5.1 The political debate on elderly care in Denmark
Annex: Model ways of working
In the course of the 20th century the public sector in Denmark has been developed continuously to secure the welfare of citizens. In the beginning of the 20th century the public sevices mainly con-cerned economic security in case of loss of income while in the second half of the century the provision of services has increased as public services were provided to improve the citizens’ living conditions. This development has also concerned the elderly.
In Denmark, health and social care is available on a universal basis dependent on need and not age or ability to pay. If an older person is in need of care, it is accepted and underwritten by legislation that the public assumes responsibility for the care services required (Blackman et al., 2001). Health service, hospitals and social care are provided at no cost to the elderly and financed through general taxation (Wagner, 1994).
Due to the fact that, in Denmark, the rate of women participating in the labour market is one of the highest in Europe, and that people retire earlier the nature and scope of informal family care has changed. Families have no legal obligations to care for elderly family members. Assistance given by family members or relatives is considered additional input to the assistance provided by the public services, rather than a substitution. Although there continues to be a culture of additional support provided by family members, in particular by children of older people, family care rarely substitutes for public care (Blackman et al., 2001).
The development of Danish policy on older persons has in the course of the 20th century been characterised by incremental changes and adaptations to different socio-economic challenges and public demands. These developmental trends in the Danish policy on elderly led to an increasing awareness that the various policies concerning older persons lacked internal coherence and in many cases policies in one area contradicted policies in another. On this background the Commission on Elderly was constituted in the late seventies. The objective of the commission was to formulate coherent visions and objectives for the Danish policy on elderly. One of the main recommendations of the Commission on Elderly was to aim at an increasing level of integration of the services provided to senior citizens. According to the commission “a higher level of coherence must be considered a central means to achieve tangible improvements in the living conditions for the individual older person, while ensuring that this is achieved without an extreme rise in expenditure” (Ministry of Social Affairs, vol. 3, 1982: 30; our translation). In the subsequent years the following developments have characterised the Danish policy on elderly.
During the 1980’s and to the end of 1990’s an increasing part of the elderly population has made use of the possibility of receiving services provided by the public (Ministry of Social Affairs, 2000). Most of the period the Danish economy has been characterised by stagnation. Consequently it has been difficult to meet growing needs of care for older people by a similar growth in the use of economic resources. Instead the growing need for elderly care has been met through restructuring and innovation for example in the form of a shift from institutional care to home care along the lines of the recommendations of the Commission on Elderly. At the same time the municipal organisation of services and the use of staff have changed (Ministry of Social Affairs, 1995). These developments have resulted in an increasing level of integration of the health and social care services provided by the local – municipal – level of government.
This process of integration, however, has until now to a large extent eluded the health services of hospital services that are provided by the regional level of government. As will be discussed over the following pages, the boundaries between local and regional government, thus, appear to constitute a significant barrier in terms of integrating the health services provided by the regionally administered hospitals with the health and care services provided by the municipalities.
In the second half of the 1990’s, however, changes in the public policy resulted in a reduction of public services, first of all in the area of care for the elderly. Economic considerations combined with an increasing request for home help had the consequence that the municipalities gave priority to personal care at the expense on the emphasis practical assistance. Altogether, this meant less time to practical assistance. At the same time there has been a change in measuring the services. Before the help was given and measured according the total need, while it is now measured according to a detailed description of the needs. For the citizens it appears that the help provided is less generous (Hansen, 2000).
However, in the following decades the Danish welfare state will increasingly be confronted with the challenges of coping with an ageing population. The challenges associated with an increasing proportion of potential recipients of elderly care, thus, put the tax-financed Danish model of universal provision of elderly care under pressure.
The presentation will focus on the following issues in the organisation of elderly care in Denmark. After a brief presentation of basic concepts in Danish elderly care the attention of the paper will be directed towards a description of the structure of health and social care services. This description will focus on who are providing and who are provided with health and social care. Furthermore, this description will discuss the conflicts between the actors involved in the provision of health and social care services. The subsequent section will discuss model projects that aim at solving various problems in the existing system through innovation of new ways of working. Finally, the presentation will focus on the lessons that can be learned from the model projects and from the aggregate experiences of providing health and social care services in Denmark.
2 Basic principles and concepts in Danish elderly care
The Commission on Elderly1 announced the principles in policy for older persons in the beginning of 1980’s. The general objective of Danish Ageing Policy is to improve the individual’s possibility of living at home or to ease his or hers everyday existence and improve his or her quality of life. Danish ageing policy is based on the general principles of (i) ensuring continuity in the in-dividual’s life, (ii) making use of older people’s own resources, (iii) preserving older people’s self-determination, and (iv) sustaining older persons ability to influence their own circumstances.
The philosophy behind these principles is that (i) older persons do not make up a homogeneous group with uniform needs, (ii) the provision of services to older persons shall not be provided as package solutions in nursing homes, but be given in accordance with the individual need for aid,
The Commission on Elderly – appointed by The Danish Government – worked from 1979 to 1982. The aim was to formulate a coherent Danish Ageing Policy.
and (iii) residents at nursing homes - as other older persons - should have influence on their own economy and daily lives (Ministry of Social Affairs, 1982).
The concept of Danish ageing policy presupposes that a broad and varied range of services and activities is available to the elderly. The services concerning integrated health and social care are home help, home nursing, rehabilitation and nursing homes2 (Ministry of Social Affairs, 1998).
The central government lays down the general legislative framework for the provision of services for older persons but the municipalities decide on and are responsible for the range and organisation of the services provided. It is furthermore the responsibility of the municipality to provide coherent services to the individual as well as monitoring that resources are used in an effective way. Even though the services will vary from one municipality to another the cooperation between home nurses, home-helpers and other social and health services is a central requirement.
2.1 Integrated care at the municipal level
The aim of Danish elderly policy is to enable older persons to live a life as close to the normal life as they want. The key phrase is “in your own home as long as possible.” It presupposes that a varied range of services is available to the elderly. Only in cases of actual illness treatment will be given in hospital. When an older person no longer needs treatment, the local authority assumes responsibility for care and services. Apart from nursing homes, Denmark has almost no institutions outside the hospital system taking care of the frailest elderly. Their needs are met through integrated health and social care within municipalities. Integration between home help and home nursing means that in practice the two professions, social and health are formally working together in integrated teams. The service includes also physiotherapist and occupational therapist.
With the social reform of 1976 social security and some health and social services were united in municipalities. The idea was that the citizens only had to contact one authority instead of several authorities, as was previously the case. But in the municipalities social services were spread on several departments. One for home nursing, one for home help, one for health, one for nursing homes and one for social work for elderly. Each department had their own budgets, management and employees. This diversion entailed that an elderly citizen might have several case managers and the cooperation between the departments was not always flexible.
During the period of economic stagnation in the 1980’s the social services were under pressure for more effectiveness. There was almost no discussion about competitiveness or of involving the market as in UK or later in Sweden. Instead focus was on gearing the municipal health and social care units for a more effective use of the resources. The result was among other things a reorganisation of health and social services for elderly.
In 1988 new legislation was implemented on dwellings for dependent elderly and this legislation was directly inspired by the recommendations of The Commission on Elderly. According to this legislation municipalities could no longer build nursing homes according to former legislation. Adapted dwellings with 24-hour assistance service replace the nursing homes. 24-hour assistance services are provided to all elderly independent of where they live.
The aim was an integrated health and social care. The integrated health and social services implies that the services are provided to all elderly – independent of where they live – by integrated teams of home-helpers, home nurses ect. Each elderly in need of support has a case manager in the municipality, who is the individual counsellor of the older person applying for support. The case manager coordinate the efforts and cancel when the elderly is hospitalised, on vacation or visiting relatives. The decision of support is made on request from GP’s, hospitals, the elderly or relatives.
As services are provided without regard to type of housing, no distinction is made between nursing homes, adapted dwellings and independent housing for the elderly. The 24-hours assistance services are accessible for all elderly in need. By providing personal assistance at all hours of the day this service contributes to reducing the demand for nursing home places, handling early discharges from hospital, and preventing some incidents of socially induced hospitalisation.
According to the Act on Housing for Older people it must be possible to call in speedy assistance at any time of the day or night to all sheltered housing. In addition, ready assistance may be made available for other types of dwelling. If an ordinary telephone does not provide an adequate means of calling, an emergency call system may be installed (Ministry of Social Affairs, 1995).
Many local authorities cooperate on measures of prevention and rehabilitation for the elderly, with the aim of enabling older people to remain in their homes as long as possible. In addition, practical and personal assistance is supplied by local authorities, which employ physiotherapists or occupational therapists.
As regards discharge of older people from hospital, there are no regulations or standards to ensure coordination, although in some counties the hospitals and the municipalities have reached their own agreements on coordination. The problems with integration health and social service are often connected with discharge from hospital. The decrease in the average number of bed days at hospital results in an increasing demand for domiciliary care. The process of integration of health and social care, thus, appears to be most advanced at the municipal level. As will be discussed later, the bulk of the problems in terms of integration occur at the interface between the regionally administered hospital system and the municipally administered health and social care services.
2.2 The concept of self-care
The provision of integrated health and social care for older persons is based on the concept of self-care. The concept of self-care includes an accept of the human being as a free, independently thinking and acting individual with the ability to make decisions about his or her life. According to Orem’s concept of self-care, the role of health care personnel is consultative and their professional skills should be used to ensure that each member of the community receives the assistance he or she requires to continue being responsible for his or her life (Wagner, 1994).
To a wide extent, Danish policy on older persons is founded on making use of older people’s own resources, to preserve older people’s self-determination, influence on own conditions and to ensure continuity in older people’s lives. The services are governed by the principle of help to selfhelp and are therefore to be performed together with the older person insofar as this is possible, so that the skills of the recipient are maintained or retrained. The home help may support the older person in maintaining social contacts and areas of interest (Bierring et al., 1987).
The concept of self-care has among other things resulted in a change for elderly in nursing homes. Nursing home staff are not supposed to take over responsibility for the life of individual residents. Each resident is to decide what services he or she wants to make use of. Staff are responsible for treatment, care and supervision.
Since 1993 all residents at nursing homes have to manage their pensions and pay rent, pay for electricity, heath and for services as meals, hairdressing, shaving etc. When older persons have to pay directly for the services, their incentives to do things themselves increase as well as their selfdetermination (Ministry of Social Affairs, 1995).
3 Provision of health and social care in Denmark
3.1 Who is receiving health and social care services?
Health and social care services constitue the largest single area of the municipal services. In 2001 roughly 180.000 persons aged 67 or more received home help from the municipalities. Thus, in Denmark 24 per cent of older persons over 67 years of age receive public home help – the highest rate in Scandinavia (Social Appeal Board, 2001; Daatland, 1997; Rostgaard et al., 1998). In total more than 212.000 persons received home help in 2001. 112.000 of these received less than four hours of help a week. Furthermore, 28.000 persons lived in nursing homes in 2001, another 57.000 were attached to a day-care centre and 63.000 adapted dwellings had been established. Finally, the municipal expenditures on elderly care amounted to 3 billion euros in 2000. In 2000 the overall direct transfers in cash or kind to elderly citizens in Denmark amounted to 10,6 percent of the GDP.
According to figures on who are doing the work in the households of elderly, however, it does not seem that the responsibilities left with the municipalities just because one has reached a certain age. A study from the end of 1980’s shows that two thirds of all elderly aged 70 years or more and living at home do not receive home help (Platz, 1990). Another study from the middle of 1990’s shows that among persons between 80-100 years more than 40 per cent do not receive home help (Hansen & Platz, 1995).
Still, more than one third of all hospitalised persons are over 65 years and are using more than 50 per cent of the total amount of bed-days in all hospitals. Over the latter years hospitals have been run more effectively, which has resulted in a decrease in the average days patients stay at the hospital. This means that also older persons are discharged earlier, thus requesting more services from the municipality once back home which again put emphasis on the provision of integrated care (The National Association of Local Authorities in Denmark, 2000; Felbo & Søland, 1996).
3.2 Who provides health and social care services?
Health and social care is characterised by an extensive delegation of responsibilities to politically elected regional and local authorities. Regional (16 counties) and local (275 municipalities) authorities administer health and social policy respectively. The Ministries (Health and Social) are responsible for overall control and for establishing the broad legislative and financial framework of health and social policy.
An important feature of Danish legislation on health and social welfare is that it provides only the general framework. The local authorities determine actual contents and organisation of the health and social care services provided. As a consequence of the decentralisation of responsibilities to counties and municipalities, there are variations in the services provided to older persons depending on where they live.
• The Ministry of Interior and Health is responsible for primary health services and hospitals.
• The Ministry of Social Affairs is responsible for pensions for and the care of the elderly.
As noted above the responsibilities of implementing health and social policy have been delegated to the counties and municipalities.
The 16 counties administer hospitals, including geriatric rehabilitation services, primary health care (except home nursing) and health promotion initiatives. Long-term care is not in general a county health authority responsibility, but older people with mental illnesses, such as dementia, may be referred for care at specialised units. Counties are therefore responsible for the running of hospitals and for the coverage of general practitioners (GPs) (Blackman et al., 2001). Hospitals and GPs are financed through general taxation, which means that the users do not pay directly for services provided by hospitals and GPs. The charges for medicine are subsidized to a high degree.
The 275 municipalities administer pensions, nursing homes and adapted dwellings for older persons, home nurses, psychotherapists, occupational therapists3 and social care as home help. The referrals of all aids to older persons, who are not in hospitals, are coordinated in the municipality by the health visitor, who is also the case-manager.
The municipalities have a statutory duty to offer home help for both practical and personal assistance, home nursing and provide housing for disabled persons – including adapted dwellings, nursing homes and attached day care facilities. Care is free of charge to the recipient irrespective of the type of housing of the recipient. Other social services provided are: transport for people requiring treatment, day centres, which may offer recreational activities as well as rehabilitation, loan of equipment and aids and, finally, meals on wheels, for which there is a charge.
The municipalities are the main provider of services, but some of the nursing homes and attached day care facilities are run by voluntary organisations. These organisations have contractual agreements with the municipality. The municipalities, however, remain responsible for standards in the home, admission criteria, and the setting of rents and services charges. In all practical ways,
3 The objective of occupational therapy is to restore or maintain the patients physical and mental abilities.
there is no distinction between nursing homes and day care facilities run by the municipality and those run by voluntary organisations (Blackman et al., 2001).