Introduction

The discussions in the previous chapters have made a number of references to the role of policy in shaping the concepts of ageing, health and care. The aim of this chapter is to focus more specifically on policies as processes which are continuous, characterised by conflicts of interests and shaped through the exercise of power. An important aspect of the exercise of power is the production of knowledge to inform policy agendas. In health and social care policies, discourses surrounding demographic trends play a crucial role. As is argued, older people are frequently characterised en masse as an economic problem, and changes in dependency ratios within ageing societies as a threat to the intergenerational contract. Paradoxically, while ageing populations are firmly established on policy agendas everywhere as a policy maker's headache, it still remains the case that policy success is measured by reference to increased life expectancy and the prevention of premature deaths. ‘League tables’ of life expectancy are produced regularly as a record of national success or failure, with Japan currently in the position of world record-holder.

Gross inequalities in health have provided and continue to provide a strong moral imperative for policy action, but demographic trends are influencing ideas about what kind of action is needed. As discussed, health systems in low-income countries are experiencing a double burden because the need to address the growth of chronic diseases combines with an unfinished agenda of tackling communicable diseases, and it is increasingly recognised that addressing this double burden will require global rather than national policies and strategies. Age is an increasingly important element in the debate concerning the moral case for policy action on health. Beaglehole and Bonita (2009), for example, drew attention to the need for a new approach in public health which is more aware of the effects of demographic trends. Demographic trends raise questions concerning distributive justice, including whether the claims of different age groups for healthcare are in competition. The question of whether the age of an individual should have a bearing on their entitlement to resources and their eligibility for services is often perceived to apply at the micro-level of professional decision making, such as making renal therapies available to older people.