The demographic transition

Demographic transition describes the impact of births and deaths on the age distribution and size of a population over time.^{Reference Grundy, Detels, Beaglehole, Lansang and Guildford2} It is most clearly illustrated with ‘population pyramids’ that describe the age structure of populations and can give an indication of previous population flows and likely future patterns. From the end of the 19th century the population structure of the UK along with that of most northern European countries changed, largely in response to falling birth and death rates (more so than migration) becoming more ‘rectangular’ in structure, as ongoing population ageing occurred from the apex of the pyramid rather than the base (as is the case in younger ‘developing’ countries).^{Reference Kinsella, Ebrahim and Kalache8}

Using Scotland as an example we can see this process in action. According to the Registrar General's Annual Review for 2010,⁹ Scotland's population numbered 5 222 100 of which 17% were 16 years or less, 66% of working age and 17% of pensionable age (in 2008 they were a proportionately larger group than children). Between 1998 and 2008 there was a fall in the number of children of 9%. At the same time, numbers of those over 75 rose by 13% and the 60–74 age bracket rose by 10%. Contributory factors include increasing life expectancy (seen since industrialisation)^{Reference Kinsella, Ebrahim and Kalache8} alongside reduced births, with the result that children born in 2009 have a life expectancy of 75.8 years for males and 80.3 years for females. Further projected changes for Scotland are illustrated in Fig. 1.⁹

FIG 1 Projected percentage change in age structure of Scotland's population, 2008–2033 (based on 2008 projections). Adapted from Scotland's Population 2010 – The Registrar General's Review of Demographic Trends.⁹

Such improved life expectancy is seen throughout the UK and remains a health outcome success story resulting from ‘a multidisciplinary and intersectoral approach to the underlying causes of premature death and disability’,^{Reference Beaglehole and Bonita10} but, allied with falling fertility rates it brings its own public health challenge.

The challenge

Are we ready to meet the challenge of our ageing population?^{Reference Doyle, McKee, Rechel and Grundy11} Or should we indulge in ‘apocalyptic demography’?^{Reference Martin, Williams and O'Neill12} Some social scientists argue that it is demographic change that has a profound impact on the social, economic and political trends of a country rather than cause and effect operating the other way round.

Irrespective of social crises, it is likely that an ‘epidemiological transition’ will accompany this significant change in population make-up in that the burden of disease becomes increasingly dominated by chronic non-communicable illness. The positive view is of a situation whereby ‘compression of morbidity’ prevails and the increasing years of life gained are lived disability free as morbidity rates fall more rapidly than mortality rates.^{Reference Colvez, Ebrahim and Kalache13} With such a scenario there is the potential for ageing ‘baby boomers’ to contribute meaningfully and productively in society, their wisdom recognised, valued and utilised. Truly ‘healthy’ ageing.

Alternative propositions include a theory of balance whereby with increased life expectancy comes proportionate but predictable levels of disability-free years lived, the easier for healthcare and economic planning. A more pessimistic theory is that of ‘chronic pandemy’^{Reference Colvez, Ebrahim and Kalache13} accompanying an extension of morbidity scenario. It is this secular theory that appears to have captured media interest and concern.^{Reference Martin, Williams and O'Neill12}

We cannot risk simply pinning our hopes on morbidity compression. The potential changes of most relevance to mental health services if it is ‘chronic pandemy’ that emerges include more people with dementia,¹⁴ comorbid chronic physical illness and mental health problems¹⁵ and depression.^{Reference Lee16}

And in a society where people increasingly live in single households⁹ and are likely to experience reduced social capital with age,^{Reference Laidlaw and Pachana5} there will be more people in need of health and social care services.

Garnering a response

As suggested at the outset, demographic work allied with epidemiological skills will help health services and governments understand and predict the outcome of population shift. A broad focus on the role of health determinants seems the most promising route to minimising negative effects on quality of life and increasing the numbers of years lived disability free. Godfrey^{Reference Godfrey17} concludes that preventive strategies aimed at reducing or delaying the occurrence of illness or disabilities associated with normal ageing involve health, socioeconomic and environmental interventions, encouraging ‘successful’ ageing as outlined below.

Sociocultural model of successful ageing

Figure 2 depicts a sociocultural model of successful ageing.^{Reference Godfrey17} Such strategies must be rationale based and easily incorporated into usual practice, along with optimism that the pace at which individuals age physiologically can be modified and their contribution to age diversity in the community and workplace assured.^{Reference Doyle, McKee, Rechel and Grundy11} Unfortunately, the wished for ‘compression of morbidity’ may not be experienced universally. From an in-depth analysis of the social determinants of health in older age, it appears that economic and health inequalities exist beyond working age, although the underlying reasons are not fully understood.^{Reference McMunn, Breeze, Goodman, Nazroo, Oldfield, Marmot and Wilkinson19}

FIG 2 Sociocultural model of successful ageing. From Godfrey^{Reference Godfrey17} adapted with permission from Baltes & Baltes.^{Reference Baltes and Baltes18}

Dementia – prevention and early intervention

Using dementia as an example, there is much that can be achieved to reduce individual morbidity, with evidence-based strategies for population-based interventions beginning to emerge. Although inconclusive thus far, more research has been called for on a number of drug treatment strategies aimed at disease modification, details of which are beyond the scope of this article. A public health-based review of policies for action at a population level targeting vascular risk factors concluded that in spite of individual gains, there was insufficient evidence to support population-based approaches as a means of reducing dementia.^{Reference Stephan and Brayne20}

Continued research on behaviours that may protect against the loss of physical and mental capabilities by focusing on individual behaviours has been recommended. Consideration has also been given to broader determinants of mental health, with genetics and ageing having an established role, but so too is a ‘socially integrated lifestyle’ seen as a relevant ‘long term multi-domain intervention’ in dementia prevention.^{Reference Fratiglioni, Paillard-Borg and Winblad21}

Interestingly, there are businesses prepared to invest in robots to act as ‘cognitive companions’ providing ‘companionship and support’ for people with failing memory. Is this an example of socioenvironmental support driven by consumerism? However, even with an increased focus on general health improvement, the predicted numbers are such that serious consideration needs to be given to who will provide treatment and care to increasing numbers of people with dementia. The implications for training and deployment of staff are such that an entire rethink of how services are provided is justified alongside a focus on what treatments are effective. Traditional age-determined boundaries will require realignment or review and, as with the challenge of providing healthcare to the ageing population as a whole, there is a need to pursue better coordination across health and social care.^{Reference Fahy, McKee, Busse and Grundy22}

Wider impacts

As the early baby boomers reach retirement in 2012, what of the remaining workforce? How might they fare? As the cost to the economy of dementia trebles over the next 30 years, adults of working age may be contributing to the care of elderly relatives while competing in an increasingly globalised market with ensuing pressures on work-life balance. There is the potential for the economic downturn to differentially affect the most disadvantaged, as has happened with unemployment in the past.^{Reference Stafford and Duffy23} Unemployment places increased demands on mental health services, which in turn may experience a ‘discouraged institution effect’ – whereby employment support is not provided for vulnerable groups such as people with mental health problems because of assumptions about lack of opportunities. The Royal College of Psychiatrists in its position statement on mental health and the economic downturn²⁴ argues against this stance and advocates taking a ‘long-term perspective’ in order to achieve the best societal outcome, while acknowledging the likelihood of reduced funding and investment levels.

Values and principles

In facing up to this demographic shift, public health and mental health services should not shy away from that which is more ‘public’ than ‘health’. In response to an article on the ‘context’ in family medicine, Watt neatly captures this when writing;

Unfortunately, a view still prevails within mental health that ‘the value of building links between the public and mental health services is more easily said than done’.^{Reference Skuse26}

The importance of equality and diversity, when offering services to elderly people, needs to be remembered if inequality and discrimination are to be avoided. Age Concern's 2007 report on improving services and support for older people with mental health problems^{Reference Lee16} rightly draws attention to Scotland's emphasis on mental health improvement and ‘public mental health’ (further developed in Towards a Mentally Flourishing Scotland ²⁷), with service developments aimed at being specifically inclusive of elderly people. This approach is echoed in the English No Health Without Mental Health: Delivering Better Mental Health Outcomes for People of all Ages’.²⁸ More recently though, mental health services have been described as ‘among the most manifestly guilty of age discrimination within the National Health Service’ and the case presented for professionals to respond to the Royal College of Psychiatrists’ position statement on age discrimination in mental health ahead of impending age equality legislation.^{Reference Anderson29} However, it remains worth emphasising the importance of focusing on the needs of all age groups in these developments, as today's younger people are the workers, caregivers and funders of tomorrow. We need to be assured of their resilience and self-esteem.

There is some evidence to suggest that today's young people do not have such a negative view of the older generations as the media portrays, choosing instead to recognise the value of intergenerational support.^{Reference Doyle, McKee, Rechel and Grundy11} Paradoxically, psychotherapists working with elderly people have recorded a more negative outlook,^{Reference Laidlaw and Pachana5} although this may be skewed by them having proportionately more contact with those whose ageing is less ‘successful’.

Recommendations

Drawing on the predicted demography for the UK's population (using Scottish figures as an example), aspects of the research base for general ageing and for dementia prevention, and some of the broad ranging public health and public mental health policies in place already, recommendations are perhaps best articulated in the style of a 360-degree feedback – when thinking of the future of mental health services, what should we do more of, less of and start doing?

We must engage more with our communities of interest if we are to respond successfully to the developing needs of our ageing population in a way that is economically and environmentally sustainable by tapping into the rich resource that is our multigenerational society.^{Reference Watt25} For clinicians this means even closer working with relatives and carers, with social work and primary care colleagues and other key clinical and voluntary support networks. For policy makers, more robust partnerships are essential, however drawn up or legislated for. By doing this we may go some way towards keeping future health and social care costs towards the lower end of what is currently predicted.

And given the financial forecast, there will need to be that bit more imagination applied by clinicians if we are to respond effectively to the mental health needs of our working-age – if not work-less – population.²⁴

Research efforts should concentrate more on the community, focusing on treatments and models of care for which we have gaps in evidence of effectiveness. Unless we do so, we risk making poor decisions from a health economics perspective.

We must lessen the negative impact of discrimination on the grounds of age, otherwise we risk maintaining age- and gender-related inequalities. Close scrutiny of mental health services with a view to reducing inequalities of access to specialist interventions will shortly be driven by legislation – not just position statements – so there is a case to be made now for planners and clinicians to review the very basics of what services are delivered to whom and by whom. This is service redesign, but with demographic shift and age-related health inequalities among the drivers.

We must become involved in effective workforce planning now to ensure that as the baby boomers age, their valuable contributions to society are not lost to retirement, and focus on the health and well-being of our current and future workforce. With the future workforce in mind, given the increasing influence of activities and skills more usually associated with public health medicine than psychiatry, as we act as ‘health advocates’ and determine the direction of mental health strategy and service development, we should update our specialty curricula to ensure that current and future psychiatrists develop the competencies required to deliver ‘public mental health’. With the support of the College this can be initiated within the curriculum review planned for this academic year and considered in future iterations of Good Psychiatric Practice. And as with effective appraisal, feedback and review on a regular basis is an essential component.