Hansard

Thank you. I am going to talk to the committee about my rapid review that compared international models of social care. The aims of the presentation are to provide an overview of the rapid literature review that I conducted and, in particular, to outline its key findings, the main features of the different models, key similarities and differences between each of the models, and some important considerations in thinking about the transferability of models. I also want to have a look at evidence-informed recommendations for decision makers. The purpose of the literature review of international models of social care was to provide a descriptive and comparative overview of the literature available and the types of evidence. The review was structured around six particular research questions: how social care is structured, delivered, funded and governed; the benefits and limitations of each model; the impacts on population health outcomes and healthcare delivery,? which are also important; the enablers of and barriers to the effective implementation and delivery of each model, ?especially around integration reforms, in other countries; the enablers of and barriers to the long-term sustainability—especially the financial sustainability—of each model; and the points that we need to consider in thinking about the transferability of the models, particularly to Scotland.? Our questions were answered for each of the countries or groups of countries, which were Australia, New Zealand, Japan, the United States and Alaska, Switzerland, Canada, the Nordic countries, the European Union countries—Germany, the Netherlands and France were particularly focused on—and all four of the United Kingdom countries. The review combined systematic, narrative and Delphi method techniques to review the existing literature, which was both academic literature and the grey literature. The ?data collection process looked at the available interdisciplinary materials, so it covered a broad range of materials, and the findings were verified via the project advisory group. The final sample consisted of 166 articles and documents, which were coded for, and subjected to, detailed scrutiny. On the findings, which are the key things, we looked at how social care is funded, structured and governed in the different countries. As members can see from the slides, there is a sample of some countries. The key details are available in the summary sheet that was given to members. We can see the key similarities in delivery in the mix of public and private providers in Australia and Canada, but we can also see the differences in funding. We can see that, compared with Switzerland, Japan and the EU placed high levels of expectation on informal care, and we can see some similarities between the German system and the Japanese system, both of which are funded through compulsory social insurance schemes, but we can also see also how they diverge in their delivery. The Nordic and New Zealand systems are quite similar to the system in the UK in some ways, but they are very different in other ways—particularly with regard to the extent of integration in the New Zealand system and the amount of provision by for-profit providers that we have in comparison to the Nordic countries, although that level of provision has been increasing in recent decades. I draw members’ attention to the slide that shows the key differences in funding and key aspects of governance and delivery. A number of countries fund care through central taxation or, in the case of EU countries, through centrally organised compulsory insurance schemes. The Alaskan model is very different and is funded through Alaska’s own version of Medicare. In France, the social insurance scheme is funded via taxation, both centrally and regionally. Japan’s insurance scheme is funded regionally. Canada is a particularly interesting example because the arrangement is made on a provincial basis, with powers transferred to the provinces via federal and central legislation. There are key differences in the locus of control. In Australia, care is under federal control, but the division of federal and state responsibility is not particularly clear, which has caused problems. In Switzerland, although care is funded centrally, municipalities have control over governance. In the Nordic countries, control is largely central, although districts have the power to make arrangements. That control is supported by strong national legislation concerning eligibility and the quality of care, which places limits on those powers. That is similar to the situation in New Zealand, where regional authorities have control but within national legislative limits. There is a broad range of eligibility, from very strict conditions to broader coverage. That is connected to the final column of the slide, which deals with expectations about informal care being used to plug gaps. In Australia, eligibility is determined by needs, on a means-tested basis, and the expectation of informal care is low. In Japan, the criteria are very strict: the coverage for those who do qualify is broad, but it is meant to plug gaps in informal care provision. In EU countries, the provision of care is based on eligibility, but the criteria have become far stricter in recent years, particularly in the Netherlands. In those countries, there is still a high level of expectation of informal care. In Germany, in the past, there was legislation that ensured that family members contributed to the cost of care for their relatives. People without children paid higher premiums, which was very controversial and contentious. In Alaska and the US, care is means tested but the level of service provision is very low, so families end up plugging the gaps regardless of the kind of cultural expectations to do so that are felt in countries such as Japan. The final column on this slide deals with the integration of social care and healthcare, which is important as it affects provision. In Australia, the two are separate. In the US and Alaska, social care is not covered by Medicare unless it is part of residential healthcare services or rehabilitation services. In that system, much of what would be part of age or social care here, in Scotland, such as general assistance in the home, is not provided. In Canada, social care is part of extended healthcare and provision is broader than in the US or Alaska, although the majority of care for older people is still provided in residential settings; home care coverage is substantially poorer. In Switzerland, social care and healthcare are linked in terms of service provision, but they are not integrated as they are in New Zealand and in Northern Ireland. In the other UK countries, there has been a move towards greater integration. We also looked at the strengths and weaknesses of the different models. In the Australian system, the opening of care provision to private providers has led to much concern about increasing inequality, and the lack of integration impacts the delivery of care for those with complex needs. However, as I said, there is a reduced need for informal care. In the US, the key problem—it overarches all the other issues—is the inequality in access to age care and the exacerbation of social, economic and racial inequalities in healthcare. Alaska is different from the other states in that the models that have been provided for indigenous people are aimed at ageing in place, with a lot less emphasis on the use of residential care. There is the potential to reduce inequalities in outcomes because these models are built on a diversity of world views with different conceptualisations of health and wellbeing. They have moved beyond simply recognising cultural diversity towards building a system that is based on it. However, the system is also primarily health focused, so the amount of social care provision remains limited. 09:15 In Canada, the majority of social care is provided in residential institutions, and there are big differences in provincial arrangements, which can create inequalities in access between provinces. However, some of the strict regulations in Canada on the licensing of care homes helps private, for-profit providers to meet care delivery standards.? In Japan, the system is very much based on a paternalistic medical model. The high levels of informal care are particularly concerning as a gender equality issue,? with women being the ones who carry out the majority of care. However, access to care is standardised and coverage is good if you qualify. In the EU countries, the system provides for ?a basic level of care only, with the rest expected to be covered by informal provision. Another downside is that single-sourced insurance schemes can be vulnerable to macroeconomic fluctuations. However, contribution-based systems have been said to be associated with a reduced need for political bargaining, whereas, in Canada, some of the short political cycles have been said to limit the effectiveness of reforms. The system in Switzerland ranks very well internationally,? but the fragmentation of governance and delivery between the federal, municipal and local authorities in terms of delivering governance has been associated with an increased risk of suboptimal quality of care. The Nordic countries, which are often considered examples of best practice by international standards, provide universal coverage, supported by national-level legislation that ensures equality in the level of care that is provided and in the quality of services. A lot of the literature discusses how marketisation has challenged the principle of universalism, because there is an introduction of payment for add-on or top-up services. In the New Zealand model, integration helps to meet the care needs of those with particularly complex needs. There is an emphasis on overall wellbeing, and it is well integrated. A lot of it is focused on addressing existing health and social inequalities. In Scotland, increasing integration has the potential to create a more holistic approach to care provision. However, the cons of what has been happening with integration include the issue that health can emerge as the dominant partner. Public expectation for social care provision is high, and eligibility in Scotland is relatively high, whereas in Northern Ireland, where there has been an integrated system for decades, there have been quite a few issues due to the multiple layers of decision making and unclear lines of accountability. Also, care user choices can be limited.? England has a slightly greater reliance than Scotland has on for-profit care providers?, but the key challenge for integration in England is the lack of a statutory basis for it. Satisfaction with social care in England has also been decreasing in recent years. In Wales, the biggest concerns are over accessibility, care quality and co-ordination. However, it has been found that pooled budgets help to facilitate data sharing and commissioning.? The third research question was about the impact of each system on population health outcomes. The answers to that question need to be considered when thinking about the pros and cons of each model. We can draw the conclusion that poor integration between health and social care can negatively impact those with complex needs, as it does in Australia. That is especially clear when we compare it to the situation in Japan, for example, where the system is positive because, although eligibility is limited, it covers a large range of services for those with the most complex disabilities and needs. Limited coverage in the US is very much linked to widening social, economic and racial health inequalities. In Alaska, there is a bit more provision for care services for indigenous people, which is associated with greater preventative health outcomes as well as better treatment for chronic disease and lower hospital admission rates. In Canada, differences in provincial arrangements result in national-level inequalities in access to care and in health outcomes. In all countries, the marketisation of social care has been linked to growing inequalities in health outcomes. However, the impacts can be somewhat mitigated by national-level legislation on the quality of care and the amount that providers can charge, as is the case in the Nordic countries and, to an extent, in Switzerland. Integrated care provision is associated with better overall quality-of-life outcomes, which affect health outcomes, and it is helpful for reducing pre-existing inequalities. In the UK, so far, there has been little evidence that attempts to increase integration have affected health outcomes, but the longer-term effects and impacts are not really known. It will take several decades before we start to see the impact of those attempts. Let us have a little think before I detail the findings from the other questions. Underpinning questions about integrated care are questions about how health-related care relates to social care. I encourage you to consider how social care needs reflect healthcare needs and quality-of-life and broader wellbeing needs. Where is the demand now, and where will it be in the future? With that in mind, think about which models you might favour in an ideal world. That may be limited by questions of funding and the ability to deliver, but we need to think about what should come under the rubric of social care. Should it be about extended healthcare needs, with wider wellbeing being part of something else, such as community, or should broader wellbeing come under social care? That is the fundamental question at the base of those models. I will move on to the findings on the barriers to and enablers of the success of different models of integrated care. We looked at what the different countries said about successes and barriers. The New Zealand approach had a clear vision of one system and one budget helping to achieve positive outcomes. In EU countries, in Alaska and the United States, and particularly in Canada, the amalgamation of the district health authorities into a single provincial health authority helped to improve outcomes. Another important lesson that we can take from this is that frameworks and standards can help to facilitate successful integration. In the Nordic countries, a key lesson is that marketisation can challenge equality of access but, if funded care services remain comprehensive enough that very few demands for top-up services are made, it will not impair the universality of provision. I will now turn to challenges to the financial sustainability of the models. It is worth thinking about how likely it is that each model can be sustained. All are affected and challenged by an ageing population, which places rising demands on care. Although the Nordic model is the gold standard, it is coming under pressure on its ability to provide universal care in the future, owing to the ageing population. Another challenge in Australia, Canada and the UK countries is the changing pattern of care needs, such as the move towards care at home, which you need to be able to fund and provide the workforce for. At the same time, in the US, where there is low state spending, the system is coming under pressure from increasing inequalities in health, with people requiring care at younger ages and often for more complex needs. So, in this case, reduced spending alone is unlikely to solve the problems. All contribution-based systems that are funded through central taxation are affected by economic fluctuations, so they are not completely stable. The integrated system in New Zealand is dependent on increased spending on community care to sustain it and to avoid some of the problems that we have recently seen in Scotland, where health spending has emerged as more dominant. Lastly, we looked at factors that we need to consider when we think about transferring a social care model to a different context. If something works, can we uplift it and implement it somewhere else? From the limited number of studies that explored transferring models to different contexts, we found that, in practice, that can be difficult. The ability of a transfer to succeed financially is dependent on the wider economy, so timing is important, and there is a need to consider how the fundamental principles that underpin a country’s model of care compare with those of a recipient country. The Nordic model is underpinned by a principle of universality that is widely accepted publicly; so, if we implemented the US system, which is founded on principles of freedom and responsibility, in the Nordic countries, it likely that the level of resistance would be high. The same would be true if we implemented the Nordic model in the US. Likewise, in Japan, there is still a strong cultural value of providing informal care. Therefore, it is likely that implementing the Japanese model in the Nordic countries or in Australia, where there is wider emphasis on supporting a dual-earner model, would result in a lot of resistance. We therefore need to think about the core concepts and values that underpin a model and determine where they fit with the social and cultural values and expectations of the recipient country. We also found other factors to consider, such as the rate of population ageing in both countries. For example, the Japanese system is coming under pressure from an ageing population; however, we need to keep in mind the fact that the rise is much more rapid in other countries than it is in Scotland, so perhaps the model might be more likely to be sustained here. Other factors include population geography and governance structures. Canada has a huge geographic area, with differences in population dynamics in each province. Although we might say that regional governance can add layers of complication, in an area as large and diverse as Canada, there is a strong case against a one-size-fits-all model. We also need to think about population diversity. We can have a universal system, which works in some contexts; a system that recognises increasing diversity, such as in New Zealand, which is helpful for addressing existing inequalities; or a system like the Alaskan model for indigenous people, which is based on diversity in how we understand health and wellbeing. What can we learn from the review? All systems face pressure due to population ageing. There is no single perfect model. Integration can help to deliver more holistic approaches to care, but strategies need to be put in place to ensure that social care does not end up in a subordinate position to that of primary healthcare. Increased for-profit provision can enhance inequalities, but that can be somewhat mitigated by higher-level national legislation and ensuring that the level of care services remains high enough that demands for extra services are low. We also learn, particularly from many of the case studies in Canada, that delivering savings should not be adopted as an immediate objective of integration. Stricter demands for eligibility risk increasing reliance on informal care and widening inequalities in health and quality of life, not only for the care recipients but for the people who provide care. From the findings, we came up with 10 recommendations for decision makers, which are available at the end of the report that the committee has. I will read a couple of those out to you: “Care services should be provided on a consistent basis across all geographic areas” to avoid geographic inequalities in provision and outcomes. “A clear ‘one system, one budget’ approach” can “reduce complexity”, and “Eligibility for access to social care services should remain high to prevent rising inequalities, unmet needs and increased dependency on informal care providers.” A lesson from Northern Ireland is that “A standardised definition of what ‘personalisation’ of care means” would be helpful for the care user as well as for the people who are responsible for delivering care. “Mechanisms that address cultural differences between locally accountable social care services and centralised health services” can “help improve integration”, but “Financial savings should not be viewed an immediate objective of integration” and “Budgets intended to support integrated care should not be used to offset overspends in acute care.” When we think about the challenge of an ageing population, we must acknowledge that “Forward planning and significant investment are required to meet future care needs.” The ageing population poses a challenge to the sustainability of all the models that we examined. 09:30