Sombre outlook over sustainable care for older people

‘For the first time, I am truly concerned about the future of care for older people. Not because the demographics are worrisome, the labour market is tight and costs are rising. We’ve known that for decades. No, what is really alarming is the increasing number of advisory reports on these issues and the lack of unity and continuity in our national governance,’ writes Vilans Director, Henk Nies in a recent blog published on

Why these concerns? The report, “Sustainable Care for Older People – lessons and experiences from other countries” (in Dutch, ‘Houdbare ouderenzorg – Lessen en ervaringen uit andere landen’ by researchers from Leyden Academy on Vitality and Ageing, IQ Healthcare Radboudumc and Erasmus School of Health Policy & Management, put me in this sombre mood. The report is a background study for the WRR (Netherlands Scientific Council for Government Policy) advisory report, “Sustainable Care”. It outlines how Denmark, Germany, Japan and the United Kingdom are dealing with an ageing population. It is a good report, which does not offer the solution for which direction we should choose for elder care, but rather, how we should choose that direction.

Wicked problem

A bit of context beforehand. Japan and Germany are a lot further ahead than the Netherlands in terms of an ageing population. Denmark and the UK are at about the same level. The Netherlands has the highest public spending, but relatively low personal contributions. Denmark has a social democratic system, Germany and Japan, a more corporate model and the UK is a liberal welfare state. This means that in one country (Denmark), the government is mainly in charge; in other countries social parties such as employers, employees and insurers (Germany, Japan); and market forces are dominant in the fourth country (UK).

None of the systems can be a one-to-one model for the Netherlands

Everywhere, the central government has a regulatory role and collective measures and solidarity are the norm. Everywhere, market mechanisms play a role. Issues over affordability, labour market, quality, equal access and social support are at stake in each system. The authors argue that none of the systems can serve as a one-to-one model for the Netherlands. The sustainability of elderly care is a ‘wicked problem’. It is complicated and there is no single solution.


Why does the report make me feel despondent? The report shows that the systems in the various countries were created in a decades-long transformation, built on shared social and cultural values. And when things have to change, as in Japan around the year 2000, the authorities take years to do so. They enlist the support of society and carefully prepare the new direction. Not one big bang, but incremental adjustments to gradually change the course of the systemic tanker that is elderly care.

Political system

Only with the British (particularly England), does this not work. The researchers write, ‘The weakest link in this system seems to us to be the political system, which, instead of continuing with what the parties have already agreed upon, starts over and over again, namely, creating a new commission, writing a new report and conducting new rounds of negotiations until the government’s term expires.’

All those reports serve primarily to legitimise the bickering

It should be obvious which system is equivalent to the Dutch situation, especially after the recent failure to form a cabinet and the constant bickering tone adopted by our politicians during debates, which now encompasses as many as eighteen political parties. Fortunately we still have the public servants, you would think! All those reports serve mainly to legitimise the bickering. There is something to be gained for everyone and if not, there will soon be another report – that’s how I think sometimes when I’m in a cynical mood.


What then? I think we need a fundamental debate over the principles of care for the coming decades. The recent consultations on, among other things, “Care for the Future” (in Dutch, “Zorg voor de toekomst”) are mainly about solutions and not about the underlying principles and values. The report “Sustainable Care for the Elderly” shows from an international perspective that the choice for one has consequences for the other.

Do you choose professional care as the starting point or informal care?

I’ll outline a few choices that are also dilemmas. For example, as a society, do you opt for mainly collective financing or personal contributions? Left or right, citizens will have to pay for care, whether it’s through taxes, premiums or out-of-pocket. It certainly makes a difference what type of consensus lies beneath it all. Do you choose professional care as a starting point or informal care? That choice matters – still – for the employment of women, for the social infrastructure (e.g., child care) and financial allowances for family caregivers.

Do you choose for a lot of care at home or mostly, institutional care? For more long-term stays for older people in hospitals or in nursing homes? Where there is little or expensive nursing home care, much more hospital care seems to be needed (Germany, Japan, England). Do you want to solve the labour market problem by paying ever higher salaries (and making citizens pay higher premiums and taxes, and saddling other social sectors with an employee shortage) or are you going to attract foreign employees, as in the other countries?

Every choice you make has an impact on other elements in the system

Do we choose market mechanisms as an incentive for good and efficient care or will it be a few public providers who are allowed to provide long-term continuity? Do we want to regulate sustainability through reduced volume, lower rates, budgeting or market mechanisms? And will centralisation or decentralisation take precedence? Every choice you make has an effect on other elements in the system. It’s a kind of waterbed that will never be calm.

Normative choices

What the lessons from abroad show is that we need to address these issues from the perspective of a societal debate. What are the normative choices we make as a society? From there we can move on to policy and operational choices. In doing so, it is wise to keep a sharp eye on ‘social sustainability’. It is necessary to have a long-term choice that we stick to, prepare the steps well, and then evaluate and adjust along the way. In short, first think, then act. And don’t come up with solutions too quickly. The more solutions, the more I worry!

Well, then I’ll write a similar blog – with solutions …!

This blog was published on the website

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