9.4.5. Control 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, 2002).

 

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:

 

·          access for all regardless of income or wealth;

·          a high level of quality of care; and

·          financial 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 Centre, 2006).

 

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:

·          The 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;

·          The WHO Active Ageing Policy Framework; and

·          The 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)