vol 17 no 2-3 - world health organization · david mcdaid: +44 (0)20 7955 6381 email: ... francesca...
TRANSCRIPT
EurohealthVolume 17 Number 2–3, 2011RESEARCH • DEBATE • POLICY • NEWS
England: NHS reform and NICE's new role • Germany: effect of hospital ownership on performanceEU Directive: patients' rights in cross-border health care
Balancing fair protectionand financial sustainability
Mapping long-term careservices across Europe
Impact of chronic diseaseon need for long-term care
Ageing andlong-term care
LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UKfax: +44 (0)20 7955 6090http://www.lse.ac.uk/collections/LSEHealth
Editorial Team
EDITORS: David McDaid: +44 (0)20 7955 6381email: [email protected] Merkur: +44 (0)20 7955 6194email: [email protected]
FOUNDING EDITOR: Elias Mossialos: [email protected]
DEPUTY EDITOR: Anna Maresso: [email protected]
ASSISTANT EDITORS: Philipa Mladovsky: [email protected] Azusa Sato: email: [email protected] Kossarova: [email protected]
EDITORIAL BOARD:Reinhard Busse, Josep Figueras, Walter Holland, Julian Le Grand, Martin McKee, Elias Mossialos
SENIOR EDITORIAL ADVISER:Paul Belcher: +44 (0)7970 098 940email: [email protected]
DESIGN EDITOR: Sarah Moncrieff: +44 (0)20 7834 3444email: [email protected]
SUBSCRIPTIONS MANAGER Champa Heidbrink: +44 (0)20 7955 6840email: [email protected]
Advisory Board
Tit Albreht; Anders Anell; Rita Baeten; Johan Calltorp; Antonio Correia de Campos; Mia Defever; Isabelle Durand-Zaleski; Nick Fahy; Giovanni Fattore; Armin Fidler; UntoHäkkinen; Maria Höfmarcher; David Hunter; Egon Jonsson;Allan Krasnik; John Lavis; Kevin McCarthy; Nata Menabde; Bernard Merkel; Willy Palm; Govin Permanand; Josef Probst;Richard Saltman; Jonas Schreyögg; Igor Sheiman; Aris Sissouras; Hans Stein; Ken Thorpe; Miriam Wiley
Article Submission Guidelines
see: www2.lse.ac.uk/LSEHealthAndSocialCare/LSEHealth/documents/Guidelinestowritinganarticleforeurohealth.aspx
Published by LSE Health and the European Observatory onHealth Systems and Policies.
Eurohealth is a quarterly publication that provides a forum forresearchers, experts and policymakers to express their views onhealth policy issues and so contribute to a constructive debateon health policy in Europe.
The views expressed in Eurohealth are those of the authorsalone and not necessarily those of LSE Health. or the European Observatory on Health Systems and Policies.
The European Observatory on Health Systems and Policies is apartnership between the World Health Organization RegionalOffice for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden andthe Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM(French National Union of Health Insurance Funds), the London School of Economics and Political Science, and theLondon School of Hygiene & Tropical Medicine.
© LSE Health 2011. No part of this publication may be copied, reproduced, stored in a retrieval system or transmitted in any formwithout prior permission from LSE Health.
Design and Production: Westminster EuropeanPrinting: Optichrome Ltd
ISSN 1356-1030
Meeting the challenge of ageing andlong-term careThe European population aged over 80 is expected to morethan double by 2050, leading to significantly increased demandfor long-term care (LTC). This demographic shift is accompa-nied by changing social patterns, e.g., smaller families, differentresidential patterns and increased female labour force participa-tion, all contributing to an increased need for paid care. Thus,accurate projections on population ageing and morbidity areneeded to determine future planning challenges for LTC.
Many of the contributions in this double issue reflect presenta-tion made at an expert seminar jointly organised by the London School of Economics, the International LTC PolicyNetwork, and the Health Status, Health Care and LTC Research Network. Comas-Herrera and colleagues look at thedifferent assumptions used in forecasting future LTC expendi-ture. Specifically, they discuss the changes in cost projectionswhen different scenarios are used for rates of disability and dementia. Jagger et al. also look at modelling future demandfor LTC. In their article they have opted to use the term – the85 and over age group – rather than the previously used term‘oldest old’, because this reflects the reality of changing demographics where 85 is now considered not that old!
For specific countries, Hanson and Magnusson present a specific type of Information and Communication Technology(ICT) that is used in Sweden by older people with chronicconditions and their carers at home. Results of an evaluation of the technology are presented and challenges discussed. Continuing on the ICT theme, Hendy et al. look at recent developments regarding four remote care programmes under-going implementation in the United Kingdom. They notesome success, but also the continued challenge due to the current policy and reimbursement landscape. With regards tothe hospital setting and long-term residential care in Finland,Murphy and Martikainen distinguish between age and proximity to death as predictors of service use.
Colombo and Mercier reflect on some findings of a recentOECD study. Cost projection scenarios for LTC are shownalongside policy recommendations on how to provide fairLTC protection, while ensuring that over the long run thisprotection is fiscally sustainable. Drawing on the same study,Tjadens et al. look at the sustainability of the care workforce,while Salvador-Carulla reports on an approach to map andbetter compare LTC care services across Europe.
In the Health Policy Developments section, Zanon discussesimplications for the National Health Service in England stemming from the European Directive on patients' rights incross-border health care. Also from England, with major healthreforms under discussion, this issue provides a reflection fromthe National Institute for Health and Clinical Excellence(NICE) on their work to date and what the future may hold.For Germany, Tiemann and colleagues look at the effects ofhospital ownership on efficiency, quality of care and other dimensions of performance following the introduction of diagnosis related groups (DRGs) and other reforms.
Stay tuned. From the next issue, Eurohealth will revamp itslook and enhance navigation through dedicated sections, including a new thematic section that will integrate the Observatory’s health policy bulletin EuroObserver.
Sherry Merkur, EditorDavid McDaid, EditorAnna Maresso, Deputy Editor
MENT
EurohealthCOM
Contents EurohealthVolume 17 Number 2–3
Ageing and long-term care
1 Introduction: The demand for long-term care for older peopleLisa Trigg
3 Help wanted! Balancing fair protection and financial sustainability inlong-term careFrancesca Colombo and Jérôme Mercier
7 The impact of changing patterns of disease on disability and the needfor long-term careCarol Jagger, Ruth Matthews, James Lindesay and Carol Brayne
10 Disability, dementia and the future costs of long-term careAdelina Comas-Herrera, Juliette Malley, Raphael Wittenberg, Bo Hu and Carol Jagger
13 Long-term care: valuing care providersFrits Tjadens and Francesca Colombo
18 Use of care services in relation to proximity to death among olderpeople: Evidence from FinlandMike Murphy and Pekka Martikainen
21 Implementing remote care in the UK: an update of progressJane Hendy, James Barlow and Theopisti Chrysanthaki
24 The role of ICT support services to promote ageing in place. The ACTION serviceElizabeth Hanson and Lennart Magnusson
27 Classification, assessment and comparison of European LTC services.Development of an integrated systemLuis Salvador-Carulla, Cristina Romero, Germain Weber, Hristo Dimitrov, Lilijana Sprah, Britt Venner and David McDaid for the eDESDE-LTC Group
Health policy developments
30 NICE supporting England and Wales through times of changeTarang Sharma, Nick Doyle, Sarah Garner, Bhash Naidoo and Peter Littlejohns
31 Which type of hospital ownership has the best performance?Evidence and implications from GermanyOliver Tiemann, Jonas Schreyögg and Reinhard Busse
34 Health care across borders: Implications of the EU Directive on cross-border health care for the English NHSElisabetta Zanon
36 Towards fairer care funding in EnglandDavid McDaid
Monitor
37 Publications
38 News from around Europe
James Barlow, Imperial College Business School, UK.
Carol Brayne, Institute of Public Health, Cambridge University,UK.
Reinhard Busse, Department of Health Care Management,Berlin University of Technology, Germany.
Theopisti Chrysanthaki, Imperial College Business School, UK.
Francesca Colombo, Directorate for Employment and SocialAffairs, OECD, France.
Adelina Comas-Herrera, Personal Social Services ResearchUnit, (PSSRU), London School of Economics and PoliticalScience (LSE), UK.
Hristo Dimitrov, Public Health Association, Bulgaria.
Nick Doyle, Research and Development, NICE, UK.
Sarah Garner, Research and Development, NICE, UK.
Elizabeth Hanson, Department of Health & Caring Sciences,Linnaeus University, Sweden.
Jane Hendy, Imperial College Business School, UK.
Bo Hu, PSSRU, LSE, UK.
Carol Jagger, Institute for Ageing and Health, NewcastleUniversity, UK.
James Lindesay, Emeritus Professor of Psychiatry for theElderly, University of Leicester, UK.
Peter Littlejohns, Clinical and Public Health Director, NICE, UK.
Lennart Magnusson, Department of Caring Sciences,University of Borås, Sweden.
Juliette Malley, PSSRU, LSE, UK.
Pekka Martikainen, University of Helsinki, Finland.
Ruth Matthews, Department of Health Sciences, University ofLeicester, UK.
David McDaid, LSE Health, LSE, UK.
Jérôme Mercier, Directorate for Employment and SocialAffairs, OECD, France.
Mike Murphy. Professor of Demography, LSE, UK.
Bhash Naidoo, Research and Development, NICE, UK.
Cristina Romero, Asociación Científica PSICOST, Spain.
Luis Salvador-Carulla, Asociación Científica PSICOST, Spain.
Jonas Schreyögg, Department of Health Care Management,Hamburg University, Germany.
Tarang Sharma, Research and Development, NICE, UK.
Lilijana Sprah, Družbenomedicinski Inštitut, Slovenia.
Oliver Tiemann, Department of Health Care Management,Hamburg University, Germany.
Frits Tjadens, Health and Social Care Associates, theNetherlands.
Lisa Trigg, LSE Health, LSE, UK.
Britt Venner, SINTEF Technology and Society, Norway.
Germain Weber, Professor of Clinical Psychology, Universityof Vienna, Austria.
Raphael Wittenberg, PSSRU, LSE, UK.
Elisabetta Zanon, NHS European Office, Brussels, Belgium.
Eurohealth Vol 17 No 2–31
AGEING AND LONG-TERM CARE
Forecasting the demand for long-term care(LTC) is a challenge complicated by arange of factors, including future trends inlongevity and health, government policiesin both health and social care, access tohealth care systems, and a range of socialand demographic factors, not least ofwhich is the availability of informal carers.
Many of the articles in this issue tackle onthe one hand, the challenges of forecastingLTC demand and on the other hand howto reduce this demand. Most of thesearticles are based on presentations made atan expert seminar on “Ageing and Long-term Care Needs” held at the LondonSchool of Economics and Political Scienceon 20 May 2011, organised by the Interna-tional Long-term Care Policy Network, inconjunction with the Health Status, HealthCare and Long-term Care ResearchNetwork.* The Research Network is partof the European Observatory on Socialand Demographic conditions, sponsoredby the European Commission’s Direc-torate General for Employment, SocialAffairs and Equal Opportunities.**
Forecasting long-term care needsProjections surrounding population ageingare vital to assist governments and institu-tions in understanding the likely scale ofthe challenge facing LTC systems and todevelop policies accordingly. The Organi-sation for Economic Co-operation andDevelopment (OECD) forecasts that thepercentage of those aged 80 and over islikely to more than double from 4% in2010 to nearly 10% in 2050 in OECDcountries.1 Behind these figures lies acritical question for the planning of LTCneeds, regarding the extent to whichincreases in life expectancy are matched byimprovements in healthy life expectancy,the so called ‘compression of morbidity’.
A 2007 OECD study showed that evi-dence from different countries iscontradictory, with levels of disability indecline in some countries and on theincrease in others.2 National differenceswere also shown in a presentation by Jean-Marie Robine exploring the patternsemerging around the health and longevityof the oldest old, particularly in the cente-narian population in the Five CountryOldest Old Project.3
With reductions in mortality for manychronic diseases, there is a need for a betterunderstanding of the extent to whichchronic disease impacts on healthy lifeexpectancy and the onset of dependency.In her article, Carol Jagger describesongoing activities to gather data from alarge UK cohort of individuals to modelthe relationship between multiple mor-bidities, levels of disability and mortalityfor older people, as well as the impact ofthese factors on the need for LTC. Changesin any of these factors can then be used tomodel the impact on future life expectancyand healthy life expectancy under differentscenarios based on the prevalence ofchronic disease in older people.
This epidemiological approach to fore-casting the need for LTC also forms one ofthe approaches described by AdelinaComas-Herrera in examining the futureoutlook for increased numbers of olderpeople suffering with dementia. The otherapproaches discussed take an arguablymore straightforward approach to fore-casting, for example, by extrapolating pasttrends or by assuming that age-specific dis-ability rates will continue at the same level.
Adoption of the different models results indifferent levels of optimism (or pessimism)in outlook. Interestingly, a Delphi con-sensus exercise established that the paneltook a ‘moderately optimistic’ view thatfuture disability levels caused by dementiawould be reduced due to scientificadvances and changes in risk factors.4
Another study by Mike Murphy andPekka Martikainen uses extensive data col-lected by Finnish municipalities on the useof health and LTC to investigate predictorsof their use. Specifically, they describe theirfinding that, while proximity to death hasbeen found to be positively correlated tothe use of acute health care, age (or timefrom birth) is more important for fore-casting the use of LTC. The impact ofother factors should not be underesti-mated; a key determinant for the use oflong-term residential care being maritalstatus.
Managing the demand for long-termcareSome of the key findings from the latestOECD report on the future demand forLTC are highlighted by FrancescaColombo and Jérôme Mercier. Theyestimate that the demand for formal LTCworkers is likely to at least double by 2050,with average spending expected to risefrom a current average of 1.3% of GrossDomestic Product to a worse case scenarioof 2.9% for OECD-EU countries.***Given this expected increase, it is not sur-prising that governments continue to seekways of reducing or moderating demandfor formal LTC, or at least for the mostexpensive option of residential care. As
Introduction: The demand for long-term care for older people
Lisa Trigg
Lisa Trigg is Research Officer, LSEHealth, London School of Economics andPolitical Science, UK. Email: [email protected]
* Additional information and presentations are available for download at:http://www2.lse.ac.uk/LSEHealthAndSocialCare/LSEHealth/eventsAndSeminars/expertseminaronaging.aspx
** Contract No. VC/2008/932
*** Including Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany,Greece, Hungary, Ireland, Italy, Luxembourg, Netherlands, Norway, Poland, Portugal,Slovak Republic, Spain, Sweden and the United Kingdom.
well as recognising the desire of individualsto stay within their own homes and toretain some degree of independence, intheory these approaches should alsodeliver more cost-effective options for theprovision of LTC.
However, a major challenge is how to takerelatively small pilot schemes and localprojects and adapt and expand them forregional or national implementation. Eliz-abeth Hanson and Lennart Magnussonreport on a regional initiative in Swedenbased on the use of information and com-munication technology to support ageingin place, through the provision of edu-cation and training, multimedia supportand videophone contact with professionalcarers and other families. The programmehas been well-received by both the familiesinvolved and the local municipality interms both of the effectiveness of thesupport as well as the cost savings shownat an individual level by avoiding wider useof health and social care services. However,the authors highlight a number of chal-lenges to the uptake of these programmeson a wider scale, for example, therequirement to change fundamental workpractices, the effort required to buildongoing support, and not least the need forrigorous and extensive evidence on costsand benefits to justify their adoption at anational level.
These are themes echoed in Hendy et al’sarticle, which describes the implemen-tation of a set of randomised controlledtrials of remote care services in the UK.The findings of their research identified anumber of barriers to scaling up remotecare, i.e., the need for strong and consistentleadership; the transferability of lessonslearned in pilots to wider projects; the needfor fundamental changes in working prac-tices; and the need for the broad policyinterventions and service redesign toensure integration between differentorganisations. The approach of using ran-domised controlled trials has been adoptedto counter the historical difficulties ofusing data from smaller projects to justifymore extensive investment, such as chal-lenges encountered during the UK-basedPartnerships for Older People Project inmeasuring quality of life outcomes and theimpact of projects on the use of health andresidential care.5
Notwithstanding advances in medical careand improvements in health status, therequirement for LTC will inevitably growas populations age. Establishing the trueextent of this challenge will allow govern-
ments to design and implement strategiesfor supporting this care, particularly fromthe perspective of adequate and appro-priate strategies for financing. Identifyingmore cost-effective options for deliveringcare is acknowledged as a priority in orderto reduce costs and to improve the qualityof life of older people. Further challengesremain in overcoming existing hurdles toimplement successful services and tech-nologies on a large scale.
REFERENCES
1. Colombo F, Llena-Nozal A, Mercier J,Tjadens F. Help Wanted? Providing andPaying for Long-term Care. Paris: OECDPublishing, 2011.
2. Lafortune G, Balestat G. Trends in Severe Disability Among Elderly People:
Assessing the Evidence in 12 OECD Countries and the Future Implications.OECD Health Working Paper No 26.Paris: OECD Publishing, 2007.
3. Robine JM, Cheung SLK, Saito Y, JeuneB, Parker MG, Herrmann FR. Centenari-ans Today: New Insights on Selection fromthe 5-COOP Study. Current Gerontologyand Geriatrics Research 2010:1–9.
4. Comas-Herrera A, Northey S, Witten-berg R, Knapp M, Bhattacharyya S, BurnsA. Future costs of dementia-related long-term care: exploring future scenarios. Inter-national Psychogeriatrics 2011;23:20–30.
5. Windle K, Wagland R, Forder J, D'Amico F, Janssen D, Wistow G. National Evaluation of the Partnerships for Older People Projects: Final Report.Canterbury: Personal Social Services Research Unit, University of Kent, 2009.
Eurohealth Vol 17 No 2–3 2
AGEING AND LONG-TERM CARE
The complex nature of many chronic diseases, which affect peoplein many different ways, requires a multifaceted response to meetthe needs of patients. The traditional relationship between anindividual patient and a single doctor is inappropriate, yet there islittle agreement about what should replace it.
Many countries are experimenting with new approaches todelivering care in ways that meet the complex needs of people withchronic disorders, redesigning delivery systems to coordinateactivities across the continuum of care. Yet while integration andcoordination have an intuitive appeal, policy makers have had littleguidance to help them decide how to move forward.
Now available in Russian, this book systematically examines someof the key issues involved in the care of those with chronicdiseases. It synthesises the evidence on what we know works (ordoes not) in different circumstances. From an internationalperspective, it addresses the prerequisites for effective policiesand management of chronic disease.
Taking a whole systems approach, the book:
• Describes the burden of chronic disease in Europe
• Explores the economic case for investing in chronic diseasemanagement
• Examines key challenges posed by the growing complexity inhealth care including prevention, the role of self-management,the health care workforce, and decision support
• Examines systems for financing chronic care
• Analyses the prerequisites for effective policies for chronic care
Caring for people with chronic conditions is key reading for healthpolicy-makers and health care professionals, as well as post-graduate students studying health policy, health services research,health economics, public policy and management.
Caring for people with chronic conditions. A health system perspective
Edited byEllen Nolte andMartin McKee
Now available in Russian
Copenhagen: WorldHealth Organization 2010,on behalf of the EuropeanObservatory on HealthSystems and Policies
256 pages
ISBN: 978 0 335 23370 0
Available at: http://www.euro.who.int/en/home/projects/observatory/publications/studies
Eurohealth Vol 17 No 2–33
AGEING AND LONG-TERM CARE
The share of the population aged 80 yearsand over is expected to more than doublein coming decades across the OECD,growing from 4% in 2010 to close to 10%by 2050 (Figure 1). Although the speed atwhich populations are ageing varies con-siderably across countries, and despiteuncertainties about future trends in dis-ability among the older population,1 thesedemographic transformations are expectedto significantly increase demand for long-term care (LTC) services. Meanwhile,declining family size, changes in residentialpatterns of people with disabilities and therising female participation in the formallabour market will contribute to a declinein the availability of family carers, leadingto an increase in the need for paid care.
These transformations will put upwardpressure on total expenditure of formallong-term care systems, and this will occurconcurrently with the growth of othermajor age-related expenditures, such aspublic pensions and health services, withthe potential risk of shifting costs to future
generations. This means that the wayexpenditures and revenues are set, particu-larly in the area of LTC, needs to be moreforward looking. After outlining LTC costprojection scenarios, this article providespolicy recommendations on how toprovide fair LTC protection, whilstensuring that this protection is fiscally sus-tainable in the long run. In doing so itdraws on findings of a major report pre-pared by the OECD.2
Sizing the challenge ahead: projectedLTC costsOn average OECD countries allocate1.5% of their Gross Domestic Product(GDP) to LTC. Some countries spendmore than 2% of their GDP (for example,the Netherlands, Sweden, Denmark andNorway) while some others allocate lessthan 0.5% (for example, Portugal,Hungary). Regardless of the share of GDPspent on LTC, systems target resources
Help wanted!
Balancing fair protection and financialsustainability in long-term care
Francesca Colombo and Jérôme Mercier
Summary: The number of people over the age of 80 is expected to double as a shareof the total population of OECD countries over the next forty years, leading tosignificantly increased demand for long-term care (LTC) services. Meanwhile,declining family size, changes in residential patterns of people with disabilities andrising female participation in the formal labour market will contribute to a decline inthe availability of family carers, leading to an increase in the need for paid care. Afteroutlining LTC cost projection scenarios, this article provides policy recommendationson how to provide fair LTC protection, whilst ensuring that this protection is fiscallysustainable in the long run.
Keywords: Long-term care financing, long-term care costs, financial sustainability
Francesca Colombo is Senior Health Policy Analyst, Health Policy Division andJérôme Mercier is an Economist, Direc-torate for Employment and Social Affairs,Organisation for Economic Co-operationand Development, Paris, France.
Figure 1: The share of the population aged over 80 years in the OECD, 2010 and 2050
Source: 4
0%
5%
10%
15%
20%
TurkeyM
exico
IrelandU
nited StatesA
ustraliaIcelandN
orway
Luxembourg
Sweden
Hungary
New
ZealandO
ECD
SlovakiaN
etherlandsC
anadaBelgiumPolandU
nited Kingdom
Czech Republic
France
Denm
arkPortugalG
reeceSw
itzerlandA
ustriaFinlandSloveniaKoreaG
ermany
Japan
% aged 80+ in 2010
% aged 80+ in 2050
Chile
among beneficiaries very differently; thesame can also be said with respect to howLTC financing takes place.
While still relatively small, there is concernacross OECD countries that the demo-graphic and societal changes we havedescribed will lead to higher future ageing-related costs. According to the 2009European Commission projection sce-narios, public LTC spending ofOECD-EU member states as a share ofGDP is expected to at least double by2050. LTC expenditures are expected to fallin the range of 2.2% to 2.9% of GDP by2050, relative to about 1.2% in 2007.3
Complementary OECD projections forselected non-European OECD countriesare consistent with these findings and Table1 presents projections for six different sce-narios (See Box).
Taken together, these projections suggestthat LTC spending might at least double oreven treble in the Czech Republic, Japan,Hungary, the Netherlands, New Zealandand Slovakia. Most cost growth is likely tooccur if new LTC beneficiaries receiveformal care in institutional settings.
Policies for fair yet financially sustainable LTC coverageThere is a strong rationale both for poolingthe financial risk associated with LTC costsand for providing basic universal coveragefor personal-care services, that is help withso-called activities of daily living such asbathing, dressing, getting in and out of bed,regardless of individual financial means.LTC expenditure rapidly becomes unaf-fordable for even relatively well off people.For those requiring a large range ofservices, LTC expenditure can represent asmuch as 60% of disposable income for allbut those in the upper quintile of theincome distribution.
Many countries are indeed moving to uni-versal LTC coverage. But, within auniversal system, policies are needed toreconcile projected demand for (and costof) LTC, with financial sustainability. Atoolkit of policies to strike this delicatebalance between fairness and fiscal sustain-ability is now outlined.
First, support should be targeted where theneed is the highest. Such targeted univer-salism requires balancing three features ofLTC coverage schemes:
The need-level triggering entitlement tocoverage. Stringent assessment criteria canbe in place even within universal LTCschemes, as is the case in the Republic of
Korea and Germany, for example, relativeto Japan. Over the years, there have beenefforts to target benefits to those with thehighest care needs in Sweden and theNetherlands, while Japan moved low needusers to a prevention system in 2006.
The level of cost-sharing on LTC benefits.No LTC system is entirely free. In France,a LTC cash benefit pays up to €1,235 per
month for a high-need/low-income user,but only €27 per month for the highest-income users, while in Sweden there is acap for cost-sharing on home-help servicesof €180 per month. Paying higher benefitsto low-income dependents as in France,Austria and Australia ensures access to carefor those who need it without excessivepublic expenditures.
Eurohealth Vol 17 No 2–3 4
AGEING AND LONG-TERM CARE
Box: Six scenarios used in projections of future costs of long-term care
Baseline or pure ageing scenario: future demand for LTC is projected assuming that the number ofyears with disability will increase in line with future gains in life expectancy. LTC spending willdouble from around 1.2% to 2.4% for OECD-EU member countries and to 2.9% of GDP for non-European OECD countries by 2050.
Healthy ageing scenario: gains in life expectancy will lead to a delay in the onset of disability, withhalf of the increase in lifespan considered to be years with lower levels of dependency. Total publicLTC costs could decrease by about 5% to 10% by 2050, relative to the baseline scenario.
Productivity gains scenario: the cost of providing LTC grows at a slower rate than real GDP perworker, for instance thanks to the implementation of new reforms or the introduction of new tech-nologies allowing for more care being provided for the same cost. This would bring a decrease ofabout 10% in projected public LTC expenditure, relative to the pure demographic scenario.
Fourth scenario: LTC costs will grow at a faster pace than average wage rates in the economy.Such cost pressure could arise as a result of the expected growing demand for LTC workers in thecontext of a shrinking workforce (Figure 2). LTC spending would grow by about 10%, relative tothe baseline scenario.
Fifth and sixth scenarios: Under both these scenarios a shift from family to formal care would resultin all ‘new’ beneficiaries respectively receiving care at home or in an institution. Public LTC costswould grow by 5% to 20% across EU Member States, compared with 10% to 35% for non-EUOECD countries.
Figure 2: Percentage of full time equivalent nurses and personal carers relative to total projectedworking population
Sources: 3–6.Notes: a. Refers to institutions onlyFor the purposes of the analysis, the number of LTC workers includes nurses and personal carersworking in an institution or at home, expressed on a FTE basis. The analysis is limited to employedLTC workers and generally does not include other LTC workers under different working arrangements,such as self-employed individuals. The range of occupations considered as nurses and personal carers, as well as the definition of full-time equivalent may vary across countries. Data for Australia,New Zealand and the United States refer to 2007. Data for Canada and Luxembourg refer to 2006.
0%
1%
2%
3%
4%
5%
6%
Slovakia
Czech Republic
Belgiuma
Canada
Australia
Germ
any
New
Zealand
Japan
United States
Luxembourg
Norw
ay
2008 2050 (pure ageing scenario)
Eurohealth Vol 17 No 2–35
AGEING AND LONG-TERM CARE
Table 1: LTC expenditure as percentage of GDP in 2050 (base year prices)
Base year
Prevalence of dependency scenarios
Changes to the LTC cost structure scenarios
Decline in the availability of family carescenarios
Pure ageing scenario
Healthy ageing scenario
-1% of GDP perworker
+1% of GDP perworker
All home care All residential care
EUa 2007
Austria 1.3 2.5 2.4 2.3 2.7 2.6 2.6
Belgium 1.5 2.9 2.8 2.6 3.2 3.1 3.5
Czech Republicb 0.2 0.6 0.5 0.6 0.6 0.6 0.7
Denmark 1.7 3.4 3.2 3.1 3.7 3.7 3.4
Finland 1.8 4.2 4.2 3.8 4.7 4.5 5.3
France 1.4 2.2 2.1 1.9 2.5 2.3 2.6
Germanyc 0.9 2.3 2.2 2.1 2.5 2.4 2.7
Greece 1.4 3.3 3.2 2.9 3.7 3.5 3.9
Hungary 0.3 0.5 0.5 0.4 0.6 0.7 0.9
Ireland 0.8 1.8 1.8 1.6 2.0 1.9 2.2
Italy 1.7 2.9 2.8 2.6 3.2 3.3 3.9
Luxembourg 1.4 3.1 3.0 2.8 3.4 3.3 3.8
Netherlands 3.4 8.2 7.7 7.5 9.0 8.4 9.2
Norway 2.2 4.5 4.3 4.1 4.9 4.6 5.3
Poland 0.4 0.9 0.9 0.8 1.0 1.1 0.9
Portugal 0.1 0.2 0.2 0.2 0.2 0.2 0.2
Slovakia 0.2 0.5 0.5 0.5 0.5 0.6 0.5
Spain 0.5 1.4 1.3 1.3 1.5 1.4 3.0
Sweden 3.5 5.5 5.3 5.0 6.1 5.8 6.3
United Kingdom 0.8 1.3 1.2 1.2 1.4 1.3 1.3
OECD-EU average 1.3 2.4 2.3 2.2 2.7 2.5 2.9
Selected non-EUOECD countries
2006
Australia 0.8 1.8 1.6 1.7 2.0 2.0 2.4
Canada 1.2 2.7 2.4 2.4 2.9 2.7 3.4
Japan 1.4 4.0 3.5 3.6 4.4 4.0 4.4
New Zealand 1.4 3.9 3.6 3.5 4.3 4.6 6.2
United States 1.0 1.9 1.7 1.7 2.1 2.2 2.6
Selected non-EUOECD average
1.2 2.9 2.6 2.6 3.2 3.1 3.8
Sources: OECD calculations based on 3,6,7
Notes: a. Public LTC expenditure as presented in the European Commission 2009 Ageing Report. For 2007, figures may differ from those found inOECD Health Data, as information from Eurostat was used to complement available data. Public LTC expenditure may reflect a broader rangeof expenditures, including cash or in-kind support for services for instrumental activities of daily living.
b. Data for the Czech Republic only reflect public health insurance fund expenditure and do not include expenditure on attendance allowances. c. The projection unit costs are indexed to GDP per worker and do not reflect current German legislation under which all LTC benefits are
indexed to prices.
The types of services included in coverage.Targeting the basket of services needs toaddress users’ legitimate requests forchoice, with appropriateness and flexibilityover time. A special challenge will be posedby the growing number of users with cog-nitive dependencies. To address arbitragesin setting the basket of services and toenhance user choice, a number of countriessuch as Austria, France, Germany, Italy,the Netherlands and the United Kingdomare providing cash entitlements to care.
Second, there is a potential role for govern-ments to facilitate the mobilisation of cashto help users pay for the costs of board andlodging in LTC institutions. It is to beexpected that LTC users will need toallocate a share of their income or accumu-lated savings to pay for meals and housing,no matter where they live. Yet these costs,typically not covered by public LTCschemes or subject to significant costsharing, can be twice or thrice as much asthe cost of personal care services. They canrapidly force users to deplete all their accu-mulated income and assets. There are anumber of possible mechanisms to helpusers with low and moderate incomes butaccumulated assets to turn some of theseassets (for example, a house) into cash topay for such expenses. An example ofpublic measure is the Irish Nursing HomeLoans under which a resident can defer tothe time of his or her death their nursinghome contribution set on the basis of thevalue of their non-financial assets, such astheir home. Under the scheme the value oftheir principal residence is included in thefinancial assessment for a three-year period.
Third, once a basic LTC protection systemhas been designed, it is vital to ensure thatfinancing is fiscally sustainable over thelong-run. All OECD countries have yearlybudgeting mechanisms to align LTC rev-enues and expenditures, but the expectedlong-term increase in age-related spendingrequires forward-looking financingpolicies such as:
Tax-broadening, i.e., financing beyondrevenues earned by the working-age pop-ulation. Japan, the Netherlands, Belgiumand Luxembourg complement payrollcontributions with alternative revenuessources.
Better pooling across generations, whichimplies avoiding unduly charging (dwin-dling) young population cohorts to pay forLTC costs of a growing cohort of oldpeople. In Japan, LTC premia are levied onthose aged 40 years and over. In Germany,
retirees are also required to contributepremia to social LTC insurance, based ontheir pensions.
Pre-funding elements, which impliessetting aside some funds to pay for futureobligations. While a fully-funded systemmay not be justifiable given the uncertaintysurrounding future LTC needs, privatecompulsory LTC insurance in Germanyincludes some pre-funding elements. TheSingapore Eldershield Programme is, inprinciple, fully-funded. In tax-funded LTCschemes, this would mean building afavourable fiscal position through a lowerdebt-to-GDP ratio.
Innovative approaches exploiting consumerinertia and public-private partnership. Vol-untary funding schemes based onautomatic enrolment with potential opt-outs are being implemented in the UnitedStates (the so-called Class Act) and havebeen established in Singapore. These initia-tives borrow features from both public andprivate insurance, although the voluntarynature of enrolment remains a challenge totheir management.
ConclusionsAs OECD countries age, addressing thetrade-off between providing ‘fair’ basicuniversal coverage and achieving fiscal sus-tainability will become more urgent.Convergence towards targeted univer-salism on the benefit eligibility side andbroad collective financing on the revenueside have the potential to strike a rea-sonable balance between these twocompeting priorities.
REFERENCES
1. Lafortune G, Baléstat G. Trends in se-vere disability among elderly people: as-sessing the evidence in 12 OECD countriesand the future implications. OECD HealthWorking Papers 2007; 26.
2. Colombo F, Llena Nozal A, Mercier J,Tjadens F. Help Wanted? Providing and Paying for Long-term Care. Paris: OECD,2011. Available atwww.oecd.org/health/longtermcare
3. Directorate General for Economic andFinancial Affairs and Economic PolicyCommittee. The 2009 Ageing Report: Economic and Budgetary Projections for the EU-27 (2008–2060). Luxembourg:Commission of the European Communities, 2009.
4. OECD Labour Force and DemographicDatabase. Paris: OECD, 2010.
5. OECD Health Data. Paris: OECD, 2010.
6. Duval R, de la Maisonneuve C. Long-run GDP growth scenarios for the worldeconomy. OECD Economics DepartmentWorking Papers, 2009; 663.
7. OECD. Projecting OECD health andlong-term care expenditures: what are themain drivers? OECD Economics Department Working Papers, 2006; 477.
ACKNOWLEDGEMENT
This article is based on Colombo, F. et al(2011), Help Wanted! Providing and Pay-ing for Long-Term Care published by theOECD. The opinions expressed and argu-ments employed herein do not necessarilyreflect the official views of the OECD.
Eurohealth Vol 17 No 2–3 6
AGEING AND LONG-TERM CARE
In a world where there is increasing demand for the performance ofhealth providers to be measured, there is a need for a more strategicvision of the role that performance measurement can play in securinghealth system improvement.
This volume meets this need by presenting the opportunities andchallenges associated with performance measurement in a frame-work that is clear and easy to understand. It examines the variouslevels at which health system performance is undertaken, the tech-nical instruments and tools available, and the implications using thesemay have for those charged with the governance of the health system.
Performance Measurement for Health SystemImprovement: Experiences, Challenges and Prospects
Edited by Peter C. Smith, Elias Mossialos, Irene Papanicolas and Sheila Leatherman
Now free to download
Cambridge UniversityPress, 2009
726 pages
ISBN: 978 0 521 13348 7
Available at: http://www.euro.who.int/en/home/projects/observatory/publications/studies
Eurohealth Vol 17 No 2–37
AGEING AND LONG-TERM CARE
Disability, as measured by the ability toundertake basic activities of daily living(ADLs) for self-care, is a major driver ofthe need for long-term care (LTC). Projec-tions of future need for LTC generallyassume that either the prevalence of dis-ability will remain constant within agegroups or that it will reduce as incomingcohorts of older people are healthier. Thelatter view is not universally held; anOECD review of the trends in ability toself-care at age 65 and over found that onlyhalf of the eight countries included showedclear decreases in disability rates.1
Moreover evidence for this in the UnitedKingdom is equivocal, with one study sug-gesting an increase of 31% in theprevalence of moderate disability in theyoung old (65–69 years) between 1991 and19972, whilst another reported a decreasein high dependency between 1998 and2008 of 6% in men and 39% in women.3
Focussing solely on disability as a driver ofLTC neglects the fact that all conceptualmodels of the disablement process begin
with active pathology or disease.4 Cardio-vascular and cerebrovascular disease,sensory problems (vision and hearing),arthritis, incontinence, dementia anddepression are major causes of late-life dis-ability5 and there have been considerabletemporal changes in a number of these.However, very old age, where demand forLTC is greatest, is not characterised bysingle diseases but by multi-morbidity.6 Inaddition to the co-occurrence of disease,treatments for one disease may have bene-ficial effects for others whilst lifestylefactors such as smoking and obesity, thelatter with increasing prevalence over time,are risk factors for a number of diseases.Not only do these relationships cast doubton the assumption that age-specific preva-lence rates of disability will remainconstant, but they also imply that pro-jecting disability through models of singlediseases and their risk factors is unrealistic.This article reports the findings from amacro-simulation model, SIMPOP, onhow trends and treatments in multiple
chronic conditions: arthritis, coronaryheart disease (CHD) and strokes, as well asdementia and cognitive impairment, mightimpact on disability and the future demandfor LTC. It is worth noting that assump-tions about future disability levels have avery important impact on future expen-diture on LTC*.
Modelling the impact of multiple diseaseson disabilityThe macro-simulation model, SIMPOP,projects the number of older people (aged65+ years) with disability from two-yeartransition probabilities to and from dis-ability and to death derived from the MRCCognitive Function and Ageing Study(MRC CFAS),7 and then applied to the1992 mid-year England and Wales revisedpopulation estimates. Disability was basedon inability to perform activities of dailyliving and chosen to be parsimonious witha model of LTC needs and costs.8
Disability prevalence at baseline (1991–92)ranged from 3.7% at 65 to 66 years to58.7% at 91 years and over. The sixteendiseases and conditions included in the
The impact of changing patterns ofdisease on disability and the needfor long-term care
Carol Jagger, Ruth Matthews, James Lindesay and Carol Brayne
Summary: Projections of need for long-term care generally assume constant age-specific disability prevalence or reductions based on the improved health of incomingolder cohorts. Explicit linkages to trends in disabling diseases are rarely made. Weaddress this through a macro-simulation model, SIMPOP, with three healthscenarios: (i) constant age-specific disease prevalence; (ii) reduced disease prevalenceand disease-specific disability; and iii) continued trends of increasing diseaseprevalence and disabling effect. We find that assumptions of constant or reduced age-specific disability prevalence in all age groups over the next 20 years still result in large increases in the numbers requiring long-term care.
Keywords: Ageing, disability, simulation model, age-related disease, long-term care.
Carol Jagger is AXA Professor of Epidemiology of Ageing, Institute for Ageing andHealth, Newcastle University. Ruth Matthews is Research Fellow and James Lindesay isEmeritus Professor of Psychiatry for the Elderly, Department of Health Sciences, Univer-sity of Leicester. Carol Brayne is the Professor of Public Health Medicine, Department ofPublic Health and Primary Care, Institute of Public Health, Cambridge University.MRC CFAS, http://www.cfas.ac.uk Email: [email protected]
* In Comas Herrera et al in this issue, thedisability scenarios presented here are usedto show how sensitive future LTC expendi-ture will be to changes in disability.
model were generally self-reported,although diagnostic scales were used forangina, peripheral vascular disease andcognitive impairment. Estimates of theprevalence of CHD (defined as heart attackand/or angina), stroke, arthritis, diabetesand Parkinson’s disease in 2006 fromSIMPOP were compared to the HealthSurvey for England (HSE) 2005,9 and werefound to be close, the exception being dia-betes whose prevalence was then increasedin SIMPOP to national values. More detailon SIMPOP and the measures areavailable.10 The condition with the highestprevalence was arthritis which wasreported by 52.3% of the 65+ populationat baseline.
Health and disease scenariosThree parameters for each disease could bealtered in SIMPOP to mimic futurechanges in mortality and morbidity: thedisease prevalence and the probabilities ofdeath and disability within two years con-ditional on the disease. To inform themagnitude of change, literature onarthritis, stroke, CHD and dementia, inboth those currently aged 65 years andover and in those who would be 65+ by2030, was systematically reviewed for evi-dence on: trends and risk factors;disease-specific disability; preventivestrategies and treatments and their efficacy,cost-effectiveness and diffusion.11 Giventhe paucity of data on the impact of inter-ventions in any of the disease areas,particularly on disability, we assumed achange of 5% in either the transition prob-abilities to onset of disability or to death torepresent a small impact, and 10% a mod-erate impact. Based on the reviews, threeglobal scenarios were developed andapplied to SIMPOP to produce numbersof older people with and without disabilityand age-specific disability and diseaseprevalence from 2010 to 2030 (Box 1).
Projections under different health scenariosThe Central Health Scenario suggests thatbetween 2010 and 2030 there will be anincrease of 49% in the total older popu-lation (65+), from 9.2 million to 13.7million, although there will be a muchgreater rise in the numbers with disability(89%, 901,000) (Table 1). This results fromthe rising numbers of older people withkey disabling diseases which occur despitethe scenario’s assumption of constantdisease prevalence, since numbers in the 85and over age group increase by 139% overthe time period in contrast to the 65–74 age
group which increases by 41%. Moreover,growth in the numbers aged 85 and overhas two further consequences. Firstly,there are different proportionate increasesin diseases, from 40% for diabetes to 80%for dementia, the prevalence of the latterrising more strongly with age. Secondly,the prevalence of disability increases (Table1), showing that constant disease preva-lence with population ageing does notimply constant disability prevalence.
Improvements in the prevalence of dis-ability for the incoming cohorts (65-66year olds) in the Improving PopulationHealth Scenario have a modest effect onthe numbers with disability and prevalenceby 2010, mostly in the youngest age group(Table 1). Further reductions in mortalitydue to disease prevention will cause thesize of the older population as a whole toincrease further, by 52% with 172,000fewer disabled older people than under theCentral Health Scenario. Nevertheless,these reductions are relatively small whencompared to the extra numbers requiringLTC under the Central Health Scenario,some 901,000 between 2010 and 2030. Inaddition, with this level of healthimprovement the prevalence of disabilitystill increases, by 2.4% in those aged 85plus (Table 1).
If current health trends continue there willbe slightly fewer older people in total thanprojected under the Central Health Sce-
nario and marginal increases in thenumbers with disability and diseases, par-ticularly stroke and dementia. But theprevalence of disability at a level that willrequire LTC will rise by over 10% in theoldest old.
ConclusionHow realistic are the scenarios that wehave explored and why were they selected?The Central Health Scenario assumes a‘status quo’ in that levels of disease andonset and recovery from disability willremain at the same levels as they werebetween one and two decades earlier. Thisscenario may also reflect that any positivehealth changes, such as reductions in riskfactors or more effective treatments fordisease, are offset by the changing compo-sition of new cohorts which will comprisegreater proportions of ethnic minorities,particularly those from South Asia, whoare known to have high rates of CHD, dia-betes and stroke, though little is known ofwhether the disabling effects of these dis-eases are the same as for the whitepopulation. Thus, the Central Health Sce-nario can be thought of as representing theeffect of population ageing alone. This sce-nario clearly shows that population ageingwill result in an increasing trend in dis-ability prevalence and a substantial increaseof almost one million in the numbers ofolder people needing LTC, many of thesebeing the very old with multiple diseases
Eurohealth Vol 17 No 2–3 8
AGEING AND LONG-TERM CARE
Box 1: Global health scenarios modelled in SIMPOP
Central Health Scenario
Prevention strategies and effective treatments offset the negative influences of obesity and other cohort trends; for example, the emergence of ethnic minorities (with increased CHD, stroke and diabetes) into older cohorts. Age-specific prevalence of diseases, incidence of, and recovery ratesto dependency, all remain at 2006 levels and mortality rates decline at levels commensurate withthe Office for National Statistics principle projections.
Improving Population Health Scenario
Individuals take their health seriously with a decline in risk factors, particularly smoking and obesity, reducing the prevalence of stroke, CHD, arthritis and mild cognitive impairment (CI) (by2% every two years from 2012). The health service is responsive with high rates of technology uptake for disease prevention and excellent diffusion rates of treatments to all who can benefit,particularly in terms of control of vascular risk factors (10% decrease in disability onset for arthritis,stroke, CHD and mild CI from 2012 and a further 5% reduction in mortality from stroke, CHD andmild dementia from 2016). New cohorts of older people are healthier than previous ones (5% re-duction in prevalence of disability for each cohort).
Continuation of Current Trends Scenario
Current obesity trends of 1–2% increase annually continue, resulting in higher prevalence of arthritis, stroke, CHD and vascular dementia (2% increase every two years from 2012) but alsotheir associated disability (10% increase in onset of disability for these diseases). Ethnic minoritiesenter the older population in significant numbers and add to the prevalence of stroke and CHD. Treatments continue to focus on reducing mortality (further 5% reduction in mortality from stroke,CHD and mild CI from 2016).
and conditions, and with 80% more olderpeople with dementia.
Evidence for reductions in the levels of dis-ability in the older population worldwideare varied.1,12 Even in countries such as theUnited States where declines have occurredin the region of 1–2% per year over the last20 years, these are alongside increases inthe prevalence of chronic disease, sug-gesting that more effective treatments andgreater use of assistive technology are
allowing older people to remain inde-pendent. Our choice of reductions of 2%every two years is therefore conservativein US terms but optimistic for countriessuch as Sweden where disability prevalencehas increased. More importantly, assump-tions that the prevalence of disability willremain constant are optimistic since evenwith improving population health, dis-ability prevalence in the very old hascontinued to increase. Our worst-case sce-
nario assumes a continuation of currenthealth trends, although the ageing of theAsian population in the United Kingdom,with its higher levels of CHD, stroke andobesity, suggests that this scenario may beoptimistic. If current levels of healthprevail and obesity trends continue, theolder population with disability at a levelthat will require care will almost doublebetween 2010 and 2030. Thus, effortsshould now be focused not only on diseaseprevention but on slowing down the pro-gression to disability.
REFERENCES
1. Lafortune G, Balestat G. Trends inSevere Disability Among Elderly People:Assessing the Evidence in 12 OECDCountries and Their Future Implications.Paris: OECD, 2007.
2. Jagger C, Matthews RJ, Matthews FE etal. Cohort differences in disease anddisability in the young-old: findings fromthe MRC Cognitive Function and AgeingStudy (MRC-CFAS). BMC Public Health2007;7:156.
3. Donald IP, Foy C, Jagger C. Trends indisability prevalence over 10 years in olderpeople living in Gloucestershire. Age andAgeing 2010;39(3):337–42.
4. Verbrugge LM, Jette AM. TheDisablement Process. Social Science andMedicine 1994;38(1):1–14.
5. Stuck AE, Walthert JM, Nikolaus T, BülaCJ et al. Risk factors for functional statusdecline in community-living elderly people:A systematic literature review. SocialScience and Medicine 1999;48:445–69.
6. Collerton J, Davies K, Jagger C et al.Health and disease in 85 year olds: baselinefindings from the Newcastle 85+ cohortstudy. British Medical Journal2009;399:b4904.
7. The Medical Research Council CognitiveFunction and Ageing Study. Cognitivefunction and dementia in six areas ofEngland and Wales: the distribution ofMMSE and prevalence of GMS organicitylevel in the MRC CFA Study. PsychologicalMedicine 1998;28:319–35.
8. Wittenberg R, Darton R, Comas-Herrara A, Pickard L, Davies B. Demandfor long-term care for older people inEngland to 2031. Health StatisticsQuarterly 2001;12:5–17.
9. Craig R, Mindell J (eds). Health Surveyfor England 2005. Volume 2: ChronicDiseases. Leeds: The Information Centre,2007.
10. Jagger C, Matthews R, Lindesay J,
Eurohealth Vol 17 No 2–39
AGEING AND LONG-TERM CARE
Table 1: Simulated total and disabled populations (thousands) aged 65+ for Central Health Scenario, Improved Population Health Scenario and continuation of current trends
2010 2020 2030
Central Health Scenarioa
Total population (1,000s) 9,181 11,224 13,663
Disabled population (1,000s) 1,011 1,366 1,912
Prevalence of disability 65+ (%)65–74 (%)75–84 (%)85+ (%)
11.05.2
11.931.1
12.25.5
12.734.7
14.05.4
13.537.9
Improved Population Health Scenariob
Total population (1,000s) 9,189 11,324 14,033
Disabled population (1,000s) 985 1128 1740
Prevalence of disability 65+ (%)65–74 (%)75–84 (%)85+ (%)
10.74.7
11.931.1
10.74.5
11.832.3
12.44.1
12.033.6
Continuation of Current Trends Scenarioc
Total population (1,000s) 9,181 11,186 13,438
Disabled population (1,000s) 1,011 1,431 2,058
Prevalence of disability 65+ (%)65–74 (%)75–84 (%)85+ (%)
10.74.7
11.931.1
12.85.7
13.436.7
15.35.8
15.242.7
Notes:a Assumption of no change in age-specific prevalence of disease, incidence and recovery rates todisability, and mortality rates continuing to decline at levels commensurate with Office for NationalStatistics principal projections.b Assumption of reduction in the prevalence of arthritis, stroke, CHD and mild dementia by 2% everytwo years from 2012 and for moderate/severe dementia every two years from 2016, a 10%decrease in disabling consequences of arthritis, stroke, CHD and mild dementia from 2012, a further5% reduction in mortality from stroke, CHD and mild dementia from 2016, and prevalence ofdisability in 65–66 year olds reducing by 5% every two years.c Assumption of increase in the prevalence of arthritis, stroke, CHD and mild dementia by 2% everytwo years from 2012 and for moderate/severe dementia every two years from 2016, a 10% increasein disabling consequences of arthritis, stroke and CHD from 2012 and a further 5% reduction inmortality from stroke, CHD and mild dementia from 2016.
Eurohealth Vol 17 No 2–3 10
AGEING AND LONG-TERM CARE
As the numbers of older people rise, so doconcerns about future levels of expenditureon long-term care (LTC) and how this careshould be funded. In the last decades therehave been increasingly sophisticated effortsto project future LTC expenditure, both atnational and international levels. As LTCservices are very labour intensive and thereis limited scope for productivity improve-ments,1 the idea that future LTC costscould be contained as a result of care needsnot growing as fast as the future number of
older people has attracted a great deal ofattention. However, in many countriesthere no evidence that this may be thecase.2
Projections of LTC demand and associatedexpenditure have shown that relativelysmall changes in the prevalence rates offunctional disability can have a substantialimpact on future expenditure.3,4 Thismeans that it is important to choose care-fully the assumptions made about future
disability and dementia rates of olderpeople, as increases in the future numbersof older people may not necessarily beaccompanied by increases of the samemagnitude in the number of peoplerequiring LTC.
Projecting LTC expenditureThis article reviews different approaches tochoosing assumptions about the futurecare needs of older people, including:extrapolation from past trends; hypo-thetical decreases in prevalence rates inorder to take into account changes in lifeexpectancy; asking experts for their viewsabout the future; and projections based onexpected changes in the prevalence ofchronic conditions and mortality rates.
Robinson T, Croft P, Brayne C. The effectof dementia trends and treatments onlongevity and disability. Age and Ageing2009;38:319–25.
11. Jagger C, Matthews RJ, Spiers NA et al.Compression or expansion of disability?London: King's Fund, 2006. Available athttp://www.kingsfund.org.uk/document.rm?id=8290
12. Parker M, Thorslund M. Health trendsin the elderly population: getting better andgetting worse. The Gerontologist2007;47:150–58.
ACKNOWLEDGEMENTS
We are grateful for the cooperation of thethen Family Health Service Authorities (a function now embraced by Primary Care
Trusts) and local general practitioners andtheir staff for all their assistance in MRCCFAS (Medical Research Council/Cognitive Function and Ageing Studies).Thanks are especially due to the residents ofEast Cambridgeshire, Liverpool, YnysMon, Dwyfor, Newcastle upon Tyne, Nottingham and Oxford for their continuing participation in the study.
Disability, dementia and the futurecosts of long-term care
Adelina Comas-Herrera, Juliette Malley, Raphael Wittenberg, Bo Hu andCarol Jagger
Summary: Increasingly sophisticated efforts to project future long-term care (LTC)expenditure highlight that this is very sensitive to assumptions made about futurerates of disability and dementia. This article reviews different ways of formulatingsuch assumptions and gives examples of their impact on future LTC expenditure pro-jections in England. Using disability scenarios from an epidemiological model (basedon assumptions about chronic diseases and their outcomes and expected treatments),suggests that assuming constant prevalence of disability may be optimistic . The projections indicate that investing in cost effective public health and management ofchronic conditions measures that moderate disability or slow down the progression ofdementia may produce good returns in terms of reducing the future costs of LTC.
Key words: disability trends, dementia, long-term care expenditure, compression ofdisability, chronic conditions
Adelina Comas-Herrera is Research Fellow, Juliette Malley is Research Fellow, Bo Hu isResearch Assistant and Raphael Wittenberg is Senior Research Fellow at the Personal So-cial Services Research Unit, LSE Health and Social Care, London School of Economicsand Political Science. Carol Jagger is AXA Professor of Epidemiology of Ageing, Institutefor Ageing and Health, Newcastle University. Email: [email protected]
Assuming rates remain constant over time
The most basic method for projectingfuture LTC expenditure is to multiply age-specific LTC expenditure by the futurenumber of people in each age group. Thismethod assumes, implicitly, that disabilityrates do not change over time5,6 and thatageing is the only driver of expenditure.More complex projection methods allowexplicit analysis of the impact of changes inthe prevalence of functional disability anddementia (and socio-demographic vari-ables) on LTC expenditure.
In the face of the inevitable uncertaintyabout future disability trends, many pro-jections of future LTC expenditure haveassumed, as a base case, that disability anddementia rates by age remain constant overtime,3,7,8 while the future number of olderpeople needing care changes as a result ofchanges in life expectancy and other socio-demographic factors. The impact ofchanges to the unchanged prevalenceassumption is then explored by changingthe prevalence rates by a small percentageper year (such as 1% or 0.5%).
This assumption has often been criticisedas being pessimistic because it does notconsider possible postponements in dis-ability as life expectancy increases. Becauseage-specific prevalence is unchanged whileage-specific mortality rates are reduced,this assumption assumes that in the futureolder people will, on average, spend alonger period of their life in disability.
Extrapolating from past trends
Another approach, taken by Jacobzone etal.6 involves identifying past trends in dis-ability rates and then extrapolating thosepast trends into the future. There are twomain problems with this approach.
The first is that evidence from past trendsis limited because consistent longitudinaldata on the health and disability status ofolder people is only available for a fewcountries (see Jagger et al. in this issue).
The second problem is that the past maynot necessarily be the best predictor of thefuture. Social, economic, scientific andenvironmental changes can dramaticallyalter the patterns of mortality and disease.Epidemiologists use the term ‘epidemio-logical transition’9 to describe these shiftsin disease patterns. In recent years, forexample, there have been important reduc-tions in the age-specific mortality rates formajor cardiovascular diseases, which havein turn led to further delays in mortalitywhich, combined with higher rates of
obesity and lower smoking rates, couldpotentially lead to new increases in dis-ability rates.10
Projections based on hypotheses linked tochanges in life expectancy
In the context of the debate about the rela-tionship between the postponement ofmortality and possible postponements ofdisability, another approach used in LTCprojections has been the modelling ofhypothetical assumptions that linkexpected rise in life expectancy withassumptions about changes in age-specificdisability rates. An example of this is a sce-nario often called the ‘Brookings scenario’as it was originally used in projections byWiener et al.11 at the Brookings Institution.A typical example of this scenario can bedescribed as follows: if life expectancy atage 65 is projected to rise by three yearsbetween 2007 and 2030, then the disabilityrate of a person aged 65 in 2007 would beapplied to a person aged 68 in 2030.
This assumption effectively decreases dis-ability rates and, to a certain extent, cancompensate for increases in the number ofolder people when projecting LTC expen-diture.3,4,8 A similar version of this methodhas been used by the European Com-mission’s Economic Policy Committee(EPC) in the context of their projections offuture LTC expenditure.12 In fact, the ‘ref-erence’ (or base case) LTC projection in theEPC’s latest projections assumes that dis-ability rates will be postponed by half theincrease in life expectancy.
In the case of England, results from thePersonal Social Services Research Unit(PSSRU) Aggregate Long-Term Care forOlder People Model3 show that, if weassumed that for every year of lifeexpectancy gained, disability rates could bepushed back by one year, future LTCexpenditure for older people wouldamount to 1.9% of Gross DomesticProduct (GDP), compared to 2.7% underthe constant disability assumption.
This scenario has the advantage of beingintuitive, not requiring information aboutdisability trends, and being easy to cal-culate. However, due to its hypotheticalnature, the results of this scenario shouldbe treated with caution as they are notgrounded on evidence.
Asking experts their views about the future
Another approach, particularly as projec-tions of LTC expenditure tend to becarried out by economists, is to consultwith experts in the field, in order to obtaintheir views about future trends in disabilityand dementia rates. This normally involvesusing consensus building methods (such asa Delphi or focus group) in order to find aset of assumptions about the future that agroup of experts agree with.
The Delphi approach was used to obtainscenarios about the future prevalence ofdementia and the future care needs of indi-viduals living with dementia.13 A panel ofexperts on dementia, including old agepsychiatrists, neurologists, public healthdoctors, basic scientists, health economistsand service professionals, consideredvarious future scenarios and were, overall,moderately optimistic about the impact offuture scientific advances and changes inrisk factors on the future prevalence ratesof dementia. However, the panel alsowarned that improvements in the qualityof care were required, which may offsetsome of the potential savings fromdecreased prevalence.
This type of research does present someimportant challenges. First of all, it is verydifficult to establish the representativenessof a panel of experts. Second, translatingthe view of the expert panel into scenariosthat can be modelled may not be straight-forward, unless the panel is given very clearparameters.
Using projections from epidemiologicalmodels of chronic conditions and their disabling and mortality outcomes
As the paper by Jagger et al (in this issue)highlights, the process by which olderpeople develop care needs is complex andunderstanding how those care needsemerge is key to being able to model them.As part of the MAP2030 project, theSIMPOP* model by Jagger et al. has beenlinked with the PSSRU Aggregate Long-Term Care for Older People Model,3
enabling the PSSRU model to produceprojections of future expenditure on LTCfor older people for the health and diseasescenarios in SIMPOP.
Combining the Central Health Scenariodisability rates obtained by the SIMPOP
Eurohealth Vol 17 No 2–311
AGEING AND LONG-TERM CARE
* SIMPOP is a macro-simulation model that projects the numbers of older people (aged65+ years) with disability from two-year transition probabilities to and from disability andto death, and is then applied to the 1992 mid-year England and Wales revised population estimates. See Jagger et al in this issue.
model (which assumes unchanged preva-lence of chronic conditions and riskfactors) with the PSSRU aggregate modelresults in higher future LTC expenditurethan in the previously used base caseassumption of unchanged age-specific dis-ability rate (by 2032, total LTCexpenditure would have grown to 3.2% ofGDP rather than 2.7%).
The reason for this is that if the prevalencerates of chronic conditions and risk factorsremain unchanged and their disability andmortality outcomes also remainunchanged, while life expectancy continuesto increase, more older people will bespending longer periods of their life in dis-ability; hence, the overall age-specificprevalence of disability will increase. Thissuggests that maintaining unchanged dis-ability rates in the LTC model (in thecontext of increased life expectancy) wouldbe an optimistic assumption, compared toan assumption of unchanged prevalence ofchronic conditions.
Under the Improving Population HealthScenario, LTC expenditure in 2032 wouldamount to 3.0% of GDP. This compareswith 2.7% projected under the constantdisability rates assumption. The Continu-ation of Current Trends Scenario wouldresult in even higher levels of expenditure– 3.3% by 2032.
ConclusionsMaking projections about the future of anykind inevitably involves a great deal ofuncertainty and, despite best efforts, allpast projections will always turn out tohave been at least slightly wrong.Choosing the right assumptions about thefuture levels of care needs is a clearlyimportant aspect of making projections offuture LTC expenditure.
This article has reviewed different assump-tions made about future disability trendsand methods, in the context of increasedlife expectancy. Recent projections fromour epidemiological model in Englandsuggest that assuming constant disabilityor dementia prevalence rates is an opti-mistic rather than pessimistic assumption.
Policy-makers using LTC expenditureprojections to make decisions need to beaware of quite how much uncertainty thereis about future disability rates and thatsubstantial investment in public health andthe management of chronic conditions willbe required to avoid LTC expendituregrowing even faster than expected.
REFERENCES
1. Oliveira Martins J, de la Maisonneuve C.The Drivers of Public Expenditure onHealth and Long-Term Care: An Inte-grated Approach. OECD Economic Stud-ies, No. 43, 2006/2. Paris: OECD, 2006.
2. Lafortune G, Balestat G and the Disabil-ity Study Expert Group Members. Trendsin severe disability among elderly people:assessing the evidence in 12 OECD coun-tries and the future implications. OECDHealth Working Papers 2007; 26.
3. Wittenberg R, Pickard L, Comas-Herrera A, Davies B, Darton R. Demandfor long-term care for elderly people inEngland to 2031. Health Statistics Quarterly 2001;12:5–16.
4. Rothgang H, Comas-Herrera A, Wittenberg R. Dependency rates and healthexpectancy. In: Comas-Herrera A, Wittenberg R (eds). European Study ofLong-Term Care Expenditure. Report tothe European Commission, Employmentand Social Affairs DG. PSSRU DiscussionPaper 1840. London: PSSRU, 2003.
5. Economic Policy Committee. BudgetaryChallenges Posed by Ageing Populations.Brussels: Commission of the EuropeanCommunities, 2001. At:http://europa.eu/epc/pdf/summary_en.pdf
6. Jacobzone S, Cambois E, Robine JM. Is the health of older persons in the OECD countries improving fast enough to compensate for population ageing? OECDEconomic Studies 2000; 30:1. .
7. Wittenberg R, Pickard L, Comas-Her-rera A, Davies B, Darton R. Demand forLong-Term Care: Projections of Long-termCare Finance for Elderly People. Universityof Kent: PSSRU, 1998. Available at:http://www.pssru.ac.uk/pdf/ltcrep98.pdf
8. Comas-Herrera A, Wittenberg R,Pickard L, Knapp M. Cognitive impair-ment in older people: future demand forlong-term care services and the associatedcosts. International Journal of GeriatricPsychiatry 2007;22:1037–45.
9. Olshansky SJ, Ault AB. The fourth stageof the epidemiologic transition: the age ofdelayed degenerative diseases. The MilbankQuarterly 1986;64(3):355–91.
10. Reuser M, Bonneux LG, Willekens FJ.Smoking Kills, Obesity disables: a multi-state approach of the US Health and Re-tirement Survey. Obesity 2009;17:783–89.
11. Wiener JM, Illston LH, Hanley RJ.Sharing the Burden: Strategies for Publicand Private Long-term Care Insurance.Washington: The Brookings Institution,1994.
12. Economic Policy Committee. 2009Ageing Report Economic and budgetaryprojections for the EU-27 Member States(2008–2060). Brussels: Commission of theEuropean Communities, 2009. Available at:http://ec.europa.eu/economy_finance/pub-lications/publication14992_en.pdf
13. Comas-Herrera A, Northey S, Wittenberg R, Knapp M, Bhattacharyya S,Burns A. Future costs of dementia-relatedlong-term care: modelling scenarios aboutthe future. International Psychogeriatrics2011;23(1):20–30.
ACKNOWLEDGEMENTS
This paper arises from work undertaken aspart of the Modelling Ageing Populations to2030 (MAP2030) project funded under agrant from the New Dynamics of AgeingProgramme in the UK, a cross-researchcouncil programme (RES-339-25-0002). Allresponsibility for analysis and interpretationand views expressed rests with the authors.
Eurohealth Vol 17 No 2–3 12
AGEING AND LONG-TERM CARE
INTERNATIONAL LONG-TERM CARE POLICY NETWORK
ILPN is a network of professionals, institutions and associations involved in long-term care (LTC).
The network was launched in September 2010 to promote global exchange of policy evidence andknowledge related to LTC and is presently based at the London School of Economics and PoliticalScience, United Kingdom.
ILPN is the first network of its kind providing an interface between researchers, policy makers andother stakeholders, facilitating contributions to, and sharing of the evidence base, which would be ofsignificant assistance in shaping and improving policies and practices in LTC. From an academicpoint of view, the Network will foster international research collaborations, and will assist thedevelopment of international comparative policy analysis.
For further information about the Network and how to join go to: http://www2.lse.ac.uk/LSEHealthAndSocialCare/PSSRU/ILPN/ILPNetwork.aspx
Eurohealth Vol 17 No 2–313
AGEING AND LONG-TERM CARE
More need for long-term care, but fewerpotential providers expectedMore than half of all LTC users are agedover 80 years in OECD countries, varyingfrom 27% of people in this age cohort inHungary to 64% in Japan.1 In Europe, onein four people aged over 85 years has hadpersonal experience with a prolonged needfor care.2 Yet, use of LTC varies widelyacross countries: of those aged over 80years between 2% of women and 3% ofmen in Poland, and 46% of women and32% of men in Norway, use formal LTCservices.
People aged 80 years or older are the fastestgrowing population segment in Europe,and life expectancy at age 65, and even atage 80, keeps increasing.3 In thirty of theOECD* countries, almost 10% of thepopulation will be over 80 years of age by2050, a near tripling compared to thecurrent share across the OECD. Over thesame period the share of the populationaged between 15 and 64 years is set todecrease from 67% in 2010 to an unprece-dented 58% by 2050 (Figure 1). Thenumber of people in an ‘extended caring-age’ population (15–79 years) for eachperson aged over 80 years will drop to lessthan a third of 2000 levels: in 2000 therewere 26 people per person over 80 falling
to less than eight people per person by2050. Meanwhile, the average age of peoplein this ‘extended caring-age population’will increase due to the higher share ofpeople aged between 65 and 79 years.**�
Family relationships and household modelsare changing too, due to decreasing fertilityrates, individualisation and increasing geo-graphical distance between familymembers. Increased divorce and falling
Long-term care: valuing careproviders
Frits Tjadens and Francesca Colombo
Summary: Long-term care can be defined as consisting of nursing care and assistancewith so-called instrumental activities of daily living (ADL), such as washing, eating,getting in and out of bed, provided to people with reduced functional and health sta-tus over an extended period of time. This article discusses some trends in demographyand use of long-term care (LTC) as a context for policy options related to family careand LTC workforces in Organisation for Economic Cooperation and Development(OECD) countries. It draws on a new OECD report on long-term care,1 reviewssome of the outcomes in terms of long-term requirements for human resources forLTC and discusses options to reduce demand for care and to support family carers.
Keywords: Long-term care workers, informal carers, human resources, carer support
Frits Tjadens is owner, Health and SocialCare Associates, Rotterdam, the Nether-lands. Francesca Colombo is senior healthpolicy analyst in the OECD Health Division. Email: [email protected].
*� These data consider 30 of the 34 OECD member countries. It does not include recentaccession countries: Israel, Chile, Slovenia, and Estonia, who all have relatively youngpopulations. Nevertheless, the overall trend remains unchanged.
** In Japan, Germany, and a number of Middle and Eastern European countries (Bulgaria,Latvia, Lithuania, Romania, Estonia, Hungary, Poland, Slovakia, Slovenia) this will coincidewith a steep reduction in the overall size of the population.
Figure 1: Working age population and population aged over 80 years as share of thetotal population, OECD, 1950–2050
Source: OECD Labour Force and Demographic Database, 2010.
54%
56%
58%
60%
62%
64%
66%
68%
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500%
2%
4%
6%
8%
10%
persons aged 80+as % population
potential helpers (age15–65)as % population
marriage rates contributed to an increasefrom 16% in 1960 to 29% by 2001 in theshare of single-person households in theEU25 2001.4 Almost one in three peopleaged 55 years and over lives alone inEurope.5 As the most intensive (and bur-densome) family care is provided within ahousehold,1,6 those living alone may partic-ularly find themselves in need of formalLTC services. The growth of the absolutenumber of older people living alone maytherefore add to the increase in the need forcare resulting from population ageing, eventhough the shares of those living alone atage 60 or 80 in the European Union areexpected to remain more or less stable.4
Demographic trends suggest increasingtensions between the need for care and thesupply thereof. While family networks arethinning, these trends may result in largershares of the population being required tocare for a family member or friend. Fur-thermore, the increase in the number of theoldest old living alone and the reducingcaring potential in societies will increasedemand for LTC workers. How will coun-tries cope?
Care workers: recruit them, keep themand increase productivityThe LTC workforce consists mostly ofwomen working part-time; which in theLTC sector occurs more often, and withfewer hours per week, than in other sectorsof the economy. While these workers oftenhave a high appreciation of their work,(staffing) shortages, bad management,harsh circumstances, poor working condi-tions and a lack of recognition or valuationof their job contributes to poor job satis-faction and a feeling of dissatisfaction withthe outcomes of their work, leading nursesin Europe, for instance, to burn out.7
Wages are usually lower than a country’saverage wages, work experience does nottranslate into higher wages, secondary ben-efits are often not granted, shifts are brokenand do not easily enable reconciliationbetween family and caring tasks, contractsrequire utmost flexibility but do not offerjob security and the work can be physicallyand psychologically demanding and bur-densome. Worker-safety measures may belacking and violence from those cared foris not uncommon. All these factors stim-ulate high and costly turnover and cancontribute to low productivity and carequality.1
Yet it remains the case that more than halfof the EU27 population believe that olderpeople rely too much on their relatives for
support and care, ranging from 42% inDenmark to almost 100% in Bulgaria.2
Enhancing the supply of formal careworkers can be seen as one way to supportfamily carers: indeed, the higher acountry’s LTC expenditure, the fewer thenumber of people who think that there istoo much reliance on relatives (Figure 2).
A growing number of countries are devel-oping formal LTC coverage and deliverysystems. Yet, many OECD countriesstruggle with the recruitment and retentionof LTC workers. Attracting and retainingworkers, and improving productivity maywell be required to face up to futuredemand. How can countries implementsuch policies? The next section discussesthe main challenges in managing demandfor LTC workers and creating successfulpolicies.
Even with shrinking recruitment pools,there is potential for growth in the LTCworkforceWhile the LTC sector is set to more thandouble by 2050, two major recruitmentpools for LTC workers are shrinking: (1)middle-aged women; (2) inactive womenand those with low qualifications (due toboth rising labour market participation and
educational levels). In addition, the globalnursing shortage8,9 may lead to increasingnursing shortages in the LTC sector, ascompetition between countries, regionsand sectors to attract nursing professionalsintensifies. Often, LTC systems andemployers are in a bad position to competein times of nursing shortages due to lowwages, lack of targeted training and jobprospects and poor working conditions.
In most countries, the LTC sector employsa relatively small share of the working-agepopulation, estimated at 1.5% across theOECD. There is reason to assume that anexpansion of this workforce is not onlymuch needed, but also possible. This oftentakes place in parallel to the developmentof formal LTC coverage schemes. Forexample, in countries such as Luxembourg,New Zealand and Japan, the LTC work-force as a share of the working-agepopulation is projected to reach the currentsize of the LTC workforce in Norway,Sweden or the Netherlands by 2050.1* Arelatively ‘old’ country with a substantialLTC workforce, the Netherlands, preparesto manage with a fully domestic LTCworkforce until 2025, through a wealth ofmeasures.10,11 Rapidly ageing countrieslike Germany and Japan have successfully
Eurohealth Vol 17 No 2–3 14
AGEING AND LONG-TERM CARE
Figure 2: LTC expenditures as a share of GDP and share of population that believethere is too much reliance on relatives for caring tasks, EU, 2007–08
Sources: 8 and OECD Health Database, 2010.
Note: Data relating to expenditure Slovakia and Luxembourg refer to 2006 and 2005 respectively; expenditure dataunderestimate private out of pocket payments or user co-payments. Data for Belgium, Czech Republic, Denmark,Iceland, Norway, and Switzerland represent nursing LTC only. Iceland: institutional care only
PT
CZR
SLK
HUPOL
ESP
SLO
AUT
GER
LUX FRA
BE
DKFIN
NL
SWE
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
0 0.5 1 1.5 2 2.5 3 3.5 4
Expenditure on LTC as % of GDP, 2008
% agreeing with too much reliance on relatives
y = -0.0775x + 0.8052 R2= 0.5039
managed an expansion in their LTCinsurance systems, and encouraged thedevelopment of a large LTC workforcesince the 1990s. Similarly, Spain, in thephase of preparation and implementationof its LTC law, experienced steep growthin its LTC workforce.
Proactive policies can facilitate thematching of supply with demandThe OECD expects many countries toimplement policies to stimulate an ade-quate supply of LTC workers in the future,often as a response to current or expectedworkforce shortages. Three main policiesto develop an adequate supply of LTCworkers exist:
1. Improving recruitment.
Countries aim to ensure adequate workerinflows by using the available workforcepools better, by opening up newrecruitment pools – such as those who haveleft, not yet entered or are distant from thelabour market, including men andmigrants. Another possibility is attractingforeign-born workers into the sector, eventhough few countries – such as Canada andAustralia – specifically include LTC as asector for labour immigration schemes orquotas. In some countries people in needof care who face high out-of-pocket pay-ments and/or those receiving cash-for-carebenefits, have managed to mobilise ‘ad-hoc’ – albeit sometimes unqualified oruncontracted – LTC workers, even whenthe ‘regular’ sector faces shortages. Finally,the decreasing average length of stay inhospitals could become an advantage forthe LTC sector, where interactions withthose in need are longer lasting.12,13
2. Improving retention
The key question, however, may be how toretain workers and how to stimulate themto work more hours per week and forlonger periods. Although wages in theLTC sector clearly matter, rising pay doesnot seem to be the primary or onlysolution. More important is the extent towhich LTC work and the workforce arevalued. Workforce policies could includespecific measures targeting the challengesof an ageing LTC workforce.14 ‘Worker-friendly’ policies – amongst whichimproving benefits, working conditions,empowering workers and giving them asay about work content, (continued) edu-
cation and career development, andincreasing job status – will have a signif-icant impact on the ability to maintain LTCworkers in their current occupations.1
Worker-friendly policies could translateinto better working conditions and con-tracts, for example substantial shares ofwomen across the OECD would prefer towork more hours. This would help a shiftfrom LTC occupations being merely dead-end jobs to professions with opportunitiesfor the workers to improve their qualifica-tions, for instance by offering options forpersonal and professional growth. Onesuch option is the setting up of courses andtraining modules that have a recognisedvalue in the system beyond the currentemployer, for instance by implementing asystem of national certification for trainingmodules. Such a system, set up to stimulateboth performance on the job as well asprofessional growth is, however, rare inOECD countries.
3. Increasing productivity
Increasing productivity and improvingvalue for money can go hand in hand withimprovements in working conditions.More say and more responsibilities forworkers, can lead, for instance, to lowerlevels of sickness leave.11 Technology cancontribute to both productivity andquality of care, even though evidence ofcost-effectiveness of technology in LTC isstill scarce. Across the OECD, variationsin the number of LTC workers per LTCrecipient and in skill mix (i.e., the share ofnurses relative to the share of lower-skilledLTC workers) suggests that there is scopefor enhancing productivity by changingstaffing ratios and workers’ mix of skills orqualifications. For instance, delegation ofnurses’ tasks to lower-qualified careworkers has been shown to lead to higherproductivity without loss of quality.15 Sim-ilarly, new mixes of tasks and functions canimprove productivity, while leading toboth better quality of care (and quality oflife) for the care recipient and better qualityof work for the worker.
Reducing demand: targeting servicesand stimulating self-managementSo far we have only looked at the supplyof LTC services and, consequentially, theneed for LTC workers. LTC is a highlylabour intensive sector and approximately60% of all LTC funding is directly related
to the LTC workforce. Reducing thedemand for care could mitigate the antici-pated rise in LTC expenditure and the needfor LTC workers. One strategy is to targetservices more narrowly towards thosemost in need of care. This seems to beoccurring in the aftermath of the economiccrisis. Another strategy is to reduce thedemand for care through preventiveapproaches and enhancing self-man-agement. Both are currently occurring butcountry circumstances vary widely, justlike their consequences for LTC systemsand ageing societies.
Economic crises and cutbacks change thedynamics of LTC labour marketsIn the wake of economic crisis, LTC oftenacts as a ‘safe haven’, reducing the sense ofurgency to further develop and implementjob improvement and retention strategiesfor LTC workers. For instance, numbers of(hard-to-fill) vacancies have recentlydropped in England and the Netherlands.People stay in the sector longer and morepeople apply for jobs in LTC in the UnitedStates. As baby-boom generation LTCworkers stay on the labour market forlonger, the expected need for a highnumber of replacements is mitigated.
The consequences for enrolment innursing education, however, are mixed.Where governments pay most costs, entryto training courses for LTC workers hasincreased, as in the Netherlands. In theUnited States on the other hand, whereindividuals pay a substantial share of thefee for their own tuition, the loss of a jobor assets by parents may lead to fewer pos-sibilities to pay for their children’seducation and thus may limit enrolment onLTC training courses. Furthermore, post-crisis cuts in funding for educationalfacilities may endanger the future supplyof qualified workers.
Social protection, including LTC is amongthe most widely targeted area for publicexpenditure cuts (see http://tinyurl.com/3vpymu3). Nonetheless, during the firsthalf of 2010 the current crisis had not yettriggered cost-cutting measures in the LTCsector in half of all EU countries.16 Policieswere rather aimed at de-institutionali-sation, as well as improving access both tohome care and end-of-life care.
As the crisis progresses, new measures maywell target LTC services, almost directlyimpacting on the need for care workers.17
While such strategies risk ignoring long-term growth in need and endanger thesustainability of some LTC services, they
Eurohealth Vol 17 No 2–315
AGEING AND LONG-TERM CARE
*� Changes in coverage or access of LTC services will impact on the required workforce. If,for instance, the Czech Republic aims for a more comprehensive and easier accessible LTCsystem, this will require more services and thus, a bigger than projected LTC workforce.
can encourage a reduction in waste and adesirable focus on improving value formoney and productivity in the sector.However, such strategies may well increasethe burden on family carers.
Preventive and supportive strategiesOther strategies to reduce the gap betweenthe demand for and supply of care aimspecifically to reduce the demand for care.Colombo et al discuss two options.1 Onestrategy involves preventing the need forcare from arising. Healthy ageing, or betterdependency-free ageing, is seen as animportant option, even though evidenceabout reduction or compression of disabil-ities among elderly populations isinconclusive.18 A second strategy aims toreduce or postpone the growth in the needfor care, for instance by supporting self-management and by implementingpreventive approaches. Japan recentlychanged its entitlement to social LTCinsurance for mildly disabled older peopleto a ‘prevention system’, with the aim ofenabling those eligible for support toremain independent longer and better.Such approaches could also be combinedwith more adequate support strategies forfamily carers, and promise to delay andreduce the need for formal care services.
A result of both strategies may be that LTCsystems focus more on the growingnumber of people having more complex –and more costly – needs.19 However, thefocus of both strategies differ. Whilestrategies to reduce demand primarilyfocus on enabling disabled people tomanage their situation better, otherstrategies may focus on de-institutionali-sation,. Cutbacks may primarily targetentitlement rules or the basket of services,and may not take preventive approachesinto account.
Supporting family carers is a three-winstrategy but how to do it?Whatever the strategy, a larger proportionof the population may well become familycarers, or may care for a dependent personmore often, repeatedly or simultaneously.Those carers will age themselves.20
However, while it could be expected thatfriends and more distant relatives willprovide more care in the future,21
according to data from the Survey ofHealth, Ageing and Retirement in Europe,friends only substitute for care by adultchildren in situations with a modest needfor care,22 leaving the main burden to closerelatives.
Family carers already provide the bulk oflong-term care. In Europe, employedwomen aged over eighteen spend elevenhours per week caring for a disabled or frailperson, compared with almost eight hoursby employed men.23 The opportunity costsof caring can be long lasting. According toOECD analyses based on householdsurveys in several EU and non-EU coun-tries, ‘heavy caring’ (more than 20 hoursper week), is associated with a reduction inpaid work, a higher risk of poverty and a20% higher prevalence of mental healthproblems than among non-carers.1 Deteri-orating health status, financial problemsdue to extra costs and loss of income (forthe caree or the family carer), and a lack ofinformation and training are also reported(see http://eurocarers.org/userfiles/file/Factsheet2009.pdf). Moreover, jugglingcare and other responsibilities can lead totime management problems and isolation,while caring by an overburdened familycarer can affect the quality of care, the (care)relationship and the health status of boththe person cared for and the family carer.Finally, where caring affects labour-marketparticipation, it can reduce or delayearnings and opportunities (includingpension rights).
Supporting family carers is a three-winarrangement, for carers (who provide careout of love or duty*), for the ‘carees’ (whoprefer to be cared for by family andfriends) and for governments (who wouldotherwise face higher costs for formal careservices and need all available support fortheir dependent populations).1 But cur-rently only two in seven people in Europeare satisfied with the public supportavailable to those caring for dependentolder relatives.5 Family carers experienceproblems accessing support, such as a lackof information, costs related to access oruse of support, waiting lists for supportiveservices, bureaucracy, a lack of transport,or even a caree’s negative attitude.24 Somefamily carers do not see themselves as agroup for whom services are available,25 ormay feel stigmatised by the term,26 andthus may be hard to target.27 In addition,while support for carers is in demand, forsome major support mechanisms –including financial payments andemployment-related measures – there islittle evidence of (cost)-effectiveness.6,28–31
Better support for family carers is therefore
required, but not easy to arrange. Needs,options and hurdles need to be balanced.For governments wishing to supportfamily carers, there are opportunity costsas well. For instance, policies for familycarers may need to balance the benefits ofsupporting carers with incentives for carersto participate in the labour market. It is alsoimportant to address any possible tensionarising from the ‘monetising’ of social rela-tionships. Support measures may lead togreater bureaucracy, which can be bur-densome for family carers and whose valueis hard to prove. Formalisation of theposition of the family carer, for example interms of rights and duties, provides moreclarity for both governments and familycarers, but it also holds risks for familycarers, including liability issues.32
Supporting family carers needs to becomea key aspect of any LTC system, and maywell require a mix of measures such as cashbenefits, flexible leave options for workingfamily carers and other support forms,such as information, training, respiteservices and peer support. However, acrucial outstanding question is how to dothis effectively, when there is still a dearthof evidence on cost-effectiveness.
ConclusionsBetween now and 2050 the need for care islikely to more than double across theOECD, while the pools of those availableto care will shrink. As LTC workforces arerelatively small, there are several potentialoptions for growth, especially if countriesimplement targeted policies aimed atrecruitment, retention and productivityimprovements. Policies to reduce demandshould also be undertaken. While, in thewake of economic crises, policies aimed atcutting back social protection services maywell reduce the need for LTC workers,such policies do not necessarily reduce theneed for care, nor do they affect optionsfor self-management, such as strategies tostimulate disability-free ageing, orstrategies to reduce a growing need forcare. Whatever the strategy, familymembers, already providing the bulk ofLTC, are likely to bear the brunt. As heavycaring can have long-lasting opportunitycosts and may endanger the quality of care,and life as well as the social relationshipbetween the family carer and caree, sup-porting family caring seems especially
Eurohealth Vol 17 No 2–3 16
AGEING AND LONG-TERM CARE
* Those caring out of duty experience high burden differently than those caring out of love.Those caring out of love are better able to cope with higher intensity or longer duration of care than those caring out of duty.33
important for the future. It is also a three-win arrangement: for governments, for theperson cared for and for the family carer.However, supporting family carers is alsoassociated with opportunity costs. Findingthe right balance will become one of themajor challenges in the years to come.Comprehensive approaches are required tobetter prepare for ageing societies,including healthy – or dependency free –ageing strategies, policies to integratehealth and care, initiatives to prevent theneed for care from arising or increasing, aswell as better valuing of care workers andsupporting family carers.
REFERENCES
1. Colombo F, Llena Nozal A, Mercier J,Tjadens F. Help Wanted? Providing and Financing Long-term Care. Paris: OECD,2011. Available atwww.oecd.org/health/longtermcare
2. Eurobarometer. Health and Long-termcare in Europe. Special Eurobarometer 283.Brussels: Commission of the EuropeanCommunities, 2007.
3. Huber M, Rodrigues R, Hoffman F,Gasior K, Marin B. Facts and Figures onLong-term Care: Europe and North America. Vienna: European Centre for Social Welfare Policy and Research, 2009.
4. Commission of the European Communi-ties. Demography Report 2008. Meeting Social Needs in an Ageing Society. Commis-sion Staff working document. Brussels: European Commission, Directorate-General for Employment, Social Affairs andEqual Opportunities, 2009.
5. Eurobarometer. Family Life and theNeeds of an Ageing Population. AnalyticalReport. Eurobarometer 2247. Brussels:Commission of the European Communities, 2008.
6. Glendinning C, Arksey H, Tjadens F,Moree M, Moran N, Nies H. Care Provi-sion Within Families and its Socio-economicImpact on Care Providers Across the Euro-pean Union. York: Social Policy ResearchUnit, University of York, 2009.
7. van der Schoot E, Oginska H, Estryn-Be-har M. Burnout in the nursing profession inEurope. In: Hasselhorn H-M, TackenbergP, Muller BH (eds). Working Conditionsand Intent to Leave the Profession AmongNursing Staff in Europe. Stockholm: National Institute for Working Life, 2003.
8. World Health Organization. WorldHealth Report 2006: Working Together forHealth. Geneva: WHO, 2006.
9. Columbo F, Dumont J-C, Hurst J, ZurnP. The Looming Crisis in the Health
Workforce. How Can OECD CountriesRespond? Paris: OECD, 2008.
10. Klein Breteler J, Theeuwes J, Bos J,Boereboom M. Zorg voor mensen, mensenvoor de zorg; arbeidsmarktbeleid voor dezorgsector richting 2025 [Care for people,people for care, labour market policy forthe care sector to 2025]. Den Haag: Zorginnovatieplatform, 2009.
11. Plexus. Werken in de zorg. [Working inCare] Breukelen: Plexus, 2011.
12. Thomas C, Hosein R, Yan J. Assessingthe Export of Nursing Services as a Diversi-fication Option for Caricom Economies.Barbados: Caribbean Commission onHealth and Development, 2005.
13. Yeates N. Migration and Social Policy inInternational Context: the Analytical andPolicy Uses of a Global Care Chains Per-spective. Arusha Conference: New Fron-tiers of Social Policy, 12 –15 December 2005.
14. van Houten G. Working longer requiresbetter working. Foundation Focus Issue2011;9:8.
15. Verkaik R, Francke AL, van Meijel B,Spreeuwenberg PM, Ribbe MW, BensingJM. The introduction of a nursing guidelineon depression at psychogeriatric nursinghome wards: effects on certified nurse assistants. International Journal of NursingStudies 2011;48(6):710–19.
16. 2010 Update of the Joint Assessment bythe Social Protection Committee and theEuropean Commission of the Social Impactof the Economic Crisis and of Policy Re-sponses. SOC 793; ECOFIN 786. Brussels:Council of the European Union, 2010.
17. Forder J, Fernandez J. The Impact of aTightening Fiscal Situation on Social Carefor Older People. London: London Schoolof Economics and Political Science, 2010.PSSRU Discussion Paper 2723.
18. Lafortune G, Baléstat G. Trends in Severe Disability Among Elderly People:Assessing the Evidence in 12 OECD Countries and the Future Implications.OECD Health Working Papers 2007;26.
19. Tjadens F. Internationale signalen. Eeneerste toetsing van de ActiZ lange-termijnvisie en ‘de 12000’ in internationale context[International signals: an initial review ofthe ActiZ long-term perspective and ‘the12,000’ in an international context] Alphenaan den Rijn: HASCA, in press.
20. Sadiraj K, Timmermans J, Ras M, deBoer A. De toekomst van de mantelzorg[The future of care] Den Haag: Sociaal enCultureel Planbureau, 2009.
21. Peters A, Wilbrink I. Krimp achter devoordeur. De toekomst van mantelzorgvoor ouderen [Shrink behind the front door.
The future of family care for older people]Utrecht: Movisie, 2011.
22. Kalwij A, Pasini G, Wu M. Home Carefor the Elderly: Family, Friends, and theState. Discussion Paper 07/2009.NETSPAR: Network for studies on pensions, aging and retirement, 2009.
23. Anderson RM. Second European Qual-ity of Life Survey. Overview. Dublin: Euro-pean Foundation for the Improvement ofWorking and Living Conditions, 2009.
24. Triantafillou J, Mestheneos E. Servicesfor Supporting Family Carers of ElderlyPeople in Europe: Characteristics, Coverageand Usage. Hamburg: Universität Hamburg, 2006.
25. Tjadens F, Duijnstee M. Visie op mantel-zorg [Vision of Care] Utrecht: NederlandsInstituut voor Zorg en Welzijn, 1998.
26. Gerstenberger B, Anderson R. Supportfor a juggling act – what employers can doto support workers who care. FoundationFocus 2011;9:9.
27. Tjadens F, Visser G, Sangers S. FamilyCare in Europe: the Contribution of Carersto Long-term Care, Especially to OlderPeople. Utrecht: Eurocarers, 2007.
28. Eager K, Owen A, Williams K. EffectiveCaring: a Synthesis of the International Evidence on Carer Needs and Interven-tions. Volume 1: the Report. University ofWollongong: Centre for Health Service Development, 2007.
29. Lee H, Cameron MH. Respite care forpeople with dementia and their carers.Cochrane Database of Systematic Reviews2004; 2 Art. No.: CD004396. DOI:10.1002/14651858.CD004396.pub2
30. Parker G, Arksey H, Harden M. Meta-Review of International Evidence on Inter-ventions to Support Carers.York: Universityof York, Social Policy Research Unit, 2010.
31. Mason A, Weatherley H, Spilsbury K etal. A systematic review of the effectivenessand cost-effectiveness of different models ofcommunity-based respite care for frail olderpeople and their carers. Health TechnologyAssessment 2007;11(15).
32. Flohimont V, van Limberghen G, Tasiaux A, Baeke A-M, Versailles P. Reconnaissance légale et accès aux droits sociaux pour les aidants proches [LegalRecognition and Access to Social Rights forFamily Carers] Louvain-La-Neuve: AidantsProches ASBL, 2010..
33. Tjadens F, Woldringh C. Achtergrondenvan informele zorg. Een onderzoek bij ouderen naar mogelijkheden en problemen[Backgrounds of informal care. A study onopportunities for and problems of olderpeople]. Nijmegen: ITS, 1991.
Eurohealth Vol 17 No 2–317
AGEING AND LONG-TERM CARE
Eurohealth Vol 17 No 2–3 18
Determinants of health care costsThe use of health and social care servicesdepend on individuals’ sex, age and health/disability status, as well as external factorssuch as availability of facilities and healthcare technology. Service use rises sharplywith age and therefore the future numberof older people is often assumed to be animportant determinant of overall use. Asimple widely-used assumption is thatfuture demand for health care remains con-stant within each sex and age-group so thatchanges in provision depend only onchanging population numbers.
However, the average costs of acute healthcare services, principally based on use ofhospital services, are greater at any givenage for those who die relatively shortlyafterwards (‘decedents’) than those who donot (‘survivors’). Fuchs1 concluded that:“health care spending among the elderly isnot so much a function of time since birthas it is a function of time to death. Theprincipal reason why expenditures risewith age…is that the proportion of persons
near death increases with age”. Studies in anumber of countries confirm therobustness of these conclusions, typicallyfinding that acute care in the last year of lifeaccounts for about one third of totallifetime costs.2
The implications of whether the use ofservices is affected more by proximity todeath than by age are substantial. If age isthe key driver, then increased longevitywill lead to more care use at older ages.However, if proximity to death is moreimportant, then pushing back the age ofdeath will reduce the number of deathsoccurring in a given year. Moreover, moststudies find that acute health care costs inthe last year of life fall with later age atdeath.2
Much less is known about the relationshipof social care costs, including long-termcare costs, with age and proximity todeath,3 although an early Canadian studyfound that: “those dying at older ages havemore rather than less expensive deaths,largely due to heavy nursing home use bythe very elderly”.4
Data and methodsMost studies have been based on cost-ori-ented data from service providers whichmay relate to selected sub-populations andoften contain little socioeconomic infor-
mation on service users (and none on non-users). Finland has good data on joint useof long-term care (LTC) and communityand hospital facilities, so we use a 40%random sample of the Finnish populationaged 65 and older at the end of 1997 withinformation on socio-demographic factorsthat were followed to death in 1998–2003or to the end of 2003. The number of daysin hospital and long-term institutional carewas assessed in each calendar year between1998 and 2003 (for survivors), and thenumber of days in twelve month intervalsbefore death (for decedents). The initialpopulation size was 301,263.5
Differentials by age and sexDays in both hospital and LTC increasewith age for men and women, althoughwomen spend more days in care than mendo, especially for LTC (Table 1). For the‘young old’, use is low among survivors,but much higher among decedents espe-cially for hospital care. Decedents typicallyhave around 60 more days in hospital thansurvivors at any age. Decedents also useLTC more than survivors, but the dif-ference is smaller than for hospital days.The number of days in LTC overtakes daysin hospital around age 80. As populationsage, this will change the balance of usebetween the two sectors.
AGEING AND LONG-TERM CARE
Use of care services in relation toproximity to death among olderpeople: Evidence from Finland
Mike Murphy and Pekka Martikainen
Summary: An analysis of register data for Finland shows that the use of health andsocial care services by older people varies by both age and proximity to death. Acutehealth care use depends more on proximity to death, suggesting that the need for such services will be less than might have been expected given the likely increase in numbers of older people. However, this is more than offset by a greater use ofresidential long-term care especially by the “old old”. The balance of care is likely to shift from acute to long-term care services.
Key words: long-term care, ageing, proximity to death, Finland
Mike Murphy is Professor of Demogra-phy, London School of Economics and Po-litical Science, UK. Pekka Martikainen isProfessor of Demography, University ofHelsinki, Finland. Email:[email protected]
Eurohealth Vol 17 No 2–319
Differentials by marital statusUse of services varies among socio-demo-graphic groups such as by marital status(Figure 1). All groups show increasing useof services with age (apart from decedents’use of hospital care for the oldest agegroups). Among the groups shown, themain difference is between those who aremarried, and the three non-marriedgroups, which are very similar, especiallybelow age 90. Married people are lowerusers of services, substantially so in thecase of LTC. This reflects the availabilityof a co-resident partner (and possiblybetter health) among the married. Whilethe proportion of older people who aremarried is likely to increase for somedecades in Finland, as for many Westerncountries, this will reverse sharply forcohorts born from the 1950s.
Differentials by socioeconomic status: occupational class and educational levelSocioeconomic differences in health andmortality exist up to the highest ages evenin the most egalitarian countries with com-prehensive, high-quality welfare services,such as in the Nordic countries. While sub-stantial socioeconomic differentials inhealth and mortality exist, differentials inthe use of care services are relatively smallcompared with those, for example, bymarital status. People with the highestlevels of education are the lowest users at
AGEING AND LONG-TERM CARE
Table 1: Average number of days spent in hospital and long-term care by sex and age group forthose who do not die and those who die in subsequent 12 months, Finland 1998–2003
Sex and age groupHospital Long-term care
Survivor Decedent Survivor Decedent
Males
65–69 4.2 48.0 2.2 10.1
70–74 6.0 56.4 4.2 18.9
75–79 9.8 65.7 9.1 29.2
80–84 14.8 72.2 18.3 45.1
85–89 21.2 78.6 35.5 66.0
90–94 27.4 80.7 62.6 91.8
95+ 31.2 85.5 84.4 119.2
Females
65–69 3.5 63.7 2.3 15.4
70–74 5.9 71.4 5.2 27.8
75–79 10.8 81.3 12.6 44.0
80–84 18.2 89.3 28.5 67.7
85–89 29.4 96.1 54.7 93.2
90–94 42.5 104.3 88.4 118.2
95+ 59.2 107.8 128.0 146.1
Source: Authors’ analysis of 40% Finnish register-based population sample
Figure 1: Days in care in previous 12 months by age, survival and marital status
Single Married Divorced Widowed
020406080
100120140160
65–69 70–74 75–79 80–84 85–89 90–94 95+
Survivor LTC
Day
s
01020304050607080
Survivor hospital
65–69 70–74 75–79 80–84 85–89 90–94 95+
Day
s
0
20
40
60
80
100
120
Decedent hospital
65–69 70–74 75–79 80–84 85–89 90–94 95+
Day
s
020406080
100120140160180
Decedent LTC
65–69 70–74 75–79 80–84 85–89 90–94 95+
Day
s
Eurohealth Vol 17 No 2–3 20
any given age, followed by the interme-diate group and then by the lowesteducation group (Figure 2). However, thelonger life expectancy of better educatedgroups means that their overall expectedlifetime use of services will not be less.While the educational level of the popu-lation is increasing, the lower use at anygiven age by better educated groups islikely to be more than offset by the higherproportions of these groups surviving tothe highest ages, when the use of servicesis much more substantial.
Proximity to death or time to death?Early studies compared decedents and sur-vivors in the last year of life, wheredecedents’ additional use of hospital care ismainly concentrated. However, the‘penalty’ associated with proximity todeath does not exist only in the twelvemonths preceding death; it can be observedup to 30 years before death.6 LTC use pat-terns are rather different, at younger ages,there is little additional use among thosewho are close to death compared withthose who survive longer, but the gapwidens with age, so that among those aged90–94, a person who dies within the nexttwelve months spends twice as many daysin LTC on average as someone who sur-vives for six years.
Concentration on the last year of lifetherefore understates the additional use of
services associated with proximity to deathespecially for LTC. This is because a sub-stantial fraction of excess hospital careoccurs in the last twelve months of life(especially in the few months immediatelybefore death). While the end-of-life expen-ditures of older patients may be lower peryear, they are typically disabled longer andtheir illnesses often continue for years sothat people in the US who die at age 73 and93, for example, cost Medicare nearly thesame amount7 and, of course, older peopleare much greater users of long-term resi-dential care.
Summary and conclusionsThese results are consistent with earliercost-orientated studies that found thatproximity to death is more important foracute care use, but age is more importantfor LTC. Populations in Europe will con-tinue to age considerably in future decades,especially for the oldest-old from about 25years time. The demand for health caremight not increase wholly in line with thenumber of older people8 and health statusimprovement may tend to reinforce thecost lowering tendencies on acute care ofproximity to death. However, the view thatneeds may not increase in line with thenumber of older people because of the‘proximity to death’ effect is optimistic,since the implied additional LTC needs(bed–days in our case) overwhelm suchfactors. LTC needs are likely to grow more
quickly than acute care needs for olderpeople, other things being equal.
A model that incorporates proximity todeath implicitly assumes improvement inhealth status since lower mortalityincreases the time to death at each age andpostpones intensive use of services. Whilesome studies show the proportion of lifespent in poor health is increasing (anexpansion of morbidity), others suggestthe opposite (a compression of morbidity).The lack of clear trends makes it difficultto predict health status in the future. Itmight be thought that later age at deathwould push back the onset of disability;however, even with optimistic assumptionsabout improvements in health status it isstill likely that there will be no change inthe proportions of people entering or timespent in nursing homes,9 nor averagelifetime health care costs.7
Recent Organisation for Economic Coop-eration and Development (OECD)10 andEuropean Union11 studies have incorpo-rated proximity to death in forecasts ofhealth care. The inclusion of proximity todeath is likely to become increasinglyimportant for forecasting health care needsand costs, especially for the balancebetween acute and social care for olderpeople, although other factors such asfuture changes in marital status distribu-tions may also be important to futureprojections of social care needs.
AGEING AND LONG-TERM CARE
Figure 2: Days in care in previous 12 months by age, survival and educational level
65–69 70–74 75–79 80–84 85–89 90–94 95+0
20
40
60
80
100
120
140
020406080
100120140160
0
10
20
30
40
50
60
0
20
40
60
80
100
120
Elementary or lower Intermediate Degree
Survivor LTC Decedent LTC
Survivor hospital Decedent hospital
Day
sD
ays
Day
sD
ays
65–69 70–74 75–79 80–84 85–89 90–94 95+
65–69 70–74 75–79 80–84 85–89 90–94 95+ 65–69 70–74 75–79 80–84 85–89 90–94 95+
Eurohealth Vol 17 No 2–321
Due to a rapidly ageing population and theincreased spread of chronic diseases,current care systems are increasingly seenas untenable. Linked to these concerns isthe recognised value of preserving people’sindependence, including enabling olderpeople to remain in their homes. Onepotential solution is to use technological
innovation to support people remotely intheir own home or the wider community.Commonly called telecare or tele-healthcare, remote care systems have beenaround for over a decade, with 8,000 pub-lished studies reporting on their impact.1
Despite the technology appearing to workand positive user feedback, health and care
services have been slow to show thatremote care implementation can result in asignificant shift in care services from hos-pital to home. In the United Kingdom, weestimate that between 300,000 and 350,000people use some form of remote care (notincluding traditional pendant alarms).
Remote care services can be split into twomain types. Telecare is used for the moni-toring of changes in an individual’scondition or lifestyle, including emer-gencies, in order to manage the risks ofindependent living. Examples include
REFERENCES
1. Fuchs VR. Though much is taken: reflec-tions on aging, health, and medical care.Milbank Memorial Fund Quarterly. Healthand Society Special Issue: Financing Medi-care: Explorations in Controlling Costs andRaising Revenues 1984;62(2):143–66.
2. McGrail K , Green B, Barer ML, EvansRG, Hertzman C, Normand C. Age, costsof acute and long-term care and proximityto death: evidence for 1987/88 and 1994/95in British Columbia. Age and Ageing2000;29:249–53.
3. Payne G , Laporte A, Deber R, Coyte P.Counting backward to health care's future:using time-to-death modeling to identifychanges in end-of-life morbidity and theimpact of aging on health care expendi-tures. The Milbank Quarterly 2007;85(2):213–57.
4. Roos NP, Montgomery P, Roos LL.Health care utilization in the years prior to
death. The Milbank Quarterly1987;65(2):231–54.
5. Murphy M, Martikainen P. Demand forlong-term residential care and acute healthcare by older people in the context of theageing population of Finland. In: Doblham-mer G, Scholz R (eds). Aging, Care Need,and Quality of Life. Wiesbaden: VS Verlagfür Sozialwissenschaften, 2010, pp.143–62.
6. Engberg H, Oksuzyan A, Jeune B, Vaupel JW, Christensen K. Centenarians –a useful model for healthy aging? A 29-yearfollow-up of hospitalizations among 40,000Danes born in 1905. Aging Cell2009;8:270–76.
7. Lubitz J, Cai L, Kramarow E, LentznerH. Health, life expectancy, and health carespending among the elderly. New EnglandJournal of Medicine 2003;349(11):1048–55.
8. Lafortune G, Balestat G, DisabilityStudy Expert Group Members. Trends inSevere Disability Among Elderly People:
Assessing the Evidence in 12 OECD Coun-tries and the Future Implications. OECDHealth Working Papers No. 26. Paris:OECD, 2007. Available at: www.oecd.org/dataoecd/13/8/38343783.pdf
9. Laditka SB. Modeling lifetime nursinghome use under assumptions of betterhealth. Journal of Gerontology: Social Sciences 1998;3(4):S177–87.
10. Organisation for Economic Co-opera-tion and Development. Projecting OECDHealth and Long-Term Care Expenditures:What are the Main Drivers? Economics Department Working Papers No. 477. Paris:OECD, 2006. Available at: www.oecd.org/dataoecd/57/7/36085940.pdf
11. Economic Policy Committee and Euro-pean Commission. The 2009 Ageing Re-port: Economic and budgetary projectionsfor the EU-27 Member States (2008–2060).Brussels: EU, 2009. Available at: http://europa.eu/epc/pdf/2009_ageing_report.pdf
AGEING AND LONG-TERM CARE
Implementing remote care in theUK: an update of progress
Jane Hendy, James Barlow and Theopisti Chrysanthaki
Summary: In 2009 we reported in Eurohealth on the challenges of implementing ‘remote care’, the use of information and communication technology (ICT) to support health and social care remotely. We discussed the potential of thesetechnologies both in the United Kingdom and elsewhere to transform the lives ofthe elderly and those with long-term chronic conditions. In this article, we reporton recent UK developments, presenting findings from our research and examiningimplementation progress.
Keywords: Remote care, long-term conditions, ICT, telecare, United Kingdom
Jane Hendy is Research Fellow, Health Management Group, James Barlow is Professor ofTechnology and Innovation Management and Theopisti Chrysanthaki is ResearchAssociate at Imperial College Business School, London, UK. Email: [email protected]
movement sensors, falls sensors, andbed/chair occupancy sensors. These tech-nologies are generally provided to patientswith social care needs. Telehealth is theremote exchange of data between a patientand health care professional to assist in thediagnosis and management of a health carecondition. Examples include bloodpressure monitoring and blood glucosemonitoring. These technologies are gen-erally provided to patients with long-termhealth conditions such as diabetes.However, growth for all these technologieshas been slow and the potential market sizein the United Kingdom could be at least1.4 million.2
In terms of changing this position, theUnited Kingdom has taken a strong lead.While there are examples of remote careschemes in other countries, major UK ini-tiatives such as the PreventativeTechnologies Grant and the Whole SystemDemonstrators Programme (WSD)3 rep-resent the most important concerted effortby a national government to stimulate thisinnovation. Over the next few years theseinitiatives should provide many opportu-nities for learning about the potentialbenefits and pitfalls of remote care.
ResearchWe have been conducting research into theprogress of these initiatives since theirinception. We followed five casesattempting to implement remote careduring the timeframe of the PreventativeTechnologies Grant (April 2006 – April2008). This funding was positioned as acatalyst for change, giving local serviceproviders in England the push they neededto trial remote services.
However, the funding was not ring-fenced,leading to huge discrepancies in levels ofremote care spending and activity, withsome organisations progressing well butothers making little progress. The focusthen shifted away from providing cash togenerating evidence of effectiveness. Thegovernment sponsored reportedly thelargest randomised controlled trials ofremote care services (the WSD). The trialinvolves implementing remote care servicesin 6,000 homes. The UK Governmentviews the trial as providing ‘gold standard’evidence that remote care benefits indi-vidual users, delivers health improvements,and is a cost effective means of future caredelivery.
As part of the WSD evaluation team, weare following the progress of the three trialsites (June 2009 – March 2012).4 Between
June 2010 and June 2011 we also examinedthe implementation of remote care in sixadditional sites. These additional sites arenot part of the trial and so not subject totrial protocol criteria and RCT controlledmanagement processes (thus we have acomparison between those sites whichprovide remote care in an environmentconstrained by the trial protocol criteria,supported by external funding and projectmanagement team and those that are deliv-ering remote care in a so-called ‘natural’environment).
Three of these six additional sites also hadimplementation support in being part ofthe King’s Fund Whole System Demon-strator Action Network (WSDAN).5 TheWSDAN was commissioned by theDepartment of Health as an additional toolfor sites that bid to be in the original trialbut were unsuccessful. The WSDAN sup-plied research and development activitiesto support lessons learnt in the main trial.The last three sites we examined had noadditional support (see Table 1). Duringthis period (2006–2011), we conductedover 200 interviews, and made over 300hours of observations, with data collectioncontinuing.
FindingsFindings from this large body of work arestill emerging but it is appropriate to con-sider progress made, and implications forthe United Kingdom and other govern-ments wishing to stimulate the uptake ofremote care. Because remote care is cross-sectoral (involving health and social careprofessionals, user communities andpublic-private partnerships) and rangesacross multiple policy frameworks andspending constituencies, scaling-upexisting pilot schemes has proved chal-lenging. Embedding remote care inmainstream care services requires spanningmultiple complex networks and organisa-tional contexts, across which these newtechnologies and their associated systems
of practice are located and operationalised.For success, contextual and cultural differ-ences between different care organisationsneed to be addressed, with the right incen-tives for innovation adoption put in placeacross the care system.
Building engagement and a shared language
Overall, we found that practical opera-tional tasks such as training staff on howto do referrals and use the technology isnot enough to build the necessary sharedlanguage and vision to push large scaleimplementation forward. Engaging staffand ‘selling’ remote care beyond the realmof enthusiasts to an organisation-wideaudience requires huge amounts of energyand continuous commitment, leadershipand top level support.
Prior to the new funding, all our cases haddeveloped small remote care projectswithout additional support. These projectshighlighted the local nuances and practical-ities of referral, assessment, monitoringand response processes. However, aproject-based approach can also createproblems with wider engagement. Despiteour cases having a history of joint healthand social care working, as implementationprogressed we found existing rivalriesbecoming heightened. Much of this rivalrystemmed from early champions developingremote care projects in their area. Even incases with a long history of ‘joined up’working, the creation of small pockets ofactivity and excellence were divisive,serving to create issues of ownership thatpushed people apart rather than together.6
Rapidly changing organisational prioritiesand a constantly moving workforce meansimplementation is often an uncertain, non-linear process. During the course of ourresearch many key staff left, taking theirknowledge and commitment to remotecare with them. Developing joint workingis particularly labour intensive because ifleft unattended, people quickly revert to
Eurohealth Vol 17 No 2–3 22
AGEING AND LONG-TERM CARE
Table 1: Case study sites
Funded initiative Preventative Technology Grant
Department ofHealth WSD
King’s FundWSDAN
Non WSD-relatedsites
No. of case study sites 5 3 6 3
Period of research study April 2006–April 2009*
June 2009–March 2012
June 2010–June 2011
June 2010–June 2011
* The authors’ study of the Preventative Technologies Grant extended one year after the grant ended.
old ways of doing things. Senior leadershipwas critical in legitimising the increasedrisks and labour involved in scaling up thisinnovation and counterbalancing the argu-ments of sceptics.
Scalability issues
Until very recently, remote care has stayedfirmly within the realms of projects andsmall trials. Our research suggests thatthese have limited usefulness when devel-oping larger mainstream services. Acrossall our cases issues ‘resolved’ in smallprojects did not translate when attemptingto implement remote care more widely.Lessons from pilot projects were difficultto disseminate and often dissolved becausepartnerships that adequately covered theboundaries of the pilot broke down whenrequiring larger resources.
Developing remote care services on a largerscale requires new levels of integrationbetween different care organisations, refo-cused beyond individual patient benefits,professional development, or particularservice providers and technologies, to oneof wider system benefits, such as reducedunplanned hospital and care home admis-sions. For some cases this need to re-designexisting services was a welcome oppor-tunity to do things better; for othersredesign was not addressed, as staffappeared to struggle to change and movebeyond the boundaries of their previousrole.
Across all sites we found high levels ofsupport for remote care as a new model ofservice delivery. Many interviewees had aninformed view of its benefits and disadvan-tages based on the experiences of staffdelivering the new service. For these staffremote care was seen as providing a pos-itive contribution to the provision of carefor patients with long-term conditions.Despite this positive attitude, we observeddivides between the rhetoric and actualpractice of integrated working. At anorganisational level, senior staff expressedbeing fully engaged and committed toimplementing remote care processes andworking in a more integrated manner.However, frontline staff often knew verylittle about it, and perceived such changesas a threat to their professional practice andautonomy.
For large scale uptake, sustained imple-mentation of remote care needs to besituated as an organisation-wide initiativeand marketed as part of ‘normal business’;a tool that everyone in the care system canand needs to engage with. Constant and
sustained attention needs to be paid to thejob of winning hearts and minds and main-taining commitment and momentum. Thisis easier if a cogent and 'joined-up'approach to remote care is developed frominception.
Many hurdles to delivering this new modelof care delivery were embedded at a sys-temic level. For example, budgetary silosmeant that the costs of implementationwere often situated in one sector (socialcare) whilst perceived cost-benefits wereachieved across another (acute care). Thismeant that there were inbuilt disincentivesto invest resources in remote care. Morebroadly, achieving the strategic redesign ofsystems and services was felt to requireorganisations involved in care services tobe open to change and to embrace a culturethat was prepared to experiment, allow formistakes and collectively learn from them.Across our cases this culture was morelikely to occur when top level managementactively supported new and risky ideas ,allocated a range of permanent staff andactively encouraged them to engage incross-sectoral change initiatives.
ConclusionTogether, the Preventative TechnologiesGrant, WSD and other initiatives aroundthe United Kingdom represent the largestsingle investment in home monitoringsystems in any country. These offer signif-icant research opportunities, providingimportant lessons on the implementation,integration and sustainability of these newservices. Gold standard evidence from theWSD will certainly help care providersmake more informed investment decisions.However, the mixed picture that our casestudies presents, with many still strugglingto move beyond small trials five years on,suggests more help is needed if we aregoing to address the organisational chal-lenges of scaling up remote care.
Our work suggests that organisations needto be clear about these challenges. Thereality of organisational and professionaldivisions needs to be recognised and nego-tiated. This should partly involve ‘selling’remote care to local stakeholders by col-lecting evidence that increases theirreceptiveness, and identifies and mitigatespotential risks from the outset. Open com-munication about the limitations of remotecare services and active management ofexpectations and organisational differencesalso results in less animosity and moreshared understanding of what remote carecan realistically achieve.
Focusing attention on how to stimulateuptake by using existing levers within thesystems for payment and reimbursement,and service commissioning also would beuseful. A central government policy shiftfrom the current situation where remotecare services are optional to one wherethey are an integral part of a care package,unless there is good reason for exclusion,would also do a great deal to smooth theway forward.
REFERENCES
1. Barlow J, Singh D, Bayer S, Curry R. Asystematic review of the benefits of hometelecare for frail elderly people and thosewith long-term conditions. Journal ofTelemedicine and Telecare 2007;13:172–79.
2. Barlow J, Hendy J, Chrysanthaki T. Sustaining innovation in remote care – four lessons. International Congress on Telehealth and Telecare. Presentation at the King’s Fund, London, 2 March 2011.
3. Whole System Demonstrator.At: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_100947.pdf
4. Bower P, Cartwright M, Hirani S, et al.A comprehensive evaluation of the impactof telemonitoring in patients with long-term conditions and social care needs: protocol for the Whole Systems Demonstrator cluster randomised trial.BMC Health Services Research2011;11:184. At: http://www.biomedcentral.com/1472-6963/11/184
5. Goodwin N. The state of telehealth andtelecare in the UK: prospects for integratedcare. Journal of Integrated Care2010;18(6):3-10.
6. Hendy J, Barlow J. The role of the organizational champion in achievinghealth system change. Social Science &Medicine (in press).
ACKNOWLEDGMENTS
This article is based on research projectsfunded by the EPSRC-funded Health and Care Infrastructure Research and Innovation Centre (HaCIRIC) and theDepartment of Health, UK.
Eurohealth Vol 17 No 2–323
AGEING AND LONG-TERM CARE
Eurohealth Vol 17 No 2–3 24
ACTION, ‘Assisting Carers using Telem-atics Interventions to meet Older people’sNeeds’, stemmed from an EU-fundedproject (1997–2000) and is an Informationand Communication Technology (ICT)based support service designed togetherwith older people with long-standingchronic conditions living at home and theirfamily carers to help empower them intheir daily lives. It is currently running asa mainstream service in the Borås munici-pality in western Sweden, with implement-ation projects in an additional twentymunicipalities across Sweden.
ACTION is a self-care and family caresupport service which promotes ‘ageing inplace’ as older people with chronic illnessesand their family carers are able to accessrelevant and accessible information, edu-cation and support when needed from thecomfort of their own home. Furthermore,the ICT based service helps to promotesocial inclusion within the current digital
information society for those older citizenswho are at risk of being excluded from thebenefits afforded by modern technology.1
The ACTION service in briefThe ACTION service consists of the fol-lowing integrated components:
1. Multimedia educational caring pro-grammes
2. The ACTION application
3. The ACTION call centre
4. Education and support
Multimedia educational programmes
The multimedia educational programmesare based on carers’ and older people’sneeds identified from the empirical liter-ature and extensive user consultation in theEU and Swedish ACTION projects. Theseprogrammes are: caring skills in daily life;planning ahead; respite care; economicsupport; a service guide; coping strategies;
living with dementia; and life after a stroke.Additionally, there are programmes forphysical and cognitive training and onlinegames for leisure2,3.
ACTION application
The ACTION application consists of apersonal computer with broadband con-nection which is installed in each family’shome. Families also have access to theInternet itself and email facilities. The mul-timedia programmes are accessed over theInternet. Internet videophone facilities areprovided via a small web camera placed ontop of the computer screen and an inte-grated user-friendly videophoneprogramme installed in the computer. Thisenables families to have visual and oralcontact with other participant families, aswell as with care practitioners at a dedi-cated call centre.
ACTION call centre
The ACTION call centre is run by practi-tioners with experience in caring for olderpeople and their families. They maintainregular contact with families to ensure thatthey are managing their situation as well asproviding advice and support on an as needbasis. They are also responsible for com-puter education and facilitate and maintaininformal networks between users.
AGEING AND LONG-TERM CARE
The role of ICT support services topromote ageing in place
The ACTION service
Elizabeth Hanson and Lennart Magnusson
Summary: ACTION (Assisting Carers using Telematics Interventions to meet Olderpeople’s Needs) is an innovative example of an Information and CommunicationTechnology (ICT) based support service that is currently running in Sweden to helpempower older people with chronic conditions and their family carers in their dailylives. The service is outlined and the main evaluation findings are presented. Sirpaexplains how ACTION has been of direct benefit in her caring situation. The mainlessons learned over a fourteen year period of implementing ACTION in Sweden arehighlighted, concluding with the main challenges facing researchers, policy makersand decision makers in the immediate future.
Key words: family caregivers, frail older adults, empowerment, videoconferencing,multimedia, Sweden
Elizabeth Hanson is Senior Lecturer, Department of Health & Caring Sciences, LinnaeusUniversity, Kalmar, Research Leader, Swedish National Family Care Competence Centre,Sweden and Visiting Reader, School of Nursing, University of Sheffield, UK. LennartMagnusson is Senior Lecturer Department of Caring Sciences, University of Borås andDepartment of Health & Caring Sciences, Linnaeus University, Kalmar and Director,Swedish National Family Care Competence Centre, Sweden. Email: [email protected]
Education and supervision
Fourth, families are invited to take part inan initial education programme to learnhow to use the ACTION service, as themajority of users are predominantly com-puter novices. This programme consists ofa series of small group ‘hands on’ computereducation sessions during which partici-pants get to know each other andsubsequently initiate videophone contact.Additionally, the comprehensive edu-cation, follow-up and certificationprogramme, including regular supervision,is targeted at care practitioners working inthe ACTION call centres in the munici-pality.4
Evaluation resultsEvaluation results from successive projectswith a total of approximately 400 usersreveal that the majority, similar to Sirpa,are highly satisfied with the service andconsider it to have helped improveeveryday quality of life. The over-ridingresult is that both family carers and theolder person they care for feel less isolatedas they developed informal support net-works with other participant families insimilar situations. Also, service users feelthat new technology is good to use pro-viding that it is easy to understand and useand is of direct benefit in their caring situ-ations. Nearly all users were previouslycomputer novices and included olderpeople with chronic long-standing condi-tions and older family carers who are to alarge extent housebound due to illnessand/or caring responsibilities2,5,6. In thisway, ACTION helped to enhance theirsocial inclusion.
Questionnaire and interview data revealedthat after using the ACTION system intheir own homes for a minimum period ofthree months, participant family carers,such as Sirpa, felt more competent andsecure in their caregiving role; they hadgained more control over their individualcaring situation and had increased their selfconfidence in their ability to care. Focusgroup interview data with ACTION callcentre practitioners highlighted that theyexperienced improved job satisfaction as aresult of working in partnership with fam-ilies to help empower them in theirsituation. They saw significant scope forfuture development in the area of telecareas a means of providing a more effectiveway of providing ‘non-hands on’ elementsof care such as advice, information givingand support for older people with longterm care needs and their family carers.5.6
At the municipality level, a small costdescriptive study involving five ACTIONfamilies revealed reduced care costs with anaverage saving of €10,300 per family peryear as a result of reduced use of home helpservices and delayed entry to nursinghome. A Needs Assessor who knew thefamilies well was asked to calculate whatthey should have needed in terms of careservices if they had not received ACTION.The researcher (LM) then carried out a costcalculation which was sent to the familiesprior to a home visit in which theresearcher and Needs Assessor reviewedthe data together with the respective par-ticipant families. All the families except oneagreed with their cost calculation. Thecarer who did not agree explained that shecould never accept under any circum-stances to ‘send’ her husband to a nursinghome. In this case, the costs were modifiedaccordingly.7
Main lessons learnedThere are relatively few examples of ICTbased support interventions for olderpeople and their carers within Europe thathave successfully undergone the transfor-
mation from a project to a mainstreamservice. This leads to the question of whatare the critical success factors behindACTION? The main reasons behindACTION’s success can be summarised asfollows.
First, the service was designed togetherwith older people with chronic illnessesand their carers to meet their needs, pref-erences and situation, as opposed to beingbased solely on what professionals con-sider older people want and need (see8 formethods of user involvement within thedesign of ACTION).
A second success factor is the overallacceptability of the mode of delivery of theservice which means that ACTION con-tinues to have an innovative appeal and isa socially desirable phenomenon amongstend users many of whom are computernovices.
Third, the service is research-based and hasundergone iterative cycles of developmentand evaluation based on extensive feedbackfrom all key stakeholder groups. Interest-ingly, the cost evaluation data togetherwith the quality of life data proved to be
Eurohealth Vol 17 No 2–325
AGEING AND LONG-TERM CARE
User testimonial: Sirpa and Magnus’s story
Over an eight year period, Magnus (aged90) had a series of four strokes which severely affected his eyesight and causeda dual-sided paresis which led to himbeing wheelchair bound. Previously, heand his wife Sirpa (aged 70) had enjoyedan active social life and they shared a mutual interest in sailing. Sirpa has cared
for Magnus since the onset of his first stroke. Initially, she continued to work full-time. However,she found it increasingly difficult to combine paid work and care so that she retired early inorder to devote more time to Magnus.
Sirpa described her caring role as follows, “I care for Magnus at home in the same way as hewould be cared for if he was in a hospital ward. I’ve now got a stair lift that I use, I change hisincontinence pads and do what has to be done. But even if I’m strong and I’m often in a goodmood, I can also be lonely and sad sometimes too”.
Sirpa described how ACTION had practically helped her in her caring situation, “Sometimes,Magnus gets food stuck in his throat. Before I didn’t know how to do the Heimlich manoeuvre butby looking at ACTION I learnt how to do it. It’s a dramatic experience but at the same time it’s apart and parcel of our day to day life you could say”.
Summing up her overall experiences of ACTION she explained, “I think that above all I’ve got agreater understanding. At one time Magnus was sullen and angry. So then I read about how depression can affect stroke survivors. I got an explanation for his anger and depression and Ilearnt how to approach him. For us it’s become quite a lonely life. Many of our friends that wehad before via work or sailing they’ve disappeared one after the other. It’s not easy for them toknow how you should relate to someone who can no longer talk or who sits paralysed in awheelchair. So, contact with others in a similar situation is incredibly important. As well I can always ring to someone at ACTION (call centre). They’ve become an important part of my day to day life – someone to share both feelings of joy and sadness is important, just as Magnus andI used to do earlier”. Photo: Johanna Wulff
critical in the formal decision makingprocess taken by Borås’s older peoplesocial services committee in 2004 to inte-grate the ACTION service within theirexisting support services for older people.Furthermore, in the case of Borås munici-pality, the ACTION service has receivedongoing support from all key stakeholdergroups from end users, care practitioners,decision makers, politicians and represen-tatives of voluntary and pensionorganisations through to business partnersand university representatives. Withoutsolid partnerships and co-operation withall these diverse players the continuedadoption of the service would not havebeen possible.
Nevertheless, there remain significanthurdles as the ACTION service has notpenetrated all 290 municipalities inSweden. The key challenges largely reflectthose previously identified within theempirical literature in the field and whichcan be summarised as follows: imple-menting ACTION within everydaypractice is not simply about installing andlearning to use the technology, rather itinvolves changing the way in which carepractitioners and managers view and carryout their work. Namely, to work proac-tively in partnership with older people tohelp empower families to manage theircaring situations, rather than being crisisoriented. A second and related barrier isthe negative attitudes held by many healthand social care professionals regarding theuse of modern technology within care forolder people. To this end we havedeveloped a comprehensive education,supervision and certification programmedirected at staff involved in implementingACTION in municipalities, so as toprovide credible role models (seewww.actioncaring.se).
A third challenge is the continuous workrequired to maintain ongoing support fromall stakeholder groups. Frequent staffturnover rates at management and grass-roots level in the municipalities calls forregular awareness raising and educationsessions with front-line staff, managementand other health and social care profes-sionals working with older people, as wellas user and carer representatives.
A fourth challenge, which is commonlyhighlighted within the empirical literature,is the lack of rigorous empirical evidence.Similarly to the ACTION service, there issome evidence with regards to its impact atthe level of the individual/family.However, it is much more difficult to
reveal the long-term cost effectiveness ofthe service at a meso or organisational leveland further at a macro or societal level.Frequently quoted challenges in the liter-ature are the lack of a suitable comparator,the need for sufficient data collected on asystematic basis over time, and the need forsensitive outcome measures.
A fifth challenge is the lack of a sufficientcritical mass of end users that have usedACTION over a prolonged period of time.Municipalities are often wary of investingin more than twenty users and for a longerperiod than a year. This leads to a ‘Catch22’ situation as the lack of rigorous evi-dence is often cited as the main reason fordecision makers in Sweden to declinemaking a major investment in ACTION.
A sixth challenge concerns the need for asound and responsive business plan andmodel. In order to make ACTION morewidely available following the EU project,a university spin-off research and devel-opment company was established and abusiness agreement struck with TeliaSonera, Sweden’s largest telecommuni-cation company. Nevertheless, a businessplan needs to continually respond to thedemands of a fluid market so that otherpotential options are considered, such as aconsumer oriented model in which theservice is offered directly to private usersand/or entering into collaboration with acivil society organisation to jointly offerthe service.
A seventh challenge concerns the need forsuitable policy to be in place at all levels:local, regional, national and EU level as thishelps to ‘push-start’ the use of new tech-nology based solutions within health andsocial care for older people. Finally, fundingfrom governmental and research and devel-opment agencies in Sweden has been crucialfor the continued research and devel-opment of the ACTION service. In thefuture, there needs to be strategic larger-scale and long term implementation work,otherwise there will continue to be the riskof financing small-scale pilot projectswhich may duplicate results without cre-ating a sufficient critical mass to have thesignificant impacts outlined in this article.
REFERENCES
1. Kubitschke L, Cullen K, Műller S, et al.ICT and Ageing: European Study on Users,Markets and Technologies, Final Report.Bonn: Empirica & Work Research Centreon behalf of European Commission Direc-torate General for Information Society &Media, Unit ICT for Inclusion, 2010.Available at: http://www.ict-ageing.eu/ict-ageing-website/wp-content/uploads/2010/D18_final_report.pdf
2. Magnusson L, Hanson E, Nolan M. Theimpact of information and communicationtechnology on family carers of older peopleand professionals in Sweden. Ageing andSociety 2005;25(5):693–714.
3. Hanson E, Magnusson L, Arvidsson H,et al. Working together with persons withearly stage dementia and their family members to design a user-friendly technology based support service. Dementia 2007;6(3):411–34.
4. Magnusson L, Hanson E. Partnershipworking: the key to the AT- technologytransfer process of the ACTION service.Technology & Disability, (special issue inpress). Available from the first author [email protected]
5. Magnusson L, Hanson E, Brito L, et al.Supporting family carers through the use ofinformation technology – the EU projectACTION. International Journal of Nursing Studies 2002;39(4):369–81.
6. Bergström I, Blusi M, Höijer C.Utvärdering av ACTION. Anhörigstöd iglesbygd [Evaluation of ACTION. Familycare support in rural areas] (in Swedish).Stockholm: Swedish Institute for AssistiveTechnology, 2010. English summary available from: www.hi.se
7. Magnusson L, Hanson E. Supportingfrail older people and their family carersliving at home using Information andCommunication Technology: A Swedishcase study cost analysis. Journal of Advanced Nursing 2005;51(6):645–57.
8. Magnusson L. Designing a ResponsiveSupport Service for Family Carers of FrailOlder People using Information and Communication Technology. Gothenburg:Acta Universitatis Gothoburgensis, 2005.
Eurohealth Vol 17 No 2–3 26
AGEING AND LONG-TERM CARE
ACKNOWLEDGEMENTS
The authors extend their gratitude to Sirpa and Magnus who kindly gave us permission toreport on their experiences of using the ACTION service for the purposes of this special issue. We would also like to thank Sirpa for directly participating in a videoconferencingsession during the LSE Seminar in which she openly shared her experiences as a family carerand explained how she and her husband used the ACTION service. In so doing, she acted asa source of inspiration to many of the delegates present.
Eurohealth Vol 17 No 2–327
AGEING AND LONG-TERM CARE
Health services are very difficult tocompare across different territories, partic-ularly when they are aimed at thelong-term care (LTC) needs of peopleliving with complex conditions. Previousservice comparison studies in Europe haveoften failed to provide useful informationfor health planning in areas as diverse asmental health,1 ageing2 or services forfunctional dependency.3 There are manypotential reasons for this including theinfluence of historical and contextualfactors in the development and organi-sation of services, as well as the increasingcomplexity in integrated care arrange-ments. One major reason is that serviceswith the same name in different jurisdic-tions can perform very different activitiesand functions. This terminological vari-ability appears across all levels ofcomplexity in care settings, from daycentres to rehabilitation and hospital units.We even lack a common definition for‘hospital’ and ‘service’.
Access to services across Europe is ham-pered by an inadequate framework andknowledge of available resources. The
development of a common coding andassessment system can also help in thebetter allocation of resources for the pop-ulation. As an increasing number ofdatabases in Europe are linked in order tohelp address this information gap, it isimportant to facilitate a greater degree of‘semantic interoperability’, that is thedevelopment of a common language thatcan be used across different informationsystems and databases. A common codingsystem, using a standardised method ofassessment, may help overcome these chal-lenges and enable better comparisons ofdata to inform policy and practice. Thedevelopment of such a system was theobjective of the EC funded eDESDE-LTC(Description and Evaluation of Servicesand Directories in Europe For Long-TermCare) project.
Led by the PSICOST Research Associ-ation and the Catalunya-Caixa Foundationin Spain, eDESDE-LTC brought togethera core group of partners in six Europeancountries with further input from expertsin the development of service mappingsystems, health agencies at national,
regional and municipal levels, and aca-demic specialists in semantics, ontologyand health care decision support systems.
ApproachA starting point for this mapping systemwas work previously undertaken to helpclassify and standardise the mapping ofmental health services and the context inwhich those services were delivered inEurope.4,5 The eDESDE-LTC instrumentwas also informed by a review of existingcoding and classification instruments, notonly in respect of mental health, mostnotably the European Service MappingSchedule (ESMS),6,7 but also building onthe original DESDE instrument used tomap services for people with disabilities.1
The eDESDE-LTC instrument wasdeveloped iteratively, informed byfeedback from sessions with expertnominal groups in six countries. Usabilityof the instrument was assessed in relationto a series of quality domains: feasibilityand relevance; consistency; inter-rater reli-ability; and validity.
The final eDESDE-LTC Toolkit incorpo-rated the instrument, coding system,training, and evaluation packages (seehttp://www.edesdeproject.eu). This tool-kit, we believe, is unique in being able toassess the availability and use of servicesfor LTC, both in small health areas and atregional and national levels. The hierarchyof the instrument has been arranged as a
Classification, assessment and comparison of European LTC servicesDevelopment of an integrated system
Luis Salvador-Carulla, Cristina Romero, Germain Weber, Hristo Dimitrov,Lilijana Sprah, Britt Venner and David McDaid for the eDESDE-LTC Group
Summary: It is important that a common coding system and classificationstandardised system for assessing long-term care (LTC) services is used to helpfacilitate meaningful comparisons across and within countries. This article describesthe development and piloting of such a classification system – the eDESDE-LTC tool, now available in six European languages.
Key words: Long-term care, Europe, service classification, information systems
Luis Salvador-Carulla is President and Cristina Romero is Scientific Secretary, AsociaciónCientífica PSICOST, Jerez, Spain. Germain Weber is Professor of Clinical Psychology,University of Vienna. Hristo Dimitrov is Director, Public Health Association, Bulgaria.Lilijana Sprah is Research Fellow, Družbenomedicinski Inštitut, Ljublana, Slovenia. Britt Venner is Senior Adviser, SINTEF Technology and Society, Trondheim, Norwayand David McDaid is Senior Research Fellow, London School of Economics and PoliticalScience. Email: [email protected] Web: http://www.edesdeproject.eu
Eurohealth Vol 17 No 2–3 28
AGEING AND LONG-TERM CARE
tree structure (Figure 1). It has six mainareas of services (Help with Accessibility,Information, Self-Help, OutpatientSupport, Day Care and Residential Care)and 89 specific service codes. The classifi-cation system includes a decimal identifier,formal description and identification label(Figure 2), to allow for future semanticinteroperability in European health andsocial information systems and databases.
Mapping services in Sofia and MadridThe potential use of the instrument can beillustrated through experience in itspiloting in urban areas of Sofia and Madrid.Piloting indicates that the instrument thatcan be applied in very different environ-ments, as is the case in these two citieswhere very different patterns of LTCservices are to be found. National, regional
and local health and social care planners inboth settings were consulted. Figure 3illustrates the availability of different typesof care service for people with all LTC careneeds in the two cities, including frail olderpeople, people with physical and mentalhealth problems, and those with intel-lectual disabilities.
The instrument can be used to highlightdifferences in the availability and distri-bution of key services. Geographicalmapping software, for instance, can be usedto plot hot spots where services are concen-trated in both cities. In Sofia there appearsto be a heavy reliance on the provision ofcare within formal long-stay institutions;while in Madrid the mix of services and theavailability of places for these services sug-gests that the LTC system relies to a muchgreater extent on the provision of support
to enable individuals to remain living inde-pendently in the community.
Careful interpretation of findings ishowever required; it is important to under-stand the context in which services aredelivered. For instance, the absence of aspecific type of service in an eDESDE-LTC analysis could signal the fact that noprovision of that type exists in a locality,but it could also mean that these functionsare provided as part of a non specialistservice.
In addition to work in piloting theinstrument, feedback from potential usersof the instrument in different countries hasbeen positive. eDESDE-LTC is regarded asa very useful and promising instrument,although more could be done to improveclarity and ease of use so as to make
Information for care
Accessibilityto care
Self-help andvoluntary care
Outpatient care Day care Residential care
Guidance andAssessment
CommunicationNon-professional
staffAcute Acute Acute
Physical mobility
Other accessibility care
Non-acute (continuing care)
Non-acuteNon-acute
(programmed availability)
InformationPersonal
accompanimentProfessional
staffHome and mobile Episodic
24 hour physician cover
Case coordination Non mobile ContinuousNon-24 hour
physician cover
Long-term care
Home and mobile
Non mobile
Work
Work-relatedactivities
Non-work structured care
Non-structuredcare
24 hour physician cover
Non-24 hour physician cover
Other residential
Figure 1: eDESDE-LTC tree structure of main and secondary branches
training less complex. Currently trainingrequires a face-to-face intensive courseconducted by experienced trainers. Thewritten eDESDE-LTC training package isa useful complementary tool but it is not asubstitute for this face-to-face training. Inaddition, guidance might in future be pro-vided on data collection and interpretation;the latter might be aided by a contextchecklist to help in the interpretation ofresults. Another future objective is to moveto a fully computerised version of thequestionnaire and coding system usingstructured algorithms. A more simplisticfront end, negating any need to see any ofthe detailed coding structure, would helpexpedite training and facilitate use of theinstrument.
Further impactIn Spain, in addition to piloting workundertaken in the city of Madrid, theeDESDE instrument and coding systemhave subsequently been used to map
services in three of the country’s seventeenregions: Cantabria, Catalonia and Madrid.Awareness of the instrument has also beenstrengthened by citation in version 2.0 ofthe International System of HealthAccounts8 and the mapping tool is alsonow being used to inform a new EuropeanSeventh Framework funded project(REFINEMENT) analysing the financing,efficiency and quality of mental healthsystems in Europe.
ConclusionsThe eDESDE-LTC instrument and codingsystem has been designed to be ontologi-cally consistent and semanticallyinteroperable, with the intention ofimprove linkages between different rel-evant information systems. It can aid inmeaningful service comparison, which inturn is an important consideration for thefuture planning of LTC services withinspecific geographical catchment areas. Infuture it might also be used as a tool to aid
in equity impact assessments, where thefocus on is eligibility, availability, accessi-bility and use of services within and acrossdifferent geographical catchment areas.
REFERENCES
1. Salvador-Carulla L, Poole M, González-Caballero JL, Romero C, Salinas JA, Lagares-Franco CM. Development andusefulness of an instrument for the standard description and comparison ofservices for disabilities (DESDE). Acta Psychiatrica Scandinavica 2006;114(Suppl.432):19–28.
2. Johri M, Beland F, Bergman H. International experiments in integrated carefor the elderly: a synthesis of the evidence. International Journal of Geriatric Psychiatry 2003; 18(3):222–35.
3. EUROSTAT. Feasibility Study: Compa-rable Statistics in the Area of Care of Dependent Adults in the EU. Luxembourg:Office for Official Publications of the European Communities, 2003.
4. Beecham J, Munizza C. Assessing mentalhealth in Europe: introduction. Acta Psychiatrica Scandinavica 2000;102 (suppl405):5–7.
5. De Jong A. Development of the Interna-tional Classification of Mental Health Care(ICMHC). Acta Psychiatrica Scandinavica2000;405:8–13.
6. Johnson S, Kuhlmann R, and the EP-CAT Group. The European Service Map-ping Schedule (ESMS): development of aninstrument for the description and classifi-cation of mental health services. Acta Psychiatrica Scandinavica 2000;405:14–23.
7. Salvador-Carulla L, Romero C, MartínezA et al. Assessment instruments: standardi-sation of the European Service MappingSchedule (ESMS) in Spain. Acta Psychiatrica Scandinavica 2000;405:24–32.
8. International Health Accounts Team. A System of Health Accounts Version 2.0. Pre-Edited Version. Paris: Organisation forEconomic Co-operation and Development,2011. Available at: http://www.oecd.org/dataoecd/27/51/47406956.pdf
ACKNOWLEDGEMENTS
The eDESDE-LTC project was supportedby the Executive Agency of Health andConsumer (EAHC) Project Ref. 2007/116.We also acknowledge the Spanish ResearchAgency, Instituto Carlos III, for fundingrelated work on the European Service Mapping Schedule II (ESMS-II). A full listof members of the e-DESDE-LTC groupand project collaborators is available athttp://www.edesdeproject.eu
Eurohealth Vol 17 No 2–329
AGEING AND LONG-TERM CARE
Figure 2: Principal characteristics of the DESDE-LTC classification system
0
1
2
3
4
5
Acute hospital
Non acute hospital
24 hour residential
Other residential
Acute day care
Other health-related
day acre
Vocational day care
Self help
Access
Information
Am
bulatory non-acute
Am
ubulatory care
Emergency m
obile
Emergency non-m
obile
Sofia Madrid
Other day care
Availability per 100,000 population
Figure 3: Availability of main service types for long-term care target groups in Madrid and Sofia
ID (identifier) DESDE-LTC descriptor DESDE-LTC label
O0101020100 Outpatient care, acute, home & mobile,24-hour, health-related care
O2.1
Eurohealth Vol 17 No 2–3 30
Background The National Institute for Health andClinical Excellence (NICE) was estab-lished in 1999 to improve the quality ofcare for patients and provide robustguidance for the National Health Service(NHS) within England and Wales.1 TheInstitute has received international acclaimfor providing evidence-based recommen-dations by using transparent andparticipatory processes that involve all rel-evant stakeholders. The remit of NICEexpanded in 2005 to include guidance forpublic health, and in 2010 it establisheddedicated programmes to identify andpromote innovative diagnostics anddevices that provide significant quality andefficiency improvements in patient care,and NHS Evidence, a web-based portalgiving access to accredited high quality evi-dence. The current coalition governmenthas proposed expanding its remit toinclude social care2 and using NICE’s eval-uations of cost-effectiveness to inform‘value-based pricing’ of pharmaceuticals.
Supporting disinvestmentIn 2006, NICE was formally asked to helpthe NHS ‘reduce spending on treatmentsthat do not improve patient care’ by sup-
porting disinvestment.3 NICE hasimproved the visibility of the disinvestmentrecommendations from its guidance by cre-ating a database summarising all thepublished NICE guidance that recom-mends complete discontinuation orstopping routine use of clinical practices/interventions.4 The NICE ‘referral advice’recommendations database contains allreferral recommendations from NICEclinical guidelines, cancer service guidanceand public health guidance.5 Additionally,NHS Evidence has developed a collectionof case studies from the field and opportu-nities from Cochrane reviews that highlightimprovements in quality of care andprovide potential productivity savings forthe NHS’s Quality, Innovation, Produc-tivity and Prevention (QIPP) programme.6
NICE Quality StandardsNICE’s Quality Standards Programmestarted in 2009 and aims to provide sets of‘specific, concise statements that act asmarkers of high-quality, cost-effectivepatient care, covering the treatment andprevention of different diseases and condi-tions’.7 The Institute has already publishednine quality standards, a further eleven areunder development, and the goal is to
achieve a library of 150 over the next fiveyears.
Health and Social Care BillThe Health and Social Care Bill2, which iscurrently passing through the UK par-liament, contains a number of items thatwiden NICE’s remit. The Bill makesquality standards an essential componentof the government’s plans for achievingbetter outcomes for the NHS. NICE willthus have a significant role in supportingthe proposed NHS CommissioningBoard,8 the body which will be responsiblefor ensuring continuous improvement inthe quality of health care. NICE will alsoproduce public health quality standards tosupport the new national public healthservice, Public Health England, and socialcare quality standards. Quality standardswill therefore become an important mech-anism for encouraging integration ofhealth, public health, and social careservices.
Amendments to the Bill based on the rec-ommendations of the NHS FutureForum’s report9 clarify that the NHS willbe required to fund drugs already recom-mended by NICE when a value-basedpricing regime for new drugs is introducedin 2014. Under value-based pricing, theInstitute will continue to provide definitiveguidance on the use of new drugs. The Billalso changes the Institute itself from aSpecial Health Authority to a Non-
HEALTH POLICY DEVELOPMENTS
NICE supporting England andWales through times of change
Tarang Sharma, Nick Doyle, Sarah Garner, Bhash Naidoo and Peter Littlejohns
Summary: NICE has evolved over the last twelve years to accommodate thegrowing needs of the NHS and the wider health community. In today’s resource-constrained environment, the Institute has been supporting the NHS by highlighting disinvestment opportunities alongside producing recommendationsfor best practice. It has established new programmes of work to support the national health agenda and is expected to move to include social care in the coming years.
Keywords: NICE, NHS reforms, disinvestment, quality standards, social care
Tarang Sharma is Senior Analyst, Nick Doyle is Clinical and Public Health Analyst,Sarah Garner is Associate Director, Bhash Naidoo is Associate Director, Research and Development, NICE, UK. Peter Littlejohns is Clinical and Public Health Director,NICE, UK. Email: [email protected]
Departmental Public Body, giving it astronger foundation for the future.
DiscussionNICE has been established as an organi-sation devoted to providing robustguidance for resource allocation of healthcare and will continue to provide clinicaland public health guidance. NICE hasbeen evolving to meet the needs of itsservice users within a changing policyclimate. It is also well placed to provideguidance to social care, and is working toconsider the methods most appropriate forthis. NICE is expected to have a greaterrole in the new NHS in the years to comewith it receiving cross-party support inparliament and continues to be committedto supporting health and care in Englandand Wales.
REFERENCES
1. Rawlins M. In pursuit of quality: the National Institute for Clinical Excellence.Lancet 1999;353:1079–82.
2. House of Commons. Bill 221 Health andSocial Care 2010–2011. At: http://services.parliament.uk/bills/2010-11/healthandsocialcare.html
3. Pearson S, Littlejohns P. Reallocating resources: how should the National Institute for Health and Clinical Excellenceguide disinvestment efforts in the NationalHealth Service? Journal of Health ServicesResearch & Policy 2007;12:160–65.
4. National Institute for Health and Clinical Excellence. The NICE 'Do not Do' recommendations database. NICE, 2011.At: http://www.nice.org.uk/usingguidance/donotdorecommendations/index.jsp.
5. National Institute for Health and Clinical Excellence. NICE 'referral advice'recommendations database. NICE, 2011.At: http://www.nice.org.uk/usingguidance/referraladvice/index.jsp
6. NHS Evidence. Quality, Innovation,Productivity and Prevention (QIPP), 2011.At: http://www.evidence.nhs.uk/qipp
7. National Institute for Health and Clini-cal Excellence. NICE Quality Standards,2011. At: http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp
8. Department of Health. Developing theNHS Commissioning Board, 2011. At:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128118
9. NHS Future Forum. Summary Report tothe Proposed Changes to the NHS. Department of Health, 2011.
Eurohealth Vol 17 No 2–331
HEALTH POLICY DEVELOPMENTS
Which type of hospital ownership has the best performance? Evidence and implications from Germany
Oliver Tiemann, Jonas Schreyögg and Reinhard Busse
Summary: The German hospital market has been subject to a variety of healthcare reforms over the past two decades. In particular, the introduction ofdiagnosis-related groups (DRGs) has aimed to increase the performance ofhospitals. This article reports on recent studies comparing the performance ofpublic, private non-profit and private for-profit hospitals in Germany. The resultsof our analysis show that public hospitals have higher efficiency, while privatehospitals provide superior quality of care compared to their public counterparts.Finally, we draw conclusions and policy implications taking other hospital andmarket characteristics into account.
Key words: Germany, hospitals, for profit, performance, quality
IntroductionBecause of increasing cost pressure, thehospital sector in Germany has beensubject to a variety of health care reformsaimed at stabilising expenditures at sus-tainable levels over the past two decades.In 1993, the full-cost reimbursementsystem was replaced by global budgets,both of which had been made up of per-diem charges. In 2003/04, a new system ofreimbursement based on diagnosis-relatedgroups (DRGs) was introduced. Since thenall 1,800 German hospitals that provideinpatient acute care receive DRG paymentsfrom statutory health insurance funds andprivate health insurance companies. Inaddition, the introduction of DRGs waspreceded by the implementation of anexternal quality assurance programme (asopposed to the internal system of indi-vidual hospitals). This included a numberof mandatory measures, including anationwide benchmarking exercise basedon 206 quality indicators. These two ele-
ments represent the most significantreforms in the German hospital sectorsince the system of dual financing wasintroduced in 1972, which made the stateresponsible for capital costs, while runningcosts were paid by sickness funds orprivate patients. The chief motivationbehind this fundamental overhaul of theold reimbursement system was to setfinancial incentives that would increase theperformance of German hospitals.1,2,3
Germany traditionally has had a multi-ownership structure in the hospitalsmarket which is also legally stipulated.German hospitals can have public (usuallyowned by counties or municipalities),private for-profit, or private non-profit(usually owned by religious communities)ownership status. Due to substantial over-capacities and the rapid changes currentlytaking place in the regulatory and compet-itive environment, the German hospitalsector is now facing an extensive process of
Oliver Tiemann is Junior Professor and Jonas Schreyögg is Professor and DepartmentHead, Department of Health Care Management, Hamburg University, Germany. Reinhard Busse is Professor and Department Head, Department of HealthCare Management, Berlin University of Technology, Germany. Email: [email protected]
consolidation and reorganisation. In thiscontext, hospitals are considering mergers,acquisitions and cooperative agreements asways to improve competitiveness. Between1995 and 2008, a substantial number oflocal and regional governments inGermany sold their hospitals to privatefor-profit and private non-profit owners.The total number of private for-profit hos-pitals increased by 44%, which representeda rise in market share from 6% to 18%measured in terms of hospital beds.4
During the same period, the share ofprivate non-profit hospitals remained rel-atively constant. Although there are severalpossible reasons for this development, themain driver has been the need to increasehospital performance.
How to measure hospital performanceThere are different concepts used tomeasure the performance of organisations.Measures often used in other industries,such as return on investment or other prof-itability measures, are not regarded asappropriate to compare the performance ofpublic and non-profit providers. There-fore, measures such as cost per case,revenue and efficiency are used in the hos-pital context. In particular, efficiency is ameasure that has been frequently used inthe hospital context over the last decade.Efficiency or, more explicitly, technicalefficiency is a measure of how well anorganisation produces output from a givenlevel of input.
Finally, quality of care is often used as aperformance measure for organisations inthe medical context. In fact, most studieson hospital performance, particularly fromthe United States, use quality of care. Indi-cators used as proxies for quality of carerange from rather rough but robustmeasures such as in-hospital mortality tovery detailed measures such as the rate ofpost-surgical infections that may befocused on specific conditions. The latterapproach has the disadvantage that notevery hospital treats the same conditionsand that these indicators may be subject tomanipulation. Thus, in-hospital mortalityrates or, if available, post-hospital mor-tality or readmission rates are commonlyused as measures for quality of care tocompare large numbers of hospitals, forexample, all the hospitals in one country.
Evidence from other countriesIn contrast to the assumed behaviour out-lined in theory, and often assumed bypolicy makers, there is no evidence thatprivate ownership is associated with higher
efficiency compared to other ownershiptypes. In four of eleven internationalstudies comparing all three different typesof ownership in terms of efficiency, publichospitals were found to be less efficientthan their counterparts, while six studiesshowed that publicly owned hospitals weremore efficient than private for-profit andnon-profit hospitals. One study found nosignificant efficiency differences associatedwith ownership. Shen et al. 20075 andHollingsworth 20086 provide goodreviews of these studies. However, none ofthese studies has considered parameters forquality of care in addition to efficiency,although the relationship between own-ership, efficiency and quality of care is ofconsiderable practical and policy impor-tance.
One reason for this might be the paucityof validated measures of quality of care.The absence of quality measures requiresthe implicit assumption that there are nosystematic variations in quality of careamong public, private non-profit andprivate for-profit hospitals, or that varia-tions in quality do not systematically affectefficiency. The large empirical literature onownership unfortunately does not provideevidence on the impact of ownership onquality of care. However, studies exam-ining the relationship between efficiencyand quality of care have provided evidenceof an inevitable trade-off between thesetwo measures.7
Findings from GermanyIn the past, there was a lack of detailed dataon the German hospital sector, whichmeant that the quality and the quantity ofthe information used to assess efficiencywas very limited (for example, aggregatestate-level data). Thus, evidence on the effi-ciency of German hospitals was verylimited. Just recently, data on all hospitalsin Germany became available for researchpurposes, enabling new perspectives on the‘black box’ of hospital efficiency andquality of care.
The first two studies that were conductedsince the hospital database becameavailable8,9 used the same data but with dif-ferent methods to determine hospitalefficiency. Both found clear evidence thatpublic hospitals have higher efficiency thanhospitals with other forms of ownership,i.e., private non-profit and private for-profit hospitals. Stated differently, publichospitals are able to use the availableresources most efficiently to produce agiven output. These findings are in line
with previous studies from the UnitedStates, but may be surprising from a policyperspective. However, in order to drawpolicy implications we have to look deeperinto this issue by considering the charac-teristics of the German hospital market, aswell as other organisational determinantsof hospital efficiency.
First, it has to be considered that efficiencyis only one way of measuring performance.For-profit hospitals may have found a dif-ferent way to maximise their profits (i.e.,financial surplus) than hospitals with otherforms of ownership. Indeed, they may seekto maximise their profits by maximisingrevenues instead of minimising inputs at agiven output. Wörz10 supports this view,having found that private for-profit hos-pitals (and especially hospital chains) wereable to generate significantly higher rev-enues per case on average than hospitalswith other forms of ownership. Even afterthe introduction of DRGs in Germany,there are still a substantial number of addi-tional reimbursement components beingpaid on top of DRGs that can be nego-tiated at the hospital level (for example,certain expensive drugs). Indeed, theseadditional components account forapproximately 20% of total reimburse-ments for non-psychiatric inpatient care.1
Shen et al.5 found comparable results forthe United States hospital sector, con-cluding that the mission of privatefor-profit hospitals puts greater emphasison earning profits (i.e., higher revenues percase due to higher prices) compared topublic hospitals, which focus primarily onefficiency, i.e. cost containment.
Tiemann and Schreyögg9 further suggestthat public hospitals outperform theirprivate for-profit and non-profit counter-parts up to a size of approximately 1,000beds. From 1,000 beds onwards, theprivate for-profit hospitals operated withgreater efficiency. However, most privatefor-profit providers in Germany operatewithin a size range of 50 to 800 beds, whileonly a few hospitals in private-for profitownership had more than 1,000 beds. Thesame study also found that private for-profit hospitals show a comparably lowlevel of efficiency in very competitivemarkets, i.e., in geographical regions withmany competitors. If private for-profithospitals operate in regions with less com-petition, then the size of these entitiesapproaches that of other ownership types.Here, it is important to recognise thatprivate for-profit and non-profit hospitalsoperate primarily in urban and other more
Eurohealth Vol 17 No 2–3 32
HEALTH POLICY DEVELOPMENTS
competitive areas, whereas public hospitalsoperate both in urban and non-competitiveregions. Thus, private-for-profit hospitalshave two major disadvantages which maybe due to wrong strategic decisions takenin the past: (1) their hospitals are too smalland (2) they operate in areas that are toocompetitive.
Finally, the study suggests that private for-profit hospitals provide higher quality ofcare, measured as risk-adjusted in-hospitalmortality rates, compared to other types ofownership.9 This is in contrast with thecommon assumption that informationasymmetries exist in the hospital marketand thus particularly for-profit hospitalshave the incentive (i.e., profit-seeking) toincrease efficiency at the expense of qualityof care. However, in the German hospitalsector, information asymmetry hasdecreased over the last decade due to avariety of health care reforms aimed atquality assurance (for example, themandatory publication of quality reportsand nationwide benchmarking exercisementioned earlier). Thus, the strategicimportance of quality of care in marketswith substantial overcapacities (i.e., cut-throat competition) may have beenunderestimated so far. There is also evi-dence that private for-profit hospitals (andespecially private for-profit hospitalchains) operating in more competitiveregions have improved their quality man-agement and hospital outcomes in order toattract patients.3
Policy implicationsRecent studies show that public ownershipin Germany is associated with significantlyhigher efficiency than other forms of own-ership; while private for-profit ownership,in particular, is associated with lower effi-ciency. Although this finding is striking, itwould not be appropriate to conclude thatprivate for-profit ownership may not be anefficient form of operating hospitals.
As the development of the German DRG-system progresses, options to focus onrevenue are likely to decrease and thusprivate for-profit hospitals will automati-cally increase their focus on efficiency.However, it may be an important impli-cation for policy makers that privatefor-profit hospitals in Germany and in theUnited States, if anything, tend to focus onrevenue. Therefore, DRG-systems have toset incentives to increase hospitals’ focuson efficiency which finally helps toimprove the allocation of health careresources. However, the observed negative
association between efficiency and qualityof care (i.e., in-hospital mortality) suggeststhat improvements in efficiency may leadto lower outcomes (or vice versa). Conse-quently, it is of crucial importance tomonitor outcomes when introducing pay-ments based on DRGs.
Moreover, linking DRG-based reim-bursement rates to process quality oroutcomes is a promising approach toovercome the trade-off between efficiencyand quality of care. While this is still rela-tively rare, it is possible to refine DRGsystems to integrate direct incentives forimproving quality.11 For example, DRG-based payments can be adjusted at thehospital level by increasing/decreasingpayments for all patients treated by a hos-pital, if that hospital providesabove/below-average quality as measuredthrough hospital-level quality indicators(cf. for example Commissioning forQuality and Innovation (CQUIN) inEngland).12 Similarly, it is possible toincrease payments to a hospital for allpatients falling into one DRG if the hos-pital scores above average onDRG-specific quality indicators, or toadjust payments for individual patients ifquality can be monitored at the individualpatient level. Germany provides anexample for this by including the secondadmission into the first DRG if the patientis readmitted within 30 days, i.e. the secondstay is not reimbursed separately.2
Finally, it is striking that private for-profithospitals in Germany have recognised thestrategic importance of quality of care.This may be one effect of recently estab-lished quality assurance programmes,which have substantially increased trans-parency regarding the quality of care. Thismay suggest that the introduction ofquality reports, which oblige hospitals todeliver data regarding the quality of carefor defined conditions, has been animportant and valuable decision. Twenty-seven of the 206 quality indicators arealready available for public use.3 Thesedevelopments may well suggest thatfurther quality indicators, as well as dataon long-term results after hospitalisations,should be made available to the public.
REFERENCES
1. Schreyögg J, Tiemann O, Busse R. Costaccounting to determine prices: how welldo prices reflect costs in the German DRG-system? Health Care Management Science2006;9(3):269–79.
2. Geissler A, Scheller-Kreinsen D, BusseR. Germany: understanding G-DRGs. In: Busse R et al (eds). Diagnosis RelatedGroups in Europe. Moving Towards Transparency, Efficiency and Quality inHospitals. Maidenhead: Open UniversityPress, 2011.
3. Busse R, Nimptsch U, Mansky T. Measuring, monitoring, and managingquality in Germany’s hospitals. Health Affairs 2009;28(2):294–304.
4. Federal Statistical Office of Germany.Fachserie 12 Reihe 6.1.1 – Grunddaten der Krankenhäuser und Vorsorge- oder Rehabilitationseinrichtungen 2009 [Basicdata of hospitals and preventive and rehabilitative institutions 2009]. Wiesbaden, 2011.
5. Shen Y-C, Eggleston K, Lau J, Schmid C.Hospital ownership and financial perform-ance: what explains the different findings inthe empirical literature? Inquiry2007;44(1):41–68.
6. Hollingsworth B. The measurement ofefficiency and productivity of health caredelivery. Health Economics2008;17(10):1107–28.
7. Shen Y-C, Eggleston K, Lau J, Schmid C,Chan J. Hospital ownership and quality ofcare: what explains the different results?Health Economics 2008;17(12):1345–62.
8. Herr A. Cost and technical efficiency ofGerman hospitals: does ownership matter?Health Economics 2008;17(9):1057–71.
9. Tiemann O, Schreyögg J. Effects of ownership on hospital efficiency in Germany. Business Research 2009;2:115–45.
10. Wörz M. Erlöse – Kosten – Qualität:Macht die Krankenhausträgerschaft einenUnterschied? Eine vergleichende Untersuchung von Trägerunterschieden imakutstationären Sektor in Deutschland undden Vereinigten Staaten von Amerika[Revenues – Costs – Quality: Does Hospital Ownership Make a Difference? A Comparative Analysis in the Acute Hospital Sectors of Germany and theUSA]. Wiesbaden: VS Verlag, 2008.
11. Or Z, Häkkinen U. DRGs and quality:for better or worse? In: Busse R et al (eds).Diagnosis Related Groups in Europe. Moving Towards Transparency, Efficiencyand Quality in Hospitals. Maidenhead:Open University Press, 2011.
12. Department of Health. Using theCommissioning for Quality and Innovation (CQUIN) Payment Framework – A Summary Guide. London: Department of Health, 2010.
Eurohealth Vol 17 No 2–333
HEALTH POLICY DEVELOPMENTS
Eurohealth Vol 17 No 2–3 34
The way health care in Europe is plannedand the range of providers that patientshave access to could look very different inthe years to come with the implementationof the EU Directive on cross-border healthcare.1 The Directive, which clarifies therights of patients to receive health care inother EU member states, was adopted inMarch 2011 after a lengthy EU decision-making process. The legislation will haveto be implemented nationally by October2013 and will have the effect of extendingpatient choice beyond national borderswith significant implications for bothEnglish National Health Service (NHS)commissioners (the NHS equivalent of an‘insurer’ in the context of cross-borderhealth care) and providers.
The NHS European Office engagedthroughout the EU decision-makingprocess to ensure the rules struck the rightbalance between the increasing mobility ofour citizens and patients on the one handand the member states’ responsibility for
the organisation, management and fundingof their health care systems on the other.We undertook a wide consultation processwith the aim of assessing the potentialimplications for the NHS,2 followed thiswith a briefing putting forward NHSviews on the proposals3 and, morerecently, summarised in a new publicationthe implications for the NHS of the agreedDirective.4
The extent of our involvement was dictatedby the symbolic nature of the Directiveand the genuinely uncertain consequencesthe Directive could have. While the impli-cations of the Directive discussed in thisarticle are an early reading of the situationand the true impact on our health caresystem is still largely unknown, adaptingto these new challenges and takingadvantage of the coming opportunities isin our own hands.
What the Directive saysIt is important to note that the Directivespeaks with the voice of the patients – it istheir rights it clarifies. Its underpinningrationale is that it should be as easy as pos-sible for patients to have access to healthcare abroad, subject to the same conditionsthat apply to accessing health care at home.The legislation confirms that it is alwaysthe home health system that decides what
health care is available to its citizens,regardless of whether they are treated athome or abroad. In the case of the NHStherefore, patients will be required to havetheir eligibility to health care assessed by ageneral practitioner. This provision is par-ticularly important to the NHS which,unlike social insurance systems, does nothave a ‘basket’ of health care to which allpatients are entitled, but instead makesdecisions on eligibility locally, taking intoaccount the circumstances of individualpatients.
From the perspective of our health caresystem, the Directive has been generallywelcomed, owing to the fact that it pro-vides clarity for those in charge of planningcare. Importantly, it allows EU memberstates the option of introducing priorauthorisation for patients seeking careabroad, applicable to health care which issubject to planning requirements andwhich involves at least one night in hos-pital, or which requires the use of highlyspecialised and cost-intensive medicalequipment. Authorisation can only berefused in limited circumstances and deci-sions have to be taken in an objective andnon-discriminatory manner, for examplewhen a patient could be exposed to a highsafety risk that cannot be regarded asacceptable.
HEALTH POLICY DEVELOPMENTS
Health care across borders: Implications of the EU Directive on cross-border health care for the English NHS
Elisabetta Zanon
Summary: The EU Directive on patients' rights in cross-border health care, agreedin March 2011, extends the reach and choice of patients beyond their traditional,national borders. Adapting to the rights and demands of the ‘European patient’ willbe a challenge for health care organisations, forcing them to think differently abouthow they plan, finance and provide health care. The Directive, however, offers opportunities too for those providers with the expertise and the resources to adapt toa more European market. This article looks at the implications of the Directive forthe English National Health Service (NHS).
Key words: cross-border health care, patient mobility, NHS, patients’ rights, entitlements, England
Elisabetta Zanon is Director, NHS European Office, Brussels, Belgium.Email: [email protected].
Further information on the role and workof the NHS European Office can befound at www.nhsconfed.org/europe
Authorisation cannot be refused when apatient is experiencing ‘undue delay’ inreceiving treatment and while there is noformal definition of what constitutes‘undue delay’, judgements must be basedon a clinical assessment of what is a med-ically acceptable period for the individualclinical circumstances of the patient.
The Directive clarifies that commissionersare not required to pay more than the costof a patient’s treatment if provided by theNHS and there is no requirement to paytravel, accommodation or other expensesthat would not be covered if treatmentwere provided by the NHS.
One of the biggest issues concerning cross-border health care is how domestic costsare determined. The Directive states thateach country should have a transparentmechanism for calculating the reim-bursement a patient is entitled to, but thedetail of this is left for the country todetermine.
For NHS health care which is not coveredby a tariff – currently around 60% of care –defining levels of reimbursement could betricky given prices are subject to negoti-ation and geographical variations. Further-more, NHS tariffs may cover a package ofcare, rather than just one procedure, whichmeans costs may need to be ‘unbundled’ ifa patient receives a different package ofcare abroad. With regards to matters ofquality, safety and liability of care, respon-sibility rests with the country where thehealth care is provided. This means thatstandards set by the UK regulatory bodieswill not apply to treatment providedabroad and NHS hospitals treating patientsfrom other EU countries will do so toNHS standards.
What will be the main implications forNHS organisations?It is unlikely that there will be a largeincrease in the numbers of UK patientstravelling abroad. Currently, the numbersare small – it has been estimated that onlyaround 1,000 UK NHS patients a year goabroad for care. But commissioners shouldbe mindful that one of the reasons given bypatients for travelling abroad is the oppor-tunity to receive treatment more quickly.So in the event that NHS waiting timesincrease in the coming years, we could seelarger numbers of patients looking to accesshealth care abroad funded by the NHS.
Neither is the Directive expected to have amajor impact on NHS budgets, withpatients in principle reimbursed for costs
no higher than NHS treatment. But com-missioners will need to bear in mind thatauthorisation cannot be refused in cases of‘undue delay’.
On a positive note, the legislation will endthe current uncertainty about the rights ofNHS patients considering travellingabroad and how commissioners handlerequests from them. With the NHSexpected to move to a system of greaterlocal variation under ongoing NHSreforms, a key issue will be for commis-sioners to have a clear ‘list’ of the types ofhealth care they do and do not provide.This will be crucial for minimising uncer-tainty for commissioners and patients, andfor reducing the possibility of legal chal-lenge from patients who want to accesstreatments that are not routinely availableon the NHS.
Looking at the impact on providers, it ispossible that the NHS could see anincrease in requests from overseas patientsfor access to treatment in some clinicalareas, especially for those NHS trusts thatprovide highly specialised care and have aninternational reputation. In such cases it isessential that sufficient capacity is plannedfor, so that additional patients can betreated to the benefit rather than thedetriment of NHS patients.
It is important to emphasise, however, thatEuropean patients must not automaticallybe classed as private patients as this wouldbe discriminatory and contrary to EU law.Providers will instead have to offer thesepatients the option to be classed as either‘paying’ NHS patients or private patients,with only the latter being subject to privatefees.
One issue for providers seeking moreoverseas patients is the fact that NHStariffs are often higher than the prices ofother EU countries. Patients will only bereimbursed up to the cost of health care intheir own country and would have tocover the difference personally whereverNHS care is more expensive.
There are real opportunities for thosetrusts with specialist expertise, especially inthe diagnosis and treatment of rare dis-eases, which are expected to emerge fromthe establishment of ‘European referencenetworks’. The Directive states that thesenetworks will concentrate knowledge inmedical areas where expertise is rare andthis could have a positive impact on partic-ipating NHS trusts in terms ofinternational reputation, collaboration andimproved patient care.
What will happen next?The Directive is due to be fully imple-mented by October 2013. Theimplementation will take place in parallelto a vast programme of NHS reforms inEngland, raising many questions abouthow the rules will be implemented on theground and which organisations will beresponsible for its different provisions.
It will be during the transposition intonational law that key issues regarding thepractical implementation of the Directivewill be decided, such as:
– decisions around how the process ofprior authorisation will work inpractice;
– how to ensure that patients can accessdetailed information on their entitle-ments to health care;
– how many contact points for cross-border health care will be establishedacross the country and which organisa-tions will be responsible for thisfunction;
– which data on cross-border health carewill have to be collected; and
– how the cost of cross-border health carewill be calculated, in particular for thoseprocedures which are not subject totariffs.
Further to this, work will continue to beconducted at EU level to develop a numberof provisions in the Directive, such as theconcept of ‘European reference networks’,and to put forward guidelines to supportmember states with the implementation ofthe Directive.
Despite the EU Directive now beingagreed, it is clear that a number ofimportant decisions on the application ofthe rules have still to be taken and that ourwork to engage and influence them willcontinue over the next couple of years.
REFERENCES
1. Directive 2011/24/EU of the EuropeanParliament and of the Council on the application of patients’ rights in cross-border healthcare. Official Journal of theEuropean Union, Brussels, 2011. Availableat: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF
2. NHS European Office. A EuropeanHealth Service? The European Commis-sion’s Proposals on Cross-Border Health-care. Brussels: NHS Confederation, 2008.
Eurohealth Vol 17 No 2–335
HEALTH POLICY DEVELOPMENTS
Eurohealth Vol 17 No 2–3 36
Available at: http://www.nhsconfed.org/NationalAndInternational/NHSEuropeanOffice/OurWork/Pages/CrossBorderHealthcare.aspx
3. NHS European Office. Healthcare inEurope. NHS Views on the European Commission’s Proposals on Cross-border
Healthcare. Brussels: NHS Confederation,2009. Available at: http://www.nhsconfed.org/NationalAndInternational/NHSEuropeanOffice/OurWork/Pages/CrossBorderHealthcare.aspx
4. NHS European Office. Patient ChoiceBeyond Borders. Implications of the EU
Directive on Cross-border Healthcare forNHS Commissioners and Providers. Brussels: NHS Confederation, 2011. Available at: http://www.nhsconfed.org/NationalAndInternational/NHSEuropeanOffice/OurWork/Pages/CrossBorderHealthcare.aspx
The question of how to fund long-termcare (LTC) services in England has longvexed policy makers. The system has al-ways been a complex mix of substantialout of pocket payments for personal care,supplemented by means tested support. Itremains difficult for the public to under-stand and has been accused of being un-fair: thrifty individuals who make provi-sion for old age or save to pass on assetsto their children lose out. The lack of anymeaningful private LTC insurance meansthere is no mechanism to mitigate the riskof catastrophic costs should someoneneed care and support.
Recognition of inequities, whilst mindfulof need for a sustainable system of publicsupport, has been the spur for several re-ports and reviews commissioned by gov-ernment, as well as by independent bod-ies since 1998. For differing reasons noneled to major change.
July 2011 saw publication of the latest re-port from the independent Commissionon Funding of Care and Support.1 Thiswas established by the Coalition govern-ment in July 2010 to review funding forcare and support in England. In particularit was asked for recommendations onpartnership funding between individualsand the state for care. It also consideredhow people could protect their assets, in-cluding homes, against care costs.
Chaired by economist Andrew Dilnot,alongside former Labour Health MinisterLord Warner and Care Quality Commis-sion Chair, Dame Williams, recommenda-tions include national criteria for care toeliminate discrepancies in care entitle-ments between local authorities. Individ-ual contributions towards costs of socialand LTC needs should be capped be-tween £25,000 and £50,000. Other than£10,000 per annum for accommodationand food, all other costs would be met bythe state. Theoretically this cap couldstimulate development of LTC insuranceproducts. The Commission also recom-mended that the mean-tested thresholdfor care support be increased from£23,250 to £100,000. Full implementation,assuming a £35,000 contribution cap,would cost £1.7 billion (0.25% of publicexpenditure) rising to £3.6 billion by2025. Overall, the package would meanno-one should spend more than 30% oftheir wealth on care needs.
Reaction Government reaction to the report hasbeen muted. Health Minister AndrewLansley welcomed the report in Parlia-ment, but made reference to significantcost implications “which the governmentwill need to consider against other fund-ing priorities and calls on constrained re-sources…we have to consider carefullythe additional costs to the taxpayer of theCommission's proposals against otherfunding priorities”. This reaction mightalso reflect political nervousness that therecommendations could be viewed as away for homeowners, i.e. those in highersocioeconomic groups, to benefit finan-
cially at a time when deep cuts are beingmade across the welfare state.
Reaction has been more upbeat fromnon-governmental organisations, withmany calling for continued momentum topublish a White Paper setting out govern-mental plans by Easter 2012. The Associ-ation of British Insurers see the proposalsas a way of reducing uncertainties whichhave made the development of LTC in-surance difficult.
Perhaps most critically, there have alsobeen renewed calls for the political partiesto put aside differences to work together.This previously has been difficult toachieve. Prior to the general election in2010, LTC became a politically charged is-sue, with efforts to build cross-party con-sensus failing amid accusations by thethen opposition Conservatives that gov-ernment plans to reclaim some of the costsof LTC from the estates of individuals af-ter death would amount to nothing shortof a ‘Death Tax’. Encouragingly, therehave been calls since the publication of theCommission’s report by politicians in allparties for a mature apolitical debate onthe issue. It remains to be seen whetherthis will help facilitate the development ofa LTC funding model acceptable to thepublic, that all the political parties arewilling to be held accountable for.
REFERENCES
1. Fairer Care Funding. Report of the Com-mission on Funding of Care and Support.London: Department of Health, 2011.Available at https://www.wp.dh.gov.uk/carecommission/files/2011/07/Fairer-Care-Funding-Report.pdf
HEALTH POLICY DEVELOPMENTS
Towards fairer care funding inEngland
David McDaid
David McDaid is Senior Research Fellow,LSE Health and Social Care and European Observatory on Health Systemsand Policies, London School of Economicsand Political Science.Email:[email protected]
Eurohealth Vol 17 No 2–337
NEW PUBLICATIONSNEW PUBLICATIONS
Help wanted? Providing and payingfor long-term care
Francesca Colombo, Ana Llena-Nozal,Jérôme Mercier and Frits Tjadens
Paris: OECD Publishing, 2011
ISBN: 978-9-2640-9758-2
328 pages
Paperback €75. E-book: €52
This book examines the challenges coun-tries are facing with regard to providingand paying for long-term care. As life ex-pectancy pushes into the late 70s for menand well into the 80s for women, ever morepeople want help in order to be able to livetheir lives to the full for as long as possible.
How will demographic and labour markettrends affect the supply of family andfriends available to care for them? Can weall rely on family carers as the sole source
of support for frail older people? Shouldfamily carers and friends be better sup-ported, and if so how? Can we attract andretain care workers – is it just a matter ofpaying them better? Will public financesbe threatened by the cost of providing carein the future? What should be the balancebetween private responsibility and publicsupport in care-giving? Can we reduce costsby improving efficiency of long-term careservices?
Reforming long-term care in Europe
Edited by Joan Costa-Font
Chichester: Wiley-Blackwell, 2011
ISBN: 978-1-4443-3873-7
184 pages
Paperback €24
This book provides a topical analysis offeatures and developments in long-termcare in Europe. It compares Europeancountries that are often less studied, includ-ing those in Eastern Europe, France, Spain
and Portugal, with the experiences of reform in Germany, the UK, Netherlandsand Sweden, looking at a range of issuesincluding approaches to financing andmaintaining quality.
Contents:
Glossary
Executive summary
Long-term care: growing sector, multifaceted systems
Sizing up the challenge ahead: future demographic trends and long-term care costs;
The impact of caring on family carers
Policies to support family carers
Long-term care workers: needed but often undervalued
How to prepare for the future long-term care workforce?
Public long-term care financing arrangements in OECD countries
Private long-term care insurance: a niche or a ‘big tent’?
Where to? Providing fair protection against long-term care costs and financial sustainability
Can we get better value for money in long-term care?
Contents:
Editorial introduction
Long-term care: a suitable case for social insurance
The long road to universalism? Recent developments in the financing of long-term carein England
Reforming long-term care policy in France: private–public complementarities
Sustainability of comprehensive universal long-term care insurance in the Netherlands
Social insurance for long-term care: an evaluation of the German model
Long-term care in central and south-eastern Europe: challenges and perspectives inaddressing a ‘new’ social risk
Devolution, diversity and welfare reform: long-term care in the ‘Latin Rim’
One uniform welfare state or a multitude of welfare municipalities? The evolution oflocal variation in Swedish elder care
Reforming long-term care in Portugal: dealing with the multidimensional character ofquality
Eurohealth aims to provide information on new publications that may be of interestto readers. Contact Azusa Sato at [email protected] if you wish to submit a publication for potential inclusion in a future issue.
NEWS FROM THE INSTITUTIONS
Health priorities of the PolishPresidency tabled in BrusselsOn 14 July in Brussels, EwaKopacz, Polish Minister ofHealth, presented the health pri-orities of the Polish Presidency ata session of the Environment,Public Health and Food Safety(ENVI) Committee of theEuropean Parliament. The sessionwas also attended by AdamFronczak, Vice-Minister ofHealth. “Poland assuming thePresidency in the EuropeanUnion Council coincides with theinitiation of the new TRIO pro-gramme, attended by Polandjointly with Denmark andCyprus,” Minister Kopacz said.“All works we have planned shallfocus on the promotion of activ-ities targeting an improvement inthe health of European Union cit-izens and protecting Europeansocieties against common riskfactors,” she added.
Priorities highlighted by the Min-ister in her speech included: actionto tackle differences in healthstatus across Europe throughinfluence on the determinants ofhealth, with special attention paidto correct nutrition and physicalactivity; prevention and control ofrespiratory diseases in children;prevention and treatment of com-munication disorders in children,including the use of e-health andother innovative measures; and theprevention of brain and neurode-generative diseases, includingAlzheimer’s disease.
More information athttp://pl2011.eu/en/content/health-priorities-polish-presidency-tabled-brussels
First informal meeting of ministers of health under the Polish PresidencyOn 5 and 6 July 2011 in Sopot,Poland, an informal meeting ofMinisters of Health of theEuropean Union was held. Also inattendance were representatives ofthe European Commission (DGSANCO), the World HealthOrganization’s Regional Office
for Europe and Marc Sprenger, theHead of the European Centre forDisease Prevention and Control(ECDC).
“The issues addressed at theforum of the EU Council by pre-siding states result from healthpolicy followed both by theEuropean Union and MemberStates, and concern topics thatconstitute vital, social healthproblems,” stressed minister EwaKopacz during the sessions. Shealso pointed to the fact that theseissues should be incorporated inthe EU’s work and priorities, aswell as be acceptable for interna-tional partners. “Poland, in itswork on health-related matters, isplanning to address subject matterconnected with the reduction ofhealth differences among Euro-pean societies, especially withregard to children,” the Ministerof Health remarked.
The talks focused on the healthpriorities of the Polish Presidency,in particular – closing the gap inhealth between Europe’s societies,through such measures as providing equal opportunities to children with communicationdisorders. Issues concerningnutrition and physical activity ashealth determinants for EU cit-izens and organ transplantationand donation were also raised.Opportunities and benefitsbrought by technologies devel-oped in the field of e-health werealso discussed. Other topicsincluded the hazardous impact ofso-called designer drugs on thestate of health of European soci-eties.
A major point on the agenda wasthe situation related to the epi-demic of food poisonings causedby E. coli bacteria. “In ourcapacity as the Polish Presidency,we concentrate on early detectionof threats to the health security ofEU citizens and an effective infor-mation flow. The recent E. colioutbreak has shown howimportant it is,” said MinisterKopacz in Sopot. “In our talks, wehave decided to continue the ini-tiative to set up an EuropeanBlood Bank and to exchangeinformation on dialysers.”
As was highlighted by MinisterEwa Kopacz, both whilepreparing to assume the Presi-dency of EU and during thePresidency, Poland attaches con-siderable weight to health issues,including public health. The Min-ister emphasised the significanceof early prophylaxis and pro-motion of health for strongmodern societies. “From an eco-nomic point of view, it has beenconclusively proven that anyexpenditure allocated for pro-grammes of early medicalintervention for hearing, sight andspeech, is much lower than theoutlay spent on special care in thepre-school and school period oron the provision of special jobs forthese children when they reachadulthood,” she noted. “It is veryimportant for us, as the PolishPresidency, to improve theexchange of information betweenEU countries, to share experiencesin a more active way, and to fostersolidarity in health” added theMinister.
More information on theinformal meeting is available athttp://pl2011.eu/en/content/informal-meeting-ministers-health
Digital Agenda: addressing thechallenges of an ageing populationOn 26 May 2010, the EU’sCouncil of Competitiveness Min-isters identified the JointProgramming Initiative (JPI)More Years, Better Lives, theChallenges and Opportunities ofDemographic Change, as an areawhere joint research programmingwould provide a major addedvalue to the current, fragmentedefforts by Member States.
The JPI initiative is bringingtogether prominent scientists ineconomics, social sciences, healthand technology, together withrepresentatives from industry,policy making and user organisa-tions in order to foster thedevelopment of better knowledgeon the impact of ageing. This is thefirst time that Member States willwork together to fund strategicresearch on the ageing population.
Eurohealth Vol 17 No 2–3 38
MONITOR
New
s
Press releases andother suggested information for future inclusion can be emailed tothe editor David McDaid [email protected]
MONITOR
This agenda is being implemented throughjoint actions and projects involving a sub-stantial commitment of funding andparticipation from involved countries. TheEuropean Commission is providingfinancial support for the coordination ofthe initiative. This is expected to startdelivering concrete results after 2012, suchas science based recommendations foradapting pension systems based not onlyon age, as is currently the case, but oncapacity to work.
The initiative will also provide a majorcontribution to the European InnovationPartnership for Active and Healthy Ageingand the Digital Agenda for Europe. Itcomplements ageing related research activ-ities in the Seventh FrameworkProgramme (FP7), the Ambient AssistedLiving Joint Programme and the Compet-itiveness and Innovation Programme.
Therefore, as part of this initiative, on 15July 2011, the European Commissioncalled on EU Member States to developand pursue a common vision on how tocoordinate research at EU level in the fieldof ageing.
A Recommendation just adopted by theCommission urges Member States to par-ticipate in the Joint Programming Initiativeon ageing populations in research areassuch as how to retain people in the labourmarket, how to help older people remainactive for as long as possible, in goodhealth and with a better quality of life andhow to make our future care systems sus-tainable.
This issue is of critical importance giventhat more than 30% of Europeans will be65 or over in 2025, while the number ofthose over 80 will almost double in thesame period. So far thirteen countries havecommitted to participate in the Joint Pro-gramming Initiative, led by the GermanMinistry for Research and Education. Thetwelve additional countries participating atpresent are Austria, Denmark, Finland,France, Italy, The Netherlands, Poland,Spain, Sweden, Switzerland, Turkey andthe UK, while a further three countries areobservers (Belgium, Ireland, Norway). TheCommission is a non-voting member ofthe governing structure.
The Recommendation calls on MemberStates to include the following actions, aspart of their research agenda on ageing:
– identifying and exchanging informationon relevant national programmes andresearch activities, as well as exchanging
best practices, methodologies andguidelines;
– identifying areas or research activitiesthat would benefit from joint coordi-nation or pooling of resources;
– considering the changing needs of olderpeople when defining the objectives forageing research programmes;
– sharing, where appropriate, existingresearch infrastructures or developingnew facilities such as coordinated data-banks or the development of models forstudying ageing processes;
– encouraging better collaborationbetween public and private sectors andbetween different research activities andbusiness sectors related to demographicchange and population ageing;
– creating networks between centres ded-icated to demographic change andpopulation ageing research.
Speaking of the initiative Neelie Kroes,European Commission Vice-President forthe Digital Agenda said that it “willdevelop new science-based knowledge onthe effects of demographic change.” Sheadded that she was looking forward to“further Member States joining so that wecan look for new opportunities generatedby an ageing society, and not be over-whelmed by its challenges.”
More information at http://www.jp-demographic.eu/
High level of premature illness and deathamongst men is preventable, concludesreportThe Men’s Health Report published on 25August by the European Commissionhighlights the state of men’s health inEurope as a serious public health concern.Commissioned by the European Com-mission’s Public Health Programme, thereport was led by Professor Alan Whitefrom Leeds Metropolitan University andcarried out by a consortium of authors. Itspurpose is to inform policy makers, healthprofessionals, academics and the widerpopulation of the health challenges menface.
Patterns emerging from data taken from allEU-27 countries, as well as Norway,Iceland, Switzerland, Lichtenstein,Croatia, Turkey and the former YugoslavRepublic of Macedonia, show marked dif-ferences in health outcomes amongst menboth between and within countries. Poorlifestyles and preventable risk factors
account for a high share of prematuredeath and illness in men, illustrating thattheir health disadvantage is not necessarilywritten in the genes but can be remedied inpart by targeted policies and actions.
Key findings from the report includeobserving that more than 50% of pre-mature deaths among men are avoidable.Even though there have been big reduc-tions in cardiovascular morbidity anddeath amongst men, cardiovascular diseaseis still one of the greatest risks to health andthe principal cause of death in the olderpopulation.
One challenge is to increase the rate ofengagement of men in routine or preven-tative health checks. Depressive disordersin men, as well as other mental healthproblems, are under detected and undertreated in all European countries. This ispartly due to men being less likely to seekhelp than women. The report also notesthat prostate cancer has become the mostdiagnosed cancer in Europe, while tes-ticular cancer, despite effective treatment,still remains the first cause of cancer deathsamong young men aged 20–35 years.
The report is available athttp://ec.europa.eu/health/population_groups/docs/men_health_report_en.pdf
Commission publishes report of publicconsultation on revisions to the TobaccoProducts DirectiveTobacco is the single largest cause ofavoidable illness in the European Union(EU) and the estimated cause of death ofover 650,000 people in the EU every year.At global level, the World Health Organi-zation (WHO) estimates that tobacco usewill kill nearly six million people this yearalone. This figure could reach eight millionby 2030 if steps are not taken to reversethis worrying trend.
On 27 July the European Commission’sDirectorate-General for Health and Con-sumers published results of a publicconsultation on the upcoming revision ofthe Tobacco Products Directive. Thecurrent Directive (2001/37/EC) dates from2001. Since then, significant scientificprogress and international developmentshave taken place. In particular, the EU andtwenty-six of its Member States are Partiesto the WHO Framework Convention onTobacco Control (FCTC) which enteredinto force in February 2005. The review ofthe Tobacco Products Directive is aresponse to these developments as some ofthe current provisions of the Directive
Eurohealth Vol 17 No 2–339
MONITOR
have now become outdated, resulting in asignificant divergence between MemberStates’ laws on the manufacture, presen-tation and sale of tobacco products.
The consultation on the revision of theTobacco Products Directive was launchedlast autumn. Respondents were asked togive their input on a number of policyoptions including: mandatory pictorialhealth warnings – or graphic images - onpacks of tobacco; plain or generic pack-aging; regulating harmful and attractivesubstances in tobacco products; andrestricting or banning the sale of tobaccoproducts over the internet and fromvending machines.
The consultation has generated anunprecedented 85,000 responses. The vastmajority of contributions have come fromindividual citizens, illustrating the greatinterest in EU tobacco control policy.Other respondents represented industry,non-governmental organisations, govern-ments and public authorities.
Contributions varied significantly. Forexample, those in favour of mandatory pic-torial health warnings and plain packagingstressed that these measures would signif-icantly weaken the advertising effects ofthe packaging and provide equal protectionfor European citizens. Opponents, on theother hand, raised legal concerns arguingthat these measures would have little or noimpact on the uptake of smoking.
Those in favour of regulating ingredientssaid that restricting certain additivesalongside sweet, fruity, floral, and candyflavours could prevent young people fromtaking up smoking and would facilitateintra-EU trade by bringing into lineexisting national regulations on ingre-dients. Opponents argued that regulatingingredients and additives would do little toprevent young people from taking upsmoking and could discriminate againstcertain varieties and brands of tobacco.
The results of the consultation will betaken into account in the ongoing impactassessment which addresses the economic,social and health impacts, as well as the fea-sibility of various policy options. Theoutcome of the impact assessment will bepresented together with a legislative pro-posal next year.
A report summarising the public consul-tation is available at http://ec.europa.eu/health/tobacco/consultations/tobacco_cons_01_en.htm
New brochure on EU funding possibilitiesto promote active ageingThe Committee of the Regions, AGEPlatform Europe and the European Com-mission have issued a brochure presentingEU funding possibilities for regional andlocal initiatives to promote active ageingand solidarity between generations. Thebrochure aims to make a particular contri-bution to the European Year for ActiveAgeing and Solidarity between Genera-tions 2012.
The majority of initiatives to promoteactive ageing – throughout 2012 andonwards – will be taken without financialsupport from the EU, but in some casesEU funding will play a role. The brochureshows what resources are available andinvites regional and local stakeholders tomake the best possible use of them,preferably working in partnershipsinvolving several countries. The brochurepresents numerous examples of projectswhich have received EU funding. It alsoincludes short presentations of the mostrelevant EU funding programmes tosupport new active ageing projects.
The brochure can be downloaded athttp://ec.europa.eu/social/BlobServlet?docId=7005&langId=en
Illicit drug use in Europe still a majorthreat to public healthIllicit drug use in Europe still represents amajor threat to public health and is respon-sible for between 7,000 and 8,000 fataloverdoses every year in the EU. So statedWolfgang Götz, Director of the Lisbon-based European Monitoring Centre forDrugs and Drug Addiction (EMCDDA),ahead of the International Day AgainstDrug Abuse and Illicit Trafficking on 26June. Gotz also noted that Europe’s drugsproblem are changing, with more problemsnow associated with the use of stimulantdrugs such as cocaine, while new sub-stances are increasingly appearing on theEuropean market.
Gotz went on to highlight achievementsmade since the 1990s in scaling up of carefor drug users, noting that at least onemillion people in the EU receive someform of treatment for drug problems peryear. The wider availability of clean needlesand syringes for drug injectors has alsobeen linked to both a reduction in newdrug-related HIV infections and an overalldecline in levels of injecting drug use.
He also noted the increased focus onpublic health in European drug policies,
citing an example from Portugal. The Por-tuguese case study, he argues, illustrateshow it takes many years of action againstan ongoing severe drugs problem todevelop a new drug policy model.
Innovative responses are required andmust be subject to evaluation. Gotz addedthat “we should acknowledge the impor-tance of developing innovative responsesand evaluating them thoroughly. Withoutsuch an approach, many of the interven-tions which are today at the heart of ourdrug policies would simply not exist.” Anew EMCDDA series of drug policy pro-files outlining the development andcharacteristics of national drug policies inEurope and elsewhere in the world hasnow been launched.
The Portuguese drug policy profile isavailable at http://www.emcdda.europa.eu/publications/drug-policy-profiles/portugal.
COUNTRY NEWS
France: proposed reform of pharmaceutical regulatory systemFrench Health Minister, Xavier Bertrand,has outlined a bill to overhaul the country’sdrug regulatory system in the wake of thescandal over the continued use of the anti-diabetes drug benfluorex in France, longafter it was banned in other countries. Themedicine is estimated by different studiesto have caused 500 to 2,000 deaths inFrance, mainly from heart valve damage.The oral drug, marketed as Médiator, wastaken by more than five million people inthe country and often prescribed forweight‑loss until it was withdrawn inNovember 2009 when new researchrevealed the extent of the heart-valveproblem.
The new legislation, which will be debatedin parliament in September 2011, proposesto introduce fines and penalties for thosein the health sector who fail to declare anyconflicts of interest. It will focus on pre-venting conflicts of interest at all levels ofthe health service from the ministry down,increasing transparency in decision-making on drug approvals, ensuring thatall drugs offer real benefits, improvingtraining for health professionals, and pro-viding better information for professionalsand the public. Measures will include aFrench ‘Sunshine Act,’ where drug com-panies will be fined if they do not declare
Eurohealth Vol 17 No 2–3 40
MONITOR
all agreements with outside groups, strictercontrols on prescribing drugs for unautho-rised uses, changes in drug marketingmethods, and a ban on the financing ofmedical students by drug companies.
The Health Products Safety Agency,Agence Française de Securité Sanitaire desProduits de Santé (AFSSAPS), the regu-latory body which was severely criticisedfor its role in the Médiator affair, will alsobe renamed as the Agence Nationale deSecurité du Médicament, the NationalAgency for the Safety of Medicines(ANSM). It will be given new powers sothat new drugs have to pass a more rig-orous approval process. New drugs will becompared with existing medications andnot just placebos.
If adopted into law, the whole package ofreforms will be reviewed in two years.However, even before the law has beenpassed, work has begun on reassessing the19,000 drugs now authorised in France, ofwhich 12,000 are on the market. Bertrandhas hinted that many of these drugs maybe dropped. The Minister has also statedthat the French system must be capable ofreacting as fast as the US Food and DrugAdministration (FDA), citing an examplein which the FDA added a contraindi-cation for another diabetes drug, just 48hours after it was suspended from theFrench market.
Finland: Downward trend in smokingand alcohol use, increase in the use ofsnus among adolescents
The downward trend in daily smokingamong adolescents has continued to fallover the period from 1977 to 2011, withadolescents starting to experiment withsmoking at an older age than ever beforein Finland. Alcohol use and binge drink-ing have also decreased among adoles-cents below the age of 18 years. On theother hand, snus (moist snuff) use and ex-posure to narcotic drugs have becomemore common.
This information appears in the nation-wide Adolescent Health and LifestyleSurvey 2011 carried out at the Universityof Tampere, School of Health Sciences.The questionnaire was completed by4,566 adolescents aged from 12 to18years. The survey, which is funded by theMinistry of Social Affairs and Health, hasbeen conducted biennially since 1977.
More information athttp://www.stm.fi/en/pressreleases/pressrelease/view/1563478#en
Hungary introduces ‘fat tax’ Food considered to be unhealthy,including crisps, soft drinks and chocolatebars, are now subject to a new tax inHungary. The new law, which came intoforce on 1 September is aimed at improvingthe health of the nation. Initially called ‘thehamburger tax’, the measure was dubbedthe ‘crisps tax’ or ‘fat tax’ after the Hun-garian government decided that it wouldnot affect fast food restaurants. The newlaw also does not cover some traditional Hungarian cuisine, such as goose fat.
Hungarians will have to pay a 10 forint(€0.37) tax on foods with high fat, sugarand salt content, as well as increased levieson some carbonated soft drinks andalcohol. The expected annual proceeds of€70 million will go toward state healthcare costs, including those associated withaddressing the country’s 18.8% obesityrate, which is more than 3% higher thanthe European Union average of 15.5%.
Hungarian Prime Minister Viktor Orbanhas said that those who live unhealthilyhave to contribute more. In other words,the new law is based on the idea that thosewhose diets land them in the hospitalshould help foot the bill, particularly in acountry with a health care deficit of €370million.
The controversial ‘fat tax’ is the most com-prehensive on unhealthy foods in theworld to date; but other European coun-tries are also moving in this direction.Denmark is one of several European coun-tries to tax fizzy soft drinks, and it hasimposed a levy on sweets for nearly 90years. The country was also the first in theworld to pass a law banning trans fats, withAustria and Switzerland following closelyafter. Later in 2011 Denmark also plans tolevy a ‘sin tax’ on foods with high saturatedfat content. Romania also considered a ‘fattax’ scheme to raise €700 million a yearthat would be earmarked for healthservices, but the idea was ditched in Marchdue to the sharp rise in general food prices.
There are differing opinions over thepotential impact of the legislation. Con-cerns have been raised about the impact onlow-income groups, given that Hungariansalready spend 17% of their income onfood and already pay an extra 25% tax onmost food and drink products theyconsume, one of the highest rates withinthe EU. While generally supportive of thenew tax, Archie Turnbull of the Brussels-based European Public Health Alliance, a
network of public health non-govern-mental organisations, suggested in a letterto the Hungarian government that it “con-sider using other pricing mechanisms orsubsidies to make the healthy options offresh fruits and vegetables more widelyavailable and affordable.”
German Parliament gives approval forlimited embryo screeningOn 7 July in a free vote the German Par-liament approved by 326 to 260 a bill thatallows prospective parents worried aboutgenetic diseases to screen test-tubeembryos before bringing them to term.The Bundestag moved to allow some “pre-implantation genetic diagnosis (PID)”, inwhich a cell or two are extracted from adeveloping embryo to test for genetic dis-order. But it also imposed strict conditions:doctors can perform the screening onlywhen the parents have a strong likelihoodof passing on a genetic defect, or when thechances of miscarriage or stillbirth are(genetically) high. In all other respects thecountry’s strict Embryo Protection Lawwill remain in place.
German Chancellor Angela Merkel wasamong those opposed to the measure.Many opponents fear the tests could leadto so-called ‘designer babies.’ Germany hasalso been particularly cautious in allowinggenetic procedures because of atrocitiesunder the Third Reich. Since PID tests areonly feasible among parents who havealready opted for in-vitro fertilisation, theytend to be relatively rare. Experience in theUnited Kingdom has shown that geneticscreening can increase the chances anembryo will ‘take’ and lower the likelihoodof miscarriage or stillbirth.
Momentum toward the vote had beengrowing in Germany. In July 2010, theFederal Court of Justice ruled that threescreenings performed by a Berlin doctordid not violate the country’s 1990 EmbryoProtection Law. The law recommends athree-year jail term for anyone using anembryo in a way that fails to promote itssurvival. The court ruled that since the goalof PID was a healthy pregnancy and ahealthy child, the screenings were lawful.
Spain: Law passed on mandatorygeneric prescribingThe Spanish government has passed newlaws to increase generic prescribing and cutup to €2.4 billion per annum in thecountry’s pharmaceutical expenditure.Doctors will have to write prescriptionsusing a drug’s generic name and pharma-
Eurohealth Vol 17 No 2–341
MONITOR
cists will be obliged to fill that prescriptionusing the cheapest available generic drug.The move will not affect newer brandeddrugs, whose patents prevent cheapergeneric versions coming to market, but itwill impinge upon companies with olderpatented medicines that have lost this protection and face generic competition.
The rule change will be most concerning tosmall-to-medium sized firms (SMEs) thatrely on single blockbusters for the majorityof their revenue. It will also have a negativeimpact on the bigger companies thatmarket branded statins and blood thinners,two groups of medicines that tend tosuccumb to generic substitution in times ofausterity.
The law also states that patients shouldonly be told the chemical name of the drugbeing prescribed, regardless of whether it isa patented medicine or a generic, meaningpatients will now not know what drug theirdoctor intended to prescribe.
Prime Minister, José Luis Rodríguez Zap-atero, told parliament the measures wouldhelp Spain continue to lower the cost ofdrugs to the state, a move that began lastyear and which has led to the first-ever fallin the national pharmaceutical bill. Thisyear’s bill was already cut by 10%, in partbecause of measures that had increased theuse of generic drugs.
Speaking to the Guardian newspaperBasque nationalist deputy Josu Erkoreka,whose party backed the move, said that thenew legislation will lead to “an importantsaving for the public accounts and will,without doubt, benefit most people whouse public health services. The interests ofthe big drugs companies must give way topublic interest, and what matters isreducing the deficit and lowering the drugsbill for millions of people who use publichealth services.” However Catalan nation-alist deputy, Josep Antoni Duran i Lleidatold the Guardian that he feared that jobswould be lost in the pharmaceutical sector.
Scotland: Alcohol sales at all time highAlcohol sales are now 23% higher inScotland than in England and Wales, thebiggest difference ever recorded during the17 years measured since 1994.The newfigure is contained in a report published on30 August by NHS Health Scotland. Thepublication shows that on average 2.2 morelitres of pure alcohol per adult were sold inScotland than in England in 2010; 11.8versus 9.6 litres. This equates to 22.8 unitsof alcohol per adult per week in Scotland,
above the recommended upper weeklylimit of 21 units for men.
In addition almost 2.5 times more vodkawas sold per adult in Scotland through off-sales than in England and Wales. CabinetSecretary for Health and Wellbeing NicolaSturgeon commenting on the report saidthat “for too long Scotland’s unhealthyrelationship with alcohol has gone unad-dressed. These shock statistics show thatthe difference between alcohol con-sumption in Scotland and England andWales is now at its highest rate for sev-enteen years. This is a situation that mustbe tackled head on.”
The impact of excessive consumption isestimated to cost the country £3.56 billioneach year. The government have throughtheir Alcohol Framework outlined apackage of over 40 measures to reducealcohol related harm. From October 2011quantity discounts will be banned and off-sale promotions restricted. Thegovernment also intend to introduce aMinimum Pricing Bill to the Scottish Par-liament in the autumn to further reduceconsumption of alcohol. Minister Sturgeonsaid “minimum pricing can and will helpus to redress the balance when it comes toour unhealthy relationship with alcohol.”
The report Monitoring and EvaluatingScotland’s Alcohol Strategy is available athttp://www.healthscotland.com/uploads/documents/16664-completeReportMESASAugust2011.pdf
Northern Ireland: details published ofhealth and social care reviewOn 25 August Health Minister EdwinPoots appointed five external advisers to apanel which will provide expert advice andindependent assurance on the Review ofHealth and Social Care Services inNorthern Ireland.
The review, announced in June, is being ledby John Compton, Chief Executive of theHealth and Social Care Board. The Min-ister has appointed the five externalmembers to provide advice, drawing on arange of relevant expertise and skills. Hehas also published detailed terms of ref-erence for the review.
The Minister said that “it is clear that thefull range of health and social care servicesis unsustainable in its current form if weare to deliver the best outcomes foreveryone, and if we are to maintain thehighest levels of quality and safety of theservices provided. It is important thereforethat this review examines the future pro-
vision of services including our acute hos-pital configuration; the development ofprimary health care services and social care;and the interfaces between the sectors.
The review needs to proceed without delaygiven the seriousness of the situation facingour health services. However, it must alsobe evidence-based with robust analysesand conclusions on future service delivery.I have decided therefore to appoint thispanel of expert advisers to provide inde-pendent assurance to the review team andmyself. The review will benefit immenselyfrom the experience and knowledge ofexternal members, including backgroundsin health policy and health care, businessand academia.”
The panel members will be Professor ChrisHam (Chief Executive of the King’s Fund),Professor Deirdre Heenan (Provost andDean of Academic Development at theMagee Campus, University of Ulster), DrIan Rutter (General Practitioner), PaulSimpson (retired senior civil servant) andMark Ennis (Executive Chair of Scottishand Southern Electricity Ireland).
The Minister said the five advisors wouldbring a wealth of knowledge and skills tothis important exercise. The Minister hasasked the review team to report to him bythe end of November. He said “I have seta challenging timescale for the completionof this Review because it is important thatclarity is provided urgently on the futuredirection of health and social care serviceshere. Our system cannot continue tooperate as it has done: there are simply notthe resources to do so; and action will berequired to ensure we provide safe andeffective services to the people here for thefuture.”
The detailed terms of reference for thereview are available athttp://www.dhsspsni.gov.uk/hsc-provision.htm
England: ‘Nudging’ alone unlikely to besuccessful in changing the population’sbehaviourOn 19 July the House of Lords Science andTechnology Sub-Committee published areport on Behaviour Change. It examinedhow successful nudging has been inchanging people’s behaviour in relation toobesity. It looked at food labelling andrestrictions on advertising, and asked howit was possible to change the choicespeople make about travel in order toreduce car use. The report – the culmi-nation of a year-long investigation into the
Eurohealth Vol 17 No 2–3 42
MONITOR
way the Government tries to influencepeople’s behaviour using behaviour changeinterventions – finds that ‘nudges’ used inisolation will often not be effective inchanging the behaviour of the population.Instead, a whole range of measures,including some regulatory measures, willbe needed to change behaviour in a waythat will make a real difference to society’sbiggest problems.
Other findings and recommendations fromthe Committee include:
– the Government must invest in gath-ering more evidence about whatmeasures work to influence populationbehaviour change;
– they should appoint an independentChief Social Scientist to provide themwith robust and independent scientificadvice;
– the Government should take steps toimplement a traffic light system ofnutritional labelling on all food pack-aging;
– current voluntary agreements withbusinesses in relation to public healthhave major failings. They are not a pro-portionate response to the scale of theproblem of obesity and do not reflectthe evidence about what will work toreduce obesity. If effective agreementscannot be reached, or if they showminimal benefit, the Governmentshould pursue regulation.
The new report contradicts an earlier doc-ument produced for the Communities andLocal Government Department that sug-gested people could be ‘nudged’ into givingto charity or volunteering. The theory ofnudging comes from the book Nudge, byRichard Thaler and Cass Sunstein. Thaleris working with the Behavioural InsightsTeam, which is based at the Cabinet Officeand is examining issues such as promotingcharitable giving.
Baroness Julia Neuberger, chair of theLords sub-committee that carried out thereview, said “there are all manner of thingsthat the Government want us to do – loseweight, give up smoking, use the car less,give blood – but how can they get us to dothem? It won’t be easy and this inquiry hasshown that it certainly won’t be achievedthrough using ‘nudges’, or any other sortof intervention, in isolation.
“Behaviour change interventions arenothing new. Governments have tried tochange our behaviour before – through
legislation, marketing campaigns and even‘nudges’, for example, rumble strips on theroad to get us to drive more slowly. Andbusinesses also try to influence ourbehaviour all the time – supermarketsinfluence us though the location of, andpromotions for, certain foods and all busi-nesses use advertising and marketing tochange our behaviour”
She added that the Committee welcomedthe government’s “desire to take thescience behind behaviour change seriouslyin an attempt to find an effective solution”but noted that “changing the behaviour ofa population is likely to take time, perhapsa generation or more, and politiciansusually look for quick win solutions. TheGovernment needs to be braver aboutmixing and matching policy measures,using both incentives and disincentives tobring about change. They must also getmuch better at evaluating the measuresthey put in place.”
The report and executive summary areavailable at http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/17902.htm
Romania: Change of Health Minister Romania’s Health Minister Cseke Atillaresigned on 4 August in protest that hisministry had not received sufficient fundsin the country’s budget settlement. On 13July, the Minister told the media that theHealth Ministry needed an extra 4 billionLei (about €948 million). He said theRomanian National Health InsuranceHouse (CNAS), the state body tasked withcollecting funds from taxpayers’ healthcontributions, faced serious financialproblems and needed three quarters of thisbudget. However the budget revisionallotted only 341 million Lei to CNAS,through the ministry, to pay arrears and 1.7billion Lei in commitment appropriationsfor medicine with or without a personalcontribution.
According to the Romanian Act Medianews agency, in a news conference MinisterAtilla said that he had warned as early asDecember that an upward budgetadjustment was needed. Atilla, who wasthe nineteenth Minister of Health since1990, noted that over the last twenty yearsRomania has had the lowest GrossDomestic Product (GDP) percentageassigned to health, regardless of gov-ernment or minister in charge. He alsoreferred to the steps taken towardsreforming the system, including the decen-tralisation of 370 hospitals in the previous
year, stricter regulation of sick leave andthe release of a number of vacant staff posi-tions. Stressing that his resignation was notpolitical, he said that reform measures willand must continue.
The new Minister is Ritli Ladislau.Ladislau, was proposed by the Hungarianparty in Romania, the UDMR, which is ajunior member of Prime Minister EmilBoc’s centre-right government. The newminister will also coordinate the activitiesof CNAS which historically had been runindependently of the ministry, though thiscaused discontent among previous healthministers who complained that they wereunable to undertake reforms withouthaving the control of finances.
Ladislau will now also have to continuereforms and apply measures agreed withthe European Commission and the Inter-national Monetary Fund (IMF). Romaniahas been struggling to reform its publichealth sector, which has fallen into a stateof growing disrepair as a result of chronicunderinvestment. Hospitals around thecountry are understaffed and short of spe-cialists and modern medical equipment.Low health sector salaries have promptedan exodus of doctors and nurses who havegone abroad to seek better paid jobs.
Romania: new rules on reimbursement ofsome drugsAs of 1 September 2011 the RomanianMinistry of Health has introduced a newmethodology for calculating reimburse-ments for drugs included on the so-calledC2 list. The C2 list includes over 1,400drugs used in national programmes foroutpatient and inpatient care. It includesmedicines distributed under nationalhealth programmes for the treatment ofcancer, tuberculosis, AIDS, diabetes andsome other chronic diseases. As comparedto other drugs on the Romanian pharma-ceutical market, the drugs included in theC2 list are the most expensive.
According to the revised provisions, thereimbursement of any C2 list drug cannotexceed 120% of the retail price of a cheapersubstitute (generic with the same activesubstance) in the same therapeutic group.The new methodology does not apply ifthere is no generic equivalent to the inno-vative drug, in which case 100%reimbursement will remain in place. Dueto the changes in the reimbursementmethodology, the Romanian NationalHealth Insurance House (CNAS) predictssavings of about RON 150 million (€36million) per year in its health programmes.
Eurohealth Vol 17 No 2–343
2012 World Congress on Public HealthThe 13th World Congress on PublicHealth will take place in Addis Ababa,Ethiopia from 23-27 April 2012. The maintheme is ‘Moving Towards Global HealthEquity: Opportunities and Threat’. Thedeadline for the submission of abstracts isOctober 21.
More information available athttp://wfpha.confex.com/wfpha/2012/cfp.cgi
Self-assessment of public health servicesin the Republic of UzbekistanSince independence, significant changeshave begun to take place in the healthsystem of Uzbekistan. By 1991, Uzbek-istan had a rather developed health systembut it was characterised by a centralisedstructure and imperfect managerial mech-anisms. In 1998, a Presidential decreeadopted the National Health SystemReform Programme on a phased approachto the formation of the national healthsystem model. It is based on the principlesof strict observance of social protectionconditions for the population, universalavailability of guaranteed medical care, andphased transition of some health institu-tions on mixed and private fundingsources.
This new assessment of the public healthservice in Uzbekistan was undertaken bythe working group of the Ministry ofHealth with the involvement of specialistsof different areas, and organised under thecoordination of the World Health Organ-ization (WHO) Regional Office forEurope team for Public Health Services,with the WHO Country Office in Uzbek-istan.
The report is available athttp://tinyurl.com/3n4rjjk
Wales: Improving picture for children'smental health servicesMental health services for children andadolescents in Wales have expanded andchanged for the better, with faster access totreatment and an increase in specialist staff,a new independent report shows.
The report on the provision of SpecialistChild and Adolescent Mental HealthServices provides data collected between2007 and 2011. Key findings include: anincrease of 25% in the workforce between2007 and 2011; growth in the number of
cases worked with and consultationscarried out; a reduction in the number ofpeople waiting to be seen; a reduction inthe length of wait for people to be seen; areduction in lengthy treatment times.
More information athttp://www.wales.nhs.uk/sitesplus/888/news/19609
Launch of pilot European Innovation Partnership on Active and Healthy AgeingThe pilot European Innovation Part-nership on Active and Healthy Ageingaims to increase the average healthylifespan in the EU by two years by 2020.It pursues objectives to improve the healthand quality of life of Europeans with afocus on older people; support the long-term sustainability and efficiency of healthand social care systems; and enhance thecompetitiveness of EU industry throughbusiness and expansion in new markets.The pilot Partnership will provide a forumfor stakeholders through a series of work-shops and a high-level steering group willassist with preparatory work. Its main roleis to draw up a strategic implementationplan with operational recommendations.
More information athttp://ec.europa.eu/health/ageing/innovation/index_en.htm
Denmark: Report on health status of menand review of effective interventions topromote their health This new report published by NationalBoard of Health is intended to identifywhich health promotion and disease pre-vention initiatives and indicators can beused to monitor initiatives to improve thehealth of men in Denmark. Data onsocioeconomic trends, life expectancy,mortality, self-reported morbidity and useof health care services are provided.
Updating a previously published sys-tematic review, the study authors concludethat there are several effective measures toimprove men’s health, but that largerstudies are needed to confirm this.Moreover the evidence base does notsupport the view that targeting interven-tions at men is more effective thantargeting interventions at everyone.
A summary version of the report isavailable in English athttp://tinyurl.com/3zl9g5b
Polio kicked out of EuropeThe European Regional CertificationCommission for Poliomyelitis Eradication(RCC) announced on 24 August thatEurope will retain its polio-free status afterthe importation of wild poliovirus type 1in 2010. At their 25th meeting in Copen-hagen, the RCC noted that wild poliovirustransmission has been interrupted. No newcases have been reported since September2010 because countries have taken effectiveaction. The response of Member States wascommended, especially their efforts toprotect their populations and stop thetransmission of the poliovirus. This wasdone through synchronised additionalimmunisation activities, often involvingnationwide vaccination campaigns.
More information athttp://www.euro.who.int/en/what-we-do/health-topics/communicable-diseases/poliomyelitis
Netherlands: Experience of personalhealth budgetsA new case study report from the UKbased Health Foundation looks at the useof personal health budgets (persoonsge-bonden budget or PGB) in theNetherlands.
The adoption of PGB arose partly fromlimitations in the traditional health caresystem, but also from a desire to offerservice users more choice and control overtheir care. There was also a belief thathanding control of budgets to the end userwould help to reduce costs. ImplementingPGB has not been without its difficulties,but the system is highly popular with boththe public and politicians. Through a rangeof perspectives, from the Health Ministryto a carer, this case study entitled The Per-sonal Touch explores the challenges andsuccesses of the PGB.
The case study can be accessed athttp://www.health.org.uk/publications/personal-health-budgets/
Eurohealth Vol 17 No 2–3 44
News in Brief
Additional materials supplied by
EuroHealthNet
6 Philippe Le Bon, Brussels.Tel: + 32 2 235 03 20Fax: + 32 2 235 03 39Email: [email protected]
Eurohealth is a quarterlypublication that provides a forum for researchers, experts and policy makers to express their views onhealth policy issues and socontribute to a constructivedebate on health policy inEurope
ISSN 1356-1030
on Health Systems and Policies
European