The effect of lengthening life expectancy on future pension and long-term care expenditure in England, 2007 to 2032.

BACKGROUND: The aim of this analysis is to examine the effect of different assumptions about future trends in life expectancy (LE) on the sustainability of the pensions and long-term care (LTC) systems. The context is the continuing debate in England about the reform of state pensions and the reform of the system for financing care and support. METHODS: Macro and micro simulation models are used to make projections of future public expenditure on LTC services for older people and on state pensions and related benefits, making alternative assumptions on increases in future LE. The projections cover the period 2007 to 2032 and relate to England. RESULTS: Results are presented for a base case and for specified variants to the base case. The base case assumes that the number of older people by age and gender rises in line with the Office for National Statistics' principal 2006-based population projection for England. It also assumes no change in disability rates, no changes in patterns of care, no changes in policy and rises in unit care costs and real average earnings by 2 per cent per year. Under these assumptions public expenditure on pensions and related benefits is projected to rise from 4.7 per cent of Gross Domestic Product (GDP) in 2007 to 6.2 per cent of GDP in 2032 and public expenditure on LTC from 0.9 per cent of GDP in 2007 to 1.6 per cent of GDP in 2032. Under a very high LE variant to the GAD principal projection, however, public expenditure on pensions and related benefits is projected to reach 6.8 per cent of GDP in 2032 and public expenditure on LTC 1.7 per cent of GDP in 2032. CONCLUSIONS: Policymakers developing reform proposals need to recognise that, since future LE is inevitably uncertain and since variant assumptions about future LE significantly affect expenditure projections, there is a degree of uncertainty about the likely impact of demographic pressures on future public expenditure on pensions and LTC.

Public expenditure costs of carers leaving employment in England, 2015/2016.

In the context of global population ageing, the reconciliation of employment and unpaid caring is becoming an important social issue. The estimation of the public expenditure costs of carers leaving employment is a valuable measure that is of considerable interest to policy makers. In 2012, the Personal Social Services Research Unit estimated that the public expenditure costs of unpaid carers leaving employment in England were approximately £1.3 billion a year, based on the costs of Carer's Allowance and lost tax revenues on forgone incomes. However, this figure was known to be an underestimate partly because it did not include other key benefits that carers who have given up work to care may receive. This paper presents a new estimate of the public expenditure costs of carers leaving employment. Key sources of information are the 2009/2010 Survey of Carers in Households, 2011 Census and 2015/2016 costs data. As well as Carer's Allowance, the estimate also now includes the costs of other benefits that carers leaving work may receive, namely, Income Support and Housing Benefit. The results show that the estimated numbers of carers who have left employment because of caring have increased from approximately 315,000 to 345,000. Due mainly to the inclusion of a wider range of benefits, the public expenditure costs of carers leaving employment in England are now estimated at £2.9 billion a year. The new estimate comprises £1.7 billion in social security benefits paid to people who have left their jobs because of unpaid caring, plus another £1.2 billion in taxes forgone on this group's lost earnings. The paper concludes that, if there was greater public investment in social care, such as "replacement care" to support carers in employment, and fewer carers then left employment, public spending on benefits would be lower and revenues from taxation would be higher.

Perceptions of unmet needs for community social care services in England. A comparison of working carers and the people they care for.

Previous UK research has found expressed unmet need for services by unpaid working carers and among disabled and older people. There are, however, suggestions from research that views on unmet needs for services differ between carers and care-recipients. Working carers in the UK say that the care-recipient is sometimes reluctant to accept services and the few international comparative dyad studies that have been carried out find that carers perceive higher unmet need than care-recipients. Recent policy discussions in England have also recognised that there may be differences of opinion. We collected data in 2013 from working carer/care-recipient dyads in England about perceived need for services for the care-recipient, disability, unpaid care hour provision and individual and socio-demographic characteristics. We find that care-recipients as well as their carers perceive high unmet need for services, although carers perceive higher unmet need. For carers, unmet need is associated with the disability of the carer-recipient and being the daughter or son of the care-recipient; for care-recipients it is associated with unpaid care hours, carers' employment status and carers' health. The majority of dyads agree on need for services, and agreement is higher when the working carer provides care for 10 hours or more hours a week. Services for care-recipients may enable working carers to remain in employment so agreement on needs for services supports the implementation of legislation, policy and practice that has a duty to, or aims to, support carer's employment.

The 'visibility' of unpaid care in England.

SUMMARY: Social work practice is increasingly concerned with support not just for service users but also for unpaid carers. A key aspect of practice is the assessment of carers' needs. The Government has recently passed legislation that will widen eligibility for carers' assessments and remove the requirement that carers must be providing a substantial amount of care on a regular basis. This article examines which carers are currently 'visible' or known to councils and which are not, and uses the results to examine the likely effects of the new legislation. In order to identify the characteristics of carers known to councils, the article uses large-scale surveys, comparing the 2009/10 Personal Social Services Survey of Adult Carers in England and the 2009/10 Survey of Carers in Households in England. FINDINGS: Carers who are known to councils provide extremely long hours of care. Among carers providing substantial care who are known to councils, the majority care for 100 or more hours a week. The focus of councils on carers providing long hours of care is associated with a number of other carer characteristics, such as poor health. APPLICATIONS: Councils' emphasis on the most intense carers is unlikely to be attributable solely to the current legislation. Therefore, dropping the substantial and regular clauses alone will not necessarily broaden access to carers' assessments and, in order to achieve this, considerable new resources may be needed. How far these resources are available will determine the extent to which practitioners can broaden access to carers' assessments.

The Effectiveness of Paid Services in Supporting Unpaid Carers' Employment in England.

This paper explores the effectiveness of paid services in supporting unpaid carers' employment in England. There is currently a new emphasis in England on 'replacement care', or paid services for the cared-for person, as a means of supporting working carers. The international evidence on the effectiveness of paid services as a means of supporting carers' employment is inconclusive and does not relate specifically to England. The study reported here explores this issue using the 2009/10 Personal Social Services Survey of Adult Carers in England. The study finds a positive association between carers' employment and receipt of paid services by the cared-for person, controlling for covariates. It therefore gives support to the hypothesis that services for the cared-for person are effective in supporting carers' employment. Use of home care and a personal assistant are associated on their own with the employment of both men and women carers, while use of day care and meals-on-wheels are associated specifically with women's employment. Use of short-term breaks are associated with carers' employment when combined with other services. The paper supports the emphasis in English social policy on paid services as a means of supporting working carers, but questions the use of the term 'replacement care' and the emphasis on 'the market'.

The decline of intensive intergenerational care of older people in Great Britain, 1985-1995.

There are increasing concerns about the future availability of informal care for older people, particularly care by their children. This article explores past trends in the provision of informal care by children/children-in-law to their older parents/parents-in-law between 1985 and 1995 in Great Britain, using successive General Household Survey data. The article suggests that, during this period, there was a decline in co-resident intergenerational care and that this was associated with a decline in highly intensive intergenerational care. The article explores possible factors underlying these trends, in particular, demographic changes and changes in patterns of formal care for older people.

When is a carer's employment at risk? Longitudinal analysis of unpaid care and employment in midlife in England.

This article examines the thresholds at which provision of unpaid care affects employment in England. Previous research has shown that providing care for 20 or more hours a week has a negative effect on employment. The present article explores the impact of a lower threshold and asks whether provision of care for 10 or more hours a week has a negative effect on employment. The article focuses on women and men aged between 50 and State Pension Age (60 for women, 65 for men). The study uses data from the first four waves of the English Longitudinal Study of Ageing (ELSA), collected in 2002/2003, 2004/2005, 2006/2007 and 2008/2009. Across these waves, there are 17,123 people aged 50-59/64 years, of whom 9% provide unpaid care to an adult. Using logistic regression analysis of the longitudinal data, the study finds that employed women in their fifties who start providing care for <10 hours a week are significantly more likely to remain in employment one wave later than similar women who have not started to provide care. In contrast, employed women in their fifties who start providing care for 10 or more hours a week are significantly less likely to remain in employment one wave later than similar women who have not started to provide care. Employed men aged between 50 and State Pension Age, who provide care for 10 or more hours a week at the beginning of the period have a significantly reduced employment rate one wave later than those who do not provide care. The study therefore suggests that carers' employment may be negatively affected when care is provided at a lower intensity than is generally estimated in England. This has important implications for local authorities, who have a duty to provide services to carers whose employment is at risk.

The role of care home fees in the public costs and distributional effects of potential reforms to care home funding for older people in England.

In England, Local Authorities (LAs) contribute to the care home fees of two-thirds of care home residents aged 65+ who pass a means test. LAs typically pay fees below those faced by residents excluded from state support. Most proposals for reform of the means test would increase the proportion of residents entitled to state support. If care homes receive the LA fee for more residents, they might increase fees for any remaining self-funders. Alternatively, the LA fee might have to rise. We use two linked simulation models to examine how alternative assumptions on post-reform fees affect projected public costs and financial gains to residents of three potential reforms to the means test. Raising the LA fee rate to maintain income per resident would increase the projected public cost of the reforms by between 22% and 72% in the base year. It would reduce the average gain to care home residents by between 8% and 12%. Raising post-reform fees for remaining self-funders or requiring pre-reform self-funders to meet the difference between the LA and self-funder fees, reduces the gains to residents by 28-37%. For one reform, residents in the highest income quintile would face losses if the self-funder fee rises.

Cognitive impairment in older people: future demand for long-term care services and the associated costs.

BACKGROUND: Projections are presented of future numbers of older people with cognitive impairment (CI) in England, their demand for long-term care (LTC) services and future costs of their care. The sensitivity of the projections to factors that are likely to affect future LTC expenditure is explored. These factors include future numbers of older people, prevalence rates of CI, trends in household composition, informal care provision, care service patterns and unit costs. METHODS: A macrosimulation (or cell-based) model was developed to produce the projections, building on an earlier PSSRU model. Base case assumptions are made about trends in key factors expected to impact on future LTC expenditure, and variant assumptions about the key factors are introduced to test for sensitivity. RESULTS: Expenditure on LTC services for older people with CI is projected to rise from 0.60% of Gross Domestic Product (GDP) ( pound5.4 billion) in 2002 to 0.96% of GDP ( pound16.7 billion) in 2031, under base case assumptions. Under variant assumptions, the projection for 2031 ranges from 0.83% to 1.11% of GDP. These figures do not include the opportunity costs of informal care. CONCLUSIONS: Sensitivity analysis shows that projected demand for LTC is sensitive to assumptions about the future numbers of older people and future prevalence rates of CI and functional disability. Projected expenditure is also sensitive to assumptions about future rises in the real unit costs of services.

Hospital care at home: an evaluation of a scheme for orthopaedic patients.

We report on an evaluation of the practicality and acceptability of the 'Going Home Service', an early discharge intensive patient support scheme for orthopaedic patients in their own homes. Patient outcomes were assessed in terms of health and functional status and the impact on patient's carers was assessed. Eight-seven patients who were successfully discharged from the service were compared with 17 patients readmitted to hospital prior to their discharge from the service, 44 patients suitable for the service who did not take it up and 15 patients discharged from hospital traditionally immediately prior to the service becoming operational. Data were collected via face to face semistructured interviews and note searching. Twenty-six of the patients' informal carers were also interviewed. The majority of patients in all four groups were elderly women, readmitted patients being significantly older than those successfully discharged. The readmitted patients were also more likely to have been admitted originally for traumatic surgery and less likely to have been independently mobile prior to the initial admission. Hospital length of stay was shorter amongst Going Home Service patients than those cared for traditionally, but the total episode of care was greater. Patients and carers were well satisfied with the service. Although there was no evidence that quality of life or functionality were affected by their early discharge, at three months post operation, there was some evidence that Going Home Service patients were experiencing less pain than those discharged traditionally. This early discharge service provided a good quality of health and social care for the majority of patients. However, it did not suit all patients and a minority were re-admitted. The findings reported here add to those obtained in other settings and highlight new aspects for consideration in the planning and delivery of high quality hospital at home schemes.