Care, ageing, and how to amplify our imagination

The great question

This piece is about one of the greatest questions of our time:

• how to make most of the extraordinary good luck of ever-longer life expectancies
• how nations can be strategic as they manage the huge demographic shifts of the years ahead
• and how to handle the transition of care needed over the next few decades.

We are the lucky ones, the beneficiaries of these changes. Yet, despite the appearance of 100-year life spans, there is not much sign of 100-year thinking and remarkable blind spots persist. Ageing is usually talked about as a problem, a crisis, a demographic timebomb. Changes are resisted—with huge marches on the streets of cities like Paris opposing quite modest rises to pension age (to 64), and nervousness in China as retirement ages have gone up (from 50 to 55 for blue-collar women workers).

There are occasional exceptions, like the Polish cities that celebrate old age. But they are very much the exception. And politicians understandably shy away from the big financial implications. According to the IMF “rich countries will spend 21% of GDP a year on old folk by 2050, up from 16% in 2015. A quarter of that will go on pensions. The rest will be required for healthcare and social care provisions”.

It’s not just them. We also shy away from thinking about it all. If you ask typical people in their 50s or 60s, let alone in their 20s or 30s, what life might be like when they are in their 80s and 90s, this turns out to be the last thing they want to think about.

Most people struggle to picture themselves in 30-50 years’ time. What kind of home will you live in? What kind of care will you have? It seems that few of us want to focus on our future decay and decline, and a world where we become weaker, frailer, more dependent, more forgetful. But the same myopia is affecting governments and politics more generally.

Few societies have yet had an honest and serious discussion about the big choices ahead, whether for pensions or care. This myopia overlaps with a broader challenge of imagining how we can reshape societies for the good. It’s often easier to picture disasters ahead—climate crisis, a world consumed by fire—or purely technological futures with ubiquitous AI and robots, than it is to think about how we might organise socially in new ways. And this pessimism and myopia are reinforced by a broader pessimism which means that in most rich countries majorities now expect their children to be worse off than them.

Pessimism is amplified in some countries by understandable anxiety about demographic change. Anxiety is especially high in countries like Japan, China, Italy, and parts of Eastern Europe—or especially in Korea, where a birthrate of 0.67 (in 2024) means that 100 people today will have perhaps 34 children and barely 10 grandchildren. These numbers reflect not just huge imbalances but also sharp declines in economic growth.

So, big transformations will be needed, every bit as big as the shift to a zero-carbon economy. This requires us to open our imagination and fight against the tendencies of pessimism and myopia. It demands innovation, the best methods we know to generate new ideas and put them to work.

Some past involvement

I’ve had quite a few involvements in this issue. I’ve worked in many manual and menial jobs, cleaning old peoples’ homes as a teenager, serving as a porter in hospitals, and then in local, national and EU government.

I oversaw UK government reviews of pensions and active ageing, which led to fairly successful policies, such as making it much easier for people to save and increasing activity rates between 50 and 65. As the head of a foundation, I funded various innovations in care.

One of my mentors, Michael Young, was a particular pioneer. Inventor of the Open University and creator of organisations for grandparents, funerals, and a University of the Third Age, he tried to transform how we think about the rhythms of life, himself marrying and having a child, and selling his first company to venture capital in his 80s.

He argued for a transformation of how societies thought about care. The old models, rooted in extended families, no longer work well; new ways of mobilising grandparents, neighbours, combinations of professional and informal, would be needed as well as new pathways in old age often combining work, volunteering as well as quiet retirement. He, like many others, made the case for moving from deficit to asset ways of thinking.

These experiences gave me some confidence that we can rise up to the opportunity and challenges of ageing and care, and in what follows I briefly set out how we might think in ten dimensions about making the most of the opportunities and not being trapped by pessimism—how we think in terms of possibilities not just crises.

1. Finance — and the need for creativity in financial tools

We can’t avoid economics and finance. All societies will need to spend more on pensions and care, have later retirement ages, have more savings, and, in some cases, have much more immigration. All will need financial creativity. We will need to connect property assets to care costs, for example, or to insure against the uncertainties of dementia.

We will also need to rethink how public finance is organised, so that preventive spending, spending that keeps people fitter longer, mentally agile longer, is incentivised.

At the moment this is not the case. Antiquated public finance rules treat social, health and education spending as an annual expense, whereas spending on roads and airports is treated as capital. This is insane since we are now in an era when people last longer than infrastructures and buildings. There are some good examples of governments bringing in an investment mindset, like patient-focused healthcare in Denmark or Asembis in Costa Rica. We know that in some circumstances intensive rehabilitation can pay for itself—it has enabled two-thirds of people in some American hospitals to return home after a fall or operation. And some promising recent research shows that if health, care and employment data are linked it becomes much easier to show how preventive spending pays for itself, particularly through keeping over-50s at work longer.

Figure 1

But these are the exceptions, not the rule. Too often, good investments and good maintenance are just not incentivised.

2. Maintain the pace of medical advance — but be sceptical of hype

We obviously need to maintain the pace of an extraordinary era of breakthroughs, cancers, heart disease, statins, and prevention MRIs.

But we need to be realistic and more radical. Eroom’s law* mirrors the well-known Moore’s law in technological advancements and shows a fifty-year decline in the productivity of pharmaceuticals R&D—ever more spending for ever fewer results.

We see this in the disappointments around dementia drugs, one of which appears to have some beneficial effects but at great cost relative to impact (though we are just beginning to see some with better results) and with genomics, where the promise far exceeded the delivery.

Obviously, we need to keep up the pace of experiments—but my guess is that we will need much more innovation in innovation, more creativity in how the pharma and other industries work, as too often they have become a powerful, well-connected black hole.

If you look at the causes of premature death most of the causes are environmental, behavioural and social. Services contribute more like 10-20%, and within them, drugs are quite small.

Yet, the biomedical establishment dominates spending, and public health tends to be a lower priority. In my view, we need to be as energetic in funding the science of health in a wider sense, as we are energetic in funding new drugs—from genetics to reshaping the environments we live and work in.

3. Technology supporting care and self-care

Technology can do incredible things to monitor, to assist, to support, from exoskeletons for reduced mobility, to AI for diagnosis (though the confident predictions made in the last decade about how all radiologists would be out of a job by now turned out to be wholly wrong). AI exoskeletons:

Robots like Pepper, a humanoid robot, and PARO, a therapeutic robotic seal, provide companionship, reminders for medication, and even help with physical tasks. Robots are still pretty bad at basic tasks like tying shoe laces, but they will have an ever bigger role. And research in Japan suggests that they can often create more work for caregivers rather than reducing it.

I like the Tovertafel from the Netherlands, an interactive table designed to stimulate cognitive activity in dementia patients through games that involve light and motion, helping to maintain cognitive function. Or ElliQ, a social robot that engages elderly individuals in conversation, encourages physical activity and helps manage digital tasks, reducing feelings of isolation. Or Synthetic Memories, using AI to recreate past memories, or Rendever in the US using virtual reality to recreate environments from the past or take elderly individuals on virtual trips, helping to stimulate memories and provide emotional comfort, particularly for those with dementia.

I’m also interested in adapting things like Microsoft’s Copilot [sic] to guide life choices, that get to know you. These should be doing a lot to make old age easier. Yet technology companies too often reflect the worldview of guys in their 20s and 30s, who are much more enthusiastic about better ways to order pizzas or make video recommendations, than the needs of their grandparents. And finally, technology can help younger people feel what it would be like to be old, an approach exemplified by Japan’s park of aging.

We need much more rigorous and systematic research on what technologies—and what combinations of technology and people—are actually effective.

4. Revalue the care economy

Then, we need to rethink our economic thinking. The 20th-century economy was all about production and consumption: stuff and more stuff. But the mid-21st century will be much more about care and maintenance—of nature, of buildings, and of ourselves.

During the pandemic in the US, for example, every job was classified by how essential it was. It turned out that 48% of the lowest-paid jobs—care, delivery, health—were deemed essential but a far lower proportion of the highest-paid jobs.

However, in most countries, the care economy is low-status. The most useful roles are the least valued. I think this reflects a bigger imbalance that will need to be addressed, so anyone working in care has not just decent pay and respect, but also status.

The imbalances were very visible during the pandemic in many countries between a high-status, influential hospital sector and a much less well-organised and influential care sector.

There are good examples that point in this direction—sector pay deals that drive up pay for care (which the UK will soon follow); imaginative organisations like Buurtzoorg which uses a very flat structure to connect its care teams of some 20,000 carers in the Netherlands; or an example I was involved in, the development of social prescribing, so that it was as easy for a local doctor to prescribe a dance class or a walk as a pill, which is now mainstream in the UK health service.

5. Readjusting provision of care

Next, we will need to rethink the models of provision and what we actually mean by care. Some of care will inevitably be about medical support—the provision of food and shelter. But I hope we will increasingly think in more rounded ways.

What could be “a new logic of care”? Read more from Demos Helsinki’s relevant work here.

I was very influenced by two striking facts from research. One was done a few decades ago and showed that in a care home the older people who were given plants to look after survived much better than those who weren’t. More recently others have followed up this insight—that we all want to be useful—by giving residents libraries to run (some even showing books they have written on the shelves), gardens to look after, pets to care for.

The other study showed—counterintuitively—that cold symptoms were more common amongst the least, not the most, sociable. In other words, interacting with other people is good for us not just mentally but also physically. Again, this has obvious implications for the organisation of care.

Figure 2. Rate of developing colds (adjusted for controls) as a function of sociability quintile.

Source: Cohen, S., Doyle, W., Turner, R.B., Alper, C.M., & Skoner, D. (2003). Sociability and Susceptibility to the Common Cold. Psychological Science, 14, 389 – 395.

The other (perhaps more obvious) direction is towards teaching people to care for themselves better. In the UK two-thirds of the health budget is spent on long-term conditions, and typical patients spend around 6,000 hours each year managing their own condition and only five or six hours being helped by a paid professional. One implication is that the five hours might be better used to coach patients on how to make the most of their other 6,000 hours.

Here, technology can also be a help. Online guides, coaches, nutrition support tools, and CBT-based digital tools help seniors manage anxiety, depression, and other mental health issues.

We are also bound to rethink what it is to be healthy—away from thinking in terms of negatives, how to avoid disease—towards a positive view of thriving.

Our culture, though, is shifting to seeing this as something you have to do. Peter Attia’s book Outlive is one of many examples, and has sold over two million copies—if you want this activity at 80, then this is what you need to do at 50 or 60, in terms of diet, fitness, and proteins.

6. Rethinking time

The great boon of this century is freed time, but we’ve not really worked out how to use it. In the long view, we are now benefitting from the combination of falling working hours—from 60 to 30 in some countries over the last two centuries—alongside rising life expectancy, often double what it was a century ago. As a result, we are both older and younger. The average age in most countries is older than ever. But years left to live are greater than ever too.

This should mean billions of hours freed up. But for what? For caring for grandkids? Creativity? Helping out in the community? Travel? Or education?

South Korea, for example, is opening up its shrinking primary schools to older people, which is part of the much broader movement for seeing later decades as a time for learning.

At the moment, there is a sharp divide between the economy of money and the informal economy of giving, and between paid and unpaid work. But increasingly we may see hybrids: twin currencies, timebanks of all kinds so that you can earn a kind of credit, perhaps by cooking meals, fixing things or helping with care.

Some cities are seeing time as the great new issue for policy—for example, Barcelona, Buenos Aires and Bogotá—and looking at how to stagger opening times, primary schools, and commuting, but also how to better orchestrate the free time of millions of people which isn’t always used in the most satisfying ways. Bogotá also provides an interesting example with its Care Blocks project to provide more systematic support for carers themselves.

7. Rethinking cities and homes

Our homes and cities were not designed for an era with so many older people, and so this is another field where imagination, innovation and creativity are needed. Some of that is in the home itself; how to enable flexibility, so that you can stay in the same home with diminishing physical powers?

Some innovation focuses on new arrangements—for example, smaller one-story homes built near your children and their families, or cooperative housing that emphasises mutual support, such as Italy’s Villagio Novoli.

In Korea, there are interesting examples which encourage groups of friends to come together to live in old age. Across the world there are many examples of co-housing, some with services provided too, though they are harder to organise for people on average incomes.

Some have sensors to spot falls, lifts, anti-slip surfaces and other adjustments to help people with impaired abilities. There are home hospices, brain gyms and much more.

For cities as a whole, there is a comprehensive agenda to make it easier for people with limited mobility or sight to get around or use, and get onto public transport. This agenda includes wider sidewalks, more benches, more quiet spaces, safer crossings, and signs to make cities more navigable. Newcastle’s ‘City of Longevity‘ is one of many interesting attempts to rethink the shape and character of cities.

We also need more radical experiments like Hogeweyk in the Netherlands, a dementia village specially designed communities where people with dementia live in a safe, normal-looking environment that mimics everyday life. Residents can move around freely, shop, and socialise, promoting a sense of normalcy and dignity.

In these examples, there’s specific knowledge about colours and shapes that I suspect will become mainstream.

8. Rethinking mutuality

My eighth theme is mutual support. We know that happiness late in life depends greatly on the quality of relationships with friends and relatives and we know more generally that mutual support is crucial to happiness.

In the World Happiness Report (2018), answers to the question “If you were in trouble, do you have relatives or friends you can count on to help you whenever you need them, or not?” explained 34% of the wellbeing score, more than income (26%) or healthy life expectancy (21%).

This should be obvious, especially after a pandemic that showed the importance of being able to call on neighbours for help. Research repeatedly confirms that social capital explains which places bounce back from disasters the quickest.

However, no governments actively support building care mutuality, there is almost no R&D on the issue, and the tech industry has been hopeless at making the most of social media and phones to encourage it.

For 15 years, I’ve been involved in making the case for policies around loneliness in the UK. The last government published a loneliness strategy (and even had a minister of loneliness for a short time), responding to evidence that loneliness has health impacts equivalent to “smoking 15 cigarettes a day”.

We set up a loneliness social impact bond—getting the municipality and health service to pay for befriending services because of the savings they would get on emergency rooms and residential care.

There are dozens of intergenerational projects which help people stay connected, like Papa in the US, which connects elderly individuals with college students for companionship and help with everyday tasks, meal sharing apps in Norway encouraging old people to cook and eat together, Humanitas in the Netherlands which allows young students to live rent-free in nursing homes in exchange for spending time with elderly residents.

9. Rethinking fun

Next, a brief turn to fun. A generation ago, fun had no place in these discussions. Once you were retired you were expected to slow down, quietly sit in your chair and await your end.

But generations brought up in the ’60s and ’70s have a very different view of pleasure from generations brought up Great Depression, WW2 and rationing. Fun is not something to be ashamed of.

Old age is the time for travel and tourism, taking risks, and starting new hobbies. For some, it’s a time for recreational drugs—especially now that some are legal in many countries. A time for dancing, new relationships, choirs and singing. Not surprisingly, dating apps for the over-70s are booming.

This was the spirit of Wroclaw’s march of hats where old people parade through the city in costumes, challenging preconceptions about how they should behave.

Oddly, to work may even fit into fun. I remember some research in Canada on what activities over-65s most enjoyed. Yes, dancing and time with friends came high up. But top came paid work. Again, because people want to be useful—so, employment agencies for the elderly are not just an economic measure but also part of ensuring old age is as meaningful and rewarding as possible.

Seoul’s 50+ initiative was an excellent example of integrating training, activities, and jobs for older people through a network of over 300 local campuses.

10. A new mindset

If this really is a great transition, with no historical precedent, then we obviously need to be creative both in the what and the how.

There are some technical changes needed within governments:

• Integrated databases – and in some cases personal data stores so individuals can combine and give access to professionals
• Whole system methods on cutting A&E and waste
• Next-generation case management methods
• Systems approaches to dementia—from training shop staff to interior design
• Housing/developing hybrid transitional models built into new towns
• Generalising social prescribing
• R&D to better reflect the burden of illness, so addressing environmental, behavioural and social causes of ill health which usually together get well under 5% of R&D
• Perhaps annual checkups with trained specialists advising on strength, mental health and other issues

But even more than this is a change of mindset. A study a few years ago showed that the difference between a positive and negative attitude to ageing explained about 7.5 years of life expectancy compared to action on blood pressure or cholesterol which could explain 4 years, obesity, smoking and exercise which could gain you another 1-3 years. I think this is both an individual and a societal point; we need to reframe how we think as well as how we act.

We also need a mindset that doesn’t fear ageing—that sees it as just part of life. Japan’s restaurant of mistaken orders is a good example, a restaurant where orders go awry, helping to acclimatise people to the reality of dementia.

Luckily the push towards a more positive mindset chimes with the things older people say they want, which they say are made hard by our systems and structures:

• to be useful and recognised
• to be helped at home when frail by a circle of support
• to end life at home surrounded by loved ones

Longer lives are a gift

This winter, I attended a concert with the Swedish conductor Herbert Blomstedt. He is 97 and did a brilliant job. It turns out that many conductors live to a very old age—in part perhaps because of the exercise they get, especially with their arms; in part because their brains are stimulated; in part because they are valued. Few ever retire, and perhaps they are the model for us all.

Longer lives should be the greatest triumph and a time for taking stock, for wisdom, for appreciating what really matters in life. They should prompt us to rethink how care is organised.

A century ago most care was provided in the family. There never was an industrial model for care—only for housing, hospitals and aspects around care. But now these questions are all becoming ones of policy; they are becoming a public matter. This is as true of care for people with impairments or disabilities as for the elderly.

So this is not necessarily a crisis, a disaster or just a bundle of problems. But to get the most out of this gift, we will have to think hard, and creatively—and break free from many of the assumptions that made sense in the past.

---

*Eroom’s law is the observation that drug discovery is becoming slower and more expensive over time.

[With thanks to Giulio Quaggiotto for comments; Donald Macaskill (ScottishCare) and Vic Rayner (National Care Forum) and Katie Smith Sloan (Global Ageing Network) for letting me give the opening keynote at their Global Ageing Network biennial conference in 2023, and to Deloitte; the UAE government for inviting me to give an opening keynote to their Global Social Care forum in October 2024; and to Sunkyung Han, Sehyon Lee and others at the International Village Forum in Seoul in November 2024 for helping me run a workshop on innovation for care].