The Netherlands Scientific Council for Government Policy (WRR) recently put a magnifying glass on elderly care in four countries: Japan, England, Germany and Denmark. One of the researchers is Tineke Abma, professor of Participation of Older People at the Leiden Medical University Centre and Executive-Director of Leyden Academy on Vitality and Ageing. What lessons can be learned from this research?
Why research in these four countries?
Tineke Abma: “These are countries with a similar demographic structure as in the Netherlands: an increasing group of older people and a shrinking younger working population that can take care of older people. In addition, these are countries that differ in the way in which they have organized healthcare. England is market oriented. Denmark is an egalitarian society where mainly local governments direct long-term care. Germany has a hybrid model just like us. Here, both the government as well as the market determine care, and the civil society plays an important role. Japan is interesting because it is a ‘super-aged society’ like no other country. No fewer than 86,000 people of 100 years and older live there. The respect with which older people are traditionally treated also makes that country interesting.”
Three dimensions of sustainability
The issues facing us as an ageing society in the field of elderly care are complex and difficult to solve, Abma emphasizes. One of the most important conclusions that she and her fellow researchers draw is: when you develop policy, you have to keep an eye on the balance between three dimensions that play a role. These concern:
- Financial sustainability: will healthcare remain affordable for society and for individual citizens?
- Personnel sustainability and quality of care: is there sufficient care personnel, and is the staff qualified to take care of the well-being of older people?
- Societal sustainability: is there support and trust for health care policy?
Abma: “There should not be one of those three dimensions dominating the policy for long-term care. Then things can go wrong, as in England where the financial dimension has come to dominate. This leads to a disbalance compared to the other countries. In England there is no broad societal support for the long-term care policy, on the contrary we saw a lot of social outrage and discontent regarding the long-term care policy. For regular and acute healthcare, the English people are insured through taxes and the National Health Service. That is well arranged. But long-term and social care, has for a large part being been privatized. People have to take out additional insurance for this, but a majority of the population doesn’t know that. This leads to a situation wherein older people out of necessity stay longer at home to save costs, resulting in a situation where they do not receive the care needed, or end up in hospital when a crisis occurs. Another consequence is that if they have to be admitted to a nursing home, many of them have to sell their house. Kings Fund College referred to the situation as ‘The road to nowhere,’ because the problem has been known for more over than thirty years. Politicians have promised to resolve the issue but nothing has happened yet..”
England is therefore not a shining example for the Netherlands. Denmark is, says Abma. This brings her to a second important conclusion: the importance of developing a global long-term vision for long-term care for the older population. “Denmark has had a law since 1891 stipulating that care is provided locally in the community. Community care is grounded in the notion of ‘ageing in place’, and community care includes physical care as well as prevention, domestic care and social care. This long-term vision ensures stability and societal sustainability, because for over a decade Denmark followed the principles of community care. New policies are always in line with the underlying vision of ageing in place, such as the home visits and reablement program, and therefore recognizable for the general population. Moreover, the values on which the community care policy is based are in line with the values of the egalitarian and democratic culture of the Danish country. One of their remarkable features for working women is the good childcare and professional support for the older population which is provided. Informal care is therefore kept to the minimum.”
Abma disapproves of the situation in the Netherlands, compared to the Scandinavian country. She recalls the great transition of 2015. The Exceptional Medical Expenses Act (AWBZ) disappeared from one moment to another, without a careful and proper preparation and information and communication to the general population. The Long-term Care Act came into being, as well as the Health Insurance Act and the Social Support Act. Abma: “It was a shame, of course, to phase out all those nursing and care homes, without at the same time investing in care and support in the local community. That is happening now, but we are very late with that. The challenge we face right now is how to facilitate the local collaboration between healthcare providers and social care and support services in order to attend well to the needs of the older population.”
“It is therefore extremely important to invest massively in local care and support networks to foster ageing in place. This should be in joint collaboration with the local communities, mobilizing their sources of resilience. Also, we should acknowledge that healthcare alone cannot resolve the challenges we face. This is a societal issue, and we need everyone in our society to develop a sustainable future, such as social workers, housing corporations, and all kinds of services older people need in order to thrive.” Abma also emphasizes the importance of unexpected coalitions in this regard, for example the collaboration between care, welfare and business companies. “The local supermarket for example can be of importance by keeping an eye on older people and jointly building up local communities. One may also think of social designers and artists who want to contribute and develop a sense of belonging in a community.”
Men and cars
The point is that our society is not designed for older people, according to the professor. “It is mainly geared to dynamic, young and fit people, and productive work. Just look at the infrastructure. It’s based on the husband taking the car going to work. Why are the sidewalks so narrow everywhere? That is residual space in this view. While wide sidewalks are important for older people, but also for children and people with disabilities. Everyone thrives in an inclusive age-friendly society.” Looking through the lens of age-friendliness may help to re-envision our society as a place for human flourishing.
Step by step
The future of care for the older population and of policy making is a complex and wicked issue, as Abma stated earlier. It is wicked, because many stakeholders are involved, with different interests and visions; the multiple dimensions, including ethical, political, economic and cultural dimensions; the entanglement with other issues like the emancipation of women, economic crises, political destabilization, migration; and because much is uncertain, hard to predict and out of control. That is not to say that it should paralyze us; that we no longer know where to start. In a complex society like ours we should not want to make master plans as if everything can be predicted and controlled. Such a strategy simply does not fit the nature of our postmodern situation. This does not mean that we can do nothing at all, or follow a laissez faire strategy. “It is much more wise and sensible to give up the high ambitions and notions of full control, and start with relatively small actions, with small wins. Starting by building relationships of trust with community partners, mobilizing their sources of strengths, and by learning-by-doing, building in feedback loops. In this way we learn step by step how we can shape an inclusive society.”
The point is that our society is also similar to the one in England where the emphasis is on the individual, Abma adds. “We still think too much in terms of: ‘there is an individual client who has a problem, a solution has to be found.’ It is much wiser to learn to think in terms of relationships, networks and communities, and to stimulate social cohesion. There are so many sources of resilience in the community, and people who are willing to contribute to society, just because it makes them feel being meaningful.”
The Dutch version of this interview was published in the magazine ‘MOVISIES’ in March 2022.