Home Care for Aging Populations: A Comparative Analysis of Domiciliary Care in Denmark, the United States and Germany

Citation

Bowerman, J. (2009), "Home Care for Aging Populations: A Comparative Analysis of Domiciliary Care in Denmark, the United States and Germany", Leadership in Health Services, Vol. 22 No. 1, pp. 98-99. https://doi.org/10.1108/17511870910928047

In a world where there is a little doubt that the demand for formal care services is set to increase significantly, this book is a timely addition to the literature of aging in place, comparing home care delivery policies and services for aging populations in three different countries – Denmark, Germany, and the state of California in the USA. The book is not perhaps for general consumption because it has a distinctive academic perspective, but it will be of particular interest to gerontologists, to those who provide direct care to the elderly, and disabled, and to those directly involved in social policy development in any country attempting to put together effective home care support for those who need it.

Using data from the UN, the authors suggests that the three countries, although different in their approach to home care policy, face similar situations including an “ageing age profile, a growth in the over‐80s population, increasing life expectancies, and increases in old‐age dependency ratios” (p. 19). Given these statistics, the questions of who gets care, how much, and who pays become increasingly important. The book clearly demonstrates that social policy and its organization tends to follow national culture orientations. It is likely not surprising that in the more individualistic and “masculine” society of the US, individuals have to cover more of their health and social costs than in Germany or Denmark where the state and family play a much larger role.

The authors take us inside the homes of the elderly in all three countries; thus we as readers get to assess policy in practice at the micro level, as well as providing us some perspective from the more macro level. Using research data from both these primary as well as a number of secondary sources, the book compares the three systems according to their regulatory structure, how they are financed, how services are delivered, and how much consumer power individuals have in terms of the respective long term care programmes that are available to them.

As the authors point out – all countries, whatever their orientation to how homecare is provided – are going to have to deal with the increasing costs for such programs, particularly in light of aging populations, and how they are funded. Universal eligibility as found in Denmark – is difficult to finance in countries such as the USA with its low tax orientation, and increasingly in Germany with its Long Term Care Insurance scheme which operates on capped budgets and where a large proportion of beneficiaries have to pay out of pocket costs to supplement the care they receive. The problem with insurance‐based systems that are not mandatory is that “countries with expanding populations cannot assume that the majority of people will take active steps to safeguard their own long term care needs” (p. 128). By not addressing properly the funding needs of home care programs for the elderly, we run the risk of having to provide more costly services at a later date.

Another issue for policy makers is that of the family and its role in supporting and providing care for disadvantaged and elderly members. It is sometimes argued that too much support from the government deters family members from caring for their own. On the other hand, often those younger family members who do care for their aging relatives receive little respite from their duties, little support from their employers, and unlike paid workers, are unable to take a break from their duties.

Other issues raised are the need for quality assurance in the delivery of programs, and the question of “who cares for the carers?” Much home care tends to be low pay low status jobs for women. As the authors point out ‘the use of a lower skilled workforce is a dangerous cost cutting mechanism in an environment where an increased number of high dependency clients with co‐morbidities and chronic illnesses are requiring care services in the community. As well as requiring basic domestic care, these recipients frequently require substantial amounts of personal care, which in some instances can only be delivered by a skilled care worker (p. 134).

This book throws some interesting light on the issue of home care, some of the possible options, and how the services are delivered in three very different countries. The writers raise important questions that policy makers need to consider as they try to mould their respective programs around their population needs. I believe the issues are important enough to merit general discussion on the part of a much larger population than just policy makers and academics. My one recommendation therefore is that the writers “de‐academicize” this book – if that is possible – so that the issues they write about can be available to a much larger and more general population. The debate about how we will care for our elders and indeed how we will be cared for ourselves is of far too much importance to be just left to the researchers, academics and policy makers.