1. Every child matters

Since 2004, UK education policy has been shaped by ‘Every Child Matters’ (ECM). This provides for a new ‘joined-up’ approach to the delivery of children’s services such as education, health and child protection. It also requires service providers to deliver measurable improvements in children’s ability to:

• Be healthy
• Stay safe
• Enjoy and achieve
• Make a positive contribution
• Achieve economic well-being

One reason for the adoption of this approach was the long running concern that specific children’s protection needs were sometimes lost in the gaps between services (Laming, 2003). There was also a concern that relative supply-side capture of both education and health services had made it difficult over the years to access efficiencies and synergies that a more holistic approach to the child might offer. For example, from a traditional teacher’s perspective it may be difficult to justify the use of limited resources to discuss curriculum and pedagogy with a non-teacher, say a health psychologist, even though learning about self, beliefs and behaviours and health outcomes might all be closely linked in the perspectives of policy makers, parents and students, and use of these connections might speed positive behaviour change. Joining up services is expected to make it easier for service providers to coordinate their efforts.

A shift of emphasis from supply-side to demand-side perspectives can also be seen in the attention ECM gives to children’s views of service provision and of their own needs, both locally in consultation with Children’s Trusts, and nationally through Children’s Commissioners. Whatever the real outcomes for the influence that children have, ECM has certainly established a default assumption that children should be consulted. It has also established the view that what matters primarily is the well-being of children, not the operational convenience of service providers. There are two features of ECM that are of particular significance to the present discussion:

• Relationships between health and education services are now open to re-negotiation on an issue-by-issue, initiative-by-initiative basis in the light of ECM aims
• Children’s views of the services they receive will be solicited and may inform future service delivery

The recently published Children’s Plan (2007), a ten year strategy for improving UK childhoods, underlines both of these key points. It adds commitments to making clear improvements in children’s health, including obesity levels, and to reducing the numbers of young offenders. Together these policy directives establish a firm connection between education services and children’s health and behaviour. These conditions arguably increase the scope for education and health providers, whether state-, charitable- or commercially-funded to form strategic alliances.

2. The promise of improved education services through Academies

Currently UK government is committed to establishing 400 academy schools, having already established about 100. Opposition party support for the programme suggests this policy will survive a future change of government. Academies are all-ability, independent state schools funded in parity with other state schools, but established and managed by academy sponsors (variously faith groups, businesses, universities, philanthropists and educational foundations) most often in partnership with local authorities. Commercial sponsors are required to invest £2 million in a newly established academy, while ‘educational’ sponsors invest their reputation rather than money in the success of the academy. Typically based in purpose-built or recently renovated accommodation, Academies have tended, so far, to serve relatively deprived communities with a recent history of failing schools.

Academies manage their own budgets, answering directly to Secretary of State for Children Schools and Families under the terms of their funding agreements. Their funding and governance, independent of local authority control, makes them relatively free to invest in educational resources, such as IT, and to meet National Curriculum objectives as their leading teachers and governors see fit, as long as they can convince OFSTED of their plans. Thus the performance of Academies is closely scrutinised, the expectation being that their relative freedom should translate into innovative and excellent teaching strategies delivering improved educational outcomes measurable in terms of pupils’ GCSE performance. Campaigners against Academies (eg www.antiacademies.org.uk) claim that Academies’ governance structure means that they lack local democratic accountability, raising questions about their ability to respond to local communities’ needs and wants.

Key points to note here are:

• Academies are expected to innovate and their leaders are under high pressure to ensure their pupils perform
• Academies are a very clear example of a purchaser/provider split in education delivery: local and national authorities are no longer to act as providers of education but should act instead as commissioners of education
• Academies’ strategic positioning within education market and ways of delivering national curriculum are relatively open to the influence of their sponsors.

Clearly, not all schools are Academies. However, their relative freedom to experiment in the new policy context set by ECM and the Children’s Plan and their close relationship with central government makes them a likely source of, and be test-beds for, future initiatives.

ECM diminishes conceptual and practical boundaries between ‘education’ and ‘health’. Couple this with the accountability regime surrounding academies and their innovation brief, and pupils’ health could become not only a key assessment criterion but also a key ‘lever’ in working toward excellence. Thus education will become more porous to health information. There are reasons for thinking that health provision may also become more porous to education providers. I am aware of an Academy that is turning its approach to pupils’ physical education into a marketable product, becoming a ‘health provider’ of sorts for other schools. Further, the attention of health policy makers is turning from informing the public with health messages toward individual behaviour change (Taylor, 2008). It may be that education professionals and institutions are seen as possessing valuable skills in this area.

3. Pharmaceutical trading conditions and future strategy

As the table of worries below indicates, the pharmaceutical industry was experiencing declining profitability even during the recent economic boom.

Pharma Marketing News 2005

http://pharmamkting.blogspot.com/2005/01/drug-pricesdeclining-profits-top.html

Pharmaceutical development and testing is a high risk business with both the efficacy and safety of candidate drugs in doubt until relatively late stages of development. From a profitability perspective a sensible development strategy is to focus attention on candidate drugs that are likely to have a large market in the affluent minority world. This accounts for the recent growth of ‘life-style’ drugs (Flower, 2004) such as Viagra and the emergence of the category ‘medically enhanced normality’ (Møldrup et al, 2003). The figures above also suggest that pharmaceutical businesses are motivated to influence government regulation of drug development and health policy.

The scoping exercise reported in ‘Drugs Futures 2025′ (Office of Science and Technology, 2005) brought policy makers, representatives of the pharmaceutical industry, and others together.  It offers some insight into the industry’s current and near future strategies. One aspect is of direct relevance here: the development of cognition enhancers (CE). Such CEs are believed to strengthen a range of cognitive functions, including memory, reasoning and concentration, by selectively enhancing or diminishing neurotransmitter function and synaptic efficacy. Regulators and the pharmaceutical industry expect both the size and product range of CE markets to expand in the near future. There is a history of soft drink and food manufacturers adding CEs to their products (Coke, Red Bull). Arguably, combining a CE with an otherwise desirable product would shift the conditions of consumer choice toward the state of ambient consumption that caffeine has long enjoyed. Food and soft drink manufacturers may act in concert with pharmaceutical manufacturers in the development of such products in the near future. An expansion of unregulated pharmaceutical CEA production by domestic and overseas concerns is also envisaged.

According to the anecdotal reports of some commentators (Turner and Sahakian, 2006) many adults and children who have no medically identified cognitive deficits are already finding uses for these agents, hoping to improve their performance in education, work and leisure. There is a large existing market for non-pharmaceutical agents such as dietary supplements and herbs and a new market is emerging in the ‘off-label’ use of pharmaceuticals. In this new market, drugs developed to treat pathological conditions are used by those with no diagnosed need in the hope of enhancement. Ritalin, for example, is often prescribed in cases of Attention Deficit Hyperactivity Disorder (ADHD), but can also be taken in the hope of boosting powers of concentration that are understood as ‘normal’. Although pharmaceutical research and development activities are often subject to the ethical constraint that they must aim at finding a treatment for a pathology, consumers with no pathological condition are relatively free to experiment with the many opportunities and risks presented by self-prescription of pharmaceuticals, sourced through the internet or social networks.

4. How effective is the current range of CEs?

Jones et al (2007) identify 27 major agents believed to have cognition enhancing potential. These include ten dietary supplements and seventeen pharmaceuticals. Horne (2008) provides a synoptic review of evidence of their effectiveness which I summarise below.

i.        Nutrachemicals: dietary supplements and vitamins

Vitamins E, B6, B12, folate, thiamine, lecithin, neurosteroids and Ginko biloba. There is insufficient evidence to assess their efficacy although there are suggestions of an association between vitamin B6 and memory in healthy individuals.

ii.        Cholinergic drugs

These drugs enhance neural transmission through the cholinergic system that uses acetylcholine as its neurotransmitter. Cholinesterase inhibitors reducing the effectiveness of enzymes that breakdown acetylcholine, thus making it more available within the brain. Lab tests have shown cognitive improvements in healthy subjects, although effects on different cognitive abilities vary between individuals. Nicotine and related compounds have been shown to have beneficial effects on attention, learning and memory in healthy subjects.

iii.        Psychomotor stimulant drugs

These are often prescribed for Attention Deficit Hyperactivity Disorder (Adderall, Ritalin), where there is good evidence of their effectiveness. Ritalin can enhance spatial working memory, cognitive flexibility and reaction time in young healthy adults, but effects on verbal learning, vigilance and long term memory are relatively small and restricted to the special conditions found in the lab.

iv.        Atypical stimulants : modafinil

Marketed as treatment for excessive sleepiness, there is evidence that modafinil (provigil) can benefit some cognitive functions in young healthy adults including verbal working memory, visual recognition, planning performance and executive inhibitory control. No memory enhancement has been demonstrated. Means by which the effects are produced is unknown.

v.        Cerebral vasodilators

Cerebral vasodilators widen blood vessels in the brain. There is little evidence that they enhance cognitive function in healthy individuals.

It is clear that there is more evidence for some CEs than for others, but also that there are gaps in evidence. While the availability of a high standard of scientific evidence may be salient for some actors, for others possibility and anecdote are just as convincing.  As Martin et al (2008) argue, bio-science development, marketing and public reception are shaped by an economy of hope as well as available evidence. The ‘gold standard’ of medicines research, the double-blind control study, is certainly not the only available metric of effectiveness, even if it can claim to be the best. It is likely, then, that individuals and perhaps organisations will find their own ‘tests’ of CEs.

Drug Futures 2025 (2005) also raises the issue of drugs testing. As more psychoactive and enhancing drugs are brought to formal and informal markets so the technology for detecting their use has become more widely available. For example Access Diagnostics (www.drug-testing-kit.co.uk) offer a saliva test kit at a rate of £5.50 per test to cover cannabis, cocaine, opiates, amphetamines and benzodiazepine that promises results within 10 minutes. According to Drugs Futures 2025 such testing is likely to be an increasingly common feature of the management of drug use in the classroom and at work, but it is unclear just what types of drugs will be tested for in what circumstances. For example a test might be used to assess a child’s compliance with a prescribed mood or performance-altering substance and another might be used to deter the same child from the use of recreational drugs. Some US schools apparently allow children who have been diagnosed with ADHD to attend school only on the condition that they have taken their medication.

B. Relationships

1. Might relationships between educators and private concerns in the information technology and health sectors come to resemble those between medics and drug companies?

There is a good deal of research and commentary on relations between pharmaceutical companies and medical service providers. Much of this work is critical in intent, raising questions about the balance between the influence over medics’ prescription habits and the support the industry offers medics in pursuing their professional goals and status. Moynihan (2003) gives pithy expression to the issues when he asks ‘who pays for the pizza?’ But this is more complicated than a question of luncheon bribery. It is not clear that the sponsorship of professional meetings and conferences by commercial interests, for example, is inappropriate. If medics and drug companies are ‘entangled’ with one another, this is the result of decades of mutual support and shared interest. Are there reasons to think that educational professionals of the near future might encounter similar relationships and ethical issues?

It has proved difficult to find published peer-reviewed evidence relevant to this question. However, the author recently enjoyed a ‘guinea-pig’ role in an information technology firm’s new marketing strategy. Having seen my name on publicity material for a conference organised by an educational research charity, the sales director invited me to address a small audience of IT marketers and academy heads. He had never invited an academic to speak before. A pleasant lunch was provided.  Key elements of this meeting indicate that strong parallels between education and health marketing and public relations strategies are emerging. These include the mobilization of an ‘expert’ to give the meeting a respectable research/professional development flavour, the provision of free lunch and travel budgets, and a smooth segue into post-lunch session of product demonstration.

2. What factors might strengthen relationships between educators and private sector organisations?

There are structural parallels between the emergent organization of primary health care and the burgeoning Academies programme that can shed further light on our issue and lend the anecdote above a policy context. As Pollock et al (2007) argue, 2003 saw the creation of a market in primary care. Primary care trusts in England, health boards in Scotland and local health boards in Wales gained new powers to negotiate contracts with commercial companies. This has brought about a diversification of providers in the health-care market. The range of health care providers, often firms employing general practitioners or practices managed by general practitioners, are now regulated primarily by commercial contract. There is a close parallel here with the purchaser/provider split that converted Local Authorities into commissioners rather than providers of educational services and the independent status enjoyed by Academies. In both cases the split is used in the hope of reducing supply-side capture, of locking ‘market discipline’ into service provision chains and, ultimately, of improving services to individuals.

Current regulations already allow academy sponsors a good deal of creative leeway when it comes to delivering on OFSTED defined targets. The Times Educational Supplement (14 November 2008) reports on a deal involving Edison Schools, a profit-making business, taking charge of up to 12 academy schools charging each academy £1.2 million for a three year contract. Full payment will be conditional on improvements in exam performance and pupil behaviour.

As this report indicates, the policy context has significant consequences for the dynamics of key relationships. The establishment of purchaser/provider splits decreases the practical relevance of the moralised and politicised distinction between ‘public’ and ‘commercial’ service provision within professionals’ everyday decision-making. It also replaces a hierarchical scheme of centralised decision making with a relatively dispersed range of decision and negotiation points. A number of assessments of this are possible. For Pollock et al (2007), like antiacademies.org, this will diminish local public accountability of service provision. From a current government point of view it will make services more responsive to individuals (including children) allowing for the greater personalisation of public services (Leadbeater, 2004). From the point of view of the current paper, however, it seems likely that educators will become more available for the influence and persuasion of commercial interests as they come to view such relationships as beneficial to the service delivery they are responsible for.

3. The emergence of a new educational ’strategic imaginary’?

Publicly funded education has long involved relationships with commercial organisations. From exam boards to publishing houses, exchange and conversion between commercial interest and ‘disinterested’ professional bodies, between saleable product and authoritative knowledge, has a long history. So what might be novel about increased pharmaceutical or IT business involvement in today’s education policy environment?

In 2007 Durham County Council investigated the effects of a fish oil dietary supplement on pupils’ GCSE exam results. They began with 3000 pupils at year 11 taking supplements at home and at school. The fish oil supplements were provided free of charge by the company Equazen, manufacturer of such products as the widely available ‘eyeq chews’, a fruit flavoured, sweetened preparation of ‘naturally sourced’ Omega 3 and Omega 6 oils. By the time of the GCSE exams around 800 pupils were still compliant with the programme. In order to estimate the effects of the supplements on GCSE outcomes, the Council’s Children and Young People’s Services division compared the results of children who had remained compliant with those of children who had not taken the fish oil that Equazen provided. The two groups’ performance did differ, Equazen takers scoring higher than the others.

This investigation generated a great deal of positive publicity for fish oil supplements. Its status as scientific research has, however, been called into question by a series of closely argued articles by the science journalist Ben Goldacre (www.badscience.net). There is no good reason to attribute the differences in performance to the oil, given that the compliant group was self-selected and perhaps more invested in educational achievement than the others. No attempt was made to control for placebo effects. Further no information was sought about the diets and supplement use of children who did not take the Equazen product.

In a recent press release (25 September 2008), the Head of Achievement for Durham County Council’s Children and Young People’s Services acknowledged that the study’s design did not allow any positive inference to be drawn about the effectiveness of fish oil in raising children’s achievement. Having said this, however, he pointed out that had no difference been detected between groups, Durham would have been likely to dismiss fish oils entirely. Combining this imaginary negative result with the actual but scientifically meaningless positive result enabled him then to maintain hope in the effectiveness of fish oils:

‘… taking all this into account, it is our view that this study has produced some interesting and possibly exciting issues for further investigation that could be the basis for future scientific trials …’

http://www.durham.gov.uk/durhamcc/pressrel.nsf/Web+Releases/9B151A656B3FD9AB802574CF002D51F1?OpenDocument

Even though they fly in the face of scientific reasoning about effectiveness, I would suggest that these manoeuvres allowed him to maintain something of value – the possibility of a strategic alliance between Durham Children and Young People’s services, Equazen, and aspirational service users designed to meet policy objectives.

Whether this trial was good or bad science and whether fish oils really can raise performance is not the central issue that concerns me here. Instead it sheds light on trends in relationships between education service providers and commercial operations.

The Durham trial and its aftermath suggest that the current education policy environment has generated a new ’strategic imaginary’ amongst key stakeholders such as Heads of Achievement for local authority young people’s services division, Academy leadership, and sales and marketing agents in pharmaceutical and IT companies. I describe the ‘imaginary’ as ’strategic’ because it is closely aligned with the delivery of ECM and Children’s Plan objectives, and is concerned with actively seeking, choosing and organising promising materials and opportunities from whatever sources become available to deliver those objectives. I describe it as an ‘imaginary’ because it is knitted together with possibility and hope. I would emphasise that this is an observation not a critique.

References

Horne, B. (2008) Brain sciences, addiction and drugs. London, Academy of Medical Sciences

Children’s Plan http://www.dcsf.gov.uk/publications/childrensplan/downloads/The_Childrens_Plan.pdf

Every Child Matters

http://www.everychildmatters.gov.uk/

Flower, R. (2004) Lifestyle drugs: Pharmacology and the social agenda. Trends in Pharmacological Sciences, 25 (4), pp.182-185

Jones, R., Morris, K. and Nutt, D. (2007). Cognition enhancers. In: Nutt, D., Robbins, T., Stimson, G., Ince, M. and Jackson, A. (2007). Drugs and the future: brain science, addiction and society. London, Elsevier.

Laming, L. (2003) The Victoria Climbié Inquiry: Report of an Inquiry. www.victoria-climbie-inquiry.org.uk/finreport/finreport.htm

Leadbeater, C. (2004) Personalisation through participation: a new script for public services. London, Demos

Martin, P., Brown, N. and Turner, A. (2008) Capitalizing hope: the commercial development of umbilical cord blood stem cell banking. New Genetics and Society, 27 (2), pp.127-143

Møldrup C., Traulsen, J.M. and Almarsdóttir, A.B. (2003) Medically-enhanced normality: an alternative perspective on the use of medicines for non-medical purposes. International Journal of Pharmacy Practice, 11 (4), pp.243-249

Moynihan, R. (2003) Who pays for the pizza? Redefining the relationships between doctors and drug companies. British Medical Journal, 326, pp.1193-1196

Office of Science and Technology (2005) Drugs Futures 2025. London, HMSO

Pollock, A.M., Price, D., Viebrock, E., Miller, E. and Watt, G. (2007) The market in primary care. British Medical Journal, 335, pp.475-477

Taylor, M. (2008) Behaviour Battles. Ethos. Edition 6. www.ethosjournal.com

Turner, D.C. and Sahakian, B.J. (2006) Neuroethics of cognitive enhancement. Biosocieties, 1 (1), pp.113-123

This document has been commissioned as part of the UK Department for Children, Schools and Families’ Beyond Current Horizons project, led by Futurelab. The views expressed do not represent the policy of any Government or organisation.

Childhood and Mass Education

Since the mid twentieth century, a special relationship has been maintained between the life course period termed ‘childhood’ (roughly 4-18 years old) and publicly funded mass education in the UK. In this period, the publicly funded education of children has been understood as a form of social investment that is expected to mature after roughly twenty years as the young enter the labour market, and to continue to yield dividends for a period of roughly forty years as their working lives continue. Educational investment has taken the form of the shaping of children’s daily activities, their supervision and on-going and summary assessment, and the provision of staff (teachers) and facilities (schools and colleges) respectively to lead and house this process. As a result childhood became, and remains, the most intensively governed section of the life course (Rose, 1989).

The dividends of educational investment were expected in the shape of educated adults’ contribution to the well-being of the population as a whole and the maintenance of the popular credibility of the state that organized and synchronised educational investment on behalf of that population. Dividends were expected to take biological, social and economic forms. Educated adults were to bear children and to raise them well in accordance with their physical and psychological needs. Adults who had been through the educational process were expected to be law abiding and to raise their children in accordance with prevalent social norms. Adults were to generate taxable income so that, amongst many other things, the costs of educational investment and subsidies for non-working adults, including the unemployed, the sick and those retired from the workforce, could be met.

Investing in children through education has been key to managing social risk across the life course. The risk of poverty in later life could be reduced by the existence of sufficient numbers of economically active adults. The risk of child neglect could be reduced by state investment in children. The risks of adult criminality and of unemployment could be reduced by good socialisation and preparation for adult life in childhood. The success or failure of this investment scheme rested on a balance between certain demographic factors: mortality rates, birth rates, rates of migration, the presence of a cohort of adults in work, and the ability to finance their own and others’ lives (Borgman, 2005).

Decade by decade, various changes in delivery of, and access to, education have adjusted this basic model to suit policy makers’ changing views of social futures – usually meritocratic, often egalitarian – and to make the preparations thought necessary for predicted economic futures (Jones, 2003; Lee, 2005). By the end of the twentieth century, inequalities of gender and of ethnicity, the consequent waste of human resource and resultant social antagonism had begun to join the range of risks education was supposed to tackle. This meant an increased sensitivity to interactions between gender and ethnicity and the functioning of educational institutions as a driver of social equality and inequality.

Considering education as a form of social investment, it is clear that a significant proportion of UK social investment has long been ‘child-centred’. The latest major turn in UK education policy which has taken place over the last decade has been toward a broader ‘child centred social investment strategy’ as described by Esping Andersen (2002). This strategy is based on a clear set of assumptions about demographic and economic change over the next twenty years. It assumes an ageing population across Europe and increasing global economic competition. Esping Andersen argues that far more needs to be invested in the welfare of children to cope with these changes over the next few decades. Following this strategy over the last decade, UK government has attempted to intervene in family life, women’s employment and children’s experiences from the earliest years in order to defend individuals, families and the state from future threats of unemployment and national economic failure. The claims of educational investment as an organizing principle of state expenditure have been broadened significantly. The following will describe this strategy and its assumptions in greater detail.

A Child Centred Social Investment Strategy

Demographics

For Esping Andersen (2002) demographic change leading toward an ageing European population means that a new model of the welfare state is needed to cope with the challenges of the next few decades. In his view, the link between childhood and mass education is more important than ever. He argues for the central importance of generating cultural, social and cognitive capital through the education of children in any strategy that is designed to reproduce a prosperous, egalitarian Europe throughout the next few decades. He argues that the elimination of child poverty across Europe is a relatively inexpensive and highly cost effective response to emerging challenges. His reasoning will be summarised in the following section.

In the decades following the Second World War, the greatest concentration of poverty risk was amongst the older population. Having lived through two world wars and the worldwide economic collapse of the 1930s, older people had had restricted opportunities for saving. This, coupled with the introduction of mandatory ages of retirement, concentrated poverty risk in the later years of life. Fortunately, in the same period, a post-war population boom had made Europe a relatively youthful continent (Esping Andersen, 2002). Consequently, there was no shortage of young human resources to be passed through the education system, as described above, to pay for pensions. According to Esping Andersen this meant that European social welfare policies of the last half of the 20th century were concentrated on addressing the problems of the elderly and were a relatively successful response to these problems.

The United Nations Population Division (UNPD, 2003) forecasts decreasing birth rates and increasing longevity in ‘more developed’ regions like Europe over the next 40 years. As late as the mid-1970s it was possible to summarise the age profile of European societies with the image of a ‘pyramid’. A broad base of young males was mirrored by a broad base of young females. Both narrowed with age toward a peak at around 80 years old. Current European profiles more closely resemble the dome of the ‘Taj Mahal’ with a pronounced bulge in 50 and 60 year olds overhanging the 0-30s range which narrows as age decreases. By 2025 profiles that more closely resemble a ‘mushroom’ (Borgman, 2005) are expected. There is a clear trend toward more elderly people and fewer young people across Europe. Clearly, as the balance between child, working adult and retired adult changes, there will be implications for the welfare state as whole, and for the nature and purpose of educational investment in particular.

We can expect difficulties in managing the risk of poverty in later life to emerge. Late twentieth century models of social/educational investment always depended on a particular balance between birth and mortality – relatively plentiful youngsters and relatively few dependent elderly – but that balance is being reversed. For Esping Andersen, however, the risks of the coming decades are not confined to the elderly as they were in the late twentieth century. The risks posed by demographic change are joined and inflected by changes in the labour market that are likely to spread the threat of insecurity across generations and along the lines of existing forms of social inequality.

Changing Labour Market

The labour market changes that concern Esping Andersen will be familiar from discussions of the shift from a Fordist production regime, characterised by high start-up costs and high geographical stability, to Post-Fordist production regimes (Harvey, 1989; Lee, 2001). This shift toward post-fordist flexible accumulation (Harvey 1989) or the ‘new economy’ (Esping Andersen, 2002; Arthur, Inkson and Pringle, 1999) involved several interlinked trends that Esping Andersen extrapolates into the future. The decreasing communication and transport costs made available by new communications technology and the containerisation of international goods transportation (Levinson, 2006) meant a decreasing need for manufacturers to rely on any one geographical region for its workforce. The globalisation of the available workforce thus decreased the wages that a relatively unskilled European worker could demand. It also created a demand for a ‘flexible’ workforce of individuals who are able to recognise and respond to emergent and relatively short term employment opportunities.

For Esping Andersen these demographic and economic factors should lead European societies to aim at becoming ‘knowledge societies’. As long as a manufacturing workforce is available at a lower price outside Europe thanks to cheap communications and transport, a sensible strategic response is to create the sort of workforce that can target the opportunities opened up by cheap communications and transport. Ideas, words and numbers are communicated most easily of all. Thus, an education system that can ready children for work in financial, legal and other services and creative industries is needed. I will examine the assumptions underlying this view more critically later. For the moment I will further describe Esping Andersen’s thesis.

Future Workforce

In the light of these changes, what characteristics should a successful future workforce have? They should be highly accomplished users of symbolic systems. They will need to be able to find out about new opportunities and to discover how to make the most of them. If employment is not secure, they will need high levels of self-maintenance skills, such as being able to organise a social support network. As Esping Andersen has it, life chances will depend increasingly on the cultural, social and cognitive capital that citizens can amass.

If we consider the UK’s ageing population alongside the changing global labour market, a range of futures become plausible. First, if today’s children are not made ready to take advantage of the opportunities opened up by low communications and transport costs, the economy as a whole will become less competitive and future tax revenue will decline. This will reduce living standards significantly for all and set close limits on the government’s ability to invest. Second, imagine that only those children who enjoy the privileges of high social class, of living in a prosperous area or of high levels of parental support are equipped with the necessary cultural, social and cognitive capital. It may be that they achieve such success in later life that tax revenues do not decline significantly despite an ageing population. This will, however, be a highly polarised society, one that locks-in privilege and exacerbates inequality. Third, if existing blocks to the development of all children’s cultural, social and cognitive capital can be identified and removed, the promise of the ‘knowledge society’ will become a reality, and European countries, including the UK, will remain prosperous, will be able to cover the costs of an ageing population, and will have the resources to invest so as to sustain their prosperity.

Esping Andersen presents us with a choice between the second and third futures. He offers two reasons to prefer the latter. If we share his egalitarian values, an increasingly unequal future will not be acceptable. Even if we do not share those values, he suggests that high levels of inequality may carry hidden inefficiencies – a limit to the knowledge economy reached when too many lack the skills to consume knowledge products. For Esping Andersen, since children’s levels of cognitive ability are strongly negatively influenced by poverty and by a low level of parental educational achievement, socially inherited under-privilege stands in the way of achieving an economically viable and egalitarian future.

Policy Recommendations

Esping Andersen’s thesis builds a set of policy recommendations to be followed by those European national and regional policy makers who are working toward a prosperous and egalitarian European future. Together these recommendations re-affirm the centrality of the education of children to the management of societal risk. Furthermore, these recommendations broaden the resource claims of educational investment in children beyond school walls into family life, parental workforce participation and into the purpose of social security transfers.

a) Focus investment on children

Given Esping Andersen’s demographic assumption of an ageing society, this focus on the young and especially on the earliest years of life may be surprising. If human resource is ageing, surely more resources should be invested in the potential of older people? His recommendation that childhood be treated as a critical period for intervention rests on two claims: first, that evidence of the high social inheritability of poverty and low educational performance suggests that childhood is a critical period for shaping life courses; and second, that remedial interventions targeted at adults are unlikely to be effective unless these adults developed sufficient social and cognitive skills in childhood to make full use of them.

b) Encourage lone parents to participate in the labour market

Esping Andersen argues that there is a growing polarisation of family life between ‘resource strong double-earner households’ and ‘vulnerable, lone parent and work poor households’ (Esping Andersen, 2002, p29). Lone parents are usually women. Left unchecked this trend will create pockets of on-going and highly stable social exclusion, permanently denying a significant proportion of children the cognitive abilities required to participate in future competition for work. The problem should be addressed at its root through policies that encourage lone parents to participate in the labour market with the proviso that their work does not detract from their ability to care for their children. Participating in the labour market has benefits but also has costs. When considering their opportunities to participate in the labour market, lone parents have to factor in the opportunity costs of working. These include the time and money used up travelling to work, the complexity of child care arrangements and potential loss of social security benefits. Esping Andersen recommends policies that make work pay by reducing these opportunity costs. Such policies would include the provision of good quality, low cost child care and the careful adjustment of social security transfers to eliminate disincentives to work.

c) Eliminate child poverty

Esping Andersen argues that child poverty is associated with inferior life chances and offers evidence that it is strongly associated with an early school leaving age, criminal behaviour, and lower earnings in adulthood. It seems that children from poorer families are much less able to parent effectively, locking poverty into the next generation. If child poverty is not tackled, then a mass of unproductive, ill-educated, potentially criminal adults who are able, at best, to attract only low paid work will be created. Given this, minimising childhood poverty in the present should yield dividends in the future.

Esping Andersen considers two approaches to the elimination of child poverty: via more generous social security transfers, and via mothers’ greater participation in the labour market. Basing his calculations on a range of countries’ existing child poverty rates and degrees of inequality he argues that social security transfers alone could eliminate child poverty at relatively little costs in countries ranging from Denmark to the USA. Eliminating child poverty on a national basis through social security transfers alone would costs 0.01% of Denmark’s gross domestic product (GDP), 0.26% of the UK’s GDP and 0.30 % of USA GDP. Clearly these costs would be reduced even further through the greater activation of lone parents as workers.

Current UK Government Response

Despite some critique (Lister 2006) Esping Andersen’s thesis has been very influential on UK policy making over the last decade. In what follows I will briefly describe two of the initiatives that bear the hallmark of this thesis. I will shortly examine the reliability of the assumptions underlying the thesis and recent UK child-related policy. If we assume for the moment that they are reliable, we still need to know how successful the various initiatives designed to provide for the next few decades have been so far.

Eliminating Child Poverty

In 1999 the then Prime Minister Tony Blair announced a commitment to halve child poverty by 2010 and to eliminate it by 2020. An indication of progress so far can be gleaned from the following. Between 1998 and 2006, 600,000 children were lifted out of poverty. The government target was to lift 850,000 out of poverty by 2004 and 1.7 million by 2010 (Joseph Rowntree Foundation). Child poverty is proving a tough nut to crack.

Improving Early Years Education

The Sure Start programme is designed to provide 3,500 children’s centres offering free integrated early years health and education services targeting deprived areas by 2010. Latest assessments of its effectiveness indicate that in deprived areas with Sure Start Children’s Centres there is less negative parenting amongst parents of three year olds and a better home learning environment, and that three year olds in deprived areas with a Centre also show improvements in social and cognitive capital as compared to those without (NESS, 2008).

Integration of Children’s Services

Building on the Children Act 2004 a programme of multi-agency integration known as Every Child Matters has been drawing health, protection, welfare and education services together at the local authority level and at the level of national accountability. The programme has the following five aims.

• Be healthy
• Stay safe
• Enjoy and achieve
• Make a positive contribution
• Achieve economic well-being.

Re-organising child services on the basis of a holistic view of the child is expected to yield synergies and efficiencies. The child-centred nature of this change is reflected in a new commitment to seek out and respond to children’s own points of view. This is understood both as a matter of good democratic practice and as an opportunity for children to gain early experience of citizenship.

It is clear that some progress is being made in the direction of improving the levels of cultural, social and cognitive capital of the UK workforce of the next few decades. Whether this progress will continue depends on many factors including possible changes of UK Government and policy, and the continued availability of funds for investment. Whether the progress made so far is enough to meet the challenges Esping Andersen sets out time will tell.

Current Assumptions

Esping Andersen’s thesis and the policies influenced by it are based on the extrapolation of a number of recent trends.

• Ageing European Population
• Little change in UK immigration policy
• Low transport costs

The containerisation of international goods shipping has reduced the costs of international trade by increasing efficiency and reliability. This has been a crucial factor in the globalisation of the labour market that underpins the ‘knowledge society’ thesis.

• Ease of communications

Technological developments such as the internet, along with falling costs of computing and the rapid building of communications infrastructure (cable and satellite), mean that the last two decades have seen great increases in available bandwidth and reliability of communications.

• Concentration of manufacture in emerging economies

Decreasing transport costs mean that China and other emerging nations have had the opportunity to develop their manufacturing base and to relate to the USA and Europe as consumers.

Section 2: Trends and Signals

As noted throughout the above, current UK policy is building on foundations laid a decade ago. Current cohorts of school children who will form the bulk of the UK workforce for the next few decades are being prepared for one of yesterday’s futures. Given the scale of the UK public education system a lag like this is inevitable. But are there significant differences between yesterday’s and today’s plausible futures that might lead us to question existing strategies? The following is a survey of trends and signals that may test current operating assumptions.

‘Majority world’ demographic change

The UNPD (2002) median projection forecasts an ageing world population over the next 40 years. However, areas with different levels of development differ significantly in the timing and scale of their contribution to global ageing. More developed regions, including the UK, are already experiencing a relative decline in children and young people. This trend will continue till 2050. Less developed regions, including India and China, will not experience a relative decline in children and young people till roughly 2050. Least developed regions such as sub-Saharan Africa, will continue to have a roughly pyramid-shaped aged profile until 2050.

The availability of children and young adults for education and training will track West over the next few decades. If the availability of children is a comparative advantage for a region, then the UK is currently losing that advantage while India and China gain it. Their advantage is short-lived, lasting only 30 years according to projections. Within that time-frame sub-Saharan Africa gains a competitive potential.

Majority world educational development

Lloyd and Turkeltaub (2006) argue that Russia and Brazil’s reliance on booming commodity prices is distracting them from making the sort of educational investments that China and India are currently making. China and India are competing strongly with the West for cognitive capital. Signals include China’s ongoing University building programme and the growth of IT industries in India.

Peak Oil

This phrase does not indicate a cliff-edge collapse of world energy resources but the observation that at some point in the near future the rate at which liquid energy supplies can be brought to market will begin to decline. The date of peak oil is hotly disputed, as is the relative power of various factors in speeding its arrival (absolute quantity of oil in the ground, economic viability of exploration/drilling, technical limitations) but liquid energy is set to become more expensive over the next few decades (Deffeyes, 2006). How rapid this price rise will be depends on many factors including demand.

Climate Change

According to Abatzoglou et al (2007), carbon dioxide levels are currently at 385 parts per million (ppm), over 100 ppm higher today than before the Industrial Revolution. It is likely that levels will continue to rise to between 600ppm and 1000ppm by 2100. The view of the International Panel on Climate Change in 2007 was that this will translate into an increase in the global average surface temperature of 1.8-4.0 degrees centigrade.

The impact of climate change by 2050 is very difficult to forecast, but a global increase in extreme weather events such as flood, drought and heatwave is likely, along with a marked rise in sea levels. Given that many major cities are coastal ports and given that ports are key nodes in international trade, this is a significant threat to human and economic security. Current expectations are that the poorest will suffer the most from climate change. DiMento et al (2007) estimate that world economic output will be reduced by 1% by 2100. This figure may seem comfortingly low but Matthew (2007) estimates that one fifth of humans survive on 1% of the world’s wealth. Arguably, war and unrest brought about by climate change are already breaking out in certain vulnerable areas.

The UK is far from immune from direct consequences of climate change. Rapid changes in seasonality – badly timed rainfall and cold or lengthening of warm periods – threaten crop yield and will alter human and livestock disease profiles. Abrupt climate change in the UK is a real possibility. Increased fresh water run-off from Siberia into the Arctic Ocean may bring about the sudden cessation of Gulf Stream circulation, thereby making the UK a much colder country (Abatzogolou et al, 2007).

Finance and Investment

At the time of writing, sums in the region of hundreds of billions of US dollars are being promised by governments to save the US, UK and European banking sector from collapse. A proportion of these sums dependent on the precise nature of the deals made will need to be paid for by the tax payers of the future. It is unclear how many generations of tax payers will be involved. The money is needed because banks no longer trust each other to be able to repay debts, so are unwilling to lend each other money. It seems that a credit ‘bubble’ formed over the last decade as regulatory change allowed historically high credit/capital leverage ratios, and increasing levels of cognitive capital enabled financial firms first to disguise and then to trade bad debt (Blackburn, 2006).

These events are relevant here for two reasons. First, the UK educational policy framework was established during a credit boom. Second, the aftermath of the current credit crisis is likely to alter our global economic expectations for the next few decades.

Section 3: Emergent Issues

Current policy makes good sense if we accept the assumptions on which it is based. An ageing population and increasingly competitive labour market with little space for the low-skilled suggest that we should focus resources on enabling children to compete with their global peers for financial resources. If work associated with manufacturing will no longer provide enough pay, then work that calls for high levels of social and cognitive capital should be targeted. If certain sectors of the population are blocked from developing sufficient social and cognitive capital, then those blocks should be removed. This section will first revisit those assumptions in the light of the new trends and signals described in Section 2. Does today’s future differ from yesterday’s to such a degree or in such ways as to cast doubt on current policy? I will then draw up a set of issues that are likely to become significant and controversial as current policy meets those new trends.

Trends and Signals: implications for current policy

The generation and distribution of social and cognitive capital has long been the core purpose of mass education in the UK. In lives of the past century when individual opportunities were tightly defined by conventional codes of class identity and were protected and contained by the nation state, both the generation and distribution of these capital forms was highly selective. Formal and informal biases of class, sex and ethnicity had a great influence on educational outcomes. They still do, but current policy works hard to disrupt codes of class, ethnic and gender identity so as to generalise access to social and cognitive capital because it takes the view that the nation state can no longer contain and protect. From a 20th century perspective the demands of current policy are quite radical: clearly, women in general should work and mothers also need to work. It is most important of all that mothers who are lone parents should work. All this with the aim of maximising the quantity and distribution of children’s social and cognitive capital. Does it still make sense a decade on?

‘Majority world’ demographic change and educational development

There is a tendency to think of future generations of relatively healthy older people as an economic problem rather than as an economic opportunity. Even as Europe ages over the next few decades, less developed regions remain young. UK policy examined in this document is based on the potential of the young rather than the abilities of the mature. That potential is clearly not the UK’s strongest suit. Are greater opportunities for ‘lifelong learning’ being overlooked?

There is a tendency to formulate policy that targets only the UK population even as it is predicated on the changing powers and significance of the nation state. Many countries in less developed regions have an abundance of youngsters. Least developed regions (sub-Saharan Africa) are set to leapfrog less developed regions in terms of the availability of young human resources within 40 years. Varieties of English are spoken worldwide. Cheap IT solutions inspired by the MIT ‘one laptop per child’ project are becoming available. Should UK educational investment ignore national boundaries in the near future? If it did, to the extent that human development is a non-zero sum game, it might benefit economically from the development of human social and cognitive capital worldwide.

Peak Oil

It is likely that peak oil will be reached during the next forty years. Currently the international trade in goods that supports a large proportion of the world economy is based on liquid energy. The world economy over the last decade involved the transfer of capital and mass production from the West to China and the transfer of goods and debt from China to the West setting the conditions in which current child-related policies makes sense. Historically, oil prices have eased these transfers. Even if a suitable alternative to oil can be developed, there may be a lag in its introduction, thereby boosting energy prices. UK export of mass production and manufacturing jobs may not remain economically optimal over the next forty years.

Climate Change

Climate stress and food and water shortages may increasingly motivate migration to the UK. Climate-based armed conflict may add to their numbers. Of European Union countries, Greece, Spain and Italy are currently most at risk. Given freedom of movement within EU borders and depending on the severity of effects, the next few decades may see increases in seasonal migration from Southern to Northern Europe, permanent migration in the same direction and/or a combination of the two. This will tend to concentrate Europe’s young in the North. Political controversy over educational resources would result in the requirement for new arrangements for financing education across Europe. Waves of migration bring the pedagogical challenge of linguistic diversity. The African continent is already a major source of immigration into the UK. It may be that the response to increased migration is a strengthening of borders at the European level and a tightening of entry criteria. Whether or not that road is taken, the UK will see an increase in numbers of immigrant children who have experience of warfare. Standards of provision for their psychological assessment and care will need to be raised.

Finance and Educational Culture

Over the last decade a generation of financial sector workers equipped with high levels of social and cognitive capital have been flexible enough in their outlook and working practices to find ways to accumulate capital through trade in disguised bad debt. Writing just as a resultant inter-bank lending crisis threatens the UK banking system, share values and pensions and the rest of the economy, it seems clear that the emphasis on personal flexibility and the capitalization of human relationships (social capital), and thought and creativity (cognitive capital) that informs current policy reflect the deregulated boom economy that may now be drawing to a close (Fukuyama, 2008). In the coming years a broader range of concepts of personal worth and human development may become attractive. Policy makers’ anxieties about performance (of government and of children) have meant that UK education has become a very tightly run ship over the last decade. There has been popular criticism to the effect that targets and performance indicators have stifled the education system’s ability to foster curiosity, independence and creativity in learners. Right or wrong, this view is likely to gain strength from the economic crisis.

Life course and investment

It is unclear just how deep and lasting the UK economic recession will be but there is a distinct possibility that it will exert downward pressure on UK public spending. Recent falls in share values will affect the holdings of pension funds and intensify anxieties about poverty in later life. Together these factors suggest a near future return to the low educational investment levels of the 1980s.

Emergent Controversy

Is childhood ’special’?

Esping Andersen (2002) discounts the significance of future inter-generational contests for public resource. His estimates of the low cost of eliminating child poverty help him do this. However, current policy may not be successful in generating a competitive workforce for the next 40 years. Chinese and Indian cognitive capital may outstrip our own, diminishing UK GDP. New factors, such as medical developments and persistently sluggish stock markets, may add to the public cost of ageing. Immigration may not supplement the UK’s human resources sufficiently. If any or all of these possibilities occur, a resource contest may develop between the need to boost and lengthen productivity of existing workforce and the need to invest in children. The long term strength of the UK economy will depend in part on whether, as Esping Andersen argues, childhood is an especially wise site for investment in human potential.

Why did such a strong relationship form between publicly funded education and children under 18 rather than any other section of the life course? The full implications of this question are too complex for the present paper to investigate fully. The following is a range of hypotheses. Which are correct and how they interact may have direct implications for how we should respond to education challenges over the next 40 years.

Investment and time

Children are a particularly wise site of investment in human potential for two reasons:

• The earlier the investment is made, the longer dividends will be paid out
• The earlier the investment is made, bearing in mind that advantage accrues advantage, the greater compound interest effects will be.

Childhood in society

Childhood has become the principle site of investment in human potential in modern societies because:

• With relatively little social autonomy, children have long presented a soft target for government
• Concentration of behavioural control of young people is consistent with culturally available notions of dependence, independence and maturity

Maturation and psychological development

Children are a particularly wise site of investment in human potential because:

• Children are especially open to positive and negative influences for reasons of developmental psychology
• Childhood is critical to social innovation for reasons of developmental psychology

References

Abatzogolou, J., DiMento, J., Doughman, P. and Nespor, S. (2007) Climate Change Effects: Global and local views. In: DiMento, J. and Doughman, P. Climate Change: What it means for us, our children and our grandchildren. Cambridge, MA., MIT Press.

Arthur, M.B., Inkson, K. and Pringle, J.K. (1999) The Boundary-less Career: A new employment principle for a new organizational era. New York, Oxford University Press.

Blackburn, R. (2006) Finance and the Fourth Dimension. New Left Review, 39, pp.39-70.

Borgman, C. (2005) Social Security Risk and Demographics. Berlin, Springer-Verlag.

Deffeyes, K. (2006) Hubbert’s Peak: The impending world oil shortage. Princeton, Princeton University Press.

DiMento, J. and Doughman, P. (2007) Climate Change: What it means for us, our children and our grandchildren. In: DiMento, J. and Doughman, P. Climate Change: What it means for us, our children and our grandchildren. Cambridge, MA., MIT Press.

Esping Andersen, G. ed. (2002) Why We Need a New Welfare State. Oxford, Oxford University Press.

Harvey, D. (1989) The Condition of Post-Modernity. Oxford, Blackwell.

Jones, K. (2003) Education in Britain: 1944 to the present. Cambridge, Polity Press.

Joseph Rowntree Foundation. Available from www.jrf.org.uk

Lee, N.M. (2001) Childhood and Society: Growing up in an age of uncertainty. Maidenhead. Open University Press.

Lee, N.M. (2005) Childhood and Human Value: Development, separation and separability. Maidenhead, Open University Press.

Levinson (2006) The Box: How the shipping container made the world smaller and the world economy bigger. Princeton, Princeton University Press.

Lister, R. (2006) Children (but not women) first: New Labour, child welfare and gender. Critical Social Policy, 26 (2), pp.315-335

Lloyd, J. and Turkeltaub, A. (2006) Financial Times. December 4^th

Matthew, R. (2007) Climate Change and Human Security. In: DiMento, J. and Doughman, P. Climate Change: What it means for us, our children and our grandchildren. Cambridge, MA., MIT Press.

National Evaluation of Sure Start. available from www.ness.bbk.ac.uk

Rose, N. (1989) Governing the Soul. London, Routledge.

p11 The world economy over the last decade involved

Levinson (2006) The Box: How the shipping container made the world smaller and the world economy bigger. Princeton, Princeton University Press.

This document has been commissioned as part of the UK Department for Children, Schools and Families’ Beyond Current Horizons project, led by Futurelab. The views expressed do not represent the policy of any Government or organisation.

Continuing mortality improvements at older ages

Mortality rates in the UK are declining at all ages and for both sexes, just as they are in the rest of the developed world. With every year that passes, there is an increase in the proportion of successive birth cohorts that reaches retirement age, and an increase in the likelihood of surviving to enjoy that retirement for several years. Declining mortality at older ages is one of the main drivers of the growth in the relative size of the older population. By 2025 one in five people in the UK population will be aged 65 years or more. By 2050 it will be almost one in four.

Since most deaths now occur in later life, it is the continuing improvement in late life mortality that is contributing most to increasing life expectancy at birth. Over the last 20 years in the UK, male life expectancy at birth has increased by 5.6 years, ie at an average rate of more than three months per year, with most of the gain accruing to men past the age of retirement. Four of those additional life years have been added to life expectancy at the age of 65. Death rates in older men have not only fallen sharply in this time – by almost one half in the 60-69 age group and one third in the 70-79 age group – and from relatively high levels, but the decline in death rates has actually been accelerating, which accounts for the more or less linear increase in life expectancy. The average annual rate of improvement between 2000 and 2005 was twice as high as it was in the late 1980s. Death rates among older women have followed a similar trend, though the gains have been not quite so large.

Is this pattern of accelerating mortality improvements apparent in the data for the oldest-old – the population aged, say, over 80 years – as well as for people in their 60s or 70s? For men aged 80 to 90 years, it seems that it is, but not for men in their 90s, or indeed for women in either the 80-89 age group or the 90-99 age group (Pensions Commission, 2005). However, contrary to the expectations of some analysts writing in the 1980s and 1990s, there is no sign yet of a stagnation in mortality gains among the oldest segment of the population, certainly not in the UK (or Japan or France), nor even of a slowdown in the rate of improvement. Clearly then, there is no evidence in these data for the view that life expectancy in affluent countries is approaching any kind of limit, let alone the limit of 85 years estimated by Fries (1980) and reaffirmed by Carnes and Olshansky (2007).

It is these recent trends in mortality that form the basis of current official forecasts for future life expectancy, and they have been sufficiently striking to prompt the Government Actuary’s Department (GAD) to change its assumptions about the trajectory of future mortality improvements. Where the 2000-based projections assumed that annual improvements in mortality rates would converge toward ½% at each age for both males and females by the year 2032, the latest forecasts reckon that annual rates of improvement will converge to 1% for most age groups, which is equivalent to the average annual rate of improvement for the 20^th century.

Earlier forecasts were further shaped by the assumption of an eventual slowdown in mortality improvements, which has now been dropped. Hence we find that forecasts of future life expectancy have been revised upwards both in the medium term and in the longer term. Over the next twenty years female life expectancy at age 65 is forecast to grow even more quickly than it has done over the last 20 years (3.4 yrs as against 2.6); and there will be only a slight dip in the rate of increase for men over the same period (3.6 years as against 4 years). Thereafter the projected trend in mortality improvements entails a marked slowdown (and convergence) in the rate of increase for both sexes. Between 2028 and 2048 life expectancy at age 65 years will increase by 1.8 years for men and 1.7 years for women.

Variations and inequalities in mortality risk

The gender gap in life expectancy is narrowing

The life expectancy of a 65 year old woman in the UK is now 19.7 years, almost 3 years longer than that of a 65 year old man. It is not surprising, then, that among the oldest age groups in the population (eg 85 years+) women outnumber men by more than two to one, nor that nine out of every ten centenarians in this country are female.

Over the course of the 20^th century, in common with most other developed countries, the gender gap in life expectancy in the UK first widened, and then in the 1970s and 1980s started to narrow (Gjonca et al, 2005). Mortality rates for men are falling faster than mortality rates for women. If these trends continue, which is what GAD expects, the ratio of men to women in the older population will of course increase, and this means that an increasing proportion of older women will have surviving husbands. Japan and Russia are notable exceptions to this pattern (ie the sex gap in life expectancy has increased over the last 20 years). In Japan, the widening gap appears against a background of improving life expectancy for both sexes whereas in the Russian Federation life expectancy has actually declined.

Social inequalities in life expectancy are widening

One of the most notable features of recent trends in mortality in affluent countries is that a pattern of international convergence in life expectancy overlays a pattern of widening within-country variation of age at death, much of which is thought to be explained by socioeconomic differences in mortality risk (Edwards and Tuljapurkar, 2005). In the UK, as in most of Europe (Mackenbach et al, 2003) and the US (Meara et al, 2008) over the last couple of decades, the increase in life expectancy has been accompanied by widening socio-economic inequalities in mortality . Although mortality rates have been decreasing at both ends of the social scale, they have been decreasing much more quickly in the upper socio-economic groups.

Here in the UK, data from the ONS Longitudinal Study show that, in the years between 1972-5 and 2002-5, the gap in life expectancy at age 65 between men in manual and non-manual occupations doubled from 1 to 2 years. The gap between men in the highest and lowest of the Registrar General’s occupational classes now stands at 4.2 years, with unskilled manual workers having more or less the same life expectancy at pensionable age (14 years) as professionals did in 1972-5 (ONS, 2006). The trends for women are the same.

A similar pattern is apparent in analyses of deaths in the British Regional Heart Study (Ramsay et al, 2007), as well as in many studies of trends in geographical inequalities in mortality. Although the risk of premature mortality (< 75 yrs) has declined everywhere in the UK over the last 25 years, the difference between the authorities with the highest and lowest probabilities of surviving beyond 75 has increased (Wells and Gordon 2008). A similar conclusion is reached by Leyland et al (2004), though he uses a lower threshold to define premature mortality (< 65 years). Between 1979 and 1998, premature mortality decreased by 36% in Great Britain as a whole. Over the same period inequalities in the risk of premature mortality increased not only between regions, but also within most regions of the country. The excess premature mortality associated with living, for example, in London increased from 14% to 19%.

Changes in cause-specific mortality

One common factor in analyses of trends in cause-specific mortality over the last half-century, not only in the UK, but in all of the developed world, is the contribution of declining mortality from cardiovascular/circulatory diseases to overall mortality decline. It has been estimated, for example, that reduced CVD mortality contributed more than 5 of the 8.8 years added to life expectancy at birth in the USA since the middle of the 20^th century (Cutler, 2004). In the USA, as in the UK, it is the decline in mortality from heart disease that has contributed most of the decline in CVD mortality – mainly because a much larger proportion of deaths were (and still are) caused by heart disease than by stroke.

In the UK, over the last ten years (1995-2005), the age-standardised mortality rate for CHD fell from 94 to 48 per 100,000; with death rates falling by about one half in both the 55-64 year age group and the 65-74 age group. If these trends were to continue, we could expect to see the end of premature mortality from CHD. Whether or not that will happen over the next few decades is unclear. A recent analysis of trends in CHD mortality in younger adults – they appear to be flattening out – suggests that increases in obesity may be starting to offset the decline in other risk factors among younger cohorts (O’Flaherty et al, 2008).

For the other main cause of death in the UK, cancer, the picture is quite different, and more complicated. Taken as a whole, age-standardised mortality from cancer changed very little in the second half of the 20^th century (Quinn et al, 2001), although more recently, mortality rates have declined substantially (10-15%) among both men and women (Westlake and Cooper, 2008). Cancer incidence, however, declined by only 1% between 1993 and 2004, and it actually increased among women (with breast cancer accounting for much of the increase). For men, the main source of the downward pressure on cancer mortality is the fall in mortality from lung cancer, and this is due to declining incidence. With breast cancer in women and prostate cancer in men, on the other hand, the drop in mortality has occurred in spite of increasing incidence.

Increasing healthy life expectancy

In the early 1970s it was feared that a combination of increasing longevity and the intractability of the major degenerative diseases of later life would lead to an expansion of morbidity (eg Gruenberg, 1977). If gains in life expectancy at older ages were being driven mainly by the increasing capabilities of medicine to postpone death in people with serious illness, then the average person should expect to spend more years living with a heavy burden of disease and disability. What is now clear is that age-related disease is not as intractable as was then supposed. There are established and effective strategies to reduce the risk of onset for many kinds of chronic disease as well as effective interventions to delay the progression of disease and minimise associated disability. There is also growing evidence that the onset of age-related ill health and disability is in fact being postponed to older ages across whole populations. What is being postponed, in other words, is the need for medical intervention to deal with the more serious problems of age-related disease and disability. At least this is what seems to be happening in some developed countries and for some forms of age-related disease and disability.

There are distinct questions to ask here. We can ask, for example, whether or not the number of years that we can expect to spend in a healthy (or active) state is increasing. We can also ask whether it is increasing as fast as life expectancy. Or is it increasing even faster, which would mean that there is a compression of the time spent in serious ill-health or disability at the end of life?

The evidence for ongoing improvements in healthy life expectancy in the UK (ie the first question) is now quite strong. Or at least this is the case for cardiovascular disease, which is, after all, not only the main cause of death in later life but also a major cause of late-life disability. Trend data for the age-specific incidence of disease (eg first coronary attacks or first strokes) confirm that the average age of onset is climbing up (Davies, 2007; Rothwell, 2004). Estimates of the relative contribution of medical care and changing levels of population risk factors to declining mortality from CHD tell the same story, though from a slightly different angle. The kind of evidence that can give us a more rounded picture of health status is, however, more equivocal. Data from the General Household Survey, for example, on self-perceived health suggest that we are keeping our health for longer (although it seems that increases in healthy life expectancy are not keeping pace with improving life expectancy). There is, on the other hand, quite a lot of evidence to suggest that the prevalence of chronic disease and related health problems is increasing in the older population, and this is not just because the older population is itself ageing. A recent analysis of the MRC CFAS dataset found that the prevalence of chronic disease is increasing in successive cohorts of the younger-old (65-69 years), though it is admittedly very difficult to be sure that most of this change cannot be explained by improved detection and earlier engagement with medical care (Jagger et al, 2007).

The evidence on trends in late-life disability is, if anything, even more problematic. Although there are some affluent countries which do show clear evidence of favourable trends in late-life disability (often in spite of an increasing prevalence of self-reported health problems and diseases), the UK is not one them (Lafortune et al, 2007). And since there is no firm evidence for increasing disability-free life expectancy in the UK, there can be no firm evidence to suggest that the functional status of the older population is improving enough to bring about a compression of disability.

Key uncertainties and potential discontinuities in longevity trends

Demographic uncertainty

Demographic forecasters make errors, not because their methods are inadequate to the task in hand, but rather because the future trajectory of mortality is inherently uncertain. We may be confident, and reasonably so, that mortality rates in the older population will continue to decline over the 20 years, but we cannot be so sure of the accuracy of our estimate for the average annual rate of improvement, that it will be 2%, for example, rather than 1.5% or 2.5%. GAD, which for many decades has persistently under-estimated mortality improvements in the older population, captures some of the uncertainty in forecasts of life expectancy through its use of variant projections. Since the likelihood of forecasting error increases with the length of the projection period, the gap between the high and low variant forecasts for life expectancy increases over the course of the century. In the 2006-based projections, there is a 2.6 year gap in 2025 between the upper and lower estimates for life expectancy at birth for men; by 2050 it opens up to 8 years (and for women it increases from 1.6 years to 6.3 years). Although the trend line for the principal projection lies of course between these limits, GAD’s current methodology gives us no mathematical handle on the probability that it will in fact fall within that range. All we can say is that it most probably will (and, of course, that the future is more likely to correspond to the principal projection than to either of the variants).

It seems very unlikely, for example, that life expectancy will start to decline after 2038, which is the boundary set by the low variant forecast (ie it assumes that life expectancy remains constant after that date). But it is not altogether inconceivable that it might start to fall some time between 2025 and 2050, and precisely this outcome has been assigned to a worst-case scenario for the obesity ‘epidemic’ in the USA (Olshanksy et al, 2005). Nor does it take much casting around to find other potential causes of such an outcome, such as a catastrophically bad influenza pandemic. As for the high variant forecast, this corresponds quite closely to a continuation of the more or less linear trend in improvements in life expectancy noted by Oeppen and Vaupel (2002) for a times series of data from so-called ‘best practice’ countries. If, however, we assumed that the trend in life expectancy projected for the UK for the next 20 years were to continue up to 2050 (ie an average annual increase of about 3 months per year), then life expectancy at birth in 2050 would exceed the high variant forecast. Once again this may be an unlikely outcome, but it is not altogether inconceivable.

Optimists and pessimists

We cannot be sure that future changes in mortality rates will be the same as those we have seen in the recent past, but unless we have any reason to think otherwise, our best bet is to assume that they will. This may be a good rule-of-thumb, but when it comes to deciding on its application to the future of human mortality in the 21^st century, it leaves some important basic issues unresolved. In particular, there is the question whether we have good reason to think that future changes in mortality rates will not be the same as those we have seen in the recent past. And this question may in turn be asked in various ways depending on which stretch of the recent past we are considering for extrapolation into the future. Do we have any reason to think that gains in life expectancy in the 21^st century will be less than those seen in the 20^th century? Do we have any reason to think that the pattern of gains in life expectancy seen in the UK over the last 20 years will not continue? More generally, we can ask whether we have any reason to think that the rate of mortality improvements at older ages is more likely to slow down than continue on its present trajectory. The kinds of answers that demographers and experts on human mortality give to these questions may be divided into four broad categories. At the extremes there are two scenarios which ‘foresee’ a fairly radical departure from recent trends, or at least they argue that such a discontinuity is much more likely than most demographic forecasters are inclined to suppose.

The pessimistic scenario assumes that the increasing prevalence of obesity in cohorts that are still relatively young or in middle age will have a very substantial impact on their mortality in later life, large enough in fact to reverse the long-term trend in life expectancy. We are to suppose that the full impact of obesity on mortality will turn out to be not very different from the impact of smoking on mortality. What distinguishes this particular pessimistic scenario from the risk of catastrophes that hit us, as it were, ‘out of the blue’, is the availability of evidence on current trends in obesity as well as estimates of the impact of obesity on mortality, which together enable a projection to be made. The basis for the scenario, in other words, is found in present trends. What makes it an especially pessimistic scenario (rather than a merely realistic assessment of the likely impact of obesity on life expectancy) is (i) the choice of the most pessimistic of the range of current estimates of the relative mortality risk associated with obesity and overweight, and (ii) a likely under-estimate of the effect of countervailing changes in lifestyle, especially the decline in smoking prevalence.

At the other extreme there is what we might call a super-optimistic scenario, which reckons on our ability to develop and apply the means of overcoming whatever limits the process of biological ageing puts to human longevity soon enough to have an impact on the evolution of human longevity in this century. Should this happen, then (so the argument goes) we should expect to see a rapid acceleration in gains in life expectancy, and there is no reason why the average age at death should not exceed the maximum observed human lifespan (approximately 125 years) before the end of the century. What makes this a super-optimistic scenario is that it offers us a reason to think that the future trends in mortality will depart quite radically from historical trends. The gains in mortality that would be required to achieve this scenario exceed anything that could be derived from the extrapolation of current trends.

Even among the majority of demographers who would reject these ‘extreme’ scenarios as highly unlikely, there remain important differences of opinion on the question whether life expectancy in affluent countries is approaching a limit; and if it is, whether this has any relevance for attempts to forecast the short- to medium-term future for mortality. For the sake of simplicity, and following Carnes and Olshansky (2007), they may be divided into realists, who argue that the rate of mortality improvements is more likely to slow down than continue on its present trajectory, and optimists, who forcefully reject the idea that we have any reason to suppose that this will happen in the foreseeable future.

The difference in practical terms between realists and optimists is large. Where Carnes and Olshansky think that combined life expectancy is unlikely to exceed 85 years, Oeppen and Vaupel (2002) puts it at 100 years by the end of the century. The key to this difference lies in differing assessments of the relevance of what is known about the ageing process to the assumptions that demographers make about the future of mortality. Carnes and Olshansky (2007) argue that humans, like other organisms, “are subject to the biological equivalent of a warranty period”. This is not to say that we cannot survive beyond our ‘warranty period’; the point is rather that the probability of death increases sharply the longer we survive beyond it. What the optimists dispute in this is not just the rate at which the probability of dying increases in later life, or the estimate of the ‘warranty period’ for humans, or indeed whether the idea of a warranty period is at all useful. The fundamental division of opinion turns on the question whether the constraints that biological ageing imposes on human longevity are going to become apparent in the mortality data soon enough at least to influence the assumptions of demographic forecasters.

Convergent or divergent trends in differential mortality risk?

Will social inequalities in life expectancy continue to increase?

Uncertainty about what is going to happen to social differentials in mortality risk is presumably at least as great as the uncertainty about overall trends in future mortality. If we suppose that there are practical limits to life expectancy which rich countries like the UK are fast approaching, then we would expect soon to see a slowdown in the rate of increase in the mean age at death and a compression of mortality around the mean (Fries 1980). In effect, most of the future increase in the mean would be achieved by a narrowing of social inequalities in mortality. It is assumed, on this view, that the benefits for life expectancy of good early life nutrition and healthy living have been more or less fully realised by a substantial minority of the population. Future cohorts in similar circumstances may still gain more in this way, but not much. There is, however, still a large gap to be closed between them and the rest.

The problem with this view, however, is that it is not supported by the evidence. To be sure, GAD forecasts a slowdown in the rate of increase in life expectancy between 2025 and 2050, and this may be accompanied by a compression of mortality (and a narrowing of social differentials). As we have already noted, however, current trends in social differentials provide no evidence for this. Quite the contrary. And this is despite a considerable effort on the part of government to do something about it. If we decided to follow, for this particular case, GAD’s standard approach to projection, we would presumably forecast a further widening of social inequalities in mortality. Given the determination of government to reverse this trend, the question we have to ask is this: how confident can we be that government efforts to narrow social inequalities in mortality will be successful before 2025 or 2050? Or should we suppose that they will be no more successful over the next 20 years than they have been over the last 10 or 15?

The future of the gender gap in life expectancy

The gender gap in life expectancy decreases by about 20% in GAD’s principal projection for 2050, and by more than a third in the high variant. Only in the low variant does it actually increase. If we take the high and low variants as the outer limits for likely outcomes, then the gender gap in life expectancy could be anywhere between 2.4 and 4.2 years by 2050. It is worth noting, moreover, that the continuing decrease seen in the principal projection happens in spite of an assumed convergence between male and female rates of mortality improvements: gains in female life expectancy will accelerate as gains for men will slow down (ie without this assumption the convergence would be much greater).

Since male-female life expectancy fails to converge only in the low variant forecast, it is perhaps worth asking how unlikely it is that we will have much greater gains in life expectancy than are forecast in this variant along with a lack of convergence in male and female life expectancy. The point has already been made that GAD’s methodology does not allow us to assign a number to the probability of this kind of outcome. However, as with Olshansky’s pessimistic scenario for the impact of obesity on future trends in life expectancy or Vaupel’s best-bet forecast of linear increases in high-performing countries, such an outcome does not seem so unlikely as to fall outside the limits of serious consideration (wherever they are).

Are we on the verge of an epidemic of frailty?

Just as there are optimists and pessimists about the future of mortality over the next few decades, so also are there optimists and pessimists about the likelihood of achieving a compression of morbidity (or disability) when life expectancy is continuing to increase by more than two months per year. Although current trends in old-age disability in the USA give grounds for optimism, here in the UK they look less favourable (Lafortune, 2007).

Even in the USA, however, it would be unwise for policy-makers to discount the risk of a slowdown in current rates of improvement in the prevalence of disability. Nor is it sufficient that disability rates continue to decline for there to be no expansion of disability (ie the amount of time that the average person spends in a disabled state at the end of life). If future increases in life expectancy outpace future increases in active (or disability-free) life expectancy, there will be an expansion of disability. The prospects for a compression of disability depend, therefore, not only on what happens to disability rates, but also on what happens to life expectancy. An increase in the prevalence of disability may look unlikely on current trends, but there is a risk, for example, that the effects of obesity will be sufficient to reverse them; and there is also the risk that gains in life expectancy at older ages exceed the current ‘best estimate’ of forecasters.

Useful as it is, however, to make this kind of broad distinction between a future compression of disability and a future expansion of disability, there are other possible scenarios for the evolution of the relationship between increasing life expectancy and increasing active life expectancy. It is possible, for example, that increases in active life expectancy will keep pace with increasing life expectancy, so that there will be neither a compression nor an expansion of disability.

It is also important to take proper account of the distinction between more and less severe states of ill-health and disability. If we suppose that current gains in life expectancy are strongly dependent on improvements in the secondary prevention of fatal chronic disease in later life, then although we should expect an expansion of morbidity, this will result from an expansion of the time spent with relatively mild and ‘manageable’ health problems, not from an expansion of time spent in a severely disabled or seriously ill condition.

The original prediction of an imminent compression of morbidity (Fries 1980) was based on the conjunction of two hypotheses: firstly, that the main driver of the current gains in life expectancy at older ages was an underlying improvement in health which has enabled people to remain free of potentially fatal chronic disease for longer; and secondly, that life expectancy was approaching its limit. As we have seen, there is no evidence yet of a slowdown in gains in life expectancy. Even, therefore, if the first hypothesis is right, there is no reason in theory to predict a compression of morbidity in the foreseeable future unless we also predict a slowdown in gains in life expectancy.

Suppose, then, as seems quite likely, that most of the current gains in life expectancy at older ages are due to a combination of improved secondary prevention of fatal chronic disease and underlying improvements in health. Can we be reasonably confident that if this is true, there will be no expansion of (severe) disability? According to Manton et al (1991), and the hypothesis that increasing life expectancy is in a state of ‘dynamic equilibrium’ with morbidity and disability in later life, we can. Not everyone, however, would agree. A good deal turns on the relationship between patterns of delayed onset and progression for different categories of chronic degenerative disease. If age-specific patterns of risk for the major fatal chronic diseases of later life (eg circulatory disease) are changing faster than the patterns of risk for severely disabling but non-fatal conditions, then the prospect of extended survival is likely to expose individuals to an increasing risk of disabling and age-related functional loss.

How longevity trends intersect with developments in

The drivers of mortality decline

“Gains in longevity are the result of a complex array of changes (standards of living, public health, personal hygiene, and medical care), with different factors playing major or minor roles in different time periods” (Wilmoth, 2000). Most analysts would accept that medicine made a relatively small contribution to declining mortality until the second half of the century, or perhaps even as late as the 1970s, after which it started to make a big difference (Bunker, 2001). It seems clear, for example, that the secondary prevention of heart disease through more effective medication and improved surgical techniques has had a substantial impact on the mortality of people with diagnosed heart disease (Jeune, 2007), and they are, after all, a large proportion of the older population. Whether or not medical interventions have contributed more to declining mortality over the last 20 years than social change or lifestyle change is not so clear. Certainly for heart disease there is an impressive body of analysis which argues that improvements in medical care account for less than half the decline in mortality in recent decades (Unal et al, 2004), though a rather different view of the impact of medical intervention emerges from some recent analyses of the contribution of pharmaceutical innovation to mortality decline (Lichtenberg, 2007).

What is at issue in these different estimates is the balance between the various components in the array of forces driving down mortality in the recent past, and even if we were to suppose this issue settled, we would still have to consider how this balance might change in the foreseeable future. There are two broad questions we might ask here. Firstly, how much life expectancy can we expect to gain in rich societies without the ever more intensive application of expensive medical interventions? Secondly, should we expect over the next few decades an increase in the life expectancy gains made as a result of the widespread application of biomedical innovation (and if so, how)?

Social change and changing lifestyles

The question of how much life expectancy we can expect to gain in rich societies without the intensive application of new medical technologies has been tackled in various ways. One approach involves an assessment of the impact of the increasing diffusion of what Carey (2003) calls ‘healthful living’ on mortality. Although Carey himself argues that social and lifestyle change probably has a rather small and diminishing contribution to make to future longevity gains, there are others who take quite a different view. The effects of the continuing recession of the 20^th century smoking epidemic may be the most obvious candidate for this kind of exercise, but there are of course other factors besides smoking which have a measurable impact on mortality risk. It has been estimated, for example, that a modest reduction in risk factor levels for CHD in the general population could reduce CHD deaths in the UK by nearly one half within a policy-relevant time frame (Kelly and Capewell, 2004). An alternative approach would be to estimate the effects on population life expectancy of the elimination or narrowing of social inequalities in mortality. What would happen, for example, to population life expectancy if standardised mortality ratios for the lowest income groups were the same as those for the highest (Manton et al, 1990)? More generally, we could assess the impact of narrowing the gap in life expectancy by eg 50% or 75%.

The role of smoking

Smoking is the single largest cause of preventable deaths in the UK (Davy, 2007), accounting for approximately one in six of all adult deaths in England in 1998-2002 (Health Development Agency, 2004). Since the gap in life expectancy at birth between the average non-smoker and the lifelong smoker is estimated at about 10 years (Doll et al, 2004), it not surprising that smoking should be widely regarded as the largest single determinant of the substantial variations in mortality that are found (i) between men and women (see eg Pampel, 2003), (ii) between different socioeconomic groups (see eg Law and Morris, 1998), and (iii) between different geographical areas (see eg Mackenbach et al, 2008). It is hard to exaggerate the importance attached by many demographers and epidemiologists to smoking behaviour in explaining changing patterns of mortality in the developed world in the second half of the 20^th century.

Smoking patterns that appear early in life of a cohort have very large effects on mortality several decades later. In many countries the spread of smoking in cohorts born at the beginning of the 20^th century acted as a substantial drag on the mortality declines that might have been expected from post-war improvements in living standards and health care (Janssen et al, 2007). As the smoking epidemic recedes, we should therefore similarly expect an acceleration of mortality declines in places where the proportion of smokers in cohorts reaching later life continues to fall. There are good reasons, therefore, to think that the continuing decline in smoking prevalence is likely to be one of the main drivers of gains in life expectancy in the developed world over the next 50 years.

Human and physiological capital

There are two other potentially important sources of continuing gains in life expectancy which are largely (but not entirely) independent of innovation in biomedical technology; firstly education, and secondly what economist Robert Fogel (2003) has called the accumulation of ‘physiological capital’.

The idea that improvements in the general level of education in society is a important driver of increasing life expectancy has its origins, partly in the well-established link between socioeconomic status and differential mortality risk, and partly in the idea that higher levels of education are associated with an increased ability to negotiate the challenges and hazards of modern life in a highly urbanised and technologically-oriented society (ie more ‘know-how’). What is gained from more education is not just a higher standard of living. Better educated individuals are more in control of their lives, which means inter alia that they are more in control of the various factors in the social and material environment which influence their own health status (Cutler et al, 2006).

The idea that the accumulation of ‘physiological capital’ early in life has large benefits for late-life health and mortality builds on the now familiar idea that nutrition in utero and in early childhood has a substantial and long-lasting impact on health via their influence on the formation of essential physical structures in the developing organism (Barker, 1995). As a result of improved nutrition in early life, more recent cohorts in the developed world are not only better able to resist infectious disease than their parents and grandparents, but also benefit from a delay in the onset of the chronic diseases that cause ill-health and death later in life. One of the key pieces of evidence to which Fogel appeals in developing these views is trend data on birth weights and adult heights. Essentially we are getting taller – which is a good marker for the improved development of internal organ systems – and there is, he thinks, a demonstrable link between adult height and mortality risk (see eg Langenberg et al, 2005). The fact there is no evidence of any deceleration in this particular trend, certainly in Europe, suggests furthermore that we should expect no weakening in the force of this source of mortality reductions (Fogel and Costa, 1997). At the very least, we might look forward to a narrowing of socioeconomic differences in adult height, and given the link between adult height and mortality risk, this would lead us to expect a narrowing of social inequalities in life expectancy.

Innovation in medicine and biotechnology

Most deaths in old age are caused by cancer, heart disease and stroke. Individualised interventions which aim to delay or halt the progression of these life-threatening diseases account for much of the medical care that is now provided in our society, and an enormous amount of research effort is devoted to developing more effective interventions. Innovations in new fields such as pharmacogenomics and nanotechnology clearly have the potential to provide some of the additional power that is needed to maintain current momentum in what Carey (2003) calls ‘disease prevention and cure’ as a driver of mortality improvements in later life. The magnitude of the gains in life expectancy that may be achieved by such developments should not be over-estimated, however. If we suppose that more effective treatment were to reduce cancer mortality as dramatically over the next two decades as mortality from heart disease has fallen over the last 20 years (ie by about 50%), this would add not much more than a couple of years to life expectancy at birth.

Can we expect to find therapeutic innovation anywhere other than in the development of technologies which offer the prospect of improvements in disease prevention and cure? Carey (2003) himself answers this question by identifying two quite distinct potential drivers of future improvements in mortality: regenerative medicine; and age-retardation. The implication of the distinction is that the development of these technologies would represent an important ’step-change’ in the capabilities of biomedicine to extend healthy lifespans. How likely is it that gains in life expectancy can be maintained on their current trajectory without such a step-change? Olshansky and Carnes (2007), for example, take the view that we should expect a slowdown in mortality improvements unless there is a radical breakthrough in our ability to control the process of biological ageing. They doubt whether Oeppen and Vaupel’s optimistic forecasts for the future of life expectancy in this century can be realised simply by the wider diffusion of healthy living and improved disease prevention and cure.

Since the aim of regenerative medicine is to develop therapies which will restore lost, damaged or ageing cells and tissues in the human body, it seems clear that it has the potential to make a significant contribution to future increases in life expectancy at older ages. As ever in such cases, it is important to distinguish between outputs that might reasonably be expected in the short term, and the more speculative long term promise. The hope that stem cell therapy might be used, for example, to repair damaged heart tissue or to ‘cure’ diabetes lies in the longer term future (DHHS, 2006).

‘Age-retardation’, as it is now generally understood, would represent a step farther even than the ability to repair ageing or damaged tissue and cells in various body systems. Effective age-retarding interventions would stand to regenerative medicine rather as prevention stands to cure. Where regenerative medicine aims to remedy age-related decline in cell and tissue function by repair or replacement, age-retarding interventions would aim to prevent or slow down the processes that underlie that age-related decline in function (President’s Commission on Bioethics, 2003). Once we assume that such interventions are feasible, there is no reason why life expectancy should not eventually exceed the current maximum observed lifespan, and it is this conclusion which has prompted discussion of their social and ethical implications.

Range of potential futures these trends might point to from present to 2025 and 2050.

Greater or smaller gains in life expectancy

What are the main scenarios for longevity apart from the range of trajectories for life expectancy that is bounded by the high and low variant forecasts made by GAD? If we follow Oeppen and Vaupel (2002) in thinking that it is feasible that there should be a more or less linear increase in life expectancy in best-practice countries for most of this century, then it is important to add this optimistic scenario to the range of possible futures for longevity. By the same token, though this does depend on contested assessments of the likely impact of the so-called obesity epidemic on mortality, it seems excessively complacent to discount altogether the risk of a pessimistic scenario in which life expectancy actually starts to fall as younger (and more obese) cohorts start reaching later life, say from 2030 onwards.

A rather different approach to the construction of possible futures for life expectancy in the UK was adopted by the Wanless review on the future of NHS spending (Wanless, 2002). The key variables in this case were (i) the public’s engagement with their own health (ii) the achievement of public health targets, and (iii) health service productivity. Solid progress in these respects would produce life expectancy gains in line with what was then GAD’s high variant forecast. Slow uptake would lead to gains in life expectancy that correspond to GAD’s principal forecast. The fully engaged scenario, however, is associated with mortality improvements beyond what is achieved even in the high variant forecast. The interest of this set of scenarios lies partly, therefore, in the fact that one of the projected outcomes falls outside the boundaries set by GAD’s high and low variants, and partly in the way that movements in mortality trends are connected with opportunities for policy action by government.

Variability in mortality risk

Quite distinct from the question of the magnitude of the gains in life expectancy that might be achieved between now and 2050 is the question of variability in mortality risk. What will happen to (i) the gender gap in life expectancy, and (ii) socioeconomic disparities in life expectancy?

In the GAD variant forecasts male-female life expectancy fails to converge only when life expectancy gains stagnate. In view of this fact, it would seem desirable at least to consider a scenario which combined moderate gains in life expectancy with an increase in the gender gap in life expectancy. In other words, life expectancy would continue to increase for both men and women, but there would no significant increase (or perhaps even a decrease) in the ratio of men to women in the oldest-old population.

The GAD variant forecasts have nothing to say about future trends in socioeconomic disparities in life expectancy. The present government target for reducing inequalities in life expectancy at birth runs to 2010 (a 10% reduction between 2003 and 2010 in the life expectancy gap between local authorities). Whether or not it is likely that our society will achieve proportionately ambitious targets for 2025 and 2050 is open to question. These are nonetheless the benchmark scenarios against which governments should presumably measure their long-term success in reducing socioeconomic disparities in life expectancy. The worst-case scenario is that the relative difference in mortality rates between high and low socioeconomic groups will continue to increase.

More or less disability and ill-health in later life

There are two ways of constructing scenarios for the future of disability and ill-health in the older population. If we want simply to clarify the range of possible outcomes for the interaction between changing life expectancy and changing active life expectancy, we should think in terms of the expansion or compression of disability and ill-health as worst- and best-case scenarios. The most commonly discussed intermediate scenario foresees some increase in the time spent with mild (and relatively manageable) health problems and a stable or decreasing amount of time spent in a severely disabled state.

The approach adopted by most projections for the future of disability and ill-health in the older population is different from this. The scenarios generated by these projections involve an estimate of the numbers of severely disabled or dependent older people in the population based on combinations of alternative trajectories for (i) trends in life expectancy and (ii) trends in age-specific prevalence rates for disability and dependency. This is the kind of approach taken by the PSSRU model for projecting future expenditure on long-term care (eg PSSRU, 2004), and the recent OECD projections on the future of old-age disability (Lafortune, 2007). We can ask, for example, what happens if age-specific prevalence rates:

• remain unchanged and life expectancy grows more quickly than GAD’s principal projection (this is the most common worst-case scenario)
• follow current trends (which generates a positive scenario if rates have been decreasing as they have done in the USA over the last 10 or 20 years)
• decrease in line with optimistic expectations about improving health (eg at an average rate of 1% per year).

A more sophisticated approach to generating the same kind of outcome is used in the scenarios prepared by Jagger et al (2006) for the Wanless review of social care. They outline three basic scenarios:

• a no change scenario which assumes that the age-specific prevalence of disabling chronic disease will remain unchanged. This is not to say that preventive efforts will be ineffective. They will be effective, but only enough to offset the negative impact of obesity on the health and functional status of cohorts that are now still relatively young.. The incidence of dependency will stay the same and mortality rates will decline in line with GAD principal projections.
• a poorer health scenario assumes that current trends in obesity will continue (which means an increase in prevalence of about 2% per annum). This problem will be compounded by the ageing of large ethnic minority populations, which will add to the prevalence of CHD and stroke. Preventive strategies will only partially offset these trends.
• an improving health scenario, which is not that different from the fully engaged scenario for life expectancy. There will be a decline in smoking prevalence and obesity as individuals take their own health more seriously. Health services will be responsive to demand with high rates of technology uptake for disease prevention and excellent rates of diffusion of treatment. Mortality will decline more quickly than in the GAD principal projection.

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Over the last 20 years the chances of a 65 year-old women reaching the age of 80 have improved from 61% to 71%. Although the odds for a 65 year old man are not so good, they are still better than evens (59%), and much better than they were 20 years ago (41%).

This is not true for all developing world. Some countries, such as the USA and Netherlands, have experienced relative stagnation in mortality improvement, especially among women (Mesle and Vallin).

In 1981, the gap in life expectancy at birth was 6 years. In 2006 it was 4.3 years, which is relatively low for a rich country at the beginning of the 21^st century.

The relative gap in death rates between upper and lower socio-economic groups has grown more in northern Europe (inc. the Nordic countries) than in the south.

Although analysis of mortality by ‘underlying cause’ suggests that stroke mortality in the UK has been declining more slowly than CHD mortality in recent years – indicative perhaps of a slowdown in the well-recognised long-term secular decline in stroke mortality – Goldacre et al (2008) have argued that a revision of these estimates may be in order (at least for the UK), since mortality based on underlying cause alone misses about one-quarter of all stroke-related deaths.

Combined life expectancy at birth would reach 100 years before the end of the century.

Though we should not underestimate the difficulties and disagreements involved in determining what the ‘present’ trajectory is.

This is not to say that the data on recent trends might not indicate that there has in fact been a compression of disability over, say, the last 20 years; and this trend may provide the basis for a ‘best-bet’ projection for the future.

When this argument was first developed, dementia was classified as a non-fatal degenerative disease. It now appears as a cause of death on death certificates. Although this change weakens the force of the distinction between fatal and non-fatal degenerative disease, the essential point remains the same.

This compares with the estimate of 6-7 years of life lost at age 40 for obese non-smokers in the Framingham cohort (Peeters et al, 2003)

Olshansky et al (1990) estimated that the elimination of mortality from cancer would add 3.2 years to life expectancy at birth in the USA.

Though presumably it might take quite some time to have this kind of population-wide effect.

This document has been commissioned as part of the UK Department for Children, Schools and Families’ Beyond Current Horizons project, led by Futurelab. The views expressed do not represent the policy of any Government or organisation.