Changes in the provision of long-stay care, 1970–1990

The objective of this paper is to map out the changes in the public, private and voluntary provision of long-stay care for elderly people and younger people with a physical handicap, people with a mental handicap and people with a mental illness in Britain over the period 1970–1990. It is also designed to bring together in a convenient form all the relevant data which are not readily available because they are published in several disparate sources. The effects on the social security budget of the expansion of private residential and nursing homes are described. National trends in provision show a marked increase in private residential and nursing homes and indicate how private provision has taken up an increasing number of people aged 65 years or over and has substituted for public provision with the closure of the hospitals for people with a mental illness or a mental handicap. The income support payments to people in independent homes increased, at 1990 prices, from $33 million in 1980 to $1390 million in 1990. The implications of this changing balance of care in terms of choice, efficiency and equity are examined in the concluding section. There is some evidence that the growth of the independent sector has increased consumer choice and improved efficiency in the provision of long-stay care but at some cost to those people who would have been provided with free NHS facilities but now have to contribute to the costs of their care.     

Costs and disability among stroke patients

BACKGROUND: The high costs of health and social care support for stroke survivors, and the development of new service arrangements, have concentrated growing attention on economic issues. However, there are few data on costs and their association with levels of disability. METHODS: Secondary analyses of data from the OPCS (Office of Population Censuses and Surveys) Surveys of Disability conducted in the mid-1980s were used to examine service utilization and costs for more than 1000 people who have had a stroke. Costs were estimated for all health and social care services. Regression analyses examined the cost-disability association in the context of other covariates for people living in private households. RESULTS: Disability problems were common among stroke survivors, particularly in relation to locomotion, self-care and holding. Among people living alone, the major contributors to costs were in-patient care (Pound Sterling 27 per week) and home help (Pound Sterling 30 per week). Among people living with others, in-patient hospital care was also a major cost (Pound Sterling 28 per week). Other services costing more than Pound Sterling 5 per week were general practitioner consultations, hospital out-patient care and day centre attendances. Resource use patterns varied considerably. Costs were associated with severity of disability, time since stroke and whether the person was living alone. Looking at the overall balance of care, a greater proportion of stroke survivors with severe disability were resident in communal establishments. CONCLUSION: The analyses provide a baseline from which more recent local studies and evaluations can be compared. Key issues for economic studies of stroke are the inclusion of a broad range of services, a reasonable duration of follow-up and consideration of the impact of the substitution of informal for formal services.     

Access to health care in nursing homes: a survey in one English Health Authority

The objective of the study was to establish the arrangements for provision of general practitioner (GP), nursing advice, chiropody, physiotherapy and speech and language services to nursing homes and to establish the charging policies for those services. To this end a telephone survey of the managers of the 51 nursing homes registered with one English health authority, Merton, Sutton and Wandsworth Health Authority, was undertaken. Forty-nine homes (96%) with 1541 residents responded. Twenty per cent of homes had no regular GP visits and half the homes had no planned medication reviews. One in five homes (27% of residents) had access to all health-care services. Eight homes (10% of residents) did not have access to therapy services or nursing advice. Thirty-three homes used private or both private and NHS chiropody services and 16 homes used the NHS service only. Seventeen homes used private or both private and NHS physiotherapy services with 10 homes receiving a regular private service. Twenty homes used the NHS service and 12 homes (15% of residents) had used no physiotherapy service. None used private speech and language services. Twenty-four of the 33 homes using private chiropody charged extra for this service compared with two of 10 homes using regular private physiotherapy. The findings suggest that there are inequalities in access to health care services in nursing homes. Moreover, there has been a deterioration in access to and levels of provision of NHS nursing and physiotherapy services since the national survey undertaken by the Office Population Censuses and Surveys (OPCS) in Great Britain in the mid-1980s. The new regulatory framework for older people must include systems for monitoring the provision of health services.     

Health care costs of people referred to an aged care assessment team: the effect of cognitive impairment

Abstract: The aim of this study was to determine the effect cognitive impairment has on direct and indirect costs to elderly people, their carers and the community over one year, by following prospectively a cohort of elderly people referred to an aged care assessment team. The 78 subjects were drawn from a random sample of people referred to the NorthWest Hospital team, and validated tools were used to assess their cognitive state. Outcome measures included total costs of community services, residential care, hospital bed use, carer burden and psychological morbidity. A comparison of outcome measures was made between those with cognitive impairment and those without. Use of community services and hospital beds was high overall. Those with cognitive impairment were substantially greater users of residential care, accounting for the higher expenditure in this group. Psychological morbidity and burden remain high in carers of those with cognitive impairment despite a high rate of institutionalisation in this group. The total costs for those referred to aged care assessment teams with cognitive impairment are double those seen for those with normal cognition.     

Assembling their own care packages: payments for care by men and women in advanced old age

A study of 93 households containing only people over 75 indicated that 74% chose to buy some form of care from the private or voluntary sector. The study included households in a middle class and a working class ward of an outer-London borough where few elderly people had children or other relatives living within walking distance. More private services were available in the middle class area but frail elderly people who needed services, such as cleaning, gardening, grocery delivery or car hire, as necessities had to compete with younger, very much more affluent households who bought the services as amenities. Personal care was less used by those interviewed, but 28 people paid for chiropody, either because they were ineligible for a free service or because the free service was inadeaquate for their needs. Paying for care did not bring market power. Elderly people were marginal customers and usually did not feel able to complain if they got poor service. The study indicates that there is a demand for care which helps frail elderly people to continue as respectable members of their communities. At present these services are not provided by the state and are in short supply in less affluent areas. Community care policies which were user-led, or which aimed at preventive care, would expand the provision of such services.     

Community care for the elderly: Costs and dependency

The aim of the paper is to examine the costs of care of elderly persons who live in their own homes as compared to those in residential homes. This is seen as a necessary first step in any planning process. From a survey of elderly persons in Britain, the levels of domiciliary services provided to those in their own homes was ascertained, and unit costs of each service was applied. Costs were based on the economic concept of social opportunity costs, so that all costs were included, and not just those accruing to the local authority. Recognising the fact that the costs of care in the community were likely to vary with the level of health of the elderly person, an attempt was made to categorise elderly persons into various levels of dependency. Secondly, regression techniques were used to ascertain whether the level of dependency did significantly affect the costs of care. It was found that variations in the average costs of care were significantly explained by both physical and mental characteristics of the elderly person. In addition, sex was important, as well as the elderly person's area of residence. This has important implications by itself for planning care services. It was also found that very few persons who were sampled in the community had a total cost of care greater than the average cost found in residential homes.     

Privatising residential care for elderly people: the geography of developments in Devon, England

The growth in numbers of very elderly people is becoming a trend in many Western societies. Often, these people may come to require some kind of assisted living environment. In Britain during the 1980s the overwhelming growth of residential accommodation has been in the private rather than the public sector. This has links with a number of other trends in health care and other sectors of the economy which are moving towards privatisation. The reasons for this are discussed and a case study of the county of Devon introduced. A survey of about one-quarter of all 450 homes in the county in mid-1984 revealed that they had important characteristics as small businesses. Countywide, a marked concentration of private residential homes has developed in some coastal 'holiday' locations. However, there have recently been changes in this pattern and growth of numbers of homes in some main towns also. There have been certain adverse reactions to the growth of homes and in a few areas, planning authorities have attempted to prevent the development of local concentrations of homes. This has been related to other policies elsewhere to prevent the concentration and ghettoisation of service-dependent groups. The nature and results of such planning policies are briefly considered. The paper addresses the overall questions of the type of care we wish to provide for our elderly people and whether privatisation of this aspect of health and welfare services is justified. This poses an important area of research for medical geographers interested in service delivery and aspects of equity in health care provision.     

Household utilization and expenditure on private and public health services in Vietnam

The private provision of health services in Vietnam was legalized in 1989 as one of the country's means to mobilize resources and improve efficiency in the health system. Ten years after its legalization, the private sector has widely expanded its activities and become an important provider of health services for the Vietnamese people. However, little is known about its contribution to the overall objectives of the health system in Vietnam. This paper assesses the role of the private health care provider by examining utilization patterns and financial burden for households of private, as compared with public, services. We found that the private sector provided 60% of all outpatient contacts in Vietnam. There was no difference by education, sex or place of residence in the use of private ambulatory health care. Although there was evidence suggesting that rich people use private care more than the poor, this finding was not consistent across all income groups. The private sector served young children in particular. Also, people in households with several sick members at the same time relied more on private than public care, while those with severe illnesses tended to use less private care than public. The financial burden for households from private health care services was roughly a half of that imposed by the public providers. Expenditure on drugs accounted for a substantial percentage of household expenditure in general and health care expenditure in particular. These findings call for a prompt recognition of the private sector as a key player in Vietnam's health system. Health system policies should mobilize positive private sector contributions to health system goals where possible and reduce the negative effects of private provision development.     

Primary health care meets the market in China and Vietnam

China and Vietnam developed low cost rural health services between the 1950s and the mid-1970s. These services contributed to substantial improvements in health. Both countries have been liberalising their economies for a number of years. Partly as a result of these changes health facilities have become increasingly dependent on user charges, and they have gained considerable independence from political or bureaucratic control. There has also been a growth in private provision. This has given people a wider choice of health services, but costs have risen and there are greater differences in access to medical care. The Chinese and Vietnamese governments face fundamental questions about the future development of the health sector.     

The evaluation of NIMROD, a community-based service for people with mental handicap: revenue costs.

The cost implications of moving from a system of services for people with mental handicaps centred on large institutions to a network of community-based services are not precisely known. The provision of the NIMROD service in a part of Cardiff, with its aim not only to meet the residential needs of adults comprehensively by providing a number of houses in the community but also to develop a support service to people living in their family home, gave an opportunity to investigate and report the revenue costs of a number of service elements with respect to a defined total population. The residential costs of intensively staffed houses in 1986-87, varying in size from two to six places, were found to range between pounds 16,473 and pounds 23,319 per person per year. With the addition of community support costs, such as the provision of day services, the total costs of care per resident averaged pounds 21,708; range, pounds 18,883-pounds 26,009. These compared to the total costs in a minimally staffed house of pounds 9,678 per resident. The costs of community support services for people living in their family homes averaged pounds 5,614 inclusive of DSS benefits, of which pounds 1,743 was accounted for by the NIMROD domiciliary support service, office base and administrative overheads. The residential costs reported were compared to other cost data in the literature. The study supports previous conclusions that there is little evidence of diseconomy attached to small scale per se but that the way staffing levels and therefore staff costs are determined is critical. No evidence was found in this study to link greater cost to better quality.     

The mental health status and long term care needs of the Chinese elderly in Hong Kong

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

What determines the use of home care services by elderly people?

The objective of the present study was to investigate the determinants of use of statutory and private home care services by older people living in the community. A questionnaire was distributed to a stratified random sample of 2,000 elderly people living in the community registered with 11 general practices in a British city (equal numbers of men and women, aged 65-74 years, and 75 years or over). The outcome measures were the use of statutory or private home care services in the previous 3 months. Logistic regression was used to explore potential determinants of the use of these services. The response rate was 79%. Increasing age, not owning a car and being a widow(er) were associated with greater use of both statutory and private home care services, as was worse self-reported overall health. Worse physical functioning, worse emotional health, problems with cognition, foot problems and a greater number of falls were determinants of use of statutory and private services. Older age on leaving full-time education was associated with increased use of private home care services. Problems with eyesight were determinants for both types of home care services for women, but only private services for men. For women, leakage of urine was associated with greater use of private services. Social networks and social support were not generally associated with use of these services after controlling for demographic factors. Understanding the determinants for the use of both statutory and private home care services is important because of the increasing numbers of elderly people in the population and the policy to maintain older people in their own homes. Purchasers and providers should be able to address at least some of the modifiable predictors.     

The Mental Health Status and Long Term Care Needs of the Chinese Elderly in Hong Kong

ABSTRACT

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

COVID-19 en residencias de mayores: factores estructurales y experiencias que avalan un cambio de modelo en España

The effects of COVID-19 pandemic on older people living in care homes have been devastating. In Spain approximately 3% of the cases and 40% of the deaths have occurred in this group. In addition, due to measures taken to control the crisis, the incidence of geriatric syndromes has increased, and residents’ fundamental rights have been violated. In this article we describe structural factors of care homes and their relationship with public health services that have influenced the impact of the pandemic. We suggest different types of group homes, and models of provision/coordination with public health services that have given excellent results protecting nursing homes residents from COVID-19, as alternative models to conventional residences and to the regular provision of health care services. We recommend that these successful experiences are taken into account in the transformation of the social-health model (to one integrated and focused on people) that has begun to be implemented in some Autonomous Communities of Spain.     

Demograghic and socio-economic determinants of community and hospital services costs for people with HIV/AIDS in London.

We examined the influence of demographic, social and economic background of people with HIV/AIDS in London on total community and hospital services costs. This was a retrospective study of community and hospital service use, needs and costs based on structured questionnaires administered by trained interviewers and costing information obtained from the service purchasers and providers, based on two Genito-urinary Medicine clinics in London: the Jefferiss Wing at St. Mary's Hospital and Patric Clements at the Central Middlesex Hospital, London, England. The subjects were 225 HIV infected patients (105 asymptomatic, 59 symptomatic non-AIDS and 61 AIDS). We found that over and above well established determinants of health care costs for HIV infected people such as disease stage and transmission category, social and economic factors such as employment and support of a living-in partner significantly reduced community services costs. Private health insurance had a similar effect, though only a small proportion of HIV people had such cover. The cost of community services for HIV infected non-European Union nationals, mainly of African origin, was one quarter that for the European Union nationals. Community services costs were highest for heterosexually infected women and lowest for heterosexually infected men after adjusting for other factors. Hospital services costs were significantly higher for HIV infected people lacking educational qualifications and employment. We conclude that access to community care for HIV infected non-EU nationals appears to be very poor as the cost of their community services was one quarter that for the EU nationals after adjusting for the effects of transmission category, disease stage, living with a partner, employment and having a private health insurance. Additional incentives for informal care for HIV infected people could be a cost-effective way to improve their community health service provisions.     

Are cognitive impairment and depressive mood associated with increased service utilisation in community‐dwelling elderly people?

The healthcare and social services utilisation of elderly people with mental disorders has not been sufficiently described, although such knowledge could indicate directions for preventive and curative interventions, and suggest unmet service needs. The aim of the present study was to examine cognitive impairment and depressive mood as correlates of specific healthcare and social services utilisation of community-dwelling elderly people. A randomly selected population sample of 1134 community-dwelling individuals aged 65 years and over living in a defined area were interviewed at home. Cognitive impairment was measured by the Mini Mental State Examination and depressive mood by the Centre for Epidemiologic Studies -- Depression scale. Cognitive impairment and depressive mood were related to the number of home care services used, and to the utilisaton of every specific healthcare and social service. After controlling for confounding variables (i.e. age, sex, education, co-residence and disabilities), service utilisation was still predicted by depressive mood, but not by cognitive impairment. Interventions to prevent and cure depressive mood should be considered to decrease the service needs of community-dwelling elderly people. Unmet service needs are suggested since cognitive impairment does not result in increased service utilisation.     

Are health services protecting the livelihoods the urban poor in Sri Lanka? Findings from two low-income areas of Colombo

Investing in pro-poor health services is central to poverty reduction and achievement of the Millennium Development Goals. As health care financing mechanisms have an important influence over access and treatment costs they are central to the debates over health systems and their impact on poverty. This paper examines people's utilisation of health care services and illness cost burdens in a setting of free public provision, Sri Lanka. It assesses whether and how free health care protected poor and vulnerable households from illness costs and illness-induced impoverishment, using data from a cross-sectional survey (423 households) and longitudinal case study household research (16 households). The findings inform policy debates about how to improve protection levels, including the contribution of free health care services to poverty reduction. Assessment of policy options that can improve health system performance must start from a better understanding of the demand-side influences over performance.     

Hitting home: a survey of housing conditions of homes used for long-term care in Ontario.

A telephone survey of a random sample of 811 long-term home care clients from three geographically distinct regions in Ontario was conducted to illuminate the living and working conditions in households receiving long-term care services. The median age of clients was 77 years and 75 percent were female. The majority had not completed high school. Almost half were widowed, had income levels of dollar 20,000 (Canadian) or less, and lived alone. Approximately one-third needed help with most basic activities of daily living. The vast majority could not bathe or dress themselves. More than three-quarters needed help with preparing meals, housekeeping, and shopping. Few clients could perform yardwork and home repairs. Many clients' homes required major and minor repairs, were not suitable in size, were not affordable, and lacked important household amenities. More than 30 percent required modifications to enable clients to live and be cared for comfortably and safely, and half the clients had not completed these because of exorbitant costs. Overall, many clients were living in homes less than optimal for domestic life and long-term care provision. These results highlight significant gaps in care provision and a need to link housing to health and social service policies.     

Can post‐acute care programmes for older people reduce overall costs in the health system? A case study using the Australian Transition Care Programme

There is an increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases. To reduce pressure and costs in the hospital system, community-based post-acute care discharge services for older people have evolved as one method of reducing length of stay in hospital and preventing readmissions. However, it is unclear whether they reduce overall episode cost or expenditure in the health system at a more general level. In this paper, we review the current evidence on the likely costs and benefits of these services and consider whether they are potentially cost-effective from a health services perspective, using the Australian Transition Care Programme as a case study. Evaluations of community-based post-acute services have demonstrated that they reduce length of stay, prevent some re-hospitalisations and defer nursing home placement. There is also evidence that they convey some additional health benefits to older people. An economic model was developed to identify the maximum potential benefits and the likely cost savings from reduced use of health services from earlier discharge from hospital, accelerated recovery, reduced likelihood of readmission to hospital and delayed entry into permanent institutional care for participants of the Transition Care Programme. Assuming the best case scenario, the Transition Care Programme is still unlikely to be cost saving to a healthcare system. Hence for this service to be justified, additional health benefits such as quality of life improvements need to be taken into account. If it can be demonstrated that this service also conveys additional quality of life improvements, community-based programmes such as Transition Care could be considered to be cost-effective when compared with other healthcare programmes.     

Health care in China: the role of non-government providers

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.