Ageing and Health:
A challenge to public health and social cohesion
Council of Europe, Strasbourg, June 23 2016

The 2003 heatwave was a wake-up call for France
 
"During the 2003 heatwave, France suddenly realized it was old and that it was failing its most vulnerable elderly citizens.” This is how Dominique Prédali started her presentation.
 
Contrary to what the government first announced, she said, the majority of these elderly victims did not die at home. Studies proved they died at hospitals and nursing homes, mainly of dehydration and hypothermia. This came as a shock to most people, remarked Mrs. Prédali, and raised the question: How could this possibly happen in a so-called civilized country?
 
She was then asked to investigate on the medical and medico-social care of old people in France and abroad. She found the same shocking and “horrible” situation everywhere.
 
Constants in all countries:
•      ER waiting time longer for old people. Younger people are a priority even though the frail elderly are at higher risk of becoming rapidly dehydrated and dying.
•      Failure to send them to the right hospital ward because of the lack of geriatric beds or a misdiagnosis due to unfavorable conditions on arrival: i.e. dehydration rapidly leading to mental confusion leading to misdiagnosis of dementia.
•      malnutrition: an old person hospitalized for a hip fracture, for example, but with no other health issues, can rapidly end up undernourished after a short stay.
•      Overmedication especially tranquilizers or antidepressants such as benzodiazepines which cause dehydration, even when the patient is given enough to drink. The situation is the same in Australia, Canada or the US.
•      Understaffing, qualified or not. A care assistant can find herself or himself alone at night with 80 dependent residents to look after. A situation that makes it impossible for them to deal with two simultaneous emergencies. Which one should she or her address first?  
•      Industrialization of care which leads to budget cuts in heating, staffing or food resulting in what Mrs. Prédali calls the "top three" causes of preventable deaths which are malnutrition, dehydration and pressure sores, closely followed by overmedication, falls and urinary infections. According to US and Canada studies, the higher the profit of the nursing home, the higher the rate of abuse.
•      The lack of studies on elder abuse in Europe 
 
Abuse or neglect? A well-kept secret
 
Everywhere, says Dominique Prédali, there are double standards when dealing with a child or an old person.
 
For the first one, it is “abuse“, condemned by law, and for the second one it is "neglect" or "structural dysfunction" 
 
Quoting Alexandre KALACHE, former head of the Health and Ageing World Program at the WHO, and John BEARD’s predecessor, Dominique PRÉDALi finishes with these words: "elder abuse is the world’s best kept secret and also the last taboo of the 21st century"!

In 2000, investigative journalist and writer Markus Breitscheidel decided to scrutinize the way nursing homes in Germany look after their residents and their employees. Unlike news journalists, Markus Breitscheidel focuses on a single topic over three years and self-funds all his research for total independence.

Recruitment without training
« On Monday, I went to the job centre in Munich to look for my first job. Two hours later I got a call for my first interview. The following day, I started as carer in charge of 12 heavily dependent residents without any training whatsoever in this field, coming from the world of business and journalism into this.”

Strict task timing leading to personnel burnout and elder abuse, an industrial business model totally unsuited to caring for and sharing with human beings
“I never thought”, said Markus, “that Fordism, which I studied at college – i.e. a set time allocated to each task – would be used in the care sector. Yet this is exactly how people work: I have one minute to give a glass of water to an old man or an old lady. I have a minute and a half to take a person to the toilet, clean them and put them back in their wheelchair or their bed. “
Markus reminds us that, in Henry Ford’s era, this system already created relationship problems between men and machines. The car workers suffered en masse from burnout and became aggressive with the machines. “This has been adapted step by step to the care sector”, deplores Markus “and it is not surprising that in a man to man relationship, this also leads to high numbers of burnout cases or to violence.
Speaking from personal experience, I can tell you that time devoted to care cannot be programmed. A lady I was looking after could, with my help when she was feeling well, go to the toilet in a minute or a minute and a half, but the following day, if she was not feeling well, she was less mobile and I needed three minutes. Spending this extra time with her meant spending less time with the next person.”

Constantly running after time drives staff mad
“No wonder carers, changed into robots, cannot hold their job for more than 5 years and that, recruiting people to work in such conditions – whether in hospitals or nursing homes – is extremely difficult in Europe. In such working conditions, no human being, wishing to look after people, can do it without breaking down at some point.
I am sure that each country has a certain number of people able and willing to work in health and care, but thanks to this system, they have been put off. They have been turned into care robots, who have to obey the system and obey their bosses’ orders.”

Investors regard it as a profit making sector
From his two-year experience in five different areas in Germany, Markus Breitscheidel concludes that the care sector is a major economic issue. And, says Markus, because of the growing demand, this is where the biggest investments will be made. With expected profits of 10 to 15%, Markus Breitscheidel tried to identify profitability elements in a country like Germany, where care needs can be classified into 5 groups and where the higher the need for care, the more time and most of all, the more money you need.

“Adverse effects linked to patient’s health”
From a strictly economic point of view according to Markus Breitscheidel, this means that the more dependent a patient is, the more money they can make for the nursing home. It is hardly surprising then, as far as he is concerned, that improving patients’ health is not a priority.
"When I saw this, he said, I decided to try, after my working hours, to give some of my time to one or two residents in my care. I did this for two or three days before being summoned to see the management because what I was doing had been noticed. Later, they threatened to sack me because improving patients’ health was not profitable: if they got better, they would go down to the lower health care bracket (where they needed less care) and the nursing home would get less money."

What improvements can we recommend?

1. A high priority need: improve staff work conditions

So, when we talk about what needs to be done to improve the situation, I think the first step would be to create more humane work conditions for the staff by making care less “industrial”.

1. Avoid speculation
   Secondly, we need to think about a democratic way to finance this sector in the next 20 years, because I am convinced that we cannot allow commercial companies to carry on making money on people’s back. It does not work. We must make sure that every euro invested in care goes to the care personnel or to building a future for this sector.
2. A voluntary credit

It is generally accepted that the answer to demographic evolution won’t be found in money alone. We must start by building a system not entirely dependent on money: young or retired people could be asked to do voluntary work to help caring for old people, reading to them or helping them with their shopping. The time they invest could be credited to them for later use, when they need help. It is an avenue to explore if we want to set a system that is not exclusively finance-led.

1. Regarding his book:

• over 85 000 copies sold in two weeks
  After a year and a half of rejections from various publishers claiming that the subject matter would not interest anyone, Markus Breitscheidel said that he finally found a publisher brave enough to publish his book. Eighty-five thousand copies sold within a fortnight, making it the number one bestseller book in Germany.
• Political pressure and over a hundred court cases won
  ​"I wanted to talk about this subject in public but politicians were not happy about it. I noticed that I attracted attention whenever I was invited on television. But I was subjected to increasing pressure regarding these television programs, to the point that a government representative would contact me before each of my TV appearances. He would tell me what I could say and what I couldn’t. And if he thought I was taking too much liberty, he would take me to court. They took me to court over a hundred times and I won every time.
  
  
• My top priority is to propose ways to improve this sector for the future. ​

"Lobbying is needed to influence politicians
because I see that, in Germany, those who sit on the board of directors of the big public corporations, including health and care companies, are often people who held or still hold political office. There is a lot of lobbying work to be done to change things and prepare a better future. In Brussels, the professional care unions spend a lot of money to lobby massively. They besiege every single influential politician to stop those who try to interfere with the future of their activity. I would like to say that I feel personally involved in my future needs for care that will be dispensed by business men. I would like, later in life, to be free until the end, and for this reason, I am starting my fight now and I hope to be strong enough in the next twenty years to see my propositions accepted."