Introduction

At the secondary level of health promotion, the focus is on restoring health and alleviating symptoms. In this chapter the focus is on healthcare systems, which are understood as incorporating a wide range of treatment and support in response to illness. A number of ethical issues are raised in this discussion, including a revisiting of the discussion about the medicalisation of old age, which is discussed in relation to particular disorders associated with later life, as well as anti-ageing medicine. Population ageing has been regarded as a ‘driver of health system change’ because of the epidemiologic transition and because of concerns about the potential rises in the costs of healthcare. The response of health systems to the epidemiological transition is therefore also explored. This includes a discussion of the ways in which the management of chronic illness has shifted relations between health professionals and older people as patients.

Health services and health

The relative importance of health services to health is a matter of debate, and particularly contentious in relation to medical practice. The popular ‘McKeown thesis’ (McKeown 1976) was that improvements in health in the UK between the mid-19th and mid-20th centuries should be attributed to wider social and environmental change, rather than to health services per se. During the second half of the 20th century, however, developments in medical treatment for diseases such as coronary heart disease and breast cancer have had a significant impact on life expectancy and on quality of life in old age. The McKeown thesis therefore needs to be understood in its historical context, and the time is right for a re-evaluation of the contribution of medical practices to health (Davey-Smith et al 2000).

In the context of health in later life, the value of medical practices can be demonstrated by reference to the 60-year-old heart attack victim in the emergency room who was introduced in the previous chapter. Daniels et al (2000) argued that this man's need for treatment could have been circumvented had not a ‘lifetime accumulation of insults’ been inflicted on his body, and placed him in a position of dependency on the health services.