1. ELDERLY CARE IN DENMARK - A LONG TRADITION OF PUBLIC RESPONSIBILITY
Denmark is one of the smallest countries in the European Community, with a population of 5 million. The mean lifespan is similar to other countries in Northern Europe (71 years for male, 77 years for female), 16% of the population being 65 years and over.
Denmark has a long tradition of public sponsorship in health and social policy. Since the 1930's the local governments of the municipalities have had the responsibility of providing health and social services, such as home care and nursing homes for the elderly. These policies were renewed in the 1970's, and after the publishing of reports by a National Commission on Ageing in 1982 a comprehensive policy on old-age policy has been initiated.

2. DEMOGRAPHIC TRENDS - THE CARE BURDEN IN DENMARK IN A EUROPEAN CONTEXT
The demographic trend in Denmark is similar to the trend in most other countries in the European Community (Table 1).

Table 1 The development of the 65+population in Denmark and the EEC from 1965-2020

However, the care burden in Denmark is the heaviest in the European Community because of rather low fertility figures and a decreasing retirement age. Thus the percentage of elderly pensioners in relation to the population of economically active adults is expected to be nearly 30 in the year 2000, the percentage in Europe being on average below 25.
The care burden is especially marked in the 80+ population. This population has increased by 250 per cent since 1960 and is expected to increase by another 50% over the coming 35 years.

3. ORGANIZATION OF SERVICES
(1) Home care
According to the Health and Social Assistance Acts the municipalities are responsible for providing home help and home nursing to elderly people with health problems and functional incapacities. Home help consists of various kinds of personal assistance, such as cleaning, washing shopping, preparing food, and assistance with personal hygiene. Municipal home helpers provide services for approximately 20% of the elderly citizens in the community. If an elderly person needs permanent home help the services are provided by the municipality free of charge.
Home nursing, subject to medical referral, is provided freely by the municipality, in most Danish communities now also on a 24-hour basis. Home nurses and home helpers are working in teams, often operating in smaller areas, dependent on the size of the municipality. When an elderly person is in need of home help, the home help office is contacted either by the elderly person herself, a relative, the family doctor, or a hospital department. The need of home help is initially assessed by a home nurse.
In some communities the home care office has initiated certain schemes of preventive visits given to elderly citizens.

(2) Housing and institutions
Six per cent of the elderly in Denmark live in nursing homes, mostly elderly residents with severe senile dementia or hemiplegic paralysis. The nursing homes are staffed with nurses and other professions such as physiotherapist and occupational therapists. According to the Danish Social Assistance Act nursing home residencies are provided by the municipality, the institutions being run by either the municipality itself or a voluntary organization as an entrepreneur.
The staff : /resident ratio of the nursing homes is approximately 1.1 and the residents normally live in single-bed rooms with their own furniture. Consequently, in an international comparison, the costs of the Danish nursing homes are rather high. The average costs per resident per year amount to approx. 7 million yen, the costs in the newest institutions being approx. 10 million yen.
In 1987 a new Housing for the Elderly Act was passed which empowers the municipalities to build suitable private dwellings for the elderly so that they may remain in their own homes as long as possible. These dwellings are often built in close connection with the home care central. Thus private dwellings can partly substitute nursing home institutions because of the availability of the 24-hour home care services. However, most housing needs of the elderly citizens with disabilities are met in their ordinary homes by housing remodelling and by providing technical aids. These services are provided by the municipalities according to the Social Assistance Act.

(3) Health services
The cornerstone of the Danish health care system is the general practitioner. Thus every Danish citizen is affiliated to his or her own family doctor, who is also the gatekeeper to specialized services in hospitals or specialist clinics.
An important specialized health service for the elderly is geriatric medicine. In Denmark long term care hospital departments were established prior to the evolution of geriatric medicine. This fact might explain the fact that geriatric medicine as an academic discipline has not been introduced until recently.
The average length of stay of elderly patients in geriatric and other hospital departments is shown in Table 2.

Table 2 Number of beds in geriatric departments and other hospital departments, and the average use of bed days among the elderly and in the total Danish population

4. PROBLEMS OF COORDINATING SERVICES
(1) Different roles of the municipal and the county administrations In general the Danish health services are paid by the counties which have an average population of 300,000. However, home nursing is paid by the municipalities which are also responsible for other services for the elderly, e.g. home help, nursing home, various aids and housing remodelling.
The existence of two levels with different economic responsibilities related to the elderly care sometimes gives rise to various problems of coordination. Obviously, the acute hospital wards must be open to all patients with acute health problems. However, when the elderly patient does not need treatment and rehabilitation anymore, the discharge to the patient's own home is dependent on resources in the community. During the past decades many elderly patients have been staying in an acute hospital bed, waiting for either home help, housing remodelling or a nursing home bed. Until recently it has been an economic advantage for the municipality to maintain a relatively low capacity of home care and nursing home services, because the prolonged stay in the hospital for the waiting patient is paid by the county.
Since 1988 a couple of counties have carried out a specific project to prevent overuse of bed days caused by limited facilities in the community. An important implication of the project is that the municipality is given a maximum of 5 days to provide home care services or a nursing home bed, as soon as the decision of discharging the patient from hospital is taken. In case the appropriate service is not available at that time the municipality is obliged to pay to the county a fee-per-day which equals the hotel costs of staying in hospital.
The result of a project of this kind which has been conducted in the county of Northern Jutland (500,000 inhabitants) has caused a significant de- crease in the bed usage among elderly citizens. Also, it has given rise to increased interest among health care staff, administrators and politicians in procedures of hospital use in the region. The interest is further stimulated by some new projects which have been initiated to improve the patterns of referral to and discharge from hospital. These projects have partly been sponsored by funding which is based upon a fixed percentage of the accumulated fee-per-day budget.
The problems of coordinating services which are paid by different administrative units are not solved merely by projects of the kind described. Differences in professional skills and attitudes, differences in political and administrative traditions also contribute. Therefore, an important issue in the planning of coordinating services is to arrange regular meetings at all levels between staff groups in elderly care, administrators and politicians from both the municipalities and the counties.
In 1985 the Danish Board of Health published a series of recommendations regarding the coordination of health and social services for the elderly. Emphasis was put on specific practical problems related to the admission of elderly people to hospital. Thus it was recommended
- to improve the procedures of hospital admission
- to improve the geriatric assessment in acute hospital
- to improve the individual planning of discharge from hospital
- to improve the procedures at the time of discharge
- to initiate follow-up procedures to prevent acute re-admission to hospital
Especially, the discharge from hospital was considered an extremely vulnerable event carrying the risk of future unnecessary re-admissions of the elderly patient. Following the publication of the recommendations several municipalities have now initiated specific schemes to improve discharge procedures. One way is to invite home care staff to participate in planning the discharge procedures. Another way is to arrange that home care staff accompany the patient from the hospital department to the home, with the purpose of securing that all practical arrangements be in place. A third way is that the hospital staff ask the family doctor to make a home call one or two weeks after the time of discharge. One purpose of such an arrangement is to secure efficient drug treatment.

(2) Waiting lists
Waiting lists are typical problems in the bigger cities. Elderly chronically ill persons are waiting for either nursing home vacancies or various kinds of housing for the elderly. Also, most of the patients waiting for an surgical operation in hospital are elderly persons.
The waiting lists related to nursing homes have been analyzed on several occasions. In 1988 approx. 4,500 people were waiting for vacancies among the 47,000 nursing home beds, the average waiting periods being about 3 months. However, a considerable number of frail elderly people have to wait for more than one year, especially people living in large cities. The existence of minor waiting lists is, of course, an inevitable consequence of rational planning of service capacity. It is generally concluded that a waiting list amounting to 10% of the total number of nursing home beds is acceptable.
An important prerequisite to minimize the size of the waiting list is to improve the assessment of the old person prior to the recommendation of offering her a number on the waiting list. During the last decades it has been discussed whether such an assessment should be made in a geriatric department in hospital or in the home of the elderly person. In Denmark there is no uniform procedure as the responsibility of referring elderly people to nursing homes lies with the individual municipality. In some communities the assessment is made in the geriatric ward of the hospital, in other communities the general practitioner is used as the medical expertise when the assessment is made.
Generally, the assessments made today are extremely accurate, and only elderly persons with severe handicaps are admitted to nursing homes. This fact, however, means increasing problems of motivating the nursing home staff, as the care burden has grown much during the past few years.

(3) Social admission to hospital
A number of studies have been conducted to elucidate the criteria for admitting old people to acute medical wards. Fairly constantly it has been shown that between 25 and 35 per cent of the admitted elderly persons are admitted for social reasons (causa socialis). The 'diagnosis' is either indicated directly on the admission sheet, or the social criterion is 'hidden' behind some medical diagnosis, such as 'vascular disturbances' or 'confusion'. The clientele admitted for social reasons consists largely of elderly persons with an array of chronic medical and social problems. They often live alone with a poor social network and have often been admitted to hospital several times within the year and characteristically they have not been sufficiently helped with their various social problems. It is also characteristic that several medical efforts, such as clinical and para-clinical diagnostic procedures, are carried out to identify and meet the needs of the old person - but still, the problems of these causa socialis patients are mostly of a psycho-social nature.
Several suggestions have been made to avoid unnecessary admission of elderly patients to the acute medical wards. One specific initiative has proven to be a success: The introduction of 24-hour services of the home care team. Whereas general practitioners on duty have been available during night and day, home care staff was not until recently available during the evening and the night. More than 60% of the Danish municipalities now provide 24-hour home care services. A home nurse is teamworking with a home helper, and the team can be contacted either by a doctor, by the elderly person herself, or her relatives. The team can be called for in acute cases when an elderly person needs nursing or some kind of assistance, or according to a regular scheme by individual appointment, e.g. at the time when the old person is going to bed. In this way the home care team functionally operates as a nursing home team, but the patient is staying in her own home (Fig.1).

Fig. 1

Whereas the 24-hour home care team might contribute to avoiding social admissions to hospital, and in addition operating as a substitute to a nursing home function, some ethical problems need consideration. The majority of home care clients are living alone and need contact with other people. Short visits by home care staff are no adequate substitutions for contacts with family members or other relatives. In the big cities it is now often discussed whether lonely people should rather be referred to nursing homes or group housing than be left alone in the community with an offer of home care services.

(4) Insufficient resources in geriatric teaching and research
Long-term medicine as a specialty was officially introduced in Denmark in 1973, but as mentioned earlier, the specialty has not been given sufficient resources to meet the needs of the geriatric patient clientele. Originally, long-term medicine in Denmark was distinguished from geriatric medicine in the UK which operates with a strict age limit and also include regular lifelong care of certain severely handicapped elderly patients and, on the other, from Swedish long-term medicine which also covers regular nursing care in so-called annex hospitals. Thus, the long-term medicine in Denmark is a medical specialty dealing with geriatric hospital patients or adult patients with severe handicap. But the stay of the patients the in long-term wards normally do not exceed 2 or 3 months. Permanent care, however, is a matter for the nursing homes which have already been described.
Recently, efforts have been made to change the long-term medicine concept in to a geriatric medicine concept according to the British model. Thus, the expertise should be defined not according to the patients' length of stay in the hospital, but rather to the diagnosis, assessment and treatment of the geriatric patient. In line with this the first Danish professor of geriatric medicine will soon be appointed and hopefully, clinical training and research in this field will be given high priority.

5. TRENDS IN SERVICE DEVELOPMENT AND ELDERLY PARTICIPATION
(1) Preventive home visits Several Danish municipalities are now engaged in projects on preventive home visits to elderly people living in their own homes in the community. These projects have been encouraged by some very interesting results of a research project in Roedovre, a suburban municipality near Copenhagen. The results were published in the British Medical Journal in 1984 (1). During 3 years an intervention group of 300 elderly citizens aged 75 and over, and chosen at random, were given home visits every 3 months by a doctor or a home nurse. The elderly persons were interviewed and given information on health promotion. If unmet needs were identified the person was advised to contact relevant professional assistance. After 3 years the intervention group was compared with a similar control group. Compared with this group a significant reduction in mortality was seen in the intervention group. In addition, a 25% reduction in hospital bed usage was found, also accompanied by reduction in nursing home referrals and use of doctor's calls.
Following the reports from Roedovre several programs on preventive home visits to elderly citizens have been initiated. Different professions participate, and different age criteria are used to identify the elderly populations who are offered the home visits.

(2) Self help groups
About 40% of the elderly in Denmark live alone. Among these elderly, about 80% have frequent contacts with their children or other relatives. However, the remaining group consists of old persons who live rather isolated lives. In addition, this group also includes those individuals with the greatest health and social problems.
Because of the changes in the Danish labour market, more than 85% of the women below 60 years of age are now active on the labour market. Partly because of this trend it is not realistic to hope that family resources are sufficient to give further support to elderly people living alone.
During the last 5 years several projects on self help groups have been initiated. These groups are formed by active elderly, mostly women. They have started various activities to strengthen the social network. In some instances these projects are sponsored by public or private funds. The municipal support might be to offer rooms where the group members can meet, or other facilities necessary for their activities. However, it is not yet possible to conclude whether the self help groups are able to include those elderly people who carry the highest risk of health deterioration.

(3) Group housing
Another issue related to the health risk of lonely elderly citizens is the possibility of establishing group housing. The idea of group housing is to give housing for a self help group. Such housing might be an old rural or suburban family house which is divided into a number of dwellings, or a block of apartments in the city which include a room for group activities.

Fig. 2

Only a few examples of group housing (Fig. 2) have so far been established, but a growing interest among the elderly has been noted. The first examples have been formed by relatively active elderly women. The question is whether it will be possible to encourage also elderly citizens with chronic diseases and handicaps to join such a group. Group housing is now formed as a result of voluntary initiatives, but might be sponsored by the municipalities in the future, especially if the establishing of group housing means lower costs for health and social services for the dwellers.
One idea is to establish group housing for elderly people with senile dementia. A number of municipalities have indicated such ideas in their planning material. Of course, some kind of staff should necessarily be allocated to the elderly living in group housing.

(4) Role of the elderly organizations
A number of elderly organizations are operating in Denmark. They were originally charity organizations, but now they tend to change in the direction of consumers' movements. The biggest organization ("ElderCase") have recruited more than 200,000 members within 2 years.
Local branches of these organizations now participate in the municipal planning and service development. Also, the elderly organizations have established companies which operate as entrepreneurs building housing for the elderly (Fig. 3).

Fig. 3

It is a general tendency that the views of the elderly themselves are of increasing importance in political decisions at both central and local levels. Also, surveys have been made to identify the attitudes and expectations among younger age groups regarding their own future life as old Danish citizens. It can be concluded from these surveys that the future elderly populations expect to be more active and self-determined than is seen in the elderly population of today.

Literature (in English)
Hendriksen C, Lund E, Stromgaad E. Consequences of assessment and intervention among elderly people: A three year randomised controlled trial. Brit. Med. J. 1984; 289:1522-4.