Incentives and Deterrents to the Supply of Long-term Care for the Elderly in England: Evidence and Experience in Two Local Authorities (original) (raw)

Policy issues in the private health sector: Examples from long-term care in the U.K

Social Science & Medicine, 1996

A~tract-The international trend towards private markets in health care can be illustrated very clearly by developments over the last decade in the U.K., where the balance of health care provision has shifted from a predominantly free, public and comprehensive system to more of a mixed economy model. The shift can be attributed to a variety of factors, and not government policy alone. The relationship between the private and NHS sectors of health care is not a simple one and there are both positive and negative implications of the public-private mix. The growth of private hospitals and acute beds has dominated debates about private health care, but further policy issues have emerged in relation to the significant growth in private residential and nursing home care. This paper briefly reviews developments in private health care and then explores the key policy issues associated with this development. Secondly, an analysis of developments in the private residential care sector is undertaken highlighting the relationship between the public and private sectors of care provision. Policy issues pertaining to the long-term care sector of private health care are raised, including the regulation of residential care, regulatory models, enforcement and quality, and standards of care. Lessons for the regulation of private health care generally are considered and the implications for the private sector of a growing trend towards market deregulation are explored. Future models of long-term care are discussed and the likely balance between the public and private sectors explored.

The 'Make or Buy' Decision in Long-term Care: Lessons for Policy

2014

This report was commissioned by the Swedish Ministry of Health and Social Affairs with the aim of analysing the decision to make or to buy long-term care services, i.e. whether to deliver long-term care services through public providers or contract them out to public and non-public providers. This report reviews existing literature on the theoretical underpinnings of the make or buy decision and how it applies to the specificities of long-term care. It analyses the implementation of quasi-markets in four European countries that represent different long-term care systems: England, Denmark, Germany and the Netherlands. It also critically reviews six quality assessment and quality management systems in Europe and the issues surrounding the definition and assessment of quality in long-term care. What theory tells us about make or buy decisions Competition should mean more efficient production, but care markets are not the usual textbook markets • According to neo-classical economic theory, competition should increase efficiency and push providers to deliver services that are more adapted to people's needs. Public service markets such as long-term care or health care differ, however, from textbook competitive markets in a number of significant ways. There are potential risks of imperfect information, e.g. regarding quality; and long-term care is a derived demand, i.e. people demand long-term care not because they want it but because they need it. Long-term care markets are thus usually highly regulated, i.e. they are more akin to 'quasi-markets'. • Several market mechanisms can be put in place to create such quasi-markets of long-term care. Chief among these are: tendering, which allows open access and competition for the market; commissioning, when integrated networks are important (e.g. in integrated care); user choice, which is aimed at improving the responsiveness of providers to users' needs; user fees, which seek to replicate the role of prices in limiting demand and rewarding providers that live up to users' preferences; vouchers, which link payment to the actual delivery of services and allow fees to more closely reflect costs without pricing poorer users out of the market. Competition incurs costs • The regulation of quasi-markets will incur transaction costs and under some circumstances these might be higher than the savings incurred in more efficient production through pure competition. Transaction costs are likely higher if performance and compliance with contracts is difficult to measure and if there is scope for powerful providers (e.g. monopolies) to emerge. • The decision whether to make or buy long-term care must involve consideration of the specific characteristics of long-term care. There is a wide body of evidence suggesting that people do not always make the best decisions for themselves without assistance, while on the other hand, allowing users to choose may be an important value of long-term care in itself. The outcomes of markets are not always equitable and as a result people with lower incomes-often those most in need of care-may not get what they need through the market. Finally, competition may erode trust and volunteering and become an obstacle to integrated delivery of care. • Whether to make or buy long-term care involves trade-offs that need to be analysed empirically to overcome what may otherwise be a purely ideological debate. Investment in quality assurance and quality development in long-term care is necessary independently from general governance options • As long-term care is an area with a relatively short history, both quality management and quality assurance mechanisms lag behind those in place in other services sectors and industries. Issues such as quality of life, dignity and personal preferences are difficult to standardise and measure. These challenges call for further research and development in order to be better able to define and compare outcomes within quasi-markets of care.

Building capacity for aged care policy reform: Aspirations and issues

Journal of Care Services Management, 2010

AbstractReform motivated by idealism runs the risk of acting on unrealistic assumptions about the need for and preferences around service types, the effects of competition, technical and organisational obstacles to implementation, and threats to other stakeholder groups which may actively resist the proposed change. For England to successfully introduce a system of long-term care that is primarily home-based, there must be careful consideration and open debate about the intended and unintended consequences of policy. For instance, families would need to be motivated and supported to care for their relatives with dementia and increasing disability; as carer responsibilities increase, employees would need support from employers and possibly review of industrial frameworks to protect their positions while undertaking the dual roles of carer and worker; quality home-based nursing care would need to be enhanced and fully supported so that services are delivered and maintained at an acceptable standard of quali...

Regulating nursing homes: Caring for older people in the private sector in England

BMJ, 2001

Over half of all beds allocated for health care in the United Kingdom are in independent nursing homes for older people; this is a result of policies initially introduced to change the basis of social security payments 1 and now directed towards privatising long term care. Official statistics from the Department of Health indicate that between 1979 and 2000 the total number of beds in the NHS in England decreased from 480 000 to 189 000, while the number of beds in the independent sector, which is run mainly for profit, increased from 23 000 in 1983 2 to 193 000 in 2000. Experiences in the United States and Australia have shown the lack of political will to promote the interests of residents against the interests of the industry and its shareholders. 3 4 In Australia the industry successfully lobbied to replace legally enforceable regulations with less effective accreditation schemes; this has had disastrous consequences. In the United States the industry successfully opposed the introduction of robust standards for minimum numbers of staff, and the result is continuously declining health outcomes for residents. The risks to residents of nursing homes in the United Kingdom are considerable as subsidiaries of large US multinationals enter the United Kingdom 5 ; some of these companies have come under scrutiny in the United States for fraud and embezzlement of government funds and for abusing patients. 3 This paper considers whether the new regulatory framework for nursing homes in the United Kingdom offers adequate protection for patients.

Long-term Care for Older People in the UK

European Study of …, 2003

Investigating the sensitivity of projections of future long-term care expenditure in Germany, Spain, Italy and the United Kingdom to changes in assumptions about demography, dependency, informal care, formal care and unit costs.