In recent years, the ageing trend has become prominent in China. In 2018, it was recorded that there were 249 million people more than 60 years old and 167 million people more than 65 years old, accounting for 17.90% and 11.90% of the total population of the country, respectively. The proportion of the population aged over 65 years old has increased year by year, and the old-age dependency ratio has also increased year by year [1]. The number of people aged more than 60 years old is expected to increase to about 255 million by 2020, accounting for 17.8% of the total population; and the old-age dependency ratio is expected to increase to around 28%; the number of elderly people of venerable age is expected to reach up to 29 million, while the elderly living alone and the empty-nested elderly are expected to reach up to 118 million [2], according to China’s ‘Thirteenth Five-Year Plan’ for the Planning of Developing the Aging Industry and Constructing the Endowment System. As the ageing trend accelerates, the number of elderly people and the disabled and semi-disabled elderly will increase in China. There were more than 40 million disabled and semi-disabled elderly people in China at the end of 2016 and 7% are cared for long term by their family. Those who need direct care also desperately require the involvement of medical services [3-4]. Compared with developed countries in Europe and the United States, China shows a unique ageing characteristic of getting old before getting rich, at a larger scale, at a faster speed and showing a heavier dependency burden etc. What is more, China’s pension security system needs to be improved and Chinese society is facing tremendous pressure from the challenge of an ever-increasing ageing trend.
With the basic national family planning policy and economic and social transformation in play, the family supporting function has been weakening, while elderly people’s demands for professional nursing institutions and community services have been steadily on the increase. In particular, people aged over 80 years old with a high morbidity rate of chronic disease desperately need systematic, comprehensive, convenient and low-cost medical services. Moreover, both medical and elderly care, as a matter of record, are indispensable for the disabled and semi-disabled elderly [5]. The elderly’s medical needs cannot currently be satisfied either in most of the old-age nursing institutions that provide low-level medical services with only a few qualified nursing staff and limited beds or in medical institutions which cannot provide long-term hospitalisation services for the elderly due to their limited resources. Besides, care resources at the community level cannot fully cover the medical and nursing demands of the disabled and non-disabled elderly suffering from diseases.
The ageing of the population has exacerbated the shortage of resources for medical services and elderly nursing, which has put forward a request for improving the allocation and utilisation of social resources. The traditional elderly nursing model cannot satisfy the all-round care needs of the elderly. It is therefore imperative to implement a new model of health care for the elderly. Nevertheless, medical treatment and eldercare resources are inadequately supplied and mutually independent, which, therefore, cannot meet the needs among the elderly nowadays. Therefore, it is of great necessity to provide them with a ‘medical–nursing combination’ service that organically combines medical and elderly care.
Since there is no standard definition of a ‘medical–nursing combination’ in China, it is defined differently by a wide range of scholars. Guo et al. believe that the ‘medical–nursing combination’, denotes a process that gradually forms a cooperative service model integrating medical treatment, recovery and nursing from service providers (including hospitals, elderly nursing institutions and communities) providing a medical and nursing service conforming to elderly nursing to the elderly in demand according to different health needs at different stages of diseases [6]. Liu et al. defined the combination of medical care and nursing as satisfying the needs of health problems at different levels for the elderly at different stages in the care process, through integrating medical resources and pension resources to optimise the allocation of medical and nursing resources [7]. Liu et al. consider that elderly people can achieve the purpose of obtaining medical treatment while suffering from diseases, and enjoying care while not suffering from diseases under the new elderly nursing model combining medical and elderly care [8]. To Huang et al., the medical–nursing combination possesses the same concept as ‘long-nursing’ overseas, which focuses on meeting the basic living needs of the elderly, as well as physical and psychological care; moreover, medical treatment should be highlighted, while the enhancement of daily living skills, the adaptation of social environment and the realisation of self-worth are also important [9].
To solve the medical problem of the ageing population, the concept of a medical–nursing combination was first proposed in ‘Several Opinions on Accelerating the Development of the Elderly Nursing Service Industry’ issued by the State Council in September 2013. It pointed out the need to provide multi-level elderly nursing services, actively respond to the ageing population and accelerates the development of the elderly nursing service industry through actively driving the combination of medical and elderly care services. ‘Guiding Opinions on Promoting the Combination of Medical Treatment and Elderly nursing Services’ issued by the State Council in November 2015 indicated two tasks for promoting the combination, firstly, encouraging elderly nursing institutions to conduct various forms of agreement and cooperation with other medical and health institutions and establish a sound cooperation mechanism; secondly, promoting the extension of medical and health services to communities and families. The ‘Thirteenth Five-Year Plan’ for the Planning of Developing the Aging Industry and Constructing the Endowment System issued by the State Council in March 2017, focused on assigning nine tasks including the active promotion of the medical–nursing combination service and improving the allocation and utilisation of social resources. As of 2017, China has set up 90 national-level pilot cities for combining medical and elderly care [11].
On that basis, the ‘medical and elderly care combination’ is a new elderly nursing model that provides the elderly with services such as uninterrupted daily care, mental consolation, disease diagnosis and treatment, health guidance, recovery from serious illnesses and hospice care through effectively integrating medical and elderly care resources to satisfy the varied health care needs of the elderly at multiple levels.
Currently, four medical and elderly care models can be found in China [12]. The first model is ‘nursing in hospital’, that is, a geriatric department is set in some large hospital with conditions to provide medical treatment, nursing, care for the elderly, rehabilitation, health education, hospice care and similar services; or some low-level primary hospitals with spare resources are transformed into nursing institutions for medical rehabilitation, convalescence and elderly nursing, to achieve the goal of integrating medical and elderly care. The second model is ‘constructing a hospital in nursing institutions’, and providing professional medical and nursing teams according to the standards of national hospitals in large-scale elderly nursing institutions or welfare homes. Meanwhile, basic medical departments such as a comprehensive medical-surgical department, rehabilitation department and pharmacy are set up to form a new elderly nursing institution, integrating elderly nursing with healthcare functions. The third model is the union of medical and elderly care, namely, a cooperation mechanism is established between medical institutions and elderly nursing institutions. In this way, medical institutions provide medical care training to nursing staff in elderly nursing institutions, and regularly conduct basic diagnosis and treatment services such as detection of common diseases, the management of chronic and geriatric diseases, as well as health education. Meanwhile, the hospital also offers a green channel to provide a timely medical referral service for the elderly in need, and conduct subsequent recovery treatment in the eldercare institutions after the individual’s condition is controlled. By doing so, a two-way continuous care model is generated. The fourth model is ‘home nursing’, which is, in essence, a family doctor model. A service team provides outpatient services and life nursing services for the elderly. It is a model that is primarily designed for the elderly in good health, allowing them to enjoy their old age in peace with familiar surroundings.
As developed western countries entered the ageing society paradigm earlier than China, they have developed a new elderly nursing model called ‘long-term nursing’ that is consistent with the medical–nursing model in concept, connotation, service purpose, content and objects. The United Kingdom, the United States and Japan are the most typical countries that have developed their unique representative research results concerning elderly nursing.
The elderly nursing model in the United Kingdom is dominated by community and home care. The main service providers are composed of managers, professional staff and caregivers, who provide four major services including life care, material support, psychological support and overall care. Specifically, life care is mainly to provide home-care services and short-term care services for the self-care or semi-self-care elderly; material support includes the government upgrading the infrastructure of the elderly’s living place and providing tax subsidies or preferences to taxpayers more than 65 years old; psychological support is where service staff visit the elderly for health inspection, publicising health care knowledge, making rehabilitation and treatment suggestions and providing psychological counselling; overall care is delivered in community activity centres funded by the government or the society and is designed to inject fun into elderly people’s lives, and some low-intensity jobs are provided to increase the elderly’s income and maintain their mental health [13].
The elderly nursing model combining medical and elderly care in the US is dominated by a programme of all-inclusive care for the elderly (PACE) that is set up for the disabled, the semi-disabled and over-55-year-old low-income groups requiring long-term medical care. Covering medical services, rehabilitation services and social support services, the purpose of PACE is to assist the elderly and the debilitated to live as long as possible in the community or family, improving the living quality of the elderly with weak self-care ability and maximally protecting the dignity of the elderly [14]. The elderly nursing combining medical and elderly care model in Japan is dominated by the following models. First, the daycare centre; this model mainly provides rehabilitation and life care services for the elderly of more than 65 years old who are unattended at home in the daytime and need rehabilitation training. Second, the nursing centre; this is supported by a service consisting of nurses, caregivers and welfare workers to provide daily services for the disabled elderly living in the centre. Third, the elderly welfare centre is targeted at the elderly in the community; service staff, mainly health care therapists, provide services including health examination, health education, health care services and family guidance. Fourth is the apartment for the elderly, which is mainly designed for the healthy elderly who can take care of themselves. It provides basic medical services and daily care services. An all-round legal system is a major reason why the elderly nursing combining medical and elderly care has been well developed in Japan [15].
Research on the ‘combination of medical and elderly care’ have been identified abroad with proven systems moving from policies to actual services, which can provide a reference and basis for researching and implementing the combination of medical and elderly care in China. Researching the ‘combination of medical and elderly care’ service model is still in its initial stage of development in China. Related research studies in the domestic literature focus on introducing and analysing foreign elder care cases based on the ‘combination of medical and elderly care’, which propose the status quo of the development of the ‘combination of medical and elderly care’ model before making suggestions or conducting a case study in the pilot region of combining medical and elderly care in China. Nevertheless, few studies cover the service requirement and influencing. Instead, most of the research discusses elderly people’s basic situation, health status, social support and income status, etc. Generally speaking, the better the health condition of the elderly, the higher the self-care level, the lower the income and the lower the social support, the less demand for a service combining medical and elderly care [12, 16]. Li et al. found that the number of children, health status, children’s support and willingness to pay have significant impacts on the demand for services combining medical and elderly care after investigating more than 420 elderly people aged more than 60 years in four major urban areas of Chongqing [16]. Hu et al. discovered that degree of education, ideal method of elderly nursing and willingness to pay are significant factors affecting the elderly’s demand for the service combining medical and elderly care in urban areas after surveying the elderly in Yinchuang [17]. According to Zhao et al.’s research, age, degree of education, number of children and occupation type before retirement are main factors affecting the elderly’s demand for the new service [18]. Through investigation, Wang et al. believe that the elderly in Changchun have a high willingness to participate in a combined service. Gender, age, education and occupation type are major factors affecting their choices [19].
The basis of medical insurance in China is comprised of a basic medical insurance system for urban workers, a basic medical insurance system for urban residents and a new rural cooperative medical insurance [20, 21]. A unified basic medical insurance system for urban and rural residents should be gradually established nationwide according to the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents issued by the State Council in 2016. The number of people insured with basic medical insurance in China has exceeded 1.35 billion with a participation rate of over 95% by the end of 2017, basically realising a full coverage from ‘insurance for few’ to ‘insurance for all’ [22].
The basic medical insurance system for urban employees is raised jointly by social medical unified planning and individual account, forming a social medical unified planning fund and individual medical account fund. The individual account is not set in the basic medical insurance system for urban and rural residents. In other words, only the social medical unified planning fund is established to raise funds through quota. The premiums consist of individual residents’ contributions and financial subsidies.
Most scholars in our country believe that the demand for the service of combining medical and elderly care is affected by the design and implementation of medical insurance systems and the elderly’s capacity to pay under the current medical insurance system. In terms of system design, there is a lack of long-term care insurance specifically for elderly nursing, and the elderly nursing service combining medical and elderly care is not involved in the designated medical insurance units. Medical insurance in China focuses on economic compensation for the loss caused by a given disease and lacks compensation for preventive health care, rehabilitation, long-term care and similar services needed by the elderly, whereas basic pensions are mainly used for daily care of the elderly [23]. On the aspect of system implementation, the reimbursement practice of medical insurance in China is characterised by ‘designated medical care with three medical directories’. Since setting up medical institutions in nursing institutions is not included in the designated medical organisation, additional medical services in the nursing institution cannot be paid through medical insurance. In this case, the elderly living in the nursing institution have to visit hospitals for treatment, reducing access to medical services [24]. Besides, a plurality of issues such as the admission of nursing institutions, the verification of medical qualifications, medical insurance designated hospitals and review and distribution of charges can be found in the nursing institution involved in combining medical and elderly care [25]. Regarding the elderly’s capacity to pay, the medical insurance only covers medical expenses and examination costs incurred during the medical process. With the lack of a long-term care insurance system, rehabilitation medical programmes, life care programmes and auxiliary equipment programmes are fully incurred by the elderly. However, elderly patients who are economically disadvantaged, especially the disabled and the semi-disabled, the elderly suffering from diseases and more than 80 years old have a limited capacity to pay for the long-term care cost [26].
The elderly are the main service object of the ‘medical–nursing combination’ model, whose demand willingness plays a decisive role in the development of the ‘combination of medical and elderly care. Therefore, it is essential to proceed from the elderly’s demand for specific services before conducting an in-depth exploration of the new model.
As of the end of 2018, the number of elderly people aged 65 years old or above in Lanzhou has reached 498,800, accounting for 16.50% of the total population [27]. Moreover, the proportion of the population aged 65 years old or above has been higher than the average level of the whole country and Gansu during the same period (See Fig. 1. Data source, national data from 2010 to 2018 were from the China Statistical Yearbook [27] and data of Gansu from 2010 to 2018 were from the Gansu Statistical Yearbook [28], data of Lanzhou from 2010 to 2018 were obtained from the Lanzhou Yearbook [29]). As can also be seen from Fig. 1, the degree of the ageing phenomenon has become more serious in Lanzhou from 2010 to 2018, in which the ageing rate was 8.20% in 2010 and jumped to 16.50% in 2018, indicating that the growth of the ageing population has been accelerating by 8.3%. By comparison, the national ageing rate was 11.9% in 2018, which clearly shows that the ageing rate in Lanzhou had accelerated. What is worse, the ageing problem in Lanzhou would be crucial, as the degree of ageing population could become serious over time. The accelerating population ageing in Lanzhou has put tremendous pressure on elderly nursing. Furthermore, elderly nursing involves a variety of requirements such as medical rehabilitation and spiritual happiness with the social progress, rather than merely basic daily care. It can be seen that a tremendous requirement has been proposed to develop multi-integrated nursing services combining nursing and medical treatment based on the huge elderly group and the serious ageing status quo in Lanzhou.
Incomplete statistics show that there are 27 nursing institutions in Lanzhou as of now, including seven institutions run publicly and 16 run privately, and four institutions combining medical and elderly care, providing a total of 6,107 beds. Specifically, 18 hospitals have set up geriatric services and geriatric beds, providing a total of 500 beds, accounting for 69% of the total number of hospitals; 26 hospitals above the county level have set up green medical treatment channels for the elderly; and 19 nursing institutions can provide medical services, accounting for 70.4% of the total nursing institutions; the contracted service rate of the home-based elderly aged more than 65 years old in Lanzhou reached 73% [30-31]. As a national pilot city for combining medical and elderly care, Lanzhou has made some progress in the process of developing a service combining medical and elderly care. However, the follow-up work remains cumbersome since the policy obstacles in the combination of medical and elderly care should be overcome. What is more, concrete service content and links should be improved, such as constrained nursing conditions in medical institutions, missing service function of nursing institutions, high cost, constrained reimbursement of medical expenses, pessimistic cognitive status of the concept of combination of medical and elderly care and the institution management system requiring enhancement [31].
Scholars tend to be more willing to concentrate on the process and obstacles of combining medical and elderly care at the macro level for such a new type of elderly nursing. However, few studies analysing the elderly’s needs for a combined medical and elderly care service can be found.
The social and economic foundation of the undeveloped region of western China is relatively weak with a low level of social security and welfare. In particular, the elderly long-term care system in remote rural areas is in its infancy. Lack of a well-defined medical– nursing mechanism seriously affects the well-being and happiness of residents in the area. As the driving strategy of combining medical and elderly care has been vigorously promoted at the national level, theoretical introduction and countermeasure are essential to regional strategic layout. A questionnaire survey concerning the need for an elderly nursing service combining medical and elderly care was conducted on residents in Lanzhou. On this basis, the specific needs of residents for elderly nursing services combining medical and elderly care were analysed. By sorting out factors affecting the demand for elderly nursing service combining medical and elderly care, policy proposals were made accordingly. The case study of Lanzhou was taken as an example to provide a referring significance of developing a combination of medical and elderly care in the undeveloped region of western China, to raise the health care levels of residents in the undeveloped region of western China, satisfy their medical and nursing requirements and improve their nursing services.