tools and policies
Control tools and policies are provided for specific
diseases in Chapter 5 and for specific health determinants in Chapter 10.
As far as control tools and policies in elderly are
concerned, it is important to consider that, partly due to the changes in
family structures, older people cannot rely as much as in the past upon the
traditional support given by their relatives. The most common living situations
of older people in the EU are: (i) living alone, not being able to rely upon
their relatives for help and care or financial assistance; (ii) living as a
couple in the community; (iii) living or staying in an institution. In Greece
and Italy, grandmothers play a very important role in looking after children
(European Commission, 2003).
Acute Geriatric Medicine. A large proportion of patients
attending general hospitals as medical emergencies is formed by elderly people.
Their needs are more complex than those of younger people - only one in six of
those over 75 has a single pathology - the other 84% have multiple illnesses
and/or rehabilitation needs. Older people are also most likely to suffer from
further iatrogenic illness including delirium, pressure sores and adverse drug
reactions if not treated appropriately (European Geriatric Medicine Society,
Nursing home care. There remains a need for the
development and implementation of assessment instruments to improve the quality
of care in nursing home care (European Geriatric Medicine Society, 2002).
Specialist care in the community. There is evidence of
effectiveness for a mixed specialist geriatric medicine and primary care
approach in both preventive and therapeutic care of older people.
Stroke Care. Five out of six of those
suffering from stroke are aged over 60 and this illness is often complicated in
later life by other pathologies and loss of function. Organised stroke care
represents a practical and realistic way to save lives, reduce disability,
lessen institutionalisation and reduce the length of acute hospital stay
(European Geriatric Medicine Society 2002).
Medication and associated problems. Problems associated
with the use of medications can be avoided by the systematic use of quality
indicators for drug use and better co-ordination among care providers. Surveys
of therapies and the inclusion of older people in clinical trials would also be
of benefit (European Healthy Ageing, 2007).
Retirement and pre-retirement. By increasing the
participation of older workers and the quality of their working lives using new
management concepts, it may be possible to keep a balance between personal
resources and work demand. It is also important that policy is developed to
ensure that age discrimination is not tolerated. A positive public health
policy for Europe would aim at preventing illness in the workplace, promote
healthy lifestyles and a supportive and stress-free transition from work to
retirement (European Healthy Ageing, 2007).
Social capital. The aim of health policy in this
regard should be to encourage the participation of older people in the
community and to increase educational and social activity group interventions
targeting older people to prevent loneliness and isolation. An emphasis on
providing opportunities for voluntary work by older volunteers could also help
to combat feelings of social isolation amongst older people (European Healthy
Ageing, 2007).About one-fifth of older people in developed countries currently
receive formal care, i.e. medical or social services. Only one-third of such
formal care is provided in institutions, while two-thirds is home-based. In
fact, in recent years, many developed countries have moved away from providing
care in institutions in favour of care that allows older people to remain in
the community, in their own homes, for as long as possible (WHO, 1999). Women
live to well over 80 in many developed countries, where the typical female
advantage in life expectancy over males ranges from five to eight years. As a
result, older elderly people in most parts of the world are mainly women.
Social isolation due to widowhood or divorce has adverse effects on health.
Playing a part in family life and being a member of a community or religious
organisation have beneficial effects on health, improve a person’s self worth
and enable older people to make a greater contribution to society (WHO, 1999).
Public polices which promote active citizenship within the EU as a whole, can
help improve social networks and reduce social isolation at community level.
These policies would have a positive effect on community life and the quality
of life of the more vulnerable members of that community, including the
elderly. Older people are both the receivers and the providers of care. As well
as caring for grandchildren and their own children, many older people care for
other family members, especially their spouses and sometimes their own and
often very old parents. In fact, many of the ‘young’ old provide care for the
very old. Such care is often provided out of affection, but also out of a sense
of obligation and with the expectation of reciprocity. The demands of providing
this sort of care may be stressful and sometimes detrimental to the caregiver’s
own health. Recognising caregiver stress and assisting the informal family
caregiver, who is most often a woman, should be an important policy objective
in the design of care giving strategies (WHO, 1999).
Care for the elderly. Social protection systems not only
provide cash benefits to replace earned income in the event of unemployment,
sickness, invalidity or retirement, or for people without sufficient resources.
They also enable people to obtain appropriate medical and long-term care
services, the costs of which often exceed the financial resources of a patient
and his or her family. A communication issued by the Commission in 1999 on ‘A
Concerted Strategy for Modernising Social Protection’ consequently identified
the ensuring of high quality and sustainable healthcare as one of the key
issues for closer cooperation among the Member States. This initiative was
endorsed by the Lisbon European Council of March 2000, which stressed that
social protection systems need to be reformed, inter alia in order to be able
to continue to provide quality health services. In June 2001, the Gothenburg
European Council, in its consideration of what is needed to meet the challenges
of an ageing society, asked the Council - in conformity with the open method of
co-ordination - to prepare an initial report for the Spring 2002 European
Council on orientations in the field of healthcare and care for the elderly.
This report was based on a Commission Communication of December 2001 which
examined the demographic, technological and financial trends that may represent
challenges to our future ability to maintain high levels of social protection
in this field. The Communication concluded that healthcare and long-term care
systems in the European Union face the challenge of ensuring at the same time
the three objectives of:
for all regardless of income or wealth;
high level of quality of care; and
sustainability of care systems.
These three broad goals were endorsed by the Council in an
initial orientation report on healthcare and care for the elderly during the
Barcelona European Council, which also stressed that all health systems in the
EU are based on the principles of solidarity, equity and universality.
The Barcelona European Council invited the Commission and
the Council to examine more thoroughly the questions of access, quality and
financial sustainability. For this purpose, a questionnaire was submitted to
the Member States. A joint report by the Commission and the Council on
supporting national strategies for the future of healthcare and care for the
elderly was adopted on 20 February 2003 (6528/03). The replies from Member
States confirm the usefulness of the three broad objectives of access, quality
and sustainability as a basis for looking at policies for healthcare and long-term
care for the elderly: All Member States are trying to find the best balance
between these goals: how to raise enough funding to secure adequate care for
all, with high quality?; how to provide more cost-effective services? The
Member States' replies show that seeking this balance poses a major challenge
for the overall management of systems. Thus, many national replies refer to the
need to ensure good decision making at the interface between their healthcare
and the emerging long-term care sectors and a better co-ordination of
healthcare provisions and long-term care services for the elderly. Achieving
the best balance also raises governance issues; there needs to be a balance
between the focus on quality, standards and cost control - often centrally driven
- and local management and delivery.
While it was not an explicit objective of the
questionnaire, some Member States' replies point to the large employment
challenges and opportunities in the care sector. The challenges include: how to
retain staff under sometimes rather difficult working conditions; how to
recruit and train new staff as demand increases over the next decades; and how
to develop the quality of work, by providing skill development and career
progression. There will clearly be opportunities to increase employment. The
health and social services sector is already a large employer with 9.7% of the
total employment in the European Union in 2014.
In relation to access, Member States express their
determination to maintain general and comprehensive access as a cornerstone of
their systems, even in the face of increasing costs, with several proposing to
further refine and improve their access mechanisms.
In the area of quality, the replies reveal that there is
scope for greater cooperation between Member States in the area of quality of
service delivery regarding both health and long-term care. This is particularly
true in the perspective of greater cross-border mobility of patients and
enlargement. The Community’s action programme in the field of public health,
which has come into force in January 2003, will be usefule for developing
quality assessment tools.
For what concerns financial sustainability, Member States
point to the challenge of ensuring that resources and in particular new technologies
can be deployed in the interest of efficiency and cost effectiveness and of
ensuring that health professionals and patients integrate cost considerations
into their decisions. A process of mutual learning and co-operative exchange
should be continued on the basis of the issues identified in the joint report.
Cooperation between Member States could concentrate on exchanging experiences
and best practices with regard to each of the three broad objectives.
Health Inequalities. As women live longer than
men, they are also more likely to become widowed. This trend is compounded by
the fact that most women marry men who are older than themselves. In fact, most
women can expect widowhood to be part of the later years of their adult life.
In some societies, social norms of widowhood impose restrictions that have
negative effects on the widow’s well-being. Inheritance rights, in particular,
are often not well established or non-existent in practice. While the vast
majority of older women in developed countries cope with adjustments to
widowhood, this remains one of the leading factors associated with poverty,
loneliness and isolation (WHO, 1999). Important inequalities in life expectancy
and overall health status are found within European countries. Certain ‘forgotten’
groups of older people are at a greater risk of ill-health compared to others.
These include older women, members of ethnic and cultural minorities, socially
isolated and older disabled people. As in other age groups, poverty and lower
socio-economic status increase the risk of ill health. Poor older people have a
30-65% higher risk of almost all chronic diseases than those in more privileged
social groups. Further research is needed to understand the particular barriers
in access, quality and outcomes of care that different vulnerable groups may
face as they age across Europe. A stronger evidence base may help inform policy
solutions. Targeted actions are needed to empower these groups and engage them
in their health and well-being. Equity of access to services is critical. It is
often said that ‘men die quicker but women are sicker’. Risk of mortality is
higher for most chronic conditions in older men; however, women present a much
greater risk of disability as they age, mostly due to the presence of multiple
conditions (co-morbidities). The gender difference in life expectancy is also
smaller when years lived with disability are taken into account. Older women
are also more likely to live alone than older men. In research, older women are
often neglected as an important subgroup. As patients, they may take on a
passive role. Many older women are carers and may devote their energies to
caring for relatives at the expense of their own health. Women typically do not
allow themselves time to convalesce in the same way as men. The healthcare
system has an important role to play in ensuring that the needs of older women
are addressed in policies and service provision (International Longevity
Education and health. In most countries, the
average education of older people is less than that of younger people.
Diversity in ageing will be influenced by these differences in education level,
and by subsequent income, social roles and expectations during the stages of a
person’s life. People of all ages with higher education levels tend to adopt
and maintain healthier lifestyles, and have better access to healthcare and
health information (WHO, 1999).
Information and Communications Technology (ICT). In June 2007, the
European Commission announced that it is going to invest more than €1bn on
research into new technologies that can improve the lives of older people, as
part of its ‘Ageing Well in the Information Society’ initiative. The plan is
accompanied by a joint public-private research programme dedicated to ‘ambient
assisted living’ with the intention of fostering the emergency regarding
innovative, ICT-based products, services and systems for Europe's ageing
population. It is believed that ICT will increasingly allow older people to
stay active and productive for a longer time; to continue to engage in society
with more accessible online services; and to enjoy a healthier and higher
quality of life for a longer time. At present, some 10 per cent of older people
use the internet, but severe vision, hearing or dexterity problems frustrate
many individuals' attempts to engage in the information society.
Special Policies. EU, UN and WHO
policies related to healthy ageing include:
EU ‘Lisbon process’ of strategic priorities to 2010 EU Treaty Article 152 on
health protection for all citizens EU policies, inter alia on age
discrimination and demographic change Health 21 – health for all in the 21st
century and the Strategy to prevent and control non-communicable diseases in
the WHO European region;
WHO Active Ageing Policy Framework; and
United Nations Madrid International Plan of Action on Ageing.
A particular model for the co-ordination of policy through
a process of policy exchanges and mutual learning was adopted in March 2000 at
the European Council in Lisbon. Known as the ‘Open Method of Coordination’
(OMC), the model has been used since 2006 in the area of long term care. The efficiency of the service will be evaluated in 2010, as the European Commission
intends to extend this voluntary tool to other social and health topics, such
as nutrition, alcohol and the achievement of the objectives of the health
strategy (EPHA, 2007).
It is clear that countries in the PROCARE study are
experiencing common pressures which are exposing similar structural
difficulties. What is also clear is that there is a search for solutions to overcome
these problems. While 'integration' forms an important part of the policy
rhetoric in all European countries part of the PROCARE programme, it remains
possible to identify a number of different approaches. Since the fragmentation
of delivery into competing health and social care organisations is one
characteristic of all the countries, it seems self-evident that structural
change - i.e. the creation of single agencies providing both health and social
care - is definitely one possible solution. Indeed, some commentators see the
creation of integrated care trusts as the way forward. However, given the time
and energy absorbed by these reforms, an alternative approach is to focus on
the activities of caring by encouraging the development of interprofessional
care teams. Both organisational restructuring and the integration of care
activities by interdisciplinary teams are a means to an end, namely the
development of integrated care. It is possible to recognise a third approach,
which focuses directly on the provision of seamless or continuous care. This
sort of person-centred approach is typified in the Skaevinge 24-hour health and
care scheme in Denmark. Therefore, once the conceptual and developmental issues
and the broad similarities across some European countries have been identified,
the next step is to examine the effects of integration projects in different
structural arrangements. This is achieved locally through audit and user
involvement and by independent research such as the PROCARE project. The next
phase of this project is to conduct an evaluation of innovative integrated
services in each partner country to identify best practice, and thus provide
useful insights for health and social care agencies grappling with the same
service challenges. (Billings et al, 2004)