Elder Care in the Priorities Discussion

Abstract

In most industrialized countries, the needs and demands for medical care and social services for elderly people are increasing, due both to demographic factors and to advances in technology. The number and the proportion of elderly persons are increasing, especially persons over eighty years of age. Since the oldest groups have the greatest need for services, this development is creating a challenge for welfare states. Coupled with this are technological developments that open new possibilities for treating disease and alleviating symptoms, both to extend life and to improve the quality of life. Some experts contend that increased costs of care are less a result of the increasing number of older people than of increasing costs per capita.[1] At the same time, many countries are experiencing a worsening economic situation in the public sector. This may lead to increased tensions among the different levels of the public sector (that is, national, regional, and local) as well as among different service areas, such as medical care, social services, education, etc. How can the dual challenges of providing needed care and containing costs best be met? One strategy is to use resources more efficiently. Resources can be rationalized through reorganization, improved efficiency within organizations, and better coordination among organizations. In the 1980s many countries, such as Sweden,[2] saw just such an enhancement of efficiency. But now that much of the slack in the system has been drawn in, it is doubtful whether there are substantial savings still to be made. We might look to technology to save the day. Advances in technology have enabled us to perform some procedures more quickly, more safely, and with fewer resources. Yet we cannot expect any simple or inexpensive cures for cancer, arthritis, stroke, heart disease, or Alzheimer disease, at least not in the coming decade. On the contrary, patients with these conditions often survive, but with a need for labor-intensive services. And as ambitions and expectations in medical care have been raised, even very old persons now receive treatment that was not given previously.[3] Yet there is much room for development of technology in home care, in the form of housing adaptations and other devices, both to increase the autonomy of elderly persons and to improve the working conditions of caregivers.[4] Although much can be done to improve the quality of life--and some adaptations and devices may even be able to postpone the need for care services--it is unlikely that developments in this area will substantially decrease the amount of service needed. Limitations in the primary activities of daily living--eating, washing, dressing--demand personalized, hands-on service. Changes in the social welfare system can also address the challenges of providing care to the elderly. Indeed, the 1990s have been characterized by the search for alternative ways to organize the care for elderly people, including changing the entire system. As John Baldock and Adelbert Evers have noted, Throughout Europe, there has been a movement from unicentric welfare systems dominated by state provision to more mixed forms in which state provision is explicitly integrated and balanced with private and informal sources. This shift involves alterations in the dominant ideologies of welfare in which traditional social rationales are expanded to include economic and market criteria.[5] The Swedish government, for example, wants to stimulate private initiatives and encourage competition to improve the quality of services, both between private and public providers and among the public providers themselves. This strategy carries certain risks, however, such as duplication of services and concentration on common problems, leaving the individual with unusual or complex needs without help. …