The hardest job I ever had was as a nursing assistant in a psychiatric hospital. On a typical shift, five or six of us would look after 60 patients or more. This was the usual staff:patient ratio throughout the establishment, except in the section for the “criminally insane”. In such conditions, the care philosophy was brutally simple. As a colleague explained on my first day, “If they move, we give them drugs. If they don’t move, we give them electric shocks”.
The hospital had been built as a lunatic asylum in the 19th century, on a moor that was miles from the nearest village. It looked exactly as you’d expect: a grim fortress with bars on the windows and locks on the doors. Our job wasn’t really to look after our patients, we looked at them to make sure there was the same number at the end of the day as at the start.
Except in the geriatric ward where I worked for a few months. Many of the patients were bedridden, and the nurses took great pride in the fact that not one of them ever got a bed sore. We even healed some horrific wounds that had become gangrenous. Some of the people I met there made me realise that in calling their institutions “asylums”, the Victorians were stressing something positive. An asylum is a place of refuge, maybe a last resort, and some of our men (the regular staff always called them “our men”, never our patients, inmates, cases, clients…) had nowhere else to go.
One man had lived on the road for nearly 30 years, making sure he got sent to prison for the winter until finally a magistrate told him he was too feeble to look after himself. The only place that would take him was the psychiatric hospital. Another man was paralysed by Parkinson’s disease and his wife couldn’t cope. A third had spent his whole life locked up after being abandoned as a baby because he had Down syndrome.
The majority of the men had a combination of psychiatric and other conditions – Alzheimer’s, alcoholism, schizophrenia, various degrees of paralysis, and so on. What they had in common was the need for the long-term care the hospital provided. It’s a need that’s going to grow, with the number of people aged over 80 in OECD countries doubling between now and 2050. The share of the over-80s will rise from 3.9% of the population now to 9.1% in 2050, and from 4.7% to 11.3% in the EU-27.
The OECD and the European Commission have just produced a report on monitoring and improving quality in long-term care. If you’re worried about growing old, A Good Life in Old Age? will do nothing to reassure you. “…at least one in two people admitted to hospital from a care home setting are at risk of malnutrition… at least 30% of older people in acute hospitals and 40% of older people in care homes meet the clinical criteria for a diagnosis of depression… There is no sign of a consistent decline in the incidence of physical restraint use… two-thirds of LTC [long-term care] users in institutions were exposed to one or more medication errors… one old person dies due to a fall every five hours… Pressure ulcers are known to affect a large number of LTC recipients in nursing homes…”.
So, what can be done, other than head north to cast yourself adrift on an ice floe before global warming melts them all? A Good Life in Old Age? suggests a combination of regulation; standardization and monitoring; and incentives for providers and choice for consumers. However, most countries do not collect information on quality systematically, and if they do, their efforts are limited to information on aspects such as staffing and the care environment, what the report calls “inputs” rather than the outcomes for the person’s health and well-being.
The OECD and EU are right about the importance of attitudes and behaviours in the quality of care, even if they use the hideous expression “leveraging consumer choice and centeredness” to say so. Apart from depression, I never came across any of the issues listed above, because the people I worked with were “consumer centred” even if the consumers in question had no choice.
That experience convinced me that it’s possible to provide quality care even in a highly unfavourable setting. The OECD-EU report suggests that there are plenty of solutions to help do so now and in the future.
Today, the OECD publishes Help Wanted? Providing and Paying for Long-Term Care. In this post, Maxime Ladaique, Manager of statistical resources in the OECD Directorate of Employment, Labour and Social Affairs looks at the question of intergenerational solidarity. Promoting Solidarity is the theme of a panel discussion on 24 May at the OECD Forum session on “Life After the Babyboomers”.
It’s an issue most of us will have to deal with sooner or later, if we’re not doing so already – as parents, grandparents or children of ageing parents.
First, I’d like to define what we mean by “intergenerational solidarity”, before looking at the actual extent our populations are ageing, and what the consequences might be regarding the demographic and social challenges looming ahead of us in the coming decades, and of the solutions for policy makers, so that all generations live together, as united as possible.
Intergenerational solidarity can refer to help across generations, either via cash transfers within a family – between parents and children for example, or via time spent to care for children, grandchildren, or for parents.
But intergenerational solidarity can also mean that generations have a positive view of one another, or that there is consensus across generations on the way forward.
Measuring such a broadly-defined concept isn’t easy. Nevertheless, relations between generations today appear to be positive, according to attitudinal surveys. For example, the Eurobarometer conducted in 2009, asked the provocative question “Are older people a burden on society?”. In 21 European countries that are members of the OECD, 62% of people strongly disagree that older people are a burden, with a further 23% somewhat disagreeing. Only 14% agree with the statement to either degree.
The problem is that this exchange across generations works well in times of demographic balance, but less so in the current context of population ageing.
You can see one change due to ageing in the fact that nowadays, families are often made up of four generations: children, parents, grandparents and great grandparents. This is thanks to what is first and foremost good news: we live longer. In 1961 when the OECD was created, citizens of OECD countries lived until 69 years of age on average. Today, that has risen to 79.
A second reason for population ageing is what many regard as not so good news: fewer children are being born. Fifty years ago, women had on average just over 3 children in OECD countries. Today, they have on average just under 2.
Some people fear that this demographic imbalance has set a social time bomb ticking.
First, because of pensions. Did you know that in 1961 there were 7 persons of working age per person of retirement age on average across OECD countries? This ratio is currently 4, and it drop to 2 in 2050.
Without reforms, spending on public pensions will double in the next 40 years. Governments will not be able to cope. We know the solutions, but they are not easy to put in place. Governments could postpone retirement age, so we’d have to work longer. Or give financial incentives to employers to keep older employees at work so that they contribute longer. Or introduce greater diversification of sources of retirement income, giving a greater role to private arrangements.
Caring could also pose problems. The share of those aged 80 and over will more than double in the next 40 years, from 4% to 10% of the population. And today, most care for older people is informal. Typically, between 70% and 90% of people providing care for older people are family members. But as populations get older and more and more people need care, families are not going to be able to cope any longer. Governments need to help them by providing either financial subsidies to help them to get some professional care at home, or by investing in the creation of retirement homes, which are already desperately needed in many countries.
I’m sure we all agree that there is an urgent need for governments to react to population ageing in order to keep our generations united, but whether you’re from my generation or not (I’m 41), I’d be interested to hear your ideas.