Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Rethinking ageing can help the NHS recover

BMJ 2023; 383 doi: (Published 28 November 2023) Cite this as: BMJ 2023;383:p2775
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on X/Twitter @scarlettmcnally

As a surgeon, I’m focused on the NHS’s huge waiting list for elective surgery and have written about how to improve it.1 But, given that only 13% of hospital bed days are used for elective surgery, this isn’t what’s depleting the NHS.2

I recently did seven different conference presentations in a week. The most effective was for a public event in Eastbourne about the health benefits of active travel, especially a slide of the chief medical officer’s new annual report3 showing places where over 25% of the population will be over 75 by 2043. We can’t afford the costs of our ageing population to healthcare, social care, and the economy unless we change our passive expectations of ageing.

In the NHS, 70% of bed days are used by people aged over 65.2 But hospital stays are damaging to older people’s future independence, as they can lose as much as 5% of their muscle strength a day.4 Data, stories, and images can be hugely powerful in understanding why change is needed and galvanising people into action. But for change to happen we need “how” as well as “why”: people need practicalities, and organisations need strategies.

Firstly, we need people across all communities and the media to champion healthy lifestyle changes, especially for older people. We’ve known for decades that the risk of developing dementia, frailty, and hip fractures can be reduced or even prevented by ensuring physical activity, maintaining social connections, avoiding smoking, and eating healthily.5 The chief medical officer emphasises that losing independence as we age isn’t inevitable, and previous CMO reports encouraged older people to break up their sedentary time and fit in stair climbing, sit-to-stand exercises, and walks.6 In 2017 I wrote that a focus on physical activity could reduce the need for social care and help people regain the fitness levels of someone 10 years younger.7

Secondly, we need more geriatricians, with teams to support them. Older people with multiple conditions and complexity need general care from all team members, as well as specific, personalised care planning. The British Geriatrics Society has highlighted the need for “optimisation of physical function and mobility for all, and a personalised multidomain intervention for those at high fall risk, including deprescribing.”8 This workforce shortage is fixable. There are competition ratios of over 2:1 for training posts in geriatrics and emergency medicine, meaning that over half of doctors who applied in 2022 were turned away.9 Training posts could be increased quickly by a few hundred, converting from locally employed doctor posts, and would be a cost effective investment. When geriatricians lead a “perioperative care for older people” service, this saves over £1100 a patient.10

Thirdly, we need to improve cross skilling across care pathways. NHS England’s recent report on intermediate care highlights the need to train some staff members in key skills to avoid waiting for an expert in each case and to empower each patient.11 Unfortunately, creating more autonomous practitioners who are not doctors can increase the number of tests ordered and encourage passivity in patients.12 We need teams led by senior clinicians where all staff can ensure that the “simple” things are done well and that critical decisions are made with the involvement of experts and patients.

Back to surgery: most major operations are in older people, most cancellations are due to a lack of hospital beds, and complications are at least four times as likely if someone is frail or inactive.1 Creating standalone surgical hubs to perform elective operations will work only for the people fit enough to go there. We need a multipronged approach such as that described by the Centre for Perioperative Care,1 including a population-wide fitness drive and surgical units co-located with hospitals’ expertise—otherwise, health inequalities will continue to worsen.

We need to redefine ageing, health, and activity to improve the NHS and reduce the need for social care. We can’t afford not to.


  • Scarlett McNally is an orthopaedic surgeon, deputy director of the Centre for Perioperative Care, and president of the Medical Women’s Federation.

  • Provenance and peer review: Commissioned, not externally peer reviewed.