Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3

Published by: Norwegian Ministry of Health and Care Services Innovation in the Care Services Internet address: www.government.no

Cover illustration: «Bakkerekord» by Kristian Finborud

Printed by: Government Administration Services 08/2012 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3

Innovation in the Care Services

Report by the Committee appointed on 26. June 2009 Submitted to the Ministry Health and Care Services on 16. June 2011

Translation from the Norwegian. For information only. Contents

1 Appointment, mandate and 2.3.4 A national programme for activities of the committee ...... 5 municipal innovation in the 1.1 Appointment ...... 5 care services ...... 16 1.2 Mandate ...... 5 2.3.5 The care services as an industry . 17 1.3 The committee's activities ...... 7 1.4 To the mandate ...... 9 3 Myths about care services and themes for the future ...... 20 2 Perspective and summary ...... 10 3.1 Future challenges for the 2.1 Innovation in the care services .... 10 care services ...... 20 2.1.1 The care services sector as 3.2 Five myths about care services .... 21 a historical innovation ...... 10 3.2.1 The myth about elderly care ...... 21 2.1.2 New solutions for six future 3.2.2 Myth about the «elderly boom» .... 24 challenges ...... 11 3.2.3 The 25 per cent myth ...... 25 2.2 New policy ...... 12 3.2.4 The myth about informal care ..... 25 2.2.1 A policy that removes barriers 3.2.5 The illness myth ...... 27 for people with reduced 3.3 Falls, loneliness and cognitive functionality ...... 12 decline ...... 28 2.2.2 An active ageing policy ...... 12 3.3.1 Falls ...... 28 2.2.3 A modern policy for 3.3.2 Loneliness ...... 29 informal care ...... 13 3.3.3 Cognitive decline ...... 29 2.3 The committee's five proposals ... 14 3.4 Borderless care services ...... 31 2.3.1 «Close caregiving» – the second 3.4.1 Patients and users without Coordination Reform ...... 14 borders ...... 31 2.3.2 «Technoplan 2015» – technological 3.4.2 International labour market ...... 31 support for the care services ...... 15 3.4.3 International providers ...... 32 2.3.3 «New rooms» – future housing solutions and neighbourhoods .... 15 Reference ...... 33 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 4 Innovation in the Care Services Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 5 Innovation in the Care Services Chapter 1

Chapter 1 Appointment, mandate and activities of the committee

1.1 Appointment gen, Adviser at KS Konsulent, have assisted with the writing of this document. In Report No. 7 (2008-2009) to the Storting, An innovative and sustainable Norway, the Govern- ment recommended that a committee be 1.2 Mandate appointed to explore new innovative solutions for meeting future challenges in the care services. Presentation «Society is facing demanding challenges in the The committee was appointed in Council on 26 care services in the coming decades related to an June 2009 and comprised the following members: increasing number of elderly, new user groups Kåre Hagen, Oslo (chair) and a shortage of health and social services per- Siv Iren Stormo Andersson, Bjugn sonnel and volunteer care providers, cf. Report Glenn Kenneth Bruun, Oslo No. 25 (2005-2006) to the Storting, «Long-term Siri Bjørvig, Tromsø care – Future challenges, Care Plan 2015.» Annichen Hauan, Oslo The municipal care services consist of exten- Karin Høyland, Trondheim sive, round-the-clock activities that are carried out Shahzad Rana, Oslo by a small number of managers, a large number of Bente Skansgård, Oslo personnel, a high percentage of employees with- Per Gammelsæther, Fræna out professional training, many part-time workers, Tove Johanna Fagertun, Bodø a very high percentage of women and often sim- Ivar Leveraas, Oslo ple technical aids. Furthermore, care services involving daily life, meals, activities, and social Committee member Shahzad Rana took part in and cultural factors are identified in most studies the first meeting only. as among the weakest services today. There is therefore both a tremendous need and a vast The secretariat has consisted of the following potential to take innovative steps and find new members: solutions for meeting future challenges in the care Steinar Barstad, Policy Director, Ministry of services. Health and Care Services (chair of secretariat) The municipal care services have gross opera- Astri Myhrvang, Senior Adviser, from the secretar- tional expenses of roughly NOK 70 billion, divided iat for the National Council for Senior Citizens until more or less equally between about 40 000 nurs- 1 february 2010 ing home residents and some 160 000 recipients Allis Granberg, Senior Executive Officer, Ministry of home care services. Despite its size, this sector of Health and Care Services from 1 february 2010 has been the subject of very little systematic Åshild Willersrud, Strategic Adviser, Division for research and development activity. Innovation and Development of the Norwegian Consequently, there is much to be gained by Association of Local and Regional Authorities (KS) focusing attention and effort on a sector in which Espen H. Aspnes, Innovation Adviser, InnoMed a great deal can be achieved with relatively limited Geir Petterson, Adviser, Ministry of Trade and resources. The municipal care services have great Industry, has followed the committee’s activities. potential to implement innovative, creative measures in relation to: In addition, Siv Svardal, Senior Adviser at the Min- – new technology in a conservative sector that istry of Health and Care Services, and Une Tan- has shown limited capacity to make use of new technical aids, new care services technology, 6 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 1 Innovation in the Care Services

Smart House solutions and new communica- based on expanded collaboration with user organ- tions technology; isations and idealistic enterprises. – new architecture in a sector that is not ade- The committee is also to assess the potential quately prepared to address the future prefer- for developing care services products through ences, demands and challenges of new user cooperation between the public and private sec- groups and new generations of elderly; tors, focusing in particular on the development of – organisational development in large enter- architecture and new technology. prises that have broad-based cooperation with Report No. 7 (2008-2009) to the Storting, An families, local communities and the specialist innovative and sustainable Norway, states: health care services and where the users should be challenged and given greater influ- «The committee must be composed in a way ence; that ensures it can view the care services sec- – research on a sector that has been the object of tor with new eyes, with representatives of the virtually no research activity and where hard- business sector and professional circles as well won research funding still comprises only a as development-oriented representatives from tiny proportion of the overall budget. the municipal sector, the care services and the users of the services.» This is some of the background for why the Gov- ernment chose to focus on the care services sec- In keeping with the mandate, the committee com- tor in its white paper on innovation policy (Report prised 11 members from the areas of business, No. 7 (2008-2009) to the Storting, An innovative technology, innovation, architecture, and health and sustainable Norway) when considering inno- and social care as well as key representatives for vation in the public sector. The white paper rec- the users. The chair of the committee has held ommended that a public committee be established positions as research director at the Institute for to address these issues and laid down some guid- Labour and Social Research (Fafo), departmental ing principles which are now more closely defined head at BI Norwegian Business School and chair and specified in the attached mandate for the com- of the programme board of the Programme for mittee. Welfare Research. He has also participated in The mandate specifies in particular that the many future-oriented research and development committee is to focus on the following: projects. – new technology There are six women and five men on the com- – architecture and new types of living arrange- mittee. ments The committee is to submit its final evaluation – user influence and skill mastery and recommendation in the first half of 2011. – research and development activity

On this basis, the committee has been charged Mandate with the task of assessing new solutions and mak- On the basis of Report No. 7 (2008-2009) to the ing recommendations for the design of future Storting, An innovative and sustainable Norway, nursing homes, types of living arrangements and and in cooperation between the public and private services to ensure that these will meet the needs sectors, the committee is to assess the potential of future users and make the most of their and make recommendations for new innovative resources. measures and solutions designed to meet the In its efforts, the committee is to emphasise future challenges of the care services, with special that the services offered must, in keeping with the focus on: Care Plan 2015, have a more active profile that –new technology encourages greater user influence, user skill mas- – architecture and new types of living arrange- tery and active participation by the individuals, ments their families and social networks. New types of – user influence and skill mastery living arrangements, forms of organisation and – research and development activities the use of new technology must first and foremost promote this objective. The committee is to assess On this basis, the committee has been charged the potential for developing new forms of owner- with the task of assessing new solutions and mak- ship and operation and new types of cooperatives ing recommendations for the design of future nursing homes, types of living arrangements and Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 7 Innovation in the Care Services Chapter 1 services to ensure that they meet the needs of tional forms and living arrangements used for future users and make the most of their caregiving purposes with a view to standardising resources. The committee is to emphasise that the terms used and simplifying the statistics and the services offered must, in keeping with the regulatory framework. Care Plan 2015, have a more active profile that The committee’s activities are to be based on encourages greater user influence, the users’ own the assumption that the care services of the future skill mastery and active participation by the indi- are rooted in publicly-funded schemes and a viduals, their families and social networks. New dynamic, humane civil society. Such community- types of living arrangements, forms of organisa- oriented care services encompass the municipal tion and the use of new technology must first and care services, family-based caretaking, local com- foremost promote this objective. The committee is munities, and user-driven and volunteer organisa- to assess the potential for developing new forms tions working in close cooperation with the spe- of ownership and operation as well as new types of cialist health care services and other sectors. The cooperatives based on expanded cooperation with committee's recommendations are to be formu- user organisations and idealistic enterprises. lated on the assumption that the collective The committee is to view its endeavours in a resources of civil society and the public and pri- light of long-term thinking and development vate sectors are utilised in an economically benefi- trends, and view its task in the context of preven- cial way for society. tion. At the same time, the committee’s activities The committee is to submit its final report and must be directed towards ensuring that the local recommendations within the first half of 2011. The care services are made capable of assuming new, ministry stipulates that the committee must professionally demanding tasks, as stipulated in employ an open work method and remain avail- the Coordination Reform. With a view to planning able to receive input and discuss key topics with the care services of the future, the committee is to various professional groups, government councils identify specific research needs and submit pro- and special interest organisations, including iden- posals that can strengthen research and develop- tifying an effective means of coordinating its ment activities in the municipal care services. The efforts with the activities of the technical aids committee may also take the initiative to raise committee (Hjelpemiddelutvalget). questions and propose measures aimed at enhanc- ing innovation and research in the care services sector. 1.3 The committee's activities The committee is to assess the potential for product development, business development and The activities of the committee are planned to be export activity arising from cooperation between carried out in three phases: the private and public sectors in the field of care 1. Autumn 2009: Brainstorming services, focusing in particular on the develop- 2. Spring/autumn 2010: Compilation and system- ment of architecture and new technology. atisation of knowledge Smart House solutions and new technology for 3. Winter/spring 2011: Writing and completion of care services create new opportunities for the the report users to master their own daily lives, and can help to promote independence and autonomy. Tele- A total of 12 committee meetings were held: one medicine and new communications technology three-day meeting, four two-day meetings and make it possible for the health and care services seven one-day meetings in Oslo, Drammen, Gard- to improve, simplify and enhance the efficiency of ermoen, Drøbak, Trondheim and Arendal. their activities. The committee is to assess the eth- At the start of its work, the committee ordered ical aspects of its proposals and the impact of three state-of-the-art overviews and reports from these proposals on the individual’s personal pri- the Norwegian Knowledge Centre for the Health vacy, especially in relation to the use of new notifi- Services: cation and monitoring technology. – Holte, Hilde H., Kirkehei, Ingvild and Gunn E Over the years, various institutional solutions Vist: Omsorgsforskning i Norge («Care Services and living arrangements featuring a wide array of Research in Norway») names, designations and schemes have been – Bakke, Toril and Hilde H. Holte: Kartlegging av developed in the municipal health and care ser- nye eier- og driftsformer i omsorgssektoren basert vices. The committee is therefore charged with på samvirke, brukerstyring og kooperasjon reviewing and systematising the various institu- («Overview of new forms of ownership and 8 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 1 Innovation in the Care Services

operation in the care services sector based on committee’s chair held talks and presentations at interaction, user control and cooperation») several large conferences in Norway. At two of – Hofmann, Bjørn: Etiske utfordringer med vel- these, the committee was responsible for work- ferdsteknologi («Ethical challenges related to shops in which the participants were invited to welfare technology») take part in the work on the future challenges in the care services. In addition, researcher Ivar Brevik of the Norwe- In June 2010, the entire committee held a joint gian Institute for Urban and Regional Research meeting with the members of the innovation alli- (NIBR) prepared an historical account of the ance for the municipal sector under the Norwe- development of various types of institutions and gian Association of Local and Regional Authorities living arrangements used for caregiving purposes, (KS). During this meeting, work groups dis- which served as the basis for the committee’s cussed the main issues set out in the committee’s work with future types of living arrangements mandate. (Brevik 2011). In connection with the annual InnoMed con- Research fellow Eline S. Lorentzen Ingstad ference in 2010, professional organisations, user submitted a memorandum to the committee organisations, municipalities, companies, etc. which was used in the committee’s discussion of were invited to attend a seminar where informa- social entrepreneurship. tion about the committee’s activities was pre- In the phase of compilation and systematisa- sented and participants were invited give their tion of knowledge, various presenters were input and responses. The seminar was organised invited to speak on relevant topics at all of the in cooperation between Innovation Norway and meetings held in 2010. InnoMed. The committee received assistance from vari- The committee’s chair gave 48 presentations ous departments in the Ministry of Health and and lectures at conferences, seminars, meetings Care Services and from the Research and Innova- and events at the national, regional and local lev- tion Department in the Ministry of Trade and els. Together with the secretariat, the committee’s Industry. chair held separate meetings with the Norwegian A meeting was held with the chair of the tech- Association of Pensioners, the State Council of nical aids committee, Arnt Holte, in which issues Equality for the Disabled, the Norwegian Associa- were discussed and boundaries for the work of tion of Local and Regional Authorities (KS), the the respective committees defined in relation to Confederation of Norwegian Enterprise (NHO), technical aids and welfare technology (see Nor- Innovation Norway, a number of professional wegian Official Report 2010:5 Aktiv deltakelse, like- organisations, associations, user organisations, verd og inkludering («Active participation, equality municipalities, industries, companies, university and inclusion»). colleges and professional circles. Input was also A meeting was also held with the chair of the received from several organisations and enter- official committee on benefits for providers of prises. informal care who replace municipal services, During the committee’s work, KS adminis- Karen Kaasa, in order to find an expedient means tered two questionnaires to its members about the of coordinating and distributing the tasks related use of welfare technology and local partnership to issues of pay for family caretakers and the pol- agreements with NGOs in the municipalities. Sta- icy for informal care. tistics Norway participated in a Nordic study of The committee’s chair and secretariat held innovation in public sector activities, and the com- meetings with various players in Scotland, Swe- mittee had the opportunity to pose questions to den and Denmark for the purpose of gathering Norwegian municipalities. knowledge and learning from the experience of On its own initiative, Abelia, a trade and others. employers’ association associated with NHO, con- In keeping with the committee’s mandate, an ducted a survey of its members which provides an open work method was employed which entailed overview of the number of people involved in the contact and meetings with a number of compa- production of services and products for the care nies, organisations and professional circles. The services sector. Abelia has followed up these committee practiced an «open door policy», mean- efforts by establishing an arena for safe care. ing that those who wished to communicate with The committee also established a dialogue the committee were given the opportunity to meet with the Data Inspectorate to achieve further clar- with the committee’s chair and secretariat. The Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 9 Innovation in the Care Services Chapter 1 ification and obtain advice related to personal pri- will always be present. The care services probably vacy and tracking technology. often view themselves as a «second-rate health service» when they compare themselves with the specialist health care services. The committee has 1.4 To the mandate therefore focused on other key aspects of the care services and touches in particular on the interac- While carrying out its activities, the committee tion with families and civil society. These services has seen a dramatic rise in interest in the issues find their own distinctiveness in their relation to that are central to the committee's mandate. The and interaction with families and local communi- committee has therefore considered it a key task ties, which no specialist health care services can to encourage this interest and to generate a com- match. This is «close caregiving». mon movement by bringing together different The mandate given to the committee is quite professional circles and linking care services in broad and addresses future-oriented topics, each the municipalities to knowledge circles that of which deserves an entire report. The commit- understand the significance of the care services tee has attempted to carry out its task primarily sector for value creation in society. by restricting itself to the main themes and then In the course of its activities, the committee selecting a few issues for more thorough assess- has determined that it is especially crucial to high- ment. By the same token, the committee has cho- light the distinctive character of the care services sen to pass on and communicate some of the ideas and to strengthen their identity and pride by giv- it has discovered along the way, not least in its ing the care services the opportunity to develop encounter with many committed users and profes- their own knowledge base. Thus, the committee is sionals in the sector or players in research and pleased that the mandate has been so clearly business that have now turned their attention defined and does not open the door for addressing towards the care services. These are ideas that larger medical and health-related issues and top- need further consideration and study. ics. A health services and treatment dimension 10 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 2 Innovation in the Care Services

Chapter 2 Perspective and summary

2.1 Innovation in the care services would mean for birthrates and the family's ability to provide care. In retrospect, the Nordic welfare The terms «innovation» and «care services» come model has proven to have both economic and from two different worlds. Many would think of demographic sustainability. Birthrates in Norway these terms as complete antitheses, and be scepti- are significantly higher than in countries where cal to using them together. However, the tension the women in the family are responsible for most inherent in their pairing gives rise both to curios- of the caregiving tasks. ity and to new ways of thinking. Innovation is a This does not mean that the solution devel- term that designates change and creation with rel- oped 40 to 50 years ago will necessarily be robust evance to all areas of life and society. enough to meet the challenges Norway will be facing in the coming decades. Most of the attempts to forecast trends by expanding on the 2.1.1 The care services sector as a historical current system with the same rate of growth expe- innovation rienced in recent years point to an impossible situ- From a historical perspective, the public care ser- ation in a few decades. The successful innovation vices sector, as developed in the Nordic countries, that the expansion of the care services represents may be regarded as a major innovation in itself. It from a historical perspective should provide inspi- is just that the term «innovation» has not been ration for new ways of thinking in the future as applied to the strong growth of municipal homec- well. If as many developments take place in the are and institutional care services that occurred sector in the next 50 years as in the past 50 years, about 40 years ago. The expansion of these ser- the situation may look entirely different. vices was a response to some of the most crucial On the other hand, the committee advises challenges that society faced at the time: against entirely dismantling a model shown to be – the dramatic rise in the number of elderly; sustainable and capable of responding to the – the lack of labour; major societal changes that have occurred during – the need for gender equality in the family and this period. The committee has therefore chosen working life. to retain the welfare model with local municipal responsibility for the caregiving tasks, and has The innovative solution was to move part of the been more concerned with identifying new adap- care arena out of the family and the private sphere tations and making changes to enable Norway to by expanding the public welfare schemes. This provide community-based solutions in the future means of transferring, or «outsourcing», caregiv- as well, as stipulated in the mandate. ing tasks helped to enhance gender equality and In the quest for areas of potential innovation, freed up women to participate in the workforce. the committee wishes to point out that the most The proportion of women in the labour force in exciting renewal may occur in the interface Norway is now one of the highest in the world. At between the public sector and civil society. the same time, this established the basis for a new Achieving such renewal may be contingent on distribution of caregiving tasks between the fam- proximity to the local administrative level. In this ily and the public sector, making it possible to sense, the care services sector is strategically combine caregiving with employment and educa- well-placed in the municipality. No major shifts are tion. Thus, the new care services sector became a required. In most places it is an integral part of key component of the social value creation in soci- the local level and cooperates closely with users, ety and the infrastructure for working life. Many families and the local community. In the coming were concerned about what this development years, the care services should better exploit the Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 11 Innovation in the Care Services Chapter 2 potential right in front of them to achieve innova- In its work, the committee has taken as its tion across the municipality as a public administra- starting point three of the most common prob- tive level and the municipality as a local commu- lems encountered by the care services: nity. –falls; The care services constitute one-third of all – loneliness; municipal activities. Consequently, what occurs in – cognitive decline. the care services sector has a crucial impact on the municipality as a whole. Innovation efforts in These three factors mutually affect one another the care services sector should therefore be con- and reach into most areas of the health and social ducted as part of an integrated innovation initia- services sector. The committee has chosen to use tive in the municipal sector, where solutions are these as an illustration and practical point of sought in the interface between the health and departure for identifying and testing new solu- social services and the other municipal sectors tions, work methods and approaches. and between the municipality, the local community and the private sector. The sixth challenge Additionally, the committee points to the chal- 2.1.2 New solutions for six future challenges lenges and opportunities inherent in these prob- In Report No. 25 (2005-2006) to the Storting, lems when viewed in an international context, «Long-term care – Future challenges, Care Plan where: 2015»», the Government identified five future – the personnel market is becoming internation- challenges. Two of these address problems that alised, and the care services workers are will increase in the future: increasingly exported and imported; – the number of new younger user groups; – larger service providers operate in an interna- – the number of elderly in need of assistance. tional market, often in the form of multinational corporations; Three of the challenges address areas in which – a growing number of patients and users are there are deficiencies: crossing national borders for treatment, recu- – the shortage of volunteer care providers and peration and physical training. health and social services personnel; – the lack of coordination and medical follow-up; The contours of the future must also be viewed in – the lack of activities and coverage related to light of the vast changes occurring in the age psycho-social needs. composition of the population in both Europe and the world at large. There is reason to believe that The committee has based its work on these five this will affect all markets and social sectors main challenges, and refers to the analyses pre- throughout the world. In this context, Norway is sented in Report No. 25 (2005-2006) to the Stort- more fortunate in that it is experiencing less dra- ing. The Government has followed up efforts matic changes in this regard than the other coun- relating to these five challenges through the Care tries in Europe. However, Norway will be strongly Plan 2015 and prepared a separate Coordination affected by events elsewhere in the world, and Reform on cooperation between the municipal should also be cognisant of the market-related health and care services and the specialist health opportunities this generates. Society will face care services. The committee has therefore major challenges relating to care services in the decided to focus its efforts on those issues and coming decades. These will be demanding needs that are not incorporated under the existing enough without being made worse by dire predic- activities to the same degree. In keeping with the tions and worst-case scenarios. In the view of the mandate and on this basis, the committee has put committee, the future challenges for the care ser- emphasis on investigating new action points and vices cannot be dealt with by the health and social solutions for meeting the caregiving challenges in services sector alone. They must be addressed on a time horizon that extends beyond the Govern- the basis of a public responsibility involving most ment's Care Plan 2015, with special focus on tech- of the sectors in society and by supporting and nology, alternative housing and organisational developing new forms of involvement and partici- solutions, research, innovation and business pation by the families and local communities, opportunities. organisations and enterprises. The issue at stake 12 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 2 Innovation in the Care Services has just as much to do with the kind of society local services, independent housing and the Norway seeks to build for the future as with how opportunity to lead as normal a life as possible. the health and care services sector will develop. If the welfare society is to realise values such as participation, independence, autonomy, dignity 2.2 New policy and normalisation, the users must have a high degree of influence and control over their own life Care services for all situations. Treatment for a wide variety of problems, diagno- The committee believes that this policy will be ses and disabilities relating to the entire life resilient enough to address the future challenges course from childhood and adolescence to adult- in a wide range of areas. It is reasonable to hood and old age are now encompassed under the assume that the new elderly generation will follow municipal care services. The care services sector the lead of the younger users of municipal ser- has experienced significant growth, incorporated vices. New generations of elderly will meet their many new user groups and assumed a number of old age with a completely different set of new tasks over the past 20 years. It has become a resources and will not accept being placed on the sector that provides services to everyone who has sidelines. Parts of what is referred to today as a need for assistance and care. institution-based elderly care are therefore ripe A future-oriented care services policy requires for reform with the same goals as similar reforms a broad societal approach to future user groups. implemented in the past 20 years for various Therefore, the committee's recommendation is groups with reduced functionality. based on the assumption that the policy of dis- Many of the innovative solutions and action mantling disabling barriers in society will be con- points that should be implemented in the munici- tinued and strengthened. The committee also rec- pal care services may simply be a matter of trans- ommends the formulation of a new active ageing ferring the experience from the responsibility policy for all areas of society and a modern policy reform for mentally impaired persons carried out for informal care that is framed on equality in the 1990s to the area of elderly care. between men and women and partnership between users, close relatives or friends and the care services. 2.2.2 An active ageing policy The committee also believes that Norway must develop a new policy for senior citizens that 2.2.1 A policy that removes barriers for encompasses more than retirement pensions and people with reduced functionality elderly care. An active ageing policy for all areas Dismantling of disabling barriers in society, equal- of society must be developed. ity and participation comprise the main elements The new generation of senior citizens will be of the struggle waged by people with impairments large. Its members will enter old age with a higher in recent decades. There is still a need to combat level of education, better health, longer life span, discrimination and prevent segregation to ensure better housing conditions and more resources. that all segments of the population achieve full More than ever before in history, an elderly popu- participation in working life and society and can lation with substantial resources and purchasing live a normal life in community with others. power will have an impact on all markets, all soci- It is primarily younger people with reduced etal institutions, trade and the economy, demand functionality who are at the vanguard in the devel- and consumption – all over the world. On the one opment of the care services sector. They play, and hand, they will have a better foundation for taking will continue to play, a leading role in: care of themselves than any other generation – the adoption of new technology and technical before them. On the other hand, they will place aids to cope with daily life on their own and to high demands on the global community. be as independent as possible; An active ageing policy invites and expects – the demand for universal design of housing participation in society and politics, in education and the surrounding areas; and cultural life, in the family and volunteer work, – user-driven ownership of service provision and for those who have the opportunity: in busi- organisations and housing options; ness and working life. – implementation of reforms involving the clo- sure of institutions and the development of Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 13 Innovation in the Care Services Chapter 2

An active ageing policy builds bridges between the generations and counteracts segrega- Box 2.1 Seven principles for active tion and age discrimination. ageing An active ageing policy in the health and care services area puts emphasis on prevention and 1. Active ageing entails all meaningful pur- provides a framework so that people can take suits which contribute to the well-being of responsibility for their own lives as they wish by: the individual concerned, his or her family, – making adaptations to their own housing con- local community or society at large, and ditions and nearby surroundings; should not be concerned only with paid – taking part in physical, social and cultural activ- employment or production. ities; 2. Active ageing must encompass all older – participating in education, physical training people, even those who for various reasons and rehabilitation. are frail and dependent. 3. Active ageing is primarily a preventative An active ageing policy is based on the principles concept and implies adopting a life course of autonomy, independence and influence over approach to understanding the ageing one's life, in spite of illness and reduced function- issue. ality. 4. The centrality of intergenerational solidar- The EU has decided that 2012 will be the Euro- ity is a defining feature of active ageing. pean year of «Active Ageing and Solidarity 5. Active ageing entails both rights and between Generations», in which all of Europe will responsibilities. prepare and plan for the demographic changes 6. A strategy for active ageing should be par- that will affect all the countries in the coming ticipative and empowering. decades. 7. The concept of active ageing must respect The committee recommends that Norway take cultural differences and promote diversity. active part in this forward-looking work and for- mulate a senior citizen policy for all areas of soci- Alan Walker, the British professor of social ety. Senior citizen policy will be so central to the policy who developed these seven principles development of society that the Government for active ageing (Walker 1999 and 2002), says should consider giving it a higher profile and a that: more prominent role on the agenda. «Active ageing is intergenerational: it is about all of our futures and not just about 2.2.3 A modern policy for informal care older people. We are all stakeholders in this Due to the future shortage of both volunteer care endeavour.» providers and care services workers, it will be necessary to combine work and caregiving in a different, more flexible way than today. The new policy for informal care must first and Family-based caretaking activity does not show up foremost direct attention towards, and establish anywhere. It remains essentially unregistered in the value of, the contribution of family members, case management files, statistics and public friends and neighbours. It must then ease the time reports, despite its magnitude in terms of man- crunch many experience by providing greater years, which equals that of the public care ser- flexibility in working life, and integrate close coop- vices sector. eration with the municipal care services as a The committee therefore recommends that means of lightening caregiving burdens. the care provided by families is given greater The committee therefore recommends a new emphasis in research and evaluation activities, policy for informal care incorporating six compo- that stronger political focus is directed toward nents: family members and volunteers as a resource, and – visibility; that an integrated policy is drawn up in this area. – gender equality; The individual’s efforts should be given much – flexibility; greater attention and recognition by the municipal – guidance; authorities. Agreements made with family mem- –relief; bers and volunteers should be recorded in the –value. case files and individual plans, both in order to 14 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 2 Innovation in the Care Services coordinate these efforts with the public care services and to assess relevant measures relating to 2.3 The committee's five proposals training, guidance, relief from the caregiving bur- den and finances vis-á-vis the family members. 2.3.1 «Close caregiving» – the second A modern policy for informal care must be Coordination Reform framed on equality between men and women. It The first Coordination Reform has focused pri- would not be desirable to have a care services pol- marily on improving the utilisation of resources in icy that sets back gender equality efforts many the collaboration between the municipal health years. It is therefore satisfying to see that accord- and care services and the specialist health sering to the health and living conditions survey (Sta- vices on health-related and medical issues. The tistics Norway 2008), almost as many sons as «second Coordination Reform» revolves to an daughters are providing help or supervision to equal degree around mobilisation of resources, their elderly parents on a regular basis. In this focusing on cooperation between the family, the context, it is important to expand the focus on social network and the local community. men's role as father to include focus on men's Being a responsible citizen entails more than caregiving functions as sons and spouses. the consumption of public services. For commu- An integrated, more cohesive policy for infor- nity-oriented solutions to work, people must also mal care will facilitate the introduction of new take responsibility for the development and rights and welfare schemes that ensure: design of the services offered, and play a role as – training, support and guidance for family mem- both producer and consumer. Caregiving should bers and volunteers; be an integral part of a thriving, dynamic society – relief for those who have heavy caregiving bur- and this should be manifested in interpersonal dens; relations in the family and local community, organ- – financial security so that family members do isations and institutions, and in informal contexts not also find themselves in a difficult financial where people meet, work and live together. situation; What is needed is to think along new lines – necessary leaves of absence so that family regarding the interplay between the public members do not lose their right to work or schemes and civil society, to explore the new have to take sick leave to care for their close forms of volunteerism, and to put focus on alterna- relatives. tive work methods, forms of operation and organisation that encourage participation of the citi- The committee believes that the future shortage zenry. The committee has decided to call this proj- of labour as well as volunteer care providers will ect the «second Coordination Reform», which tar- require solutions that make it easier to combine gets the family and local community. This reform employment with caregiving, and on this basis will be based on close caregiving, responsible citi- proposes that consideration be given to extending zenship and co-production, and includes: the leave of absence permissible in connection – a national agreement and local contracts for with caring for close relatives to one year. partnership between public and volunteer The committee also proposes the establish- enterprises in the care services area; ment of more comprehensive, flexible schemes – new forms of ownership and operation, such as that provide relief to caregivers in their own cooperatives, user-driven schemes and social homes, as a daytime activity programme and as entrepreneurship; short-term stays outside the home. – new work methods and professional Furthermore, the committee takes note of the approaches that give higher priority to active potential of measures using the new social media caregiving, ordinary rehabilitation, group and new communications technology to reduce methodology, culture and well-being; worry and provide security, guidance, establish – a new, modern policy for informal care; contact and provide follow-up in relation to users, – care services that are organised with the family family members and the care services. and local community in mind and that emphasise homecare services, open institutions and networking activities.

The committee wishes to emphasise the importance of seeking new solutions and patterns of cooperation through dialogue and negotiations Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 15 Innovation in the Care Services Chapter 2 between public and volunteer enterprises in the investment grant for nursing homes and residen- care services. It is in the interface between the tial care homes must include adaptation for the public sector and civil society that new community connection of alarms, sensors and Smart House solutions can be developed. technology. In this context, the committee also Idealistic measures and enterprises in the notes the need to develop a standardised commu- form of NGOs and user-driven cooperatives nications platform in the home with services that should be given a much larger role in the develop- can be adapted to the individual user's needs over ment of the future care services. The committee time. believes that this will strengthen innovation and The committee also recommends more direct development activities in the care services and regulation of the use of tracking and warning encourage active participation and co-creation of devices (e.g. with GPS) in the statutory frame- the new forms of ownership and models of opera- work for health and social services. This will pro- tion needed to meet the exponential growth in vide clearer rules, simplify case management and caregiving needs expected after 2025. Ambitious clarify which considerations must be weighed targets should be set. The committee proposes when employing technical aids that clearly will that one target should be to allow 25 per cent of all result in greater independence and freedom for the activities in the care services sector to be many users. organised and operated as idealistic enterprises At the committee's request, the Data Inspec- by 2025. torate has carried out a new assessment of personal privacy issues related to the use of welfare technology, which the committee finds clarifying. 2.3.2 «Technoplan 2015» – technological The Data Inspectorate’s letter of 9 May 2011 is support for the care services therefore attached to this report. The care services have an enormous unexploited potential to utilise available technology and develop new technology. This applies to welfare 2.3.3 «New rooms» – future housing technology that can give the users greater secu- solutions and neighbourhoods rity and a better ability to take care of themselves An important part of the planning of tomorrow’s in daily life, telemedicine solutions to help in treat- society will deal with making dwellings and sur- ment, supervision and care, and technical support rounding areas good to grow old in. Most of the for communication, administration and manage- housing and institutions in which people will live ment that frees up care workers to spend more and receive health and social services in the com- time on direct user contact. ing decades have already been built. This con- The committee has submitted a three-phase cerns primarily the ordinary building stock such plan for the expansion and practical application of as single-family homes, row houses and apart- welfare technology, and proposes its inclusion as ments, but also the more than 40 000 beds in part of the Government's Care Plan 2015: retirement and nursing homes and the almost Phase 1 further develops the security alarm 50 000 dwellings built for caregiving purposes. concept into a security package which includes an adaptation for Smart House dwellings. Phase 2 uses modern communications technol- The large-scale renovation project ogy and social media to enable users to contact The committee is concerned that too much atten- the health and social services, moderate loneli- tion on new building may lead to neglect of reno- ness, maintain contact with family and friends, vation, and recommends strengthening the instru- and participate in user forums. ments used in housing policy to encourage reno- Phase 3 uses technology that stimulates, enter- vation and renewal of the homes that already tains, activates and structures daily life for the exist. Given the challenges that society is facing elderly. with regard to health and social services, it will be The plan gives priority to training and compe- crucial to dismantle barriers and adapt homes and tency measures, organisational development, and surrounding areas so they can function through- the establishment of cooperative arenas for inno- out the entire life of an individual. The committee vative municipalities and professional circles. seeks to promote a general line of thinking in The committee proposes that the specifica- which it is just as common to prepare a home for tions for new or renovated buildings financed one's old age as it is to adapt it in other life phases. through the Norwegian State Housing Bank’s Thus the committee proposes that an advisory 16 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 2 Innovation in the Care Services service for housing adaptation be established as a The committee finds that the time of the large cooperative effort between the Norwegian State institutions has passed, and is of the opinion that Housing Bank, the municipalities and the techni- the care services should include homes and prem- cal aid centres of the Norwegian Labour and Wel- ises that are an integrated part of the local com- fare Administration. The committee also proposes munity in towns and urban areas where the public a system for classifying various types of homes common areas are shared by the rest of the popu- based on the specifications for universal design. lation. A hub where a welfare centre and various types of housing are located must therefore be a component in the municipality’s overall planning. New concept The committee wishes to incorporate these An exciting development is underway in the principles into the basis for the expansion of municipal care services, as two different tradi- tomorrow's municipal housing solutions for peo- tions are in the process of merging into one. On ple in need of health and social services. In this the one hand, the rooms in nursing homes are connection, the committee notes that the Care becoming more and more similar to rooms in full- Plan 2015 estimates a need for the renovation and fledged residential care homes. On the other expansion of 12 000 24-hour care spaces in the hand, today's residential care homes are being period up to 2015. built together and used both as a supplement and The need for dramatically increased capacity alternative to nursing homes. The committee envi- will arise in 10 to 15 years. Therefore, importance sions a solution in which the best of each of the should be attached to modernising, replacing and two different traditions is combined rapidly and renovating existing nursing homes and residential constructively. care homes. Almost half of Norway's 90 000 The new concept proposed by the committee spaces in institutions and residential care homes entails a «fusion» in which a high standard of will soon be in need of renovation and replace- housing and services can be combined in various ment. The location and design of some of this ways, prompting the development of a range of building stock make it poorly suited to future user solutions based on six fundamental principles: needs. The committee is concerned with ensuring – a division between municipal housing policies that the renovation of the older building stock is and the municipal service policies in the area of completed well in advance of 2025, when the need health and social services so that the services for services hits the sector. It is also important to and resources are linked to the individual’s actively use this period to plan the expansion that needs, regardless of type of living arrange- will then take place. ments; Such renovation will pave the way for new – a clear physical and legal division between pri- structures and surrounding areas both for those vate areas, common areas, public areas and who need services and for those who will provide service areas in all buildings used for health care services in the future. This will generate and social service purposes; opportunities for industrial development and a – a professional and organisational division higher demand for construction and technology between health services on the one hand and specialists. The committee recommends that food service, cultural activities and other ser- municipalities, professional circles and companies vices on the other; view this as a call to innovate, in which the need is – housing solutions that provide access to all nec- to find new solutions that both are adapted to the essary living functions (bath/toilet, kitchen, needs of future generations and the preferences of sleeping area and general living area) within tomorrow’s local communities. the private area, adapted for both residents and family members; – the adaptation of the infrastructure of homes 2.3.4 A national programme for municipal for the use of new welfare technology; innovation in the care services – a joint scheme for rent and self payment Innovation in the care services will occur primar- regardless of living arrangements, with an ily at the local level in the individual municipality, equal right to housing allowances from the close to the users and the publicly elected officials Norwegian State Housing Bank, the same pay- responsible for the services. The central government for services and same coverage of phar- ment’s role will be to establish an incentive struc- maceuticals and technical aids under the Nor- ture that promotes innovation within the sector wegian National Insurance Scheme. and to develop an infrastructure for research, Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 17 Innovation in the Care Services Chapter 2 development and innovation in the care services these services. The financing scheme should be that takes the initiative and responsibility for coor- used primarily to test and disseminate new ways dination, network-building and the dissemination of performing the caregiving tasks, i.e. through of results at the national level. the use of technology, work methods or forms of Activities within the care services sector are organisation that help people to take care of them- also crucial to municipal development. In the view selves longer or that frees up care services work- of the committee, it is therefore necessary to give ers so they can spend more time with the individ- the municipalities access to instruments designed ual users. The allocation of additional funding to alleviate some of their risk and protected finan- assumes a three-way collaboration between a ser- cial schemes that enhance their ability to inno- vice provider, a municipality and a third party vate, test new work methods and find new ways of comprised of civil society, the business sector or performing caregiving tasks. The development of the research community. the care services sector is closely linked to other segments of municipal activity, and would benefit from the allocation of similar contributions from NISO – An overall national responsibility for knowledge other ministries to other municipal sectors in the dissemination and innovation in the care services municipality. The committee proposes that the Ministry of Health and Care Services and the Ministry of Local Government and Regional Development, in A municipal school for innovation cooperation with the Norwegian Association of The committee proposes that, in cooperation with Local and Regional Authorities (KS), establish a the Norwegian Association of Local and Regional secretariat for municipal innovation, which will ini- Authorities (KS), a national training programme tially focus on the care services sector with links in innovation be established for high-level munici- to the regional centres for care research for the pal administrators and others who carry out key health and care services and the county centres functions in or for the care services, or if appropri- for development of institutional and home care ate other parts of the municipal sector. services. The main task of the secretariat will be: – advise the service providers regarding the testing and development of new solutions; One per cent of the budget to research, development – allocate and manage innovation grants, includ- and innovation (RDI) ing evaluation, documentation and dissemina- The committee believes it is irresponsible to oper- tion of results; ate a public care services sector with an annual – coordinate and further develop local and operating budget of some NOK 80 billion while regional innovation networks. allocating less than .002 of this amount to knowledge development and research, innovation and development activities. The major challenges NORAGE – An event-history study relating to care services that society faces will The committee proposes the establishment of a require: national database (NORAGE) and an extensive – more research-based knowledge in order to research project that follows a large number of plan future services at the local as well as the individuals through the last third of their lives to national level; obtain knowledge for use in the planning of the – the willingness to take risk and ability to inno- care services and society’s senior citizen policy in vate in order to test new professional a wide range of different areas. A database of this approaches and find new ways of performing type will provide a good framework for the design caregiving tasks; and investigation of questions for researchers – long-term development activities in order to with a background in the social sciences, medi- prepare and implement the necessary changes cine and other fields. and restructuring.

The committee recommends the allocation of 2.3.5 The care services as an industry additional funding from the central government The committee sees great potential for developing through an escalation plan in the period up until a Norwegian-based industry for deliveries to the 2020, so that one per cent of the total care services care services. The demand for appropriate hous- budget is used to develop the knowledge base for ing solutions, activities and welfare technology 18 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 2 Innovation in the Care Services tools will increase from households and the based public schemes will become available «off- municipal care services sector alike. This means the-shelf». The senior citizens’ market is vast. that the care services will become increasingly Therefore, Norwegian care services companies more open, and like other industries, will be more should cultivate an interest in, and focus their exposed to import and export. efforts on, market segments other than just the domestic public sector. This applies especially to the individual senior citizens’ market and to the An overall knowledge and industrial development potential for exports to other countries’ public pro- policy curement of services. In order to highlight and In the care services today, cooperation with other increase demand from the individual senior citi- industries occurs mainly through the municipal zens’ market, the committee recommends mea- procurement of sub-contracted goods or services. sures to: With regard to housing, this comprises a crucial – raise the awareness of and strengthen the indi- part of the service provision, with large invest- vidual consumer in the markets for adapted ments in nursing homes and residential care housing solutions and welfare technology; homes. Growth in the procurement of welfare – increase demand for housing renovations to technology solutions is also anticipated. It is achieve more appropriate overall design and important that this procurement power is home interior elements. strengthened, developed and managed so that it promotes innovation among the suppliers of ser- In a business context, the committee also wishes vices. In this way, clearer signals will be given to to mention the advantages in renovating and players in the business sector and other suppliers upgrading today's homes and residential areas, about what the care services sector requires in and the need to replace or renovate up to half of order to carry out its responsibilities in a better Norway's 90 000 residential care homes and way in the future. spaces in institutions in the next decade. The com- To enhance the ability of the care services sec- mittee appeals to both the construction industry tor to perform its function as a visible, competent and the municipalities to find future-oriented solu- and demanding procurer of services, the commit- tions to this based on knowledge about the prefer- tee recommends three types of measures: ences and needs of new generations and user – Systematic training of municipal players to groups. improve the performance of their role as procurers of services with innovation potential and to increase their expertise in managing sup- Cooperation among companies plier development and innovation processes in Cooperation among private companies is critical cooperation with players outside of the care to the development of products in demand within services sector. the care services. It is especially important that – A financing scheme for innovation projects in the housing industry and technology circles coop- the care services sector, organised through a erate in viewing housing solutions and welfare national secretariat for innovation in the care technology as part of the same whole. Industrial services sector. cooperation with the involvement of research and – A national programme for the spread of welfare development groups should be encouraged, technology that will both increase the munici- regardless of the municipal dimension in the care pal players’ knowledge of and interest in wel- services. In the view of the committee, three key fare technology, and develop municipal exper- conditions must be in place to promote such tise as procurers in this market. development: – the need for industrial technical standards must be elucidated and clarified so that Norwe- Senior citizens’ market gian products are developed according to stan- The committee notes in particular that the individ- dards that are future-oriented; ual senior citizens’ market will likely see strong – the general system of public instruments must growth in the future, both domestically and inter- be used to boost interest in opportunities in the nationally. A large generation of senior citizens care services, and to encourage and finance with considerable buying power will have an development projects with relevance and com- impact on demand. Many services and products mercial potential for individual senior citizens’ that were previously channelled through needs- markets and for export; Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 19 Innovation in the Care Services Chapter 2

– Norwegian export of care services products and solutions must be promoted, and the com- INN scheme mittee proposes establishing a special founda- The committee also sees the potential for great tion for this purpose. economic gains by involving other sectors of society as suppliers to the care services sector. This can both revitalise the content of these services «NORCARE» – care services as an export product and evolve into a new, alternative source of Many countries have shown an interest in the income for these enterprises. Nordic model with well-developed public welfare «Inn på tunet» is an initiative under the Agri- schemes, gender equality and a high level of cultural Agreement that uses farms for municipal employment. With this as a trademark, a 50-year daytime activities for people who need special tradition of care services as a professional field resources. The committee recommends that the and a more favourable demographic trend than in INN scheme not be limited to agriculture, but be the rest of Europe, it is reasonable to consider expanded to include a variety of industries, work- exporting Norwegian care services to a rapidly places and enterprises that can provide interest- growing international market in close cooperation ing environments for a daytime programme with other Nordic countries. adapted for activity, learning and skills mastering. With this in mind, the committee recommends In this way, individuals can find activities that the Ministry of Health and Care Services and suited to their own histories, backgrounds and the Ministry of Trade and Industry establish an interests, and companies and enterprises can export foundation for care services modelled after make use of their particular surroundings and the Swedish foundation SWECARE, and in so expertise to develop a supplementary product doing lay the foundation for Nordic cooperation in that is lacking in the health and social services. this area. 20 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

Chapter 3 Myths about care services and themes for the future

«We did not come to fear the future. meet and cope with old age owing to its We can here to shape it.» improved state of health and greater resources Barack Obama in the form of higher education and better financial situation.

3.1 Future challenges for the care services Shortage of care providers

In Report No. 25 (2005-2006) to the Storting, Due to changes in the age composition of the «Long-term care – Future challenges, Care Plan population, there will be no substantial 2015»», the Government identifies five future chal- increase in access to labour and potential vol- lenges for the care services: unteer care providers. A lack of growth in informal care means that the public sector must Society is facing demanding challenges in the assume responsibility for the entire increase in care services in the coming decades. These needs that is anticipated, and will be dependent cannot be dealt with by the health and social on locally based care services that cooperate services sector alone, but must be addressed more closely with families, volunteer care pro- on the basis of a public responsibility involving viders and local communities. most of the sectors in society and by supporting and developing new forms of involvement and participation by the families and local com- Medical follow-up munities, organisations and enterprises. As far as we can see today, the challenges will be There is a need for better medical and interdis- related primarily to: ciplinary follow-up of recipients of public home care services and residents of nursing homes and residential care homes. This applies espe- New user groups cially to people with chronic and complex medical conditions, dementia, mental health prob- Due to the dramatic rise in the number of lems and others who have a need for coordi- younger users with reduced functionality and a nated services from both the specialist health wider array of health and social problems, the care services and the municipal health and care services will need to incorporate a differ- social services. ent type of professional expertise and an integrated life course perspective. Active caregiving

Ageing Care services involving daily life, meals, activities, and social and cultural factors are identi- The growing needs of a larger number of fied in most studies as comprising the weakest elderly will require an expansion in capacity services today. Improving these areas will and greater expertise on ageing, especially require a greater breadth of professional exper- related to dementia and complex medical con- tise that includes a wider variety of professional ditions. The scope of the challenges must none- groups so that the care services are able to theless be viewed in light of the fact that the meet users’ psychosocial needs and can be new elderly generation is better equipped to given a more active profile. Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 21 Innovation in the Care Services Chapter 3

The committee has used these five main chal- worse by dire predictions and worst-case scenar- lenges as the basis for its activities, and refers to ios. the analyses performed in connection with the In the view of the committee, the future chal- Government’s Care Plan 2015 (Report No. 25 lenges for the care services cannot be dealt with (2005-2006) to the Storting). The Government has by the health and social services sector alone by also followed up the efforts related to these five employing more professional staff, building more challenges in its Care Plan 2015, which lays out a institutions and implementing new, formal assis- main strategy that utilises the upcoming period of tance schemes. On the basis of a public responsi- relative demographic stability to: bility, most sectors of society must help to further – plan and prepare for the rapid growth in the develop community-oriented solutions that are need for care services that is expected to occur adapted to the new needs and available resources. in 10 to 15 years from now, and It will be essential to support and develop new – gradually expand the care services by invest- forms of involvement by volunteers from families ing in preventive measures, education and and local communities, user-driven organisations competency building, new technology, housing and enterprises, based on interaction between the and facilities. public sector and civil society. The issue at stake has just as much to do with the kind of society In addition, the Government has drawn up the Norway seeks to build for the future as with how Coordination Reform to improve cooperation the health and care services sector will develop. between the municipal health and care services and the specialist health care services. The committee has decided to explore those issues and 3.2 Five myths about care services needs not covered in the reform. In keeping with the mandate and on this basis, the committee has In order to address the future challenges of the focused its efforts on assessing new approaches care services, it has been crucial for the commit- and solutions for meeting the caregiving chal- tee to obtain a clear picture of the current caregiv- lenges in a time horizon that extends beyond the ing situation. Many ideas about this have been Government's Care Plan 2015, putting special formed, partly from descriptions in the media and emphasis on technology, alternative living partly as a result of the particular focus in the pub- arrangements and forms of organisation, and lic debate at the national level. It has been impor- research and innovation. tant for the committee to clear away some of the Moreover, the committee points to the chal- misconceptions that have long been associated lenges and opportunities inherent in these prob- with the care services sector and to obtain an up- lems when viewed in an international context, to-date picture by using relevant data and where: research in the field. – the personnel market is becoming internationalised, and the care services workers are increasingly exported and imported, 3.2.1 The myth about elderly care – larger service providers operate in an interna- The municipal care services are no longer for the tional market, elderly only. They cover the entire life course and – growing numbers of patients and users are offer services to families with children, adults crossing national borders for treatment, recu- with reduced functionality and elderly with seri- peration and physical training. ous illnesses and loss of functionality. Services are provided in all types of dwellings, from homes for The future outlook must also be viewed in light of disabled children with a great need for assistance the vast changes occurring in the age composition to residential care homes and nursing homes, of the population in both Europe and the world at although most of the people receiving care ser- large. There is reason to believe that this will vices are living in their own homes. affect all markets and social sectors throughout In the public debate, however, the care ser- the world. In this context, Norway is more fortu- vices are often discussed as if they were synony- nate in that it is experiencing less dramatic mous with elderly care. The media and partici- changes in this regard than the other countries in pants in the public debate often measure the suc- Europe. Society will face major challenges relat- cess of these services in terms of the number of ing to care services in the coming decades. These nursing home beds. The actual situation is far will be demanding enough without being made more nuanced. While only about 40 000 people 22 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

70000

60000

50000

40000

30000

20000

10000

0 1992 1994 1996 1998 2000 2002 2004 2005 2006 2007 2008 2009

Under 67 years 67-79 years 80-89 years 90 years and over

Figure 3.1 Number of recipients of home care services by age. 1992-2009 Source: Statistics Norway. See http://www.ssb.no/pleie/ (in Norwegian only) receive care services in nursing homes, 225 000 years the number of elderly users of these ser- people receive care services in their own homes vices has not grown, while the number of users or in residential care homes. One-third of these under the age of 67 has tripled in the same period. are under the age of 67. Almost all of the new resources invested in the Twenty years ago, two-thirds of the care ser- sector in recent years have gone to covering the vices resources were used in homes for the aged growth in the younger user groups. and nursing homes, while only one-third was used Despite the strong growth in the oldest age on home care services. Today more than half of groups in recent decades, the number of elderly the resources in the sector go to home care ser- users of homes for the aged and nursing homes vices and measures outside of institutions (Brevik has not increased. Thus developments are not 2010). only being driven by ageing, but are also influ- The fact that the municipal care services have enced by other changes in society and the shift in recipients of all ages with a variety of needs, both the distribution of tasks which has occurred over with regard to the type of living arrangements and time between the specialist health care services, the services offered, is often left out in discus- informal care providers and the municipal care sions of nursing homes versus residential care services. In this context, the municipal care ser- homes and institution-based services versus vices fall right in the middle between the special home care services. health care services and informal care providers, This is why the concept of «elderly care» does and have a broad scope of interaction with both not figure in health and social services legislation areas. or in the national or municipal budgets. The statu- The committee sees the importance of con- tory framework and access to resources are pri- tinuing to ensure that care services are provided marily based on the principle that age must not be to everyone regardless of age. More than ever used in a discriminatory fashion. The care ser- before, it is crucial to build a foundation for the vices therefore encompass everyone who has a welfare schemes that is based on support from need for them, regardless of age, gender, diagno- young and old alike and that encourages solidarity sis, level of functionality or problem. between the generations. Equal rights to services The idea that the municipal care services are for everyone with a need, regardless of age, is a synonymous with elderly care has become less basic principle underlying mutual understanding and less correct over time. In fact, in the past 20 and joint responsibility. Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 23 Innovation in the Care Services Chapter 3

0,07

0,06

0,05

0,04

0,03 Tot. population 80+ 0,02

0,01

0,01- 1950 1970 1990 2010 2030 2050

Figure 3.2 Percentage change from the previous year in the number of persons 80 years or older and for the population as a whole. 1950-2050 Source: Statistics Norway 2010 Population projections, median alternative

The services must nonetheless be adapted to care services sector has limited historical experi- various phases of life and to the individual’s partic- ence with applying new technology, it is the users ular resources and needs. The services provided themselves who will more often be the driving to a younger user with reduced functionality who force behind innovations and the implementation requires assistance to complete an education or to of such technology. Demand from a much larger gain employment may therefore be different than user group with greater buying power will also the services provided to an elderly couple where probably create a basis for more market-based one of them has developed severe dementia. In services. one instance, the main focus will be the person's Given how care services evolve, there is great potential to live an independent life, relying as lit- potential for new solutions for the traditional care tle as possible on others. In the second instance, services to elderly users to be found in transfer- the need for safety and protection will be more ring the experience gained from reforms imple- important, even if it comes at the expense of inde- mented for other user groups. For example, the pendence. reform for people with disabilities showed that it With regard to the use of new technology and was possible to establish effective 24-hour ser- advanced technical aids, younger people with vices outside of the institutional framework. The reduced functionality are at the vanguard in the reform also encouraged other sectors to take development of this sector precisely because responsibility for people with disabilities on par these advanced technical aids help individuals to with the rest of the population with regard to cope better with daily life on their own and be everything from education, employment, activities independent of others. There is reason to believe and transport to participation in cultural events that the new generation of senior citizens will fol- and sport. In the view of the committee, these low suit, given their attitudes towards indepen- should be key objectives for the development of dence and control over their own lives. Since the care services in the future. 24 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

2000 2010 2020 2030 2040 2050

Figure 3.3 Number of persons of working age (16-66 years) per person 67 years and older. 2000-2050 Source: Statistics Norway 2010 Population projections, median alternative

ageing is combined with continued population 3.2.2 Myth about the «elderly boom» growth. The Potential Support Ratio shows the The demographic changes facing society are often relationship between the working population depicted as an unchecked «elderly boom» about (16-66 years) and the elderly population (67 to inundate the world. Crisis scenarios are being years and older), and is of great interest with applied to pension systems, the labour force and regard to the financing of pensions, welfare ser- the lack of health and social services workers, and vices, and health and social services. Figure 3.3 dramatic projections are being made about the shows that while there were 4.7 persons of extent of illness and caregiving needs among the working age per elderly person in 2000, the population. Potential Support Ratio will decline to 3.5 in However, the «elderly boom» will be demand- 2030 and 2.9 in 2050. ing enough without painting the blackest picture. – The new generation of senior citizens will meet The committee takes a more moderate view of the their old age with more resources. The «new impact of the changes that will occur in the age elderly» will have a better financial situation, composition of the population, and identifies cer- better living conditions, a higher level of educa- tain factors that will mitigate the challenges facing tion and better health than any previous gener- Norway, especially in the area of care services: ation of elderly (ÆldreSagen 2001, Barstad – The number of elderly over 80 years of age will 2006). Studies also show that in the future not increase in the next 10 to 15 years. Since a more elderly will have someone to live together substantial share of the resources in the care with (Keilman 2010). Thus, an 80-year-old in services sector are dedicated to the 80+ age 2030 will not be the same as an 80-year-old in group, Norway now has a «demographic mora- 2010. On this basis, long-term planning should torium» or «breathing room» (Barstad 2006). not only project the scenario involving prob- This period should be used to prepare and plan lems and illnesses, but should also take into for the dramatic increase in this age group that account the elderly population’s resources and will occur from 2025 onward (Fig. 3.2). ensure that these are used. – In terms of demographics, Norway is the coun- – It is uncertain what the relationship between a try in Europe that will experience the fewest longer life span and the needs for health ser- dramatic changes in the age composition of the vices will be in the future. Three different population, in part because Norway has hypotheses are possible: already undergone such changes and in part a. A longer life will mean more good years of because Norway has a higher birthrate, so that life because the period of serious loss of Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 25 Innovation in the Care Services Chapter 3

functionality will be about the same length sponding to approximately 25 per cent of the pop- as for today's elderly. ulation 80 years and older.» b. A longer life also will entail overall better The report emphasises that this is an estimate health so that the period of serious loss of of the need for coverage on a nationwide basis functionality will be shorter than today. provided that well-developed home care services c. The period of serious loss of functionality and reasonable access to adapted dwellings are will be longer. available. This applies to all age groups regardless of whether 24-hour care is provided in nursing Another relevant factor is that although the homes, in residential care homes or in people’s elderly of the future will have more health prob- own homes. lems, they will also meet reduced functionality In other words, this figure is a 15-year-old esti- with more resources (Thorslund and Parker mate that was never meant to serve as a norm for 2005). the degree of coverage in the individual municipality, but which was used at the time as a basis for calculating the costs of the Action Plan for 3.2.3 The 25 per cent myth Elderly Care. This estimate, however, has begun It is claimed in many connections in the public to live a life of its own and gained status as a gov- debate that there is a need for 25 per cent coverage ernment norm in the public debate. of nursing home beds as a percentage of the elderly In recent years, it is primarily the number of 80 years of age and older, and that this is a govern- recipients of municipal care services under the ment norm for nursing home coverage. This is a age of 67 that has risen. As a consequence, the myth that is used in political exchanges, by special degree of coverage viewed only in relation to the interest organisations and in local planning. number of elderly over 80 years of age becomes In fact, no such government norm exists. The less and less relevant. According to Statistics Nor- figure of 25 per cent coverage also lacks any scien- way, 24-hour coverage in nursing homes and resi- tific basis and becomes particularly problematic dential care homes comprises 28 spaces per per- when applied to individual municipalities. centage of the population over 80 years of age, and The government has never established a norm is higher than anticipated when the Action Plan or a minimum degree of coverage for 24-hour care for Elderly Care was implemented. spaces in nursing homes or residential care homes. It is the needs of the population in the individual municipality at any given point in time that 3.2.4 The myth about informal care determine how many people will be given 24-hour The perception that public sector care displaces services in a nursing home, in a residential care informal care and that the family withdraws if the home or in their own homes. There is a relatively public sector assumes responsibility remains wide variation in needs among the municipalities widespread. due to differences in the composition of the popu- However, there is little evidence to suggest lation and various local conditions. Contrary to that families are failing in their caregiving duties. claims, Report No. 31 (2001-2002) to the Storting, On the contrary, it appears that public sector care Avslutning av handlingsplan for eldreomsorgen providers and volunteer informal caregivers coop- («Conclusion of the Action Plan for Elderly Care») erate with and complement each other. Informal warned against applying such norms: care has proven to be dynamic and strong, and is more independent of public care services policy «The Government wishes to emphasise that than presumed (Lingsom 1997). The level of sta- the degrees of coverage should not be bility in the extent of informal caregiving during regarded as norms or minimum standards and the 20 to 30 years when this trend has been fol- that in this connection they should only be lowed is striking (Daatland and Solem 2000, Røn- used as target figures for the action plan.» ning 2009). Nor is there evidence to suggest that the family withdraws when the public care system The figure of 25 per cent is taken from Report No. becomes involved by providing home care ser- 50 (1996-1997) to the Storting, Handlingsplan for vices. Although the welfare state has assumed the eldreomsorgen («Action Plan for Elderly Care»), family’s previous obligations related to ageing, ill- which states that «for the plan period 1998-2001, it ness and disability, it does not appear that this has is assumed that there will be a need for 24-hour diminished family solidarity, as is often claimed care services provided in suitable dwellings corre- (Langsether and Hellevik 2002). 26 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

The elderly who receive municipal home care occurred simultaneously with a situation in which services actually receive more help from their the needs of a rapidly increasing elderly popula- daughters and sons than the elderly who do not tion exceeded what families and volunteers could receive such services. The relationship between provide. public and informal care is more cooperative than There used to be a widespread belief that the competitive in nature. A study of cooperation participation by women in working life would between public services and informal caregivers cause them to fail to perform their caregiving in the period from 1965 to 1995 shows that the tasks in the family. In reality, there appears to be a amount of care provided to the elderly by family positive correlation between participation in work- members remained stable rather than declined. ing life and caregiving. Working men and women Even though family members who provide care provide as much care to their parents as those do so slightly less than before, there is much evi- who are not employed. dence to suggest that a larger number of people In addition, the middle-aged women and men participate in this type of care provision (Lingsom of the 60s generation have been shaped by the tra- 1997). More men participate, and the caregiving ditions and values of the society in which they tasks are divided among several generations. grew up, and it seems unlikely that they will turn Although the overall amount of informal care has their backs on their parents. There appear to be remained at roughly the same level, the tasks are small differences between the people who have now divided among more recipients due to the made modern, individualistic choices regarding major changes that have occurred in the age com- the family and working life and those who have position of the population. made more traditional choices (Gautun 2003). However, families have less contact and pro- However, there is reason to monitor whether the vide less practical help when their elderly rela- new generations will provide less care to the tives live in nursing homes. It is easier for families elderly due to their focus on self-realisation and and the public sector to share responsibility for individualisation or whether the amount of care caregiving tasks when the person in need of care they provide will remain stable or increase lives at home or in a residential care home rather because it assumes new forms. than in a nursing home (Lingsom 1997; Bogen Next to the children of the elderly, it is primar- and Høyland 2006). As a result, the expansion of ily the grandchildren who provide practical help home care services has ensured that the welfare to their older relatives. A reciprocal relationship state can continue to rely on, and cooperate with, exists between the younger and older genera- the family in the provision of care services. The tions, whereby the assistance provided by public home care services allow the family to pro- younger adults to the elderly is counterbalanced vide assistance without having to assume the by the financial and practical assistance younger entire responsibility, leading to a kind of partner- adults in the establishment phase of their lives ship with an informal distribution of tasks and receive from their parents and grandparents. The responsibilities. This strengthens what the com- potential for assistance inherent in family relation- mittee’s refers to as the «complementary hypothe- ships remains great and must be viewed as a sign sis», meaning that under certain circumstances that the family ties are strong. Geographic prox- the public sector services and informal care can imity appears to be significant for the amount of complement and strengthen each other. In con- help children provide to their parents. The closer trast, some argue that the public care services children live to their parents, the more help the replace, and in part compete with, informal care- children provide to their parents (Gautun 1999). giving, a situation described in the «substitution Friends of the family also serve as important hypothesis» (Lingsom 1997; Daatland and Solem care providers throughout a person’s lifetime. In 2000; Daatland 1994). fact, friends often provide more assistance than The public care services have not expanded siblings, including to the oldest age groups. Of because families, friends and volunteers have people 80 years and older, three-fourths received failed their loved ones, but because there has practical help from their children in the past year, been a need to move some of the caregiving arena almost 40 per cent received help from their grand- out of the family and private sphere and to organ- children and about one-fourth received help from ise some of the caregiving tasks in a different way. friends (Langsether and Hellevik 2002). The impetus for this was mainly to facilitate the While people have longer life spans they are inclusion of more women in working life in a also having fewer children. More and more people period with a high demand for labour. This have both grandparents and great-grandparents Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 27 Innovation in the Care Services Chapter 3 who are still living, and many live to see both their care services have become more medically ori- grandchildren and great-grandchildren in their ented (Romøren 2007): old age. Since practical help and contact are exchanged primarily through direct ascending «And it could be asked to what extent the home and descending generations, it may be that more care services for the elderly have become med- help from grandchildren will compensate for the icalised at the expense of prevention and social lower number of siblings, nieces and nephews. and practical assistance» (Brevik 2010). The «generation squeeze» experienced by the «sandwich generation» — that is, people with In addition, as homes for the aged have been responsibility for providing care to their older par- phased out, medical care has taken on greater ents as well as to their children — is limited in importance in institution-based care. This is a key scope. If such a «generation squeeze» exists, it feature in the development of the municipal care relates instead to people who care for their older services in recent years, and is reflected in the parents and who themselves are grandparents professional groups that manage the sector and providing care to their grandchildren (Hagestad the expertise that is sought. 2003). The committee is concerned about this trend There are indications that formal and moral as it relates to finding solutions to the future care- obligations are met through mutual commitments giving challenges. spawned through cooperation and the develop- People with reduced functionality are not nec- ment of good mutual relations throughout one’s essarily patients nor are they sick. Ageing is not life (Gautun 1999 and 2003). More than before, an illness either. It entails completely normal loss people need to form their own networks and not of functionality, greater practical obstacles, social just maintain the ones into which they were born. factors and living conditions. The response must Perhaps close personal relationships and agree- be to remove disabling barriers and to provide ments between family members and friends can in practical and personal help, assistance, activities, the future compensate for and replace what is lost, healthy meals, a satisfactory daily life, active pre- should it turn out that the highly normative care- vention and early intervention. giving obligation vis-á-vis family and friends Anxiety and grief may be an appropriate reac- breaks down in modern society. tion to one’s own loss of functionality or to the loss Close, strong personal relationships may of a loved one, but this need not manifest itself in therefore play a more important role in future illness. As a general rule, problems in human rela- care provision than pure moral obligation. This tionships or in a person’s relationship to their paves the way for more care providers both inside social and physical environment should also be and outside the family circle and puts focus on solved before they result in illness. people’s ability to build social relations. From this A system which requires that people first have perspective, the opportunity for people to obtain status as a patient before they are eligible to informal support and care will depend more than receive help with simple, basic tasks in daily life before on solid social networks and the amount of risks becoming involved too late. This implies a «social capital» people bring with them into old trend away from early intervention and prevention age (Barstad 2006). and towards the treatment of those patients with the greatest needs. This trend is probably an adaptation to a health service comprised of profes- 3.2.5 The illness myth sional health personnel whose level of expertise in The municipal care services are developing a medical treatment is constantly being enhanced. stronger health orientation, emphasising medica- The field of «anti-ageing medicine» is growing tion-based treatment, medical follow-up and nurs- rapidly throughout the world. The World Anti- ing care. A report by the Norwegian Directorate Aging Academy of Medicine (WAAAM) was of Health on care services in the past 20 years established in 1995 and states the following about states that «Medical services are given priority its activities: over social services» (Norwegian Directorate of Health 2010a). The report points out that in-home «Anti-aging and regenerative medicine are nursing services account for most of the growth in among the fastest-growing medical specialties the sector, while the number of recipients of prac- throughout the world and are founded on the tical assistance and housekeeping services has application of advanced scientific and medical declined. Researchers note that in this way home technologies for the early detection, preven- 28 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

tion, treatment, and reversal of age-related dys- The Irish Centre for Technology Research for function, disorders, and diseases. It is a health- Independent Living (TRIL) (see www.trilcen- care model promoting innovative science and tre.org) has shown how a poorer general condi- research to prolong the healthy life span in tion in individuals, both physically and mentally, humans (WAAAM 2011).» can result in: – Instability or a tendency to fall It is no longer just about wrinkle creams and lipo- – Social isolation suction, but also about plastic cosmetic surgery, – Cognitive decline hormone therapy, gene therapy, biotechnology, stem cell therapy and nanotechnology. The committee has chosen to use these three fac- The committee cautions against turning age tors as a point of departure and illustration in its into an illness. It is true that the elderly fall ill efforts to find new solutions and test them out. more often than others and will need treatment. This applies to various types of living arrange- But ageing must also be allowed to be a natural ments, technology, new work methods and ways part of life, both for the individual and in a societal of approaching the future caregiving challenges. context. Ageing is a biological, social and psycho- In many ways, these factors also represent the logical process, and there is good reason to various professional traditions in the health and review and assess the cultural and social aspects social services sector, and show that interdisci- of ageing, not least in relation to the role that the plinary activities will be essential for developing elderly should be assigned in the society of the new lines of thinking and innovative solutions in future. the care services. Similarly, one should avoid viewing people with reduced functionality as ill and instead help to dismantle physical, social and cultural barriers 3.3.1 Falls to their participation in working life and society at Falls have many causes. They may be a pure acci- large. dent or coincidence or they may be a sign of illness and a poor general condition. Falls and injuries from falls is one of the most common single 3.3 Falls, loneliness and cognitive reasons that the elderly are admitted to hospital. decline Each year about 30 per cent of all people over the age of 65 and 50 per cent of people over the age of Many people will experience accidental falls, lone- 80 experience a fall. Roughly 10 000 people over liness and cognitive decline in the course of their the age of 65 break a hip due to a fall. Of these, lives. This may be because they are afflicted them- eight of 10 are women. A broken hip causes exces- selves or because someone they know is affected. sive pain and a deterioration in quality of life, and The result is often a poorer general condition and the consequences are often so severe that they reduced functionality. Much evidence suggests may lead to a long-term reduction in functionality, that these three factors are closely related and complications, accompanying diseases and death. have a reciprocal impact on each other. A poorer Many never return to the same level of functional- general condition in one area often has conse- ity they had prior to the break, becoming reliant quences for the other areas, which in turn has rip- on housekeeping services, in-home nursing care ple effects in other areas of life: and stays in a nursing home (Skadeforebyggende – Unpleasant experiences with falls often result Forum 2011; Sletvold 2010). in a fear of falling again, leading to withdrawal, The risk factors for falls among the elderly are social isolation and inactivity. complex, but they can be classified into three cate- – A lack of social contact and stimulation can lead gories: internal, external and risk exposure (Todd to more rapid cognitive decline. & Skelton, 2004). Internal factors include age, – Cognitive decline can lead to forgetfulness, gender, whether a person lives alone, the use of reduced coordination and less attention to risk. medication, overall medical condition, reduced This can in turn increase the likelihood of falling. mobility/ability to walk, deficiency diseases, cognitive decline and diseases of the foot. External This «vicious circle» can be turned into a «circle factors include poor lighting, slippery floors, of opportunity» with the help of preventive mea- uneven surfaces, footwear, clothing, inappropriate sures, innovative actions and appropriate, sensible walking aids or other technical aids. Risk expo- use of technology. sure involves the level of activity. Internal factors Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 29 Innovation in the Care Services Chapter 3 appear to be the most common among people elderly lack good friends to a somewhat greater over 80 years old, while external factors are most degree than younger people, but the number of common among younger people. people between 60 and 79 years of age who say A project in Nord-Trøndelag county analysed they lack good friends has declined, from seven the more than 1 200 incidents of falls that per cent in 1980 to three per cent in 2007 (Barstad occurred in the course of a year (Kjølstad, Pet- A. 2009). About one in 10 states that they do not tersen, and Tvete, 2009). The data was taken from have any good friends in the place where they live. five municipalities and pertained to people over This figure remained stable from 1987 to 2007. the age of 65. The findings showed that almost Elderly, single men comprise the largest group half of all falls occurred in the bedroom. In one- with a relatively unsatisfactory friendship situa- third of the cases the falls were caused by illness tion. They have a low level of education and are or dizziness, and in another third of the cases the often without jobs. They may receive a disability person had tripped. Fifteen per cent had fallen pension or work at home, and they tend to be in from a chair or out of bed, and 13 per cent had poor health and have financial difficulties. fallen due to a slippery floor. Breaks and head Women state more often than men that they injuries are among the most serious injuries from feel lonely (Barstad A 2000). Men have fewer a fall. close friends than women have, and they often say Falls and injuries from falls are a health prob- that their spouse is their only close relationship. lem as well as a socioeconomic problem with a Loneliness is most widespread among the oldest major negative impact on those affected. The con- age groups, among those 80 years and older and sequences of a fall include not only the injury in the 70-79 year age group, and the difference in itself, but also the fear of falling again, leading to perceived loneliness between women and men inactivity with accompanying decline in functional- increases with age. Women are usually married to ity, social isolation, reduced quality of life and, in older men, they experience the loss of a spouse the most serious cases, death. Many fall without more often, they live alone more often, they live injuring themselves physically, but they experi- longer and they have more health concerns. All of ence the same insecurity and fear of falling again these factors may play a role in why women tend and injuring themselves. In many cases, this leads to feel lonely more often than men. to a reduction in physical activity and social with- Young people often blame their loneliness on drawal. their own personal qualities, and this affects their The risk of falling can be prevented and self-esteem to a greater extent than the elderly, reduced through various forms of physical activ- who are more likely to attribute their loneliness to ity, physical training, rehabilitation and medical external factors such as the death of their spouse treatment. One example of a prevention measure or closest friends. The group that feels the least is the «Fall Project» in Trondheim. The project is lonely is young adults, people in the establishment a cooperative effort between several players who phase of life and established adults. work in an active, targeted way to prevent falls Feelings of loneliness are also associated with among the elderly (Sletvold 2010). poor health. Poor health may lead to loneliness, and feelings of loneliness may lead to poor health. It is known that loneliness can cause depression, 3.3.2 Loneliness insomnia, tension, anxiety and despair (Luanaigh Loneliness is the feeling of a lack of desired contact and Lawlor 2008). Three times as many people with others. The person who is lonely has less con- who say they are in poor health have feelings of tact with others or the contact is less meaningful loneliness as compared with people who say they than he or she would like. Thus the person’s desire are in excellent or very good health (Tornstam for contact, and not only the contact itself, is of sig- 1988, Lunaigh and Lawlor 2008). There appears to nificance. Being lonely is therefore not the same as be a stronger correlation between loneliness and being alone or isolated, living alone, having few mental health than between loneliness and physi- friends or have little social interaction. Loneliness cal health (Thorsen and Solem 2005). and «aloneness» are two different conditions. Nonetheless, people with only a few contacts say more often that they are lonely than people with 3.3.3 Cognitive decline many contacts (Thorsen & Clausen 2009). It is generally understood that cognitive function- Only about one per cent of the population says ing refers to the ability to comprehend and obtain that they do not have any good friends. The information from the world around us, store it, 30 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

18-79 years Men 18-79 years Women 20 60-79 years Men 60-79 years Women

0 1980 1983 1987 1991 1995 1998 2002 2007

Figure 3.4 Percentage who state that they do not have anyone outside of their own family in whom they can confide. 1980-2007 Source: Statistics Norway, A. Barstad. Living conditions survey and LOGG 2007, Statistics Norway and Norwegian Social Research (NOVA) and plan and act on the basis of this information. they produce. However, many feel that their ill- Even ordinary tasks, such as engaging in conver- ness is not limited to the physical aspect, but that sation, require complex interaction between many a decline in cognition is a crucial aspect of their different thought processes. Although there are overall condition. individual differences in people’s natural cognitive Dementia is an umbrella term for several dif- abilities, there is good reference data to indicate ferent brain diseases that often occur in old age what may be considered normal cognitive func- and result in cognitive decline. The most impor- tioning. In order to apply the term «cognitive tant symptom or defining feature of dementia is decline», the deficiency must be significant memory loss. People afflicted with dementia have enough as to have a negative impact on the per- difficulties maintaining learned skills and master- son’s ability to tackle daily challenges and ing daily tasks. Some people develop changes in demands. Thus, cognitive decline is a concept their personality such as a lack of insight and poor viewed in relation to the individual person’s life judgment. Other frequent symptoms are anxiety, situation (Follesø 2010). depression, suspicion, delusions and obsessive- Mild cognitive decline may be described as a compulsive behaviour. gradual reduction in cognitive performance, and Currently in Norway about 70 000 people have commonly occurs with increasing age. In some some form of dementia, and it is estimated that cases, a slightly more pronounced cognitive 10 000 people are stricken with the disease each decline occurs than is expected with age, even year. Studies show that only half of them are though this does not fulfil the criteria for a diagno- examined and diagnosed (Ministry of Health and sis of dementia. This may often be manifested in Care Services 2007). Activity and social contact an experienced or proven memory problem, and it may enhance the quality of life for people with may have many different causes. dementia and cognitive decline, and to some Neurological diseases caused by pathological extent delay the development of the disease and changes in the central nervous system are often reduce the need for treatment with medication. classified according to the physical symptoms Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 31 Innovation in the Care Services Chapter 3

ation of senior citizens has more resources than Conclusion before and appears to be more mobile. Certain Falls, loneliness and cognitive decline constitute a countries address some of their caregiving chal- «vicious circle» which has major ramifications for lenges by sending people in need of care services the people afflicted and for society at large. Pre- to other countries where labour is less costly and ventive measures that help to remove the risk fac- access to care workers is simpler (Isaksen 2005). tors or reduce the consequences of falls, loneliness and cognitive decline will therefore be a good investment in the future. 3.4.2 International labour market The committee has chosen to use these three The labour market, including health and social factors as the point of departure and illustration care personnel, is becoming internationalised, for its efforts to find new solutions and test them and care workers are crossing national borders to out. Falls involve a person’s relationship to the provide care to other people’s families abroad. physical environment. Loneliness involves the person as a social being and the relationship between people. Cognitive decline involves the «The global care chain» brain and the person as a biological being. An increasing proportion of the world’s population Together they represent crucial challenges that is migrating from one country to another. A large call for interdisciplinary cooperation between the part of the labour migration that occurs among medical, social and technical fields in order to find women is related to what could be called the «care new solutions in which the use of new technology deficit» in the rich part of the world. The export of and new housing solutions, combined with activity care workers has therefore already become a and treatment, can prevent falls from occurring major growth industry for poor countries. and loneliness from arising or reduce the conse- On the one hand, women are employed as au quences of increasing cognitive decline. The com- pairs or maids by families caught in a time crunch mittee refers to the discussion of this in chapter 5 between employed work and caring for their chil- and onward of this report. dren and elderly relatives. Many of these women support their own children and families in their home country by taking care of other people’s 3.4 Borderless care services children and families abroad. This situation has been termed the «global care chain» (Hochschild The committee has chosen to refer to the interna- 2001, Isaksen 2001, Yeates 2005). Some also get tionalisation of care services as the «seventh chal- married in another country, and after some time lenge». In the future people will cross municipal they bring their mothers with them to take care of boundaries and national borders more often to their children. These «transnational grannies» obtain health and care services, and health and expand the global care chain even further. Part of social care workers and companies that provide this picture includes illegal immigrants who are such services will operate in several different exploited as undocumented maids and home countries. assistants, some of whom are forced into prostitu- tion (Isaksen 2001). 3.4.1 Patients and users without borders Today more and more patients and users are «Care drain» crossing national borders to obtain treatment and On the other hand, there are health and social participate in recreational activity and physical care professionals who have the opportunity to training. Some combine their holidays with dental emigrate to Western countries in order to help treatment or an eye operation in Asia; others meet the demand for health and care personnel in travel to the Mediterranean coast for parts of the hospitals and elderly care facilities. They come year for recreation and for health-related reasons. from India, Thailand and the Philippines to the Norway is not the only country where this is hap- US, Europe and the Middle East, or they come pening. Throughout the world, patient and user from countries in Eastern Europe to Western flows are becoming internationalised across Europe (Isaksen 2005). In this way, the «care regions and national borders. It is easy to obtain drain» becomes one aspect of the «brain drain», a information from the Internet, and the new gener- situation in which expertise moves from the areas 32 Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 Chapter 3 Innovation in the Care Services

Box 3.1 Sunrise Senior Living Box 3.2 Two small projects on the Sunrise Senior Living operates 365 «senior liv- Norwegian-Swedish border ing communities» with almost 40 000 residents in most US states as well as in Canada, Gränsprojekt England and Germany. The company offers: The EU-funded INTERREG project Midt-Skan- Independent Living Assisted Living Alzhei- dinavisk Regionprosjekt encompasses the mer's Care Frostviken region in Strömsunds municipality Nursing & Rehabilitative Care and the Hotagen region in Krokoms munici- Hospice Care pality in Jämtland county, both in Sweden, and Short-term Stays Lierne and Røyrvik municipalities in Nord- Source: http://www.sunriseseniorliving.com/ Trøndelag county in Norway. The project promotes industrial development, cooperation on and development of public service production, and the removal of border-related barriers as a means of reversing the negative population where the need is greatest to areas where demand trend in the region. The cooperative project and the ability to pay are greatest. also entails health and care services. See http://www.gransprojekt.eu/

3.4.3 International providers Gränslös omsorg («Borderless care») At the same time, service providers are crossing national borders. Norwegian municipalities are Gränslös omsorg is a cooperative project establishing nursing homes, physical rehabilita- between Inari municipality in Sweden and Sør- tion services and residential care homes in the Varanger municipality in Norway which aims Mediterranean countries, or entering into agree- to develop new, innovative business models ments with others that provide these services. for cooperation on elderly care and home care And the thousands of Norwegians who have services that extend across national borders. become residents or long-term tourists of Spain Source: See www.interregnord.com/ are working to expand Norwegian involvement in social measures and care services along the Span- ish coast. The relationship between health and climate is given as a main motivation factor for the rather A growing number of service providers offer extensive emigration to and long-term tourism in recreational activities, physical training services Spain. Individuals suffering from rheumatism and and care services in this international market. asthma experience especially positive health Both major international humanitarian organisa- effects, such as less pain, a simpler daily life, bet- tions and more commercial players offer every- ter training opportunities and less use of medica- thing from short-term, traditional spa stays to tion. Although only scarcely one-fourth of Norwe- long-term stays in institutions or permanent relo- gians in Spain say they would travel home to Nor- cation to senior living communities. These com- way if they were to become severely ill or injured, munities are targeted at people 55 years and older they nonetheless harbour worries about finding and offer activities, daytime programmes, practi- themselves in such a situation and are working cal and personal assistance, separate nursing actively for the establishment of good care servi- home facilities and special services for people ces with assistance from their home country. The with dementia (Barstad 2007). question then becomes whether it is easier, less In Norway, Nordic companies such as Nor- expensive and better, not only for the users but landia Care and Alleris provide home care ser- also for their home municipalities in Norway, to vices and institution-based services to various finance or establish care services in Spain, as user groups, and Adecco, the world’s largest staff- many would like (Helset et al. 2004, Sørbye et al. ing agency, has been involved in the operation of 2004). several nursing homes. Official Norwegian Reports NOU 2011: 11 Chapter 1, 2 and 3 33 Innovation in the Care Services Reference

Reference

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