Adelina Comas-Herrera

Relying on informal care in the new century? Informal care for elderly people in England to 2031

The research reported here is concerned with the future of informal care over the next thirty years and the effect of changes in informal care on demand for formal services. The research draws on a PSSRU computer simulation model which has produced projections to 2031 for long-term care for England. The latest Government Actuarys Department (GAD) 1996-based marital status projections are used here. These projections yield unexpected results in that they indicate that more elderly people are likely to receive informal care than previously projected. The underlying reason is that the GAD figures project a fall in the number of widows and rise in the number of elderly women with partners. What this implies is that ‘spouse carers’ are likely to become increasingly important. This raises issues about the need for support by carers since spouse carers tend to be themselves elderly and are often in poor health. The article explores a number of ‘scenarios’ around informal care, including scenarios in which the supply of informal care is severely restricted and a scenario in which more support is given to carers by developing ‘carer-blind’ services. This last scenario has had particular relevance for the Royal Commission on Long Term Care.

How much risk is mitigated by LTC Insurance? A case study of the public system in Spain

We present a methodology that allows to calculate the impact of a given Long-Term Care (LTC) insurance protection system on the risk of incurring extremely large individual lifetime costs. Our proposed methodology is illustrated with a case study. According to our risk measure, the current Spanish public LTC system mitigates individual risk by more than 30% compared to the situation where no public protection were available. We show that our method can be used to compare risk reduction of alternative LTC insurance plans.

Care by Spouses, Care by Children: Projections of Informal Care for Older People in England to 2031

The future market costs of long-term care for older people will be affected by the extent of informal care. This paper reports on projections of receipt of informal care by disabled older people from their spouses and (adult) children to 2031 in England. The paper shows that, over the next 30 years, care by spouses is likely to increase substantially. However, if current patterns of care remain the same, care by children will also need to increase by nearly 60 per cent by 2031. It is not clear that the supply of care by children will rise to meet this demand.

Future costs of dementia-related long-term care: exploring future scenarios

BACKGROUND This study explores how the views of a panel of experts on dementia would affect projected long-term care expenditure for older people with dementia in England in the year 2031. METHODS A Delphi-style approach was used to gather the views of experts. The projections were carried out using a macro-simulation model of future demand and associated expenditure for long-term care by older people with dementia. RESULTS The panel chose statements that suggested a small reduction in the prevalence of dementia over the next fifty years, a freeze in the numbers of people in care homes, and an increase in the qualifications and pay of care assistants who look after older people with dementia. Projections of expenditure on long-term care that seek to capture the views of the panel suggest that future expenditure on long-term care for this group will rise from 0.6% of GDP in 2002 to between 0.82% and 0.96% of GDP in 2031. This range is lower than the projected expenditure of 0.99% of GDP in 2031 obtained under a range of base case assumptions. CONCLUSIONS This paper attempts to bridge the gap between qualitative forecasting methods and quantitative future expenditure modelling and has raised a number of important methodological issues. Incorporating the panels views into projections of future expenditure in long-term care for people with dementia would result in projected expenditure growing more slowly than it would otherwise.

Modelling an entitlement to long-term care services for older people in Europe: projections for long-term care expenditure to 2050

As the numbers of older people rise in Europe, the importance of long-term care services in terms of numbers of users and expenditures can be expected to grow. This article examines the implications for expenditure in four countries of a national entitlement to long-tem care services for all older people, based on assessed dependency. It is based on a European Commission-funded cross-national study, which makes projections to 2050 of long-term care expenditure in Germany, Italy, Spain and the UK. The policy option investigated is based on the German long-term care insurance scheme, which embodies the principle of an entitlement on uniform national criteria to long-term care benefits. The research models this key principle of the German system in the other three participating countries, with respect to home care services. The study finds that, if all moderately/severely dependent older people receive an entitlement to formal (in-kind) home care, the impact on expenditure could be considerable, but would vary greatly between countries. The impact on long-term care expenditure is found to be the least in Germany, where there is already an entitlement to benefits; and the greatest in Spain, where reliance on informal care is widespread. This article discusses the policy implications of these results.

Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)

Summary Background Little is known about how the proportions of dependency states have changed between generational cohorts of older people. We aimed to estimate years lived in different dependency states at age 65 years in 1991 and 2011, and new projections of future demand for care. Methods In this population-based study, we compared two Cognitive Function and Ageing Studies (CFAS I and CFAS II) of older people (aged ≥65 years) who were permanently registered with a general practice in three defined geographical areas (Cambridgeshire, Newcastle, and Nottingham; UK). These studies were done two decades apart (1991 and 2011). General practices provided lists of individuals to be contacted and were asked to exclude those who had died or might die over the next month. Baseline interviews were done in the community and care homes. Participants were stratified by age, and interviews occurred only after written informed consent was obtained. Information collected included basic sociodemographics, cognitive status, urinary incontinence, and self-reported ability to do activities of daily living. CFAS I was assigned as the 1991 cohort and CFAS II as the 2011 cohort, and both studies provided prevalence estimates of dependency in four states: high dependency (24-h care), medium dependency (daily care), low dependency (less than daily), and independent. Years in each dependency state were calculated by Sullivans method. To project future demands for social care, the proportions in each dependency state (by age group and sex) were applied to the 2014 England population projections. Findings Between 1991 and 2011, there were significant increases in years lived from age 65 years with low dependency (1·7 years [95% CI 1·0–2·4] for men and 2·4 years [1·8–3·1] for women) and increases with high dependency (0·9 years [0·2–1·7] for men and 1·3 years [0·5–2·1] for women). The majority of mens extra years of life were spent independent (36·3%) or with low dependency (36·3%) whereas for women the majority were spent with low dependency (58·0%), and only 4·8% were independent. There were substantial reductions in the proportions with medium and high dependency who lived in care homes, although, if these dependency and care home proportions remain constant in the future, further population ageing will require an extra 71 215 care home places by 2025. Interpretation On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations. Funding Medical Research Council (G9901400) and (G06010220), with support from the National Institute for Health Research Comprehensive Local research networks in West Anglia and Trent, UK, and Neurodegenerative Disease Research Network in Newcastle, UK.

Winners and losers: assessing the distributional effects of long-term care funding regimes

Using two linked simulation models, we examine the public expenditure costs and distributional effects of potential reforms to long-term care funding in the UK. Changes to the means tests for user contributions to care costs are compared with options for the abolition of these means tests (‘free’ personal care). The latter generally cost more than the former and benefit higher income groups more than those on lower incomes (measuring income in relation to the age-specific income distribution). Reforms to the means tests target benefits towards those on lower incomes. However, the highest income group are net losers if free personal care is financed by a higher tax rate on higher incomes and the effect on the whole population considered.

Mapping the future of family care: receipt of informal care by older people with disabilities in England to 2032

Many long-term care systems in economically developed countries are reliant on informal care. However, in the context of population ageing, there are concerns about the future supply of informal care. This article reports on projections of informal care receipt by older people with disabilities from spouses and (adult) children to 2032 in England. The projections show that the proportions of older people with disabilities who have a child will fall by 2032 and that the extent of informal care in future may be lower than previously estimated. The policy implications, in the context of the Dilnot Commissions report, are explored.

Residential care for mentally ill people in Andalusia and London - a comparison of care environments, users' attitudes and cost of care

Background: This collaborative study evaluates newly developed residential facilities in Andalusia and compares them with the established care network in London. Aims: The study aims to discover the similarities and differences in the quality and effectiveness of residential care provision in the two regions. Method: A comparative study of matched samples, comprising 136 former long-stay psychiatric patients living in 30 community facilities in Andalusia and London. Domains explored included: the demographic and social profiles of residents, objective measures of care environments, cost of residential care and attitudes of service users. Residents and facilities were assessed, using a batch of cross-translated schedules with established psychometric properties. A cost related analysis was conducted using the Client Service Receipt Interview (CSRI). Results: While residents in both locations are equally disabled the level of support is significantly higher in London than in Andalusia. The Andalusian facilities are more restrictive in management policies, offering less privacy to their residents. A higher proportion of staff in Andalusia are professionally qualified, but the training opportunities for British staff are greater. Both British and Andalusian residents prefer living in the community. The average cost of residential care is markedly higher in London than in Andalusia. Conclusions: There is a need to extend the network of residential facilities in Andalusia and apply less restrictive policies. The cost-effectiveness of staffed group homes should be scrutinised and professionalism among British residential staff increased.

The effect of lengthening Life Expectancy on future pension and Long-Term Care expenditure in England, 2007 to 2032

AbstractBackground 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 MPolicymakers 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. List of Tables, 36