James (not his real name), is 69 and receives four social care visits a day. After ending up in hospital in need of oxygen, he falls into a familiar trap for patients with complex needs. Although discharge coordinators in the large teaching hospital in central England expect him to be medically fit within a couple of days, the company in charge of his care package declines to suspend it, closing his case instead.
Now the hospital must start from scratch, consulting with social services to establish a new care package. It’s a process that frequently takes more than a week. In the meantime, James is frustrated that he cannot leave the hospital, and the respiratory ward where he has been placed is left with another unnecessarily occupied bed.
Iris has been living independently before she falls and breaks her hip. She’s taken to hospital where she undergoes surgery and, after a few day’s recovery, she’s ready to be discharged. However, the operation has made her much less mobile, meaning she cannot go back to independent living straight away. The operation has made her frail and a lingering heart condition starts playing up again. If she’s too well for the hospital, but too immobile to live at home, where can she go?
Patients like Iris and James highlight the problems facing even the wealthiest healthcare systems, where there are persistent gaps between expenditure on healthcare and the funding and provision of social care. This trend, which is reaching a critical level in mature economies with aging populations, is being exacerbated by tight budgets and increasing demand on healthcare systems.
While many developed countries offer universal healthcare financed by taxes or social insurance, far fewer provide comprehensive social care. According to a 2014 report by the UK-based think tank The King’s Fund, which compared nine Organization of Economic Cooperation and Development (OECD) member countries, such services are generally provided by the private sector, increasing cost-related barriers to access.
Sweden and the Netherlands are among the few countries with universal government-funded social care insurance programs. Both, unsurprisingly, had the highest rates of public spending on social care of those reporting data to the OECD. Japan and France introduced mandatory long-term care insurance (LTCI) schemes in 2000 and 2002 respectively. The UK and Germany spend the highest share of GDP on long-term care, primarily through out-of-pocket spending, although Germany introduced a mandatory LTCI scheme in 1995. By contrast, Switzerland has the highest level of private spending on social care as a percentage of GDP.
However, these countries all face increasing financial pressures on their systems and many have been forced to tighten benefits or raise contributions to maintain their viability.
According to a report from The Health Foundation, the funding gap for adult social care in the UK is at least £2bn ($2.6bn USD) for 2017/2018. In many European countries, local governments have been managing more stringent budgets in part by reducing fees paid to social care providers, putting pressure on the companies providing carers. This, the report says, presents “risks to new models of care…because the precarious state of the social care provider market is threatening plans to support people in non-hospital, lower-cost environments.”
The goal of integrated care
Health systems in most developed countries are structured around an increasingly outdated model of healthcare delivery. This can leave healthcare professionals working according to models that focus on a single illness at a time or give greater priority to the management of disease and symptoms, rather than the quality of life, independence, and support.
Greater integration of health and social care services is particularly important for those with complex care needs, and a crucial stress point comes during preparations for hospital discharge. As the cases of James and Iris suggest, a range of health care services and social services – such as rehabilitation and adaptations to the home environment – are often necessary, and failure to put them in place makes it difficult to free up beds in a hospital, as well as making readmission more likely.
New models are likely to involve healthcare delivery that crosses the boundaries of traditional care structures and puts an emphasis on preventive health and rehabilitation. This will involve delivering care in or close to the homes of patients and reorganizing hospital services, as well as making better use of both electronic health records (EHRs) and telemedicine. At the same time, policymakers need to address the legacy of separate funding streams for healthcare and social care, as well as finding innovative ways of integrating these budgets.
Steps in the right direction
Buurtzorg (Neighbourhood Care) Nederland, a Dutch non-profit, is trying to fill part of the social care gap by reintroducing district or community nursing in the Netherlands. Buurtzorg was launched in response to the existing high-cost, fragmented commercial home care industry, which was criticized for focusing on protocols and administration above care.
Buurtzorg employs and coaches teams of professional nurses and assistants, but eliminates management layers, with one unit covering 40-60 patients. Sweden took up the Buurtzorg team model in 2011 and other developed countries, including Germany, Austria, Japan and South Korea, are looking to implement a similar system.
Elsewhere, the Grand-Aides project, which operates in the US, Bangladesh, and Indonesia, provides primary, palliative and preventative care through home visits, with the goal of reducing the pressure on hospitals. Another program, Le Nest, serves a target population of elderly and older adults in China by providing disease management education, psychological health intervention and physical therapy through a network of community health stations.
Towards a unified future
Conserving scarce resources – while maintaining as high a quality of life as possible for elderly patients and those with complex needs – will demand increasingly nimble footwork. This, in turn, will require greater use of multidisciplinary medical teams able to work across the hospital and community care.
Yet the introduction of new models must be accompanied by a more unified approach to financing health and social care. This approach must recognize that the complex needs of elderly populations and people with multiple health problems make it difficult to draw a clear line between where healthcare requirements end and social care needs begin.