A dichotomous narrative surrounds ageing in the 21st century. On the one hand, there is increasing research and recognition of healthy ageing, and a recognition that age is not synonymous with ill health. On the other hand, there is the fear of looming economic costs and providing care for increasing numbers of older people with increasingly complex needs. These two narratives are hard to marry. Even the name long-term care (given to the latter narrative) is at odds with a short-term neoliberal political economy and, as a result, is generally low on government agendas. Many societies are so caught up in viewing individuals as contributors to the economy only that they have devalued the lives of older people. Nothing shows this denigration more than the fact that in April only five countries had data on older people living in care homes and COVID-19 infection rates. Or, furthermore, the nasty libertarian question during COVID-19 over why we are damaging the economy for members of society that are regarded as economically inactive. In fact, between 2008 and 2018 people older than 55 years accounted for 79% of employment growth across OECD countries, and there is evidence that the market activities and productive non-market activities of older people (volunteering, caring, and supporting) make up a good proportion of the gross domestic product in many countries. But surely, regardless of economic activity, we want to live in a world where all lives are valued equally?
Nursing homes do not have salubrious origins. In the UK, during the 1800s older people who could not support themselves financially or had no family to look after them were housed in workhouses—institutions with conditions so grim that Thomas Wakley called them “the antechambers to the grave”. In 1920, many of these buildings were turned into nursing homes and, in a move of pure convenience, the residential care home was born. Thankfully, conditions have improved, but many care homes are still not very good at either caring or being a home, in the comforting, emotional sense in which people have control over their environment and feel safe. The International Long-Term Care Policy Network (a collaboration of researchers) has reported that in 21 countries, on average, nearly half of all COVID-19 deaths have been in care home residents (although data are poor and inconsistently measured). COVID-19 has been linked to the deaths of more than 4% of the population living in care homes in the USA, the UK, Spain, and Belgium. Care homes cannot be called safe.
In The Lancet, a policy document looking at China's long-term care system highlights recurring global problems—a rapidly growing, often private, institutional care sector, the slow and small development of home and community-based care (despite a desire to increase home care, years of conflicting policy measures have in fact incentivised institutional care), inconsistent data monitoring, shortages in workforces, poor regulation, poor governance, and a lack of organised financing.
The world is beginning to wake up to the importance of healthy ageing. The 73rd World Health Assembly endorsed the Decade of Healthy Ageing 2020–2030 and a broad agenda (including guidance on long-term care) will aim to lengthen the time older people spend in good health—ie, increasing healthspan, rather than lifespan. The Lancet Healthy Longevity, a clinical journal addressing all aspects of healthy ageing, publishes its first issue this week.
Concurrent with political and academic engagement in this aspect of ageing is the need to reconcile and embrace the inevitable requirement that many people will need extra care as they age. Long-term care must value the heritage, experience, and contribution of older people, and see them as individuals who are part of a wider social network. Some countries already do so. Denmark stopped building care homes in the 1980s and older people living in social housing with care facilities are considered tenants. Singapore is building integrated, so-called enabled communities, where residents are fellow citizens who contribute to a resilient society. Long-term care should be diverse, focusing on the importance of a home and community with multi-generational possibilities, with built environments designed for older people, and access to flexible and high-quality care, reflecting the many and unique ways that people age. The care workforce must be valued and receive better training, better pay, and a structured career path that reflects their important and highly skilled roles. Traditional care homes should be a last resort. The dehumanising way that COVID-19 has been managed in people in care homes makes a mockery of the purpose of medicine to extend life and allow people to live life in the fullest sense. The long-term care system in many countries is broken and must be reimagined.
For The Lancet Healthy Longevity see https://www.thelancet.com/journals/lanhl/home
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