Intended for healthcare professionals

Editor's Choice

We need to separate “old” and “age”

BMJ 2013; 347 doi: (Published 14 November 2013) Cite this as: BMJ 2013;347:f6823
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

Gloomy predictions about the social and economic impact of an ageing population are part of our accepted world view. They are used to pour cold water on aspirations for universal healthcare and to justify raising the statutory retirement age. But have we got the predictions wrong? Is the future rosier than we have been led to believe?

Jeroen Spijker and John MacInnes think so. In their Analysis this week (doi:10.1136/bmj.f6598) they say that doomsday warnings of an ever growing elderly dependent population, with fewer and fewer people for them to depend on, are based on a flawed measure. The “old age dependency ratio” uses the statutory retirement age as a cut-off. It then divides adults into those above this age (dependent) and those below (the working population). By this measure, most countries are nursing a demographic timebomb, triggered in the past by increased birth rates and reduced infant mortality, and fuelled more recently by increased life expectancy.

But this measure doesn’t take account of improvements in older people’s economic, social, and physical circumstances. Rising life expectancy makes older people “younger,” healthier, and fitter, the authors say. In aggregate terms, compared with 100 years ago, the current population is older in terms of years lived but younger in terms of years left. They also point out that, because of unemployment, there are currently more dependants of working age than there are older people who do not work.

Their alternative measure uses “remaining life expectancy,” which they say is a better indicator of the onset of dependency. The “real elderly dependency ratio” tracks the proportion of people with a remaining life expectancy of 15 years or less and divides this by the number of people actually in employment.

Even a conservative projection, keeping unemployment stable, delivers a rather less depressing version of the future for almost all countries. (Japan is the exception because of its relatively low birth rates and immigration.)

Why does this matter? Predicting the future is a fool’s game. But policy makers have to base their decisions on something. If this view of the world is credible, and if it encourages or at least reduces the discouragement of those pushing for universal healthcare, I’m all for it.

Which brings me to the subject of older doctors. For those of you who are retired or planning to retire, how easy is it for you to continue in a part time medical or academic capacity if you would like to do so? Anecdotal reports reaching the BMJ suggest that this has never been easy and is getting harder. Requirements for reappraisal and other barriers are discouraging some from considering part time work after retirement, we are being told. Faced, as many countries are, with a shortage of doctors in key specialisms such as primary care and emergency medicine (, why are we not making it easier for older doctors to continue to contribute?

We know that some important clinical skills decline with age, especially those that depend on manual dexterity, but others don’t or may improve, such as diagnostic skills and clinical judgment ( Patients’ needs and safety must dictate what happens, but provided older doctors keep up to date, is there any reason not to do everything we can to hold on to them? Could we not do more to make use of 40 years’ investment in their training and development.

We’d like to hear from you on this. Should older doctors be encouraged to continue in some capacity? And if so, what are the barriers to continuing to work in medicine and teaching after retirement, and what should we be doing to lower them?


Cite this as: BMJ 2013;347:f6823


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