One of the most urgent dilemmas now facing governments around the world is how to provide adequate medical care for rapidly increasing aging populations. In Sweden, for instance, people over the age of 65 already account for 18 percent of the population, in the UK, 15.7 percent, and in Japan, the number of elderly is expected to double by 2025. In Bermuda, according to the Health Care Review Report of 1996, by 2020 one-third of the Island's population -- approximately 18,000 people -- will be over 55 and likely to require increased medical attention.

The urgency of manageable care for the Island's increasing elderly population was last placed in the spotlight a year ago when Andrew Martin, chairman of the Friends of Hospice, made an impassioned plea for action on behalf of the elderly and terminally ill, called for a policy "backed by implementation and not rhetoric''. Although people were now living longer, he pointed out, "the downside is that medical expenses are continuing to increase.'' For the past 18 months, Bermudian David McHarg and the Ministry of Health and Social Services have been attempting to find a solution to these problems which loom larger with each passing year and, says Mr. McHarg, "I am hopeful that, as a result of our consultations, a new philosophy is emerging which provides alternative care settings, the most obvious being home care.'' He adds that the project, entitled `Working Together to Enhance Quality Care', has already made significant strides which should place Bermuda among the leaders of home care management.

In his opinion -- increasingly shared by other professionals in the field -- long-term hospital care is not appropriate for the elderly for several reasons. "Quite apart from the expense (the average cost of acute patient care in Bermuda is around $17,000 per month and, between 1990 and 1993 alone, inpatient costs increased by 17 percent), there are many germs hovering around in hospitals. As most elderly people's immune systems become weaker, they are more susceptible to infection. There is also, of course, the very important consideration of the quality of life, so if we can devise a system whereby people get back to their own homes, they get back their lives. No one likes to feel dependent on a person or an institution, so the more independence we can give back to people, the better.'' One of the recent, important developments in the area of health care has been the realisation that in many cases, elderly people (or anyone with illnesses requiring infusion products) can be sent home after a week or so of hospitalisation -- provided that adequate home nursing care is available. In other words, the new direction is pointing in the way of `community' care.

This is usually achieved through a system of rehabilitation through home nurses, health visitors and counsellors who also instruct the patient (and, if necessary, family members) in administering medication and infusions, or in ancillary services such as cleaning and washing. "After all, community nursing involves the whole family, and we need to provide standardised training and counselling so that this may become a reality in practical terms,'' says Mr. McHarg. "There has, in fact, been quite a lot going on in Bermuda in the way of home care,'' he adds. "As I saw it, when I first met with the Minister over a year ago, everyone was aware that a fully developed home care service needed to be established. There was also the recognition that standardisation in care is vital if this project is to have any chance of success. It is, after all, very important that Bermuda gets the best care for its people at the best price. I believe there can be no doubt that home care makes economic sense.'' Mr. McHarg, a Bermudian whose consulting firm, Bowers & McHarg is based in Philadelphia, specialises in standardising quality and consistency in health care and ancillary services. "We believe very strongly that there have to be core standards established -- and once they are established, ensure compliance of standards through regular monitoring.'' To that end, he and his business partner, Marcia Bowers, have prepared a 16-chapter presentation on their proposed Bermuda Homecare Standards Development.

Ms Bowers, an independently registered nurse and author of several publications on home care in the US, served as director of quality improvement at PENtech Inc. She has also conducted national seminars on home healthcare and has taught extensively on this subject at the Brandywine Hospital and Trauma Centre and the Chester County Hospital in Pennsylvania.

Mr. McHarg, who was educated at Saltus Grammar School and Warwick Academy, has developed community programmes for traumatic brain injury rehabilitation and, at PENtech, was marketing coordinator for physicians dealing in such speciality fields as organ transplants, HIV, and pain management programmes.

"I am well established in the States,'' he says, "but I am Bermudian, and would like to have closer links with the Island. I have no doubt that Bermuda, like the rest of the world, has to face some very real problems in caring for far more elderly people in the future. I believe the proposals we have made -- and drafts of which are now with the Permanent Secretary and Chief Medical Officer -- would signal a big advance. We have to realise that there has to be an entirely new philosophy in our approach to caring for people. We believe our programme helps people to live more productive, happier -- and far more independent -- lives and this would be a benefit to the entire community.

There is no doubt that, as a country, we have to find better value for money spent. We also have to be equally sure that any and all standards established are complied with. My firm would certainly like to continue to work with the Bermuda government and help agencies to reach goals in compliance standards.'' Noting that in writing the Home Care proposals, his firm had taken the best from the US and other countries and modified these to the particular needs of Bermuda, Mr. McHarg says he believes it would be a "misservice'' to Bermuda if standards of care are not monitored so that the highest possible care is available to all of our elderly on this Island.'' A NEW KIND OF CARING -- David McHarg, who returns to Bermuda with a new plan for care of Bermuda's elderly.

SENIORS SR