasons, family reasons—one of them is going back to Scotland; she is fabulous, Frank; we will miss her dearly—we are not replacing those GPs because we do not think we can afford to. Ask us in 12 months’ time what the finances will look like. It is worth noting that we are NHS and are exempt from those contributions.
Chair: Thank you so much, Dr Attwood, a real pleasure to have you with us here today.
Witnesses: Dr Ruth Law, David Finch and Toby North.
Q177 Chair: Welcome back to the pensioner poverty inquiry. For our final panel this morning we have David Finch, Ruth Law, and Toby North. Would you like to start with a brief introduction, David, and we will go down the line?
David Finch: I am David Finch, assistant director in the Healthy Lives team at the Health Foundation, which is an independent charity working to improve health and reduce inequalities.
Dr Law: Hello, I am Dr Ruth Law. I am a consultant doctor working in north London. I work in hospitals and in the community, but I am here on behalf of the British Geriatric Society. We are a membership organisation, and our mandate is to improve healthcare for older people. I am vice-president for policy there.
Toby North: Morning. I am Toby North, head of public affairs at Marie Curie. We are the largest and leading end-of-life charity in the UK here for anyone with any illness that they are likely to die from and those close to them. We take a very holistic view of what good end-of-life care looks like, including both physical and emotional support as well as practical support such as ensuring people have their material needs met at the end of life.
Q178 Chair: I will kick off with questions and other members of the Committee have questions as well.
You probably heard the other panellists, but from your point of view, to what extent is ill health in older people due to their earlier life experiences or down to the ageing process? I am also very interested—if you could include that in your answer—on how poverty impacts on the ageing process.
Dr Law: In answer to the first part of your question, it is generally understood that about 25% of how we age is genetically predetermined. That is the figure that is usually quoted, so there is quite a large potential for influencing ageing well. As the CMO report in 2023 about the ageing society showed, if you are wealthier, you not only live longer but your years in ill health are shorter. That is what we are aiming for, for the entire population: to manage those risk factors in that 75% so that people can have fewer older years in ill health.
There are many things that contribute to that, and many are not expensive at all, but there are many that are contributed to by poverty. The commonest things we would recommend to people who are trying to age well are around physical activity, however small an amount each day, but we know about half of people over 75 in the UK are not physically active, so are moving for less than 30 minutes in an active way. Social contact has already been mentioned: loneliness contributes hugely to ill health through social disconnection. It also affects people’s cognitive development if they are not interacting regularly with people. About 4 million people over 65 are living in single occupancy households in the country, and the majority of those are women.
There are also the things that have been mentioned around following a healthy lifestyle: choices around nicotine, alcohol, and food. Age UK has found that one in five older people have to cut back on food and groceries at the moment due to pensioner poverty. The message is that living in poverty makes all those things harder. A simple example: some of my patients like to go down to the café to have their lunch, and if they do not have enough money, they are no longer doing that. They do not realise that that means they are not getting their daily walk, they are not getting their daily social contact, and they are also not sitting in a warm place. Quite basic things can contribute to that 75%.
Q179 Chair: David, do you want to add to that?
David Finch: Poverty is absolutely shaping people’s health through their lifetime. Even short periods of poverty when people are young can affect their health through future ages. As we have heard a little bit before, over the lifetime these factors can interact. If you have a lower income, you are less likely to have good health. That can also affect your ability to earn or work, which means you can have this accumulation over a lifetime of worse health and worse outcomes.
It is probably most easily described in the deprivation gap in healthy life expectancy where there is an 18-year gap between how long a person living in the most deprived areas is expected to live in good health compared with people in the least deprived areas. It is also quite apparent where we have looked at diagnosed conditions, where a woman aged 60 in England living in the most deprived areas has the same kind of health outcome as a 76-year-old living in the least deprived areas.
You can see when you start to look at outcomes by a deprivation area how the interaction with those circumstances are affecting people’s health over their lifetime. For pensioners particularly, there are specific challenges in an instance of a shock, as we have seen with the cost-of-living crisis recently. Pensioners will be less able to adapt their income to cope with that shock, and then also are perhaps more immediately vulnerable to the health outcomes that can arise from that—things like living with cold or being unable to eat.
Although those things will affect people’s health at working age, it will not necessarily lead to an acute instance of healthcare need as it comes through. One of the factors is also the increasing complexity of health conditions in older ages. People at older ages are increasingly likely to have more than one health condition. It is that interaction and the inability to adjust over a period of time to shocks that can make outcomes defined by people’s lifetimes become much worse quite quickly in older age.
Q180 Chair: Thank you. Toby?
Toby North: Our focus is less on long term causation and more on the immediate and significant financial impact that a terminal diagnosis can have on somebody. We know that diagnosis can come with higher costs for people and push them towards financial insecurity. Last year we commissioned research from the University of Loughborough, and we found that 88,000 pensioners, or more than one in seven, spend the last year of their life in poverty—that is significantly higher than pensioners who are not in their final year of life—and 110,000 pensioners are dying in fuel poverty each year, highlighting that it is often energy costs that are driving some of those challenges.
Q181 Chair: You mentioned pensioners who had not been in poverty being given an end-of-life diagnosis and falling into poverty. Can you explain, is that because of changes in circumstances, such as not being able to work?
Toby North: Largely it is because of additional costs. Whether it is paying for medication, travel to hospital appointments, paying for personal care that might be a direct result of their diagnosis. The sharpest cost pressure we know is due to rising energy costs. We may come on to talk a bit more about the impact of cold and energy costs later, but we know that things like needing to be warmer, being at home for longer during the day, but also needing to run essential medical devices that have quite high electricity needs, can have a real impact.
Q182 Chair: Can I come back to you, Ruth, in terms of what we were talking about in the previous panel with Dr Attwood around frailty and poverty. Obviously, Dr Attwood was mentioning his own particular programme that his practice is running, but is this a trend more broadly—the relationship between poverty and frailty—that we are seeing across England?
Dr Law: As I have already said, poverty makes ageing well harder, so you are more likely to be frail in older age. There was a longitudinal study on the impact of what we might call the austerity years, and it did show that the mean frailty score in the population increased disproportionately during 2012 to 2018 as opposed to the pre-austerity period, so there is certainly a suggestion that poverty is worsening frailty in this country.
Q183 Chair: Can I ask what age group you are looking at?
Dr Law: Going back to what David said, as a clinical term, frailty usually references people over the age of 65. About 10% of people over the age of 65 are living with frailty and then as you get up to 85, it is up to 50% of people. The good news is many people are not living with frailty. I do not want to be all doom and gloom about older age, but there is a big cohort of people where we have the opportunity to improve how they age.
Similar to what Toby has just said, living in poverty means it is harder to access healthcare services, transportation—any services that have charges associated—and dentistry particularly is a big issue, with the knock-on effects of that for older people in terms of nutrition. Everything has a domino effect, and it is important to remember that older people are the biggest users of healthcare services. If poverty makes them more likely to be frail and poverty makes it harder to access healthcare, it is a double whammy for older people.
Q184 Chair: We also touched on the state pension age, and it was Professor Sir Michael Marmot who mentioned that and the impact on living in disability-free years. How could that affect working—basically, those over 65 living in poverty who are deemed frail who are then expected to work? What would be the impact on that?
Dr Law: As a condition, frailty can be categorised as mild, moderate, and severe. It is unlikely that someone who was severely frail would still be able to work, but it is the same as any long-term condition, really. As it gets worse, it impacts on your ability to contribute to employment and would definitely make working more difficult.
Q185 Chair: We are in the process of reviewing the state pension age. It is going up to 67, but whether that will increase even further, we just need to recognise if frailty is something that is also—
Dr Law: It often coexists with multimorbidity and physical disability. There is a huge overlap. It has already been mentioned: as people age, they accumulate more long-term conditions over time as well.
Q186 David Pinto-Duschinsky: Thank you so much for sharing that testimony. I want to focus my questions on poor outcomes for certain groups. Obviously, we see health inequalities across different ethnic groups, for instance. I would be interested to get your views on what is driving that. Is that fundamentally a reflection of earlier life experiences and earlier life inequalities, Ruth?
Dr Law: David, you have written a whole report on this.
David Finch: Yes. The short answer is: it is complicated. To really understand it, particularly if we are talking about ethnicity, you do have to look at specific groups and understand lifetime experiences within them. I don’t think I would do it justice with a short answer. We can submit the full report to you, to explain it.
What we do find is that at pensioner age there are certain groups who are more likely to be in poverty—so, particularly Asian and Asian British pensioners and black African, Caribbean Black British pensioners are more likely to be in poverty than white pensioners.
I suppose part of the issue in thinking about ethnicity is thinking about the change in population over time, which will also mean that that picture will change as different cohorts age and come through the population. It is quite important to think about that in considering how those effects might vary over time. We also know that there are specific populations that are more likely to have certain health conditions. I do not want to get it wrong and give you the wrong detail on the ethnicity.
Chair: Yes. Do not feel under pressure to do that.
David Finch: We can send you more details on those diverse groups, which I think is really about looking at diagnosed illness within the population.
Q187 David Pinto-Duschinsky: Just to come back to it so I understand it—it has been helpful to hear that the trends are potentially changing, and it is a complex landscape—are there any things that you can particularly pick out? Relating back to the conversations we have had, what lies beneath that and, critically therefore, what are the kinds of things that should be done to address it?
David Finch: If we are particularly thinking about pension outcomes as well, then it will go back to people’s lifetime labour market experiences, and we know that there are inequalities in some ethnic groups around earnings levels and lifetime employment histories. Another factor will soon be migration, when people have arrived in the UK and how long they have had to build up UK pension rights.
If you are worried about inequalities across ethnicity, it is often about going back to understand challenges and inequalities that they will have through their working life related to employment outcomes, their earnings and whether people are growing up in poverty as well.
Q188 David Pinto-Duschinsky: Are there any other drivers that particularly speak to the health inequalities picture of that?
David Finch: Within literature, and in some of the work we have been funding, we see that discrimination and access to services and treatment will play a role perhaps in people’s hesitancy in accessing services. I do not have detail on anything else beyond that.
Dr Law: It is not national level data but, just from personal experience, there is a real problem with access to translation services. It just feels as if the odds are stacked against people if they are not English speaking or white British residents. They are more likely to be living in multi-occupancy households, which has an impact on health. It is harder to access the voluntary sector and there are the cultural things that have been mentioned around access to healthcare as well. It is quite multifactorial.
What it needs is locally led targeted interventions. I work in an inner-city area, and there are particular ethnic groups living in communities that we specifically approach and try to include in our focus groups and how we are managing access to the hospital, so that we are doing things in a way that people can relate to and interact with. That is quite locally based rather than a national model, but that kind of approach needs to happen everywhere. The structures are such that it is difficult for people to access healthcare.
Toby North: To bring it back to people with a terminal condition, we know that there are particular groups that have massive inequities in access to palliative and end-of-life care. That tends to be people living in more deprived and rural areas, certain minoritised ethnic groups, as well as other protected characteristics and also people with a non-cancer diagnosis also struggle to access good palliative end-of-life care. That tends to be because there is a clear diagnostic pathway for cancer that results in clear prognostication and an earlier assessment that that condition may be incurable.
That means that, when we have special rules for the end of life within the welfare system, which rely on a terminal diagnosis of 12 months or less to live, giving you fast-tracked access to benefits normally at a higher level for those groups who are suffering significant inequities, they also have a barrier to accessing the financial support they might need, as well as the clinical support through good palliative and end-of-life care.
Q189 David Pinto-Duschinsky: That leads us neatly to my next question. Obviously, we have approached this through the lens of minoritised communities, but are there other groups that particularly need additional support? You flagged those up towards end of life. Are there any other groups that stand out?
Dr Law: Sorry, in what way?
Q190 David Pinto-Duschinsky: In terms of health support and other things—exactly the kind of stuff that our inquiry is looking at.
Dr Law: I am representing older people as a whole and, from all the work we have done, we see that the health and social care system is not set up for them in general. Even if it is broken down into smaller minority groups, the system is just not internalised. We have this ageing population, and it is not ready for the amount of complexity that is coming. These people have already been born, and the statistics are already there. We can see the graphs, but we need frailty-attuned healthcare across the piece and that would then have a positive impact for all groups of older people.
David Finch: If we are thinking about poverty, renters are another group who tend to be at a substantial risk of living in poverty. We also know that rented accommodation—at least in the private rented sector—tends to have lower quality. There is a specific risk there for pensioners who are in poverty, and so more likely to have health conditions, and also living in the private rented sector, and so more likely to have higher housing costs. Because we are looking at poverty and health, there are other aspects to that. If we are thinking about housing specifically, for example, there are more home-owned houses that do not meet the Decent Homes Standard than other types of tenure.
There is an issue there where it can be quite hard to get people who own their own home to do things to it, whereas through the rental system you have more triggers in place where you can look for moments where you can intervene and upgrade. Rent is another area to think about and also possibly thinking about future cohorts and their ability to have adequate incomes in retirement. When we look beyond the current generation we start to see slightly lower home ownership across those generations and so you might expect greater challenges coming from things such as private rental costs into the future for some cohorts.
Q191 David Pinto-Duschinsky: That brings me to my last question as I am conscious of time. Toby, you called for the gap in support available for people with different diagnoses to be closed. What would that look like in practice?
Toby North: The key to that would be earlier identification of palliative and end-of-life care needs. There is also a need to look again at the special rules for the end of life. While they have been welcome, and they have enabled much greater support for people with a terminal diagnosis—people approaching their end of life—we still see that there are many people who have a terminal condition who are living with the increased costs that that brings but because they do not have a 12-month diagnosis they are not able to access additional support. They are not able to access support at the higher levels and so we would encourage that to be looked at.
We talked a little bit about the increased pension age and the impact that will have. The reality is that the pension age benefits provide a much higher level of support than working-age benefits, whether you have a terminal diagnosis or not. We see higher rates of poverty among working-age people who are terminally ill. What we would suggest is that we need to see something like a pensioner level equivalent of income for people of working age with a terminal diagnosis.
These are people who may have been paying into the system for their entire lives but because they have a terminal diagnosis and are likely to die before they reach state pension age they are struggling to make ends meet. We urge that to be looked at particularly as year on year we estimate that 7,700 more people will die every year the state pension age goes up and they will die without access to their state pension.
Q192 Danny Kruger: Two quick questions for David and one for Ruth. David, thinking about cold, is it easy to categorise the conditions that people have that make them particularly susceptible to cold at home? Secondly are you aware of any work going on into the effect on health outcomes of the winter fuel payment cut?
David Finch: On the first question, it tends to be people with respiratory diseases and things such as heart diseases that are most linked to issues of cold, but it can also worsen musculoskeletal conditions such as arthritis. You can quite possibly have people with a mix of all three of those conditions, particularly if we are looking at the older population. On the impact of winter fuel payments, I am not aware of specific work that is ongoing there, but it is something that we are thinking about how far we will be able to look into that—
Q193 Danny Kruger: Can you just say a bit more about that? How easy is it going to be to try to analyse the effect of that particular policy on health outcomes?
David Finch: In trying to understand the health impacts for different policy changes, often the fall-down is the lack of linked administrative data. Ideally you would have data that links people’s health outcomes and their usage of the health services with things such as their income, maybe their receipt of benefits as well, and I suppose you could also link in data related to temperature changes, which is probably slightly easier to do.
Where it tends to fall down is being able to link those two things together. We have had a programme of work called the Networked Data Lab, which is trying to support local areas to link up different bits of data from across the health and social system. It is just that it can take time to get the efficiencies—
Q194 Danny Kruger: The data exists; it is a question of effective linking and access to it. Thank you. That is brilliant.
Ruth, a rather general question. I was struck by what Professor Sir Michael Marmot was saying earlier about the social determinants of health, and he referenced income and social infrastructure and the facilities in the community. He really did not mention family structure at all. Do you have views on that? Is it possible to make effective analysis of the causal links between particular family types, the extent of extended families and the relational component of health that is not specifically about either income levels or community provision but is more particular to families?
Dr Law: I do not have data, but I certainly have views. Thinking about the social contact that we have spoken about and the impact of loneliness, that would be addressed very effectively if you are in a strong family or social network. A lot of older people talk about just feeling invisible and feel that they have disappeared from society. We know that lack of social contact is a risk factor for dementia in older life, for example. It is also just that lack of encouragement to get out of the house if you are on your own.
The other thing that springs to mind—again, I am sorry I do not have the data—is the amount of care that is provided in this country by unpaid carers, family members. Our social care service is under such strain, and a huge amount of care is given by this hidden population. Certainly, as you get into older age, often your informal carer is also an older person, and it is not a sustainable situation. While there are positives, there is a real risk around relying on family to be the solution to the situations we face.
Q195 Danny Kruger: Great. Any other thoughts on that topic from the other panellists?
Toby North: Just picking up Ruth’s point about unpaid carers, unpaid end-of-life carers are a significantly under-recognised and understudied group. We commissioned research earlier this year that attempted for the first time to put a number on unpaid end-of-life carers—people looking after someone with a terminal illness—and what we found was it was up to three-quarters of a million. We also looked in detail at the financial impact of that unpaid end-of-life caring, which is significant, and it gets even worse after a bereavement. What we are finding is that up to 15% of household end-of-life carers are living in poverty, but that doubles when someone is bereaved. A response to that that we are recommending is that the entitlement to carer’s allowance after a bereavement should be extended from two months, where it is, to six months, to give people in that position a bit more of a cushion.
Q196 Danny Kruger: Is it your suggestion that the care that is being provided by unpaid carers is insufficiently supported—and so we should be supporting unpaid carers, paying them a bit more or providing more generosity in the system—or that they are in fact doing work that should be provided by paid professionals?
Toby North: The former. The unpaid end-of-life care workforce, although it is not a workforce as it is voluntary, is absolutely vital and we will need that to continue, but the reality is that we need to support those people.
Q197 Danny Kruger: It is a benefit system rather than a health system problem?
Toby North: Yes.
Q198 Steve Darling: A significant part of my question was around winter fuel, but it has already been picked up by the previous colleague, so I will leave my question as it has now been covered.
Toby North: Just on that point, we looked at the number of terminally ill people who would have been eligible for the winter fuel payment who after the changes were not. We found that there were 44,000 pensioners who were receiving benefits, disability benefits through the special rules, who would no longer be eligible for the winter fuel payment. That is a substantial number, particularly given what I have already set out in terms of the particular challenges around energy costs for people with a terminal illness. We urge the Government to look at that moving forward and to consider that particular group, which needs additional energy support.
Q199 John Milne: There has been talk about moving to a more preventive approach to health. What do you think the main challenges are to taking that path? Toby, do you want to start?
Toby North: In the context of good end-of-life care, it is that early identification of palliative and end-of-life care needs. We might assume that a terminal diagnosis is quite a straightforward process and people understand what that palliative care journey looks like, but the reality is that we are very bad at having conversations about death and dying in this country and that extends to advanced care planning with care professionals, discussions with people’s families and also those other advice and support services that may be able to help.
At Marie Curie, with our information, support and advice lines, money troubles are one of the most frequently raised concerns, often before clinical concerns. A real concern we have now is that recent changes to the GP contract has removed the requirement for GPs to maintain a palliative care register so that removes one of the main incentives for early identification of palliative care needs, which is very concerning. We hope that will be addressed through some other mechanism through the NHS long-term plan.
Dr Law: The more I see patients in their homes, the more I am humbled by the fact that really my intervention as a doctor is not the biggest thing that is going to make them well. It is often quoted that only 10% of health is contributed to by healthcare itself so this big prevention agenda is so important for the wider determinants of health. They just do not have enough focus.
With frailty it is similar. It is recognising it early, so using the electronic identification systems we have in patient records to pick out those people and give them access to things that help them age well and stop their frailty progressing. Those things are not really things that come from doctors and allied health professionals. They do come from the voluntary sector and things that local authorities are doing, and that is where we need to be—so, all the things that Sir Michael Marmot was talking about really, in terms of the wider determinants of health that keep people well.
Q200 John Milne: David, same question but if you could also think of it in the context of what returns or benefits might the Government see from such an approach.
David Finch: We tend to think about prevention as well in a slightly broader sense in thinking about the wider determinants of health. I suppose ultimately it is about taking actions that will prevent acute need arising, and I think beyond perhaps what can sometimes be political challenges around sometimes short-termism in policymaking.
Putting the current fiscal position to one side to some extent—which may be too easy a get-out—the things that we are thinking about and tend to consider, one thing is that we do not measure what we spend on prevention in any meaningful way. It is hard to identify it. We have been working with CIPFA recently and with local authorities to develop a framework to allocate the elements of spend that they are doing so that we can start to get a picture of what preventive spend is. It is quite hard to shift into preventive spend if you do not know what you are spending your money on.
There is also definitely a consideration of the long-run return, and I suppose this is a more structural thing in that, if you think about fiscal events, the focus tends to be on the five-year horizon, and sometimes in that fifth year there are question marks about the plausibility of assumptions made even into the fifth year. However, with prevention activity you know that investments are very likely to have their return over the longer term. Just thinking about things such as employment changes, work that has been done to look at an increase in the health of the population and the impact on employment, 60% of the economic gains from that are appearing over five years after that gain in health. If you do not have a long enough period over which you are assessing the benefits, you are not going to prioritise those types of policies.
More practically, it is cross-government working. We are hearing, where people have more experience of local interventions and working on the ground, that the way in which programmes are delivered or budgeted by central Government can get in the way of people working together more cohesively on the ground. There is a question about trying to shift and create the conditions for local areas to act better together and be able to work in a more preventive fashion. The moves towards greater working between local government and health boards locally are potentially steps in that direction.
You asked specifically about investments. There is one big policy that has had a lot of backing, and that is auto-enrolment. There is a really clear case there, but it is a very long-term policy before you will see the benefits. There are examples of things that have happened that have been successful. In the shorter term and with a more direct impact, thinking about cold homes again, analysis has shown that there is a £900 million a year cost to the NHS from cold homes. It would cost £6 billion to fix those problems so within about seven years you would get that payback.
Obviously, it depends on how you structure the improvements. They are not all very long-term benefits that can come back. More anecdotally, you do hear about people working together more locally—things like being able to move people back into homes instead of into beds in hospitals can be a big cost saving as well. If you can get case studies and examples, there are examples of much more immediate changes that could be made that could help to get a return more quickly.
Q201 John Milne: Thank you. I absolutely agree with you: it is a challenge for Governments to look more than five years ahead at the most, across any issue. We heard earlier from Dr Attwood about the fantastic work going on in the south-west. How could we scale that up across the country or is it already happening in places around the country?
Dr Law: Talking specifically about proactive identification of frailty?
Q202 John Milne: Frailty, yes, sorry.
Dr Law: Yes, absolutely. It really varies between integrated care boards across the country. There are areas with people like David who are passionate advocates for this and are quite far forward in their frailty journey in terms of identifying their population and introducing a system-wide approach, but it is not consistent across the country. I mainly know about England, apologies, but we are working at the British Geriatric Society with the integrated care boards to try to produce policy documents that can help shape that more systematically. Were there two parts to that question? I have lost my drift.
Q203 John Milne: To what extent it is out there and how we could scale it up.
Dr Law: I think it will be at ICB level. I want to mention the voluntary sector again. Our most recent publication from the society again was all based around how important the voluntary sector is at a local level in delivering this wider determinant of health agenda.
Age UK is the charity that I am most familiar with locally. We have a navigator who sits as part of our health multidisciplinary team, who is incredible at helping people access the social prescribing side of the things that keep them well. I know there are big projects going on in Leeds, but it is all pockets around the country where champions have managed to gather things together. Some more national leadership around that would be really valuable.
Toby North: Picking up that theme around national leadership, the big challenge that we have in the context of end-of-life care is that so much of that is being channelled towards hospitals because the community services just are not there. We have a situation where, since the Health and Care Act 2022, in England the responsibility for commissioning palliative and end of life care has been a legal duty on ICBs, but we have not seen that prioritised.
Where you have end-of-life care services that are so dependent on charitable fundraising to meet their costs, we are not seeing those services. There are pockets of good practice, but we are not seeing that consistency and equity in access to services across the country. We need to see greater national leadership on end of life care. We have not had a national strategy since 2008. We think it is about time that is addressed so that we can start thinking about how we address inequalities in access to end of life care but also the wider inequalities that impact that.
David Finch: I have nothing significant to add. The observation about champions is important because you do tend to find the pockets can often be related to specific people who have been very enthusiastic and have driven the change through, so I suppose it is thinking about how to create the conditions where that happens in a more widespread way, which is partly about trying to insert those champions in other areas. Also, from a national perspective, it is about making it easy for people to start to make those changes so that there are not those significant barriers getting in the way of people improving things.
Q204 Frank McNally: In Sir Michael Marmot’s evidence earlier he spoke about the impact of changing the state pension age particularly on those who are living in poverty. David, I am conscious that the Health Foundation has stated its concerns about increasing the state pension age particularly regarding the existing health inequalities and higher poverty rates for those who are just under the state pension age. What is your assessment of the impact that you foresee the changing of the state pension age will have particularly on those who are already living in poverty?
David Finch: There is a slight backdrop to this, in the longer-term trend where we have seen life expectancy gains stalling over time. There is often mixed understanding of what life expectancy is, and the measure. The main measure reported is about people’s current mortality rates, and the one to think about more for state pension age is your cohort life expectancy—so, how long you think people reaching state pension age in a given year will live beyond state pension age.
When you look at that measure, the effect of the slowdown in mortality gains is that it has been revised downwards quite significantly since around 2008 and 2010. We are now expecting the 2020 cohort of men aged 65 to have 20 years in retirement, but that is 2.7 years less than was expected for that same cohort about a decade ago. There has been quite a significant downgrade in longevity. It does not quite seem yet to have hit the point where the people reaching state pension age in the next 10 years will have less time in retirement than the people reaching state pension age now. I think the important thing to think about is: will future generations have as long in retirement? If there is not an improvement or if there is a worsening, that will start to move in the wrong direction.
I have talked about the lack of data before. There is not good data on the future time spent in retirement in good health. It tends to be based on current health patterns effectively, but when we have looked at things such as current mortality patterns across regions, what you can see is that, in certain regions and in more deprived parts of those regions, life expectancy has been reducing—so, Scotland, the north-east, East Midlands and Yorkshire and Humber were all falling behind the least deprived areas before the pandemic.
The pandemic has had a big effect on mortality and confuses those trends a little bit. From that you could think that, if those patterns continue, the people retiring at age 67 and possibly beyond, we will start to see people living in more deprived areas falling behind and the increase in state pension age is taking a greater share of their life in retirement away from them, which is a key concern.
The work the IFS has done, looking at the last state pension age rise from 65 to 66, found that one of the key impacts was that absolute poverty for that pensioner cohort aged 65 increased to 24%, instead of what was estimated would have been 10% if the state pension age had not risen. That was because people were unable to continue working.
I suppose that goes back to the point that if you are not in work at age 65, unless you have voluntarily retired and can quite easily go back and find other work, it is reflecting that some people are unable to work anymore due to their health. Their chances of going back to work at that point are very slim and, coupled with the trends we have seen around incapacity benefits over the last few years, there is a real risk that there will be a bunch of people who are likely to be thrust into poverty by the pension age rise to 67.
Q205 Frank McNally: To all members of the panel to conclude: we know where we are going in terms of the state pension age for now, but are there any particular steps that you think the Government can take to mitigate some of the challenges that you have just outlined?
David Finch: There is employment support. It is challenging for a group who have been out of the labour market for a while, but perhaps to focus on preventing people from falling out of work in the first place and probably working beyond state pension age where that is possible. There are not many other options. It is financial mitigation effectively—so, something along the lines discussed before of topping up people’s benefit income to reflect more what you would receive at pension age rather than at working age, because there is such a big gap between the two.
Dr Law: I have nothing further to add.
Toby North: I refer you back to my earlier comments that, because of the change in the state pension age, more people with a terminal illness will die in poverty. We suggest that to mitigate that people with a terminal illness should be guaranteed a state pension level-equivalent if they have a 12-month diagnosis.
Q206 Chair: Thank you very much. Just a final one—since we are ahead of time, which is very unusual—about what recommendations you would like to put to the Government if you were a member of the Committee. Toby, you have been quite forthcoming—for example, making sure there are care pathways around a non-cancer diagnosis for end-of-life care. You had a couple of others as well.
Toby North: Absolutely. I think it is about looking at the special rules for the end of life again and being clear that in other benefits—one example is around attendance allowance—if you are subject to the special rules and you apply for attendance allowance, the requirement that you have had a condition for six months is waived, but if you do not have a prognosis of 12 months or less to live, even if you have a terminal diagnosis with a prognosis of 13 months to live, you do not get access to attendance allowance on that fast-track basis at the highest rate. We think that is something that should be addressed.
Q207 Chair: Thank you. Ruth, what would you like to see?
Dr Law: I think just back to that message of creating health, not just preventing disease and particularly that healthcare services should be designed to support the most complex users rather than blaming them for the challenges that their complexity presents. It might be a good point to mention as well that we do not have a commissioner for older people in England like they do in Wales and coming soon in Scotland.
Q208 Chair: We were in Greater Manchester and that was a strong recommendation that came out there.
Dr Law: Many of these issues are cutting across all the Committees and there are the same messages in each. I am concerned that the three pillars of the 10-year plan, while we support them, are not going to hold up without that underpinning of the wider determinants of health.
Q209 Chair: I remember working in the NHS at the time of the national service framework for older people. Would the roll-out of a national approach to healthy ageing—one that did not just rely on wonderful people like Dr Attwood—help to focus attention?
Dr Law: Yes, is the quick answer. It has been attempted multiple times, and obviously the current restructuring in NHS England is going to make the work that has happened more challenging to roll out, but we will keep going.
Q210 Chair: What about you, David? What would you like to see?
David Finch: I suppose there is a bigger picture thing about the shift towards a more preventive approach and treating people’s health and thinking about poverty through their lifetime, so that you do not get the disadvantages that you see. That is really the only way we are going to make significant inroads, although it will obviously take time. It is ultimately about having the focus on determinants of health underpinning the 10-year plan and generally the health missions and Government policy in this area.
More specifically, I think there is something about the availability of flexible financial support for people, because I think, particularly if you have limited funds and cannot change that income for whatever reason, particularly for pensioners, you ultimately will need some financial support to prevent things from getting worse, so maybe in a time of crisis. By “crisis” I mean a global shock-type crisis, but also perhaps someone’s washing machine breaking and needing to get it fixed.
The other route is trying to deal with the underlying issues. Some of the things that we are talking about are a consequence of cold homes. You do not have to have an income boost for that. You can deal with that by improving the quality of the housing stock and pressures such as energy costs, and you can work towards reducing those costs. Those are three broad approaches to try to mitigate issues.
Q211 Chair: A very quick one: social prescribing is becoming more prevalent, which is fantastic, but could that be used more widely across the NHS for older people?
Dr Law: My experience locally is that it is very well embedded in both primary care and the proactive services that are running but, as we have already said, it is quite patchy, depending on which area of the country you live in, and access to healthcare services is more difficult, including access to a GP, in a deprived area. Again it is that knock-on effect.
Chair: That is so helpful. Thank you so much. It has been an informative final panel for this evidence session.