HONG KONG’S CARE SYSTEM STRUGGLING TO COPE WITH AGING POPULATION As the number of elderly people rises, demand for places in public nursing facilities is soaring, as Shadow Li reports from Hong Kong.

When Peter Lam arrived home one morning in October after a brief breakfast outing, he realized something was wrong. He knocked on the door of his mother’s room, but there was no response. He knocked again, but she still didn’t answer.

The 40-something graphic designer pushed the door open, only to discover that what he had dreaded was true; his 80-year-old mother had had a stroke and was lying unconscious on the floor.

Lam called an ambulance, which took his mother to the intensive care unit at the Caritas Medical Centre near their home in Sham Shui Po. It was lucky that he came home early that day, he told himself.

But the next few weeks needed more than luck; instead, patience and time were required. Lam’s mother was in the ICU for several weeks, and is now in palliative care at the hospital. The doctor has said even if she recovers, the senior will not be able to care for herself as well as she used to.

Lam and his mother may even have to leave the two-bedroom apartment in which they have lived for years because the elderly lady will be bedridden, but it’s unlikely that anyone will be available to provide full-time care. Given the circumstances, it would be natural for Lam to apply for a place in one of the many public nursing homes sprawled across the city.

However, by the end of last year, the waiting time for a place in a public nursing home was about three years, according to the Social Welfare Department, and 36,948 seniors were in line for the service, although it is thought that many may have already died.

The latest available figures show that 3,392 people died while waiting for a place in a public nursing home in 2005, but in 2014 the number was 5,568.

Varying quality

The quality of services offered in nursing homes in the city varies widely, according to an audit report published in October 2014. Public nursing homes, which receive extensive government funding, have always been popular, but the city’s rapidly aging population means demand is rising rapidly.

In response, the government has started purchasing places in private nursing homes. However, seniors opting to take this path can still expect to wait as long as nine months.

For Lam, that’s too long because he will need immediate help if his mother’s health improves and she is discharged from the hospital.

However, the choice is limited to signing up for a place in one of the private nursing homes, which generally offer lower-quality services, or waiting for a place in a public nursing home, which is unrealistic.

Hong Kong has a relatively high admission rate for care homes, with 6.8 percent of seniors being admitted. That’s between two and four times higher than in a number of regional neighbors, including Japan, Singapore and Taiwan.

Public versus private

Providing more places at public nursing homes has long been on the government’s to-do list, but a shortage of land has restricted development. Moreover, it takes about five years to build a contracted nursing home once funding has been approved by the Legislative Council, which oversees the administration of the city.

“The number of residential care places provided by public nursing homes is already at a record high. The government shouldn’t expend too much effort building more nursing homes. A quarter of the city’s nursing homes are public establishments, which are heavily funded by the government,” said Timothy Kwok Chi-yui, professor in the Department of Medicine and Therapeutics at the School of Public Health at the Chinese University of Hong Kong.

More than 80 percent of seniors who stay in private nursing homes receive social allowances such as Comprehensive Social Security Assistance and disability subsidy, he added.

Kwok is also director of the Jockey Club Centre for Positive Ageing, a nursing home that mostly provides care for people with dementia. He said that on average, the ratio of seniors to available beds is 15-to-1, almost double that in many countries.

Funding shortfall

The government has approached the issue on the principle of “aging in place as the core, institutional care as backup”, meaning seniors should live at home whenever possible and receive care there, and should only enter care homes if absolutely necessary.

However, the policy requires a large amount of support from local communities, meaning the focus should be on greater provision of community care services, rather than residential care.

But community care services only received funding of about HK$1 billion ($127 million) in the financial year 2014-15. That’s less than onethird the HK$3.9 billion spent on residential care services, according to a survey conducted by the Legislative Council and published in December 2015.

This underfunding took a toll on people such as Lam and his mother, who have to rely on community care services before they can obtain a place at a nursing home.

“If the community support is strengthened, there will be a chunk of elderly people who will not opt for nursing homes,” Kwok said.

He added that community care support — services such as meal deliveries and household chores, and even some visiting medical services for seniors with chronic illnesses — is the weak link in the care ladder.

Care via community support programs is essential for the well-being of seniors recently discharged from hospital, and also allows them to delay moving into a nursing home.

According to Kwok, it makes more sense to subsidize elderly care in the community instead of pumping money into care homes. He noted that the government used to subsidize nursing homes, but the policy resulted in a mismatch of public resources.

“Those who can stay on the waiting list for a long time usually don’t need that much care, while those who are in desperate need of care have to forget about the list and turn to private nursing homes,” he said.

The policy may also exacerbate the effect of a rising elderly population and cause the long-standing list of seniors waiting for residential care services to snowball.

Under the government’s centralized system, many seniors are eligible for the “dual option” of either residential or community care services, but in most cases, they opt for residential care services.

A University of Hong Kong study in 2009 showed that if the dual-option model were to be cancelled waiting times for residential care services would be cut and the line would disappear by 2013.

Given that the dual option still exists, a number of surveys and studies suggest that governmentbacked improvements to community care services would lift confidence and allow far more seniors to stay at home or within their own communities.

Seniors at a facility in Hung Hom district run by Culture Homes, a nursing home chain in Hong Kong, watch TV in the canteen.

Improvements urged

In 2015, the city was shocked when it was revealed that seniors at a private nursing home in the New Territories were forced to wait naked on a rooftop before taking showers. The reports sparked criticism and public calls for improvements.

After several attempts to improve the quality of nursing homes, the government started a pilot scheme in March last year to hand out vouchers for residential and community care services. Seniors could choose to switch homes or community care centers if the service was substandard. The policy, dubbed “money-following-the-user”, aimed to review the practice of giving subsidies to nursing homes even though seniors have no say in the services offered.

Kwok, from the Chinese University of Hong Kong, said the coupon program will create a market driven by the elderly, resulting in nursing homes competing for clients, boosting the quality of services offered. Above:

No easy answers

However, there is no easy answer to Lam’s problem. The hospital constantly asks when his mother will be able to vacate her bed, but although he has been looking for a government-funded place in a private nursing home, he has had no luck.

As a stopgap, Lam is trying to arrange for his mother to live short-term in a private nursing home on the first floor of their apartment block. That would allow her to have the best of both worlds; she would receive high-quality care, but if she found her circumstances overwhelming, she could visit him, which woud help her to regain a sense of normality.

However, at the moment the only certainty Lam and his mother have is that their quest for a place in a public facility is unlikely to end soon.

School of Public Health at the Chinese University of Hong Kong