Life expectancy has increased very fast over the past fifty years. A woman age 65 in Sweden in 2003 had a life expectancy of 20.3 years, while a man had 17. In contrast to the earlier situation, male life expectancy is now rising more rapidly than female. Most of this increase concerns life expectancy after age 50.
One important question related to future care needs is if we get older with improved health or if poor health will increase due to longevity. There are three common theories to describe care needs in relation to health in the population. According to the most optimistic theory-compression of morbidity-the years with poor health will decrease if the number of years in good health increases faster than the total number of years of life. This might be wishful thinking. Still hopeful is the theory of postponed morbidity, which states that the period of poor health will not increase as the mean age for onset of poor health is postponed and life expectancy increases. This is an acceptable prospect. The third alternative, the theory of expanded morbidity is more pessimistic telling us that we will live longer also with poor health. An increasing number of old people with serious health problems will survive due to good medical treatment. Thus, increased life expectancy will give us more years with poor health due to severe diseases like dementia and the need for elder care and medical treatment in old age will continue to increase. Even if we do our best to prevent illness, longevity in itself is a risk factor.
In Sweden, long-term care is a public responsibility and for the most part financed by taxes. The users pay a low fee, on the average 5 to 6 percent of the cost. Everyone, regardless of income should be able to afford elder care. Public expenditure on long-term care for older people is nearly 3 percent of the GDP. As shown in the figure below, it is much higher than in other OECD countries.
To meet the needs of an aging population the Swedish Government and Riksdag (parliament) have decided on a policy for elder care based on home care. There is an ongoing development with a decreasing number of beds in long-term care institutions and increased resources directed to home care. Today, and even more in the future, elder care will be provided by home care. Institutional care will probably be more or less reserved for people with dementia related diseases or other conditions difficult to care for in a private home.
The large majority of Swedes manages their chores and lives independently in old age. Up until age 80, few people need elder care. In 2004, 128,000 persons age 65 and over were provided for by home care. Elder care institutions housed 110,900 people. An illustration of the coverage ratio for home help and institutional care is given in the figure above. It shows clearly how the need for elder care increases with age. The coverage ratio is considerably higher for people age 80 and over than for all people over 65. The ratios are the same for home care and institutional care. Formal long-term care is well developed in Sweden with regard to coverage ratio, content, and quality. Still, informal care, provided by relatives, has an even larger coverage ratio. The figure above also shows diminished utilization of long-term care from 1993 to 2003. This decrease is above all due to stricter assessment of care needs. This also means that old people are more frail and dependant today in terms of physical functioning as well as cognitive capacity when moving to institutional care.
Sweden is different from most other countries with regard to the variety and complexity of needs that can be satisfied by home care.
Home Base Service and Care:
- Home help (including domestic chores and personal care)
- Home nursing care
- Meals on wheels
- Technical aids
- Day care
- Security alarms
- Transportation services
- Housing adaptations
- Snow removal and gardening
- Handy-man service
Home help includes a wide range of services, from help with domestic chores to advanced nursing care. For a frail, but fairly healthy old person who lives alone, a security alarm connected to a home help center might be just the right level of support to continue an independent life. Transportation services enable people with disabilities to participate in normal life. Meals on wheels are often combined with other services provided by home help as house cleaning and laundry. Most receivers of home help however have larger needs and get help with personal care and medication. For people with dementia there are day care facilities. There are also facilities for short-term care either for rehabilitation purposes or as relief-care.
There is the possibility to provide home care to people with extensive and complex needs of care around the clock. Of those age 65+ with home care, 3.5 percent (4,500 persons) receive help more than 120 hours per month. The clients receiving home care to such an extent have care needs comparable to people living in nursing homes. For this group, home care means a possibility to age in place in spite of frailty and ill health in old age.
To meet the needs of an aging population traditional long-term care is not enough. We have to develop new strategies and integrate the knowledge on health promotion and prevention. We need to develop methods to support an increasing number of healthy elderly to maintain their functional ability. That is an important challenge!