Posts Tagged ‘caregiver’

“Supportive policies such as respite care or training and counselling may […] be needed in order to sustain informal care as an important resource of our health care systems.” The quote comes from Ellen Verbakel et al in their paper on informal care in Europe[i]. But is it just “respite care or training and counselling” what is needed? The paper indicates that, on average, one in every three people in Europe are informal care givers. What is more, one in every six of those care givers is 65 or older. In a back of the envelope calculation, 22 million Europeans are informal care givers and over 65. I do not think that respite, training and counselling is enough.

In Europe, when reaching 65, most of the population looks forward to a nice peaceful retirement but instead, 22 million face a continuation of their dedication to somebody else with bad heath or ageing deterioration. This happens at a time when the carer is going through ageing himself. We need to manage the situation from a holistic point of view. The interrelation between carer and cared takes place in a particular environment: the home. Even if some aspects are outside of the participants’ control, such as the neighborhood, some others are within their reach. I am referring mostly to those aspects of the household that can make life easier and safer for both carer and cared. Aspects that are not only geared towards the comfort of the cared, but also to the comfort of the carer.

Ergonomics was born in the workplace. Its aim is to design the workplace taking into consideration the characteristics and limitations of the worker. The result is that, by reducing risk factors, the worker improves his performance. The workplace of the carer is the home. By introducing ergonomic design into the home, we can create a safer place for both carer and cared and a more efficient care process. And last, but by no means least, a more enjoyable life for the carer.

[i] Ellen Verbakel, Stian Tamlagsrønning, Lizzy Winstone, Erlend L. Fjær, Terje A. Eikemo, Informal care in Europe: findings from the European Social Survey (2014) special module on the social determinants of health, European Journal of Public Health, Volume 27, Issue suppl_1, February 2017, Pages 90–95, https://doi.org/10.1093/eurpub/ckw229

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During the pandemic, care-homes have been rat-traps for old people. In Canada more than 80% of deaths attributed to Covid-19 have been in care-homes; in places like England or Germany, the ratio was almost 40%. In Spain, the ratio is 68.67% according to estimates published by RTVE. I would say that something must be done.

I have written before about care-homes (see Services and conveniences) and the need for trained carers. But beyond that, what is needed is a complete overhaul of the way we care for old people. In most countries the system pivots on care-homes instead of caring at home.

Very few people argue that staying at home is the preferred choice of old people. It gives autonomy and independence, as well as familiar surroundings. Those characteristics are invaluable comforts as age advances. And not only that: according to a study, in Alabama those receiving care at home saved the State $4,500 a year, compared with those in care-homes.

As I see it, the only barrier to change the system is the system itself. Care at home implies a complete disruption of the care system logistics. It is easier to hire and control a care person in an institution. In the institution, the system can control comings and goings as well as productivity through close supervision. When you have people going from house to house, you have to give the person autonomy and trust that the work will be well done.

It is easy to see that the professional doing one institutionalized job, and the one doing the home care job have to have quite different training. They do basically the same work, namely helping with basic daily activities, so the difference is not in the acts to be performed. The basic difference is in trust, and trust comes with professionalism to be learned through proper training of attitudes more than aptitudes, even if the latter are also important. Unfortunately, I think the system is not ready for training real care professionals when it is relying on mostly immigrants, untrained and underpaid, who do the best they can with very little preparation.

Note: all the figures cited are taken from The Economist July 25th 2020 “The pandemic shows the urgency of reforming care for the elderly«

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When we talk about healthcare, even if nominally we are focusing on the patient, the reality is that we program the care process based on the capabilities and needs of the healthcare professional. If we didn’t do that, we still would have the family doctor coming home or, more realistically, Primary Care would be the prima donna of the healthcare process instead of the ugly duckling.

When we talk about social care, we rarely focus on the caregiver. We take for granted that the dear unmarried daughter will take care of her parents; is there anything better that she can do with her life? With that goes the assumption that the public purse does not need to divert its valuable resources to care for old people; there is always a family member willing to take care of the ageing person.

And this is the norm all over the world, and certainly all over the European Union.

In a previous post, “Beyond Covid-19”, in a back-of- the-envelope calculation, I estimated that Europe needs 23 million persons per year to work as caregivers. Let us assume that 10€ an hour is a reasonable medium wage in the EU, and we will get to a staggering 354,200 million € a year, roughly twice the annual budget of the EU.

I am not very optimistic about countries in the EU adding 2% of their GNP to their budgets. From now on, we will have to rely on imaginative approaches to care for our old people’s caregivers.

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I am taking the title from one of the chapters of the book New Ageing by Matthias Hollwich. The introduction to the chapter reads “At some point in our lives, things will get a bit harder and we will need help in one way or another. The best kind of help eases the way forward without replacing the capabilities we still have”.

It is this last sentence that has been haunting me for years. And not only in reference to informal care but also with formal care, including institutional care. Many years ago, I directed a study for nursing homes all over Spain. Of the many months I was involved in the project one comment from the director of one of the nursing homes has been engraved in my head. He told me, and I quote, “We are a factory of dependent persons; put an independent person in a nursing home and, in less than six months, that person will become dependent”.

Add to that, the above average incidence in the mortality rate that Covid-19 has caused in nursing homes all over Europe, from Sweden to Spain, and you will get a much less  rosy picture of nursing homes as a recourse for old people’s care.

A recent paper by the European Commission, Informal care in Europe: Exploring Formalisation, Availability and Quality, states that “Informal care forms a cornerstone of all long-term care (LTC) systems in Europe and is often seen as a cost-effective way of preventing institutionalisation and enabling users to remain at home”.

What I see as a problem is that, because of their lack of proper training, informal caregivers, and more if they are family members,  tend to overpower the old person: “Don’t do that”; “I’ll get it for you”; “Be careful, you’ll fall”, etc.. So, we go back to the beginning: the problem is to help the old person “without replacing the[ir] capabilities.”

We need to train informal caregivers. Basically, we need somehow to care for informal caregivers, to train and support them, even provide financial support for them, as the EC maintains. But training should be the first objective, since a properly trained caregiver will know how to take care of the old person and, equally important, of him or herself.

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I can understand that what happens today is more pressing than what will happen tomorrow, but that does not mean that today is more important. I think we should start looking at tomorrow and start planning what we will need for a world beyond Covid-19.

As of today, one of the few things we know for sure is that SARS-CoV-2, which produces the Covid-19, infects more old people and mainly those with previous chronicity. That means that it is old people who need more care.

Care that, we have also learned, would be better given at home than in nursing homes. Gathering vulnerable people in close quarters has proved not to be the best solution if we want to avoid the spread of a communicable disease.

Only if we are capable of building an army of caregivers will we be able to give home care in the EU to that 19% of the population aged 65 and older.

With a total population of almost 513 million people, we will need to take care of 97 million old people (all figures from Eurostat). Just for the sake of discussion, let us assume that we need one hour per day of care per old person. With an estimated 1.540 productive yearly hours per person, we will need almost 23 million caregivers. The fact that many of those 23 million will be informal caregivers does not make the hours and the people less essential.

Who will take care of that army of caregivers? Who will be providing training, moral and physical support for them? Very little is done today in that domain and almost nothing if we focus on informal caregivers. I think we must start getting ready to tackle caregivers’ needs, formal and informal, so that we will be able to provide our old people with the best possible care by the healthiest and most motivated caregivers.

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