Live Longer Better in England
 
The challenge
The challenge posed by population ageing was set out in the 2023 Annal Report of the Chief Medical Officer Sir Chris Whitty titled Health in an Ageing Society. The Live Longer Better system has been designed to meet the challenge he described so clearly
 
The number of people with what is called multimorbidity or complex needs is increasing in part due to population ageing in part due to greater use of diagnostic technology and changing thresholds for diagnosing conditions such as pre-diabetes or high cardiovascular risk. The numbers of people with three or more disorders rises significantly with age
 
Geriatric medicine supports people with the most complex needs but it is essential to improve services for people with fewer disorders and less disability because they also make heavy demands on the NHS. Although at lower risk of needing emergency care there are so many more of them that, following  the principles of the excellent London epidemiologist’ Professor Geoffrey Rose we need to shift the whole curve as well as dealing with those at highest risk
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The impact on individuals
People with ‘multi morbidity’ face a number of problems from the present structure of the NHS divided into primary and secondary care and the latter further divided into single condition specialties. The importance of this has been emphasised by the Chief Medical Officer in both a BMJ editorial and his 2023 Annual Report Ageing in a Healthy Society. This increases what has been called ‘the Burden of Treatment” interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments.  Factors that patients reported as increasing treatment burden included too many medications and appointments, barriers to accessing services, fragmented and poorly organized care, lack of continuity, and inadequate communication between health professionals.” Source:  Gallacher, K., May, CR., Montori, VM, Mair, FS.  (2011) Understanding Patients’ Experiences of Treatment Burden in Chronic Heart Failure Using Normalization Process Theory.  Annals of Family Medicine, 9 (p.235-43). In addition they may suffer from the effects of polypharmacy

What will not work
There is no point in introducing yet another reorganisation of the structure of health and social care or new market mechanisms. As Oliver Williamson, winner of the Nobel Prize for Economics in 2008, emphasised some problems are too complex for bureaucracies and markets and need complex adaptive systems. It is also clear that simply planning for more GPs, practice nurses as the way forward will not work by itself, as the recent BMJ article on the massive growth of one to one interventions in primary care makes clear Sacrificing patient care for prevention: distortion of the role of general practice BMJ  2025; 388 :e080811  (Published 21 January 2025)
 
Why a system is needed
Population ageing presents a complex challenge but ageing is only one factor affecting ability and independence.

There is no evidence that ageing can be influenced but there is strong evidence that the other three factors, loss of fitness, disease complicated by accelerated loss of fitness and social pressures can be modified to increase healthy life expectancy

 A system is a set of activities working to a common specification (Appendix 1)

The aims of the system are to:

• Increase healthy life expectancy
• Close the gap between the most and the least deprived
• Reduce the need for health and social care
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and the objectives of the system are to:  

• prevent and mitigate isolation
• increase physical ability and resilience and increase healthspan
• promote knowledge and understanding about living longer better among older people and the wider population to counteract the detrimental effects of ageism
• involve older people from all ethnic and cultural groups in the leadership and management of transformation
• create an environment in which people can fulfil their potential
• enable strengthening of purpose
• support carers better
• minimise and mitigate the effects of deprivation
• reduce the risk of and delay or prevent dementia
• prevent and minimise the effects of disease and multimorbidity
• optimise the use of resources
• enable both living well and dying well
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There are also a set of strategic objectives to:

• Promote research
• Make optimal use of resources
• Be accountable to the population served
• Lead a cultural revolution to change the negative ageist culture to one that is positive and celebrates healthy longevity

 
The system’s objectives are delivered by local population based networks
Well managed bureaucracies are of vital importance in delivering services efficiently and at high quality but these services are for linear or non-complex challenges, for example the delivery of the home care service or the delivery of the a replacement service.  Population ageing is a complex or non-linear challenge that requires a different organisational type – the network . This has been called the network century, in part facilitated by the internet but also as a result of an understanding that bureaucracies no matter how organised, regulated or inspected, are not the right type of organisation for complex challenges.  The award of the Nobel Prize for Economics to Oliver Williamson and Elinor Ostrom highlighted the need to move from the century of the bureaucracy to the century of the network and the system.
 
The principal aims of each network are to:

• deliver the objectives of the system and to
• provide the leadership required to change the culture
  
  

The network needs to bring together all the key organisations However this will vary from one population to another.  If for example there is a charity funded by local bequest that is influential and plays an important role, it will be involved in that particular population’s network.  The aim should be for large numbers of people, perhaps a thousand people per million population, to feel they are part of this network and they are part of the mission to help people live longer better by achieving the system objectives.  This would mean, for example, staff in every health centre, all the wardens of sheltered housing, care staff either helping people in their own homes or in care homes, people working in gyms, fitness and wellbeing centres and volunteers as well of course as more highly qualified professions.  It is very important to involve the department of Geratology, including rehabilitation teams, and specialists in Mental Health including psychologists so that their knowledge can contribute to the network. 

This means that there will be a core group of individuals, perhaps ten or fifteen who will each be spending a day or two a week working to develop the collaborative culture that is required and different patterns of service, coordination and delivery that result from variations in local history and geography.

It is helpful for one organisation to volunteer to take responsibility not for funding the network but for its organisation. This would mean that someone not necessarily a chief officer but, for example, a deputy director of public health or a Community Services manager would chair the meetings with the network core set of individuals and be responsible for managing the person called the reticulant.
 
It is useful to have a website, floating beside the bureaucratic websites and not seeking to give the appearance of being at a higher level.The website www.livelongerbetterinherts.co.uk is an example of a population using a website to ‘float  alongside’ the organisations which are members as described in a key source on network thinking , The Knowledge Creating Company,
 
“A business organisation should have a nonhierarchical, self-organizing structure  working in tandem with its hierarchical formal structure …the most appropriate name is the ‘hypertext’ organisation”
Ikujiro Nonaka and Hirotaka Takeuchi
The knowledge creating company
OUP 1995

Accountability for culture change
The network should play a leading role in changing culture in part by ensuring that a common language is used in part by delivering online learning to a thousand or more key people per million population to help them understand what is happening as people live longer and what agencies, professionals and volunteers can do to help people live longer better The plan is for all older people to receive this learning opportunity in a different style

Key nodes in the national network:

• AgeUK
• U3A
• Sport England
• UKActive
• Let’s Dance
• The National Academy of Social Prescribing
• Key Government Departments – DHSC, DWP, DCMS
• The British Society of Lifestyle Medicine
• The Football League and other national Sports organisation
• The Faculty of Public Health
• NASW
• NAPC  ​

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Appendix 1
Live Longer Better system criteria and standards

Objective	Structure Criteria	Process Criteria	Outcome Criteria
To increase physical ability and resilience and increase healthspan	Number of bikes & Number of Wizdishes in community housing Number of trainer sessions weekly Number of Generation Games classes	Mileage cycled Mileage walked % attending classes at least 80% of times	Timed get up and go data
To prevent and mitigate isolation	Number of people willing to act as voluntary drivers % of people online with ‘software’ that enables active group membership​ % of people over 60 , by decade able to set up a conference call % of people with a hearing problem who have been helped to adjust their phone % of churches and mosques with conference call services	Number of face to face and digital group meetings per week in people who are moderately or heavily dependent and who live alone % of people who have had a conference call event in the previous 24 hours or in previous week	Wellbeing measure
To increase physical ability and resilience and increase healthspan	Number of bikes & Number of Wizdishes in community housing Number of trainer sessions weekly Number of Generation Games classes	Mileage cycled Mileage walked % attending classes at least 80% of times	Timed get up and go data
To promote knowledge and understanding about living longer better among older people and the wider population to counteract the detrimental effects of ageism	Explicit commitment to a learning programme for defined groups of professionals and volunteers Number and % of people in each decade who are members of the library service % of library service members who can be contacted digitally	Numbers of each group who had completed the programme Number and % of members in each decade who are regular users of the library service	Ability to explain what happens as we live longer accurately % of the population in each decade who are alive but are no longer members
To involve older people from all ethnic and cultural groups in the leadership and management of transformation	Explicit identification of key sub groups defined by ethnicity or culture	Involvement in meetings	Results of interviews with representatives
To create an environment in which people can fulfil their potential	Explicit policy for housing and accommodation Investment in local authority home support services	Number of older households who had energy efficiency improved Number of people receiving home support visits Number of new housing units developed in year Number admitted to ‘care homes‘ in year	Number of admissions with hypothermia
To activate older people and enable strengthening of purpose	Explicit recognition of the importance of purpose in documents	Numbers of people 60 and above providing voluntary leadership in organisations	% of people able to provide and answer to the question “what are your top priorities your purpose in life?”
To support carers	Clear policy recognition of the importance of carers particularly women and the impact this might have on their income and pension contribution
To minimise and mitigate the effects of deprivation	Population analysis to show distribution of older people in most deprived wards Number of volunteers helping people claim benefits	Number of older people helped to make a claim	Total amount claimed £
To prevent and minimise the effects of disease and multimorbidity	Annual report on the number of people with multiple medication by age
To reduce the risk of and delay or prevent dementia	Number of people identified as having dementia in past year
To enable dying well as well as living well	Information about advance directives and sources of advice included in guidance for new members	Information about advance directives and sources of advice included in guidance for new members	Percentage of people dying in their preferred place in last three years