A home away from home

Germany’s elderly seek out more affordable care in Eastern Europe, forever leaving their homes behind — but at what price?

Two German seniors in a care facility in Swinemünde, Poland. Photo: Tanya Falenczyk

When Magdalena Lawyer packed her father’s bags for Poland, she was in good spirits. The facility her and her mother picked made a great impression on the website, and a friend of theirs had visited it before to make sure everything was in order. The Red Cross organised the transport to the Polish Świnoujście, 900km off the family’s home in Kaiserslautern, Germany.

“It’s all good here”, Christopher White repeatedly told his family over the phone ever since he arrived in Poland in October 2015. He never said anything else, his daughter recalls. White suffers from dementia, only allowing him a few clear moments every now and then, “but I think he also didn’t want us to worry, he knew how hard the separation was for my mother, and he didn’t want to make it harder”, says Lawyer. “So all he ever told us was that it’s all good. But nothing about it was good.”

The family’s path to Poland started out on TV. Lawyer saw a news report about a home on the Czech-Polish border, offering better care for a third of the price of a German facility, thus the report’s verdict. Her mother had just been in the hospital — after taking care of her husband for multiple years the task had overburdened her body and mind. Lawyer decided that something needed to change, and since they were unable to find affordable quality care anywhere close to home, Poland became an option.

A ticking time bomb?

This option seems to become a reality for a growing number of Germans in need of care. An increasing number, around 400.000 according to the federal bureau of statistics, is unable to afford a retirement home, having to apply for further financial support, the “help for care” (=Hilfe zur Pflege). But this extra funding is only provided, if all personal savings run out and there is no next of kin to cover the costs either.

Which means, as long as there is still family and any form of financial heritage to leave them, further support from the state is not an option. For many elderly, having nothing to leave behind and burdening their dependents is a worst-case scenario.

In the future, even more Germans will be faced with this scenario, with an ageing and shrinking population and the growing costs of care facilities due to the chronic care crisis. For years, Germany has dealt with the lack of workforce in the care sector, trying to fill the gaps with a lot of migrant workers while keeping the costs as low as possible. But even this system doesn’t seem to be working anymore, costs keep rising and with more and more people in need of care, the staff-patient ratio is getting worse.

So, if the affordable care can’t come to Germany, then Germany might need to come to the affordable care. According to numbers published by the German health ministry, out of 2,5 Mio. Germans receiving care allowance, only 5000 live abroad. So this is by far not a mainstream path yet, but a growing one.

Even 10 years ago, Finance&Development, a magazine of the International Monetary Fund (IMF), asked the question: “can Europe afford to grow old?”, warning about the major economic impact that ageing will have on the EU in the future. It looks like they were right, but EU legislation has not yet picked up on it. Care is a sector that is mainly left for the member states to decide upon.

In their World Population Ageing report, the United Nations estimate: “Between 2015 and 2030, the number of people in the world aged 60 years or over is projected to grow by 56 per cent, from 901 million to 1.4 billion, and by 2050, the global population of older persons is projected to more than double its size in 2015, reaching nearly 2.1 billion. “

Therefor, Germany might be a warning sign of a challenge the rest of the EU will face eventually as well. Right now, it has one of the fastest ageing populations, and a few marks have already been left. In Germany, the pensionable age of 67 is the highest in the EU, while the neighbours in France are throwing in the towel seven years earlier. A new study of the Institute of German Economy (IW) predicted that there might be the need for raising that number even more — to 73 — in the next decades in order to keep the pension level and contribution rates stable.

In a country like Germany, that is usually known for economic stability and its well-functioning social welfare system by the outside world, those predictions are even more worrying. The European Commission’s report on long-term care expects the state’s expenditure for care to double by 2060, taking up 3,3 percent of the GDP — an increase that won’t go unnoticed. In fact, just looking at the changes in the EU’s population pyramid gives quite a good idea of upcoming challenges.

Source: European Commission, Long-term care: need, use and expenditure in the EU-27

The German Focus magazine even went so far as to call the situation a “ticking time bomb”.

This mentality doesn’t seem to have reached politics just yet. The government, a coalition between the conservative Christian Democratic Union (CDU/CSU) and the Social Democratic Party (SPD), only seems to agree to disagree. The CDU wants people to work longer and invest in private pensions, which sparks outrage among the SPD, as the newspaper ZEIT reports. A group of leftist SPD members of parliament wants to make pensions the central topic for the upcoming Bundestag elections in 2017 — in a strategic paper, they demand a raise of taxes for the wealthy in order to achieve a stabilized retirement age and higher pensions in general.

While the government is still looking for common thread, people will have to find their own ways of coping, and for some, this way might lead to Poland, as it did for Magdalena Lawyer. Her decision to entrust her father to the care of house Jantar in Świnoujście seemed like the only viable choice, she recalls. So were has that decision left her family?

Empty promises

Świnoujście, or Swinemünde, is a seaside resort located on the island Usedom in the north-western corner of Poland, right at the border to Germany. Before the reallocation of land following World War II it was part of Germany, hence the German name.

Crossing the German-Polish border, the first thing Swinemünde greets you with is a so-called black market. On display are tourist highlights like garden gnomes, lighthouses and beach gear, and the goods that Germans always liked to come to Poland for — tobacco and alcohol, for a fraction of what they would cost a few metres down the road in Germany.

The “black market” in Swinemünde, where Germans come to bulk-buy cheaper Polish goods. Photo: Tanya Falenczyk

Not part of the black market, but only a bit further down the road is the Jantar residence. Instead of cheap goods, cheap services are on offer. A spot in a German facility is usually over 3000€ a month, even with the highest possible care allowance and an average pension, this would leave any family with a bill over 1000€ a month. In Jantar, a single room is 1300€, and even though the care allowance abroad is limited to a maximum of 700€, for most people this and their pension covers all costs. Lawyer did the math, but the house in Poland also promised professional, personalized care and the restorative atmosphere of a seaside resort.

Christopher White spent almost six months in Swinemünde until his family was able to visit. Lawyer and her mother drove the 900km in March 2016 in order to spend a few days in the Jantar home, since they offer rooms to visiting families as well. At first glance, they thought it looked alright, the staff was friendly and they liked the town, Lawyer recalls. “You only see beyond that when you actually spend some time there, so it wasn’t until after the first night that we started noticing all the problems.”

The Jantar care facility is located in a stately building in the centre of Swinemünde. Photo: Tanya Falenczyk

Although Lawyer mentions the low hygienic standards they started noticing, what threw her off most was the state of the provided care. “We complained about the hygiene to the manager on the first day, but what mattered most was that my father was looked after alright.” She says the main problem was the lack of staff, and the conditions the staff had to work under. Often, one or two caretakers were left alone with all 45 patients of the facility, with no supervision or assistance.

What shocked Lawyer most was that almost none of the staff was trained for the job. “They told me themselves that they used to work here as cleaners, and when the facility lost more and more caretakers, they filled in”, says Lawyer. Now they work 12 hours a day without a break because there is nobody to take over their shift. “Can you imagine? They are downright exploited.” And all of that for 400€ a month, as some of the staff told Lawyer. “But they don’t want to speak about it publicly, they are all young women with children who are happy they have a job at all.”

The manager was a rare sight at Jantar, Lawyer says, so when they desperately needed a person of contact, no one was responsible.

“There were a lot of empty promises”, says Lawyer, from a regular medical pedicure for the diabetic White that turned out to be irregular nail-cutting by the cleaners, to a doctor that didn’t even read his patient record — because it was only provided in German and English.

Like the majority of rest of the staff, the doctor only speaks Polish. “Even though my mother speaks Polish, the language never stuck with my father. The house told us beforehand that there were a lot of German speakers, but it turned out they only spoke Polish to my father. The poor guy, didn’t understand a word while he was there.”

Anna Lyson, who works at the reception desk at Jantar, says that there is one nurse who speaks German, and she herself speaks a little bit, but is more comfortable in English. “We want to have more German speakers here, but it’s not easy. They all go to Germany to work.” But how do the residents communicate with the staff? “It depends. They don’t speak too much, you know, there’s a lot of dementia and Alzheimer’s. Some learn a bit of Polish.”

Yet, the facility is directly targeted at German patients, they even work with someone who acts as a broker — finding new potential residents in Germany in return for provision. It is a practice that becomes more common now that Eastern European countries have discovered the potential of the market — Jantar for example charges its five German patients up to twice as much as the Polish.

“Yes, Germans pay more than the Polish people here, but they still pay less than in Germany”, Zofia Wielebinska, manager of the Jantar home, explains. Zaneta Krüger, who works as a broker for Jantar, sees the reason for the higher price in additional expenses that come with German patients. “Of course they are more of a challenge, the staff needs to work on their German, and the bureaucracy with Germany is a bit more complicated as well”, she explains.

So what are those additional expenses exactly, and what adjustments have been made for the first German patients two years ago? “We didn’t change anything specifically”, says manager Wielebinska, “for us, it doesn’t matter if it’s a Polish or a German, we are neighbours.” They were the ones who were contacted by the German broker company Carefinder and Zaneta Krüger, explains Wielebinska. “We didn’t ask, but if they call us and say that people are interested, why should we not take them in?”

Zaneta Krüger explains that her job is not only brokering, but also counselling. “I take care of the patients after I found a spot as well, especially because barely anyone speaks German in Jantar. I help as much as I can.” She says she has little talks with everyone anytime she visits, and they seem happy enough. “Most of them have dementia and for them, it doesn’t matter where they are. Language doesn’t play a big role either, it’s just important that the care is nice and everyone’s friendly.” Krüger doesn’t recall any negative experiences or complaints.

Bernhard Marusiak is the only German resident at Jantar who doesn’t have dementia. He has lived there since 2014, his son found the facility through Carefinder. “I only know content people here.” For him, what he likes about Jantar it is the close proximity to the sea and the accessibility and independence, despite his wheelchair. “I wouldn’t be allowed to just come and go when I want to in other facilities. I still have my independence, and here they let me keep it”, says Marusiak. Does he feel at home here? “I don’t see much besides the house and the beach. I barely notice I’m in Poland.”

But what about residents who need care and comfort instead of independence? For Magdalena Lawyer, her experiences have made the case clear: “Those people running those homes, they exploit the distress and misery of others to enrich themselves.”

But her family wasn’t ready yet to give up on the hope of good affordable care abroad. Lawyer was searching for another facility that would take her father in and get him out of Swinemünde as soon as possible, but she was worried that conditions could be even worse in another home. Then she remembered what had first planted the idea of care abroad in her mind — the positive TV report about a house in Zabelkow, at the Czech-Polish border. She called the facility immediately to secure a spot for her father, and she was in luck.

A different take

“If a house is on TV, it is checked upon, and they really value their reputation”, says Lawyer, “and that’s why I know my father is in good hands now.” The manager of the new home, Fabrice Gerdes, helped her with the transition, organising the transport from Swinemünde all the way down to the southern Zabelkow. He says that what Lawyer and her family went through is not an isolated case. “We’ve had a lot of those in the past twelve months, at least nine or ten new residents came from other Polish houses where they were ripped off or treated poorly. We’ve heard the wildest stories from those places.”

The “Seniorenresidenz an der Oder” in Zabelkow currently has 75 residents — all German. Zabelkow is part of Upper-Silesian, just like Swinemünde it is former German territory that got reallocated after World War II. Gerdes makes sure the staff speaks German as well, he says they are currently at around 80%, but everyone is taking obligatory lessons.

The location does not seem ideal at first glance, since it is not directly at the German border like many other houses. “You can’t find a proper German-speaking facility that close to the border”, Gerdes explains, “why should you work in Poland as a caretaker for 500€ if you can just go 30km further and get paid the four-fold amount in Germany? Especially when you’re German-speaking, all the German homes take you with the greatest pleasure.”

Originally, Gerdes, whose family has a background in real estate, wanted to open a high quality senior home in Germany. “After a while we realized that it just wouldn’t work with the standards we had in mind. We looked at a few public records of other homes in Germany, they barely make ends meet and it just doesn’t pay off.” But he didn’t want to give up on affordable quality care, so he moved his plans to Poland. “There are two reasons why people come to us, it is more affordable, yes, but the care is also better than in most German facilities”, Gerdes explains.

Another thing he is proud of is the employment situation. The facility is in the top league when it comes to wages, Gerdes says, from what they could gather, they are approximately 20% above average. Combined with a patient to caregiver ratio of 4:1, so the number of patients one caregiver is responsible for, no overtime and Christmas bonuses, all very uncommon in Poland, Gerdes can hand-pick his staff from a crowd. “We can have high demands, everyone is educated and they value our working conditions.”

The residence has revived a formerly weak economic region. “We are the biggest employer of the region right now, with 70 employees, a lot of them full-time, we’ve made quite the difference.” Especially for women, there were no other opportunities around, so Gerdes wants to make sure their desperation is not exploited. “The way I see it, what we do is to export care services to Germany, bringing German money in the region that wouldn’t have been there otherwise.”

Gerdes doesn’t agree with the sentiment that the environment and language don’t play a role for demented residents. “Whoever says that should explain to me where they learned how to take care of people.” According to him, a sense of being home and an environment that they can easily grow familiar with is very important and can make a big difference. “We have the advantage of being in this historically German region, and we work a lot with the locals who have German origins and carry a lot of the traditions and culture with them. Of course it helps that everyone in our house speaks German as well.” There’s also an emphasis on German meals and German products — from the kitchen itself right down to the last detail, the porcelain, everything is made in Germany, as the documentary “Pflege in Polen” by the German public broadcaster ARD shows.

Sabine Jansen, head of Germany’s Alzheimer Society, has a similar take, as she tells the Guardian: “Surroundings and language are often of paramount importance to those with dementia looking to cling to their identity”, she explains, “they’re very much living in an old world consisting of earlier memories, so they need similarities to orientate themselves.”

With this different take on things, Gerdes’ facility is very popular. They are currently full and started their waiting list, but Gerdes’ wouldn’t call it a trend yet. “We had a lot of media coverage, so people get interested. But it’s not a flood of Germans sweeping into the East to leave their relatives here. Yet.”

Care abroad — a sector with a future?

So what are the chances of it actually becoming a trend? The opinion research institute EMNID tried to get some numbers. According to their survey “Care abroad — ageing in exile?”, every fourth person in Germany could see themselves in a facility abroad. Especially younger participants are open to the idea, possibly because it is further away for them. Someone wrote that “that is something I won’t have to deal with anytime soon, I hope”, as EMNID reports.

When it comes to putting dependents in homes abroad, they are more reluctant. Only 17% would be willing to take that step. The main reason for a rejection of the idea is that people want to keep their family close, but logistic and moral aspects also play a role.

Reasons in order of frequency: 6: Keeping dependents close to home, 5: language barriers, 4: culture shock for the elderly, 3: no control about the day-to-day care, 2: medical standards don’t comply with Germany, 1: moral reasons like shame. Source: EMNID

The story of Magdalena Lawyer and her father clearly showed that those are all valid arguments — but also that they heavily depend on the respective facility. This is linked to the issue of quality control — while German facilities have minimum standards that the state can check upon, this sort of monitoring is not possible for facilities abroad, yet.

According to the newspaper Welt, some German health insurances have care abroad on their monitors already. Both AOK and Barmer GEK, two of the biggest insurers, are open to explore the idea of contracts with care facilities abroad, or at least discuss it, as they told Welt. A contract like this would mean even more financial support for patients that comes in hand with quality control, as Ingrid Drolshagen from Barmer GEK explains to Welt. She also adds that right now, EU-legislation as well as German social legislation both currently permit direct cross-border contracts.

Member of parliament and care expert Willi Zylajew thinks that this needs to be rethought. “If we look at the impending state of emergency that comes with overageing, it is time to at least think about an alternative legislation”, he tells Welt. “After all, those types of contracts with Eastern Europe already exist in the rehab sector.”

But the government stresses that no legislation changes are planned for the near future. The Guardian suggests that this shying away from dealing with the subject might be linked to fears of a voter backlash, if legislation allowed state insurers to rather finance work abroad than in the domestic industry.

A new era for the elderly

Katrin Markus, board member of the Association for Senior Organisation (BAGSO), thinks the number of people seeking care abroad is still just too minor for a political reaction. “If there was a drift off to the East all of a sudden and seniors would stream to Eastern Europe, things would change. But right now, there is no pressure to act.” She personally thinks that the issue is also between the rich and the poor. “The rich will be able to afford quality care in Germany in the future as well, the only people who have to turn east are on a lower-income. This can’t end in social dumping, where quality care only comes with a high price tag.”

Markus hopes that in the future, the sector of more affordable care in Germany will get broader again. “If there is a market for it, someone will be tending to it soon. Prices for care in Poland will rise eventually as well, the same thing happened with production. Everything used to be produced over there because the wages were much lower, then that went elsewhere.”

For her, it is important to encourage the elderly to stand up for themselves. In order for positive change to happen, demands need to be made. “There is a new generation of seniors coming, the ones who grew up in the famous time of ’68”, Markus is referring to the worldwide wave of social protests in 1968, “I am one of those as well, we have been politically active all our lives and that won’t stop with age.” She is positive that this will lead to a higher visibility of elderly’s issues in politics.

Stepping in before it’s too late — supporting care at home

For many, the step into a retirement home might be avoidable, if there is enough support, thinks Frank Schumann. He is the project manager of the Department for Informal Caregivers (=Fachstelle für pflegende Angehörige) — people who take care of their dependents at home.

This is a big sector. According to Schumann, out of all 2.6 million Germans in need of care, about two thirds, so 1.8 million are looked after at home. Out of those, 1.3 million are looked after exclusively by their dependents, so without the involvement of care services, that adds up to 50% of all people in need of care.

In many cases, the people who are alone in this task burn out the quickest and are unable to hold their system up for a long period of time. If the support system was stronger and the caring dependents could be at least partly disburdened, the move to a professional care facility could be avoided or at least adjourned, says Schumann. “The thought behind this is: the bigger the support system, the more people will be able to take care of their relatives, friends or neighbours in need.”

Predictions are that by 2050, twice as many people will be in need of care, says Schumann. “We already have a state of emergency in professional care, it’s hard to imagine this will ease up in the future, so it is in our interest to widen the percentage of private care.”

Taking care of a dependent is always linked to a constraint of the own independence and autonomy. “This can only be compensated by a societal emphasis of the importance of this task. Whoever is faced with it needs to be able to know that they are doing something important, and that they are seen doing it. A culture of appreciation needs to be established”, explains Schumann.

He wants to move those private caregivers out of the dark and into the light, this should also encourage them to accept help and support — bringing the gravity of a task to public attention helps fighting the isolation that comes with it. Balancing outlets are extremely important, so people need to be able to talk to others about the challenges, and also get the feeling that they are being heard. “Otherwise the point will come where everyone says: I can’t do this anymore. This is when the admission into a care facility becomes the emergency button. A button that maybe wouldn’t have been pressed if the support was stronger.”

For Schumann, there are three basic measures that can help with establishing this appreciation culture: publicity, a proactive public approach towards the private caregivers, and a reliable public support system.

Publicity, either through news media or in the entertainment culture, will bring the issue more attention and if it becomes more present in society, people will be more aware of it in their own environment as well. A proactive approach aims at identifying the points of contact with private caregivers, for example in hospitals, pharmacies or through nursing services, and make them aware of the support options they have through those points of contact. Caring dependents should know that they are not only the appendage to the people in need of care, but that their individual challenges deserve support as well. Finally, the support that is offered needs to be embedded in a reliable system to not cause the dependents more frustration and bureaucracy than they are already facing.

“Taking care of someone in need shouldn’t be done out of moral obligation — this is what leads to a burn out, but it should come from a place where you can say: ‘I am doing this because I want to, because it is a good thing and because I can be proud of it.’ We need a change of paradigm”, concludes Schumann.

This private care doesn’t necessarily have to come from the next of kin — as the project “Living for Help” (=Wohnen für Hilfe) proves. The concept is simple: a place to live in return for help. It is currently implemented in over 30 German university cities and maintains around 250 partnerships, so over 250 living communities.

“When he rang at my door, all I could see from upstairs was his hat. My husband used to wear a hat just like that, and I didn’t know anything about this person in front of my door, I didn’t even know his name or where he was from yet, but I said to myself: That’s him, that’s the one.” This is not the beginning of a romantic novel, but Adele Reese’s first meeting with her new housemate.

Gennadiy Garmash, 30 years old and originally from Kasachstan, moved to Kiel to study. Adele Reese, 75 years old, was looking for someone to share the big house with her after her husband died. “It was a match. And he was wearing the right hat at the right time”, says Reese and laughs. “I still have that hat downstairs in my room, on display”, adds Garmash.

The rules for the programme state that one square meter of living space equals one hour of work per month. For Garmash, that makes it 30. His task is to take the dog for a walk everyday. On top of that, they struck a deal where Reese cooks for the both of them while Garmash helps with other duties like garden work or the groceries, “anything that comes up, when I need help, he’s there”, says Reese. For Garmash, practicing German everyday is just an added bonus.

Gennadiy Garmash and Adele Reese in their shared kitchen. Photo: Gennadiy Garmash

What are the problems that come with a living arrangement like this? “The only problem we ever had was when Ms. Reese took me to a classical concert. That was not my world, I almost fell asleep”, says Garmash and laughs. “So I told her: I’ll take you there and pick you up anytime, but I won’t come with you ever again.”

For both of them, communication is key. Garmash learned that from seminars he organizes at his university. “Everytime there is a problem, it turns out they haven’t talked about it properly beforehand. So me and Ms. Reese, we talk, we talk about everything and there are no problems.”

Reese can’t say where she would be without this arrangement. “It’s so familiar, it gives me comfort and ease. It just rolls, and whenever he’s gone, I get a bit nervous, I definitely miss him very quickly.” Before Garmash moved in with her, she thought about selling the house to move into an assisted living facility. “But then I thought, no, I can’t do this”, Reese recalls, “We’ve always lived in this house, and I wasn’t ready to loose my independence all of a sudden. And then all those rollators… No, that wouldn’t be for me.”

With all those options out there, some bigger, some that have yet to grow, it does seem unlikely that the escape to the East will be the only option left in the future. Rather, if done right, it might become one of the paths to choose from — because if all those viewpoints show one thing, it is that there is not one solution out there for everyone, and diversity is key. It is up to Germany to pave the right ways now.