HEALTH

Key points

Introduction

In 1994, the population aged 65 and over comprised 12% of the total population, while it accounted for 40% of all health costs. People aged 65 and over are major users of health services and older people are a growing proportion of the population. This will present significant challenges to the health care infrastructure and has profound funding implications for Government.

While the OECD reports that most people in their 60's and early 70's share many of the same health and social characteristics as younger adults, after the age of 60, average personal health care expenditure grows steeply, with preliminary estimates suggesting that per capita expenditures around age 70 are twice the average, peaking to four times higher for those aged 80 and above. New Zealand health data shows that from age 85 the cost per head is approximately eight times that for adults aged 45 to 64 years.

The most significant feature of the ageing population, in relation to health expenditure, is that the most rapid increases will occur amongst the "old-old" (those aged 80 years and over), who will grow by 17 percent (16,750 persons) in the five years to 2001 and 37 percent (41,950) in the decade to 2011. By this time, the "old-old" will make up 28 percent of the population aged 65 and over. By the year 2031, people aged 80 and over are expected to number 259,300.

A major contributor to the increased cost of health care for older people is expenditure on residential care services, such as long-term rest home or hospital care. The OECD states that the increases in expenditure are less pronounced in other areas such as consultations with physicians, pharmaceuticals, medical appliances and other ambulatory services. Some of the most expensive chronic conditions such as dementia occur mainly in older age. An analysis of the cost of health care for older people illustrates that major health expenses are directly related to chronic illness and incapacity, much of which does not occur until very old age.

Health Status

To date, there has not been a definitive study of the health status of older people in New Zealand, although older people are regarded as the age group most likely to experience poor health and/or disability. A study undertaken by Statistics New Zealand in 1992-93, found that 70% of people aged 65 years and over reported either a diagnosed or self-identified long-term illness or disability, compared with around one-third of the overall sample. Even so, nearly three-quarters of older people reported their health as either "excellent" or "good".

The survey demonstrates a disparity between individual's perceptions of their health status and popular perceptions of relative health and disability. For example, a person may have impaired mobility, requiring them to use a walking stick, but may nevertheless consider themselves to be in excellent health and able to maintain an independent life-style.

The Ministry of Health has commissioned two surveys on the health of New Zealanders; A New Zealand Health Survey and A National Nutrition Survey. The two surveys, to be run from October 1996 to November 1997, will provide the Ministry of Health and Regional Health Authorities (RHAs) with information on which health services can be planned and programmes developed.

Life expectancy has increased significantly in recent decades. For instance, between 1980-82 and 1990-92 life expectancy at birth for men and women increased by 2.5 and 2.3 years respectively. However, it is not clear whether increased longevity has been matched by improved health status. Three competing theories dominate international debate in this area:

1. as people live longer, the ratio of "well' to "disabled" years will remain relatively unchanged;
2. improvements in technology means that fewer years will be spent "disabled"; and
3. more years will be spent "disabled" as improvements are unable to keep pace with gains in life expectancy.

At the current time, there is little research to support any one of these theories over the others. However, it would appear that the third theory fits contemporary evidence best. That is, while people live longer "well", they also live longer "disabled".

As noted above, chronic ill-health is generally concentrated among the very old, particularly in the year or two preceding death. While physical changes do take place throughout the ageing process, much of the physical decline commonly associated with older age can be attributed to inactivity, rather than the "ageing process". The OECD notes that the health characteristics of most people in their 60's and on into their 70's are broadly similar to the rest of the adult population.

The incidence of mental disorders does appear to increase with age, especially for conditions such as Alzheimer's Disease and related dementias. It is estimated that 10% of people aged over 65 have some form of dementia and that this figure rises to 20% in the 80 plus population. By 2001, it is estimated that there will be 45,000 people in New Zealand with dementia. It is anticipated that the incidence of dementia will further increase in line with the forecast growth of the older population, particularly in the 80 and over age group.

Older people receive hospital care at higher rates than younger adults, and have longer average stays in hospital. From 1986 to 1991, hospital discharge rates for people aged 75 and over rose by around 30% compared to a 16% increase in number of people in this population cohort. The increase in hospital discharge rates cannot, therefore, be attributed entirely to an increase in the cohort size.

In summary, while some older people may experience increased ill-health as they age, there is considerable individual variation in the health status of older people. For this reason, it is important that old age is not treated as a medical condition.

Maori health status

The Public Health Group of the Ministry of Health is at present preparing an issues paper, "Health of Older People and Kaumatua Well-Being", which will be ready for public consultation early in 1997. A study of the well-being of kaumatua is being undertaken by Massey University for Te Puni Kokori and the Ministry of Health which should provide better information on what factors contribute to well-being for older Maori. An analysis of submissions and hui that contributed to the Public Health Commission's document, He Matariki (1995) identified that the contributors believed that the major determinants of Maori public health status were social and economic.

Maori life expectancy is lower than that for European/Pakeha New Zealanders but is, nevertheless, improving. In 1950-52, a Maori baby girl had a life expectancy of 56 years, compared to the 72 years that a non-Maori baby girl could expect to live. A Maori baby girl born in 1990-92 could expect to live 73 years, compared with 79 years for her non-Maori counterparts. Maori males have also experienced improved life expectancy, from 54 years in 1950-52 to 68 years in 1990-92. However, the difference in life expectancy between Maori men and Maori women has widened.

The causes of death which accounted for most of the differences in life expectancy between Maori and non-Maori in the 1985-87 period were circulatory disease, respiratory disease and cancer, particularly lung cancer. Subsequently, rates for hospital care for Maori aged over 65 are higher than for non-Maori of the same age, with hospital rates for respiratory and circulatory diseases being particularly high.

Health Promotion

Addressing the issues of health and well-being at each of the life stages is an important strategy for improving the health of the older population. Health promotion needs to start at an early age, recognising that an individual's early life-style impacts on their future health and well-being. Such a strategic approach, while not producing immediate results, will have a significant impact in the longer term.

Demographic factors, socio-economic status, the physical environment, food and nutrition and other life-style factors such as physical activity all have an influence on health status. These determinants may act alone, but more generally interact. For example, demographic factors such as gender and ethnicity may also influence an individual's socio-economic status and together these factors combine to determine health status. The responsibility for the promotion of good health must therefore be shared across a range of sectors.

Significant work on health promotion with older people was undertaken by the Department of Heath from 1985-91. This work was continued by the Public Health Commission, however, the Commission was disestablished in 1995. While the Ministry of Health considers that many of the Commission's programmes will be continued under the current structure, the focus on older people's issues in the short-term appears to have lost some momentum.

Many government agencies have a potential policy role in health promotion. The housing issue, in particular, is one that can be directly linked to health. For frail older people, unsatisfactory accommodation can mean increased likelihood of moving into residential care rather than remaining in the community. While government health policies encourage older people to remain in their own homes, there are few specific housing policies which support this objective. Such incongruencies in government policies need to be addressed.

The Hillary Commission for Sport, Fitness and Leisure is one example of a government agency that has embraced the health promotion concept. Its aim is to improve quality of life by enabling all New Zealanders to participate and achieve in sport, fitness and leisure. The Commission's "Active-in-Age" programme, which promotes local recreational activities for older people, has gained international recognition.

While the OECD notes that it is possible the baby boom generation may reach old age in far better health than did their predecessors, as a result of their better education and information about healthy life-styles, this is nevertheless dependent on sustained investment in educational programmes and preventative measures.

Health Services

Since 1992, health services for older people have been delivered through two systems; personal health services and disability support services. If an older person has an illness requiring acute care, their needs are addressed through personal health services, but if their condition has stabilised and is expected to continue for at least six months, services are provided through disability support services.

Both personal health services and disability support services are funded through the RHAs, although the funding streams for these two services are distinct. The separation of funding for the two areas has had service delivery implications. Health professionals involved in the review of the assessment protocol reported that services for older people had become fragmented since the separate funding regimes had been introduced.

Rather than ensuring that clients are provided with an appropriate mix of services, the current system has the potential to encourage cost-shifting between the two funding streams, resulting in delays in service delivery. Comment from older people suggests that, in some areas, cost-shifting has become a reality. Discussions with geriatricians and feedback from organisations representing older people indicate that greater co-ordination between these services is necessary to ensure the effective utilisation of health funding for this age group.

Disability support services

Access to disability support services is largely controlled by way of an assessment protocol. In order to receive disability support services, older people must be assessed by Assessment, Treatment and Rehabilitation Units, of which there are 22 in the country, to determine the level of care and the services they need. Disability support services purchased through RHAs can also be subject to income and/or asset testing.

A national protocol to assess the support needs of older people was introduced in July 1993 to ensure that services would be provided only to those who were assessed as needing them. While the assessment protocol is an important control mechanism, there is considerable regional variation in the waiting times for assessment and for service provision. RHA guidelines stipulate that a needs assessment should take place within two weeks following contact with the assessment service. A survey of RHAs undertaken by the Advisory Council for Senior Citizens in mid-1996 showed that, in some areas, older people were waiting for more than 12 weeks to be assessed.

The continued viability of needs assessment-based disability support services is dependent on adequate resources being available to ensure that older people receive the services they are assessed as requiring. Comments frequently made by older people and health professionals indicate that service delivery is not consistent throughout the country.

Residential care

At the current time, 60% of the disability support services budget is ring-fenced for services for older people, and 90% of this expenditure is attributed to the Residential Care Subsidy. The high level of expenditure on residential care is due not to a large volume of older people in residential care, but to the high cost associated with the provision of residential services. It is estimated that only 7.4% of people aged 65 and over, or 31,000 individuals, are in residential care.

These figures support the OECD analysis which identifies expenditure on residential care as the major contributor to the increased cost of health care for older people. Residential care services have an important place in the overall health framework providing intensive, specialised services to those older people experiencing chronic ill-health in their latter years. Given New Zealand's ageing population and, in particular, the forecast growth in the over 80's age group, the demand for residential care services is likely to increase.

The current focus of policies in the residential care area has been to tightly target the services to those people who are no longer able to continue living in their own home or with a caregiver. A Residential Care Subsidy is provided to assist older people who are assessed as requiring residential care and who meet the criteria of an income and asset test. Regional health authorities contract with rest homes and private hospitals to care for older people who are assessed as being eligible for the Residential Care Subsidy. One of the contract conditions is that the provider agrees to only accept residents who have undergone a needs assessment. The reason for this policy is to prevent private-paying people being inappropriately admitted to residential care facilities who, at a later point, may then require a Residential Care Subsidy.

Home-based services

Current government policy is to promote community care which will assist older people to remain living in their own homes for as long as possible. This policy is in line with a general desire among older people to remain living in the community. Home-based services currently funded by RHAs include meals on wheels, cleaning and personal care services for bathing, dressing, and feeding. The provision of home-based support services for older people with a significant disability is not only desirable from a social perspective, it is also attractive in economic terms. North Health RHA estimates that it is cost-effective to keep someone at home with up to the level of 34 hours of home-based care per week.

Targeted access to residential care has meant that the demand for community care is increasing dramatically and RHAs are looking at how to best meet this demand within a capped budget. With the growth of New Zealand's older population and the increased geographical spread and mobility of families, the requirement for home-based services is expected to further increase. An adequate level of funding for these services is therefore essential.

Personal health services

Personal health services received by older people are essentially the same as those provided to the general population. The main issue of concern to older people is the waiting times, particularly for elective surgery such as cataract and hip replacement operations.

While the Unit is not aware of any data on the opportunity cost of delayed surgery, it is reasonable to assume that such costs would be considerable, and could include items such as income support, home care services, hospital care, residential care and other health and social services. There are also social costs as older people in this situation would have less opportunity to continue to contribute to their community and family.

The National Health Committee, formerly the National Advisory Committee on Core Health and Disability Support Services, is working in conjunction with RHAs to produce standardised criteria for assessing patient priority. In making these decisions, there is a need to take into account the opportunity cost of delaying surgery. It is therefore important that health planners have access to robust data on opportunity costs on which to base their assumptions on how services should be prioritised.

Future Directions

The forecast increase in older New Zealanders, in particular those aged 80 and over, will have a major impact on the country's health services. Early co-ordinated planning is needed to determine how best to cope with this demographic change.

Health promotion strategies, implemented throughout the life stages, will have an important role in improving the health status of future generations of older people. Health promotion policies need to recognise the multiple determinants of health status and a co-ordinated approach should be adopted across a broad range of government agencies.

A co-ordinated inter-agency approach is also essential to the development of broader positive ageing strategies. For instance, if health policies are promoting ageing in place, then housing polices need to be congruent with this objective. The need for better co-ordination between government and non-government agencies has been raised at consultations undertaken by the Prime Ministerial Task Force on Positive Ageing. Any recommendations that the Task Force may make in response to this concern will be particularly pertinent to health issues.

More immediately, current tensions in health service delivery, apparently caused by the separate funding streams for disability support services and personal health services, should also be addressed. Greater co-ordination of service delivery in these areas is essential for the well-being of older people.

While high levels of expenditure on residential care are expected to remain a feature of disability support services for older people, it is essential that funding for home-based services is sufficient to meet the needs of an increased number of older people who will live longer, and to mitigate against the use of residential care in circumstances where community support could sustain living in the community.

Advancing technology, medical knowledge and pharmacology continue to increase the range of procedures and medications that can improve the quality and length of life in older age. The expectation of many older people, as with other sectors of the population, is that they will have access to publicly-funded health services as they need them. It is anticipated that despite the work in defining core health services, public debate will continue on priority areas for health expenditure. Ultimately, public opinion will influence decisions on the level of resources allocated to health.

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