Sunday, 1 December 2013

Pennies, pence, sense and sex

I've collected some thoughts about the Health 2.0 Europe conference held in London last month. Now in its fourth year, this event is a coming together of ideas, creativity and plentiful energy chasing dollars, pounds, pennies and pence. There's interest in making sense out of digital health's huge remit and its potential to transform later life and end of life care. Or is there?

The context for this event was punctuated by reminders of the problems still plaguing the Obama Care rollout in the states, along with potent reminders of the mid-Staffordshire fiasco and the Colchester cancer records scandal. Uncomfortable truths locked in a swirl of gamesmanship, dilly dallying, management weaknesses, human error and that unmistakable whiff of institutionalized corruption, again. Only this time we are talking about violations to our basic human access, to dignity. Unutterable, amidst the whole, shiny shebang, was the specter of what Health Secretary Jeremy Hunt has labeled our national shame; the new untouchables, our lonely old.

It seems however, that we're putting the cart before the horse here. The US has apparently spent some £2B on digital health compared to £700M in Europe. That's a lot of dough. There is some evidence that self tracking of chronic conditions seems to be working and "Big Data" is happening.  In NY state, a reported 19M people out of a population of 19.57M are sharing health data over a network! Then, in the UK there is a remarkable resource called the HES or Hospital Episode Statistic that contains records for the entire population where each interaction of the NHS has been tracked since 1989. Wow, but what does this actually mean?  I'm curious about this sharing and tracking - with who and what data? Clearly, patients are becoming more demanding about involvement in their own care. This is a good thing because chronic disease management is certainly one of the biggest challenges our ageing planet faces. But while all the signs of progress that were bandied about at the conference sound exciting, it somehow doesn't jive with the statistic that 80% of care homes in the UK have zero internet access. Shocked? Surprised? Data access and even data collection aside, assuring that data content is meaningful, so that it can be beneficially interpreted, seems to be another missing link. Taking this down to the basics, it is probably a good thing to track how many times someone has fallen down. Wouldn't it be more important to understand why they fell in the first place?

In the opening remarks and again at the keynote, mention was made of a £1B innovation fund. I must have misheard that because I can only find mention, on November 15th, of a new Regional Innovation Fund (RIF) of £5million made available this year to support and promote the adoption of innovation and the spread of best practice across the NHS. This, on the heels of the October announcement that NHS England had scrapped a £50m fund designed to promote innovation as part of the flagship government policy aka Innovation, Health and Wealth. This IHW program was announced in 2011, finally rolled out in August 2013 and then "suspended indefinitely", two months after its launch.  From £1B, to £50M to £5M? Exactly how serious can we really be about moving the conversation forward? This is not just technology and treatments, it's about the patient provider dynamic and the future design for optimizing the most basic ADL (activities of daily living) for an increasingly, ageing global citizenry.

Leaving the sadness of loneliness aside, the wave of older people dealing with increasing frailty and the projected increase in people living with dementia is the profoundly shocking visual to take on board, beginning with the people who are innovating and designing for our future. Older people and even the ageing boomers may not be so technologically savvy as we'd like to believe and while advanced technology can be great, personal interaction is not advanced. We need cleverer, simpler ways for the increasingly, simpler needs of these now, not as clever people.

Help Age International continues to hammer home the message that the continual exclusion of ageing from national and global agenda's is inscrutable and must be addressed. This makes the first ever G8 Dementia Summit in London, on December 11th, a very important gathering for anyone living.  The point is clear, ageing needs to be on the agenda and fast, but I disagree with Victor Wang of GeriJoy who says that ageing isn't sexy, so we need to make it as sexy as global warming. I don't see ageing and global warming as comparable. Climate change has slid sideways on the agenda because of insufficient, conflicting evidence. Evidence of ageing surrounds us, if we choose to look. Silence remains the most outspoken form of denial. Ageing is multi-dimensional, complicated, challenging and reaches far wider than health care alone because it is rudimentarily social.

Ageing is about real life. So is sex. The race to make ageing, a sexy part of life, is officially on.

Deborah Gale

Tuesday, 19 November 2013

The intergenerational conflict fib

Intergenerational conflict. Let's make some effort and disassociate these two words. Fiercely negative, this political and media fueled construction is drip by drip, convincing us that the young and the old are involved in some life or death struggle, for scarce resources. 

"Hey, it's the age of austerity!"

"Wait, the stock and housing markets are on a tear!"

So, who's right?

Dr Debora Price, King's College, London considered this toxic groupthink in her remarks: "Challenging Futures: Intergenerational Conflict and Critical Gerontology in the Age of Austerity" for the ERA, Emerging Researchers in Ageing, at the 42nd BSG (British Society of Gerontologists) Conference on 10 September.
As is generally the case, whoever wields the power allows popular discourse to run and flourish, right alongside unpopular counter discourse. It's effective. The roller-coaster titillation diverts attention, albeit momentarily. Meanwhile, the deluge of conficting information becomes so incessant, that most of us are inclined to tune out. And so we do, except the niggling is now in our brains and it festers. Simultaneously, a very, selective, evidence base is supporting this head pounding discourse.
Intergenerational friction has a long, rich history. Today's young have been made to feel that the boomers have hoarded housing, education and health care while less attention has been focused on the increase in boomerang kids; those who return to the safe haven of "home". Previous generations were more likely to be escaping from home, in search of something different and sometimes better. Some boomer parents have made things so much better that the cocoon of home can look infinitely superiour to the big, bad world. University degrees and bags of promise aren't enough and cushy homes with full refrigerators and free wifi are in some cases, turning these hard earned edifices into the next graveyard of ambition.
It's as if a collective terror of ageing has coalesced, resulting in a confusing melange of increasing attacks on the accumulated wealth of the boomers. Then, it gets lumped together with the vitriol heaped on "senior" perks like free bus passes, TV licenses and winter fuel allowances. "Watch out!" These are being gobbled up by the preceding generation, the over 85's who are also regularly accused of bankrupting the NHS and clogging up A&E's.
In 2013, its everyone's turn to be anxious and for good reason. Putting inheritance, the biggest driver of inequality to the side momentarily, some research suggests that only 50% of people over 50 have more than £100K in savings for retirement and another 25% have zero housing equity. These same people are predicted to live another 30 years. Concurrently, financial transfers via the bank of mom and dad have increased significantly in the last 10 years. Stingy, aren't they.
In addition, some 63% representing 7M grandparents in the UK provide essential child care, unpaid and the incidence of intergenerational co-housing has also steadily risen. Selfish, too.
So why is the inequality fib so pervasive, who is it benefiting and whose interests is it serving? The political debate has been structured erroneously and it is really up to us, to speak the truth to power. What can be done? Here are a few ideas to get the new discourse started:

1. In the case of equity release programs, the government enthusiasm is markedly flawed. Those who need it the most have the least housing equity and this makes it highly regressive.
2. More progressive taxation will be necessary to fund social care going forward.
3. Rethink the way that NI money is actually used.
4. Particularly pertinent now, correct the divide between health care and social care, beginning with reclassifying dementia as an illness instead of a social problem.
5. Re-engineer the financing mechanisms in reforms of the NHS and make social care also free, at the point of delivery.
Obviously so simple! But changing the political discourse means acknowledging that the marketization of the welfare state can not be reduced to another left vs right debate. This could be better accomplished by advancing the disassociation suggested above and replacing it with intergenerational cohesion as the new, more powerful discourse. People, seriously, do need people.
Change might be in in the air. Sir Andrew Dilnot, architect and champion for social care funding reform and Chairman of the Statistics Authority recently challenged the views of David Willets, author of The Pinch and Frances Becket author of What Did the Baby Boomers Ever Do For Us. He believes that material improvements in the lives of Britons, already in evidence, will continue to improve. Longer, living boomers and their also ageing, former charges, have every motive to actively participate in contributing substantively to these improvements.

Deborah Gale

Monday, 11 November 2013

How do we make 'elder care' sexy?

I had an interesting chat with Maneesh Juneja last week, ahead of my participation in a panel discussion at Health 2.0 Europe. We were talking about how, despite the current hype in the health technology industry, events specific about technology for elder care often fail to attract large numbers of young technology developers and entrepreneurs. Looks like, despite its importance, developing tools for older people is just not sexy enough for this crowd.

Think about all the cool solutions that have emerged in recent years in the Health 2.0 space. Think about sleek looking activity tracking devices like Fitbit. Think about awesome apps like Runkeeper or GetHealth that motivate people to pursue healthier lifestyles. Think about Scanadu and its promise to enable anyone to conduct sophisticated physical examinations from home (while using a beautifully designed piece of equipment!). These companies are doing a great job in terms of turning things like eating healthy and exercising, perceived by many as tough or boring, into something social, fun and cool. So why can't we do the same for elder care?

Unfortunately, for many, elder care is still a topic to avoid. On a personal level, a large number of people don't want to think about 'ageing' until they are about to retire or suddenly find themselves caring for an older relative. On a professional level, many find the idea of working with older people dull or depressing. If you consider these perceptions,  it is not hard to understand why developing technology for people with dementia or caregivers, for example, fail to appeal to the majority.

I think one of the problems here is that we keep talking about older people as if they were this separate entity that never has anything to do with us. We often forget that we are all (hopefully) going to age ourselves, and many of us will care for an older relative before that. To me it seems obvious that innovation in elder care should be seen as something super exciting since we are all potential users and consumers of these solutions. I certainly want my 'elderhood' to be as awesome as my child and adulthood were and I believe you should feel the same. So it is about time we start thinking more seriously about ways of turning elder care into something really cool, something to be celebrated rather than avoided.

So I guess my questions to you are: How do we get more technology developers and entrepreneurs interested in developing awesome solutions for older people and their caregivers? In other words, how do we make elder care sexy?

I have a few ideas myself and I will be writing about this soon, but for now I would like to hear your thoughts and ideas.


Brenda Reginatto

Health 2.0 EuropeHealth 2.0 Europe is taking place in London, November 17-19th. Brenda Reginatto will be part of the final panel discussion at the pre-conference workshop "Health 2.0 Tools for the Elderly" (November 17th) moderated by Maneesh Juneja.

Friday, 1 November 2013

Health2Dublin: Can technology increase well-being among older people?

After spending a year in France, it’s been great to return to Ireland and find a significant increase in interest in the health tech space. Over the last year, several initiatives in healthcare innovation research have been announced and partnerships between academic centres and enterprises of all shapes and sizes have multiplied. But I was particularly surprised by the community of healthcare innovators that is rapidly growing around here. Health2Dublin is one of these communities.

Health2Dublin is the Dublin chapter of Health 2.0, an international movement known for facilitating and creating worldwide events that promote and demonstrate how information technology can transform healthcare practice. By putting the leaders of the healthcare innovation scene together in one place they are hoping to create the future of healthcare.

Last week I attended my first Health2Dublin meetup, the topic of the evening was "Technology for Healthy Living". I was interested to see whether the 50 or so attendees, many of whom have background in technology, were also thinking about how technology can support older people and their caregivers to live longer, healthier and happier lives. Here is what I found.

Dr John Dinsmore (Trinity College Dublin) opened the evening with a key note talk about how to use technology to manage and promote health. There was a long discussion about the potential role of assistive technologies in increasing well-being among older people who suffer from chronic conditions or disabilities, but the key message for me was the acknowledgement that well-being is a subject concept, and therefore has different meanings for different people.

I know this should sound obvious, but it is not. As healthcare professionals, carers, family members, technology developers, we are constantly thinking about what would be good for our older clients or relatives, based on our own sense of well-being. Dr Dinsmore urged healthcare innovators to engage deeply with their consumers before technology development stage, in order to fully understand their needs, wants and technology literacy levels, instead of making a bunch of assumptions about “how they think older people are like”.  In Dr Dinsmore words “we must understand that it’s not about cool technology; it’s about changing the user experience”. And in order to do that, you must know your user first.

The discussion continued through a panel discussion formed by Liam Ryan (Get Health), Dr Robert Grant (GetHealth) and Dr Ronan McDonnell (Quantified Self Dublin). The message was clear - if you cannot create an enjoyable and engaging experience for the user, your technology is doomed to be forgotten, no matter how cool it is, no matter the user’s age.

The evening concluded with a short demonstration of a new healthcare video messaging application  called HealthSnap, which I will talk more about in another post. Overall, it was a great session. It was great to see such a young and enthusiastic crowd talking about how to improve the care of older people. And, more importantly, how to do it by putting the older person at the center of the debate.

Brenda Reginatto

Tuesday, 29 October 2013

Unlikely bedfellows - Arab, German, Japanese social constructions and ageing

At first glance, nothing obvious ties these things together. And yet, a single thread does connect distinct geographies, across seemingly inconsistent time frames, to the overarching reality of an ageing world.

Last week, I was on a panel at the UCL (University College London) Festival of Ageing. This panel included Aaron Parkhurst, PhD candidate/Research Fellow in Anthropology and expert on skin-whitening practices across the Emirates, Ulrike Neundorf, PhD candidate in Medical Anthropology, expert on surveillance techniques of the Stasi secret police in the GDR(German Democratic Republic) through its abolishment in 1989, Jesse Bia, MPhil/PhD candidate in Medical Anthropology, expert on organ transplantation practices in Japan, and myself on longevity in the 21st century. So what's the connective tissue?

It's the link to our identity. On a superficial but ultimately defining level, each topic is or was reliant on the suppression and masking of identity. More specifically, in the case of Japan, the very essence of self as it relates to the complicated definition of "brain death" was explained. Plumbing the deepest reaches of ourselves is fiendishly visceral!

So, I googled skin whitening in the Emirates  and got 11,200,000 results. When I limited it to "in the Emirates", I got 290,000 results. Apparently when using products like "Fair and Lovely" (58,400,000 results in .4 seconds), increased attractiveness to the opposite sex, maximized virility and a pathway to life successes can be yours. Out of curiosity, I next googled fake tanning and got 6,860,000 results and a whopping 14,100,000 for Fake Bake. The opposite desirability is playing out in the west. And we know, this equates to big business, $170B annually of which $48B gets spent in the UK alone. The malleability of identity is laid bare.

The Stasi exploration probes the exacting, seemingly emotionless and institutionalized investigation of persons deemed to have been a threat to the GDR. The very finest minds, including those of PhD students at the time, were directed toward refining techniques of intimidation and sublimation to ensure conformity. Notably, there are faint echoes in the recent NSA breaches of friendliness, between allies. The fragility of identity is exposed.

In Japan, strong cultural views about life and death and a tacit distrust of western medicine is central to this countries skepticism and relatively lower rates of organ donation. Conversely, Japan is a major, world class player in stem cell research, with a permissive regulatory framework and highly experimental environment. The dichotomy is unmistakable and underscores that the socio-cultural construction of identity is fundamental.

Add ageing to this mix, a period of life that so many people have never experienced, at the same time, ever before and personal identity is the linchpin. Given that not a single one of us can know our ageing fate, the unpredictability is real. For those of us who survive into old age the physical is stripped away. In time, we will accept that along with our outer image, every other element of life we have invested in, does not last either. All that remains is the inner self, the elemental identity.

Unsurprisingly, in the 21st C, it may turn out that our instinct for life will allow us to ascribe value to our ageing identity, and the positive acknowledgment of this as a different, rather than a less than time.

Deborah Gale

Monday, 1 July 2013

Are we ready for ageing or not? NOT.

Here is an opinion piece on the House Of Lords Ready for Ageing report. We are So. Not. Ready. Makes for interesting reading, join the debate. Should Gove get Ageing AND Education?

Ready for Ageing? No! Ready for Ageing? No!
By Deborah Gale

The Select Committee of Public Service and Demographic Change, an adjunct of the House Of Lords, was formed in May 2012. They solicited evidence based inputs from experts and then published their Ready for Ageing? report on the 14 March 2013. The answer to the question posed then, as now, remains the same. No, we most certainly are not.

However, the degree of un–readiness has been dissected here and I was encouraged to see that the select committee had female representation with five women out of the twelve members. That said, the message from the House Of Lords, that fundamental reform was undesirable at the same time that radical change was necessary, sounded confused instead of constructive. Merely highlighting the collective failure of past and present governments to address the growing implications of population ageing by requesting yet another White Paper feels like a hand wringing, delaying tactic. The 2011 Dilnot Commission on Long Term Care, another grim governmental review which was specifically focused on long term elderly care, was also starkly critical of the seriousness of this issue but we have barely moved on since then.

Once again, the Ready for Ageing? report raises the right issues in exhaustive detail but the combination of a lack of political will and initiative to address the realities of a rapidly accelerating, ageing population remains obvious. It is as if no one in a decision–making capacity has taken this on board. Is it because the scale of the problem is, as yet, unrecognizable and that there aren’t any personal consequences for this massive, predictable risk?

While firmly in the policy stream and the thrall of the media, the fact remains that ageing terrifies every one of us. A weak stance is borne out in this 105 page report. Progress surrounding approaches to ageing issues will eventually demand a serious ideological, socio–cultural shift. This will require a new narrative with new words, definitions and ways to define and appreciate our thirty–year longevity bonus. We are nowhere near ready for this either.

Preparing this report, the committee issued a call for evidence to some 93 experts across central and local government, think tanks, academics, the NHS, several builders and providers of retirement homes as well as volunteer groups from the third sector. Notably, witnesses from the private sector were limited to BT and The Saga Group. The questions posed to these experts were purposely broad with respect to how British culture perceives age, what people’s expectations were regarding work, savings, retirement and independence, what their attitudes were about the scope and responsibilities of public service along with how they thought the public purse ought to be allocated.  Questions also included a call to action for addressing present and future deficiencies within the existing systems and concluded by asking the experts what was required to stimulate a national debate on population ageing and its attendant challenges.

Given this scenario, the impact on public services will be immense. The delineation between health care and social care and how each will be delivered requires disentangling with surgical precision. Right now the concerns and condemnation regularly voiced in the media surround inappropriate levels of care for the current older population. Crucially, we not only have a situation where present needs are unmet but are looking at a future where unknown levels of demand are also unlikely to be met. This is occurring at the same time that the global financial crisis has contributed to a significant spending crisis. The report makes clear that the not yet old have every reason to be concerned, even if they have decided they aren’t ready and don’t want to tick the “old” box yet. That is why stimulating a national debate and moving beyond the impasse and inertia is at the crux of this overarching issue. Following a review of the key areas of the report, I suggest a potential, immediate, albeit short–term solution to moving ageing up on the agenda.

Depending on your point of view, ageing projections make for celebratory or sobering reading. Longevity equals human progress but also represents a challenge when longer life spans with reduced health and less wealth are anticipated. Between 2010 and 2030, a 51% increase in the over 65’s and a 101% increase in the over 85’s is forecasted. Simultaneously, this illuminates several critical issues: the under–saving problem and the inadequacy of retirement incomes, the deterioration in wellness when the number of people with three or more long term conditions is growing, along with estimates that the number of over 65’s with moderate to severe cognitive impairment will rise 80% over the next 15 years.
At the same time, the divergences between the rich and poor as well as men and women; women being the primary users of social care in later life, are markedly different. The difference is also seen and predicted in the outcomes for those facing a comfortable longer life vs those with greater exposure to multiple risk factors, who also have significantly fewer assets to draw upon in later life.

As was previously detailed by the Dilnot Commission, the structural and budgetary split between health and social care is unsustainable. The Dilnot report made clear that individuals must plan for the likely costs of their own long term care and also encouraged private investment and pension sectors to enter this specific market and provide options. Clearly, the current model is inappropriate and unable to cope with the unpredictable but changing patterns of ill health that are to be expected from a longer living, aged population. We see on a daily basis that the lack of quality care for older people in both the private and the public sector has a domino effect. Health care needs not satisfied by a 7 minute visit to their GP eventually accelerate to a crisis situation, usually requiring a visit to A&E or hospital. This results in significant increases in health care costs and generally negative outcomes. Studies reveal that older people who are admitted to hospital for more than three days are more likely to die there. Modern medicine does disease not decline.

The call for patient centred treatment would radically change service provision in the NHS and make care at home the new hub and minimize hospitalizations. Putting this system in place, whenever possible, is the real goal. This, however, would require a radical shift in NHS service provision by front–loading health care towards prevention and early intervention.  In this way, reversible conditions could be caught earlier and prevented from contributing to further declines from the chronic ill health that is seen to accompany advancing age.  However, in order to achieve a truly 24/7 NHS, it has to work in conjunction with a 24/7 community based health and social care system which does not yet exist. The report proposed the introduction of a 10 year spending envelope for the NHS and publicly funded social care to make this viable. This, however, would require stewardship which does exist either, particularly after the decision to decentralize responsibilities to 200 clinical commissioning groups. Presently, an organic, bottoms–up solution would not be sufficient given the scope of unmet need.

In the meantime, the absence of preventative strategies, excessive waste and a lack of integration of services was detailed and the report highlights the benefits of making hospital admissions for older people restricted to essential procedures and used only as a last resort.

Medical care typically treats symptoms and single manifestations of illness whereas prevention is very complex. Multiple factors from genetics, to individual diet and exercise choices and/or social circumstances must be considered. The requirements for any prevention program necessarily expand to require management of multiple funding streams with a commensurate increase in complexity. For example, a single decision by NICE as to how the NHS would cover end–stage renal disease is easier to achieve than a community based program to tackle high blood pressure through diet, physical activity and smoking cessation. Prevention initiatives remain outside the purview of traditional health policy because of these requirements for massive coordination between entities with different agendas. Unfortunately, policy makers are not into deferred gratification. Any demonstration of the effectiveness of any initiative must be seen to be of immediate benefit. Those benefits must then be seen to accrue directly and immediately to the taxpayers making the investment.

Another example of how the introduction of prevention strategies may become even trickier is in a situation evolving right now. There are medical advances in the pipe line that could reduce the likelihood of someone developing dementia but other medical breakthroughs might allow that individual to survive a disease, only to find themselves in a further disabled state and subjected to the related escalation in their costs of care.

The unpredictability of who benefits from prevention activities makes it a hard sell. If the public can be persuaded of the payoffs resulting from a change in lifestyle and feel confident that a change in social conditions is actually possible, available and won’t be too difficult, change in attitudes regarding the power of prevention is also realistic.

In the past, people only had to try to predict how many years they would need a pension. At the time, longevity risk and care costs were born by the state. This risk was moved to employers for a time and now the pendulum has swung the other way so that individual workers and the already retired are required to bear this risk. In the current climate, this is politically and practically unsustainable and yet, to date, no major financial services provider offers any product with pre–funded insurance against social care costs. Likewise, the possible creation of social impact bonds as a new funding mechanism while oft discussed, has still not come to fruition. Even though the recently introduced Lord Turner reforms  do represent some progress by linking state pensions to earnings, the introduction of auto enrolment and single tier state pensions that do not penalize people with intermittent employment history, the a state of political denial remains.

Furthermore, evidence of chronic under–savings only serves to underpin the need to change pensions and employment practices, across the board. Longer lives and under saving deficits are unable to be met by taxpayer funded sources. Looking at existing schemes, the report also calls for an end to both defined contribution and cliff edge retirement as unfit for purpose given their unclear payouts.

All of the above underscores the core disconnect. People’s expectations in terms of pension provision remains far greater than reality and the squeezed middle, once again, faces the biggest challenge.

While the least exacting, I found this part of the review made for the most compulsive reading.  It is abundantly evident that it is not only governments but individuals and markets who also fail spectacularly in preparing for ageing. Procrastination is simply human nature. While no one knows their ageing fate, people misjudge and deny the likelihood of having to face adverse life events from the ageing process. And it is not just the older people, even younger people underestimate their own longevity expectations by about six years. There is also a great misconception about who is responsible for looking after older people in need and people excel at shying away from complexity when they have a poor understanding of the risks involved.

The report calls for the government to help people be better informed. This runs the gamut from healthy lifestyles and longevity expectations, pension projections, the likelihood of needing social care and the costs of that care and the best use of personal assets. It is anticipated that by making people begin to understand the costs of care and realizing that they may have personal responsibility for some portion of their own care needs, they can begin to take some interest in analyzing their own situations and be in a position to make better informed decisions. This is a big ask.

It is impossible not to notice the parallels between education and ageing. Ageing is a lifelong process and it is clear that education should also be perceived to be one. Research indicates education is a key predictor of health outcomes and it appears that re–skilling in later life for post–traditional retirement employment will become the new normal. Ever since Michael Gove was appointed Secretary of State for Education after the formation of the Coalition Government in 2010 he has been on the hot seat, particularly for his latest overhaul of secondary school curriculum for GCSE’s and A levels. One month ago, at the NAHT, (National Association of Head Teachers) in Birmingham, he was mercilessly heckled and they passed a vote of no confidence in his policies. Gove was ruffled but patently undeterred.

His enemies sited the short term–ism of targets and the constant churn of change in curriculum without proper consultation. They view the negative rhetoric from government as damaging to the morale of schools and the piecemeal approach to standards as having no visible aim. While there is no argument about the importance of raising standards and making UK education the best in the world, Gove’s tactics have not been appreciated to date.

This essay has highlighted the limitations of this and past government’s response to population ageing. These challenges are not dissimilar to those facing education and given that they are inextricably intertwined, I propose that Gove’s purview be enlarged and expand his role as a new Secretary of State for Ageing AND Education. I feel that substantive, positive change in our approach to ageing has been stalled. It will only be possible to inch forward if the tops down view to managing these complementary life course processes are combined, potentially with synergistic consequences.

In the final analysis, health care and population health differs from education and so is not a pure return on investment formula. The health care policy priority must be driven by quality of life and health status across the life course of the entire population.  That said, in the same way as education, ageing is everyone’s issue. However, it is not an issue that is impossible to overcome but political gamesmanship and short–termist thinking makes a coherent policy response that much more difficult. In the existing climate and given current market conditions, the baby boomers represent the cohort who will be responsible for driving change, either as they watch their own ageing parents or when they seriously consider their own care needs. The boomers do represent the cohort with the most “skin in the game” now but that perception has to change too.

Unfortunately, with longevity gains, many boomers appear to be sprinting in their attempts to run away from death. They might say they don’t want to live longer but they really don’t want to die either.

The reality is, living with a long term conditions including cognitive decline is more likely than not and we are at a critical crossroad now in terms of figuring out how we will pay for it. Engaging British society to participate in the national debate is the way forward.   It makes sense that this gets firmly imbedded in the public psyche as everyone’s problem and getting everyone on board must happen, now.

Comments welcome:

Deborah Gale

Message in the movie: The Internship

The Internship (aka Google's new feature film length marketing message!)

Reviews from friends, who actually reside in the valley of Silicon, were unanimous. The new Vince Vaughan/Owen Wilson movie was a train wreck. I know a few people who even walked out. So, I viewed my free, premier tickets from Times+ as a low risk investment! I told the friend who went with me that we could leave whenever it got too bad. There was a slew of bad stuff but we stayed.

Here's why.

The Internship  is packed with all the ingredients, sex, drugs, rock and roll....and even a point. Getting past the first three obscures this crucial fact but the denouement, eventually makes it worthwhile. Mind you, this is not a direct consequence of several things including:

-   the unnecessary, gratuitous sex and barroom brawl type violence. While someone, somewhere still thinks these will turn a turkey into box office gold, those parts still felt all wrong. 

-   of it being at least a half an hour too long or that the first Vaughan/Wilson reunion since 2005 managed to rewring every lick of acting talent out of those two.

-   of it being overly clever. Think Wedding Crashers meets University Challenge.  Despite being a running cliche it ticks boxes and pricks emotions in a shameless rework of the best parts of Vaughan's 2004 underdog triumph,  Dodge Ball. There is even a nod to Harry Potter via a quidditch match thus providing some cross generational appeal. Like I said, it has everything.

And why it succeeds is because the message to every working-wounded-human out there, is simple: Stop thinking about retiring because for most of us, that is likely to be impossible. Rewarding ourselves for stopping is no longer a reasonable option and to be honest that is a good thing. Keeping bodies and gray matter active and moving is the only way forward. Meanwhile, that is not just a message for the baby boomers, Owen (44) and Vince (43) are relative youngsters in their roles as has been's.
I actually think it would have made for a nice change to have seen a couple of women trying to make it into Google. Juggling child rearing and ageing relative caring, while showing what it takes to make a new start (with humor!) would have been harder, but it would have broadened the appeal. While you would need big names like Sandra Bullock (48) and maybe even some official boomers like Sharon Stone (55), the ubiquitous Meryl Streep (64) or Susan Sarandon (66) to carry the film, I think it may have made it that much sharper and a bit more accurate.

In the end, The Internship succeeds. It starts a new thread to the debate about shifting perceptions and changing boundaries. It even speaks to the limits or the extent of wisdom. But while we cogitate boundaries, there is immediacy and urgency required - reset expectations, reskill, be resilient, reap new benefits. Ready, steady, GO!

Deborah Gale

Monday, 10 June 2013

Longevity is Opportunity: Riding the Demographic Wave

On 1 May 2013, at the Milken Institute Global Summit, a panel of thought leaders considered this topic: Longevity is Opportunity: Riding the Demographic Wave.  The panel members were:

Jody Holtzman,  Chair and Senior Vice President, Thought Leadership, AARP
Pinchas Cohen, Dean University of Southern California Davis School of Gerontology
Mike Hodin, Executive Director, Global Coalition on Ageing
Paul Irving, President, Milken Institute
Dan Houston, President, Retirement, Insurance & Financial Services, Principal Financial Group

The conspicuous absence of female thought leaders on this panel was notable. Statistically, women are still living longer than men and thus, historically, have more to lose if they suffer ill health or have failed to save sufficiently. Female contribution to and their ability to participate in the creation of new longevity opportunities are equally vital.

Quoting Sarah Harper of the Oxford Institute on Ageing, “A young girl born in the 90’s today will live in three centuries”. From a personal standpoint, in the first years of their young lives, my five daughters have already lived in a decade, a century and a millennium. Along with their boomer parents, they will definitely be in position to catch this particular wave.

Here are my takeaways from the discussion:

  • the growing disconnect between lifespan and health span will directly affect wealth span and have far reaching implications with respect to consumer behaviour
  • seek to improve healthiness, earlier
  • the new longevity will reveal opportunities for new markets
  • we must raise expectations positively with respect to our mature years
  • it is necessity to embrace encore careers
  • this will require insight and innovation in both the public and private sphere
  • the new longevity brings a time of great change will require great restraint and great responsibility
  • we have a serious under savings problem that is only getting worse; need to shift reliance on Social Security
  • onus is on the individual to take personal responsibility for actions, lifestyle choices
  • boomers need to be willing to accept change across every dimension of life and make this the new normal
  • we must be more proactive about planning/integrating our additional 20-30 years and not just tack it on as a later life bonus.
It would be stunningly naive to pretend that ignoring or denying what is presently occurring will sort itself out without instituting sweeping changes and public policy reforms.Therefore, the time is now to devise life-long, lifestyle choices to enable present and future ageing persons the opportunity to carefully nurture and avoid squandering the new longevity. 

Staggering opportunity clearly exists but in order to ride that wave, you've got to catch it first. The time to catch old is now not nigh.

Deborah Gale

Full report follows here:
Milken Institute Global Summit
Longevity is Opportunity: Riding the Demographic Wave
1 May 2013

Jody Holtzman,  Chair and Senior Vice President, Thought Leadership, AARP
Pinchas Cohen, Dean University of Southern California Davis School of Gerontology
Mike Hodin, Executive Director, Global Coalition on Ageing
Paul Irving, President, Milken Institute
Dan Houston, President, Retirement, Insurance & Financial Services, Principal Financial Group

This panel spoke in global terms, though arguments were mainly presented in the US context. They directed their attention on the imperative to improve outcomes that will correlate positively with longer lives. The remit for this task is vast and will require brave new thinking about the new longevity.
It was likewise acknowledged that because the caliber of the work force is also shifting across ages, adjustments will be necessary so that productive human capital can be re-utilized in completely differently ways.

Pinchas Cohen
Dean University of Southern California Davis School of Gerontology

Cohen opened with a quick overview of how life expectancy has risen by 30 years since the turn of the last century. That said, it is well documented that health enjoyed in those extra years has declined substantially while health care costs, in general, have risen dramatically. This is unsustainable and he reiterated the need to stop unnecessary spending on healthcare.

Changing these spending patterns represents a tremendous economic opportunity. Healthcare and care are both givens, across the life course and at varying stages of disability. As we age, care is inevitable because assuming we stay alive, everyone will eventually need care. Therefore, as the world ages, this need for care will become the most powerful economic force for years to come.

Consequently, building communities with appropriate gradations of care and creating the correct labor force, with proper skills and training is fundamental to seeing this economic opportunity fulfilled. At present, 80% of healthcare dollars go into the last year of life and 50% in the last month of life. It is therefore logical to shift healthcare investment towards prevention, earlier. This will prolong and promote healthy lives and most importantly, postpone disability.

Cohen also addressed criticism directed at the concept of delayed retirement and second careers. Both are too often seen as direct competition to already marginalized and unemployed youth, particularly during the current period of no economic growth. This, however, ignores the fact that we actually do face anticipated employment shortages. He sees the new entrepreneur or “olderpreneur” as a way of helping society address formidable skills gaps. They make job creation possible for the very people who will be creating the new, and necessary products required to service ageing populations. This group also has the highest spending power in society. Cohen sees this confluence as addressing two problems, firstly youth unemployment and secondly, not limiting opportunities for people to remain productive post retirement.

Mike Hodin
Executive Director, Global Coalition on Ageing

Globally, there will be over 1B > 60 year olds in 2020. For businesses, this demographic shift – longevity plus low birth rates - is transformational. Gradually, the market is realizing that it can no longer be exclusively focused on the youth market. To date, 200 companies are participating in the Global Coalition on Ageing and they recognize this shift is occurring.  Concurrently, the implications for public policy cannot be underestimated.

Case in point: the specter of AD (Alzheimer’s disease) is at present an unavoidable potential pandemic by 2050. Potentially, this is more than just a health crisis and it could also contribute to a fiscal nightmare. The statistics at present are that 20% of over 70’s have AD and if you include mild cognitive impairment in the numbers, over 2/3rds of over 90’s are affected.  Current costs run to around $200B/yr and are estimated to rise to $1T over the next 30 years.   This represents a critical point where health care costs are being directly impacted.

Consequently, we need to change the way we look at the over 50-90 year old cohort. Not as a homogeneous entity but as a cohort of which some percent, yet unknown, can remain active and economic contributors to society. This necessitates policy adjustments that allow us to spend differently in two areas: a public spend on wellness and a willingness to increase public spend on research that will bring us answers, even if they won’t come until much later. Hodin spoke of a new organization, the CEO Initiative, where companies, not solely involved in health care, are recognizing that the dramatic increase in costs from AD are impacting the economy.

He emphasized the importance of doing everything possible to defer or delay the  onset of cognitive decline. Intellectual stimulation through life long learning opportunities must be acknowledged as fundamental to any attempt to postpone decline but educational institutions will have to lead the charge. The importance of education is a recurring theme to harnessing and retooling this economic engine. It becomes increasingly clear that the barriers now being presented by AD must be managed at the same time as we focus attention on turning able and willing 60-90 year olds into a new form of economic opportunity and productivity. Hodin continued with his observation that the current global financial crisis has masked this issue and only now are we beginning to treat our ageing population as a potent economic opportunity.

This is because progressive employers who look at low birth rates, as well as the fact that we are living longer, are starting to realize the employment shortfall we face. Hodin believes this represents a basic structural issue and because of low birth rates, we are already running out of young employees. In Singapore, with a population of 2M, this employee deficit has already been recognized and programs are in place allowing ex-employees to return to work.

He optimistically suggested that the global success of the women’s movement, recognition of their human capital and economic productivity potential might offer a template for changing the societal norms regarding the employment of 60-90 year olds. At present however, the burden of entitlement, inadequacy of pensions, rising costs of health care and challenges of disease remain serious impediments. Further, he pointed to restrictive retirement policies still operating in places like the World Health Organization, WHO. The rhetoric has yet to jive with reality. He used Dr Alex Kalache of Help Age International as an example. Kalache had to exit WHO when he turned 62 but now heads up the International Center for Policies on Ageing in Rio, acts as a special advisor to the New York Academoy of Medicine and a member of the advisory board of the World Demographic and Ageing Forum.

Jody Holtzman
Chair and Senior Vice President, Thought Leadership, AARP

Jody opened by lamenting the fact that only in Washington would “addressing the unmet needs of 100M people be viewed as a dual financial burden and unaffordable cost.” He added, that given this mindset, it will be up to the private sector to address this enormous unmet need.

Therefore, meeting this unmet need constitutes a huge commercial opportunity for new markets across industry sectors including: health care, fin services, technology and consumer. Focusing specifically on healthcare, he explained that it was now possible to diagnose AD, with a 90% accuracy, in pre-symptomatic people. Obviously, treating people in advance is an area of great interest and increasing attention:

Healthcare is the huge opportunity and it also represents a significant part of GDP. The healthcare issue, however, needs reframing so that it is recognized as a strength, instead of a liability. Given the huge global implications it represents, innovation, for all ages, is required. To this end, the AARP has a new program for healthcare innovation where innovators are put in front of venture capitalists and financiers to pitch their ideas.  Authors note: This is along the lines of the work being done by Steven Johnston at Aging2.0.

Holtzman continued by suggesting that because population ageing is exponential and can’t be solved with a linear solution. At present, the AARP estimates the unpaid value of care giving in the US is $450B annually. Notably, this figure is not considered as part of GDP. Consequently, there is a desperate need to monetize that and he suggested that some progress is being made in this regard.  Senior Link, a venture capital backed company in Boston is paying family caregivers for previously unpaid care: The results have been impressive; not only do the carers feel valued but the quality of care and better health care outcomes have resulted. In addition, this translates to less public expense, the potential for new business creation and also represents a paradigm shift. Related to this and another area of necessary change is within the insurance industry. Insurers must undergo a transformation and instead be incented to keep people out of the hospital. This is particularly true  in this era of no fed funding. Holtzman reiterated his observation that it becomes increasingly necessary for the private sector to step up to the plate.

Looking at Europe for inspiration, Jody then used BMW as an example of how to retain and utilize existing talent. BMW opened a new assembly line and populated it with employees at the ages they forecasted the age distribution of their work force would be in five  years time. They then asked those employees on the new line to recommend improvements to productivity. Overall productivity was shown to have increased by 7% and absenteeism dropped to the lowest level in all of BMW. This experiment demonstrates the benefits of employee involvement in the process as well as an acceptance of the realities of an ageing work force.

Dan Houston,
President, Retirement, Insurance and Financial Services
Principal Financial Group

Houston began by explaining that Principal Financial Group (PFG)  speaks from a position of some authority given that globally, they have $450B of retirement assets under management.
According to Houston, the advent of the employee based 401(k) defined contribution system in 1978 represents the most important development in retirement savings. Unfortunately, this breakthrough is now 35 years old and we have a situation in which 50% of today’s 45-54 year olds have not made sufficient savings. In addition, less than 1/5th of this cohort have what they need for retirement. This, he explained is due to the rising costs of nursing home cover and unreimbursed health care expenditures. He also noted that unfortunately, the distinction between events covered and not covered by Medicare and Medicaid is widely misunderstood.
Houston offered that saving for retirement has traditionally been a three-legged stool: personal savings, social security and pension.  In the post global financial crisis world, losses in the value of the housing market has produced a decline in personal savings across the board. Simultaneously, shortfalls in saving and pensions do not suffice and thus have made people solely reliant on Social Security. The current challenge will be to replace Social Security and move all workers away from defined benefit to defined contribution pension schemes.

In addition, because no one knows with any degree of assurance what their ageing fates will be, we must develop better models for predicting costs of healthcare and spending during the retirement years. PFG estimates 13-14% of annual income must be saved between the years of 30-67 in order to replace 85% of income at retirement.  In the recent past, reliance on social security allowed retirees “to limp across the finish line”. That worked to a degree when people retired at 65 and died at 68. In the age of new longevity, this is no longer the case.

Further, he made the point that today is the first time we have ever had four generations in the work force, at the same time.  At the same time, the sandwich generation is being squeezed to the limit with dependent children at one end of the age spectrum and caring for ageing relatives at the other. While policy improvements have been made with the 2012 introduction of the new Family Medical Leave Act, such provision is often insufficient. Echoing Mike Hodin’s comments about Singapore’s rehiring initiative, Houston explained that programs like PFG’s own rehiring scheme, “Happy Returns”, are on the rise.

The secret to the success of such programs is in understanding the changed profile of these returning employees. While they want increased flexibility and fewer hours, what they bring in intangibles like work ethic, wisdom and institutional knowledge can turn such career resumption opportunities into an economic win-win situation. Likewise, there is evidence that mentoring can also teach younger employees about the choices they are making as employees. This brings work/life balance issues out into the open and has demonstrable, positive impact on employee retention.

Paul Irving
President, Milken Institute

Irving opened his remarks stating that “….with 78M boomers in the US, the most glaring observation is our stunning naivete and stubborn reluctance to recognize the opportunity imbedded in something that is unavoidable.”

He continued by reminding us that beyond the substantial business opportunities already discussed, there are also significant entrepreneurial opportunities for boomers. Research out of the Kauffman Foundation indicates that people at 50 start companies at 2X the rate of people in their 20’s.

Obviously, growth and innovation will be required to solve the broadening spectrum of social problems but from a personal standpoint, it is clear that other quite ordinary while pressing problems already exist. He cited some examples:
-       women want and need shoes that don’t hurt but are stylish,
-       everyone wants cars that we can get into easily,
-       better hearing aids

We are in a state of denial and not taking advantage of the opportunity to serve what will clearly be a welcoming audience. Irving explained that  we are living what is now a much longer life but that it was actually designed for a completely different time. Where ageing used to represent precipitous decline into disability and decrepitude, it does not necessarily equate to disability in the 21st C.  Therefore, we need to innovate with respect to maintaining wellness. He used Ken Dychtwald’s linear life plan model to further the case for life long learning. He emphasized the importance of rethinking our new 30 year longevity bonus so that we start to incorporate it throughout life and not just consider it as something we now get to tack on at the end. Authors note: message to boomers, incorporate changes now in order to inspire younger and future generations to emulate and take the life long learning message on board.

He then suggested that retirement offered a clear demonstration of our societal reluctance to accept that this demographic change and the new longevity, is actually underway. Irving pointed out that 25 years ago, the average age of retirement was 63 while today it is only 64.  Retirement today however, comes under many guises be it self-directed choice, forced by health issues of the retiree or their spouse, or skills obsolescence leading to lay off’s. Arguably, within those categories, there is a gap in terms of what decisions are made based on personal circumstances.  What is worryingly clear however, is that no structure exists in the system to take advantage of this new asset class of human capital.  We are talking about educated, trained and talented people with a potential thirty more years of productive capacity. Authors note: We need to motivate and inspire the willing and able and economic imperative will help to motivate willingness.

In addition, despite all that we now know about lifestyle choices and health, we still aren’t taking personal responsibility seriously enough. He pointed to research showing that for every dollar a company spends on wellness programs, there is a $6 cost savings recognized by the employer. He also explained that a pack a day smoker who quits today will save $71,296 over twenty years. While it is obviously good for companies to embrace wellness and recognize the cost savings from healthy employees, it is fundamentally incumbent upon each of us to take responsibility for our own longevity.

Further worrying, despite the fact that the over 60’s already represent the majority of the population and will continue to do so, Irving noted that there is only one school of Gerontology in the US, the Davis School of Gerontology, part of UCLA where expert panelist Pinchas Cohen is Dean . Authors note: There are 20 other schools in the US with gerontology programs. Geriatric training in medical schools in addition, is also lacking. Research data is scarce, but only 56 percent of medical students nationwide had clinical rotations in geriatrics in 2008, according to a University of Cincinnati study.

Returning to AD, Irving continued by suggesting that like breast cancer, AD is the next pink ribbon disease. More women are affected at the same time that 2/3rds of caregivers are women. Furthermore, caregiving is additionally debilitating for women because it reduces opportunities for advancement in the workplace and restrains income generation potential. He then suggested that this might represent an opportunity to retrain and redeploy ageing women as caregivers, thus allowing younger women to advance in careers. Paying these care givers, as in the Senior Link of Boston example cited by Holzman is the way forward.

Next, Irving turned to the recent success of the 2011 movie, The Best Exotic Marigold Hotel‎ to further the case for mentoring and downplaying the Washington DC driven us vs them narrative surrounding intergenerational tension. He cited research by Participant Media and encore. Org who found that 70% of the boomers interviewed said that they would be prepared to make a financial sacrifice in order to act as a mentor    

This dovetails perfectly with Laura Cartensen’s work at the Stanford Longevity Center.  Her research on adult intelligence indicates that even though short term memory can suffer in the form of “senior moments”, changes to our intelligence gives us a greater degree of wisdom and judgment. In turn, mixing young and older workers together offers intergenerational benefits and makes for better business. It is this combination of IQ and EQ that can occur when older workers return as mentors. Like the BMW example, they need to look at an ageing work force in a positive way and change in business practices to optimize opportunities. This does require progressive thinking by companies but offers a pathway for how to win the competitiveness race in the 21st C.

Irving observed that companies regularly invest in physical plant, technology and infrastructure but we let ourselves down on investing in human capital. Confining continuing education to 18-28 year olds is shortsighted. He believes we must commit to retraining talent through programs that move beyond trying to put returning employees back into their old jobs. We need to look at mini-continuing education to mine the demographic assets of older people and find them something new to do instead.

Irving believes that from a societal perspective, growth occurs at the convergence of demographic change and innovation. He thinks we  are at this critical juncture now and there is a desperate need for change and a lack of innovative ideas trying to catch this age wave. He speculated on the lost opportunity in that to date, given the degree of upheaval from the global financial crisis, no one brought a private equity longevity fund to the market yet. This represents a glaring omissions and there will be a need to give the ageing boomers choice. In turn, the ageing boomers must seek to improve healthiness before retiring and be open to retraining or finding new jobs or encore careers.

Q and A

1.    What is a diet for the new longevity? 

Pinchas Cohen answered, anything except what Americans eat before espousing the scientifically proven benefist of a Mediterranean diet, weight control and exercise both physical and mental.
2. A question was posed  by the CEO of AntiAgeing Games. She said that a third career track exists for people who don’t need full time and therefore work part time, for benefits. Unfortunately, however, from an insurance standpoint, part time employees preventative testing is not covered by their policies.

Mike Hodin offered his view that in order to move from public awareness of a problem to implementation of a solution, a philosophy and a political position were required. You don’t get on the agenda by force. Similar to the way that the sustainable development agenda gained traction, he believes that a new set of business principles for population ageing currently under development by the Global Coalition on Ageing and the World Economic Forum will provide dewcata good starting point.

·      the growing disconnect between lifespan and health span will directly affect wealthspan and have far reaching implications with respect to consumer behaviour
·      seek to improve healthiness, earlier
·      the new longevity will reveal opportunities for new markets
·      we must raise expectations positively with respect to our mature years
·      it is necessity to embrace encore careers
·      this will require insight, innovation public and private sphere
·      this time of great change will require great restraint and responsibility
·      we have a serious undersaving problem that is only getting worse and we need to shift reliance on Social Security
·      onus is on the individual to take responsibility for actions, lifestyle choices
·      boomers need to be willing to accept change across every dimension of life and make this the new normal
·      we must be more proactive about planning/integrating our additional 20-30 years and not just tack it on as a later life bonus.


In the author’s opinion, the conspicuous absence of female thought leaders on this panel was notable. Statistically, women are still living longer than men and thus historically, have more to lose if they suffer ill health or have failed to save sufficiently. Female contribution to and their ability to participate in the creation of new longevity opportunities are equally vital. Exploiting ageing for positive outcomes is the goal. That said, it would be stunningly naive to pretend that ignoring or denying what is presently occurring will sort itself out without instituting sweeping changes and public policy reforms.

Therefore, the time is now to devise life-long, lifestyle choices to enable present and future ageing persons the opportunity to carefully nurture and avoid squandering the new longevity. Staggering opportunity clearly exists. Quoting Sarah Harper of the Oxford Institute on Ageing, “A young girl born in the 90’s today will live in three centuries”. From a personal standpoint, in the first years of their young lives, my five daughters have already lived in a decade, a century and a millennium. Along with their boomer parents, they will definitely be in position to catch this particular wave.

Deborah Gale