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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’
作者是哈佛大学(Harvard University)莫萨瓦尔-拉赫马尼商业与政府中心的研究员(Research Fellow)，著有《额外时间：活得更长更好的十个教训》
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，我曾见过一个人形机器人与一位理疗师一起跳舞，带领热情的老年人进行晨练。在荷兰，我曾与一位护士一起拜访老年妇女的家，她带着她的狗来给她们带来快乐。在美国，我曾去过一家养老院，居民们负责管理图书馆，书架上陈列着他们自己写的书。随着每个富裕国家都在努力应对越来越多的长寿人口、日益虚弱或被孤独困扰的人，保持人们尽可能长时间的独立成为了重要的一环。
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.
一个承诺给我们所有人在老年阶段带来更多意义的照护系统，比起一个听起来像是应对衰退的最后手段的系统，会更具吸引力。在英国，关于社会照护的辩论再次引起了热议，财政大臣蕾切尔•里夫斯(Rachel Reeves)放弃了一个长期推迟的“限制”某些照护费用的计划。这让那些担心限制是唯一选择的人感到担忧。但里夫斯的直觉是正确的。
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.
解决社会护理问题需要更深层次的思考，包括资金和对残疾人的方法。要解开目前看起来像是一个复杂的困局——低薪护理工人、绝望的家庭、家庭医生短缺和拥挤的医院——唯一的方法就是改变叙事方式。应该将老年护理定位为整个社会的积极投资。
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”.
在我与哈佛肯尼迪学院的同事共同发表的一篇工作论文中，我们推荐了一系列实际政策，以改善65岁以上人群在健康和护理方面的结果。例如，不必要或延长的住院时间可能会导致人们过早地依赖他人，因为食物不好、睡眠受扰和身体康复不良。密集康复可以自负盈亏——在一些美国医院，它使三分之二的人在跌倒或手术后能够回家。但这需要员工从“对待”心态转变为“与人合作”的心态。
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.
同样，把人们送到日间中心并不能总是治愈孤独。在挪威，倡导者们正在使用点对点技术让老年人在线共享餐食。普遍认为老年人不需要选择权或控制权。但事实并非如此，他们确实需要——应该允许更多人使用自己分配的护理预算并雇佣亲属，就像德国正在做的那样。
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，我们认为英国需要一个连贯的资助体系来取代那种不透明、武断和不公平的体系。在养老院中，有资产的家庭实际上在为那些有资格获得国家援助的人提供交叉补贴。英国国家医疗服务体系(NHS)的持续医疗预算成为了人们绝望地争取证明“基本医疗需求”的法庭案件的对象，而这一概念没有严格的法律定义。
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，英国的制度看起来与30年前的德国并无二致。德国和日本都建立了透明、可预测和可持续的社会护理保险基金，并营造了一种社会团结的氛围。包括养老金领取者在内的每个人都缴费，每个人都受益。
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.
这些方案远远超出了2011年提出的护理费用上限，里夫斯刚刚停止了这一提议。这个值得赞赏的目标是设定一个任何人在其一生中必须支付的个人护理费用的最高金额（不包括日常生活费用）。但政治家们从未实施过它，部分原因是它只会保护相对较少的家庭，部分原因是财政部不愿意在没有相应的护理质量改善的情况下提高税收。
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“按需付费”福利制度国家中，一个政治挑战是许多老年人认为他们已经缴纳足够的税款来支付他们的养老费用（可悲的是，许多人并没有）。另一个争议点，特别是在英国，是住房问题。传承房屋给下一代的愿望是强烈和合理的，这导致连续的政治家承诺，不应该有人不得不出售自己的房屋来支付护理费用-但是忽视大多数人最大资产的价值可能是不可持续的。
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.
工党必须找到更多的资金，尤其是因为工党提高护理人员工资的承诺有可能使雇主破产。但改革并不仅仅是一项枯燥的技术工作：它必须让公众参与进来。正如阿图尔•加万德(Atul Gawande)在其著作《成为凡人》(Being Mortal)一书中有力地指出的那样，这意味着要制定一个能给人们带来意义的美好晚年愿景。我们如何对待老年人和残疾人是对文明社会的最终考验。