For the most up-to-date news and information about the coronavirus pandemic, visit

Living wills: a must have

Living wills: a must have

This article first appeared in Personal Finance: 1st Quarter 2019

“The issues surrounding your right to a dignified death are relevant to Janet Hugo, whose husband was diagnosed with a rare blood cancer. Although he has recovered, the couple still had to make some changes to his estate plan, including his living will.

There’s been a powerful global movement towards recognising people’s right to decide about their preferred medical treatment at the end of their lives including decisions relating to pain management that potentially shortens life, refusing life-sustaining treatment, and assisted dying.

Our right to life is entrenched in our Constitution and we need to question what this right means at the end of our lives from a practical perspective. Our right to life is closely tied to our right to dignity, entitling us to a dignified death. We don’t have an obligation to live irrespective of our circumstances, including unbearable suffering at the end of life. I believe that we have a right to die, which requires, among others, clarity and certainty about the legal status of living wills.

Despite the current uncertainty, the National Health Act 61 of 2003 affirms our right to refuse any treatment whatsoever, even if it would thereby shorten our lives. Treatment against our will constitutes assault. Moreover, this Act specifies which of our relatives can make healthcare decisions on our behalf should we be unable to do so.

Professor Willem Landman, from the Department of Philosophy at the University of Stellenbosch, who has been assisting the initiative to table a private member’s National Health Amendment Bill in Parliament to clarify the legal status of living wills, says: “The ethical and legal principles underlying the Draft Amendment Bill are already enshrined in the National Health Act and in our law more generally. Those principles just need to be made explicit in respect of a living will, by clarifying its legal status, addressing its practical requirements, and protecting medical professionals against prosecution should they follow its directives.”

What is a living will? 

A living will is a very specific document regarding your health care at the end of your life. It states that any treatment that would otherwise lengthen your life should be withheld, in very specific circumstances, including being in a permanent vegetative state, irreversibly unconscious, or terminally ill and suffering.

In essence, through a living will you express the desire to die a natural death, free from having your life extended artificially using life support in any form, such as medication, tube feeding, dialysis, or a life-support machine. A living will would never withhold any necessary and adequate pain management, even if it shortens life.

A living will can also specify whether you would like to donate organs or tissue to assist others to live or to use for research.

Although the legal status of living wills is still uncertain in South Africa, they certainly do have evidentiary value regarding your treatment preferences that doctors should take into account.

I therefore prepare living wills similarly to any other fiduciary document, such as a last will and testament or a power of attorney. My clients sign the document when I know that they are in sound mind and it’s a free expression of their preferences. It’s witnessed by two people who are not family members or their doctor.  I regard the preparation of living wills as an essential part of an estate planning process. Our bodies are, after all, our most valuable asset.

It’s important not to include your living will as part of your last will and testament, which is only of use once you have passed away.

The benefits of living wills

Living wills provide peace of mind as they give us the opportunity to express our choice of medical care should we be terminally ill and unable to communicate. They also assist in settling arguments among family members and medical professionals regarding appropriate treatment. Sometimes a child, who is the primary caregiver of a terminally ill parent, may be comfortable with refusing treatment, while a sibling not living near the parent would want everything done to prolong the patient’s life.

Conflict within families is confirmed by Dr David Bass, the medical adviser to the Western Cape Hospitals: “Dispute usually originates from offspring who were either not consulted about the living will or have a personal motive to keep the terminally ill person alive. Therefore, it is vitally important for anyone making a living will to inform their close family about the nature and content of the will while they are still of sound mind.”

Another hard truth and benefit of living wills are that they assist in containing the cost of dying.  Most people would prefer to pass away rather than live for years on life-support, which can lead to astronomical medical bills that can jeopardise their family’s financial security. It’s very tough for a family member to request the withdrawal of medical treatment based on affordability.

I asked Dr Bass how the Western Cape Hospitals managed the cost of terminally ill persons. He said: ‘’Our approach is to continue to care for the critically ill person, guided by the response to treatment, and the prognosis for survival with a reasonable quality of life. If we think that survival entails an undignified or miserable quality of existence, we de-escalate management to the essentials, such as pain relief and hydration. If there is pressure on critical-care beds, we may transfer the patient to a general ward. If family members want to take the patient home, we will consider that option as well. However, we will not relinquish care or force a patient out of a hospital even if there is very little we can do for them. In that respect, we are not much different from the private health sector.”

It isn’t always as kindly in other provinces where there may be a lack of resources. There was the court case Soobramoney v Minister of Health 1998 in KwaZulu Natal. The patient was suffering from renal failure and after he ran out of funds he turned to a public hospital for renal dialysis since he failed to meet the medical criteria for a kidney transplant. He claimed entitlement to the emergency treatment given his Constitutional right to life.

The Constitutional Court held that the right to life did not impose an affirmative obligation on the state to provide lifesaving treatment to a critically ill patient where there is a scarcity of the requisite resources.

How about a power of attorney?  

We’re all human and by nature don’t like to consider the circumstances that may surround our passing, and some people mistakenly regard a general power of attorney as a substitute. A power of attorney is only of use when you are in sound mind and can communicate and authorise a person to act on your behalf. For instance, if you’re in a hospital and unable to manage the sale of your home, you can instruct the person to whom you’ve granted authority, to proceed on your behalf. A general power of attorney is thus not a substitute to a living will, which only applies when you are unable to make your own medical decisions.

The complexities 

Living wills present a range of complexities, but they are certainly not insurmountable.

Practical issues regarding living wills should be actively managed by putting in place various measures. They need to be made accessible to doctors when a critically ill person is admitted to hospital. Doctors are trained to save lives and may automatically treat someone and then face the very difficult decision to withdraw the intervention.

Doctors’ responses may vary when terminally ill patients are admitted to hospital. Some fear litigation and revive patients regardless of an existing living will and their family’s consent to withdraw treatment. The National Health Amendment Bill anticipates putting a stop to this.

The motivation to preserve life at all costs can also be due to the Hippocratic Oath tradition which doctors take at medical school. The oath dates back more than 2 500 years and requires doctors to swear by the healing gods that they will uphold specific medical standards. Our challenge is to understand those standards in an era of extraordinary medical technology which may extend life beyond what was ever contemplated in the oath. We need to rethink what the fundamental values underlying the oath mean for end-of-life decisions.

Some doctors believe that only God should determine the time and manner of our death, which means that they should always attempt to prolong life. This fails to take account of other accepted ways in which we “interfere” with the length of life for instance using antibiotics and surgery. So, it would be inconsistent to argue that God would approve of our fighting disease using medical technology but disapprove of allowing a natural death by means of a living will.

On his 85th birthday Archbishop Desmond Tutu said: “With my life closer to its end than its beginning, I wish to help give people dignity in dying. Just as I have argued firmly for compassion and fairness in life, I believe that terminally ill people should be treated with the same compassion and fairness when it comes to their deaths. Dying people should have the right to choose how and when they leave Mother Earth. I believe that, alongside the wonderful palliative care that exists, their choices should include a dignified assisted death.”

Another complexity relates to the symbolic value of food and water. You may refuse medical treatment but wish to receive artificial nutrition and hydration. A living will could take care of this preference. Still, these are indeed forms of medical treatment and they would certainly lengthen the process of a natural death.

There are also different views on the management of pain and on how much morphine to administer to ensure the relief of pain. Prof Landman says that there is evidence that doctors globally under-medicate for pain in fear of legal consequences. He argues that all measures necessary for the adequate treatment of pain should be pursued and if such pain alleviation also inevitably happens to hasten death, that would be acceptable medical practice.

At the end of the day

Life is finite and dignity always our Constitutional right. I firmly believe that everyone needs a living will as the complexities can be managed, and all the underlying principles are already embedded in our law and the National Health Act. One needs to prepare the document when you’re well and likely to make rational decisions. Also, follow Dr Bass’s advice and discuss the document with all members of your family and fiduciary specialist, and make it widely available to all who might manage your medical care.

Janet Hugo, a Certified Financial Planner and member of the Financial Planning Institute, is director of Sterling Private Wealth and Financial Planner of the Year 2018″

To read more about our services to the retirement industry, click here.


Frail Care: What you should know

Frail Care: What you should know

This article was first published in the first-quarter 2015 edition of Personal Finance magazine. 

Laura du Preez writes:

“Healthcare issues loom large in later years when illnesses linger and can result in loss of control over daily living. At these times, residents of retirement villages or homes and their children often take comfort in the fact that the village or home has healthcare or frail-care facilities.

But you may be in for some unpleasant surprises if you are not acquainted with exactly what is on offer in a particular village or home, what additional costs you will incur and what you can claim from your medical scheme. The specifics of an illness and the requirements of your care may also determine whether or not you can be assisted in your community or need to go beyond it.

It is important to know that there is a difference between medical care and frail care, and while your medical scheme will pay for your medical care, it will usually not pay for the care you need when you are unable to manage the normal activities of daily living without assistance.

There are some exceptions, mostly among the restricted medical schemes. Open schemes, which must accept anyone who applies to join at any stage of their lives, cannot afford to contribute to the costs of the long-term care you need when you are frail.

What exactly is frail care?

Frail care is the care you need when you are unable to perform activities of daily living, such as eating, personal hygiene and moving about without assistance.

When you are no longer able to look after yourself because of frailty or mental incapability, you are unlikely to return to independent living.

Frail care is the care you need when you are no longer able to look after yourself because of physical frailty or mental incapacity.

Peter Jordan, the principal officer of Fedhealth, a large open medical scheme, says that while medical care falls within the ambit of medical scheme cover, frail care, or any kind of assisted living, is considered a social welfare responsibility.

Alain Peddle, the head of research and development at Discovery Health, says there may be times when you are recuperating from a health event, such as a stroke or an accident, and when you need short-term assistance with daily living before returning to your former independent state. Such short-term help could be covered by your scheme, but cover for the cost of your longer-term accommodation in a frail-care facility is rare.

Bankmed, a restricted scheme, contributes to the costs of frail care on some options. Dr Niri Naidoo, the clinical and operations executive at Bankmed, says that members of the scheme’s top three options, Traditional, Comprehensive and Plus, are entitled to a benefit of 50 percent of the cost of frail care to a maximum of R355 per beneficiary per day. You have to motivate for the benefit, and the claim is assessed by a medical adviser, Naidoo says.

Contributions on the least costly of the three options, the Traditional option, start at R1 917 for a single member earning less than R5 000 a month, to R2 326 for a member earning more than R10 000 a month. These options also pay 100 percent of the cost of home nursing, to a maximum of R270 per beneficiary per day.

Another restricted scheme, Anglo Medical Scheme, has a benefit of R54 355 per beneficiary per year on its top option, which costs R3 170 a month including contributions towards a medical savings account. But the benefit is only for “medically related frail-care services”, which means you will receive it only if you are recovering from an illness, injury or surgery.

Principal officer Fiona Robertson says the aim of the benefit is to keep high-risk members out of hospital, because one expensive hospital event may cost the equivalent of several years of frail care. Once members require constant nursing or assistance, usually when their condition is medically irreversible, they may be classified as at high risk of fractures or repetitive infections, or may be mentally incapable of taking the correct medication, she says.

The scheme will not pay for frail care when the needs are not medical, but the line between social and medical needs is not always clear, Robertson says. Alzheimer’s disease and dementia, for example, are common reasons for granting frail-care benefits.

Jordan says that while your scheme may not cover accommodation and care in a frail-care centre, any chronic medication you require when you are frail, visits to or by a general practitioner (GP) or specialist, as well as the cost of various appliances you might need while in the frail-care facility, may still be paid by the scheme in line with your benefits.

Levels of care

A frail-care facility should be staffed by carers under the supervision of a nursing sister. Carers may be trained to take care of older people, but are normally not medically trained.

Frail-care facilities need to be registered with the Department of Social Development under the Older Persons Act. The Act sets standards for these facilities and requires annual inspections.

The department is also working on introducing training for carers in these facilities.

While “frail care” sounds straightforward, confusion arises when a retirement village offers both frail care and what is known as a sub-acute care facility. To understand what a sub-acute care facility is, it is useful to know what is regarded as an acute care facility.

The Board of Healthcare Funders (BHF), which represents medical schemes and their administrators, issues the practice code numbers that are used by schemes to identify registered healthcare providers. The BHF explains the difference between an acute care facility and a sub-acute care facility as follows:

* Care in an acute care facility: this is typically care in a facility registered and licensed as a hospital by the provincial department of health in terms of the Health Care Act. An acute care hospital has operating theatres and intensive and/or high care units.

A day clinic, which has an operating theatre but is not equipped for overnight stays, is also regarded as an acute care facility, the BHF says.

A third type of acute care facility is a mental health hospital that treats patients with acute mental health problems, according to the BHF.

These hospitals should have practice code numbers, which you need to claim for admission, in line with your medical scheme benefits.

* Care in a sub-acute care facility: these hospitals treat you when your condition is less serious, or after your release from an acute care hospital, the BHF says.

A sub-acute care facility is equipped like a hospital, has appropriately qualified and registered nursing personnel and must be licensed by the provincial department of health under the Health Care Act. However, Peddle says a sub-acute care facility lacks operating theatres, high-care or intensive care units, and pathology and radiology services.

In a sub-acute care facility, you will receive high-quality nursing care, but should have no need for the high-tech care you would receive in high care, intensive care or in a theatre unit, the BHF says. Your condition must, therefore, be stable.

Some sub-acute care facilities will treat you only after surgery or if you have a non-psychiatric medical condition, depending on the discipline code allocated to the facility, the BHF says.

Some facilities focus on psychiatric conditions and others offer physical rehabilitation. Some are post-natal units and some offer all sub-acute services.

Sometimes the term step-down facility is used to describe a sub-acute facility. However, the BHF says step-down care is less intensive than sub-acute care and is typically for short stays. It is a substitute for an extended hospital stay, and you may be referred to a facility offering step-down care if you still need significant medical involvement and skilled nursing care of more than three hours, on average, a day, as well as pharmacy and laboratory support.

Sub-acute care facilities also need a practice code number, and if you are admitted to such an establishment, you can claim for your stay there, in line with your benefits, from your medical scheme.

If a sub-acute facility is focused on rehabilitating you to normal or near-normal functioning after a disease or injury, you are likely to have access to practitioners across medical disciplines. The care they provide will be goal-orientated, and once their goals are reached, you are likely to be sent home. For example, you may be sent to a sub-acute care facility after a stroke. A neuro-physiotherapist could assist you to walk, a speech therapist could help with your speech and swallowing, and an occupational therapist could help with your movement, vision and concentration.

Peddle says therapies might be supplemented by consultations with a social worker, dietician, psychiatrist or medical doctor.

This treatment can occur in acute care settings, acute care rehabilitation units and sub-acute care units that are licensed to provide rehabilitation.

Asked if Discovery Health Medical Scheme would require a member to use a particular facility, Peddle says this would depend to a large extent on the range of healthcare services you need, compared with what the facility is able to offer. In all instances, he says, Discovery Health will fund services only from registered healthcare professionals and facilities that have practice code numbers issued by the BHF. This means that if a retirement village has a healthcare facility, it must be registered and have a practice code number before any scheme will consider funding the services it provides within what the scheme regards as clinically appropriate.

Peddle says members of Discovery Health who require extensive medical services – for example, after an accident or stroke – will be referred to the scheme’s care co-ordination programme. The facilitators of this programme have a list of accredited facilities that have agreed to meet the scheme’s requirements.

Jordan says that if you have a stroke and need rehabilitation, it is possible that a retirement village frail-care facility may not be suitable, and you will instead be referred to a rehabilitation centre for the best possible prospect of recovery.

If, for example, you fall and break your hip, you are likely to be discharged from hospital before you are able to walk unaided, Jordan says. Fedhealth would offer you care in an accredited sub-acute facility, where you could get both physiotherapy and nursing care, but this may or may not be the facility at your retirement village, depending on what your village offers.

Many sub-acute facilities are situated at retirement villages and some are open to the public, but there are also some independent ones, such as MCare and Intercare.

You may also be referred to a sub-acute facility if you need convalescent care to recover from an operation or health event. Jordan says the length of your stay in a rehabilitation centre will depend on the treatment plan formulated by a multi-disciplinary team working on your rehabilitation and the clinical appropriateness of the treatment within the care you are entitled to in terms of the prescribed minimum benefits (PMBs). PMBs are benefits that medical schemes are obliged to provide to all members, and they cover all emergencies, common chronic conditions, and conditions that, if not treated, would seriously affect your life.

Similarly, the length of your stay at a sub-acute facility would depend on your circumstances, and in this respect you would be assessed by trained specialist case managers employed by your scheme in line with the level of care provided in the PMBs and your progress. If you are discharged and still need physiotherapy, for example, you may need to access your scheme’s day-to-day benefits, unless your treatment is still covered under the PMBs.

Jordan says Fedhealth has a special benefit for physiotherapy, which is paid from the in-hospital benefit for 30 days after discharge, leaving your day-to-day benefits intact. The scheme also has an appliance benefit should you require a walking aid or crutches, he says.

Lizzie Brill, manager of the Oasis Care Centre, situated within the Oasis Retirement Resort in Century City, Cape Town, says large schemes, such as Discovery Health and the Government Employees Medical Scheme, have care co-ordinators who oversee treatment and care for patients who have, for example, suffered a stroke. Typically, these schemes pay a global fee to a rehabilitation facility that covers most of the treatment and care required from a multi-disciplinary team.

Some schemes, however, have separate annual benefit limits of, for example, R35 000 for physiotherapy. The limit will not apply if the condition is a PMB, such as a stroke, and the service is required as part of its treatment.


In two other situations there may be confusion about whether your condition and care is covered by your medical scheme. The first is when you have a form of dementia, such as Alzheimer’s disease.

Despite the fact that Alzheimer’s is a progressive and terminal illness, you are unlikely to receive much help from your scheme.

The disease generally affects people when they are over the age of 65, and in the advanced stages requires full-time care, which is usually not covered by your medical scheme. Alzheimer’s is not a PMB, and most schemes cover the chronic medication you require from your day-to-day benefits, which are usually inadequate.

Jill Robson, the regional director of Alzheimer’s South Africa, says Alzheimer’s medication is expensive – in the region of R800 a month – and other medications may be required for other symptoms, such as anxiety or depression. Alzheimer’s patients may also need brain scans, which cost thousands of rands, she says. Some schemes pay for scans only if they are done in hospital and others impose co-payments.

The treatment of other illnesses in patients with Alzheimer’s is also often more expensive as a result of the disease, Brill says.

She says her experience has been that certain restricted schemes offer some benefits for Alzheimer’s, but most open schemes do not, because such long-term care is not regarded as medical care, but as care you require as a result of ageing.

According to Robson, some 750 000 people in South Africa have Alzheimer’s. A group, Alzheimer’s in Action, has launched an online petition to collect signatures from friends and relatives of Alzheimer’s patients who object to the lack of medical scheme cover for the illness.

When you need full-time care, despite the fact that you live in a retirement village with a frail-care centre, you may find that the frail-care centre will not admit residents with dementia.

Some facilities have a separate wing for dementia and Alzheimer’s patients, however. The Oasis Care Centre, for example, has a sub-acute care facility with a licence to provide sub-acute and physical rehabilitative care, a frail-care section for people who are physically frail but still mentally competent, and an entirely separate dementia and Alzheimer’s wing.

Brill says the Department of Health encourages the registration by frail-care centres of separate dementia wings, because dementia have such different needs and they may have behavioural problems. This results in mentally strong but physically frail patients not wanting to be housed together with those who have dementia.

Although not everyone shares the view that dementia patients should be housed separately, Robson believes that it is best. Dementia patients can wander into mentally competent residents’ rooms and upset those residents with their behaviour, she says. They need to be in facilities where they are protected from wandering off and are not at risk of being allowed to leave the facility by someone who is not aware of their condition.

Brill says dementia patients need to be cared for by staff that are not only passionate about providing special care for these residents, but also have been trained to provide appropriate care for them.

The Oasis Care Centre facility for dementia and Alzheimer’s patients is like the frail-care centre, but has its own qualified nursing sister on duty and staff nurses and carers who have been trained by Dementia SA, she says. Continuous in-house training is also required to ensure the best care, Brill says.

To make matters worse for retirement village dwellers who develop Alzheimer’s disease or any other form of dementia, if their village’s frail-care centre is unable to accommodate them, they may be asked to leave the village if they are regarded as being a nuisance to other villagers. In this case, family members will have to find alternative accommodation and care.

When it’s near the end

The other situation that gives rise to confusion about what is covered is imminent death. Medical schemes are obliged to pay for what is known as palliative or terminal care intended to improve quality of life when there is no prospect of prolonging life. Typically, care focuses on pain relief.

The PMBs state that when death is imminent, your scheme must pay for comfort care, pain relief and hydration. These can be done in a sub-acute care unit or hospice environment that may be provided by a retirement village frail-care facility.

Peddle says Discovery Health determines the appropriateness of the facility for your condition and the treatment required. If the nurse or GP who provides the palliative care has a practice number and can bill your medical scheme, the scheme should pay for these services, according to your benefits.

Jordan says Fedhealth will approve treatment in an accredited hospice or nursing facility for palliative care. He says while palliative care is a PMB, the scheme also has a specific benefit for the terminally ill of R25 000.

Peddle says Discovery Health’s Compassionate Care Benefit offers benefits for the terminally ill beyond the PMBs. This benefit provides:

* Access to psychosocial support for the member and his or her family, aimed at easing the resumption of normal life and preventing the consequences of traumatic situations.

* Access to any medication the member requires to be comfortable, and this is not limited to pain medication. This medication is also not restricted to a formulary (or list of approved medications), which normally applies to PMBs.

* A choice of caregiver – a nurse, GP or hospice. In the case of PMBs, these services are usually provided by nurses.

* Pathology services where this is required as part of the member’s medical management.

Peddle says that medical management delivered by a registered healthcare professional – that is a nurse, GP or social worker – will be covered by the scheme as far as it relates to palliative care. The scheme will not, however, cover any bills from a frail-care facility that is not registered with BHF and does not have a practice number.

Discovery Health has introduced a new service this year offering home-based palliative care, as well as home care for other needs, such as wound care and intravenous infusions. These services from nurses and caregivers contracted by Discovery Health are covered by the scheme in line with your benefits.

You can also get respite care – temporary relief for the caregiver to an elderly person – but this will not be covered by the scheme.


There are about as many different healthcare facility arrangements as there are retirement homes and villages, Paul Rosenbrock, a director of the South African Association of Retired Persons, says.

Some villages have no healthcare facilities, some offer home-based care, some have only a frail-care centre and possibly an on-duty nurse, and others offer a full range of services, from assisted living to sub-acute care and rehabilitation to frail care, as well as separate facilities for people with dementia.

Assisted living is also known as midcare or supported living. In most cases, a person will live in his or her own unit, but enjoy support from cleaning services, a carer assisting with personal hygiene and the administration of medicine, a nurse on 24-hour call and meals. Often, these units are available to rent or are sold on a life rights basis – you buy the right to live in the unit for the rest of your life or until you are too frail to live alone. If you buy a life right, when the last-surviving partner dies, the right ceases. Some value may be returned to your estate, but not the full resale value of the unit – for example, your estate may be reimbursed your original purchase price, or the purchase price plus a percentage of the profit on the sale.

Marelize van Rooyen, an estate agent and market research consultant to retirement village developers in Cape Town, says some developers of villages with frail-care or sub-acute care facilities provide the equipment and the building for a healthcare facility and then bring in a company with the necessary expertise to run it. In other cases, the facility is owned by the body corporate of the retirement village.

Val Heighway, a former nursing services manager at the Cape Peninsula Organisation for the Aged (CPOA), says most CPOA-associated homes and villages offer frail care. Many now also offer home-based care, which delays the need for frail care, because frail care, with staff on duty for 24 hours a day, is expensive. Once you need 24-hour care, however, frail care is cheaper than home-based care, she says.

CPOA employs professional nurses on all shifts and provides occupational therapy groups daily. Palliative care is provided, and assistance is obtained from a hospice.

Some newer villages have purposely chosen not to provide healthcare centres, preferring instead to promote home-based care and the concept of “ageing in place” – or ageing in your home and community.

Rayne Stroebel, the managing director of Gerontological Research, Training, Education and Care (Geratec), which offers catering, caring, housekeeping, management consulting and training to retirement villages and facilities involved in the long-term care of older people, says that around the world there is a move to ageing in place.

He says the health and mental state of residents in frail-care facilities decline much more quickly than those of people who remain in their communities. In addition, healthcare facilities tend to become bottomless financial pits, and when they are a drain on a village, a facility will start cutting corners, leading to potential problems.

Keeping people in their communities means that they buy from a care provider only the services they need. Rosenbrock says the advantage of this is that if a healthy spouse is not strong enough to provide for all his or her ill partner’s needs, the couple can enlist home-based services, to help with bathing, for example, and the healthy spouse can continue to do whatever he or she is still capable of doing, such as cooking.

Van Rooyen says a common problem with healthcare facilities is that retirement villages start with relatively young residents, between the ages of 60 and 65, but 10 to 15 years later, the residents are older and have greater medical needs, so the costs of running the healthcare facility rise.

Henry Spencer, the former chief executive of the Association for the Aged and the manager of a retirement village, says that villages in which the majority of residents have been in the village for some time tend not to attract younger residents, even when vacancies arise.

Stroebel says retirement villages with healthcare centres are booming, but younger generations will not necessarily choose these villages, now that there is a trend towards ageing in place. They are likely to prefer villages that form partnerships with service providers. For example, Geratec is in partnership with, among others, Langverwacht, a retirement apartment block in Stellenbosch. Geratec provides care, catering and cleaning services and has guaranteed the residents of Langverwacht that they will not have to move from their apartments to get the healthcare and other services they need.

Van Rooyen says villages that partner with providers such as Geratec typically have a healthcare centre with consulting rooms, a nurses’ station and emergency stabilisation room, but care, including nursing care, is delivered in your home. She says some newer villages have a frail-care centre nearby for those who need it and/or an independent dementia village.

Evergreen Lifestyles, a division of the Amdec property development group, has four retirement villages in Cape Town and one in Johannesburg where home-based care is promoted. The company believes home-based care is the best option, Arthur Case, the former general manager, says. frail-care facilities are sad places, as people seldom move out of them and only a small percentage of people really need to use them, he says.

Evergreen Lifestyles has trained nurses providing nursing care, and all homes and apartments have emergency buttons with which to summon assistance 24 hours a day. The healthcare functions are outsourced to the CPOA in the Western Cape and 24/7 Care in Johannesburg. Healthcare staff will also check on you to see that you are being cared for properly through home-based care.

Case says home-based care is likely, at its cheapest, to work out to about R16 000 a month, because two live-in workers are required to provide care each week. If the carers do not live in, four a week are needed.

Frail-care facilities cost between about R13 000 and R25 000 a month, depending on the facility and the quality of care, he says, although Robson says she knows of places that charge about R5 000 a month.

Lizzie Brill, the manager of Oasis Care Centre in Century City, Cape Town, says Oasis encourages home-based care for those who would like to use these services, but residents must use carers or nurses from agencies that Oasis has approved.

There will always be a market for frail care, because some people are not comfortable with carers or nurses in their homes up to 24 hours a day, she says.

In addition, Brill says when older people are cared for at home they often become isolated and their interaction with others is limited to their care givers, especially in families where younger members have moved overseas.

Brill denies that the Oasis Care Centre is a sad place, saying all the facility’s residents are encouraged and assisted to live full lives as far as possible. A full-time occupational therapist runs daily programmes, which include events and activities, as well as outings. In addition, Brill says the centre’s facilities are like a five-star hotel, which few residents and patients, even the wealthiest, could themselves provide.

She says while home care has its place, it is the daunting demands of running a fully-fledged care centre that have led some developers and bodies corporate to shy away from running such facilities.

Van Rooyen warns about retirement developments that make promises about developing healthcare facilities but never deliver on these promises.

She says often the villages have not been developed as retirement villages as defined in the Housing Development Schemes for Retired Persons Act, and the “promises” are not included in the deed of sale, which leaves you unable to take action against the developer.

Van Rooyen says some villages are marketed as “retirement lifestyle estates”, but they are not registered under the Act.

She advises you to look for a developer with a proven track record to make sure the village is registered under the Housing Development Schemes for Retired Persons Act, and that the frail-care facility is registered under the Older Persons Act. Then read the agreement of sale and the village’s constitution, she says.

Stroebel says people often move into a retirement village during a crisis and do not do enough research. He suggests talking to as many people as you can at a village about the facilities and how they are run.

Rosenbrock suggests you read the constitution and rules of each village you are considering.

A resident of Noordhoek Manor on the Cape Peninsula told Personal Finance magazine that the brochures about the village stated that it offered sub-acute and frail-care facilities. But after she moved in, the village decided to scale down its healthcare services and offer only frail care.

Villagers who need sub-acute facilities are expected to use facilities at a nearby village, the Noordhoek Manor resident says.

Mike Vietri, the chief executive officer of Faircape, the developers of Noordhoek Manor, says the village’s management rules bind it to offering primary healthcare through nursing staff. He says the village fully complies with these obligations and more. In 2011, Faircape obtained a sub-acute care licence to try to improve the Noordhoek Manor healthcare centre’s occupancy levels. Vietri says there was limited demand for this service and it was therefore withdrawn. The licence is maintained, however, so that, if there is a demand for this service, it could easily be re-offered.

Thuli Mahlangu, the chief director of care and services to older persons at the Department of Social Development, says the Older Persons Act, which came into effect in 2010, has introduced some protection for people living in retirement villages and homes, including the registration of frail-care facilities, but there are still many gaps. The department hopes to introduce amendments to the Act to Parliament to deal with some of these loopholes, she says.

Mahlangu says the department is aware of the issue of retirement villages not building healthcare facilities as promised, or, after opening them, declaring them too expensive and shutting them down.”

To read more about the services on offer by Shire Retirement Properties (Pty) Ltd, click here.