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The writer is a Research Fellow at the Mossavar-Rahmani Center for Business & Government, Harvard University, and author of ‘Extra Time: Ten Lessons for Living Longer Better’
作者是哈佛大學(Harvard University)莫薩瓦爾-拉赫馬尼商業與政府中心的研究員(Research Fellow)，著有《額外時間：活得更長更好的十個教訓》
In Japan, I’ve watched a humanoid robot dance with a human physio, leading enthusiastic elderly people in a morning exercise routine. In Holland, I’ve visited old ladies in their homes with a nurse who brings her dog to cheer them up. In America, I’ve been to a care home where the residents run the library — whose shelves display books they’ve written themselves. As every rich country grapples with growing numbers of people living longer, getting frail or being crippled by loneliness, an important part of the answer lies in keeping people independent for as long as possible.
在日本，我曾見過一個人形機器人與一位物理治療師一起跳舞，帶領熱情的老年人進行晨練。在荷蘭，我曾與一位護士一起拜訪老年婦女的家，她帶著她的狗來給她們帶來快樂。在美國，我曾去過一家養老院，居民們負責管理圖書館，書架上陳列著他們自己寫的書。隨著每個富裕國家都在努力應對越來越多的長壽人口、日益虛弱或被孤獨困擾的人，保持人們儘可能長時間的獨立成爲了重要的一環。
A care system which promises us all more meaning in old age would be far more attractive than one which sounds like a last resort to manage decline. In the UK, the debate about social care has taken off again, with chancellor Rachel Reeves ditching a long-delayed plan to “cap” certain care costs. This has alarmed those who feared the cap was the only game in town. But Reeves’s instinct is right.
一個承諾給我們所有人在老年階段帶來更多意義的照護系統，比起一個聽起來像是應對衰退的最後手段的系統，會更具吸引力。在英國，關於社會照護的辯論再次引起了熱議，財政大臣蕾切爾•裏夫斯(Rachel Reeves)放棄了一個長期推遲的「限制」某些照護費用的計劃。這讓那些擔心限制是唯一選擇的人感到擔憂。但裏夫斯的直覺是正確的。
To fix social care requires bigger thinking, about both funding and the approach to those with disabilities. The only way to untangle what currently feels like a monstrous Gordian knot — with underpaid care workers, desperate families, GP shortages and clogged hospitals — is to change the narrative. Elderly social care should be framed as a positive investment for the whole of society.
解決社會護理問題需要更深層次的思考，包括資金和對殘疾人的方法。要解開目前看起來像是一個複雜的困局——低薪護理工人、絕望的家庭、家庭醫生短缺和擁擠的醫院——唯一的方法就是改變敘事方式。應該將老年護理定位爲整個社會的積極投資。
In a working paper I have published with associates at Harvard’s Kennedy School, we recommend a series of practical policies to improve outcomes for people over 65 in both health and care. Unnecessary or prolonged hospital stays, for example, can condemn people to become dependent on others too early because of bad food, disturbed sleep and physical deconditioning. Intensive rehabilitation can pay for itself — it has enabled two-thirds of people in some American hospitals to return home after a fall or operation. But it requires staff to change from a mindset of “doing to”, to “doing with”.
在我與哈佛肯尼迪學院的同事共同發表的一篇工作論文中，我們推薦了一系列實際政策，以改善65歲以上人羣在健康和護理方面的結果。例如，不必要或延長的住院時間可能會導致人們過早地依賴他人，因爲食物不好、睡眠受擾和身體康復不良。密集康復可以自負盈虧——在一些美國醫院，它使三分之二的人在跌倒或手術後能夠回家。但這需要員工從「對待」心態轉變爲「與人合作」的心態。
Similarly, loneliness is not always cured by shunting people off to a day centre. In Norway, campaigners are using peer-to-peer technology to get elderly people sharing meals online. There is a widespread assumption that older people don’t want choice or control. But they do — and more should be allowed to spend their own allocated care budget and employ relatives, as Germany is doing.
同樣，把人們送到日間中心並不能總是治癒孤獨。在挪威，倡導者們正在使用點對點技術讓老年人在線共享餐食。普遍認爲老年人不需要選擇權或控制權。但事實並非如此，他們確實需要——應該允許更多人使用自己分配的護理預算並僱傭親屬，就像德國正在做的那樣。
Above all, we argue that the UK needs a coherent funding system to replace one which is opaque, arbitrary and unfair. In care homes, families with assets are effectively cross-subsiding those eligible for state help. NHS Continuing Health Care budgets are the subject of court cases from people desperately battling to prove a “primary health need”, of which there is no strict legal definition.
最重要的是，我們認爲英國需要一個連貫的資助體系來取代那種不透明、武斷和不公平的體系。在養老院中，有資產的家庭實際上在爲那些有資格獲得國家援助的人提供交叉補貼。英國國家醫療服務體系(NHS)的持續醫療預算成爲了人們絕望地爭取證明「基本醫療需求」的法庭案件的對象，而這一概念沒有嚴格的法律定義。
In some ways, the UK’s system looks not dissimilar to Germany’s 30 years ago. Both Germany and Japan have gone on to craft social care insurance funds which are transparent, predictable and sustainable, and have created a sense of social solidarity. Everyone pays in — including pensioners — and everyone benefits.
在某些方面，英國的制度看起來與30年前的德國並無二致。德國和日本都建立了透明、可預測和可持續的社會護理保險基金，並營造了一種社會團結的氛圍。包括養老金領取者在內的每個人都繳費，每個人都受益。
These schemes go far beyond the cap on care costs proposed in 2011, which Reeves has just stopped. The worthy aim was to set a maximum amount that anyone would have to pay for their personal care over their lifetime (excluding daily living costs). But politicians never implemented it, partly because it would protect relatively few families, and partly because the Treasury has been reluctant to raise taxes without any commensurate improvement in quality of care.
這些方案遠遠超出了2011年提出的護理費用上限，裏夫斯剛剛停止了這一提議。這個值得讚賞的目標是設定一個任何人在其一生中必須支付的個人護理費用的最高金額（不包括日常生活費用）。但政治家們從未實施過它，部分原因是它只會保護相對較少的家庭，部分原因是財政部不願意在沒有相應的護理質量改善的情況下提高稅收。
One political challenge in countries with “pay as you go” welfare systems is the belief among many older people that they have paid enough tax to cover their costs in old age (sadly, many haven’t). Another sticking point, especially in the UK, is housing. The desire to pass on a home to the next generation is strong and legitimate, and has led successive politicians to promise that no one should have to sell their home to pay for care — but it may not be sustainable to ignore the value of most people’s largest asset when assessing their wealth.
在「按需付費」福利制度國家中，一個政治挑戰是許多老年人認爲他們已經繳納足夠的稅款來支付他們的養老費用（可悲的是，許多人並沒有）。另一個爭議點，特別是在英國，是住房問題。傳承房屋給下一代的願望是強烈和合理的，這導致連續的政治家承諾，不應該有人不得不出售自己的房屋來支付護理費用-但是忽視大多數人最大資產的價值可能是不可持續的。
Labour will have to find more funding, not least because it risks bankrupting employers with its pledge to raise care staff wages. But reform is not simply a dry technical exercise: it must bring the public with it. That means setting out a vision for a better old age which can give people meaning — as Atul Gawande argued so powerfully in his book Being Mortal. How we treat our elderly and disabled is the ultimate test of a civilised society.
工黨必須找到更多的資金，尤其是因爲工黨提高護理人員工資的承諾有可能使僱主破產。但改革並不僅僅是一項枯燥的技術工作：它必須讓公衆參與進來。正如阿圖爾•加萬德(Atul Gawande)在其著作《成爲凡人》(Being Mortal)一書中有力地指出的那樣，這意味著要制定一個能給人們帶來意義的美好晚年願景。我們如何對待老年人和殘疾人是對文明社會的最終考驗。