Exploring differences between private and public prices in the English care homes market.

This work quantitatively assesses the potential reasons behind the difference in prices paid by care home residents in England. Evidence suggests that the price paid by private payers is higher than that paid for publicly supported residents, and this is often attributed to the market power wielded by local authorities as the dominant purchaser in local markets. Estimations of private prices at the local authority level are used to assess the difference in price paid between private and public prices, the fees gap, using data from 2008 to 2010. Controlling for local area and average care home characteristics, the results indicate that both care home and local authority market power play a role in the price determination of the market.

Carer Social Care-Related Quality of Life Outcomes: Estimating English Preference Weights for the Adult Social Care Outcomes Toolkit for Carers.

BACKGROUND: There is increasing interest in assessing the effects of interventions on older people, people with long-term conditions and their informal carers for use in economic evaluation. The Adult Social Care Outcomes Toolkit for Carers (ASCOT-Carer) is a measure that specifically assesses the impact of social care services on informal carers. To date, the ASCOT-Carer has not been preference-weighted. OBJECTIVES: To estimate preference-based index values for the English version of the ASCOT-Carer from the general population in England. METHODS: The ASCOT-Carer consists of 7 domains, each reflecting aspects of social care-related quality of life in informal carers. Preferences for the ASCOT-Carer social care-related quality of life states were estimated using a best-worst scaling exercise in an online survey. The survey was administered to a sample of the general adult population in England (n = 1000). Participants were asked to put themselves into the hypothetical state of being an informal carer and indicate which attribute they thought was the best (first and second) and worst (first and second) from a profile list of 7 attributes reflecting the 7 domains, each ranging at a different level (1-4). Multinomial logit regression was used to analyze the data and estimate preference weights for the ASCOT-Carer measure. RESULTS: The most valued aspect by English participants was the 'occupation' attribute at its highest level. Results further showed participants rated having no control over their daily life as the lowest attribute-level of all those presented. The position of the 7 attributes influenced participants' best and worst choices, and there was evidence of both scale and taste heterogeneity on preferences. CONCLUSION: This study has established a set of preference-based index values for the ASCOT-Carer in England derived from the best-worst scaling exercise that can be used for economic evaluation of interventions on older individuals and their informal carers.

Exploring the views of being a proxy from the perspective of unpaid carers and paid carers: developing a proxy version of the Adult Social Care Outcomes Toolkit (ASCOT).

BACKGROUND: Outcomes-based policy and administration of public services present a compelling argument for the value of outcomes data. However, there are a number of challenges inherent in collecting these data from people who are unable to complete a paper-based survey or interview due to cognitive or communication impairments. In this paper, we explore the views of being a proxy from the perspective of unpaid carers and paid carers who may be asked to act as a proxy on behalf of the person(s) they care for. We consider the key issues that need to be addressed when adapting an instrument designed to measure social care outcomes, the Adult Social Care Outcomes Tool (ASCOT), into a proxy-report tool. METHODS: Participants took part in either a focus group (35 paid carers in eight focus groups), or a one-to-one interview (eight unpaid carers). All participants were recruited via carer organisations and care providers. Transcripts, field notes and audio data collected during focus groups and interviews were analysed using a thematic framework approach. RESULTS: Participants agreed that any person acting as a proxy would need to be very familiar with the care recipient, as well as their needs and care provision. A number of provisions for proxy respondents were proposed to improve face validity and acceptability of completing a questionnaire by proxy, and to ensure that any potential bias is reduced in the design of the questionnaire. These included: providing two sets of response options for each proxy perspective (the proxy themselves and the proxy view of how they think the care recipient would respond); a comments box to help people explain why they have selected a given response option (especially where these indicate unmet need); and providing clear guidance for the proxy respondent on how they should complete the questionnaire. CONCLUSIONS: This study has shown some of the challenges involved in assessing outcomes by proxy and explored some potential ways these can be mitigated. The findings highlight the benefits of developing and testing proxy measures in a robust way to widen participation in social care research.

The impact of long-term care on primary care doctor consultations for people over 75 years.

Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper, we study the interdependencies between the long-term (home care) services and consultations with a primary care doctor, as used by people over 75 years. Starting with a model of individual's demand for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the British Household Panel Study for 1991-2009. To address potential concerns about endogeneity, we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.

The impact of long-term care on quality of life.

Long-term care services are provided to help people manage the consequences of impairment, but their impact goes beyond the meeting of basic needs. Accordingly, the main aim was to explore the marginal effectiveness of care when measured in terms of people's overall care-related quality of life (CRQoL) and assess changes in marginal effect for increasing intensity. The associated aim was to refine and apply an observational method to estimate marginal effectiveness. A "production function" approach was used with survey data, including Adult Social Care Outcomes Toolkit-measured CRQoL, whereby we statistically modelled the expected relationship between service utilisation rates and CRQoL. This method seeks to limit endogeneity issues by controlling on observables and using instrumental variable. Using a survey of publicly funded long-term care service users in England, we found that community-based long-term care significantly improved people's CRQoL but with diminishing marginal effects and effects differentiated by baseline impairment levels. There are implications for how the care system should respond to changes in global public budgets. For example, where there is unmet need, a system aimed to maximise (unadjusted) CRQoL would put more emphasis on access (more recipients) than intensity of support compared to a system operating on a needs basis.

A study of dyadic interdependence of control, social participation and occupation of adults who use long-term care services and their carers.

PURPOSE: Unpaid care is an important source of support of people with long-term conditions. Interdependence of carers' and care recipients' quality of life would be expected due to the relational nature of caregiving. This study aims to explore interdependence of quality of life in carer/care-recipient dyads, especially in relation to mutual interdependence due to social feedback in the caregiving relationship and also the partner effects of one partner's experience of long-term care support on the other's outcomes. METHODS: Using data collected in an interview survey of 264 adults with care support needs and their unpaid carers in England, we employed regression analysis to explore whether there is mutual interdependence of care-related quality of life within carer/care-recipient dyads for three quality of life attributes: Control over daily life, Social participation and Occupation. The influence of factors, including satisfaction with long-term care, were also considered on individuals' and dyad partners' care-related quality of life. RESULTS: We found mutual interdependence of quality of life at the dyad-level for Control over daily life, but not Occupation or Social participation. A partner effect of care recipients' satisfaction with long-term care on carers' Control over daily life was also observed. Higher care recipient satisfaction with care services was associated with higher Control over daily life. By contrast, for Social participation and Occupation, there were only significant effects of care recipients' satisfaction with long-term care and their own quality of life. CONCLUSIONS: These findings highlight the importance of considering the wider impact beyond the individual of long-term care on quality of life in the evaluation of long-term care policy and practice.

Measuring the productivity of residential long-term care in England: methods for quality adjustment and regional comparison.

Productivity trend information is valuable in developing policy and for understanding changes in the 'value for money' of the care system. In this paper, we consider approaches to measuring productivity of adult social care (ASC), and particularly care home services. Productivity growth in the public sector is traditionally measured by comparing change in total output to change in total inputs, but has not accounted for changes in service quality and need. In this study, we propose a method to estimate 'quality adjusted' output based on indicators of the Adult Social Care Outcomes Toolkit (ASCOT), using data collected in the annual adult social care survey (ASCS). When combined with expenditure and activity data for 2010 to 2012, we found that this approach was feasible to implement with current data and that it altered the productivity results compared with non-adjusted productivity metrics. Overall, quality-adjusted productivity grew in most regions between 2010 and 2011 and remained unchanged for most regions from 2011 to 2012.

Perspectives from health, social care and policy stakeholders on the value of a single self-report outcome measure across long-term conditions: a qualitative study.

OBJECTIVES: To explore the views of a range of stakeholders regarding whether patient-reported outcome measures (PROMs) can be developed to measure key attributes of long-term conditions (LTCs) care in England, and the potential value of a single generic measure. DESIGN: Qualitative semistructured interview study, analysed using a framework approach. PARTICIPANTS AND SETTING: Interviews with 31 stakeholders from primary care, secondary care, social care, policy and patient-focused voluntary organisations in England. RESULTS: There was broad support for a single PROM that could be used to measure outcomes for patients with any LTCs in any health or social care setting. Interviewees identified three desired uses for a PROM: to improve the quality of individual care; to increase people's engagement in their own care; and to monitor the performance of services. Interviewees felt that a PROM for LTCs should incorporate a mixture of traditional and non-traditional domains, such as functioning, empowerment and social participation, and be codesigned with patients and professional end-users. Stakeholders emphasised the need for a PROM to be feasible for practical implementation at the individual clinical level as a first priority. A number of concerns and potential problems were identified in relation to the application and interpretation of an LTC PROM. CONCLUSIONS: This study has demonstrated support for a single self-report outcome measure that reflects the priorities of people with LTCs, if such a measure can be shown to be meaningful and useful at the individual level. People with LTCs and professional end-users in health and social care should be involved in the development and evaluation of such a measure.

Local variability in long-term care services: local autonomy, exogenous influences and policy spillovers.

In many countries, public responsibility over the funding and provision of long-term care services is held at the local level. In such systems, long-term care provision is often characterised by significant local variability. Using a panel dataset of local authorities over the period 2002-2012, the paper investigates the underlying causes of variation in gross social care expenditure for older people in England. The analysis distinguishes between factors outside the direct control of policy makers, local preferences and local policy spillovers. The results indicate that local demand and supply factors, and to a much lesser extent local political preferences and spatial policy spillovers, explain a large majority of the observed variation in expenditure.

The impact of competition on quality and prices in the English care homes market.

This study assesses the impact of competition on quality and price in the English care/nursing homes market. Considering the key institutional features, we use a theoretical model to assess the conditions under which further competition could increase or reduce quality. A dataset comprising the population of 10,000 care homes was used. We constructed distance/travel-time weighted competition measures. Instrumental variable estimations, used to account for the endogeneity of competition, showed quality and price were reduced by greater competition. Further analyses suggested that the negative quality effect worked through the effect on price - higher competition reduces revenue which pushes down quality.

Using cost-effectiveness estimates from survey data to guide commissioning: an application to home care.

The aim is to describe and trial a pragmatic method to produce estimates of the incremental cost-effectiveness of care services from survey data. The main challenge is in estimating the counterfactual; that is, what the patient's quality of life would be if they did not receive that level of service. A production function method is presented, which seeks to distinguish the variation in care-related quality of life in the data that is due to service use as opposed to other factors. A problem is that relevant need factors also affect the amount of service used and therefore any missing factors could create endogeneity bias. Instrumental variable estimation can mitigate this problem. This method was applied to a survey of older people using home care as a proof of concept. In the analysis, we were able to estimate a quality-of-life production function using survey data with the expected form and robust estimation diagnostics. The practical advantages with this method are clear, but there are limitations. It is computationally complex, and there is a risk of misspecification and biased results, particularly with IV estimation. One strategy would be to use this method to produce preliminary estimates, with a full trial conducted thereafter, if indicated.

Personalization in the health care system: do personal health budgets have an impact on outcomes and cost?

OBJECTIVES: In England's National Health Service, personal health budgets are part of a growing trend to give patients more choice and control over how health care services are managed and delivered. The personal health budget programme was launched by the Department of Health in 2009, and a three-year independent evaluation was commissioned with the aim of identifying whether the initiative ensured better health- and care-related outcomes and at what cost when compared to conventional service delivery. METHODS: The evaluation used a pragmatic controlled trial design to compare the outcomes and costs of patients selected to receive a personal health budget with those continuing with conventional support arrangements (control group). Just over 1000 individuals were recruited into the personal health budget group and 1000 into the control group in order to ensure sufficient statistical power, and followed for 12 months. RESULTS: The use of personal health budgets was associated with significant improvement in patients' care-related quality of life and psychological wellbeing at 12 months. Personal health budgets did not appear to have an impact on health status, mortality rates, health-related quality of life or costs over the same period. With net benefits measured in terms of care-related quality of life on the adult social care outcome toolkit measure, personal health budgets were cost-effective: that is, budget holders experienced greater benefits than people receiving conventional services, and the budgets were worth the cost. CONCLUSION: The evaluation provides support for the planned wider roll-out of personal health budgets in the English NHS after 2014 in so far as the localities in the pilot sample are representative of the whole country.

An assessment of the construct validity of the ASCOT measure of social care-related quality of life with older people.

BACKGROUND: The adult social care outcomes toolkit (ASCOT) includes a preference-weighted measure of social care-related quality of life for use in economic evaluations. ASCOT has eight attributes: personal cleanliness and comfort, food and drink, control over daily life, personal safety, accommodation cleanliness and comfort, social participation and involvement, occupation and dignity. This paper aims to demonstrate the construct validity of the ASCOT attributes. METHODS: A survey of older people receiving publicly-funded home care services was conducted by face-to-face interview in several sites across England. Additional data on variables hypothesised to be related and unrelated to each of the attributes were also collected. Relationships between these variables and the attributes were analysed through chi-squared tests and analysis of variance, as appropriate, to test the construct validity of each attribute. RESULTS: 301 people were interviewed and approximately 10% of responses were given by a proxy respondent. Results suggest that each attribute captured the extent to which respondents exercised choice in how their outcomes were met. There was also evidence for the validity of the control over daily life, occupation, personal cleanliness and comfort, personal safety, accommodation cleanliness and comfort, and social participation and involvement attributes. There was less evidence regarding the validity of the food and drink and dignity attributes, but this may be a consequence of problems finding good data against which to validate these attributes, as well as problems with the distribution of the food and drink item. CONCLUSIONS: This study provides some evidence for the construct validity of the ASCOT attributes and therefore support for ASCOT's use in economic evaluation. It also demonstrated the feasibility of its use among older people, although the need for proxy respondents in some situations suggests that developing a version that is suitable for proxies would be a useful future direction for this work. Validation of the instrument on a sample of younger social care users would also be useful.

Каковы возможные пути создания в европейских странах эффективных, справедливых и устойчивых систем финансирования для обеспечения длительного ухода за пожилыми людьми?

Имеющиеся в странах Европы данные свидетельствуют о том, что старение населения, которому сопутствуют изменения в доступности неформальной семейной поддержки, рост стоимости ухода и повышенные требования к качеству, интенсивности и гибкости обслуживания, может создать серьезные трудности для руководящих должностных лиц, ведущих нелегкую борьбу за сохранение или расширение охвата услугами систем длительного ухода и продолжение и усиление поддержки этих систем. Достижение устойчивости систем длительного оказания помощи требует, чтобы они были финансово доступными, справедливыми и гибкими. В этом контексте внедрение любого механизмафинансирования возможно лишь при условии достижения общественного консенсуса. Национальные правительства, в рамках стратегического управления системой здравоохранения, могут предусматривать действия по следующим направлениям: (i) обеспечивать предоставление понятной информации и практической помощи гражданам по ориентированию в имеющихся системах длительного ухода; (ii) обеспечивать стандарты качества и оказывать поддержку лицам, осуществляющим домашний уход за престарелыми, а также содействовать гибкости в выборе пакетов услуг (например, черезналичные выплаты); (iii) предпринимать меры по улучшению координации между службами длительного ухода и родственными секторами. Поскольку многие страны сталкиваются с однотипными проблемами, государства – члены Европейского региона имеют возможность использовать уроки международного опыта по организации системдлительного ухода, накопленного как в Европе, так и за ее пределами.

How can European states design efficient, equitable and sustainable funding systems for long-term care for older people?

Across Europe data suggest that an ageing of the population, coupled with changes in the availability of informal family support, increasing costs of care and raised expectations on the quality, intensity and flexibility of services mayraise major challenges for policy-makers contending with maintaining or extending coverage and support for long-term care systems. To be sustainable long-term care systems need to be affordable, fair and flexible. In a given context, public consensus needs to be achieved aroundany mechanism of long-term care funding. National governments, as part of their stewardship of the health system, can consider steps to: (i) ensure that comprehensible information and advocates to help individuals navigate long-term care systems are in place; (ii) assure quality standards, provide support for informal carers and facilitate flexibility in care package choices (such as through cashpayments); and (iii) pursue measures to improve coordination between the long-term care and associated sectors. With many countries facing similar challenges, member states of the European Region may be able to draw on lessons from international experience in long-term care systems, both from Europe and beyond.

The cost implications of the changing population and characteristics of care homes.

BACKGROUND: Recent increases in care home closures suggest that homes may not be able to balance pressures to reduce costs against pressures to increase standards. Commissioning requires an understanding of the factors affecting costs and how they change over time. METHODS: A survey of care homes for older people was conducted in 21 local authorities in England in 1996. A complete response was obtained for 618 homes (75%) and 11,900 residents. Findings were compared with surveys conducted in 1986 and 1988. RESULTS: Dependency was significantly related to prices, primarily due to the differential payments to nursing and residential homes. Home characteristics were also related to price, the proportion of single rooms having the largest impact. However, prices were most sensitive to local wage rates, particularly in residential homes. Compared with previous surveys levels of dependency had increased, particularly in voluntary residential homes and nursing homes. Independent homes were more likely to be purpose built, and a higher proportion of beds were in single rooms, although only 30% of private residential, dual registered and nursing homes achieved the proposed level of 80% of beds in single rooms. Staffing ratios appeared to have increased, but price rises were modest, particularly for nursing homes. CONCLUSIONS: Standards of provision have improved over time, although prices appear to have been kept below those expected from increases in costs. Continuing pressures on costs and prices are likely to lead to further closures and a restriction of choice for older people.