“I am in a hurry,” says Conny Helder, a Dutch minister who juggles the portfolios of sport and care for the elderly. She is referring to the second half of her job. The number of Dutch people aged 75 and older is expected almost to double by 2040, to 2.5m. The proportion of Dutch gdp spent looking after the elderly is already among the highest in the world (see chart). Without big changes, it could double by 2050. The share of the workforce helping the sick and frail could rise from one-seventh to one-third, the government fears.
So, on July 4th, Ms Helder announced that the Netherlands would not carry on as before. In future, she said, old people will have to rely more on themselves and less on professional caregivers. Care in a nursing home, which costs the government one-fifth more than looking after people in their own houses, will be a last resort.
The Netherlands is hardly alone in worrying about the coming stress on its finances. In North America and much of Europe the oldest baby-boomers are pushing 80. They will “stretch every part of the system” in America, says Da Grabowski, a scholar at Harvard Medical School. Workers who take care of the elderly are ageing themselves. In the oecd, a club mainly of rich countries, their median age is 45, 18 months higher than that of all workers. Labour shortages, already a problem, are bound to get worse. To maintain the current ratio of care workers to people over 65 (which is one to 20), oecd countries would need to find 13.5m more care workers by 2040, a rise of 60%.
Few promises are harder for governments to keep than to proe good care to the next generation of the elderly. A survey in 2020 by the oecd found that the availability of affordable old-age care is among people’s biggest worries about the future. Pensioners already claim a big slice of governmental budgets, and the share will only rise as their numbers swell. Yet governments are loth to pay by taxing windfalls from higher property values that have largely benefited older voters. Many are also reluctant to increase immigration, which could help them cope with labour shortages.
Some are beginning to make changes. In February President Joe Biden proposed minimum staffing requirements and better enforcement of rules in America’s nursing homes. A bill in Congress would boost state funding for the provision of care to people in their own homes. California’s “master plan for ageing” calls for the creation of 1m “high-quality caregiving jobs”. In 2021 Britain raised payroll taxes in part to pay for care of the elderly. In April this year it enacted a law that is supposed to improve collaboration between medics and carers. After 20 years of discussion, in 2021 Slovenia adopted a law that introduces compulsory insurance to pay for long-term care.
One reason people worry about the future is that, in many places, things are already dismal. In 2018 some 800,000 Americans had been waiting an average of more than three years for state-funded help with care in people’s own homes. In England, before the pandemic, 1.6m people aged 65 or older were getting subpar care, estimates Age uk, a charity. Da, an 85-year-old retired railway worker who lives in “sheltered accommodation” in Luton, north of London, says the number of around-the-clock staff to take care of the 40-odd residents has fallen from three to one. “I get out of the room once a week, if I’m lucky,” he says.
In much of Europe and North America pay for carers is low and working conditions are sometimes terrible. That is bad for their charges, too. In Canada, where 69% of deaths early in the co-19 pandemic were in nursing homes, workers often lack adequate sick pay and work in more than one home, says Samir Sinha, a geriatrician in Toronto. That made them ideal vectors to spread the virus. “Conditions of work,” he says, “are conditions of care.”
The less governments spend, the more indiuals fill the gaps. In America 42m people take care of someone over 50, says Brendan Flinn of the AARP Public Policy Institute, which does research on issues that affect the elderly. The European Commission puts the value of informal care of elderly people and adults with disabilities at perhaps 2.5% of the European Union’s gdp. Such responsibilities impose hidden costs in the form of stress and lost hours of paid work. As families shrink and disperse and more women work, fewer informal carers may be willing to pay them.
Conditions are better in places with well-funded systems, such as the Netherlands and Denmark. But even they are beginning to suffer from staff shortages, and wondering how to maintain standards, as numbers surge. “There are simply not enough people to proe the same service ten to 15 years ahead,” says Morten Just, the head of health and care services in Faxe, a municipality near Copenhagen, Denmark’s capital.
Frederik Schut of the Erasmus School of Health Policy and Management, in Rotterdam, reckons the future will see a “kind of convergence”. The cheapskates will look to higher-spending nations for ideas on how to improve things. At the same time, generous countries like the Netherlands and Denmark will be forced to economise. That does not mean just cutbacks: some big-spending countries are innovating in ways that may allow them to do more with less. Some of these may even “change how society is structured”, says Ester Kuiper, a member of the board of KwadrantGroep, a Dutch care proer.
A venerable system
The Dutch are rethinking a care system that is the envy of other countries. Reforms in 2015 split care for the elderly into three strands. Municipalities pay for such services as cleaning and transport for people who do not require constant care. Mandatory private health insurance covers medical bills. The most enfeebled get help either at home or, more often, in nursing homes, which is paid for by a mix of payroll taxes, contributions from those being looked after and governments. The total cost is about €18bn a year, around 2% of gdp.
Even though spending per person has been rising, carers say they are stretched. A decade ago nurses would make beds or take out rubbish for their clients, recalls Ijda Arendz, a district nurse in Oudega, a village in Friesland. Now they only have time to proe medical care. Denmark has similar problems. Faxe has 20-30 vacancies for a workforce that is responsible for 1,200 people, says Mr Just. It plugs the gaps with temporary workers. Last summer some senior citizens had visits from 28 different people in a month.
Ms Helder’s plan to make the elderly more independent is a bet that the interests of the old and those of the state coincide. She wants to “make sure people feel more independent…so they still remain part of society and interact with other people”. Over the next 20 years the government hopes to reduce the proportion of people receiving long-term care who are in institutions from 80% to 50%.
The safest part of Ms Helder’s wager is that senior citizens share her view that prevention is better than cure. Before she joined the government, Ms Helder ran a commercial care proer. She talks up whizzy gadgets such as airbags embedded in belts, which cushion people’s falls. These, coupled with “smart floors”, which can detect whether people are prone to falling, can reduce the chances of a hip fracture by 70%. That could save both money and lives: between one-fifth and one-third of old people with such fractures die within a year.
She also talks of a trip to Denmark to learn about “reablement”—training elderly people discharged from hospital to resume normal activities themselves. This, she says, can reduce the need for professional help at home by 40%. Prevention and rehabilitation “will be the dominant focus in the next years”, says Karen Storgaard Larsen, director of social and health services in Aabenraa in southern Denmark. “Otherwise an already stressed system is going to collapse.” The European Commission reckons that investment in prevention could limit the rise in long-term care costs to 62% by 2070 compared with 2019, rather than 82%.
The shakier part of Ms Helder’s bet is her plan to use technology and non-professional carers as a substitute for paid human labour, for instance by offering calls with nurses. A sign of the new thinking is the founding in 2018 of the Academy for Patients and Informal Caregivers at Maastricht University Medical Centre+, a partnership between a hospital and a university. This is a pilot programme that seeks to keep hospital stays short and infrequent by training patients and their families to carry out simple tasks, such as putting in eye drops. It encourages patients to use technology, like apps that record the heart rate, weight and blood pressure of those with congestive heart failure; and to accustom them to coping with chronic conditions. All that, it is hoped, could reduce the number of nursing visits people require at home.
There are unanswered questions, admit the academy’s leaders, including whether it is ethical and legal to shift responsibilities to patients and caregivers, and whether its ideas really will help hospitals use resources more efficiently. “We are very keen to continue,” says Matthijs Bosveld, a medical and doctoral student who is evaluating the academy’s results, but “there’s a lot to be explored before we scale this up.”
Also up for discussion is the received wisdom, shared by many governments, that people’s homes are the best place to look after them. Perhaps it would sometimes be better for elderly people to cluster, making it easier to deliver services while encouraging them to help each other. The concept is a sort of hybrid between a nursing home and the more fashionable option of “ageing in place”.
An example can be found near the centre of picturesque Haarlem in the western Netherlands. Hof van Leijh, opened in 2020, has 172 flats and homes, most with subsidised rents. They are occupied by a mix of elderly folk and people with disabilities, all of whom accept a “social contract” to help each other out. A non-profit care proer, Zorgbalans, and two social-work outfits proe additional help.
Els van der Doe, 75, a lively former bookkeeper, is a walking advertisement for the concept. Alone in a big house after she was widowed, she was enticed to move by Hof van Leijh’s ethic of “reciprocity”. Now she says she’s busier than she was when she worked. She helps neighbours operate their computers; they walk her dog. She started a group, “Old But Not Dead”, which organises games of sjoelbak, a Dutch version of shuffleboard. She plays French horn in a wind band.
Helping each other means Hof van Leijh’s residents have less need for professional care, says Tamara Pieterse of Zorgbalans. Their proximity to one another makes it easier to proe such services when they are needed. Hof van Leijh also acts as a social hub for people who live nearby. And, points out Conny van Vollenhoven of Elan Wonen, the landlord, when people leave big houses to move in they help ease the country’s housing shortage. The government’s new policy calls for building or renovating 80,000 “clustered homes” by 2030.
Faxe in Denmark is adapting a model pioneered by Buurtzorg, a Dutch care proer that gives small teams of nurses freedom to decide how to take care of clients in their neighbourhood. Dorthe Hansen, a carer in the area, sees this as a way of restoring the personalised attention that has gradually been lost. The idea of clusters may catch on. Germany’s long-term care insurance finances new forms of collective housing.
Not everyone is a fan of the new Dutch policy. In place of the human touch, says Carin Gaemers, a historian who campaigns for better care of the elderly, it fobs people off with technology. Rather than making caring a more attractive career, she says the government has simply given up trying to solve staff shortages. Some critics contend that self-reliance among the elderly should take the form of paying more tax. Marcel Canoy of Vrije University says that a 10% tax on capital gains from property could cover much of the projected rise in the care bill.
Other countries will find in the Netherlands’ and Denmark’s efforts to future-proof their care systems reasons for both inspiration and dread. Mr Sinha, in Toronto, extols Denmark for its efforts to allow people to age in their own homes and to advise them on how to stay healthy. Denmark’s success in discharging patients from hospital could prove instructive in Canada and in England, where in February 2020 more than 5,000 people a day were “bed-blocking”, in part because local authorities could not proe care to them at home.
Doing nothing is not an option. The extra money Britain has set aside is not enough “to address the twin issues of wider unmet need and the workforce”, according to an analysis by the King’s Fund, a think-tank. In America there is concern that costs will “break the bank for a lot of states” if Medicaid continues to shoulder the burden, says Harvard’s Mr Grabowski. With the oldest boomers still in their 70s, care systems have a few years left to adapt. But they will have to hurry. ■