Examining coordination and equilibrium: an analysis of supply index and spatial evolution characteristics for older adult services in Zhejiang Province

Objective

This study aims to analyze the spatial distribution and dynamic evolution of older adult service supply in Zhejiang Province from 2010 to 2019. Additionally, this research seeks to propose an optimized resource allocation strategy for older adult care services, promoting regional fairness and coordinated development.

Methods

To evaluate the older adult service supply capacity, this research first constructed an evaluation index system based on the Chinese modernization development pattern. Then, an empirical analysis was carried out using a combination of the entropy-TOPSIS method, kernel density estimation, Markov chain analysis, Dagum Gini coefficient, and panel regression model.

Results

The results show an overall upward trend in the supply and service capacity of older adult care in the whole province. However, the spatial distribution of older adult service supply capacity in Zhejiang Province still exhibits a gradient effect, even in the most recent year of 2019. Furthermore, the supply capacity of older adult services shifted to a higher level in the whole province, and regions with high supply capacity had a positive spillover effect on adjacent regions. The overall difference in the older adult service supply capacity of the province showed a decreasing trend. The level of economic development, urbanization rate, transportation capacity, the level of opening up, and the proportion of employees in the tertiary industry had a significant impact on the supply capacity and spatial difference of older adult services.

Conclusion

From the findings, this study puts forth countermeasures and suggestions to optimize the spatial distribution of older adult care services. This includes giving full play to the regional spatial linkage effect, promoting new-type urbanization construction, upgrading the transportation network, and expanding the opening up of the industrial structure. By implementing these measures, a more equitable and coordinated older adult services system can be developed in Zhejiang Province.

[COVID-19 and mental health services in Europe]

The area of mental health is directly affected by the pandemic and its consequences, for various reasons: 1-the pandemic triggered a global lockdown, with dramatic socioeconomic and therefore psychosocial implications; 2-mental health services, which treat by definition a fragile population from the psychological, biological and social points of view, have a complex organizational frame, and it was expected that this would be affected (or overwhelmed) by the pandemic; 3-mental health services should, at least in theory, be able to help guide public health policies when these involve a significant modification of individual behaviour. It was conducted a narrative review of the publications produced by European researchers in the period February-June 2020 and indexed in PubMed. A total of 34 papers were analyzed, which document the profound clinical, organizational and procedural changes introduced in mental health services following this exceptional and largely unforeseen planetary event.Among the main innovations recorded everywhere, the strong push towards the use of telemedicine techniques should be mentioned: however, these require an adequate critical evaluation, which highlights their possibilities, limits, advantages and disadvantages instead of simple triumphalist judgments. Furthermore, should be emphasized the scarcity of quantitative studies conducted in this period and the absence of studies aimed, for example, at exploring the consequences of prolonged and forced face-to-face contact between patients and family members with a high index of "expressed emotions".

Cohort profile: The prospective study on Chinese elderly with multimorbidity in primary care in Hong Kong

PURPOSE

This is an ongoing prospective cohort aiming to examine the biopsychosocial health profiles and predictors of health outcomes of older patients with multimorbidity in primary care in Hong Kong.

PARTICIPANTS

From April 2016 to October 2017, 1077 patients aged 60+ years with at least two chronic diseases were recruited in four public primary care clinics in the New Territories East Region of Hong Kong.

FINDINGS TO DATE

After weighting, the patients had 4.1 (1.8) chronic conditions and 2.5 (1.9) medications on average; 37% forgot taking medication sometimes; 71% rated their health as fair or poor; 17% were frail; 73% reported one (21%) or two or more (52%) body pain areas; 62% were overweight/obese; 23% reported chewing difficulty, 18% reported incontinence; 36% had current stage 1/2 hypertension; 38% had handgrip strength below the cut-off; 10% screened positive in sarcopenia; 17% had mild or severer cognitive impairment; 17% had mild to severe depression; 16% had mild to severe anxiety; 50% had subthreshold to severe insomnia; 28% indicated being lonely; 12% needed help in at least one out of the five daily functions and the EuroQoL-5-Dimensions-5-Level index score was 0.81 (0.20) and its Visual Analogue Scale (VAS) score was 67.6 (14.6). In the past 12 months, 17% were hospitalised, 92% attended general outpatient clinics, 70% attended specialist outpatient clinics and 10% used elderly daycare centre services, the median out-of-pocket health cost was HK$1000 (US$150). Female and male patients showed significant differences in many biopsychosocial health aspects.

FUTURE PLANS

With assessments and clinical data, the cohort can be used for understanding longitudinal trajectories of biopsychosocial health profiles of Chinese older patients with multimorbidity in primary care. We are also initially planning cohort studies on factors associated with various health outcomes, as well as quality of life and healthcare use.

COHORT REGISTRATION NUMBER

ChiCTR-OIC-16008477.

Geographical Accessibility of Community Health Assist System General Practitioners for the Elderly Population in Singapore: A Case Study on the Elderly Living in Housing Development Board Flats

Accessible primary healthcare is important to national healthcare in general and for older persons in particular, in societies where the population is ageing rapidly, as in Singapore. However, although much policy and research efforts have been put into this area, we hardly find any spatial perspective to assess the accessibility of these primary healthcare services. This paper analyzes the geographical accessibility of one major healthcare service in Singapore, namely, General Practitioners (GPs) services under the Community Health Assist Scheme (CHAS) for older persons. A Python script was developed to filter the website data of the Housing Development Board (HDB) of Singapore. The data derived was comprehensively analyzed by an Enhanced 2-Step Floating Catchment Area (E2SFCA) method based on a Gaussian distance-decay function and the GIS technique. This enabled the identification of areas with relatively weak geographical accessibility of CHAS-GPs. The findings are discussed along with suggestions for health practitioners, service planners and policy makers. Despite its initial nature, this study has demonstrated the value of innovative approaches in data collection and processing for the elderly-related studies, and contributed to the field of healthcare services optimization and possibly to other human services.

Senior Services that Support Housing First in Metro Vancouver

Housing First is a model and philosophy for housing homeless people in immediate and permanent housing. In order to implement and deliver Housing First, research is essential to understand the system of support services as they currently exist. Guided by principles of community-based participatory research, this paper presents the findings from a senior-focused deliberative dialogue workshop in Metro Vancouver, Canada. Participants (16 service providers and 1 service recipient) identified services and resources available to support seniors in maintaining housing and barriers and facilitators for accessing services. Broadly, data were organized into seven themes: (1) Housing; (2) Home support; (3) Transportation; (4) Information availability, accessibility, and navigation; (5) Cultural diversity; (6) Discrimination; and (7) Funding and financial support. Results found that affordable housing that adapts to changing health conditions, income supports, health services, homecare, transportation, and culturally appropriate and nondiscriminatory informational resources are among the supports most needed for persons as young as 50 years old to succeed under the Housing First model in Metro Vancouver. Barriers to Housing First service provision, including rigid eligibility criteria for chronically and episodically homeless, should be revised to better support the growing number of older adults who are newly entering homelessness in Metro Vancouver.

Adult Children and Their Parents' Expectations of Future Elder Care Needs

Objective: Lifestyle changes and medical advances warrant an investigation into perceptions of elder care needs held by today's adult children (AC) and their parents. Method: Surveys were distributed to 200 AC. Eighty AC and 102 of their parents responded. Results: Paired sample t tests revealed that AC ( M = 10.61, SD = 4.5) and parents ( M = 10.4, SD = 4.60) did not differ in their own expectations of future care needs. However, ACs' expectations of their parents' needs (M = 15.82, SD = 5.77) were significantly higher than both self-expectations. In addition, among six caregiving tasks minimal but significant differences were found in expected receipt of assistance. Discussion: Consistent with Weinstein's (1980) theory of unrealistic optimism, results demonstrated the tendency for AC and parents to underestimate their own future care needs. Such underestimation may in turn, lead to inadequate planning for future care needs.

The European Hematology Association Roadmap for European Hematology Research: a consensus document

The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.

Acute Care Hospitals Providing Elderly and Long-term Care Services: A Survey of the Massachusetts Experience

To assess the involvement of hospitals in geriatric, community and long-term care services, a survey was undertaken of the 104 acute care hospitals in Massachusetts. Results show that hospitals (N = 81) are adding geriatric expertise but as yet have taken on community services and long-term care only to a small extent. Hospitals perceive major deficiencies in physician service to nursing homes (89 per cent) and in availability of inpatient geriatric units (94 per cent). Responding hospitals have targeted for development by 1985 geriatric inpatient units (17 per cent), respite care (16 per cent), and hospice care (16 per cent). The financial implications of the survey results are discussed with respect to prospective reimbursement and public health implications.

The 3 A's of the access process to long-term care for elderly: providers experiences in a multiple case study in the Netherlands

The access process is an important step in the care provision to independently living elderly. Still, little attention has been given to the process of access to long-term care for older clients. Access can be described by three dimensions: availability, affordability and acceptability (three A's). In this paper we address the following question: How do care providers take the three dimensions of access into account for the access process to their care and related service provision to independently living elderly? To answer this question we performed a qualitative study. We used data gathered in a multiple case study in the Netherlands. This study provides insight in the way long-term care organizations organize their access process. Not all dimensions were equally present or acknowledged by the case organizations. The dimension acceptability seems an important dimension in the access process, as shown by the efforts done in building a relationship with their clients, mainly through a strong personal relationship between client and care advisor. In that respect it is remarkable that the case organizations do not structurally evaluate their access process. Availability is compromised by practical issues and organizational choices. Affordability hardly seems an issue. Further research can reveal the underlying factors that influence the three A dimensions.

Inequity in oral health care for elderly Canadians: part 2. Causes and ethical considerations

The Canadian Health Measures Survey, conducted between March 2007 and February 2009, revealed unmet dental needs among older adults in Canada. This article, the second of a 3-part series, explains that the inequity in oral care faced by elderly Canadians is due largely to the current fee-for-service dental service system. However, the inequity has arisen because of financial, behavioural and physical barriers, and both the community at large and the dental profession have a social responsibility to reduce this unfairness and provide equitable access to oral care for older people.

Patient Engagement: The Key to Redesign the Exchange Between the Demand and Supply for Healthcare in the Era of Active Ageing

The last decades' changes in the epidemiological trends of chronic disease - also due to the ageing population - and the increased length and quality of life among the majority of Western population have introduced important changes in the organization and management of the healthcare systems. Consequently, health systems throughout the world are searching for new and effective ways to make their services more responsive to new patients and the public's health needs and demands. The idea of patient engagement - borrowed from the marketing conceptualization of consumer engagement - moves from the assumption that making patients/clients co-producers of their health can enhance their satisfaction with the healthcare system as well as their responsibility in both care and prevention by improving clinical outcomes and reducing health delivery costs. To make people aware of their health services options by supporting them in the decision-making process and to engage them in enacting preventive and healthy behaviors is vital for achieving successful health outcomes and preventing waste of resources. In this chapter, we outline a model (PHE model) that explains the patients' subjective experience with their health management process and the levers that may enact the passage from one phase of the process to the other. Based on this conceptual model of patient engagement will be proposed a tool kit of priority actions that may sustain the patient in its process of engagement.

[Description of cognitive-behavioral specialized units in France: results of a national investigation]

Through a national survey, the SFGG's UCC Task Force worked and liaised with the DGOS as to establish a national inventory of the UCCs in France. 43 of the 55 newly opened UCCs in 2011 filled up the survey. These UCCs largely supported patients meeting the admission criteria's from the book of specifications edited by the public department. Those patients were demented, valid and with disruptive behavior disorders. Earnings for the stay were commonly measured by a reduced NPI (32 to 18). Body therapies, cognitive and sensory were mainly performed, even if a quarter of the UCCs also provided acute missions (diagnosis and management of acute diseases). Medical staff and caregivers were very different. Nearly half of the UCCs reported an insufficient staffing and a third of them reported a lack of training. Among the most often claimed difficulty (81% of UCCs), the release of patients is noted, with an average length of stay of 36 days. From an architectural point of view and even if the amount of beds was by the book (in average: 11), 58% of the UCCs proposed only single rooms. The lack of homogeneity shown with this survey tells us to share more our practice.

Promoting careers in gerontology to students: what are undergraduates seeking in a career?

The graying of the Baby Boomers has created a shortage of professionals in aging-related careers. However, colleges and universities with gerontology and aging programs face a challenge of recruiting students. The purpose of this study was to determine what students are looking for in a career and whether these attributes are congruent with careers in gerontology. Results of this study indicated that factors important to students in a future career include whether career is enjoyable, has adequate benefits, provides personal fulfillment, provides excitements, provides an opportunity to help others, is well respected by others, and provides opportunities for employment.

[Health and disability in the elderly: old paradigms and future prospects]

The projections regarding the ageing of the Italian population are cause for great concern; however, the ageing scenario may actually be interpreted in a more optimistic way. Theories formulated in the 80s envisaging a decline of mortality, morbidity and disability in the elderly are now confirmed and prefigure an unexpected decrease in disability rates in the elderly population. The aim of this review is to attempt to explain the reasons for this by analyzing the role played by the various determinants of health, in particular social isolation, which are likely to play an important role in the future as well.

Framing the decision to contract out elderly care and primary health care services - perspectives of local level politicians and civil servants in Finland

BACKGROUND

In the literature there are only few empirical studies that analyse the decision makers' reasoning to contract out health care and social services to private sector. However, the decisions on the delivery patterns of health care and social services are considered to be of great importance as they have a potential to influence citizens' access to services and even affect their health. This study contributes to filling this cap by exploring the frames used by Finnish local authorities as they talk about contracting out of primary health care and elderly care services. Contracting with the private sector has gained increasing popularity, in Finland, during the past decade, as a practise of organising health care and social services.

METHODS

Interview data drawn from six municipalities through thematic group interviews were used. The data were analysed applying frame analysis in order to reveal the underlying reasoning for the decisions.

RESULTS

Five argumentation frames were found: Rational reasoning; Pragmatic realism; Promoting diversity among providers; Good for the municipality; Good for the local people. The interviewees saw contracting with the private sector mostly as a means to improve the performance of public providers, to improve service quality and efficiency and to boost the local economy. The decisions to contract out were mainly argued through the good for the municipal administration, political and ideological commitments, available resources and existing institutions.

CONCLUSIONS

This study suggests that the policy makers use a number of grounds to justify their decisions on contracting out. Most of the arguments were related to the benefits of the municipality rather than on what is best for the local people. The citizens were offered the role of active consumers who are willing to purchase services also out-of-pocket. This development has a potential to endanger the affordability of the services and lead to undermining some of the traditional principles of the Nordic welfare state.

Politics of a policy for aging in Canada

Canada's health and social care system is paralyzed by our decentralized federalist governing structure. Public policy change, such as that suggested by Chappell and Hollander, will require a new political paradigm that recognizes the need for a multi-sectoral, co-operative approach to integrated systems of care delivery. The federal government must provide the necessary leadership, and the provinces and territories must show the political will to co-operate if Canada is to embrace the challenges of an aging population.

An evidence-based policy prescription for an aging population

In this paper, the authors provide a policy prescription for Canada's aging population. They question the appropriateness of predictions about the lack of sustainability of our healthcare system. The authors note that aging per se will only have a modest impact on future healthcare costs, and that other factors such as increased medical interventions, changes in technology and increases in overall service use will be the main cost drivers. They argue that, to increase value for money, government should validate, as a priority, integrated systems of care delivery for older adults and recognize such systems as a major component of Canada's healthcare system, along with hospitals, primary care and public/population health. They also note a range of mechanisms to enhance such systems going forward. The authors present data and policy commentary on the following topics: ageism, healthy communities, prevention, unpaid caregivers and integrated systems of care delivery.

Paradigm shift: shaping policy to meet the needs of our aging population

The extent to which our aging population impacts the health system is, as Chappell and Hollander suggest, dependent on (1) how that system is defined and organized and (2) our attitudes as a society to aging and the elderly. The Canadian Home Care Association supports the policy prescription described by Chappell and Hollander and believes that a paradigm shift from a reactive and episodic system to one that is proactive and supportive is required. This article expands upon the lead essay by further discussing the role of home care and the need for its integration into the healthcare system. And the article concludes by asserting that we must change our attitude toward aging by improving our understanding of and attention to the needs of older adults.

Integrated care for the frail elderly

Chronic disease management initiatives have thus far focused on single disease entities. The challenge of an aging population is the occurrence of multiple diseases, complicated by geriatric syndromes, in the same person. The term frailty is used to denote such persons, who are more vulnerable to poor health outcomes when challenged by a health stressor. In this paper, it is argued that frailty is a chronic condition and thus requires a chronic disease management approach. Hospital-based and community interventions for managing frail seniors are discussed, with a focus on enhancing primary care, and with appropriate and targeted support from geriatric specialists in the form of capacity building as well as direct clinical service. Finally, a model for integrating individual geriatric interventions into a broader system is proposed.

Canada's population is aging

Canada's population is aging, and the authors of this issue's lead article, Neena Chappell and Marcus Hollander, present a policy prescription for how to design a healthcare system that better responds to needs of older Canadians. The timing of this issue of Healthcare Papers is important: the first of the baby boomers turned 65 in January 2011. There is a pressing need to develop policies and implement sustainable reforms that will allow older adults to stay healthier and maintain their independence longer in their place of choice, while also creating efficiencies and quality improvements in our overall healthcare system that will benefit Canadians of all ages.

Chicken little? Why the healthcare sky does not have to fall

If the healthcare sky is falling, it is because we have not yet grasped the opportunity to do better. Here we comment on three points in Chappell and Hollander's lead article. First, rather than looking to new federal-provincial mechanisms, which do not currently appear on the political agenda, we propose that federal and provincial governments honour their current commitments, including an extension of the 2004 First Ministers' agreement, set to expire in 2013-2014, that flows federal healthcare dollars to the provinces. Second, we concur that small things (e.g., transportation and medication management) matter in big health systems. Access to a full range of services in integrated systems of care permits cost-effective "downward substitution" instead of more costly, and often inappropriate "upward substitution" to hospital and institutional care. Finally, given the current political climate of fiscal constraint, it is helpful to consider the lessons of successful local initiatives such as supportive housing, which can integrate care "from the ground up" including essential primary and preventive care. Rather than seeing an aging population as the harbinger of healthcare doom, we suggest seeing it as a motivator to rethink, refresh and innovate.

How we move beyond a policy prescription to action

In response to "Evidence-Based Policy Prescription for an Aging Population," by Chappell and Hollander, this paper proposes that efforts be made to execute strategies to build the political momentum and public support necessary for concrete action toward achieving the recommended policies. It also suggests the implementation of knowledge translation strategies to assist in disseminating and integrating existing successful programs across the wider health system. Finally, this paper proposes a concerted and robust mobilization of forces in order to move from evidence-based agenda setting into active policy implementation. A key element of this transition involves placing greater emphasis on interest group activation and public policy deliberation. Such a focus would enable consensus between policy makers, decision-makers, interest groups and the public, garnering the political traction necessary to allow for the implementation of healthy public policy that best serves the needs of an aging population.

The underserved aged and the role of the African American church

Historically, the church has been a central institution in the life of the African American community, and caring for bodies, as well as souls, has been a critical aspect of its ministry. The significance of this role will increase in importance in the foreseeable future given the escalating costs of health care services. There is an increasing realization that churches must be involved in the provision of health services if society is to improve the health status of this population. This paper examines the role of the African American church in providing formal and informal health care services to the underserved aged.

[The supply of long-term care services for the elderly in Italian regions]

In Italy, as in other European Countries, ageing population drives policymakers to redesign the Long Term Care (LTC) system for the elderly. This study analyses the LTC supply for elderly considering the distribution of different components: formal care (institutional and alternative), and informal one in Italian regions. An observational, cross-sectional, ecological study was carried out using statistical data drawn from the Italian National Institute of Statistics and Ministry of Health referred to 2004. Factorial analysis selected the most important components of LTC phenomenon. These components were used for the application of cluster analysis. Cluster Analysis was performed on main components of Factorial Analysis. Then, the ratio of mean value in each cluster on national mean value was calculated for each indicator. Factorial analysis showed three factors characterized by autovalue > 1 that accounted for 61% of the total variance. Cluster analysis highlighted four groups of regions with different way of supply. High level of home care (141,9) and social network (121,3) emerged in group 1. High level of family who received help and family paying a caregiver (108,3 e 121,1) resulted in group 2. High level of no profit LTC (168) supply was reported in group 3. High level of public residential care (451,4) was found in group 4. These remarkable differences in the way of service supply, highlight the need of improvement of the information system on LTC. Thus LTC policy and practice might be better supported both in planning and organizational targets.

[Demographic aspects of social security of elderly population in the Barents Euro-Arctic Region]

Social security of elderly people is discussed at different levels of the realization of the geronto-social policy in the Barents Euro-Arctic Region within the context of the Madrid Plan of Actions on Aging. There have been comparatively analyzed demographic indicators that show age structures of the regions which are parts of the Barents Euro-Arctic Region. There have been defined regional differences and trends of improvement of geronto-social policy for providing security of life activity of elderly people in the Russian part of the Barents Euro-Arctic Region.

Elderly people's perspectives on health and well-being in rural communities in England: findings from the evaluation of the National Service Framework for Older People

Addressing the problems of meeting the needs of ageing populations in rural areas is recognised as a political and service delivery challenge. The National Service Framework (NSF) for Older People (NSFOP) set out a series of service standards to raise quality, to redress variations in service use and to enhance the effectiveness of services across health and social care in England and alluded to the challenges of meeting such standards in rural communities. This paper reports findings from the consultations undertaken with 713 elderly people as part of the midpoint review of the NSFOP in 2006, presenting and analysing the views and experiences of elderly people from rural areas. The consultations to engage with elderly people employed a mixed methodology that included public events, focus groups and individual interviews. The data reveal participants' views of how different patterns of social change in diverse country areas in England influence health and well-being in later life. The costs and benefits of centralization of services, and the pivotal issue of transport are important themes. The findings raise questions about the unclear and contradictory usages of the term 'rural' in England and the portrayal of rural ageing as a homogeneous experience.

Access and limitations of community services for older persons - a guide for the GP

BACKGROUND

Increasingly aged care services are shifting from residential to community care. As a result, systems of access to services for older persons in Australia have become more complex. It is important for general practitioners to know how to navigate these systems.

OBJECTIVE

To provide a practical guide for the GP on available aged care community services; how to refer to them, how to recognise their limitations, and how to build partnerships to improve care.

DISCUSSION

There is a range of affordable community services for older Australians. However, the system has limitations including long waiting lists in some areas and lack of continuity of care. Improvement of communication between medical practitioners and community services is required.

Clinical prioritisations of healthcare for the aged--professional roles

BACKGROUND

Although fair distribution of healthcare services for older patients is an important challenge, qualitative research exploring clinicians' considerations in clinical prioritisation within this field is scarce.

OBJECTIVES

To explore how clinicians understand their professional role in clinical prioritisations in healthcare services for old patients.

DESIGN

A semi-structured interview-guide was employed to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis.

PARTICIPANTS

20 physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway.

RESULTS AND INTERPRETATIONS

The clinicians struggle with not being able to attend to the comprehensive needs of older patients, and being unfaithful to professional ideals and expectations. There is a tendency towards lowering the standards and narrowing the role of the clinician. This is done in order to secure the vital needs of the patient, but is at the expense of good practice and holistic role modelling. Increased specialisation, advances and increase in medical interventions, economical incentives, organisational structures, and biomedical paradigms, may all contribute to a narrowing of the clinicians' role.

CONCLUSION

Distributing healthcare services in a fair way is generally not described as integral to the clinicians' role in clinical prioritisations. If considerations of justice are not included in clinicians' role, it is likely that others will shape major parts of their roles and responsibilities in clinical prioritisations. Fair distribution of healthcare services for older patients is possible only if clinicians accept responsibility in these questions.

Aging, primary care, and self-sufficiency: health care workforce challenges ahead

A combination of "environmental factors" in the U.S. has led to an increased demand for health care professionals. However, there has been a significant decrease in the number of U.S. medical graduates selecting careers in family medicine and general internal medicine, thus driving demand for international medical graduates. At the heart of our national workforce policy needs to be good domestic and foreign policies, such as self-sufficiency approaches that include strategies to incentivize rural and underserved practice for U.S. medical graduates.

[Development of memory clinics in The Netherlands]

AIM

Memory Clinics (MC's) are multidisciplinary teams involved with early diagnosis and treatment of people with dementia. In order to attain more insight into the development of this kind of services in The Netherlands, we compared the data of two inventories, one of 1998 and the other of 2004.

RESULTS

The number of MC's increased from 12 to 40. The number of referrals per service has also increased. Dementia was the most important syndromal diagnosis. The focus is less exclusively on academic centres. An growing number of MC's has structural collaborations with local service providers for mental health. Differences among MC's exist with regard to the number of referrals per week, the intensity and duration of the diagnostic procedures and the proportion of people without dementia. There is much interest among MC's to participate in a national network for harmonisation and quality control.

CONCLUSION

MC's are an increasing part of standard care for people with early dementia and other cognitive disorders.

Priorities in identifying unmet need in older people attending general practice: a nominal group technique study

BACKGROUND

Primary care practitioners are encouraged to identify unmet need in older people, but the best mechanisms for doing this are not known.

OBJECTIVE

To identify common unmet needs, as perceived by older people and professionals, that could be enquired about during routine encounters in primary care.

METHODS

This was a nominal group technique qualitative study conducted with older people in London and primary care professionals working in the same localities. Subjects were seven nominal groups of 5-12 participants each, four with culturally diverse user groups recruited through local community and voluntary sector resources and three with primary care professionals (GPs and nurses). Group interviews were conducted with two facilitators and one observer recording field notes and were tape-recorded and transcribed for data collection.

RESULTS

Older people and professionals share some ideas about unmet need, but there are important differences. Older people may emphasize their autonomy and right to make choices, while professionals may use epidemiological knowledge to justify their own agendas, which may be considered intrusive. Nominal groups can be useful tools for capturing perspectives of different groups, but prioritization of themes identified by nominal groups may not always be feasible.

CONCLUSIONS

Unmet need is a complex concept, with different interpretations according to the perspective taken. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients.

Changing health needs of the ageing population

The drama unfolding in this century can be viewed in terms of the age at which people are now dying. Most medical needs, attention and costs occur in the last years of life. At the turn of the century about 25% of people survived age 65. In the developed countries at least 70% of the population now survive beyond this age and 30-40% of deaths are at age 80 or over. Entirely different diseases, conditions and social structures are involved when most people survive to these late ages. Increasing longevity raises the issue of net gain in active functional years versus total years of disability and dysfunction. The available evidence gives rise to pessimism: at present for each active functional year gained we add about 3.5 compromised years. The need for long-term care will continue to grow. Improvements in long-term care involve economic considerations, political will and better mechanisms for the delivery and acceptance of this labour-intensive practice. The education and preparation of the ageing population in terms of normal realities and expectations are even more important. Health-care givers, politicians, and other decision makers are increasingly likely to have first-hand exposure to the good and bad realities of an ageing society, and thereby to perceive the realities of ageing more clearly than ever before. A new political will for more creative and equitable responses to the needs of the elderly and their families is rapidly emerging. The greater our familiarity with the problems of old age, the greater the likelihood for us to find means for improvement.

[Expansion or reduction of geriatric care structures in Germany? A critical analysis on the significance of the official statistics and other surveys]

The legal survey basis for the hospital statistics of the Statistisches Bundesamt (German Federal Statistical Office) affecting the recording of data starting in the year 2002 has been also adjusted to improve the quality of information on geriatric care structures. The basic hospital statistics data for the year 2003 published in April 2005 report 171 geriatric hospital facilities for in-house treatment and 97 for partial in-house treatment as well as 74 geriatric rehabilitation facilities for inpatient treatment. In an additional internal investigation, another 46 geriatric rehabilitation facilities for outpatient treatment were ascertained for the year 2003. Compared to other, earlier surveys, the Statistisches Bundesamt reports an almost equal number of geriatric care facilities in the hospital sector, but a far lower number of such facilities in the sector of rehabilitation facilities for inpatient treatment, and therefore is highly incomplete. Hence, despite modified recording conditions, the official statistics do not provide a realistic representation of geriatric care structures. Under consideration of these limitations and corresponding corrections, the average geriatric care ratio (inpatient and partial inpatient or out-patient geriatric treatment places in hospitals and rehabilitation facilities per 10,000 persons aged 65 and above) amounted to 10.2 geriatric treatment units in 1997, 12.2 in 2000, and 12.3 in 2003. There were significant differences regarding the total capacity and the shares of different kinds of geriatric care structures in the individual federal states. All in all, that means that the expansion of geriatrics that had taken place until the year 2000 has slowed down significantly over recent years and has largely been limited to demographic adjustments. As far as the relevance of reliable numbers on the existence of geriatric care structures for requirement planning, secondary statistics, and state-related comparative analyses is concerned, the ongoing weaknesses of the hospital statistics must be taken into account when developing corresponding interpretations. They call for examining further improvements of the procedure of recording geriatric facilities for the official statistics. So far, they are no reliable basis for cross-sectional analysis.

Our Aging Societies: Ethical, Moral, and Policy Challenges*

The aging of industrialized nations poses grave ethical, moral, and policy challenges for health professionals and our societies. The demand for both acute and long-term health care for the elderly will increasingly strain the economic resources of older persons and our nations. These pressures generate a number of difficult issues for our aging societies. Three of the most important issues are: (1) How aggressive should curative medical treatment be for severely demented patients?; (2) How should the financial burden of long-term care be distributed between the public and private sectors?; (3) Should public policies establish old-age-based limits on acute medical care in order to conserve resources? These issues are complex, of great importance, and require substantial reflection and discussion by health care professionals and the public at-large.