The ageing of our societies is at the same time one of our greatest achievements and one of our biggest challenges. A longer lifespan is something few people would spurn and it opens up great opportunities in our personal, social and economic lives; yet in practice it is often accompanied by living with disease. Indeed, increasingly people – and the health systems that serve them – have to cope with more than one chronic disease at a time, a situation known as multimorbidity.

When the OECD was founded in 1961, health systems were gearing themselves up to deliver acute-care interventions. Sick people were to be cured in hospitals, then sent on their way again. Medical training was focused on hospitals; innovation was to develop new interventions; payment systems were centred around single episodes of care.

In order for the transformation of the health care system to be successful, all aspects of the health care system must evolve to meet the new challenges created by a changing burden of disease. This chapter focuses on five components of the health care system that have evolved continuously over the past 50 years and will continue to need to evolve if the health care system is going to be responsive to the current and future burden of disease. The five components of the health care system are: 1) biomedical and health services research, 2) health professions education, 3) financing of health care services, 4) delivery systems, and 5) quality metrics.

While all OECD countries are experiencing unprecedented demographic change, which has the potential to unravel health and social care systems, a negative outcome is not inevitable. This chapter presents some of the policies and measures that can be implemented to support and facilitate healthy and active ageing. These policies have the potential to mitigate the impact of demographic change on society as well as helping older people to continue to be active and productive citizens whether as workers, consumers, volunteers or care givers.

All OECD countries will face a growing population of older people with complex needs but despite this common challenge they have taken different approaches to financing services. The main thesis of this chapter is that we are at a crossroads in thinking about financing care for older people with multimorbidity and multiple needs. One path leads to detailed care plans, bundling payments, transferring risk and traditional market competition. The other path leads to whole system targets with minimum specification, pooled budgets and innovative market models. Demographic and epidemiological realities will force governments to chose and they need to think carefully about which direction to go.

The professional organisation of health provision no longer reflects the changing patient and population health needs caused by the growing number of complex illnesses. Health reforms in certain countries have tended to enforce co-ordination and remove some of the power from the health professions in order to respond to these changes. However, it may be better to rethink the nature and type of professionals and to initiate basic changes to their way of working...

Health care systems in developed countries face a series of sustained structural challenges over the next decade. The demographic and technological dimensions of these systemic pressures are well documented. A third structural pressure is the long-term fundamental shift of wealth creation away from developed nations toward the emerging economies...

This chapter provides an overview of the descriptive epidemiology of multimorbidity in terms of its prevalence and distribution within the population and its associations with mortality, functional status and quality of life, and health services use and healthcare quality and safety. The analysis draws on both the published literature and on data about the prevalence of 40 long term conditions from 1.75 million primary care patients in Scotland. The implications for health service organisation and the measurement of health system performance for people with multimorbidity are discussed.