Executive summary
This article explores why finding new and better ways to support and care for seniors holds the key to solving First world countries health and social care services sustainability dilemma.
Most First world countries are racing against time to find credible and sustainable solution for their struggling health and social care system. Countries like France, UK, Germany, Japan, USA, Canada, Australia and New Zealand regardless of how well there are funded faces this growing tipping point challenge.
One of the common themes for First world countries health and social care system is the increasing demand pressure from aging, aged or super aged population. For many of these countries it translates into constant and unrelenting pressure to increase funding and resources for more services. The current higher percentage of health and social care spending on seniors compared to average is a major contributor to the current service and fiscal pressure in many First world countries. This will increase exponentially to an unsustainable level in the next 5, 10 to 30 years if nothing changes.
Talk to any experienced healthcare clinicians or other frontline carers and they will tell you that they are caring for more and older seniors. Many are also sicker and require more support to remain independent. It is therefore not surprising that this population group currently consume proportionately significant higher level of expenditure compared to other population groups.
Despite the dedication and commitment of many frontline staff and carers there is an increasing and loud disquiet about access, choice and quality of care for seniors. Mainstream media both print and digital runs disturbing and sometimes graphic stories of poor care either in nursing homes, supported living, primary care and in hospitals. One of the common theme from these stories is that it is the family members (many are seniors themselves) that are raising concerns on the poor care for their parent generation. This growing dissatisfaction and frustration of this “new seniors” should not be underestimated as a key catalyst for significant change.
Today’s consumer networks for baby boomers’ new seniors have similarities with traditional advocacy groups. The main difference is how they are using smart technology to express and share their views and resources with speed and reach a wider audience.
Any re-designing and implementation of new services need the active partnership and participation of seniors and be anchored on “values” principles fundamental to seniors. Health and social care institutions and decision makers will need to learn from other sectors that has successfully activated strong consumer networks. Such activation creates ownership and value of solutions from consumers.
There is no doubt that smart consumer focus technology will feature strongly in new services. These technologies are unlikely to totally replace human carers but rather it will augment and support future models of care. Apart from technology other changes needed to support future models of care includes changes to policies, regulation, funding, use of Big data and advance data analytics, augmented and new workforce and new business models.
This article explores four significant themes in many First world countries:
The silver tsunami numbers
Increasing disquiet amongst seniors and their families – a catalyst for change
Unsustainability of current health and social care system to care for seniors.
Better ways of caring and supporting our seniors.
The silver tsunami numbers
The silver tsunami relates to the significant number of baby boomers reaching retirement age. When it comes to statistics and numbers on the silver tsunami there are three key numbers to focus on.
The number and percentage of over 65s to total population.
The velocity of aging (how fast the percentage is increasing).
The number and percentage of over 80s to total population
The first number is the most common cited number. However it is equally important to look at the second and third number to get a comprehensive insight into the challenges ahead.
The second number is important because it provides the window available to respond to the change.
The third number is important because many of these over 80s seniors currently live most of their remaining years in poor health. This then drives exponential increases in health and social care services for seniors well past their 80th birthday.
Over 65s - aging, aged, super aged, ultra-super aged societies and beyond!
Common working definition for aging society is where the population of over 65s make up more than 7% of total population. Likewise an aged society is over 14%, super aged society is over 21% and an ultra-super aged society is over 28%. There is no working definition yet when the percentage gets beyond 35% (perhaps mega-ultra-super aged), yet a number of First world countries (Korea, Greece, Portugal, Spain and Japan) are forecast to 2050 to exceed this threshold.
Currently many First world countries are an aging and aged society. There are a few who are already a super-aged society. Traditionally two factors are driving this trend, a reducing birth rate and increasing life span. However, a third factor, migration is becoming a strong driver in recent years for some First world countries.
Based on an OECD 2017 report (here after referred to as the OECD report) in 2015 there were 4 countries that are “super-aged” societies with no countries in the “ultra-super-aged” or “mega-ultra-super-aged” categories. By 2050, there will be 22 “super-aged countries”, “10 ultra-super-aged countries” and “5 mega-ultra-super-aged countries”.
All things being equal, as countries move along the aging, aged, super-aged, ultra-super-aged and mega-ultra-super-aged continuum, the proportion of health and social care expenditure for their seniors will increase exponentially. This trajectory could get to a staggering unsustainable level and it will be hard to imagine what the health and social spending will look like for these countries.
2015
2050
Velocity of the aging
For some countries this number is critical. Currently they maybe have a relatively lower number for the population over 65s, it is how fast their population is aging that is of grave concern. Two clear examples Korea and China. Their over 65s will reach 35.8% and 26.3% in 2050 compared to 12.3% and 9.6% in 2015 respectively. This gives them a much smaller window to get prepared for that future. It will be beneficial to keep an eye on the responses from both these countries in the foreseeable future to meet their silver tsunami challenge
Seniors 80 years and older - living longer but more years in poor health
Advances in medicine and public health have successfully prevented and cured major illness and diseases that contributed to increasing life expectancy in many countries.
According to an OECD report in 2015 there are no countries where 80 years and older exceeds 10% of its population. By 2050 however, 15 countries cross the 10% threshold, 13 in Europe, 2 in Asia (Japan and Korea) and 1 in North America (Canada).
While the average life expectancy is increasing this does not mean that they are living these longer years in good health. Growing number of seniors living longer are living many of these years in poor health.
An OECD report shows for 25 European countries at age 65 the average life expectancy is approximately 19 years and average healthy life expectancy is approximately 9 years. That means there is approximately 10 years of these European seniors living with poor health or disabilities that limit an active and healthy life.
Longer life expectancy currently can bring with it increasing and often multiple chronic conditions as seniors get older. In addition, older seniors can often have increasing sight, hearing, strengthen, , continence, balance and mobility limitations that can rapidly lead to loss of independence. Therefore the need for more health and social care support increases significantly as seniors get older.
Unfortunately current health and social care systems are not able to cope with these demands. This growing chasm between growing and changing expectations of seniors (and their families) and the rate of change in health and social care services has two glaring consequences:
Increasing disquiet from seniors & their families
Unsustainable mounting pressure on both health and social care to provide services for seniors
Increasing disquiet from seniors & their families – a catalyst for change
In First world countries while many seniors receives great care and are grateful for the support they receive from dedicated and caring health professionals and carers it is not difficult to find on media both print and digital disturbing and sometimes graphic stories of how health and social care systems are failing our seniors.
Stories of neglect, abuse, medication errors, falls, malnutrition, neglect and financial affordability for seniors in care are familiar themes. Such stories for example in the aged care sector in Australia have prompted the Australian Prime Minister to launch a royal commission of inquiry recently. Even in countries that are “well-funded” for example both Germany and Japan health system are under pressure from workforce shortage.
Family members (many are baby boomers) of seniors in care are raising concerns and expressing lack of confidence in the health and social care system caring for their parent generation. This growing dissatisfaction and frustration of the baby boomer generation of “new seniors” will become a key catalyst for significant change.
What’s behind the increasing disquiet from seniors and their seniors? The current health and social care system have focus largely on the functional well-being and needs of seniors. However, increasingly other fundamental unmet expectations are fuelling the seniors and their families disquiet and frustrations.
Beyond the physical and functional needs – what matters to seniors!
Some fundamental unmet expectations for seniors and their families includes, to remain connected, to contribute, be valued, independence, choice and control, belonging to a community, to be treated with respect and dignity.
These fundamental expectations become more important as seniors come to terms with diminishing mobility, hearing, sight, cognitive abilities and physical health. One of the more significant decisions often as a consequence of these diminishing capabilities is alternative living arrangements. Downsizing and shifting out of family homes are significant decisions for seniors and their families and can be difficult times for all. For seniors without children such time presents different challenges. Baby boomers as they go through the decision making process with their parents are thinking through for themselves how they might want to handle this transition differently when their time comes.
Baby boomers – the new senior
Baby boomers are born in the two decades after the Second World War (1946 to 1964) and in 2018 the oldest and youngest baby boomers turned 72 and 54 respectively. Compared to their parent generation there are some important points to bear in mind about this generation:
More are mentally and physically active and on average at least half of baby boomers are still in active workforce. For example in the US, 2 out of 3 baby boomers are still in active workforce.
On average baby boomers have greater wealth and higher income per person. For example in Australia and UK they make up 25% and 30% of the population respectively but own over 50% of the total nation’s wealth. In the US, boomers make up 24% of population and account for 47% of total income.
Many are open-minded and embrace new technology and social media.
Some baby boomers for different reasons are not part of or not up to-date with the digital society. Some baby boomers will rely largely on government retirement payments and services to support when they retire. In the US for example about 50% of baby boomers will fall into this category. They should not be forgotten or left behind.It is not uncommon to hear baby boomers after a bruising experience in arranging care for their parents say “I am not going to allow this to happen to me. I have started to look at better options now rather leave it to others to decide for me”.
Baby boomers are increasingly turning to modern technologies and the web to obtain information, share and express their views. Emails, Facebook and LinkedIn are most popular with this generation. A Forbes 2018 article reports that in Netherlands for example over 75% of baby boomers use Facebook, 89% of baby boomers have personal email accounts and of these 82% have at least one or more social media account.
The already exists numerous websites, blogs and online communities focusing on baby boomers for example SilverEco, Startsat60, Elder One Stop, Senior Planet and Silvernest. It is not beyond the realms of possibility that in the not too distant future ecommerce giants partnering with these organisations will make an entry into the health and social care services for seniors. After all they are already entering the health market in screening, diagnostics, primary care and some treatment therapies. With the right partners such networks and platforms have the potential to directly drive change in health and social care services.
Unsustainability of current health and social care system to care for seniors
Currently in most First world countries the health and social care expenditure per person for seniors is much higher than for the average person. In 2017 UK seniors make up 18.2% of the population and account for 66% of health expenditure. Likewise for Canada, in 2015 seniors make up 16.5% of the population and account for 46% of health expenditure. This pattern will be similar for most First world countries.
As these countries move up the aging, aged, super-aged, ultra-super-aged to mega-ultra-super-aged curve, it unrealistic to imagine that these countries can afford to carry on providing and funding health services in the same way. For politicians and policy makers there is more at stake beyond the fiscal risk.
The good news is the baby boomers new senior wants this sorted as well and can play a much more significant role in finding new and better solutions.
Pressure on health and social care services
Ask any frontline health staff working in First world healthcare system and they will tell you that the average age of patients continue to increase, generally sicker and with multiple chronic conditions.
Hospitals are now routinely caring for seniors in their 80’s and well into their early 90’s. Even in surgical wards the average age is also increasing as some seniors over 90 are receiving major joints procedures such as hips and knees replacements.
Rehabilitation services such as physiotherapy, occupational and speech therapies are also facing increasing demand from seniors recovering from surgery, stroke, heart attacks and falls.
Primary care like their hospital colleagues is also now caring for older seniors with multiple chronic conditions. Most of their senior patients are on multiple medications that need careful management especially when patients are being referred to or discharged from hospital care.
In nursing homes, aged residential care facilities as well as home support services for seniors, this increasing complexity of seniors needs has also not gone unnoticed. The higher level of disabilities and dependencies are requiring workforce with greater knowledge, skill and expertise.
Ambulance and patient transport services also face increased demand as seniors are unable to drive or arrange alternative transport to get to health facilities. Older seniors with increased disabilities are requiring additional and higher skill and knowledge from attending staff.
Increased cases of dementia amongst seniors require more social care and psychogeriatric support for them and their families.
Understandably many if not all of the above services continue to ask for more funding to be able to adequately resources more services to meet increased complexity and demand. Needless to say no jurisdiction to-date has adequately met these funding expectations.
Inquiries and reviews are the normal start points for many governments. There are two big issues with this traditional responses, one the recommendations are predictable largely focus on more funding, more staff, more facilities, tinker with organisational and structural change and maybe appoint some oversight commission or ombudsman. The second issue is while waiting for these reviews and subsequent recommendations to navigate its way through political priorities, public services policy and machinery of government processes, appropriation of funding, contracting providers with right capacity and capability to deliver new or expand existing services the chasm continues to grow. Better ways of caring and supporting our seniors cannot just be left alone to the usual incumbents and decision makers. It is not just the how and what needs to be done but who needs to be driving this.
Better ways of caring and supporting our seniors
New and better models of care for seniors are needed right across the care continuum from self-care to end of life care. There already exists interesting and innovative models that demonstrate direction of travel envisage in this article.
In self-care and home support, the recent explosion of self-monitoring wearables and use of sensors is gaining acceptance. Basic monitoring functions such as weight, diet, exercise, sleep and heart rate now comes as part of many smart mobile devices. The use of mobile devices for multi-media communication and connection is becoming a norm. The use of household, social and service robots (Paro, Pepper) for self-care and home support is emerging and wide spread adoption can be expected within the next 10 years.
In residential care, initiatives like De Hogeweyk dementia village in Netherlands, Aalborg Care Consortium development in Denmark, Beacon Hill village in USA and HOMESHARE in Australia are attracting new interests. On the back of these exemplars other innovative solutions are emerging including the University of Wollongong 700 hectares intergenerational connectivity project due to open in2022. Smart technology is and will continue to play a big part of future innovations and places like Shintomi Nursing Home in Japan showcase what is possible with their use of over 20 different types of social and service robots.
In primary care and hospital care, initiatives such as advance care directives and community based palliative care model needs greater tractions to avoid unnecessary medical treatment especially in the last year of life. The deployment of smart technology in primary care and hospitals to improve the care experience and provide seniors with more convenience, choice and control are right direction of travel. In the next 10 to 20 years advances in genetic screening and editing will offer new options that will be more personalised, less invasive and minimise unnecessary treatments.
It will also be interesting to keep an eye out in Asia especially in Japan, Korea and China as they come to grips with what it takes to care for their rapidly aging population. World Health Organisation predicts that by 2030 these three Asian countries will have health care workforce shortfall of 1.4 million. Japan with the highest percentage of senior population have been and is experiencing the realities of caring for a super-aged society. Confronting insights such as “kudokushi” or the phenomenon of elderly dying alone and remain undiscovered for long period of time has sparked significant initiatives to care for their seniors. One such initiative is the increase use of technologies including automation, sensors, wearables, exoskeletons and robotics as they forecast huge shortage of human workforce. A recent 2018 Nuffield report “What can England learn from the long-term care system in Japan?” provides useful insights of how Japan cares for their seniors.
Underlying “values” principles
Development and implementation of new services need to be underpin by “values” principles that are important to seniors. These include:
Dignity, respect, independence, security, cultural context, contribution, companionship, choice, control and sense of being part of a community.
Well-being is about the reasons one wishes to be alive. Early discussion on why and what seniors want to achieve rather than just focusing on functional needs.
Deliberate activation and partnership with seniors in any design process.
Dual purpose of improving services for those receiving them AND increasing access for those currently missing out especially for the most vulnerable seniors.
Improvement should result in strengthening and simplifying the wider system supporting seniors.
Managing change and transition – strengthen the “relevant” current and creating the “new”
Scaling existing and new innovative models is the fundamental issue in almost all health systems. A common assumption is that it is largely a question of funding. While funding is an issue, there are other more significant drivers that need to be addressed including changes to organisation and business models, policies and regulation. Finally and probably the most deciding factor in managing successful transition is the new talent, capabilities, capacities, skills and knowledge to manage the change and transition.
Careful transition will be needed to both improve current service models where it is still relevant and create new and better models. The best of the current models need to be retained and improved, while others will need to be discontinued.
Within current models courageous leadership is needed to execute what one Health Affairs article calls the 6 categories of waste (overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse). The same article estimates that wastage is at least 20% of total health expenditure. It is not uncommon to hear those currently in charge to say “there is no more efficiencies left, any further cuts will result in compromising patient safety and the real problem is that it is a lack of funding!” That is why these 6 categories of waste are unlikely to be realised by incumbents if that is their starting position.
Creating and implementing new services is the second part of this transition. This is about creating and developing new services not re-engineering or changing or modifying existing services. Different talent, capabilities, capacities, skills and knowledge are needed compared to what is needed to manage or improve current services.
How incumbents make this transition will almost entirely be dependent on the quality of their organisation leaders, their awareness of seismic and rapid changes taking place around them and their ability to appropriately respond. Too often managing change also suffers from a lack of discipline in implementation and inappropriate knowledge and use (sometimes none at all) frameworks and tools. Without a sound understanding of the complexity of presenting challenges and the use of appropriate tools and frameworks, implementation takes too long, ineffective and fails to make any impact.
Useful frameworks
Some useful frameworks to provide a discipline approach to support development and implementation of new services include:
Complex change requires a “discovery approach” to implementing portfolio of safe to fail initiatives. Complicated and simple change can benefit from good practice and best practice but are inappropriate for complex change.
An integrated reform in four key domains for change to be sustainable:
1) New Service Model
2) New policies, regulatory and funding regimes
3) New organisation and business models
4) New enablers & resources (workforce, IT, facilities, devices, data)
- The 10%, 20%.30% and 40% of change:
1) 10% being the good idea
2) 20% is the passionate leadership
3) 30% is the organisation culture, talent, capacity, and capability
4) 40% is the operating environment and context at local to international levels
- Disruptive change to solve unmet need requires:
1) New partners. They must share not just the same ambition but also the same values. Some must come from outside the health sector
2) New networks. This is necessary to mitigate barriers from mainstream networks that will be difficult or costly to access.
3) New organisation and business models. They mean different things. Of particular interest will be the platform organisation models and the complementary platform business models
4) New talent, capabilities, capacities, skills and knowledge for improving current services as well as creating new services.
5) Focus on the edge and margin. Look for where the edges are. It is where there is currently significant unmet need. At the edge, mainstream and incumbents are paying least attention.
6) New services design to reach those consumers currently missing out need to be affordable and initially do not need all the bells and whistles.
New entrants collaborating with like-minded health care sector players
A big part of the new and better models of care for seniors is to take a broader system view of well-being. This includes making changes to, connecting with the broader determinants of well-being including housing, utilities, transport, diet and social interactions.
Many of these services are already being provided by ecommerce organisations. It should not be a surprise that in the near future these non-health sector players collaborating with like-minded health care sector partners are likely to drive many of these disruptive changes in the health care sector. Successful ecommerce organisations are good at engaging and improving consumers’ experience, use of modern technologies and have an appetite to innovate and enter new sectors including the healthcare market. The entry of Amazon, Berkshire and JP Morgan into the US healthcare market and their appointment of Dr Atul Gawande as CEO is the most obvious example of such an approach.
Conclusion
Solving and finding better ways to care for seniors holds the key to a sustainable future for health and social services. The catalyst for this change is a growing disquiet and frustration of seniors and their families coupled with the entrance of new players partnering with liked minded incumbents that understand how to harness consumer power. The development of new and better models of care and associated business models will happen and will be disruptive. The challenge of managing the transition of this disruptive change is to make sure in maximising the benefits and minimising the cost, the gains are inclusive, equitable and sustainable.
Change has to take place right across the continuum from self-care to palliative care. Retaining, improving and eliminating the wastage from the best of current services are necessary but not sufficient. New and better service models supported by appropriate business models need and will emerge. This is unlikely to happen if left to the current decision makers and vested interest running the system. That is why seniors especially the baby boomers cannot sit back but have to drive this change as consumers.