SPECIAL ARTICLE
Policy implication and the way forward
WM Chan FHKAM(Community Medicine)
Elderly Health Service, Department of Health, Hong Kong
Correspondence to: Dr Wai Man Chan, Elderly Health Service, Department of Health, Hong Kong. E-mail: [email protected]
ABSTRACT
Care for the elderly was one of the 3 main policy objectives of the Hong Kong Special Administrative Region in 1997. Many policy initiatives have been introduced in terms of financial support, better housing, and long-term care services. For active ageing, an innovative project known as the ‘Elder Academy’ aimed at promoting intergenerational cohesion, which is now under threat owing to changing social patterns. With the rapid increase in the number of ‘old-olds’, more resources on dementia care, community support, professional staff development, carer training, and coordination of care are necessary. In terms of financing, shared responsibility is the only viable option. In the 2012-13 budget speech, a pilot for community care service voucher as a means of promoting ageing at home was announced. As the coming cohorts of elders are more affluent and knowledgeable, they tend to be healthier and have different demands and expectations, such as independent living with better quality of life. The private sector may explore the markets of community care services and elder-oriented products. To meet the emerging needs, a holistic approach should be adopted, with modifications of the labour laws to make use of the talents of elders and to provide more flexible work arrangements for family members to care for elders.
Key word: Health services for the aged
for the elderly is the responsibility of every family, the Chief Executive affirmed the government’s commitment and support to help improve the quality of life of elders by providing them with a sense of security (老有所養), a sense of belonging (老有所屬), and a feeling of health and worthiness (老有所為). The Elderly Commission, comprising professionals, academics, and service providers, was established to provide advice to the government on policies and services for elders.5 Policy initiatives have
been introduced in terms of financial support, housing, long-term care (residential care, home, and community care), and active and healthy ageing.
Regarding financial support, the ‘three pillar approach’ recommended by the World Bank for old age financial protection was adopted. This comprises (1) a privately managed mandatory provident fund, (2) private savings, investment, and annuities, and (3) a social safety net. As the mandatory provident fund was just implemented in 2000, the pillars are not yet balanced, and the current cohorts of elders rely heavily on their own savings and family support, and/or on the Comprehensive Social Security Assistance (CSSA), which is received by about 15% of elders aged >60 years. There is also an Old Age Allowance, which is subject to income and asset declaration for those aged 65 to 69 years and non-means-tested for those aged >70 years. For those not on CSSA, there are also non-means-tested allowances for those with severe disability, which is common in old age.
AN UNFORESEEN SITUATION
“Population ageing is first and foremost a success story for public health policies as well as social and economic development.”1 Population ageing is attributable to the
reduction in fertility worldwide and to the lengthening of life through advances in medical care and disease prevention. Many people may view elders as burdens to society owing to their decreased economic productivity and higher need for medical and personal care. Population ageing is inevitable as fertility continues to decline and life expectancy continues to increase.
In 2010, the life expectancy of men in Hong Kong was the longest in the world at 80.2 years, whereas that of women was second to Japan at 86.4 years.2 The local birth
rate remained very low, and the proportion of elders in the community will increase rapidly. Elders aged ≥65 years constituted 13% of the population in 2010; this is projected to increase to 16% in 2016 and 26% in 2031. The age group of 85+ years is the fastest growing: from 118 800 in 2010 to 168 900 in 2016 and to 244 400 in 2030, representing an increase of 42% and 105% compared with 2010 figures.3,4
POLICY ON CARE FOR THE ELDERLY
Care for the elderly was one of the 3 main policy objectives of the Hong Kong Special Administrative Region in 1997. Apart from emphasising the traditional value that caring
Regarding housing, about 57% of elders aged ≥60 years live in subsidised public housing estates. Applications from families with elderly members have priority for allocation of housing units. This facilitates family support for elders and ‘ageing in place’. Under the Senior Citizen Residences Scheme, the Hong Kong Housing Society provides purpose-built flats with integrated residential care, recreational and healthcare service facilities for elders in the middle income group on a lease-for-life basis.
Regarding long-term care, comprehensive, client-centred services are provided, with appropriate support for family carers. These services include residential care, day care, respite and community care services. About 5% of elders aged ≥60 years reside in institutions.6 Community
care services include integrated home care, which provides assistance in personal care and household chores. Since 2001, enhanced community care services have provided tailor-made packages for frail elders being cared for in their own homes to reduce institutionalisation. The Integrated Discharge Support Trial Programme for Elderly Patients uses a multi-disciplinary approach to provide holistic care for elderly patients discharged from hospitals so as to help reduce unplanned hospital re-admissions and premature or unnecessary institutionalisation.7
HEALTH CARE AND ACTIVE AGEING INITIATIVES
Most Hong Kong elders enjoy good health and independent living in the community. Although 70% of elders have chronic diseases and 41% have visited a doctor within the past 60 days, 93% do not have impairment in their daily activities. Most of these elders make use of the affordable comprehensive medical care provided by the Hospital Authority, where elders constitute the major users, both for in-patients and out-patients.6
To enhance primary care for elders, the Elderly Health Service was established in 1998 in the Department of Health. Elderly Health Centres provide comprehensive primary care services using a family medicine approach with multi-disciplinary input from dietitians, clinical psychologists, physiotherapists, and occupational therapists. Visiting health teams provide health education and training programmes to the elderly and their carers. Health promotion activities are carried out using a multi-media approach including television, radio, press, leaflets, videos, and books.
In 2009, the Elderly Healthcare Voucher Scheme was introduced to enhance primary healthcare services for elders. This provides five HK$50 healthcare vouchers a year to elders aged ≥70 years to subsidise their use of private primary care services provided by doctors, dentists, chiropractors, registered and enrolled nurses, physiotherapists, occupational therapists, radiographers,
or medical laboratory technologists. In 2011, the pilot was extended for 3 more years and the number of vouchers was doubled to 10 per year.
ACTIVE AND HEALTHY AGEING
In 2001, the Elderly Commission launched the Healthy Ageing Campaign focusing on both physical and psycho-social health and adopting 4 strategic directions to promote personal responsibility, strengthen community action, create a supportive environment, and improve the image of ageing.8
In 2003, the focus changed from healthy ageing to active ageing. According to the World Health Organization, active ageing is defined as the process of optimising opportunities for health, participation, and security as people age. Health is not just the end, but the means as well.
The elderly centres subsidised by the Social Welfare Department were re-engineered to take up a larger role in health promotion and carer support in addition to conventional community support services. The Elderly Commission formulated new strategies to promote self-efficacy through lifelong learning and community support at the neighbourhood level. In 2007, the school-based Elder Academy Scheme collaborated primary, secondary, and tertiary schools with elderly service providers. More than 100 elder academies have been set up in various districts offering education programmes, making use of the school premises and the network and expertise of District Elderly Community Centres and Neighbourhood Elderly Centres.9
Apart from issuing the Senior Citizen Card (by the Social Welfare Department) to promote voluntary concessions for elders by the commercial sector, the Leisure and Cultural Services Department also provides concessions for the use of recreational facilities. In 2011, a monthly ticket scheme was provided for public swimming pools. Moreover, a scheme to allow elders to travel on public transport at a concessionary fare of $2 per trip will be provided to promote active ageing.10
A CHANGING TREND WITH CHANGING NEEDS
Since 1997, the principle of ageing in place has been advocated, but the rate of institutionalisation remains high despite policy initiatives to promote community care with interdisciplinary approach.
Another area of concern is that elders are often viewed as health care burdens or social problems. This may be due to media portrayal of elders focusing on bad news, such as the destitute, the needy, and the abuse of elders. Another explanation is the general lack of familiarity with elderly
issues. With the use of foreign domestic helpers, fewer children are raised with helps from grandparents, and the gap between young people and the old widens. Reduction in average household size indicates a decrease in extended families. Do these social patterns point towards a greater reliance on the government rather than the family to take care of elders in the future? What is the impact of the rapid increase in the number of the ‘old-olds’? Will there be an increased need for institutional care or expensive medical care?
Although physical impairments are more common with age, many old-olds, being survivors, may actually use fewer medical services than younger-olds or the middle-aged with multiple chronic illnesses. Nonetheless, advanced age is a main factor for cognitive impairment (dementia), and it will exert a heavy burden on society.
In a population-based study on the prevalence of dementia jointly conducted by the Elderly Health Service of the Department of Health and the Department of Psychiatry of the Chinese University of Hong Kong in 2005/06, about 1 in 10 elders aged ≥70 years suffered from dementia. The prevalence of dementia doubles for every 5-year increase in age after the age of 60 years, from 1.2% among those aged 60 to 64 years to 32.1% among those aged ≥85 years. There is also general ignorance of the disease: only 11% of the cases have been diagnosed; for every diagnosed case of dementia, there are 8 undiagnosed cases.11 Even when Prof Charles K Kao first presented
with symptoms in 2004, he was told by a local doctor that dementia is rare in Hong Kong and there is no treatment for it.12
Dementia is disabling and places heavy burdens on the family and the medical and social services. The pressure of caregiving poses immense emotional stress, which may cause carers to become ‘silent patients’. Moreover, ignorance and inability to cope with behavioural problems lead to conflicts and dispute, as well as premature institutionalisation of the demented patients. It is no surprise that about 31.6% residents in elderly homes have dementia.6
NEW DIRECTIONS FOR THE EMERGING NEEDS
Early identification of dementia is necessary for management, as early use of drugs can help alleviate the symptoms and modify the course. Non-pharmacological interventions such as behavioural therapy, reality orientation and reminiscence therapy help patients to maintain their self-care ability for as long as possible. Early use of community support services such as day care, support groups, and respite services enables family members to acquire proper skills in tackling the emotional and behavioural problems, minimising the stress of caregiving, which in turn improves the quality of care
provided for the demented. Moreover, public awareness and education should be enhanced so that the community is better prepared. For it is not just the elders, carers, or health professionals, but also people in the street like bus drivers, watchmen, and policemen who can give help when needed.
Quality of life
Quality of life is important for old-olds. Although institutional care may ultimately be required, it should be reserved for the really frail and severely impaired towards the end of their lives. The percentage of elders in elderly homes (5%) is higher than in many other countries and the average life expectancy of the residents seems to be longer, suggesting premature institutionalisation. As this is costly and undesirable, both policy changes in long-term care and the enhancement of community care services would be needed to change this situation.
Community support
Long-term care for elderly should adopt the principles of friendly, ageing in place, shared responsibility of care, and equitable allocation of resources. In addition to putting more resources into community care services, support to families should also be enhanced to fill in the gaps. This includes lengthening service hours, increasing carer training, re-aligning service boundaries, providing more respite for ad hoc needs, and promoting better interface among health and social sectors and among different social services.7
Financing
Introduction of means testing in long-term care and the use of vouchers is recommended for sharing responsibility between government and family. Currently, family members do not have incentives to opt for community care, as the heavily subsidised elderly homes are not means tested. Many elders apply for CSSA to cover the cost of private homes after claiming ‘no financial support’ from the family. This is an undesirable practice as it alienates the elder from the family and creates additional burden to the society. In the 2012-13 budget speech, a pilot scheme on community care service voucher was announced, while more resources are allocated to enhanced community care services and day care services. These measures help increase choice and promote ageing at home. Moreover, a Community Living Supplement under the CSSA has been added to encourage ageing at home.13
Shared responsibility is the only viable option for the ageing population. In terms of health issues, the voluntary health protection insurance scheme was proposed as part of health care reform, aiming at greater sharing of responsibility in health care financing. In terms of social issues, elderly services need not be just welfare services. With a voucher scheme, the private sector needs not to focus simply on institutional care, but has incentive to develop more community care services.
Human resource development
As the society continues to age, the needs for various kinds of human services increases. Training institutes must anticipate the growing demand, not just for medical and nursing staff, but also allied health professionals, particularly physiotherapists and occupational therapists for physically and/or cognitively disabled elders. There is also lack of geriatric expertise in the private primary care sector. Although diploma courses in community geriatrics for doctors have been provided, the demand for more in-service training to enhance management of elder health problems remains great. Conditions common in the elderly, such as dementia, incontinence, and depression are often considered to be most difficult to manage.
Carer training
To ensure the quality of personal care, formal and informal carers should be trained to be alert to symptoms, and have basic skills to help the physically or cognitively impaired, so as to reduce the risk of preventable morbidity such as falls and getting lost. Many institutions offer such training, but ageing of the workforce is a problem, possibly due to the unattractive work nature or remuneration. There is need to strengthen the career path to attract more young people to join the field. Since 2006, the Social Welfare Department has been organising enrolled nurse training programmes for the welfare sector, providing more opportunities for advancement in the elderly care field. More can be done on the image of the profession and promoting intergenerational cohesion. To improve carer support, training for family carers, neighbourhood volunteers, and domestic helpers should be provided. At present, many elders depend on domestic helpers to provide personal care. More training and possibly financial incentives may enable better use of domestic helpers, volunteers, and family carers to help elders ageing at home.
Holistic approach
Elders do not just eat, sleep and require medical and personal care. They have social and spiritual needs too. They want dignity in their daily living. Society used to adopt an age-differentiated social structure in which the young, the adult and the elder were allocated to education, work, and leisure, respectively. Such demarcation in role is no longer in line with current views and expectations. We need to adopt an age-integrated view, and people of all age groups should have access to education, work and leisure. For elders, opportunities for learning provide cognitive stimulation and help prevent dementia, whereas work (volunteering or mentorship) helps maintain vigour and self-esteem. The Elder Academy has provided a starting point for lifelong learning. For the future, the University of the Third Age, where students are teachers and teachers are students, may provide an integrative approach for elders to enjoy their golden years.
Inter-generational cohesion
The Elder Academy also serves as a platform for inter-generational cohesion. About one-third of elders in Hong Kong live alone or with their spouse only, although 90% do have children living in Hong Kong. This physical separation, as well as the fact that more children are raised by domestic helpers instead of grandparents, affects the intimacy between generations (and across 2 generations), with impact on the future pattern of community care of elders. There is a possibility that the old-olds may survive their adult children and need to be cared for by their grandchildren. Society must be prepared for it and incentives should be provided to avoid financial burden on society and decreased quality of life of elders. The incentives of housing priority schemes and tax rebates for caring for parents should be enhanced.
Other modifications in the community
Flexible working arrangements for employees would enable them to provide care to elder members of their family. Options include flexi-hour, part-time, or home office. To create an age-friendly environment, transport, housing, recreation, sports, etc should adopt universal design to cater to the different needs of elders.
The grey market
The coming cohorts of elders are better educated and have greater personal assets and buying power. They want choices and have higher expectations. They are more knowledgeable about preventive measures and enjoy better health in old age. Most of them would opt for more independent living, so the demand for community care services would increase, facilitating the use of vouchers for private elderly care services. Elders have different tastes and needs for various products such as special clothing to deal with their disabilities. The demented need special ‘toys’ to keep them engaged. Carers need special gadgets to monitor the condition of their elderly relatives.
OPTIMISM FOR THE FUTURE
Intergenerational cohesion projects have shown that elders can be an asset. With their wealth of life experience, elders can be mentors to young people, helping them to acquire life skills. Relationships can also be built through cyber space so that elders can provide input to nurturing of the young, just as their forefathers have always done.
The world belongs to people of all ages and it is up to everyone to make the best out of whatever demographic profile. Hong Kong has survived well in a young society and should be able to survive well in an ageing society. It remains for policy makers, elderly service providers, carers and elders themselves to take up the challenge, so that everyone can enjoy life to the full, whether young or old.
REFERENCES
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2. Census and Statistics Department. Hong Kong Life Tables 2004-2039. Hong Kong; 2011.
3. Census and Statistics Department. Population estimates in 2010. Hong Kong.
4. Census and Statistics Department. Population projections 2010-2039. Hong Kong; 2011.
5. The 1997 Policy Address. The HKSAR Government, 8 Oct 1997. 6. Census and Statistics Department. Socio-demographic profile,
health status and self-care capability of older persons. Available from http://www.statistics.gov.hk/publication/stat_report/social_data/ B11302402009XXXXB0100.pdf.
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9. http://www.elderacademy.org.hk/en/welcome/secretary.html 10. The 2011 Policy Address. The HKSAR Government. 12 Oct 2011. 11. Dementia in Hong Kong. Public health & epidemiology bulletin.
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