1. OBJECTIVES FOR THE ELDERLY

For many years in Denmark we have worked towards the objective "As long as possible in your own home", and meaning the elderly with somatic illness as well as the demented elderly.
Holbaek municipality in which I live and work, has adopted the following objective for the elderly: "The life of the elderly in the municipality is not different from the life that the rest of the citizens in general have".
The offer of service must be adapted to the individual requirement, with the weight on security, and supporting own resources of the elderly seen from the principle - Help to self-help.
The possibilities for the elderly to organize their own life must be supported, and there must be the offer of advice to the elderly, so that they can make the necessary choice themselves with regard to the conduct of their lives.
The political objectives for the elderly must be prepared and carried out on the following principles:
Decentralization
Right of self-determination
Freedom to choose
The possibility of choice
Challenges
Dignity as a human being
They were a few words about our objectives for the elderly in my town. Now I will continue to speak about the administrative systems in Denmark generally, and in my municipality.
Earlier the demented elderly in Denmark were admitted to mental hospitals, which until 1970 were administered by the state. This delegation of authority was in 1970 given to the counties.
At that time, the municipalities were not able to take care of the demented elderly in their nursing homes, partly because of lower number of staff than today, and partly because the staff had too little knowledge to take care of the problems among this group of elderly. These things have slowly changed, but it is still not satisfactory. Today there are many demented elderly in the nursing homes in the municipality. Only the most heavy cases, where the demented elderly is a big inconvenience for the other inhabitants, the municipality pays for care in an institution in the county.
Holbaek municipality has approximately 31,000 citizens, about 20,000 in the city and about 10,000 in the country. Per 1/1 1991 there were 3,861 people over 67 years - 4,444 people or 14.2% over 65 years of age .
The number of staff involved in elderly care in Holbaek municipality is about 500 people or about 375 full time staff.
The number of demented elderly has never been counted, but in the institutions and in special care we have about 60 people. Many others live in their own homes and many are taken care of by their family or spouses.
Denmark is one of the few countries in the world, where the state has adopted that it is the obligation of the public to help all its inhabitants, when they because of age and health are no longer able to take care of their lives or their homes.
It is national law which says, that all persons over 67 years, or persons under 67 years with a handicap, are entitled to a pension. It is also national law which gives admittance to nursing homes, to home nurse, to home helper, to aids, when it is necessary. It is also a special national law which takes care that the elderly has an economic possibility to rent a good modern flat, by a system of subsidies. This system ensures that the rent for the flat will be about 15% of the elderlys income, when the elderly have a smaller fiat of about 60 square meters.
It has always been the municipalities who have the authority to ad-minister the laws, but the state pay 100% of the pensions, and the counties pay 50% of the costs for home care and nursing homes for persons under 67 years. The rest is paid by the municipalities. It is also the municipalities who pay for all costs for persons over 67 years. The state pays 75% of subsidies for flats, the municipality pays 25%.
About flats for the elderly, the municipality has agreements with the public supported cooperative housing societies about the right to rent some of the flats in housing blocks where people of all ages live. Such fiats are built all round the municipality, both in the country as well as in the cities. The elderly get the possibility to rent a smaller modern fiat without (or nearly without) stairs, when they are no longer able to live in their own house, or when they live in an older fiat with many stairs. In my town Holbaek we have such agreements about the right to rent such fiats for about 13% of the elderly in the municipality. It means that the elderly can stay in the neighborhood where they have lived all their lives, with their friends, and this can prevent, or postpone, the time when the person has to move to a sheltered fiat or a nursing home. These arrangements are found in all smaller municipalities, but our largest cities such as Copenhagen, Arhus and Odense have many problems with the elderly who live in old, unsuitable flats. The big cities build many sheltered fiats, but not enough. It will be many years before these problems are solved.

2. EDUCATION

Denmark has adopted new education for nursing staff from l/1 1991. It consists of modules. In one year you can qualify for so-called social and health helper. It substitutes home helpers and assistant nurses. You can choose further education of 1.5 years and then you are so-called a social and health assistant. This education substitutes occupational therapists and male nurses in special institutions in the county. Finally, you can take further education to be a nurse, physiotherapist or midwife.
In another way Denmark is different from other countries. All medical treatment and hospitalization is free of charge. The system is split up into 2 organizations - the hospitals and the family doctors. The hospitals are administered by the counties, and the doctors in the hospitals are employed by the counties. The family doctors have an agreement with the county, but they are self-employed. The social services departlnent in the municipality cooperate with the hospitals as well as with the family doctors. But at the moment we are trying hard to develop this cooperation. The government has the opinion that a better cooperation will give the citizens better conditions, and the money spent will be better used.

3. ADMINISTRATION OF CARE IN THE MUNICIPALITY

The earlier laws shared home service and institution service in the city in 2 organizations. The expenses - especially for the institutions -the last 2 decades have greatly increased, both because the numbers of the very old have been greatly increased and because the municipalities have allowed the number of staff to increase. (Figure 1 shows the division in percentage of institution costs and costs for care at home. The institutions have about 300 people and use 63%, but the home care takes care of about 950 people and uses only 37%.)

Fig. 1 Holbaek: Devision of Expences o/65 Years

In many municipalities in Denmark we have introduced home service round the clock, and we can see that many more elderly prefer to stay in their own homes, when it is possible to choose.

Fig. 2 Projection for the Development of the Population in I Holbaek Municipality

(Figure 2) A projection for the development of the population in Holbaek (municipality) shows that the population of over 67 years from 1990-2002 will rise 8,1%, but the total number of citizens will rise 11%. It means that the number of elderly does not rise in percentage. But the people over 80 years will in the same period rise 26%. We also know that the population of the elderly - and here I mean those over 67 years -around the year 2010 will again rise very much. (Figure 3) On account of the increase of the very old in the population, we have tried to calculate the costs for the municipality. The in-crease you can see in this picture.

Fig. 3 Holbaek Municipality: Projection of the Budget for the Elderly Care

Because of the immense rise in the costs, and because of our opinion that the elderlys own resources or the resources and the abilities of the staff are not used enough in the old system, Holbaek (municipality) has adopted a plan for switch-over. This plan was adopted in June 1989, and in a period of 5 years we wilt put all care of elderly (at home or in institutions) into one organization in order to get a better continuity in care. We are rebuilding the nursing homes into 5 service centers and building elderly fiats close to the centers instead of rooms in nursing homes. An elderly fiat is a 2-room fiat with kitchen, bathroom and toilet (Figure 4). There will be help available from home helpers and nurses around the clock. Every occupant will get help according to individual requirement, and every occupant in the elderly fiats will have an emergency system, so that by pressing a button on a bracelet they will be able to talk with the home helper or the nurse. The call goes by telephone and radio.
The elderly flats are built close to a center. Holbaek (municipality) will have 5 centers, when we are finished in 1994. The first center started in August this year. We have started to build the next center and it will be finished in September/October next year (Figure 5).

Fig. 4 Bolig-Plan (Nybygning)

Fig. 5 Elisabeth-Centret

The structure for the service in the future will be decentralized. We will divide the municipality up into 5 geographic areas with their own center and with their own elderly flats. Each area will have the authority to allocate flats, aids and care. They will have their own budget. In the centers you can buy warm meals in a cafeteria. There is retraining. There will be a library, and the possibility for occupational therapy and amusement.
The centers and those nurses and home helpers who have their job at the center, give help both to the occupants who live in the elderly fiats, and to the citizens who live in that geographic area. All the helpers have in this way the possibility to get to know the citizens in their own area.
The centers have another function. In the first center which has been opened in August this year, there are 45 elderly fiats next to the center. and in the center there are 9 flats which will be used as temporary flats. A temporary fiat is furnished, and the citizens in the area can come in for short periods for retraining, if they are unable to stay at home, or if the family member who takes care of them at home needs a holiday. Also it can be that a very sick person who in the last time of life must be very close to nurses and home helpers (about 3 months). In such a situation a spouse in good health can come with the sick person in an elderly flat. They do not pay rent for a temporary fiat. They pay for the meals they have and for medicine. They can have their own flat in the municipality and can move back to their own flat.
In the Danish system of care, there is no limit to physical illness for being at home. The family doctor, the nurse and the home helper can care for the elderly in their own home, if the flat is adapted to the handicap, and if the elderly wishes to stay in his own home. The condition is, however, that the elderly is mentally capable and understands what is going on about him.
Here we meet the group of demented elderly. The numbers in this group have been increasing, and it has been told all over the world, that the numbers will increase further in the future. The group is difficult to define, and the staff in our nursing homes have different definitions. Are you demented because you one or two times forget things and don't remember correctly? There are many degrees of senility, and we think that in Denmark we have for many degrees of senility, and we think that in Denmark we have for many years neglected this group of people. Naturally we know that we can't cure these people, but we think in return, that with the experiments we have done in several municipalities in Denmark, we can at least put off the time when the demented can be quite absentminded. We can stimulate them in a much higher degree than done earlier, and we can give them dignity as a human-being in the last time of their life. At a certain time, the demented elderly can't live in an ordinary fiat or home in the town. They can't see what is day and what is night. They forget to eat, they forget personal hygiene. They can go out in the middle of the night, they can go out without clothes. They can be distrustful of the family and other people, and they think that people steal from them when they can't find their things. Today the most demented have to stay in special institutions in the county (at this time about 15). The others are staying in the nursing homes in the municipality, but this solution is not good enough. The staff in the nursing homes don't take care of them. They are sitting without attention and stimulation.
In Denmark several municipalities have tried to take care of these people in another way. We have found out, that the demented elderly are becoming more confused when they are staying in larger groups. They will be better when they are staying in small groups of 5-6 people with the same staff every day. This staff is educated to stimulate the demented elderly, and we cooperate with the psychiatrists. Also in Holbaek municipality in December last year we established so-called a protected unit. It is 5 elderly flats, built in a self- contained building together with 40 other elderly flats. Everyone has his 2-room flat but there is also a community living room and a community kitchen. In this building we try to make their daily-day safe partly by talking with the elderly and partly by drawing them into the day-to-day activities. I shall try to describe a day in such a protected unit.
At seven o'clock in the morning 2 home helpers come to work. They ring the bell. The elderly live in their own fiat you see. They say good morning. They ask them to start their morning toilet. Some of the elderly do it themselves, others need to be told what to do, and others need the support of a home helper during their toilet. When you wake up in the morning, most people are hungry and glad to eat breakfast. One or two of the elderly walk to the community kitchen and set the table and they help (if they can) with the cooking. Then one of the most important times of the day comes. It is eating their meal together with the staff. The staff takes care that they talk together about what day it is today, how is the weather, and what shall we do today. The fiat must be cleaned, and the elderly shall do as much work as they can. There shall be shop-ping, and here we wish very much that one or two of the elderly join the home helpers when shopping - of course, if the elderly witches to go shopping. The others stay at home, and the home helper and the elderly prepare the lunch. An old demented woman - usual in women at that age - can be tempted to prepare vegetables and cook simple first courses, because she has been doing this all her life. The meat course will be sent from the cafeteria in the center. Then all the elderly again eat together with the home helpers and talk together about the afternoon. What shall we do? Some of the elderly will perhaps take a little nap, and some wish to take a walk. Then the home helper takes a walk with the elderly. In the afternoon perhaps some of the elderly will receive a visit from family or friends, and the visit will take place in tneir own flat. The elderly - or one or two of them - take part in serving the afternoon coffee. After the meals we try to involve the elderly in doing the dishes. After the evening meal, and when the dishes are done, the elderly can either go to their flat and see the television or they can stay in the community living-rooms until bedtime.
There are some things we have observed about these demented elderly. They feel more pleased, they feel more secure, and they are tired when the time comes for them to go to sleep. Very soon we saw that nearly everybody slept through the night Except for a nap after lunch, the elderly do not have the opportunity to sleep in the daytime. Another problem was solved at the same time. In the nursing homes we saw that some demented tried to leave the home, and the staff knew that the elderly couldn't find back again. When the staff tried to prevent the elderly from leaving, then the demented became very aggressive. In the temporary flats they are allowed to go out, but the home helper looks after the elderly. When they suddenly become perplexed and can't see where they are, then the home helper can meet the demented. Then the demented will be glad and goes home with the helper.
The temporary flats have a terrace around the corner of the house, with garden furniture. The demented can go out there, when the weather is good. Quickly we observed that we could not use the terrace. The demented could not find the door to the house, because it was around the corner. When they could not see the door, they were confused. Instead of this we have placed the furniture in front of the door, and now they can go in and out of the house by themselves. They don't run away any longer, and we believe that the demented meet the demand for movement by going with the home helper for shopping or only for a walk, when they wish to. In August this year we have established another group in the center, and we know that in the future we will establish more groups.
In the municipalities we don't know very much about how many demented elderly live with their families or with spouses. The easier demented can take care of themselves, when they live in secure surroundings with common everyday doings. Just the same things we try to do in the temporary flats. We don't meet these demented elderly until the family member they live with dies or becomes sick and the family can't support the demented.

4. ECONOMY

You can now ask: How can we in Denmark have money for both buildings and a better service? First a little about capital expenses. The law which we refer to in our building, gives admittance to borrowing money at an advantageous interest. The municipalities themselves must pay 9% of the expenses with the flats and 100% with the centers. The municipalities own the nursing homes with adjacent grounds, and they are today without debt. When you build elderly fiats and centers, you can borrow on the existing grounds and buildings, and also on the newly built elderly flats. Popularly said, we begin with buildings and grounds without loan, and end with elderly flats and centers where we have borrowed up to the commercial value. Interest and repayment of the elderly fiats have to be paid by the tenants, who get subsidies from the state and municipality.
Now I will say something about the working expenses. Holbaek town council adopted, at the same time as the plan for switch over - that the working expenses for the care of the elderly must not be higher in the 5 year period of switch over. We are allowed to have bigger expenses one year, if we have lower expenses the next year. Holbaek used 120 million Danish crowns in 1989 on nursing homes, home help, nurses, aids and subsidies for flats. As I showed you earlier, the 63% or 76 million crowns were to nursing homes where we at that time, in 1989, had 300 occupants. The first thing we did in 1989, was to establish around the clock care. Before this time we only had care in private homes until 11 o'clock in the evening. Here we had the happy development that more people had the opportunity to stay in their own homes. The number of elderly in nursing homes this summer has decreased from 300 to 220, and the numbers are decreasing continuously. We don't have citizens who are waiting for a room in a nursing home - only 1-2 people with newly arisen problems.
Because of the very expensive costs per person in the nursing homes this development has already freed money for use in the centers.
Then you can ask, why are the nursing homes so expensive? Because in a nursing home all the elderly in principle get help for anything. In an elderly flat you only get help with the things you can't do yourself. The rest you do yourself. We have seen that elderly in nursing homes who move into an elderly flat, in many cases, can make their own breakfast, perhaps with support from a home helper. Some can also make an open sandwich, which we cat in Denmark at lunch. We only have one warm meal a day. Even if you are handicapped and sit in a wheelchair, in many cases you can do the dishes and dust, down to the level you can reach, and then the home helper will do the rest. In a nursing home you don't have your own kitchen, and the staff traditionally take care of the cleaning for the elderly. We have seen that, in practice, one of the biggest problems in the switchover is to get the staff in the nursing homes working in another way, but I believe that it will succeed, and in all municipalities we try to work in this way.
When Holbaek municipality bas completed the switchover, we expect that the working expenses for the care of the elderly will have decreased by 5-10 million Danish crowns per year, but the best is, if we can give the elderly a better life with the right of self-determination, freedom to choose, challenges and dignity as a human-being.
One of the intentions in the switchover has been influence from the citizens - both the elderly and the younger people. There have also been many people who have taken an active pan in the plans, and it is the citizens who have come with the demand for self-determination, freedom to choose and dignity.
Still there are many critical voices saying that we can't do without out traditional nursing homes, and that we are deserting the elderly. It is now up to the municipality to prove that we give a better service. How-ever, we know that the things we are doing are not for the elderly of today who are in nursing homes, but for the elderly in the future. Those of us who are close to 60 years old today can't imagine that if we were handicapped, we must sleep in the same room where we have been all day long, and can't have family or friends to visit in the evening, or being without kitchen, bath and toilet.
We have just seen that with the move from nursing home to elderly flats, the elderly are happy and they are more active than before. By using the elderly's own resources, we can free other resources to give a better care to those who badly need it.
In Denmark the staff involved in the previous system of elderly care was divided at all levels - the housemaids did the cleaning, the staff in the kitchen cooked, the assistant nurses took care of personal toilet and care, and the nurses took care of wounds and gave the medicine. There was nobody who had the total responsibility for the whole person.
In the new system, the single home helper has the responsibility for her own clients, and must care, clean and cook if necessary. In my municipality it is the home nurses who assess the dimension of help needed. and they have the responsibility for the overall situation as regards each client. The idea is, that the staff must cooperate at all levels, and disregard the previous divisions of professional qualifications. It will give a better service for the elderly, and lessen the number of staff in the flat.
I will allow myself to give the following piece of advice - don't introduce a system if the staff cannot cooperate at all levels. It will give a lesser service, and the costs will be much more expensive. The staff must be able to work together across the range of their professional qualifications. There must be a high degree of cooperation, and the en-tire staff must have the same attitude.
I know that in your country, you are working hard towards service for the elderly, and I hope for you, that you will succeed in establishing a nationwide system where it will be possible to give your elderly citizens the care needed, in its entirety, regardless of where they live.