Residential Care for Frail and Marginalised Older People in Hong Kong 1990-2006: targeting and efficiency?

Rapid growth in the number and proportion of older people in Hong Kong is shown to have taken place since the late nineties. The substantial increase in the number of older people (particularly the old-olds) and their declining ability levels accelerated the need for long-term care, including residential care. This has exerted heavy financial pressure on the government. Subsequently a new policy - the ‘Standardised Care Need Assessment Mechanism’ (SCNAM) - for elderly services was introduced in November 2000; giving rise to both intended and unintended consequences.

In this cross-sectional and longitudinal study of the populations of two older peoples residential homes, the focus is on evaluating the outcome of the policy (SCNAM), which intended to target care on older people ‘in greatest need’. It explores how the profile of residents in long-term care has changed since this policy implementation. Specifically, the dependency characteristics of residents (including their physical health, functional status, cognitive levels, and degree of frailty) in two care homes of the Helping Hand charity in Hong Kong between 1990 and 2006 are compared. Moreover, the study explores whether the changed populations in these homes suggest greater efficiency and effectiveness in the allocation of residential care. It examines impacts on the costs of care, particularly relating to staffing and funding across a 16-year interval. Furthermore, the outcomes of residential care are assessed in terms of the quality of interaction between staff and residents, and participation in various kinds of social activities within the home.

Efficiency is judged not by cost per person alone, but by the ratios of costs to outcomes. Findings in the study show that the quality of publicly-funded residential care in Hong Kong fell over the period, and this evidence puts any suggestion of greater efficiency in doubt. Most importantly, the quality of life of residents has been adversely affected and this is an ‘unintended consequence’ that needs to be taken into account by the policy-makers.

Throughout its recent history Hong Kong has adopted a residual model of welfare, in which the government’s paramount focus has been on economic development. This is clearly reflected in the provision and financing of long-term residential care homes as operated under ‘a mixed economy of welfare’ system, in which the government only assumes a role as a funder. Other crucial issues such as the quality of care by front-line personal care staff as well as the quality of life of residents are largely outside of its policy concerns. Current evidence shows that better targeting and lower unit costs have been achieved in the two Care Homes of the Helping Hand, but at the expense of the effectiveness of care. The policy shift has produced new winners and losers. A focus on controlling the costs of public support for older people amounts to what Titmuss (1968, p.133) called a price that some pay ‘for the costs of other people’s progress’.