Governance structures and person related social services in the German health care system: The case of Ambient Assisted Living Jens Becker, Ulrike Goletz Institut für Sozialforschung und Sozialwirtschaft e. V. (iso)
The following contribution deals with some structural problems establishing a service-culture to manage the demographic challenges. Using the example of AAL-technologies (ambient assisted living) and corresponding to social related services the central question is which governance and competition structures exist at the micro, meso and macro level. While marketization and competition penetrate the health care sector in the EU member states the meaning of governance in state and private regulated health care sectors is diffuse. Indeed decentralise government principles, we argue on the German example, market and competitive elements are necessary premises providing AAL-technologies and a framework of person related social services.
1.
Introduction
Against the background of an increasing impact of the health sector, especially new forms of technology are capable of balancing human needs - such as telemedicine or ambient assisted living (AAL) - with economic constraints, such as efficiency and effectiveness (Eberspächer/ Picot/ Braun 2006). No doubt, the implications of information and communication technology (ICT) touch upon the conference topic: "Productivity of Service NextGen - Beyond Output/Input" (Reser-conference 2011). However, it seems unclear which forms of market regulation and implementation especially with regard to AAL - will prove adequate to allow the effects of related social and technological services to unfold. Under an optimistic scenario, AAL technologies can support the self-reliance and independence of elderly people (Georgieff 2008). The cost pressures, which the healthcare system continues to be exposed to, could be reduced through ambulant and other forms of person and technology related services. „Especially elderly people will benefit from the technological assistance helping to compensate the constraints of their age"(VDE 2008, 6). Aging would translate into the equivalent of a great achievement of modern culture, namely “an essential implication of wealth, education, freedom, social security, medicine, hygiene, nutrition science, even science per se.” (Hondrich 2007,13). But until then, there is still a long way to go. Although the relevance of innovative health technologies is considered to be high already, AAL has tended to be stagnat1
ed. As will be described later in this paper, even experts1 consider AAL as a widely unknown technology and urge governments to provide support. There are still no convincing governance or marketing concepts. This realization leads to the assumption that a wide implementation of AAL technologies and services needs to be carried out initially via the "second", privately-financed health market. This idea corresponds with the currently prevailing paradigm of individual responsibility and self-empowerment of hypothetical or potential customers or patient groups. Their „mobilization” could be considered as an essential requirement to overcome the „demographic challenge“ in a socially acceptable way (Bieber 2011) through a competitive, techno-scientific health system. Following this idea, the purchasing power of individuals would generate a variety of technological and social innovations, causing another boom in the services trade sector. This concept is consistently supported by the high tech offensive of the federal government, as well as the German Ministry of Education and Research (BMBF) supports the focus on "technology and services in the wake of demographic change". According to Lessenich (2008, 17), the individual is most notably oriented towards the common good and therefore "productive", if and when it demonstrates forward-looking individual responsibility and proactive behaviour in order to take pressure from the contributors to public health and tax pools, while purchasing goods and services in the healthcare market. Using the example of AAL the question is how governance structures, marketization and competition help to penetrate the health care sector. Together with decentralised government principles, we argue, market and competitive elements are necessary premises for the provision of AAL-technologies and a framework of person related social services. Therefore we examine the institutional macro sphere of governance in the techno scientific German (and European) system (chapter 2). Then we continue with considerations about self-empowerment as a basic concept for implementing an AAL-governance (chapter 3). Furthermore, we argue, the private health care market could be seen as a vehicle to establish AAL-services and technologies (chapter 4). At last we sum up some crucial points (chapter 5).
2.
Governance in the techno scientific health care system
It should be emphasized that the term 'techno-scientific healthcare system' implies objective, scientifically-based approaches to problem-solving in order to push solutions. Suitable technology-intensive and preventively activating "policy" measures with regard to social and health policy are shaped "from the realm of political discourse, and recast in the neutral language of science“(Dreyfus/Rabinow 1982, 196). Especially problem-solving approaches concerning the AAL and telemedical technologies are considered as objective and necessary actions to deal effectively and efficiently with the above-mentioned problems. These problems are associated with marketization and economization trends within the healthcare and nursing systems,
1
The data base for an explorative study contents seven expert interviews in 2011, made by members of the iso institute.
2
which in turn favour the establishment of decentralized governance structures. Governance can generally be defined as the whole of institutional arrangements for coordination of collective actions (Lange/Braun 2000).This refers to activities and interactions of agents from the private and public sectors, whose operations are shaped by institutional control structure/ structures of regulation; however, the welfare-stateoriented Keynesian claim of the 1970s for the most well-targeted political option of regulation, is already being questioned due to the complexity of the situation and inherent conflicts of interests, particularly in the German health care system (Mayntz 2004: 4). In the meanwhile, decentralized governance structures already dominate the system, meeting better the requirements of market-oriented ways of implementation and efficient competition. They are a part of a "Governance and Welfare State Reform" that has led to fundamental changes in European health and social policies (Dingeldey/Rothgang 2009; Kuhlmann, Saks 2008). Marketization and re-regulation are thus an interdependent relationship. Against the background of EU regulations, Germany is integrated in a comprehensive governance process which reduces national scope of action and increases the pressure to search for market-oriented solutions (business models for person related social services). Regulation from the national to the European level as well as convergence between countries has risen. Within the German welfare state model, especially with regard to the cost-intensive (health) care sector, efficiency and money in organisations of social service provision have always played a role. It is not about if but rather how in those organisations economic management tools are being introduced. And it is also about which models of organization – non-governmental or private – can cover the demands. The interaction process between service provider and service addressee constitutes an essential precondition for high-quality productivity of person related services. This process is thus quite personnel-intensive. Economic management measures that are adopted in an unconsidered way from other branches often focus exactly this aspect which often results in restructuring and work intensification. The problem here is not the management model itself, but the unconsidered use of tools and measures which neglect the specific characteristics of person related social services. Within the German welfare model – a model of the „activating“ and „providing“ state – clients are increasingly expected to actively contribute and cooperate in return for social services. This paradigm has to be put into practice by employees of social service interacting with their clients. Likewise the dynamics of change with regard to public services will be taken up and its effects on person related social services will be clarified. The transformation towards a service society where person related services are gaining in importance is under way. A growing number of employees in the service sector will be involved in person related work processes. The specific characteristics of person related services in terms of “labour on persons, with persons and by persons” reveal new dimensions of creating work processes. These dimensions also bring forward new symbioses between technology and services. The productivity of services is strongly dependent on the cooperation of clients on the one hand and on the motivation of service providers on the other hand. Thus, the specific and hard-tocalculate dynamics of interaction has to be made compatible with the requirements of standardization and controlling.
3
The healthcare provision in the European welfare states is increasingly shaped by competitive control mechanisms (Burau, Vrangbeck 2008). A characteristic feature is the growing gap in cost sharing, with funding contribution of employers decreasing, the insured and sick are burdened with a rising share of cost (Bäcker et al. 2008, 231). In addition, over the past few years, the German health industry has evolved into a boom sector with a strong growth outlook in which about 4.6 million people of different professions are employed. The German healthcare sector is divided into a "first" and a "second healthcare market". While the first healthcare market is part of the conventional medicare that is covered by the statutory healthcare insurance (Gesetzliche KrankenversicherungGKV) as well as the private healthcare insurance (Private KrankenversicherungPKV), the second healthcare market includes privately financed health benefits (e.g. alternative medicine or supplementary insurances), “as well as private consumption with the underlying buying motivation of health and prevention (health tourism, foods from organic farming, natural cosmetics, fitness” (David 2008). The forecast for the German market volume in health services is valued at 453 billion euros in the year 2020, corresponding to an increase of 74 percent, compared with 2003. (Hajen 2010,54). The German healthcare system is also subject to diverse plans of reformation, of which mainly the following have emerged as prominent: implementation of a law concerning the health care service reform (the GKV- Gesundheitsreformgesetz 2000); a law concerning the modernization of public health care ( the GMG- Gesetz zur Modernisierung der gesetzlichen Krakenkasse); and a law strengthening competitive aspects within statutory health insurance (GKV- WSG -Gesetz zur Stärkung des Wettbewerbs in der Gesetzlichen Krankenversicherung) - featuring the establishment of a health fund, elements of competition in public health insurance with regard to additional contributions, etc. They appear as an attempt, to „break with the encrusted structures“(Relittke 2011). The most important instruments of “solidarity-based competition” are the insured individual's free choice of health insurance combined with the “risk structure balancing system" (RSA- Risikostrukturausgleich), a move to prospective remuneration (flat rates, budgets), as well as the implementation and gradual extension of individual contracts between financing party and health service provider (Gerlinger 2009, 22 f.).„On the federal level, the key agents in this regulated healthcare market are the ministry of health with extended legal supervision authority and extended rights of intervention, as well as the negotiation partners of the renewed central association of the public health system (GKV), and the care provider in the Federal Joint Committee (Gemeinsame Bundesausschuss GBA). In contrast, on a regional level individual health insurance companies play a key role in adapting and fulfilling the orders of the nationwide legal guidelines“ (Bandelow, Schade 2009, 97). This touches upon several regulation options or phenomena – either directly or indirectly, either governmental or economical –, which also relate to concepts of competition, legitimized by European Union legislation (comprehensive regulations can be found in the European competition law), such as the German medical benefit and service market (Gerlinger/Urban 2006). The accessibility of private health insurance for all interested clients reflects an approach of comprehensive deregulation in previously corporatist healthcare services. Especially non-profit associations operating in voluntary welfare work (Caritas, Deutsches Rotes Kreuz, Diakonisches Hilfswerk, Arbeiterwohlfahrt, Paritätischer Wohlfahrtsverband) are coming under increasing pressure to compete with each other and occupy their position in the "market". Their 4
survival, according to Rock (2010), is only conceivable through distancing themselves from the competitive logic and by enhancing their own social profile.
3.
Market processes and self-empowerment – governance options for AAL?
This development is promoted by another paradigm shift, revolving around the more active social investment welfare state and the associated „economization of the social sector“(Bröckling et al 2000). The central focus is reminiscent of Foucault´s entrepreneurial self (Bröckling 2007) or the corresponding preventive self (Mahtar 2010; Allosp, Jones 2008)). The re-actualisation of the Governmental Studies (Foucault 2006) is basically about strategies of self-empowerment, demanding a high level of personal responsibility from the „clients“ or „patient-clients“, while also asking for their individual potentials (and personal interest) in the service of health or nursing (self)care. Therefore, techno-scientific systems have an assisting, helping, but also streamlining function which is based on self-management of private risks and disease symptoms (also considering curing and rehabilitation). This can also be interpreted as 'Government by Patient' or 'Government by Customer' (Mahtar 2010) and – as the BDI/BDA (2009) demand – the client/patient can be informed comprehensively about the purpose of, and the price for, such techno-scientific services (and AAL- products), in order to accelerate their implementation. While both the introduction of the electronic health insurance card as well as various telemedical innovations have previously failed in the face of the heterogeneous structures of the German healthcare system, or its antagonistic patterns of interests (from health insurance companies, medical organizations, and telemedicine producers and service providers), the situation has now changed; especially since agents from the political and economic areas have been showing an interest in the implementation of a techno-scientifical healthcare system that relies on a sustainable health care business sector (Mahtar 2010). This involves - also with regard to the AAL context - market-viable products and business models; the involvement of health insurance companies as well as other solvent health institutions; plus technology-friendly patients or clients, or at least some with a self-responsible mind-set that are willing to learn. However, quite obviously, an AAL governance structure does not yet exist. It is rather the state - or, more precisely, the federal government of Germany with its promotional "innovations and services" program, with its "high-tech-strategy" as well as other measures - that has given important impulses for health services and technical design options in the areas of age and disease. According to experts specializing in the marketing of AAL technologies, governance itself cannot be reduced to a legislative decision. The participation of enterprises, associations and other stakeholders, but also the inclusion of patients in order to assure the necessary transfer of information, becomes urgent. As interviewed AAL expert states: "There should be a process, where people develop a common approach to AAL. Therefore it is not acceptable that a single person decides how it is done and everybody else needs to get along with it, but the process should be about involving as many people as possible."
5
From the perspective of the welfare association, on the macro level, it is often a long process to implement something new, "even if it is recognized as a way of saving costs with certain technologies, it is difficult to implement these." The positive effects of AAL - such as cost reduction - should be transported through lobbying in various institutional contexts. In order to ensure the implementations of AAL technologies in a broader area, it is necessary that the state (and also the Federal Joint Committee, GBA) provides a general framework for the integration of AAL into the "first health care market”. Firstly, instead of incorporating these technologies into the list of services covered by the health insurance, the demand for necessary services and technologies should be determined, on the basis of disease patterns. On the other hand, a growing involvement of health insurance companies seems to be indispensable for AAL service providers. Red tape-heavy health insurance approval for AAL technologies and services appears unattractive to many suppliers. A basic level supply of AAL technologies, argues a telemedicine provider, will be necessary in urgent cases. "It can be assumed that, in the future, our social system will focus more strongly on personal responsibility and financing of the individuals. So far, this process has not been adequately communicated to the public. Therefore, everyone should build a parallel safety net for himself that enables them to buy services beyond state-guaranteed support." Since it is expected that not all services will be provided to everyone to the same extent, a differentiated framework is needed for both suppliers and patients. If we follow the expert the legislator should establish a market "which is transparent and people know that if they follow certain rules, they will be insured and enjoy protection. That means, in particular, there is a quality standard that I can rely on." From the perspective of an interviewed health sociologist, the integration of AAL technologies into public German healthcare and governmental insurance system will lead to additional mechanization of the healthcare market. This does not necessarily go hand in hand with savings potentials. “But what could be stated is”, the expert argues, “that such new offers (telemedicine) by all means create chances for the patients to remain autonomous, and on the basis of wide distribution." He estimates that the health insurance companies, the Association of Statutory Health Insurance Physicians (KV- Kassenärztliche Vereinigung), the nursing insurance, associations, as well as care facilities representing different ways of caretaking, could only accept AAL technologies if the government and other involved agents take the necessary precautions in creating a framework and delegating competences. "However, the involved parties are not showing sufficient openness to put such differentiated ways of caretaking into practice, neither in the shape of contracts nor in reality." Especially the compensation system should be designed in a specific way, promoting modern healthcare practices. „Furthermore, the regionalization of arrangements in general could be an option. Keeping in mind that the need for healthcare of insured persons always exists locally, and specifically in a certain town, in a district, in a specific urban space - and I think that our system of regulation is not taking this feature into account sufficiently“.
Respondents working in the health care economy: a representative of a public health insurance company Allgemeine Ortskrankenkasse (AOK), as well as the representative of a private healthcare company, are also pleading for clear structures, a self6
respondent patient and a market economy-oriented solution for AAL. It is already clear for the AOK representative that „the next innovative step will be the expansion of telemedicine in the entire healthcare and nursing system. Since there is no need for the patient to leave the house anymore, a strengthening of the competitive market situation will occur. The one who are failing to offer this kind of service and are unable to participate in the market, will be out”. However, if the healthcare insurance companies should invest in this kind of technology, legal framework has to be provided. (Preconditions are minimum standards in technology, followed by a legislative framework, which will enable providers and the health insurance companies to negotiate and deal with each other). But “right now, there are no fixed policies. A pilot scheme is the only way of gaining financial support for health insurance companies. Additionally, since the apparatuses transmit the data of the customers/patients (telemedicine), privacy protection policy must be adapted. The AOK insurance representative pleads for the spread of AAL technology in the “second health care market” so that supply and demand will lead to a competitive environment among the providers: „If products are not being regulated by the state, but are demanded and bought by the market, they will have the best opportunity to penetrate a wide market.“ In order to break open the perceived inflexible structures of the regulated healthcare market, private health care providers prefer the liberalization of the paying parties. The separation between the “first” and “second health care market” should be further broken up, and more choices for insured clients have to appear; also basic services have to be accessible for everyone. Another expert considers AAL, respectively telemedicine, as a control- and rationalization instrument that could simplify the work among different agents in different countries, with the benefit of better forms of communication and information. „In order to make the patient assume more responsibility“, a reduction of fees is advisable, „with regard to the fixed basic contribution; however in return, citizens should be obliged to use the amounts saved to pay for some services on their own“. An infrastructural service (architecture) for AAL could be compared to certain call centres, which provide different kinds of services. „Problems will occur, if the affected person is not technically affine enough to order these services (this concern especially today’s 60+ generation). For that reason, an additional local service will be needed to advise patients properly. At the same time, the technology has to fulfil the requirements of the user; „the older the technologically affine generation will be, the more basic knowledge and acceptance of using such systems will occur“. Therefore it becomes apparent that new governance structures are convincing through the improvement of quality and personal service less than is often claimed. In fact, the client should be adapted for the organization and handling of new technologies. During the interviews with experts, the self-management and individual responsibility-theory is often being portrayed. A part of the experts plead for a „holding or participation structure“ which intends a combination of guaranteed minimal- or obligatory care as well as self-financed, additional services. Everything that „affects the comfortable and the pleasant and the beautiful“ passes over „to a more personal responsibility“. A representative of the healthcare sector sees „the first starting point within the personal responsibility of the patients“ by „attaching and maintaining an electronic health record.“ He postulates „a reduction of the fees considering the fixed basic contribution“ in order to „have citizens to be obligated to use the abounds saved to buy some services on their own“. In brief, the self- responsibility should be increased by a bonusand penalty-system. According to the AOK representatives, „a part of the responsibility has to be handed over to the patients. Common sense is what should be used 7
first. An individual comes up with more potential for savings than legal regulations targeting a range of political agents”. It becomes obvious that the parameters around the implementation of governance structures for AAL technology are influenced by different interests. This also concerns the question which healthcare market is preferred as a transmission belt for the dissemination of AAL as a part of the care program. Solutions are up-and-coming which, in the context of a regulated healthcare sector, bet on individual responsibility and the empowerment of patients. 'Government by Patient' or 'Government by Customer' turn out to be comfortable and profitable solutions within a techno scientific healthcare system. The idea of solidarity has proven to be a residual category.
4.
The private health care market
Against the background of demographic changes, the elderly care market is undoubtedly a growing one. The case of “ambient assisted living” demonstrates very well the difficulties and contradictory structures within the German health care system. Although there is up to now no common definition of AAL-products, “there is at least some kind of consensus that AAL-products are developed and designed to mainly meet the needs of elderly people. They use information and communication technologies, at least in an accompanying service. The product provider explicitly addresses older adults as target group. An AAL product can be everything starting from hardware components and ending in complex system solutions that integrate devices as well as services.” (Gaßner, Conrad 2010, 29). AAL is based on helping older people to maintain and improve their wellbeing, social integration, autonomy, safety, mobility and health within their familiar environment. There has been a lot of government investment in AAL on a national and European level during the past years. However, the many pilot projects have rarely reached a level of wide-spread implementation. Within the research activity „Technology and services in the wake of demographic change“ funded by the German Ministry of Education and Research (BMBF), 16 single research projects have been dealing with AAL-related products and services (www.dienstleistungundtechnik.de). One of the (so far still many) unanswered questions is how all these technology-based solutions will be financed in the end. There is an implicit expectation that AAL-solutions are cofinanced by the compulsory health as well as long-term care insurance. The rationale is that those technologies enable elder people to stay longer at home instead of having to move to a nursing home and that they guarantee a higher lever of quality of life, thus better health conditions. To put it in a nutshell, AAL is supported with the argument of saving costs for national health care systems. However, so far, there is no evidence of any of these assumptions. This lack of evidence makes co-financing through public sources or insurances basically impossible. The question therefore is how to use the private market effectively in order to introduce AAL-solutions to the target groups and to demonstrate that AAL can do what it is expected to do. Furthermore, the role of services as to market introduction has to be thoroughly analysed. Within the above mentioned research activity, a strong focus is explicitly put on services. It is assumed that AAL has a high potential for service innovation. The de8
velopment of innovative services and the development of new technologies could be cross-fertilizing. In order to clarify more specifically what solutions and products AAL refers to, some examples will be given. There are several product groups such as for instance “communication devices”, “safety and security” or “smart home”. But also telemonitoring or medical assistive technologies belong to AAL. That means that AAL products range from visual telephones, specified internet applications, ICT-based games, locking systems, alarm systems to fall alarms, mobility aids and automatic transmission of vital parameters to medical institutions. The challenge is to interlink all these products with services in order to render them useful and practicable for target groups. It has to be pointed out that the primary target group are indeed mostly elderly people – but family friend/friends as well as care service providers are likewise users of AAL-technologies. The problems of a too specific focus on the primary users and the neglect of the others will be expounded later. Back to our first essential question of how the private market can be used effectively, a number of positive and critical aspects will be outlined: The private health care market booms. For several years this market has been described as constantly growing and resistant to crisis (BMWi 2008; BDI 2009). This success will continue in future. In addition, especially high-tech products are said to be important drivers for the health care market of the future (Hilbert et al. 2010). The growing number of old and very old people and the consecutive growing need of elderly care on one hand as well as people’s raising awareness of prevention, health promotion and stress-reduction are good indicators for the rising demand for health and care-related products and services. For several years, ambient assisted living has been predicted a successful future. Many research projects ended with the conclusion that there was a high market potential for AAL – however no sustainable existing market yet (Fraunhofer IGD 2009). AAL-products have not yet shown the evidence which is necessary for public or institutional funding. A change of mind-set is necessary in order to allow other financing sources to develop. This means that the step towards the private market has to taken first even though it is intended to reach public co-financing later. AAL products do not automatically belong to the field of responsibility of health or care insurances. For instance, the product group “safety and security” has not much to do with the general tasks of such insurances. The question gets more complicated of course when we refer to AAL in terms of “systems” where technologies are interlinked throughout a whole house or flat with various functions. In any case the basis of further discussion is the “experiment” under real-life conditions. We assume that this is the only way to check whether research activities meet the actual needs of elderly people and their carers. The fact that so far only a limited number of examples of AAL-related business success exists also points to the fact that successful business models are missing (Braeseke et al. 2011). There are some good approaches identifying the most important actors for AAL-business models (Gersch et al. 2011), however, they are not enough to stimulate willingness to invest on a broad scale. The lack of cost-benefit evidence of AAL-solutions is certainly the most prominent reason why market launch has not been successful yet. However this lack of evidence seems to be the tip of the iceberg only. Many minor and major factors contribute to that misfortune. These factors will be discussed in the following. 9
AAL-products are not all new innovations. The term “ambient assisted living” which is rather new, hides the fact that indeed such products are already on the market. Taken for instance the target group of deaf and hard-of-hearing people, a lot of technology-based devices have already helped to improve those persons’ quality of life and social integration. The same applies to smart home technologies – including remotecontrolled electronic devices – have already found their way to the private market. Certainly the main consumer group of this ladder example is rather not old and in need of assistance. It is therefore firstly a matter of how things are labelled and secondly a matter of taking already existing successful business cases as an example for further development. Elderly people have to be addressed in a very specific way when advertising products (Meyer-Hentschel; Meyer-Hentschel 2010). They do not want to be stigmatized because of their age. Elderly people are often mistakenly thought of as ill, senile, fragile and slow. These attributes apply to some of old people however not to all having reached the age of 60. This age-group is as heterogeneous as all other age-groups as they differ by sex, income, education, culture and biography. The gender aspect plays a crucial, yet neglected role within AAL development. As mentioned above, remembering the definition cited in the beginning, (health) care providers are an important target group for AAL solutions. The care sector has always been a sector of female employment. Besides, among the target group of primary end-users the “feminization of age” indicates that starting from a certain age, there are more women than men due to the higher life expectancy. Additionally, it seems that anyway women are more likely to influence consuming habits within a household than are men. Clearly these facts have to be thought of when developing products and services as women have different preferences as men do and they select according to different criteria. The rising demand for housing suitable for elderly people draws attention to the housing industry. This industry is a very important partner for the realization of AAL solutions. In Germany, only one percent of the entire housing stock is barrier-free and adapted to the needs of the elderly respectively. There is no doubt that “the one percent share in Germany must be significantly raised in the medium term to cope with the challenges resulting from demographic change” (BFW 2007, 24). It is estimated that at least further 800.000 houses are to be adapted or newly built by 2020. Most people wish to stay at their own home as long as possible and they fear having to move to a nursing home. As an answer to those wishes many alternative forms of housing for elderly people have been evolving. One example is the sheltered housing where independency is guaranteed to a certain extent on one hand but all potentially necessary services can be used when needed. This concept reminds the idea of an “AAL system”: sheltered housing could be an ideal place to test the combination of new technologies and services. What might seem at first sight primarily technical questions and problems turns out to be a rather social and societal challenge. In fact, most of the technologies declared as innovative did or do exist already. They might be combined in special ways in order to create some AAL-solution. What is actually innovative about AAL is undoubtedly the social dimension. AAL requires a profound understanding of social systems especially those older people are part of. It is crucial to understand family structures, community structures and the organizational structures of service providers. Interestingly these structures are often taken-for-granted, seen in a superficial or clichéd way and are not questioned. Despite the growing awareness for “user integration”, the 10
focus on structural questions has been neglected. It is one thing to find out what endusers want or what they do not want (Bieber; Schwarz 2011). It is another question to understand how families nowadays work, who actually takes the decisions and how the support within families is organized. Besides, equally important is the question about organizational structures. Especially the strongly regulated (health) care sector features barriers to innovation. The pure existence of AAL-technologies is worthless if there are no structures supporting them. Despite all “service society” rationales and service science theories claiming the shift from product-dominant logic towards service-dominant logic, the necessary change has not yet fully taken place in practice as concerns AAL. Within the context of state funded AAL research service providers are so far the minority group compared to research institutions and technology developer. Consequently the focus is put on technology development rather than service development. In order to succeed in a market introduction however, it turns out that many AAL devices are better accepted if accompanying services are offered at the same time. It is therefore striking that especially (health) care service providers are underrepresented in AAL research projects – whereas they are the biggest group of service providers especially against the background of the strong association of AAL with elderly care. Likewise other service providers should not be neglected either. Housing companies or providers of technical solutions are some examples. Looking at all the above stated aspects, the last two aspects – knowledge about structures and integration of service providers – are the most important ones to be developed for a stimulation of service productivity on the basis of AAL solutions. For that purpose an infrastructure for AAL services is needed. Given the fact that many different players are potentially involved in AAL services, this infrastructure needs to be innovative. Especially the person related (health care) services could be benefiting from AAL. It could be a new business segment to be developed. In order to avoid potential prejudices or defence against the use technological devices, these service providers have to be integrated into planning and development of AAL solutions. It is necessary to understand the very specific characteristics of person related services which involve a high percentage of interaction with the clients and emotional labour respectively. AAL needs therefore to be accepted as a helping and assistive tool both for the service provider and the end-user rather than a threat to familiar working structures. As a result it can be concluded that the private health care market offers good conditions for ambient assisted living. Therefore marketing strategies have to be strengthened in the future. These marketing strategies have to take into consideration several sensitive aspects in order to be successful. Only when the private market is able to show evidence that AAL is cost-effective and accepted by users, social insurances will be willing to co-finance AAL products and services.
5.
Conclusion
The mentioned technological options are also subject to certain instrumental rationality: So, the financial burden of health insurances, such as chronic diseases, persistent lament of service providers and professional elites concerning inefficient and in11
effective structures in health care, the anticipated demographic crisis until 2020 (lack of doctors and professionals, aged population, increase of patients suffering from dementia), as well as the pressure on the care and nursing economy prove in itself a macro social trend. However, the political and economic healthcare system tries to counteract that trend through "health technologies, such as an electronic health insurance card, telemedical networks, and telemonitoring solutions for patients with chronic diseases." (Mathar 2010). This includes personal service offerings and cognitive- emotional application expertise of the potential patient or customer. AAL is a challenge for Schumpeterian entrepreneurs, who want to capture the benefits of the demographic change. Market solutions are still favoured. In order to transform the anticipated market potential of AAL-services and -technology into a marketable and customer- oriented product, the “making” of an AAL governance is necessary. But, as has been shown above, AAL governance is still in its beginning, and moreover under economical pressure to succeed. This raises the question, whether new governance structures are less characterized by quality improvement and the direct personal services or whether the customer itself will be made suitable for the organization and management of the new technologies (self-empowerment, personal responsibility argument).
6.
References
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Author(s): First name, surname, title(s) Becker, Jens, Dr. Goletz, Ulrike, MPH Institution Institut für Sozialforschung und Sozialwirtschaft (iso) Trillerweg 68 66118 Saarbrücken E-Mail:
[email protected] [email protected]
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