Dignified ageing

The concept of dignified ageing cannot be summed up in one sentence. For some, it means an opportunity to work until an advanced age or to be an active member of society. For others, it relates to income and a sense of financial security. Still others value health and the joy of living and wish to decide for themselves what happens to them in the event of a serious illness. And yet someone else might hold that dignified ageing is ensured by a well-functioning and well-funded system of care homes. The Chancellor of Justice has had to deal with all these aspects one way or another. 

Working, pension, taxes

Shortcomings of the unemployment insurance system

The state can do a lot to enable people of all ages to be useful to someone by letting them make best use of their knowledge and skills, for example by going to work if there is sufficient will and energy to do so. The Chancellor analysed conformity of the unemployment insurance system with current needs, and made a proposal to the Riigikogu and the Minister of Health and Labour to open a debate with a view to changing it. 

The current unemployment insurance system deprives the majority of people who have lost work-related income of financial assistance. For years, only one in three persons registered with the Estonian Unemployment Insurance Fund has received unemployment insurance benefit from the state. Following loss of employment and income, many elderly people are forced to resort to the emergency solution of early retirement. However, recipients of early retirement pension may not do any remunerated work. Unfortunately, the organisation of unemployment insurance and labour market services counteracts the aim of keeping people active in the labour market for as long as possible, including acquiring new skills and occupations in the course of lifelong learning. Instead, people are forced to make impractical decisions. In the Chancellor’s opinion, it would be worth considering what the conditions for unemployment insurance benefit should be so as not to compel people to make such impractical decisions. It is also necessary to consider how to better facilitate re-training. 

Setting the retirement age 

A nationally established retirement age has a direct impact on employment of the elderly. The system must be clear and predictable – people must know at what age they may retire and what entitlements are involved. 

Retirement is an important milestone in every person’s life. When debating the State Pension Insurance Act in the Riigikogu, an issue was raised whether someone else besides the Riigikogu may decide on the retirement age. Section 28, second paragraph, of the Constitution says: “Every citizen of Estonia is entitled to government assistance in the case of old age, incapacity for work, loss of provider, or need. The categories and extent of the assistance, and the conditions and procedure for its allocation are laid down by law.” If the right of setting the retirement age were to be given to the Government or a single minister, then the executive, i.e. the government, would begin to determine the conditions for receiving the old-age pension. This is not allowed by the Constitution.

Ability to cope financially

Single pensioner allowance

Since 2017, the state pays an allowance of 115 euros once a year to single pensioners to improve their financial independence and alleviate poverty. The allowance is paid automatically to all persons who have reached the retirement age and are receiving a pension which is 1.2 times lower than the average old-age pension and who live alone according to population register data. The state does not verify the existence of other income or the fact of the person living alone. 

During the reporting period, the Chancellor was contacted by a couple of dozen people with the concern that because of incorrect address data they were deprived of the single pensioner’s allowance. Investigation revealed that in most cases a rural municipality or city had failed to amend the address data of these people. At the Chancellor’s request, the necessary amendments were made to the registers. 

Another finding was that local authorities acted very differently when amending address data. Receiving a state benefit should not depend on how a local authority interprets a legal act. It is also not acceptable to keep people running between different authorities. Therefore, the Chancellor asked ministries and the Association of Estonian Cities and Rural Municipalities to cooperate in order to harmonise the rules on determining address data.

The Chancellor explained to rural municipalities and cities that the single pensioner allowance may not be calculated as part of a person’s income when rural municipalities and cities assess a person’s ability to pay for the general care service (the so-called care home service).

Death allowance

The fact that a person’s right to assistance depends on the activities of rural municipalities and cities was also revealed by another petition received by the Chancellor. The Chancellor received a letter from a person who buried a close family member but did not receive support for funeral expenses from any local authority. The petitioner was not entitled to support from Tallinn, where they lived, because under the regulation in force in Tallinn the support is paid according to the residence of the deceased. The petitioner also did not receive support from Pärnu city, where the deceased had been living, because under the regulation applicable in Pärnu the support is paid according to the residence of the person covering the funeral expenses.

That situation could arise because the Riigikogu had not determined to whom and on what conditions rural municipalities and cities must pay the death allowance. 

The Chancellor contacted the Riigikogu Social Affairs Committee with the issue of the death allowance. The committee considered it necessary to amend the legislation so as to make clear whether rural municipalities and cities rely on the residence of the deceased or of the organiser of the funeral when paying the allowance. The committee also considered it important to analyse the duties of rural municipalities and cities in assisting people in need in the future. 

Health and social services

Patient’s last will

The idea of the patient’s last will requires a wider debate and a legally clear solution. The patient’s last will (also termed a ‘living will’ or ‘advance directives’) means guidelines that a person may write down concerning their medical treatment in a situation where they are no longer able to make decisions.

Under the law, doctors must also take a patient’s will into account when the patient is no longer capable of making decisions. It is not prohibited or ruled out for a person to express their wishes in a written document, i.e. the ‘patient’s last will’, drawn up before losing their capacity to decide. However, the law does not use this or any similar term, nor does the law lay down any substantive or formal requirements for a patient’s last will. 

A patient’s last will (or end-of-life instructions) is to date a very rarely used instrument in Estonia, most probably precisely because of the absence of substantive or formal requirements for it. Neither doctors nor patients are certain what exactly this document should look like so as to be able to rely on it. For example, at present there is no clarity as to whether a doctor must execute the ‘patient’s last will’. There are also no rules to guarantee the validity of a patient’s last will: was the person capable of sound judgment when making it, how long should the document remain valid, and what effects should be attributed to the document when its validity has expired? It is also unclear how to ensure that a patient’s last will is accessible to those healthcare professionals who will decide on the person’s medical treatment in the future.

Although Estonian laws do not prohibit a person from giving instructions as to their medical treatment ‒ i.e. drawing up a patient’s last will ‒ the possibility is illusory in practice. The Council of Europe Committee of Ministers has recommended that, with a view to individual self-determination, states should regulate the possibilities for advance directives and has made suggestions to that effect (see the article in the journal Sotsiaaltöö).

General care homes

During her entire term in office, the Chancellor has drawn attention to the situation in care homes, or in other words, has dealt with the concerns of those elderly people who according to the official definition are “receiving the general care service”. Last year the Chancellor drew up a circular aimed at all general care homes and local authorities as well as politicians and officials having a role in shaping social policy, drawing attention to widespread problems and making proposals for improving the quality of the service. According to data from the Ministry of Social Affairs, 11 874 clients received the general care service in 2017.

The availability of care home places and living conditions in care homes have become the centre of public debate in recent years. Among other things, this also means that awareness of both the elderly and their next of kin has improved. Many elderly people are extremely vulnerable due to their advanced age and/or deteriorating health. It is difficult for them to influence their living conditions and the quality of the care service by themselves, so that the rights of people living in care homes need particular protection. 

Inspection visits to care homes

The Chancellor’s advisers from the Inspection Visits Department inspected the activities of eight care homes during the reporting year. A healthcare expert (a general practitioner or geriatrician) was involved in all the visits. During the visits, the advisers inspected the rooms, perused documents, and interviewed staff and clients of the care home under inspection.

Particular attention was paid to the accessibility of rooms, as well as whether individuals’ freedom of movement had been restricted (e.g. locking them in their rooms, securing them to their beds), whether people were treated with dignity (e.g. ensuring privacy, living conditions), and whether no risks to their life and health existed (e.g. number and presence of staff, nursing and care, meals, medication, access to healthcare). During the inspection visits, the Chancellor’s advisers also checked how the right to vote of the elderly in social welfare institutions was ensured. 

The main problems in care homes relate to ensuring decent living conditions, the number of staff, proper preparation of care plans, unlawful restriction of people’s freedom of movement, and availability of healthcare services.

Inspection of living conditions revealed that people were not ensured privacy during hygiene procedures. In some care homes, high doorsteps, narrow doorways and absence of a lift made it difficult to move around in a wheelchair or a wheeled walking frame. Problems also occurred with using aid devices corresponding to people’s special needs. 

In several care homes, the numbers of care staff were insufficient, in particular at night. For example, it may be difficult for the residents of a care home to call for assistance if no staff call system exists. Many care homes lacked mandatory care plans, or these were incomplete and not up-to-date. Inspection of several care homes revealed that residents’ freedom of movement had been unlawfully restricted: by locking doors of departments as well as rooms. 

Absence of care service suitable for persons with dementia

Freedom of movement was restricted mostly for people with dementia, whose behaviour could be problematic and unpredictable and who have serious memory problems, so as to be difficult for care home staff to handle. The cause of the problem lies in the fact that no care service has been developed corresponding specifically to the needs of people with dementia-related behavioural problems. The Chancellor has already drawn attention to this previously.

A positive development is a Ministry of Social Affairs initiative to set up a dementia competence centre and a plan to support adaptation of rooms for provision of the general care service to the elderly with dementia. Currently, it is difficult for the next of kin as well as for local authorities to find a place providing a service that meets the needs of people with dementia, including offering a suitable environment as well as an opportunity to implement the non-pharmacological approach set out in the treatment guidelines for Alzheimer’s disease. In April, the Chancellor and her advisers visited the De Hogeweyk care centre at Weesp in the Netherlands, which uses a unique concept for care of dementia patients that has attracted worldwide attention. 

Healthcare services in care homes

Residents of care homes need regular nursing care but the law does not oblige care homes to provide nursing care services. Primary healthcare in care homes should be ensured through the system of general practitioners and the home nurse service (home visits carried out by general practitioners and their nurses). However, many people live in a care home that is distant from their registered place of residence as well as the service area of their general practitioner. 

Inspection visits have revealed that often a patient’s health needs are not assessed by a healthcare professional (doctor or nurse). The need for a healthcare service is also not assessed on a regular basis. As a result, people’s main health concerns may not receive the required attention and problems may deteriorate to the point where often an ambulance has to be called. The Health Board has also indicated in its survey  that the number of ambulance calls in care homes has increased significantly and not always are the calls justified.

Due to absence of nursing care, problems have arisen with handling and administering medicines. A critical situation may develop when a doctor has prescribed psychotropic medication to a patient that should be used only in case of need. Only a healthcare professional with medical training can decide on the need to administer this kind of medication. However, there have been cases where a carer or another care home staff member without the necessary education decides on administering medication to be used only in the case of need. 

Due to the absence of a nurse, carers often have to perform the tasks of healthcare professionals. In care homes inspected by the Chancellor, there have been cases where medical negligence could be suspected. For example, a care home delayed calling a doctor for an unreasonably long time. Such a situation may also be caused through ignorance because carers without medical knowledge are unable to correctly assess a person’s condition. 

Assessment and proper monitoring of a person’s health may also be impeded by the fact that most care homes have no access to the health information system. Often a care home only has the information concerning a person’s health which was submitted to them on paper by their next of kin. Absence of previous health data (including information on previously used medication) may lead to wrong conclusions by a care home in assessing a person’s need for a healthcare service. In turn, if a person’s health status changes, information from the care home does not reach the heath information system, so that general practitioners might lack an overview of the condition and needs of their patient. 

Improving the situation of care homes

Improving the quality of the general care service was discussed at the information day organised at the Ministry of Social Affairs, where the Head of the Chancellor’s Inspection Visits Department talked to heads of care homes about problems observed during inspection visits. The Chancellor’s advisers also gave an overview of their work and discussed critical problems in the frame of the development programme for the Social Insurance Board’s supervisory specialists. 

In the media, the Chancellor’s advisers have provided comments and clarifications about the care service (e.g. 30 November 2017 Radio 4 programme „Подробности“). The problems of restricting the freedom of movement of people were dealt with in the journal Sotsiaaltöö (see the article „Vabatahtlikkuse põhimõte üldhooldusteenuse osutamisel“ [The principle of voluntarism in providing the general care service]). 

Everything begins from mentality

Dignified ageing is often supported by changes that are small and feasible for everyone. One could start with revising the wording of contracts concluded by care homes and remove expressions that refer to people as objects. 

For example, contracts often refer to “exclusion of a client from the care home” or the obligation of a “service purchaser” (a person’s next of kin who pays for the service) “to place the service recipient elsewhere in the event of termination of contract”. Finding out the needs and wishes of the elderly is called “cost of care calculation”, which sounds rather like vehicle maintenance terminology. Communication by an elderly person with care home staff is described by a contract provision in the following terms: “disturbing the staff” is prohibited. As regards issues of quality of the care home, “the client is entitled to file a written application to remedy the deficiency”. According to some contracts, care home staff have three days to inform a care home resident’s next of kin about their death.