Reverence and obedience

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Chow (2001) stated that filial piety is defined in accordance with the teaching of Confucius in that children should treat their parents with reverence and obedience. The practice of filial piety is divided into three levels. The first level includes providing parents with the necessary materials for the satisfaction of their physical needs and comforts, including attending to them when they are ill. The second level includes paying attention to parents' wishes and obeying their preferences. The third level includes behaving in such a way as to make parents happy and to being them honor and the respect of the community.

Chow (1998) conducted a study on how Hong Kong people actually practiced filial piety, incorporating the three level of tradition Confucian teaching, which shown 82% of the respondents said that they regularly gave money to their parents, regardless of whether their parents needed financial support. 69.7% said that they were prepared in provision of financial help for their parents to recover from their illness. However, less than a third of the respondents thought that they would follow the advice of their parents in decisions like looking for a job; some did not even think it is necessary to seek advice from their parents. Though nearly half of the respondents said that they would try to make their parents happy and not to bring them disgrace, filial piety could not be regard as a primary motivating factor or guide to decision-making. The practice of filial piety in Hong Kong is now mainly confined to the first level: satisfaction of parents' physical needs and comforts.

Chow and Lum (2008) conducted another study on how the attitude of Hong Kong people towards filial piety and found that their support is mixed. Sixty percent of the survey respondents agreed that family disgrace should be keep within the family. Fifty-nine percent agreed that one should work hard to move up in order to bring honor to the family. Seventy-three percent agreed that children should consult their parents before major decision. However, only 36 percent agreed that one should seek help from elders to settle conflict. Only 39 percent agreed that it is important to have a son to continue the family name. Seventy two percent of respondents disagreed that it is better to have a son than to have a daughter.

It also noticed that Age, gender, and socioeconomic status are related to attitude towards filial piety. In general, support towards filial piety had a "U" shape relationship across age groups. For example, compared with younger adults (of 29 years of age or younger), middle age adults (of 40 to 49 years of age) were less likely to agree that it is important to work hard to bring honor to the family. However, older adults (of 60 years of age or older) were more likely to agree with it. Similarly, compared with younger adults, middle age adults were less likely to agree seeking help from elder's to settle conflict and having a son to continue family name while older adults were more likely to agree to these attitudes. Female respondents and those who received more education were less likely to agree to the filial piety value. Respondents who had higher income were less likely to agree the importance of working hard to bring honor to the family, of seeking elder's help to settle conflict, and of having a son to continue family name.

Moreover, rapid industrialization has contributed to changing family values in relation to care of elderly members and women are now less likely to adopt this traditional role due to their increasing labour participation rates, caring of the elderly is increasingly seen as a shared responsibility of families and government. What we can say is that the value of filial piety is not totally forgotten currently in Hong Kong but upheld by most Hong Kong people as a value that they should treasure and practice in the ways that they believe suitable and appropriate. It is anticipated that the need for aged care, especially the demand of institutional care, will rapidly increase as the ageing population of Hong Kong.

On the other hand, difficulties encountered in providing aged care are:

Hong Kong's ageing population

Similar to many Asian communities, Hong Kong's population has been ageing throughout the 1980s and 1990s. The proportion of its population aged 65 or above increased from 6.6% in 1981 to 11.2% in 2001 and the total number of elders so defined increased from 344,300 to 753,600. It will start turning 65 in 2011 and by 2031, 24.3% of our population will be aged 65 and above.

Lack of residential care for the frail elders

In a community wide survey conducted in the late 1990s, Hong Kong's elderly population was found very healthy. Very similar to elderly population in other advanced economies, only about 5% of our elders were of different degrees of physical or mental impairments so as to require assistance with their activities of daily living. The great majority of those with severe physical or mental impairments were living in residential care homes, either subvented or private. However, a good proportion of those with mild or moderate impairments were living in the community. Traditionally Hong Kong was very similar to other Chinese communities world-wide in relation to who took care of the frail elderly. The family provided the support. In the community-wide survey conducted in the late 1990s, spouse was the number one carer for frail elders, followed by daughters and daughters-in-laws. That is, female adults are the main informal carers for frail elders. The survey findings were no surprise, and even without comparative data ready in hand, the situation in Hong Kong must be very similar to that in other Chinese communities, and indeed many Asian communities. Underlying the basic situation uncovered by the 1997 survey, there has been however an increasing trend of frail elders being sent to residential care institutions in the past 20 years. As large number of Hong Kong people migrated overseas throughout the 1980s and 1990s, there was an increasing need to put frail elders in residential care. Although the Government was incessantly increasing its funding for subvented residential care throughout the 1990s, the waiting list for the service continued to lengthen in that decade and so was the waiting time. In 1997, there were a total of 17,000 subvented residential care places in Hong Kong, but 19,000 people were on the waiting list.

Confusion on ageing policy of the Government

It is an issue of debate whether a policy on ageing currently exists or has ever existed in Hong Kong. If "policy" is taken to mean a coherent conceptual framework linking different practices for the achievement of a goal or mission, the gradual development of such a policy framework has been evident since the 1970s, but services provided have not always been consistent with the policy. However, if "policy" is taken more generally and pragmatically to imply a central government effort towards collating public services, then there has been only a direction for formulating such policy. Today's policy on ageing in Hong Kong represents a piecemeal evolution over thirty years. Policy over the past decade has definitely become more coherent and considered. Whilst policy is undoubtedly emerging, many issues remain to be tackled in terms of the health and social needs of older persons. The Hong Kong government is also going through a learning process in attempting to meet these needs through policy formulation and implementation. Policy imperatives to be addressed include the need for data for policy-making and evaluation, the poor integration within and between health and social services providers, which has resulted in a fragmented delivery of services, and the lack of clear operational or policy implementation plans for service delivery. Some policy and service initiatives are being taken to address these challenges, especially in view of the projected rapid increase in the elderly population. The Hong Kong Government has tried to base the development of aged care on the principle of "ageing in place" - that is, elderly people should live with their families or in a familiar environment for as long as possible. This principle has been effectively underpinned Hong Kong's social welfare policy since 1977, reasserted in the 1991 White Paper and in many policy statements since then. Whilst Chinese tradition also assumes the readiness of the family to care, the fact that more families unable or unwilling to do so, coupled with many more older persons themselves asking for residential care, has made the grave shortage in home places become evident. The government has responded to such needs by building different types of residential homes. However, recent reviews on aged care provision indicate that there is a need to encourage realistic community care and support, and to revamp residential care. A greater emphasis is being put on the role of community support services in maintaining older persons in the community. At the same time, residential care types are increasingly considered in terms of matching residents' levels of dependency, resulting in the emergence of a more refined system of need assessment and integrated service delivery.

Finally, how those difficulties could be resolved or minimized?

Strategic policy by Government of Hong Kong

The Government of Hong Kong should form a designated committee comprising multi-disciplinary members from the medical, social welfare, academic, rehabilitation, and business sectors which a clear policy and services for aged care would be formulated accordingly. The committee should also provide a steer to the studies into various aspects of the situation in relation to aged care and set up various sub-committees with a view to overhauling the existing services and making recommendations for improvement in Hong Kong. The Government of Hong Kong was asked to increase the supply of quality long term care service for the frail elderly. For example, the total supply of subsidized residential care beds should be increased according to the actual need. Despite the willingness of the Hong Kong Government to commit additional resources to the Strategic Policy Objective of care for the elderly, the Committee has always been aware of the high cost of long term care services. For example, each bed of a care and attention home costs more than HK$100,000 a year to operate. Only 20% of the cost is covered by users' fees, whereas 80% is subsidized in the form of subvention paid to the welfare agencies operating the residential care homes. Furthermore, some two-thirds of the residents are welfare recipients and therefore even their users' fee is covered by welfare benefits payable to them. That is, over 90% of the cost of the subvented residential care programme is paid for by public subsidized money. The unit cost for nursing home beds is even higher. At a cost of $150,000 a year to operate, users' fee is only comparable to that of care and attention homes. Therefore, 95% of the cost of nursing homes is paid for by public subsidy. Under such funding arrangement, any attempt to increase the supply of long term care services is very expensive to the taxpayers. The Committee might adopt a strategy of targeting and re-engineering to stretch the purchasing power of the tax dollars. The following initiatives should be taken in this respect:

Purchase of service from the private sector, instead of building new subvented residential care homes; the Government has to decide for purchase residential care beds from existing private residential care homes if they are able to satisfy enhanced standards of care. In addition, those private residential care homes must upgrade their space and care standards to those higher than the minimum statutory standards. To obtain maximum beneficial effects, the entire private residential care homes must achieve the "Bought Place Scheme" standards, although typically the Government will purchase 20% - 50% of the beds in a private residential care homes. The monthly cost of purchase per bed is about 30% cheaper than that of subvented residential care homes because private care homes can follow market wages in their employment of nurses, caretakers and other essential staff. Furthermore, the Government can achieve savings in capital expenditure which is usually very sizeable in Hong Kong given the high construction cost in Hong Kong.

Encouragement of self-financing services - traditionally there is no income criteria restricting access to subvented residential care beds. The situation was considered acceptable as in the past rich families were generally not inclined to send their elderly parents to residential care homes to avoid the social stigma attached to such behaviour. Nevertheless, changing social and economic conditions in Hong Kong have made it socially acceptable for middle class families to send their elderly parents to subvented residential care homes. Actually, both the husband and wife in many middle class families are working full time, making it difficult to care for a frail elder at home. Many who are willing find themselves lacking the appropriate care skills and find it of mutual benefit to the elders and their adult children to seek professional care services. As private residential care homes generally offer services of lower standards, middle class families have no choice but to send their elderly parents to subvented residential care homes to enjoy a higher standard of care. To tap the purchasing power of these middle class families, the Government has made greater efforts to encourage the third sector to operate self-financing care homes, rather than concentrating their efforts in operating subvented care homes. Indeed the demand for self-financing homes has been so high they are all fully occupied. Those situated at better locations command very high prices per bed and are always full. As a matter of fact, many of these self-financing homes actually achieve "surplus" in their accounts that can be used to cross-subsidize the organization's other welfare activities. At present, some 3,000 frail elders are receiving residential care in self-financing residential care homes.

Gate-keeping - to tackle the problem of some elderly people seeing residential care homes as a housing option and apply for admission even though they are in good health conditions, there is a need to conduct an assessment on the care needs of the elderly and to target the long term care services at those genuinely in need. For such purpose, an elaborate gate keeping mechanism was so required, adopting the internationally accepted but locally validated MDS care assessment tool. The care assessment has been successful in ensuring that only frail elders with long term care needs are admitted and has shown that some 20 - 30% of applicants do not have the care needs to quality for services.

Services re-engineering - the Hong Kong Government has been encouraging the service provider to re-engineer their services in these aspects. For resources previously devoted to provision of services to healthy elderly people are re-oriented to provide care services to the frail elders. For example, social centers for the elders which are designed to provide recreational programmes and social support for the elders are given additional resources to employ nursing and therapist staff if they are to re-focus their services to provide support services to the frail elders. These centers are also encouraged to work with home help or home care teams to provide a community network of care services for frail elders ageing at home.

Home care services as an alternative to residential care service - capitalizing on some families' inclination to care for their elderly members at home if support services are available, the Hong Kong Government has to introduce home and community care packages to frail elders who are otherwise eligible for admission to residential care homes. The cost of care in such arrangement is on average 80% cheaper than residential care.

Product differentiation - to reduce the reliance on public subvention in the provision of residential care, new subvented homes are required to provide a proportion of their beds as fee-collection beds. To encourage payment of fees, some beds are accommodated in rooms of a higher standard of decorations and improved privacy. In so doing, some beds are charged a fee that recovers the full cost of provision, whilst some others can reduce the degree of subsidy to say 50% or less. The total amount of subvention payable to such homes is lower than otherwise by some percentage.

Optimization of use of resources - to make best use of the staffing and other resources, care institutions are encouraged to provide other types of care services with their spare capacity. For example, since all residential care homes have vacant beds because of turnover of residents and short term admission to hospital for acute care, they are encouraged to provide day and overnight respite services without additional subvention from the Government.

In conclusion, I would say it is an incumbent for us to see that this virtue of filial piety does propagate and prosper, and is elevated to the dignity of a conscious social practice. Shall we reap acquire fully the serene bliss and mirth of this virtue, relish the delight and joyfulness into practice, elicit a multiplier effect through mutual encouragement and reinforcement, avoid blunders by sharing and learning from others' experience, and most importantly, preclude the omission of proper acts in due course, then realizing the omission later which plunging into lifelong remorse.


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