Komentar dr. Brigita Skela Savič: Recimo ne neenakostim v družbi in uredimo dolgotrajno oskrbo v Sloveniji!

Staranje populacije je eden od največjih družbenih in ekonomskih izzivov s katerim se sooča Evropska unija (EU). Ne gre samo za povečevanja deleža starejših od 65 let in več, ki hitro narašča, narašča tudi število starejših od 80 let in več. Delež populacije 80 let in več danes znaša 5,1 odstotka, leta 2060 bo znašal že 12,3 odstotka. Zapisana dejstva nimajo samo učinka na potrebo po razvoju ustreznih zdravstvenih in socialnih storitev, ima tudi svoje učinke na trg dela, socialno varnost, pokojninski sistem, razumevanje ekonomske rasti in prioritete v vladnem financiranju.

Brez odločnega ukrepanja lahko ta demografski razvoj ogrozi finančno vzdržnost zdravstvenih sistemov in sistemov socialne oskrbe. Tako napovedi kažejo, da se bodo v državah EU do leta 2060 povečali izdatki za javno zdravstvo za  vsaj 3 odstotke BDP ali več na račun akutne zdravstvene obravnave starejših in dolgotrajne oskrbe.

Evropske politike na področju staranja in s tem povezanih ukrepov v zvezi z zdravjem so v zadnjih letih usmerjene v razumevanje in udejanjanje aktivnega staranja. Poudarki so dani na prepoznavanje potencialov, ki jih imajo starejši ljudje, promoviranje njihove aktivne vključenosti v družbi in gospodarstvu ter ustvarjanju pozitivne podobe o dolgoživi družbi. Pojem aktivno staranje je predstavljen kot pomoč ljudem pri ohranjanju čim daljšega aktivnega obdobja samostojnosti in priložnosti, da prispevajo k razvoju skupnosti, družbe in gospodarstva.

V okviru Evropske komisije je v letu 2012 nastal usmeritveni dokument »Izvajanje Strateškega izvedbenega načrta evropskega partnerstva za inovacije za dejavno in zdravo staranje«, ki v ospredje postavlja cilje, da bodo starejši ljudje živeli čim dlje zdravo in neodvisno od pomoči drugih, izboljševanje vzdržnosti in učinkovitosti zdravstvenega in socialnega varstva in omogočiti razvoj storitev kot podporo dolgoživi družbi.

Odbor za socialno zaščito EU se zavzema za ustrezno zagotavljanje dolgotrajne oskrbe v dolgoživi družbi, pri čemer spodbuja preventivne mehanizme za čim daljšo ohranitev zdravja starejših, učinkovito rehabilitacijo v primeru izgube zdravja, razvoj spodbudnih okolij za življenje starejših ljudi in širitev možnosti za nudenje zdravstvene nege in oskrbe, ki bo prilagojena na potrebe starejših ljudi.

Dolgoživost kot fiziološki pojav in izziv za strokovnjake

Pri staranju prihaja do številnih fizioloških sprememb, ki se odražajo  v zdravstvenem stanju oseb. Je proces, ki ga ni mogoče ustaviti, je pa mogoče prispevati, da ima človek v tem obdobje čim manj zapletov, ki vplivajo na kakovost življenja in da čim dlje ohrani samostojnost in samopodobo, da zmore skrbeti zase. Dolgoživost populacije je tako potrebno razumeti kot pojav, ki neizogibno spreminja zdravstvene stroke, ki se bodo morale bolje povezovati tako znotraj zdravstvenih timov in nivojev zdravstva. Še več, ključnega pomena postaja medsektorska povezanost zdravstva in sociale na področju implementacije dolgotrajne oskrbe. Z višanjem starosti se namreč povečuje potreba po tovrstni oskrbi.

V Sloveniji še nismo razvili sistema formalne dolgotrajne oskrbe kot integralni del skrbi za starejše in druge kronično bolne. Tako je neformalna oskrba, ki jo izvajajo družinski oskrbovalci, trenutno pomemben in večinski segment dolgotrajne oskrbe v Sloveniji. Družinski oskrbovalci svojim starejšim družinskim članom ali sorodnikom zagotavljajo različne pomoči, kot so gospodinjska pomoč, osebna nega, pomoč pri ohranjanju socialnih stikov, pomoč pri denarnih zadevah, nakupovanje, prevozi, itd.

Nujna je sistemska ureditev dolgotrajne oskrbe

S pojmom dolgotrajna oskrba razumemo niz storitev ob zmanjšani stopnji telesnih in kognitivnih sposobnosti posameznika, ki je odvisen od pomoči pri izvajanju osnovnih in podpornih dnevnih opravilih. Delež neformalne družinske oskrbe je v Evropi še vedno večji od deleža formalne dolgotrajne oskrbe, zato tudi opisana skrb in spodbude EU za razvoj tega področja.  OECD za neformalne oskrbovalce pravi, da so temelj sistemov dolgotrajne oskrbe v vseh državah OECD-ja.

Neformalne oskrbovalce opredeli kot tiste, ki vsaj eno uro na teden nudijo pomoč pri temeljnih dnevnih opravilih, družinske oskrbovalce pa kot tiste, ki dnevno ali tedensko svojim družinskim članom, prijateljem in drugim iz svojega socialnega omrežja, ki živi­jo znotraj ali zunaj njihovega gospodinjstva, nudijo pomoč pri temeljnih in podpornih dnevnih opravilih. V poročilu Evropske komisije in Odbora za socialno zaščito navajajo, da v večini evropskih držav neformalni oskrbovalci opravijo velik delež dolgotrajne oskrbe starejših ljudi, in obenem ocenjujejo, da je neformal­nih oskrbovalcev dvakrat toliko kot formalnih.

Nič drugačna ni slika v Sloveniji. V neformalno oskrbo so najpogosteje vključeni družinski oskrbovalci, ki so najpogosteje zakonski partnerji in hčerke, sledijo drugi sorodniki. Zaradi obremenitev in načinov današnjega življenja neformalni družinski oskrbovalci čedalje težje opravljajo to nalogo.

V Sloveniji žal še vedno nimamo zakona o dolgotrajni oskrbi, je pa bilo sprejetih nekaj zakonov, ki so se posredno navezovali tudi na neformalne oskrbovalce, kot so Zakon o pokojninskem in invalidskem zavarovanju, ki omenja pravico do dodatka za pomoč in postrežbo; Zakon o zdravstvenem varstvu in zdravstvenem zavarovanju, v okviru katerega je zagotovljena pravica do nadomestila za nego ožjega družinskega člana; Zakon o spremembah in dopolnitvah zakona o socialnem varstvu, ki omogoča družinskim pomočnikom denarno nadomestilo na podlagi posebnih predpisov, idr., vendar le ti ne rešujejo dolgotrajne oskrbe kot pravice iz zdravstvenega in socialnega zavarovanja.

Le ta je prepuščena iznajdljivosti in zmožnostim družine. Takšen starostnik je ranljiv in oseba, ki prevzame tovrstno skrb, je preobremenjena, kar so pokazale že številne mednarodne raziskave. Dolgotrajna oskrba na domu lahko namreč traja več let, pri tem pa se slabša telesno in duševno zdravje oskrbovalca. Raziskave opisujejo pojav depresije, tesnobnosti, zaskrbljenost, psihološke stiske ob slabšanju varovančeve funkcionalnosti in bližanju smrti.

Politiki morajo prevzeti odgovornost za delujoči sistem dolgotrajne oskrbe v državi

Slovenija se uvršča v tretjo, najmanj razvito skupino Evropskih držav glede urejanja sistema dolgotrajne oskrbe in deleža sredstev, ki je temu področju namenjena. Prvo skupino predstavljajo severne evropske države, drugo zahodne države in tretjo države Mediterana, centralne in vzhodne Evrope ter Irska. Prav tako je Slovenija na repu držav v usposobljenosti delovne sile za področje dolgotrajne oskrbe, predvsem je pereča nizka vključenost diplomiranih medicinskih sester v dolgotrajno oskrbo.

Tako lahko zaključimo, da so v Sloveniji podporni mehanizmi dolgotrajne oskrbe v zametkih in razpršeni med sektorsko ter niso ustrezno koordinirani (zdravstveni sistem, socialnovarstveni  sistem, sistem pokojninskega varstva, sistem družinskega varstva, sistem invalidskega varstva, idr.). Taka razpršenost pravic onemogoča, da bi se dolgotrajna oskrba razvila v odzivni sistem pomoči posamezniku, ki je središče te oskrbe. Pojavljajo se odprta vprašanja, kdo so odgovorni za financiranje storitev v skupnosti, kakšna naj bo enotna ocena upravičenosti do storitev dolgotrajne oskrbe, kdo naj izvaja storitve in v kakšni mreži, kdo bo odgovoren za koordinacijo sistema, njegov nadzor in financiranje.

V Sloveniji tudi ni kulture, da bi se zdravstveni in socialni delavci izobraževali na način, da bi imeli določene vsebine skupne v času visokošolskega izobraževanja ali v okviru kontinuiranega profesionalnega izobraževanja. Le to se potem tudi odraža v delovanju teh dveh sistemov, ki delujeta premalo povezano, dolgotrajna oskrba je pa integrirana dejavnost socialnih in zdravstvenih storitev.

Ne smemo pozabiti, da uporabniki dolgotrajne oskrbe niso samo starejši nad 65 let. Uporabniki so tudi otroci do starosti 17 let (prirojene okvare, poškodbe ob rojstvu, hude in redke bolezni, idr.) in odrasli v obdobju med 18 in 64 let (hujše poškodbe, resna bolezenska stanja, zapleti po zdravljenih, idr.). Zato OECD dolgotrajno oskrbo poimenuje kot hitro rastoči sektor, ki je ni mogoče več graditi na neformalni oskrbi, temveč večinsko na formalni oskrbi na domu in formalni oskrbi v institucijah.

Predlaga se kombiniran sistem, ki bo integriral neformalne oskrbovalce, oskrbo na domu in v skupnosti ter oskrbo v institucijah. Integriran sistem dolgotrajne oskrbe na ravni države mora prepoznati neformalne družinske oskrbovalce, jih vključiti v formalno dolgotrajno oskrbo, oceniti njihove potrebe in jim dajati podporo pri delovanju. Naslednji element kombiniranega sistema dolgotrajne oskrbe je oskrba v skupnosti, ki vključuje razvoj  različnih servisov na domu (zdravstvena in socialno oskrbovalna pomoč na domu, idr.), ki naj bodo regulirani iz vidika ustreznosti storitev in kompetentnosti izvajalcev le teh.

Zdravstveno varstvo primarne ravni se naj fokusira na krepitev zdravstvene pismenosti starejših in izvajanje presejalnih programov za zgodnje odkrivanje bolezni, značilnih za starejšo populacijo. Pomembni so skupnostni pristopi na primarni zdravstveni ravni, kot so duševno zdravje starejših, koordiniranje skrbi za posameznika s potrebami po dolgotrajni oskrbi na domu (case management), organizirana zdravstvena oskrba usmerjena v starejše, povezanost z institucijami za starejše, potrebno je povečanje storitev patronažne dejavnosti za potrebe starostnika in potrebe neformalnih oskrbovalcev, idr.

Tretji segment dolgotrajne oskrbe je obravnava v institucijah, ki se jo razume kot urejena ponudba organiziranih namestitev, prilagojenih potrebam starejših z vključeno zdravstveno nego. Zdravstvena nega naj bo usmerjena v posameznika in v pomoč pri temeljnih življenjskih aktivnostih starejšega, poleg tega naj institucija zagotavlja tudi zdravstveno nego specialnih področij, subakutno zdravstveno nego in specializirano zdravstveno nego na področju bolezni značilnih za starostnike. Opisana dolgotrajna oskrba se odvija v domovih za starejše, varovanih enotah za starejše in negovalnih oddelkih v zdravstveni dejavnosti.

Dolgotrajno oskrbo je potrebno umestiti v sistem zdravstveno-socialne obravnave, ki se naj financira iz sredstev, s katerimi upravlja ZZZS, saj je dolgotrajna oskrba preplet storitev, ki pokrivajo zdravstvene in socialne potrebe uporabnika. Glede na dolgoživost družbe, razumevanje potreb starejših in glede na trenutne zmogljivosti nastanitve v domovih za starejše, je problem pomoči starejšim, ki potrebujejo dolgotrajno oskrbo, v Sloveniji izjemno pereč. Prav tako ne sme biti cilj politik na področju dolgožive družbe staranje institucionalizirati, temveč čim dlje nuditi pomoč in oporo v bivalnem okolju, kjer starejši človek živi.

Ureditev dolgotrajne oskrbe v Sloveniji je eno od pomembnih področij zmanjševanja neenakosti v družbi, ki potrebuje podporo na politični ravni ter ustrezno med poklicno povezovanje strokovnjakov in raziskovalcev. Le tako bo dolgotrajna oskrba zaživela kot medsektorsko obsegajoči in delujoči sistem. Uspehi naslednje vlade se bodo merili tudi v ureditvi tega področja v Sloveniji.

dr. Brigita Skela Savič je znanstvena svetnica in profesorica na Fakulteti za zdravstvo Angele Boškin

Viri:

  • 2012 European Year for Active Ageing and Solidarity between generations – Evaluation report. Report, 15. 9.2014. http://ec.europa.eu/social/main
  • Evropska komisija. Izvajanje Strateškega izvedbenega načrta evropskega partnerstva za inovacije za dejavno in zdravo staranje. Bruselj, 29. 2. 2012.
  • Evropsko partnerstvo za inovacije za dejavno in zdravo staranje. Resolucija Evropskega parlamenta z dne 6. februarja 2013 o evropskem partnerstvu za inovacije za aktivno in zdravo staranje (2012/2258(INI)).
  • Social Protection Committee and the European Commission, 2014. Adequate social protection for LTC needs in an ageing society. Luxembourg: Publications Office of the European Union.
  • http://ec.europa.eu/economy_finance/publications/economic_paper/2012/pdf/ecp469_en.pdf
  • http://www.ennhri.org/Long-term-Care-in-Europe
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