In brief

The Netherlands is faced with an increasingly ageing population. This demographic change means that the number of people requiring assistance will also grow, increasing the burden on existing income, healthcare, social services and retirement systems. At the same time, there is growing evidence that traditional nursing homes negatively affect the mental wellbeing of elderly people.

The Levensloopbestendige movement, known in English as Apartments for Life (A4L), offers one solution to this challenge. It was founded in 1995 to provide cost-efficient housing and care solutions to meet the physical and mental needs of the elderly. Its principal objective is to ensure the happiness and autonomy of its residents, and in this it has been largely successful. The number of A4L facilities in the Netherlands has grown since 1995, and other countries have also shown interest in adopting its care provision model.

The challenge

The Netherlands, like other advanced economies, is experiencing a dramatic trend of population ageing. In 2016, the number of over-65s in the Dutch population stood at 3.2 million, a million more than 20 years before. This group of over-65s now makes up 18.2 percent of the entire Dutch population.[20] This demographic change means that the number of mentally and physically frail people requiring assistance will also grow, increasing the burden on existing income, healthcare, social service and retirement systems.[8] The Dutch government estimates that “every year between now and 2021, the Netherlands will need an extra 44,000 homes that are suitable for older people”.[3] As fewer new homes are being built in the Netherlands, largely as a result of the 2007/08 global financial crisis, the government concludes that “existing homes will need to be adapted instead”.[16]

Another significant challenge is the negative effect of traditional nursing homes on the mental wellbeing of elderly people, a problem highlighted by a growing body of research. Norwegian scientists found that sadness, or even depression, among people residing in nursing homes was linked to three main issues:

  1. A loss of agency in organising their everyday life
  2. Loneliness linked to a loss of family and friends
  3. A perceived loss of identity.[19]

A recent study by the Network for Studies on Pension, Ageing and Retirement reflected these views, finding a strong preference among older age groups in the Netherlands for remaining in their current dwelling instead of moving to a care home.[11] The challenge is therefore to provide housing solutions that both reflect the needs and preferences of elderly people and relieve increasingly strained publicly-funded welfare systems.

The initiative

The Levensloopbestendige movement – known in English as Apartments for Life (A4L) – is run by Humanitas, a Dutch NGO founded in 1945. It provides cost-efficient housing and care solutions that meet the physical and mental needs of the elderly. The principal objective of A4L is to ensure the happiness of its residents by mixing age groups and providing clients with a maximum level of autonomy.[13]

Dr Hans Becker, former CEO of Humanitas, set up the first A4L home in Rotterdam in 1992. The home comprises 350 apartments in three complexes. Since then, the organisation has grown to incorporate 3,000 apartments across 30 sites across the Netherlands and has an annual turnover of £86m.[6]

This approach is based on four key values, developed by Dr Becker. The first is autonomy, allowing individuals to remain in charge of their own lives, even in old age. Second is the value of use it or lose it, which in the words of Becker “views the over-provision of care as more damaging than the under-provision”. The third value is a yes culture, which departs from the strict rules in nursing homes and instead takes the wishes of old people seriously. The fourth value is a family-centred approach to caregiving.[3]

To achieve the objective of happiness for residents and to enforce its values, A4L buildings integrate aspects of public and residential life. They typically incorporate first-floor common spaces that are open to neighbourhood residents and those living in the housing above. These common areas include activity spaces, but might also have room for neighbourhood-friendly services like restaurants or local shops. The buildings’ units are primarily rentals, but are increasingly mixed with condominium-style choices.[9] The “age-proof dwellings” can accommodate patient lift-equipment, oxygen, and wheelchairs as needed. They also include modifiable components, such as sinks that can be raised or lowered as required.[3]

In terms of its social structure, A4L hosts residents from three groups of seniors:

  • Those who are 55 or older, but still independent
  • Seniors who need some assistance with daily tasks
  • People who need regular assistance, including medical care.

Instead of keeping these three groups separate, they are integrated, so that someone requiring frequent assistance may live next to a 55-year-old who still works.[2] This is made possible by homecare workers, who provide scheduled assistance ranging from once to eight times a day.[9]

The public impact

A4L has had a positive public impact in spreading its model and achieving its goals of promoting independent lifestyles and happiness among its residents. It has promoted and expanded its model of care provision within the Netherlands and abroad. Since the first A4L building opened in Rotterdam, there are now more than 15 residences in the Netherlands, with 1,700 apartments and about 2,500 residents. With a reported 10,000 to 12,000 people on its waiting list, A4L enjoys high demand and appears to be a popular model for old age living and care provision.

The aim of promoting an active lifestyle for older people has spread well beyond the Humanitas Foundation and is a stated goal of the Dutch government.[16] In addition, countries across the globe, from Australia [15] to China and the US, have shown an interest in the A4L model as a way of dealing with their very own challenges of old age housing and care provision.[13]

Even though the evidence is mainly anecdotal, it appears that A4L’s approach has been widely successful in helping older people remain independent and in enhancing their mental wellbeing. The physical and social design of the A4L buildings supports active, independent lifestyles. Hosting cafés, zoos, supermarkets and other services, A4L provides residents with an infrastructure to take care of themselves if they are physically capable of doing so. The fact that these facilities are also accessible to the wider public facilitates social contacts not only between residents but also with other people of all age groups. The claim of Dr Becker and the Humanitas Foundation that these characteristics of A4L enable old people to remain active for longer is also supported by the minimal number of residents who request a transfer to a full-time nursing home.[9]

While happiness is difficult to gauge objectively, the popularity of A4L with its residents and the high number of applicants indicate a positive impact in this regard. Victor Regnier, a University of Southern California professor, describes the A4L residences as “a place where you can be like Peter Pan. You don't have to worry about growing old.”[2] Because there are none of the separate full-time care units that exist in traditional nursing homes, residents are not worried about being transferred to areas where individuals with mental and physical disabilities are clustered together – “misery islands”[14] as Dr Becker terms them.[3] According to Dr Becker, the rate of euthanasia requests – a legal practice in the Netherlands – has also dropped to nearly zero since he introduced the A4L concept to Humanitas’ care houses, another indication of the improved mental wellbeing of their residents.[10]

Written by Mirjam Büdenbender

This case study is part of a series of international policies that focus on easing the transition to retirement and later life. The case studies and the accompanying report were produced for the Calouste Gulbenkian Foundation (UK Branch).

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What did and didn't work

All cases in our Public Impact Observatory have been evaluated for performance against the elements of our Public Impact Fundamentals.

Legitimacy

Stakeholder Engagement Strong

The entire philosophy of A4L is based on a belief in self-actualisation and community support, reflected in the say yes culture and the extended family approach. This makes stakeholder engagement a central principle of its business model.

Life in A4L buildings is defined less by established rules than by the needs and desires of its residents and other stakeholders, such as volunteers.[13] This is enshrined in the say yes culture, which is essentially about empowering residents and starting a dialogue to enable stakeholders to participate in shaping the movement. As Dr Becker puts it: “Dialogues help implement ideas. They help us innovate. They help us adapt to the changing needs and values of the people… They feel empowered to make requests. The approach allows the residents to decide how to live their lives.”[13]

The values of A4L and especially the extended family approach find strong support from residents and other stakeholders. This is best reflected in the important role of volunteering in A4L’s everyday functioning. Volunteers, including residents themselves, and external people of different ages and professional and social backgrounds, support the extended family approach by assisting residents with various tasks, from grocery shopping to basic care. Dr Becker suggests that “we use everyone’s experiences to improve the happiness of our residents. We create a strong sense of community among the employees and volunteers. They support one other, provide feedback to one other, and create improvements to enhance working practices.”[13]

Political Commitment Good

The political commitment behind A4L is evident from the financial, legislative and scientific measures the Dutch state has taken over the past two decades to support this and similar initiatives.[2]

Since the 1980s, the Dutch state has increasingly withdrawn from traditional welfare programmes and supported entrepreneurial approaches to healthcare and care of the elderly. This has also involved a shift in policies to support the elderly to live independently for as long as possible.[8] The 2007 Social Support Act reflects this change in the relationship between government and citizens, calling for increased autonomy at local levels and more responsibility for NGOs and individual citizens.[1] In 2012, for example, the government stopped funding nursing home costs for citizens over the age of 80 who were not medically in need of full-time assistance.[21]

The 2015 Social Support Act allows Dutch municipalities to offer assistance at home or to support care solutions other than a nursing home.[1] Programmes such as A4L fit into this new focus on civil society and private sector solutions, because they are cheaper on average as a result of their less intensive care provision – unless medical requirements dictate otherwise – and their greater use of volunteers.

While not directly involved in A4L’s design, the Dutch government supports A4L and similar initiatives through its research, such as the Nationaal Programma Ouderenzorg [National Programme of Elderly Care], which was initiated by the Ministry of Health, Welfare and Sports and which aims to develop a coherent long-term programme tailored to the individual needs of older adults.[1]

Public Confidence Good

The public’s confidence in A4L is evident from the popularity of its service and the active involvement of the wider public. There are long waiting lists for apartments in A4L buildings (see Public Impact above). In addition, the whole programme is designed in such way that it involves and benefits the wider public, thereby enhancing public confidence. A4L facilities are woven into the surrounding neighbourhoods by offering community services, such as adult day programmes, home care, and dementia housing, and by having spaces that welcome the community. For example, one A4L building in Rotterdam has a childcare centre on the first floor of the building.[14]

In addition to benefiting elderly people by promoting social interaction, these measures also enhance public support of the movement,[13] with the visit of Queen Beatrix of the Netherlands to one A4L facility indicating its high profile.[17] General confidence in A4L is demonstrated the appreciation of the achievements of its founder, Hans Becker. In October 2016, for example, “China’s National Real Estate Managers’ Association appointed him chief international expert of ageing care”.[10]

However, some critics have lamented the fact that the rise of alternative care providers is indicative of the decline of the traditional welfare state. There is concern that private sector organisations may undermine the solidarity between poor and wealthy Dutch citizens, as only the latter are able to afford some of the services. A study by a Dutch scientist suggested that “many Dutch citizens have mixed feelings regarding the ‘care market’”.[1] However, it should be noted that this concern does not to apply to Humanitas and A4L, as the foundation is a not-for-profit organisation that also provides subsidised apartments as part of its overall services.

Policy

Clear Objectives Good

A4L has as its principal objective the happiness of its residents, which it seeks to achieve via four essential values that characterise its activities:

  1. Autonomy or “be your own boss”. Residents are encouraged to rely on themselves, rather than being forced to rely on others.
  2. The “use it or lose it” approach. The elderly lose their life skills if they do not use them regularly. Once lost, physical or mental abilities are difficult to regain. The staff at A4L encourages residents to use their abilities, to build on their strengths, to learn new skills, and to take up new hobbies.
  3. The “extended family approach”. This approach eliminates the divide between the residents and the care providers. This concept combines the knowledge and expertise of both groups. Each resident has something to offer that can benefit others. Examples include the work experience of residents, their professional skills, and personal experiences. The goal is to improve the self-esteem and self-worth of residents. The residents feel useful and appreciated. These feelings contribute to their happiness.
  4. The “say yes culture”. This means that the staff agree to any new idea, proposal, or request that the residents may reasonably make. The staff explore possibilities to find a workable solution to any challenge that arises.[13]

While sometimes overlapping, together these approaches or values aim to enhance the overall objective of improving the quality of life and mental wellbeing of the elderly at A4L. The goal of happiness was clearly stated at the outset of the movement. Dr Becker himself said that “I realised we had to transform the core business of elder care. We had to focus on happiness. Diseases including Parkinson’s and Alzheimer’s have no cure. We cannot cure or prevent all illnesses or avoid death. Instead, we can empower people with a sense of happiness. This focus improves the quality of life for the elderly. That is the goal of the elder care homes at Humanitas.”[13]

Evidence Good

Dr Hans Becker drew both on his personal experience and later academic research to determine the policy direction of A4L. His initial decision to set up A4L was driven by his experience with his father: “Humanitas had 12 elder care homes in 1995. My father was 85 years old. He said to me, ‘I am worried about the current state of elder care. Chronic illnesses cannot be cured, yet most elder homes focus only on the medical part. What can you do? How can you improve care?’ He was sceptical about change. I realised we had to transform the core business of elder care. We had to focus on happiness.”[13]

Hans Becker then pursued a PhD in Humanism – he was awarded a doctorate in 2003 – in which he developed his theory of happiness and outlined guidelines for “good practice” in the Humanitas Foundation.[22] Dr Becker has also invited researchers to study the concept of happiness, related care protocols, and happiness measurement methods. In his own words: “Dare to be unorthodox, but make sure you have a good story”.[22]

Feasibility Good

While A4L faced several legal and organisational challenges in its early years, it is now cost-efficient and is supported by appropriate legislation and government subsidies.[2]

Dr Becker recalled that when he developed the A4L concept, there was resistance from health insurers and civil servants, who were sceptical about the emphasis he placed on happiness and the mix of services, including the publicly accessible cafés and shops that were provided in A4L facilities.[22] The financial feasibility of alternative care providers was also weak in the early 2000s, as was found by a study funded by the European Commission’s Fifth Framework Programme Quality of Life and Management of Living Resources. In addition, it observed a lack of clear division of competencies between the Ministry of Housing, Planning and Environment and the Ministry of Health, Welfare and Sports.[18]

In recent years, the Dutch government has addressed these challenges through legislative reform, including the 2007 and 2015 Social Support Acts, which allow municipalities to offer assistance at home or support other care solutions outside the nursing home. As a result of these reforms, A4L is now backed by appropriate legislation.

A4L is also financially successful. Given the structure of services it provided, the A4L housing model requires that at least 175-200 people occupy a building in order for it to be cost-efficient.[9] While there is no statistical data, anecdotal evidence suggests that the costs of these non-institutional care providers such as A4L are 10 percent to 25 percent lower than comparable traditional care. The reasons suggested for this are a high level of volunteering that builds interdependence, and a strong focus on self-actualisation in these communities.[3] Dr Becker claims that within 20 years Humanitas has gone from making a loss to achieving a surplus of EUR54 million, which was reinvested in renovation, decoration, and new homes.[10]

Action

Management Good

A4L is part of the Humanitas Foundation. Across the Netherlands there are more than 80 Humanitas departments, located across five districts, each with its own board and district manager. The National Office is located in Amsterdam. The central management of Humanitas is responsible for general management and strategic policy decisions. The board supervises and appoints the central management. The board consists of 25 members, who are elected for four years by the departmental representatives of the five district councils. They may be re-elected once after their first term.

The board meets at least three times a year to approve the policy pursued on the basis of the annual accounts and the annual report, the adoption of the association annual plan and the association budget, the establishment of strategic plans and changes to the board of managers. In addition, Humanitas employs 300 professionals to oversee the foundation’s different programmes and to train and manage the volunteers.[17]

Less is known about the management structure of A4L itself. In 2007, the A4L care homes had 6,000 clients and 2,300 employees, of which approximately a thousand were volunteers.[22] Volunteers receive regular training through the Humanitas Foundation.[17] The supervisory board of Humanitas visits the A4L facilities four times a year. Dr Becker, however, considered this insufficient to decide on the strategic direction of A4L and, in his own words, tried “to keep them at a distance”.[22] His own management style has been described as “chaotic”, often relying on the input of residents and care providers rather than the views of the supervisory board.[22]

Measurement Weak

Despite A4L’s objective – the happiness of its residents – being clearly stated at the outset, and the values to achieve these objective being clearly defined, the nature of happiness makes it difficult to track change over time and define what the impact on it will be.

There is no available evidence suggesting that A4L measures its performance in any systematic way. A4L argues that the “Say yes culture” and “Extended family approach” ensure a constant dialogue that safeguards and improves residents’ the quality of life. It is also able to point to the number of A4L buildings and residents and the long waiting lists as ways of measuring success (see Public Impact above).[9]

Alignment Strong

Strong alignment among the stakeholders involved in A4L can be seen from the government’s focus on non-traditional care solutions, older people’s preference for living in facilities that ensure their independence, and the wider public’s benefits from facilities such as cafés and parks in A4L complexes. In addition, the “extended family” approach aligns the interests of volunteers, staff and residents by allowing all of them to rely on each other’s expertise and thus to support each other. As Dr Becker puts it: “Each resident has their competencies, expertise, and experiences. We bridge the gap between the residents and care professionals. This connection allows everyone to share their experiences and knowledge. Shared knowledge can lead to improvements in care.”[13] Volunteers also receive regular training through Humanitas to support their work with the elderly in the A4L facilities.[17]

Bibliography

[1] Aging in The Netherlands: State of the Art and Science, Carolien H. M. Smits, Hugo K. van den Beld, Marja J. Aartsen and Johannes J. F. Schroots, June 2014, The Gerontologist, Volume 54, Issue 3

https://academic.oup.com/gerontologist/article/54/3/335/719901

[2] Apartment for life seen as godsend by the Dutch, Jane Adler, 22 December 2002, Chicago Tribune

http://articles.chicagotribune.com/2002-12-22/business/0212220194_1_apartment-one-bedroom-seniors

[3] Apartments for Life – A Dutch Senior Housing Innovation, Roscoe Nicholson, 5 November 2014, InvestigAge, Mather Lifeways Institute on Aging

https://www.matherlifewaysinstituteonaging.com/2014/11/05/apartments-life-dutch-senior-housing-innovation/

[4] Apartments for Life in Australia Lessons for Australia from Humanitas in the Netherlands, 2009, The Benevolent Society

http://library.bsl.org.au/jspui/bitstream/1/1921/1/Apartments_for_Life_in_AustraliaReport.pdf

[5] Assisted Living Platform – The Long Term Care Revolution: A study of innovatory models to support older people with disabilities in the Netherlands, Anthea Tinker, Jay Ginn and Eloi Ribe, September 2013, Housing Learning & Improvement Network, Case Study 76

https://www.ifa-fiv.org/wp-content/uploads/2013/11/HLIN-Case-Study76-Netherlands.pdf

[6] Care homes: The new way to get old, Ike Ijeh, 28 February 2013, Building

https://www.egm.nl/public/uploads/EGM-architecten-Humanitas-Building-co-uk--Care-homes-The-new-way-to-get-old-1.pdf

[7] Does Moving to a Nursing Home Cause Depression? Marlo Sollitto, AgingCare.com

https://www.agingcare.com/articles/nursing-home-depression-147347.htm

[8] Dutch Households’ Strategies for Old Age and the Role of Housing Wealth, Janneke Toussaint and Marja Elsinga, May 2010, Teorija in Praksa

https://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/DEMHOW/B17.pdf

[9] Going Dutch: A Mixed Use Housing Model From The Netherlands Responds To The Aging Demographic, Victor Regnier, 19 June 2012, Aging Today, American Society on Aging

http://www.asaging.org/blog/going-dutch-mixed-use-housing-model-netherlands-responds-aging-demographic/

[10] Hans Becker, the maverick seeking to transform retirement living, Hugo Cox, 20 January 2016, Financial Times

https://www.ft.com/content/8a0c31ba-bab8-11e5-b151-8e15c9a029fb

[11] Housing Preferences of an Ageing Population: Investigation in the Diversity Among Dutch Older Adults, Petra de Jong, Jan Rouwendal, Pascal van Hattum and Aleid Brouwer, 2012, Network for Studies on Pension, Ageing and Retirement, Netspar Discussion Paper

https://www.netspar.nl/assets/uploads/024_De_Jong.pdf

[12] How the Dutch Lead the Way in Senior Housing Innovation, Josh Crites, 29 May 2017, International Observatory on Social Housing

https://internationalsocialhousing.org/2017/05/29/learning-best-practices-in-housing-for-the-elderly-from-the-dutch/

[13] Humanitas Foundation Rotterdam: Interview with Dr. Hans Becker, Sofia Widén and William Haseltine, October 2016, ACCESS Health Sweden

https://accessh.org/wp-content/uploads/2016/10/Dr.-Hans-Becker-Humanitas-Foundation-Rotterdam-for-publication-1.pdf

[14] Innovative seniors housing and care models: What we can learn from the Netherlands, Anne P. Glass, January 2014, Seniors Housing and Care Journal, 22(1), 74-81

https://www.researchgate.net/publication/274700006_Glass_A_P_2014_Innovative_seniors_housing_and_care_models_What_we_can_learn_from_the_Netherlands_Seniors_Housing_and_Care_Journal_221_74-81?enrichId=rgreq-d6b12ef37c7d4b64f3f2a9b0f9ce854e-XXX&enrichSource=Y292ZXJQYWdlOzI3NDcwMDAwNjtBUzoyMzM4MjEzMzc1NTA4NDhAMTQzMjc1ODc1OTQzNQ%3D%3D&el=1_x_3&_esc=publicationCoverPdf

[15] Integrated housing, support and care for people in later life, Andrew Jones, Cheryl Tilse, Helen Bartlett and Robert Stimson, October 2008, Australian Housing and Urban Research Institute, Queensland Research Centre, AHURI Positioning Paper No. 108

https://www.ahuri.edu.au/__data/assets/pdf_file/0013/2731/AHURI_Positioning_Paper_No108-Integrated-housing,-support-and-care-for-people-in-later-life.pdf

[16] Living independently for longer, Ministry of Health, Welfare and Sport, Government of the Netherlands

https://www.government.nl/topics/care-and-support-at-home/living-independently-for-longer

[17] Over ons (About us), 2016, Humanitas

https://www.humanitas.nl/over-ons/about-humanitas/

[18] Providing integrated health and social care for older persons in the Netherlands, Carine Ex, Klaas Gorter, Uschi Janssen, March 2003, The Verwey-Jonker Institute

https://www.verwey-jonker.nl/doc/participatie/Dutchpaper_D1881746.pdf

[19] Residents’ perceptions of their own sadness – a qualitative study in Norwegian nursing homes, Kristina Riis Iden, Sabine Ruths and Stefan Hjørleifsson, March 2015, BMC Geriatrics

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356108/

[20] Society Figures – Population Dynamics 2016, Trends in the Netherlands 2017, Statistics Netherlands (CBS)

https://longreads.cbs.nl/trends17-eng/society/figures/population/

[21] The Nursing Home That's Also a Dorm, Tiffany R. Jansen, 2 October 2015, CityLab

https://www.citylab.com/equity/2015/10/the-nursing-home-thats-also-a-dorm/408424/

[22] The Value(s) of Civil Leaders: A Study into the Influence of Governance Context on Public Value Orientation, Steven P.M. de Waal, 2014, University of Utrecht

https://www.publicspace.nl/wp-content/uploads/Appendices-proefschrift-Steven-de-Waal.pdf

[23] Trends in activity limitations: the Dutch older population between 1990 and 2007, Coen H van Gool et al, 18 February 2011International Journal of Epidemiology, Volume 40, Issue 4

https://academic.oup.com/ije/article/40/4/1056/679496

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