Andrew Bebbington

The expectation of life without disability in England and Wales

This paper calculates the Expectation of Life Without Disability (ELWD) for England and Wales, following the method of Robine et al. (Population 6, 1025-1042, 1986), using a question about limiting long-standing illness from the General Household Survey. Trends over the last decade are estimated. At present ELWD from birth is about 59 years for men, 62 for women. The trend is upward, but by no more and possibly less than the rate of increase in expectation of life. Men live a greater proportion of their lives without disability than do women. The improvement in ELWD is most marked in the highest age-groups, but the evidence is that the health of the elderly in relation to that of the population as a whole has been poorer in England and Wales than in two other countries for which similar evidence is available.

Residential or nursing home care? The appropriateness of placement decisions

Routinely-collected statistics show considerable variation between local authorities in Great Britain, in the proportions of supported residents placed in nursing and residential care. This raises the question of whether this is due to variations in demand (the type of resident approaching authorities), supply (the level and type of provision available for local authorities to purchase), or policy (in terms of eligibility criteria or interpretations of need at field level). Data were used from a national longitudinal survey of individuals admitted to publicly-funded residential and nursing home care. Information was collected from 18 local authorities on a cohort of 2,544 local authority supported residents who had been admitted to residential and nursing home care. The paper examines the pattern of admissions, the characteristics of people admitted and the relationship between these characteristics and admissions to residential or nursing home care. Characteristics of the individual explained the placement of over 80 per cent of admissions. Supply factors were statistically significant but did not improve the explanatory power of the model. Survival among those admitted to a type of care that was not predicted by the model, suggested that some unmeasured aspects of prognosis may account for some of the residual variation in placements. Overall, the results indicate a reasonably high level of consistency between authorities in nursing home placement decisions. This suggests that either there is considerable variation in the types of individual approaching local authorities or, more likely, that some authorities are more successful in maintaining people for longer at home than others. In addition to maintaining people at home to a higher level of dependency, prevention of admission to residential care is likely to be associated with: interventions that address carer support, safety issues among people who are deaf, and motivation.

Equity and Efficiency in the Allocation of the Personal Social Services

This paper investigates two issues of equity in the receipt of the home help service, one about territorial justice, the other about sex discrimination. It uses GHS data for 1980. An argument is developed about the efficiency with which services are targeted on persons who by normative criteria would appear to have most need of them. Efficiency is of two types: horizontal efficiency, the proportion of persons judged in need who receive services; and vertical efficiency, the proportion of services allocated to persons judged in need. The findings are that there is evidence of inequity both between different areas and between the sexes. Metropolitan areas are advantaged compared with rural areas, and this cannot be explained by differences in social support nor by the availability of other domiciliary services. Among the elderly living alone, neither sex is advantaged, but in elderly married couple households the home help service is more frequently provided in the case of a husband caring for a disabled wife than in the case of a wife caring for a disabled husband.

Residential and nursing home care of elderly people with cognitive impairment: Prevalence, mortality and costs

Cognitive impairment among residents has considerable resource implications for both individuals and those responsible for publicly funded care. Two linked surveys were carried out in England: (1) a longitudinal study followed 2500 admissions to publicly funded care up to 42 months after admission; and (2) a cross-sectional survey of 618 homes collected information about 11,900 residents. Information was collected about cognitive impairment using the Minimum Data Set Cognitive Performance Scale. Cognitive impairment was associated with source of funding and type of home. Although level of cognitive impairment has some effect, fees and costs were most influenced by type of home. At the same level of impairment, self-funded residents were more likely to be located in relatively low-cost settings than publicly funded residents. In independent homes fees were lower for publicly funded than for self-funded residents. Overall median length of stay of publicly funded admissions was 18 months. For the most part length of stay was not associated with level of cognitive impairment on admission. It is concluded that more information is needed about the effect of quality of care on people with cognitive impairment in different settings. If the same quality of care can be achieved in residential and nursing homes, the evidence would suggest that changes in placement policies could result in potential savings to the public purse.

Policy Applications of Health Expectancy

Empirical estimates of trends in health expectancy throughout the nations of the developed world provide conflicting evidence on the debate whether increasing life expectancy is accompanied by a compression or expansion of morbidity and disability. Complicating this issue is the fact that various methods are available for calculating health expectancy, each requiring a unique and often difficult to obtain source of data. It is suggested here that to reliably communicate the policy relevance of the measure of health expectancy it is necessary for countries such as the United Kingdom to make a long-term commitment to developing longitudinal databases that permit the most reliable estimates of trends in the health status of the population.

Efficient Targeting of Community Care: The Case of the Home Help Service

By 1985 community care, of which the home help service is one of the cornerstones, was on the brink of a major change which would fundamentally affect targeting. The new focus is a concentration on those in greatest need, responsiveness to the needs of carers, and to the potential for the self financing of care. The analysis given here indicates that huge changes in targeting of the service will have been needed from the situation in 1985 to meet these new policies, changes which might be expected to move the service away from its traditional role of monitoring the very old living alone. Analysis of the period between 1980 and 1985, using the General Household Survey, shows that the targeting effect of new policies is not easy to predict. The slight increase in home care during the period did not reflect an improvement in targeting on the demonstrably most needy, but instead apparently spread the service more widely. Re-examination of equity, territorial and gender issues shows that only limited progress had been made. Indeed, gender discrimination may even have increased. While the UK may not wish to go as far as some other countries in allocating community care according to fixed eligibility criteria, come what may, targeting concepts will be increasingly salient for monitoring the community care policys achievement.

Territorial Need Indicators: A New Approach Part I

Territorial indicators of need, describing variations in the characteristics of areas ranging from wards to standard regions of the United Kingdom, represent a mainstream application of social indicators in this country. The development of these indicators has, for the most part, been based on an intellectual tradition which has paid little attention to theoretical argument. In Part I of this article, a typology of existing need indicators is developed. By analysis of some of the best-known and most sophisticated examples, it is illustrated how this lack of theory has severely limited their usefulness in policy practice, particularly with regard to resource allocation, where they are potentially very important. A predominant symptom of the problem encountered with empirically based need indicators is the difficulty of establishing criteria for testing their validity. For the ‘meaning’ of a need indicator to be clear, the indicator must be theoretically based. More specifically, it should be rooted in theoretical conclusions about the policy of welfare interventions. In Part II of the article, the theory of the need judgement as a cost-benefit decision is used to provide a basis for a need indicator. This method is then explicated with regard to social services provision for the elderly, so as to provide an indicator which is in fact a standard level of expenditure for social services departments in England and Wales.

Volunteers in an HIV social care organization

This study describes volunteers who were trained at a large HIV social care centre in South London during its first two years of operation. Many shared similar backgrounds to their clients; indeed some service users were also volunteers. Common motivations for volunteering were to learn more about HIV, to give something back to affected communities, and for gaining job-relevant experience. Selection, training and induction procedures were elaborate. But there were problems. Turnover was high, with half the volunteers dropping out in their first year. This matches reports for HIV organizations elsewhere, but is higher than for the voluntary sector in general. The high rate is attributed not to the nature of the work, but partly to the unusual social groups from whom volunteers are drawn and partly to the changing relationships between volunteers and the organization, symptomatic of which was loss of communication with staff and managers, and a consequent feeling of being undervalued. This can be linked to pressures arising from the pace of change in such organizations which have had the effect of marginalizing the role of volunteers. The new contractual arrangements with statutory agencies are contributing to the alienation, though ironically they were intended to strengthen the voluntary sector. The study questions whether AIDS service organizations should accept that the voluntaristic basis on which many originated is now over.

A comment on Hirst's “Evaluating the Malaise Inventory”

SummaryAn item analysis of the Malaise Inventory by Hirst (1983), reported in this journal, suggested that there no was no evidence of a single dimension of emotional disturbance underlying the set of items. Hirst concluded that Malaise scores were untrustworthy for testing empirical hypotheses about degrees of stress. Consideration of Hirsts paper leads to the conclusion that an inappropriate methodology was used for the factor analysis, since the correlation coefficients were based on dichotomous items that were simplifications of continuous variables. A confirmatory factor analysis of the Malaise scores of 200 mothers of severely mentally handicapped children finds that the Malaise Inventory yields a single moderate factor of stress.

Expenditure Planning in the Personal Social Services: Unit Costs in the 1980s *

During the 1980s, unit cost inflation more than swallowed up all the increased spending on local authority social services, leaving a 10 per cent net reduction in service volumes. This increase can be only partly explained by increased labour prices and increased client needs resulting from the implementation of community care. Explanations in terms of quality and efficiency changes are explored in relation to individual services, and there appears to be a prima facie case that efficiency reduced during the 1980s. Variation between local authorities in the costs of apparently similar services rose during the 1980s. An analysis of these variations shows that those authorities which experienced the greatest rise in unit costs also had the greatest reduction in service volumes. Unit cost containment has been greatest where there was grant reduction and a declining local tax base, while volume declined most where there was rate-capping. The rising variation in unit costs has been responsible for the widening gap between standard spending assessments and what local authorities have wanted to spend on personal social services. If these increased variations reflect widening efficiency standards, then reversing this trend will require that social services department managements have both the motivation and capacity to implement unit cost monitoring and control.