[SCMP Column] Challenges of Aging

November 26, 2016

It was 3.20 in the afternoon on September 23 – just over two months ago – that my father rasped his final breath after a grisly two year battle with cancer. I now understand what people mean when they talk of a “death rattle”.

Despite the desperate sadness, I will always recall his passing as a “happy death” – not just because he was 88 and had lived until the age of 86 in robust good health, nor because the descent was mercifully steep. More than anything else it was “happy” because he died with my mum and all of us five kids around him, and because he was never hospitalized. Even through the worst final days, he was at home, and was able to die exactly where he wanted to be. My father’s fervent wish was always to avoid incarceration in a hospital as he died.

As I understand it, this is the ideal of what “ageing in place” is all about. Elderly people do not want to be uprooted and institutionalized in those final, often challenging, months or years. They want their lives to remain as normal as possible. They want friends and family around them. They want the dignity of independence rather than being infantilised by hospital or nursing home routines.

And the medical profession worldwide is beginning to agree. Just read Atul Gawande’s “Being Mortal” for an inspiring but sobering assault on how current mainstream medical approaches to management of those final fragile years are failing our communities, and the benefits of enabling “ageing in place”. Not only do the elderly live longer and more happily, but governments save money. It cost hugely less to equip my parents’ house with devices that made it safe for dad to live at home, to bring in a proper hospital bed to make sure he did not get bed sores, and bring nurses to my father, than it would have done to occupy a hospital bed through his final months.

So far, so obvious. Except that this is precisely not what our own Hong Kong government is doing. In 2014 (the latest year for which we have numbers) 90% of the 46,000 people who died did so in a hospital bed. Over 40% of our 38,000 hospital beds are occupied by elderly patients. As the Hospital Authority makes the case for a HK$200bn programme to build more hospital wards and add elderly care homes, so the Housing Authority says it does not have the funds to build more housing for the elderly, nor to “retrofit” existing homes to make them safe and livable for the elderly infirm. We are failing to build convenient community clinics embedded close to peoples’ homes. We are actively ignoring the role that private sector care homes might play. And we are head in the sand in terms of training carers in the numbers that will be needed for our rapidly ageing society.

It would be comical if it were not tragic that between them, the Housing Authority, the Hospital Authority, the Health and Welfare Bureau, the Elderly Commission, the Poverty Commission and other concerned official and advisory bodies cannot work together to provide a holistic solution that not only saves us money and provides a more effective solution to the ageing challenge, but also closely matches the deeply-felt needs of most of our elderly and their families.

Few in government seem to appreciate the speed at which a crisis is approaching us. In the three decades to 2045, the number of people in Hong Kong aged over 65 will rise from just over 1m to over 2.5m – an increase on average of 50,000 a year. In the coming decade alone, the number of homes occupied by elderlies only will rise by 200,000 – from 350,000 to 550,000 – to account for around 20% of all households.

The Housing Authority says it does not have funds to build on the scale needed to accommodate the needs of our elderly. The thought that some of the funds currently being set aside to build hospital wards and elderly homes for them could be diverted to the Housing Authority seems not to have occurred to them. Or at least silos sit in the way.

A single glimmer of comfort comes from the fact that a template for action has already been tailor-made for the government. The Housing Society, headed by Marco Wu, has devoted significant resources to building homes that enable “ageing in place”. They divide the elderly into three: the “young old” (who need homes that enable independent living); the “middle old” who need “assisted living” that includes some home support services; and the “old old” who may also need dedicated facilities like care homes, rehabilitation centres or dementia centres.

For the rich, they have built a marvelous 588-unit development called Tanner Hill that has all of these components built in – elderly friendly design, an integrated medical clinic, panic button alarms to bring nursing staff straight to your door, and a wide range of in-home facilities to enable even fragile elderly to live at home safely.  But for low income communities they have begun fitting and retrofitting homes with similar “ageing in place” features. For the government they have provided a template that can work – provided that land premiums are waived.

So far the Society has built 576 units under their Senior Citizens’ Residential Scheme. The only problem here is that with the elderly population rising by 50,000 a year, this scheme needs to be multiplied 200-fold. Clearly this is a job not for the not-for-profit Housing Society, but for the government and the Housing Authority.
The way forward is clear: Funds need to be diverted from the Hospital Authority. All new developments – private or public – should be required to include elderly-friendly features that make it possible for elderlies to age safely at home. Land premium waivers should be used to incentivize these provisions. A budget must be allocated for large-scale retrofitting of homes to meet the immediate needs of elderlies. A proportion of the hospital building budget should be diverted to building large numbers of community-based medical centres. And we need an explosion in training for carers.

All this needs is joined-up government. We need our leaders to come out of their silos to meet a massive social challenge. If only I could be optimistic this will happen.
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