As Malta begins moving towards providing more services to an ever-increasing number of older adults, the government is also radically changing how these services are provided. Initiated in 2015 with the termination of contracts with the Malta Memorial District Nursing Association, government homes for older adults are now run by private operators.

A new class of business based on long-term services to older adults is emerging in the country. Standards for elderly care homes will become crucial to ensure that services are consistent, of certain quality and in order to provide oversight. With one in six Maltese being 65 years and older – totalling more than 72,000 – protecting older adults in long- term care is a national concern.

This is just what the new Maltese standards being proposed in a new 2016 Bill are set to accomplish. Based on earlier criteria published in 2003 by Britain’s Secretary of State for Health, these standards aim to provide guidance for these new businesses.

But there are problems. Although the standards are excellent, how they will be enforced and implemented is still undefined. But there are other much more pressing problems, lurking behind this national trend of institutional care, that the standards do not address. And to expose this we have to look deeper into the history of long-term care in Malta.

Initially, care of frail older adults in Malta was exclusively based on a number of local nursing homes and  St Vincent de Paul Residence (formerly known as L-Ingiered), a geriatric hospital initially operated as a Victorian mental asylum. Then, in 1987 – with the establishment of a junior minister responsible for the care of older adults – the continuum of care in Malta expanded.

This continuum of care refers to the spread of individual services designed to meet specific needs (e.g. bathing, cooking, transportation). Initial services included home care services, meals-on-wheels, home help, handyman assistance, telecare and more recently day care centres. Continuum of care is more efficient and cost-effective because it provides the most appropriate level of care while allowing clients to stay at home.

With 1,990 people on the list waiting to enter SVPR, (with 1,100 beds) at the end of 2014, there already is a problem in meeting demand

With the migration in 2013 of the Department for Elderly and Community Care from its position within the Health Ministry to the Ministry for the Family and Social Solidarity, there is a move towards expanding the continuum of care. But it does not work well in Malta because most Maltese remain attracted to institutionalised care. The surprising reason for this came in a 2012 Ministry of Health report compiled by Dorianne Farrugia and Deborah Stone.

They reported on a growing trend where one in 13 older Maltese – 75 years and older – had no next of kin on whom they could rely should they need help. Although one in nine older adults (75 years and older) reported receiving some medical care at home, one in 20 were on a waiting list for a nursing home.

The percentage of participants on the waiting list increases with the severity of impairment, age, females and small households. Although the authors reported that other community-based services were utilised, the lack of family support invariably meant that a nursing home was the primary and preferred option.

Surprisingly, the survey found that four out of 10 older adults reported being socially isolated, with women suffering more than men. For a small island, it was surprising to find that one in six older adults do not have strong family relationships and more than half did not have strong friendships.

Because older Maltese are experiencing a fragmented family structure, they look at institutional care as a solution once they become frail.  Older Maltese tend to see nursing homes as doing a good job, and when asked if they are likely to use them, twice as many Maltese as any other Europeans say that they will likely use a nursing home. As a result, more than 300 new residential beds a year are needed over the next decade to cope with the increase in the older adult population.

Even today, with 1,990 people on the list waiting to enter SVPR (with 1,100 beds) at the end of 2014, there already is a problem in meeting demand. The expectation of Maltese older adults cannot be fulfilled by current provisions especially if they are privatised, and no amount of standards will help.

With increasing healthcare costs made worse by further privatisation, standards might become unenforceable.  Charles Pace from the University of Malta and his colleagues discuss this emerging policy. While pensions cover most of the cost of government-provided homes, private long-term care requires private funds above the maximum government pension. As poverty among older adults continues to increase – currently at 7.1 per cent in 2013 – economics will play a crucial role in determining the feasibility and affordability of private long-term care options, especially nursing homes.

Having standards is all well and good. The main problem is an increasingly restrictive bottleneck – caused by increasing cost and the fragmentation of family support. Throw into this mix the growth of foreign older residents and caregivers, large foreign businesses’ involvement and increasing inequity, and the standards of care seem shortsighted when facing a much larger problem looming in the future of older adults in Malta.

Mario Garrett was born in Malta and is currently a professor of gerontology at San Diego State University in California, US.

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