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'Eurocare’ – Challenges and Options for Wales and EU Social Care Systems in the early 21st Century
Whilst the UK prepares to go to the polls to decide its European fate, some economic and social issues cut across national boundaries and pose challenges to many EU member states. Amongst these is the future of care. So in a special series of five articles I am going to look at social care within a Welsh/European perspective. This article considers challenges to long term care within the EU. The second article will consider some examples of overlooked need within ‘minority’ groups. The third article will consider the challenges posed by the huge influx of migrants to the EU. The fourth and final articles will profile some examples of EU best practice relevant to Wales.
In response to increasing pressures the care systems of many member states have undergone fundamental change during the past decade concerning financing, service-planning, provision, and quality management. England with its new Care Act (2014) and Wales with its Well-being Act (2014) are a case-study in how member states are trying to meet the challenge of providing 21st century social care.
The biggest single area of care expenditure across the EU is provision for older adults (pensions, day and long term care). Europe’s population is ageing. Although an ageing demographic does not necessarily increase demand, increasing life-expectancy is usually accompanied by higher levels of dependence and multiple morbidity. Demand will therefore increase over the next two decades leaving many systems insufficiently resourced to meet current and especially future levels of demand. For example the number of very old people aged over 80 will increase by over 50% in most member states within that time-scale, and is likely to have tripled by 2050.
Meanwhile economies continue to have to display austerity for the foreseeable future, whilst many member states face a future with a shrinking workforce to pay into state funds due to falling birth-rates. More specifically in the EU care sector, there are already problems recruiting sufficient staff, educating them to the required level and retaining them. High turnover has a negative consequence on the quality of care. The forecast is that recruitment and retention problems will be further exacerbated in coming years.
A further complication for EU policy makers is the lack of consistency in state systems. Considerable diversity exists within member states based upon historical levels of publicly funded long -term care services. For example in some member states such as Spain, Italy and Ireland care of the frail elderly has historically been seen as a family duty and only recently become a focus of public policy.
With Europe’s ageing demographic beginning to place a significantly greater demand on services, there is trouble ahead. This leaves member states having to address the policy challenge of providing more with less. The EU does not impose micro-regulation concerning the design of health and social care systems, resulting in diversity of organisation, financing and provision of long term care across member states. Similarly member states will be free to come up with their own strategies to address the policy challenge. Amongst the options are;
- Retrenchment and rationing within existing systems - essentially raising thresholds of entitlements and thereby rationing service provision. A supplement to this option is the expectation that families will pick up the care deficit, a more realistic option for states where family units remain extended.
- On the credit side of the balance sheet, there is evidence to suggest that older people are staying healthy longer and a delay in becoming dependent offers states an opportunity to manage resources more effectively. A realistic public-health policy-goal therefore is the prevention of ill-health in old age, delaying the onset of disability or dependence and offering opportunity for cost-containment.
An alternative to retrenchment and rationing is redesign and reform and modernisation of existing systems. This is the direction that the English and Welsh governments have opted for in their respective Acts:
- Greater involvement of the private, and not for profit sectors, offers some possibility of greater value for money and a more diverse market. Many EU states have already explored, to a greater or lesser extent, the contribution which the private sector can make as an alternative to the state having a monopoly on provision which was the case say 30 years ago.
- Measures to increase the scope of services can be seen in extending the rights of informal carers who are belatedly being recognised as a mainstay of the burden of care and support. In cost management terms, supporting carers whilst an additional cost will be seen as a sound long term investment given their overall contribution.
- Providing service users with the option of direct payments will ensure relevance and ‘fit’ of service to need and requirement. This measure is dependent upon more ‘players’ entering the market to offer diversity and choice.
- There is a trend towards rehabilitative and enabling care models and care coordination to maximise efficacy of inputs and ensuring an adequate continuum of care.
- Stricter accreditation through inspection and improved training of staff are other routes for quality improvement.
Demography and especially the numbers of people living into very old age at a time when the economies of EU states are struggling to balance the books, pose significant challenges to care systems across Europe. Each member state will have to find a way of addressing increasing demand within a tight fiscal environment. This article proposes that there are two basic options for policy-makers, either rationing within existing systems, or developing new patterns of care within reformed ‘evidence-led’ systems. The latter is the choice that the English and Welsh governments are opting for, but their plans are contingent upon wholesale reform and adoption of new practices across the sector. Lessons of public reform tell us that reform especially where culture and established habits are concerned is not just a matter of cash, but also hearts and minds. Reform on the scale required by the Care Act and the Well-being Act is a massive public-sector project which will need to be afforded considerable political will.
These then are the issues facing EU states in providing 21st century social care. There is the fundamental funding challenge of doing more with less due to the increase in demand. Further challenges exist to reforming services, improving and regulating quality and ensuring that planning and provision is based upon research, population-based evidence and best-possible practice.
Nic Bowler – QCS Expert Welsh Care Contributor