On the way to a Caring Community: Old people between Health and Social Care

On the way to a Caring Community: Old people between Health and Social Care Thomas Klie, Freiburg (D) Ladies and Gentlemen, Dear colleagues, Let me first thank you warmly for inviting me to this keynote lecture. It gives me the opportunity to thank for the experience I could gain two years ago during a study trip into the Emilia Romagna with colleagues from German ministries and students. The regional policy for older people, I got to know at that time, is in its structure an international scale model. The Emilia Romagna supplies a variety of professional offers in the field of Health Care. I was fortunate to experience a familiar and cooperative form of self-organization of old-aged people, such as the self-managed senior centres and the geriatric assessment service with comprehensive assessments. They are exemplary in many respects, at least for us in Germany, because they build intelligent bridges between Health Care and Social Care. The Emilia Romagna shows clearly how Care and Case Management can be implemented in work principles, which are focused on efficiency not only as a slogan, but in practice. Right here in the interconnections between cure and care, between Health Care and Social Care are, in my view, the major challenges of the coming decades in many European countries. Some words to my presentation: I would like to begin my lecture with a brief sketch of the challenges in supply and participation of frail old people. For this, I will cite some numbers from Germany. Then, I would like to give you a summary of the different answers related to the similar challenges that we outline in European countries, before explaining a scenario technique developed in Germany, in which different future developments are calculated and which shows clearly the need for action at the local level. In a fourth step, I would like to speak about the concept of welfare pluralism, before I discuss the concept of Caring Community that is related to the central question "Who cares?". Finally, my lecture will end with some basic anthropological modals for the gerontology. 1.) The gap between needs, opportunities and resources In all European countries the number of older people and consequently of the very old is increasing. This group of population is particularly affected by frailty, multimorbidity and dependence on care. Simultaneously the number of children is sinking in almost all European countries. In the medium term it will lead to reinforced participation rates on the labour market, especially of women, whose participation still varies. In this overview, the gap development becomes clear: The number of people depending on care, the so-called nursing potential, increases. The number of potentially available carers and partners will be reasonably stable, but it will significantly decline in the ratio of support need to support potential. There is a great challenge in this development. This gap will not only be closed by professionals and stationary institutions. In fact there is more need for new forms of Welfare Mix. 2.) European countries in comparison In comparing answers of social policy to the issue of "Who cares?" there are clear differences in Europe. In a typical Scandinavian country like Norway the welfare benefits are particularly pronounced. Here, we find the expectations of the government in terms of supply. In other countries, as for example Italy, the responsibility of families is much more 1

emphasized. Especially in Italy there is also an extremely high rate of immigrants in the care sector that shows: The limits of capacities of family care and the lack of welfare assurance at the national level lead to a high proportion of self-organized care in accepting precarious working conditions. The welfare-states in Europe react in different ways to the challenging question "Who cares?", but the development concerning the need on one hand and opportunities in good supply on the other hand is quite similar. 3.) Future Scenarios in issues of care We simulated in various locations in Germany so-called scenarios in which different courses of future developments can be calculated. Who cares? 25 2 Index Pflegebedürftigkeit Index-Werte 15 1 Scherenentwicklung 5 Index Pflegepotential Szenario 3 26 21 214 218 222 226 23 234 238 242 246 25 Begleitforschung zur Einführung des Pflegebudgets FIFAS In regard to our studies concerning demographic and social changes in care issues, we developed a model scenario, both for Germany as a whole and on a city/ municipality level. It allows us to generate possible future outcomes in terms of the demand in in-patient units on the one hand and home care services on the other hand. We distinguish between three basic assumptions, which are manifested in three possible future scenarios: 1) In the first scenario, we consider the demographic change and stabile conditions in terms of the attitude towards willingness and readiness to care. 2) In the second scenario, we presume a moderate social change, i.e. a decrease in readiness to care in large parts of the society. 3) In the third scenario, we reflect the influence of infrastructures supporting the readiness to care taking into account the employment law. A connection between the possibilities to reconcile care tasks with working life could clearly be identified, even in relating to rather modern households where certain attitudes towards care were expected. This connection in regard to the contribution of the families in care tasks is foreseeable. 2

Explaining all three scenarios would be beyond the scope of this lecture. However, I would like to explain with the help of a diagram, how differently the three scenarios would affect the development of nursing homes and home care services. Whereas in scenario 2, the demand of nursing homes reaches its peak in requiring 1.9 million nursing home beds in the year 25 (in contrary to 57 in year 22). A supporting infrastructure and changes in the employment law on the other hand would evoke an enormously decreased demand: Under these conditions, only 85, nursing home beds would be required. For the city of Kassel and its 2 inhabitants, the difference would effectively vary in 2 nursing home beds. Of course, these scenarios contain certain imponderables. As a matter of fact they rely on continuity in care-related legal framework and determining factors as well as the reliability of demographic anticipations. Nevertheless the scenarios clearly illustrate that there is not just one predetermining principle. Instead there are several interacting effects, possibly influenced by our interventions that will lead to a variety of conceivable situations in future. In our approach of welfare pluralism in social policy, the Welfare Mix, we assume that we have to achieve a combination of statutory benefits, care-related services provided by the market, support from the family and also the contribution of volunteers. The scenario model provides a useful basis to rethink conceptions of national social care services as well as to establish preconditions on different levels needed to implement the new Welfare Mix. After all, our research shows that today s 4-year-old remain, by all means, willing to take over responsibility for their ageing relatives but within their range of possibilities and not in the way care needing persons are being looked after at present time. The German long term care insurance would have been insolvent since 1999, if in 1994, when it was established, the government s anticipation would have been correct, that 5% of all home care cases would involve professional help. Fortunately, it turned out differently. Nonetheless the long term care insurance is likely to run into insolvency in the next years. In terms of the underlying financial presumptions, it is obvious that the German long term care insurance as well as concepts of other countries widely rely on, sociologically seen, premodern care patterns in which the contribution of the family is dominant. Even though these concepts are important steps within the framework of existing policies, they cannot be seen as sustainable in terms of the actual social and demographic changes. There will be completely new challenges in the next decades scrutinising traditional dogmas like, for instance, the principle of care in Germany. 4.) The importance of social networks In direct connection, the distinction between Health Care and Social Care gets relevant. Health Care or Cure refers to the medical-preventive, curative and palliative tasks in the attendance of frail old persons and their families. The geriatric and professional care measures are of high importance at a technical level. The focus of support services for people with care needs, especially with regard to the temporal resources, lies in the domestic sphere and in terms of organizing everyday life. The social network is also very important for a "patient" who is being cared for in his private household. The question whether a person lives in a rural or urban structured location plays an important role. The probability that the need for assistance and support can be "fulfilled" completely is extremely high, if the patient lives together with relatives in one household and in a rural structured area. And vice-versa: The probability that the need for assistance and support can be "fulfilled" satisfactorily is extremely low, if the patient lives alone and in a so-called precarious network situation (Blinkert / Klie 1999), i.e. if he lives in an urban structured area and there is no supporting social network in his close environment. In the first case, a "patient" gets on average about 84 hours of assistance time per week, in the second case just 9 hours per week (Blinkert / Klie, 28). 3

8 4 9 8 e r 7p k 6e r w 5e p 4rs u o 3h 2 1 5 4 28 36 15 9 u ns tab ly lab il e N et zw er k s tab il ur b an r eg io n r ur al region (Blinkert / Klie 28) Depending on care is first of all a social destiny. Professional nursing services are not able to compensate the "weakness" of social networks. 5.) Who cares? "Who cares?" is one of the key challenges of the coming decades in fact, not only with respect to old people, but also in relation to children and people with disabilities. This is of cultural relevance: We have to be prepared for a large number of frail old persons in our families, our neighbourhoods, our city and our countries and we will most likely also be affected and a part of it. We will have to include "times of care" in our life planning, but also in our lifestyle. This will also be valid for companies and employers who need to align more strongly on issues of reconciliation of work and care. This is also of economic relevance: A social state care system is needed, because the families will not able to take over completely all tasks of caring and working. The support and assistance can not only be paid by income and financial properties. But they will never be able to fund the "care tasks" just with welfare-state transfers. The care profession has to be more appealing and attractive. But at the same time they have to remain financially viable from a fiscal and an economic point of view. 6.) Welfare Mix In my view, the most stable socio-political approach to face challenges of demographic change in a creative way is the concept of welfare pluralism. On the analytical level it assumes that welfare is always based on different social sectors and produced by them. Each one of the four sectors family, market, state and third sector follows its own ratio, central values and principles for action. 4

The Welfare Mix is a common phenomenon, whether in parenting or in the care of the elderly. It appears in the European countries in varying degrees, depending on culture and social policies. It is also subjected to processes of change, for example the proportion of the sectors in welfare production. Many welfare states believed in the past, without really questioning it, that this mix works somehow. For the future we will have to create and form conditions for a modern Welfare Mix under the terms of demographic and social change in a different way. As we have seen in the scenarios, the following factors are prerequisites for a reconciliation policy: the maintenance of care and exhaustion of the willingness to take over care tasks of family members and partners. We can find reconciliation policy related to employment and child education on the agenda of most European countries. The reconciliation of employment and care has been pursued so far less consistent. The focus on market mechanisms is quite different in European countries, when it comes to development and expansion of care infrastructure. The over-emphasis on market aspects of care seems at least because of the experiences in Germany quite senseless, even though competitions can carry items to a diversification of services in terms of care. The third sector plays in responding to care needs a very different role: It takes over responsibility for institutions and services, in a way it is more connected to the market; in other cases it is confined more on social self-organization and volunteering in regard to care tasks. The governments in the European countries act quite differently: sometimes they dominate and are responsible for institutions and services; sometimes they are confined to financial transfers and quality assurance of institutions and services. In all European countries, I argue, the respective mixtures will have to be weighted in a new Welfare Mix. Neither supply expectations of the state, nor the delegation of care tasks to families nor the sole and predominant focus on the market will help to shape the future challenges in care. The biggest challenges in quantitative terms are to compensate the decline of informal care, especially of and for family members. The growth of single person households and the decline of the individual number of children are the key drivers that provoke a readjustment of the Welfare Mix. Not only the shortage of professionals, but the decline of family care capacities is the largest socio-political challenge for the issue of care. Intelligent, economic and efficient Welfare Mixes are in demand as well as an efficient interaction of Health and Social Care, as it appears in the Emilia Romagna. This calls for investments in the social architecture of a long life society, but also for investments in new and especially local forms of solidarity: intra-and intragenerational. 7.) The model of a Caring Community A stable model that is able to contribute to a cultural reorientation, is the Caring Community. In contrast to Community Care, which is about to organize and to provide care services at the local level, Caring Community stands for an approach that settles the local and civic responsibility for care tasks in the middle of the society. Caring Community does not only include the delegation of nursing tasks (in case of overburdened families), not only the call for a strong governance and a more effective quality control in the institutions, but also participation in the care tasks and the co-responsible shaping of care issues. The model is often connected with approaches of inclusion, when it comes to integrate people with disabilities into local neighbourhoods and communities. It will be one of the main requests in the future to be tolerant and helpful towards old-aged people depending on care and people with dementia and accompany them in their daily life as a neighbour, as a fellow citizen. This includes in urban as well as in rural areas the following aspects and cultural challenges for answering the question "Who cares?": to care for sustainable social networks which are available in time and socially even in case of need for assistance, to be helpful and tolerant towards neighbours and fellow citizens. The model of the Caring 5

Community is not necessarily compatible with developments of modern urban societies and with the trends to greater isolation and individualized lifestyles. We have to form an on-site culture of caring and concerning in our society, against these trends, for children, for people with disabilities and old-aged. In this cultural dimension lie the promises of participation. There is a need for workshops to deal with intergenerational relationships creatively. The approach of Caring Community does not relativize the importance of a state of the art geriatrics and care, but it embeds the professional attendance of elderly people in a cultural context based on the ability to care within the society. 8.) Four anthropological models In this case, the following four anthropological models, Andreas Kruse likes to use, can be supportive: a.) The model of independence. It requires of an old-aged person that he is committed to the preservation of his independence. It also requires that the government invests in prevention in the field of education, health and social affairs. b.) The model of self-responsibility. It prevents paternalistic assault against an old-aged person, and admits to a large extent, that he can be responsible for his life, for his decisions and his social networks. Here, the model of self-responsibility is superior to selfdetermination, because it emphasizes issues of lifestyle and value orientation. c.) The model of joint responsibility. It sees the old-aged person in his capacity for empathy, solidarity and active participation in his environment. Joint responsibility of life is closely connected with the commitment to others, tolerance and shaping of public affairs. This includes also the care issue. d.) The fourth model could be: acceptance of dependency. It considers that humanbeings are depending on others, and conveys the cultural appreciation of frail old people. Our concept of life and self-image do not fail, just because we accept that sometimes each one of us needs help of other people. The experience show existential aspects of life and the importance of human relationships. Accepting that individuals as well as a collective depend on human help is a kind of counter-proposal to an image of elderly that sees frail old person as a burden and denies any value of them. An ethically reflected gerontology, I am convinced, will always be committed to developing the productive forces of the old-aged. It will argue that we can understand aging processes and control them in a better way. It will also ensure that the lives of frail old persons can be dignified, so that each one can look, if not joyful, but calmly and confidently into the future. Well, that is the model of a Caring Community. I was fortunate to experience a lot of such a Caring Community in the Emilia Romagna, an intelligent mix of well-coordinated assistance, a "state of the art" geriatrics and a culture that is characterized by self-reliance of old-aged people, who strengthen the idea of community in old age, who make it powerful and vivid. 6