Urbani izziv, thematic issue, 2015, no. 1 71Reflections Matic KAVČIČ Health, social and spatial planning policies and accessibility of services in the ageing society This short article outlines some of the important issues arising from the dis- cussion on ageing in Slovenia and the related challenges of health, social and special planning policies in the Alpine area. This discussion raises many ques- tions. What kind of policy approaches, measures or social organisation should be followed to improve the quality of life of the ageing society in times of austerity and uncertainty? Are health and social services equally accessible for all population groups regardless of the place of residence? Can special atten- tion to questions of age and ageing re- sult in positive discrimination towards the elderly? Are the policy efforts for older people’s quality of life of marked by a zero-sum game and consequent loss of quality of life for the younger generation, which may cause intergen- erational conflicts, or can a positive sum be achieved through intergenerational solidarity, intersectoral governance, in- clusive policies and thus increased social cohesion and quality of life that lead towards inclusive growth and sustain- able development despite demographic change? The following text is a short and tentative reflection on the current situation, which looks at many possible angles through a sociological perspec- tive. The limited space of this article does not allow exhaustive discussion, and so the article mainly focuses on public policy principles and the acces- sibility of health services in particular as well as social services, including some examples of other services of general in- terest. First, there are key principles that should provide a suitable guide when tackling the issues mentioned above. For health as an important element of quality of life, it is crucially important to understand this ubiquitous concept in a broader sense. This also means rec- ognising social determinants of health among its biomedical dimensions; for example, the WHO definition of health (1948) also emphasises mental and so- cial wellbeing among other dimensions. Therefore health policies should not focus solely on disease prevention and organisation of healthcare systems. Fur- thermore, WHO states several funda- mental preconditions and resources for health: peace, shelter, education, food, income, a stable ecosystem and sustain- able resources. It is therefore important to be aware that health is highly depend- ent on and derives from the physical and social environment. This means that taking care of health is strongly connected with governance across vari- ous sectors, including spatial planning. Many of the most pressing health issues are outside the healthcare sector. Since the First International Conference on Health Promotion in Ottawa, WHO (1986) has called for “healthy public policy”. This means that health aspects should be implemented in all public policies and a whole-of-government ap- proach should be taken. In addition to the “health-for-all” principle, the Alma- Ata declaration (WHO, 1978) also set user involvement as an important norm by stating that “people have the right and duty to participate individually and collectively in the planning and imple- mentation of their health care”. An- other guiding principle to be respected is “nothing about us without us”  – a slogan often used by NGOs, especially pensioners’ associations and patient or- ganisations. At its core, spatial planning is bound to similar principles developed in the European Regional/Spatial Plan- ning Charter (the “Torremolinos Char- ter”), which among other things include improving quality of life, coordinating different policy sectors, coordination and cooperation between various lev- els of decision-making, and promoting public participation (Council of Eu- rope, 1983). This brief overview of the current situa- tion starts with population ageing. Slo- venia has morphologically heterogene- ous terrain, and demographic change has been particularly intense in remote mountainous areas (Statistical Office of the Republic of Slovenia, 2012). Lack of employment opportunities and remote services of general interest have accel- erated out-migration of young people. Older people that are attached to the community and their place of resi- dence do not out-migrate unless they are forced to move into a nursing in- stitution, for example, due to ill health or infirmity. This breakup of family networks threatens intergenerational solidarity, which is an important source of wellbeing and welfare of all genera- tions. A number of characteristics make older people one of the most vulnerable groups. With increasing age, the elder- Urbani izziv, thematic issue, 2015, no. 1 72 Reflections ly face a multitude of risks, including worsening of their physical and mental health, aggravation of their financial status, breakup of their social networks and consequently a reduction in their autonomy and quality of life. All poli- cies including spatial planning should pay careful attention to these processes in order to tailor their interventions to the needs of an ageing population. Older people in remote areas face the risk of spatial and social isolation. A comparative quantitative study on so- cial exclusion between EU countries has shown that older people in Slovenia are among the worst off with regard to low income and spatial exclusion (i.e., poor access to services in their local area), which is all the more worrying consid- ering their limited mobility (Filipovič Hrast, 2011). A qualitative study (Hle- bec et  al., 2010; Kavčič, 2011) found numerous coping strategies that older people use to overcome problems of so- cial isolation. The main disadvantages of older people living in remote rural areas were related to difficult access to various service infrastructure (from health ser- vices and administrative offices to disap- pearing local corner shops replaced by remote shopping centres), difficulties in transport (due to low availability and adaptation to their needs) and a short- age of cultural activities. Although access to Slovenian healthcare is insurance-based, the rights of entitle- ment to healthcare are universal. Nearly total coverage and healthcare facilities evenly spread across the country of- fer generally accessible services to all citizens. Nevertheless, in practice, there are limitations to universal access and choice due to waiting times and a short- age of providers in certain areas. For ex- ample, there is an insufficient number of dentists. Some providers (public or concessionaires) might reach full capac- ity for publicly funded programmes; hence, users are unable to choose their services. Less common and more com- plex pathologies can only be treated with certain specialists concentrated in main urban areas. Compared to other EU countries, accessibility of healthcare was found to be worse than in the old EU member states (Pahor et al., 2011). The main drawback of public services was found to be the waiting times (see Siciliani et al., 2013; Health Consumer Powerhouse, 2013). The rationale of concessions is to complement publicly operated services, deliver services in a more efficient and user-friendly man- ner, enhance patient choices and thus improve access to services, especially in remote and understaffed areas. How- ever revisions by the Court of Audit (2008a; 2008b) have shown that in the process of granting concessions the key principle and condition of improv- ing accessibility (in terms of distance and time) has often been disregarded. Furthermore medical doctors are less eager to choose a career path in a remote place, which leaves some distant places without suitable care. All of this results in less than optimal access to health ser- vices. Similar social services, in particu- lar community care for the elderly, were found to be unequally accessible across municipalities. Municipalities where institutional care is not provided are predominantly rural and less developed. The majority of older people must leave their municipality of residence when moving into institutional care. Such a change of environment has various negative effects on the quality of life of older people. A similar situation can be observed if one takes social home care into account. A group of smaller rural municipalities with low availability and quality of services, a small number of users of home care and high costs turns out to be the most problematic (Filipovič Hrast et  al., 2014; Hlebec et al., 2014). Having named a few illustrative exam- ples of health and social care accessibil- ity issues, this article now outlines some of the policy recommendations that should be drawn into the discussion. An important and often overlooked is- sue in policymaking is the heterogene- ity of older people (Nelson & Dannefer, 1992). Across the lifespan, diversity also increases due to cumulative advantage/ disadvantage processes. It is therefore increasingly important for sectorial policies and spatial planning to also ac- knowledge the diversity of older people in order to avoid age-based generalisa- tions in their policy measures that could render them ineffective. A few guiding policy principles have already been mentioned; for example, health in all policies (McQueen et  al., 2012). Be- cause health depends so much on the social and physical environment, it is absolutely necessary that it also be im- plemented in social and spatial policies. Spatial planning also recognises the need for coordination and cooperation with other policy sectors. In general, it is im- portant to consider the broader impact of sectorial policies, which is becoming increasingly more difficult in complex postmodern societies. Public policies that tackle such complex issues should be coordinated and integrated as much as possible. Here further steps should be taken. Anecdotal evidence suggests that ministries often act decoupled from each other, like “silos” without proper and effective cooperation and integra- tion to take advantage of desired syner- gies. The nature of cooperation rarely exceeds formal consultations; moreover, intensive joint work between differ- ent ministries towards common goals seems to be rather limited and is rarely translated into real policy integration – a point all too obvious in the case of the awaited act on insurance for long- term care. This anecdotal evidence of weak coordination is supported by the revision report of the Court of Audit (2012) on regulatory impact assess- ment. Impact assessment is often car- ried out insufficiently and is more or less regarded as a mere administrative obligation. The lack of monitoring of existing regulations in practice and the absence of a mechanism for monitor- Urbani izziv, thematic issue, 2015, no. 1 73Reflections ing proposed regulations has also been identified. In addition, the Court of Au- dit has called for further improvements in public participation in the processes of adopting laws. In conclusion, it seems that in Slovenia public policies address issues of age-related quality of life sepa- rately. These fragmented policies cannot adequately manage diverse and complex social problems related to demographic change, and so it is increasingly impor- tant to follow new approaches. Without measures towards intersectoral govern- ance of social problems and implemen- tation of user involvement in all steps of policymaking and implementation, policymakers also run the risk of public opposition. Reorganisation and a new holistic approach focused around social problems to integrate intersectorial and interprofesional cooperation together with public involvement are needed. Only in this way can one hope for a positive sum of interventions for all generations leading to social cohesion, inclusive growth and sustainable devel- opment despite demographic change. Matic Kavčič University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia E-mail: matic.kavcic@zf.uni-lj.si References Council of Europe (1983) The European re- gional/spatial planning charter: “Torremolinos Charter”. Torremolinos. Court of Audit (2008a) Revizijsko poročilo. Podeljevanje koncesij v zdravstvu – Ministrstvo za zdravje. Ljubljana. Court of Audit (2008b) Zbirno poročilo. Podeljevanje koncesij v zdravstvu. Ljubljana. Court of Audit (2012) Revizijsko poročilo: “Ali v Sloveniji preverjamo učinke predlaganih predpi- sov na družbo (2)”. Ljubljana. Filipovič Hrast, M. (2011) Socialna izključenost starejših: Slovenija v primerjalni perspektivi. In: Mandič, S. & Filipovič Hrast, M. (eds.) Blaginja pod pritiski demografskih sprememb, pp. 61–81. 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