Abstract
The growing demand for long-term care (LTC) due to demographic pressures related to a fast-ageing baby-Boomer generation has increased focus on funding schemes. The research aimed to explore the pros and cons of LTC financing options, programs, or plans based on the views of family caregivers. The specific objectives were to describe LTC services used by the elderly in the UK, determine their advantages, and assess their disadvantages. The research design used was a qualitative, cross-sectional approach that involved interviewing a purposive sample 40 family caregivers of an elderly loved one drawn from three care homes in Edinburg. Participants indicated that the three most used LTC services by the old adults were home health aides (52.5%), physiotherapy (27.5%), and care home support (15%). The LTC funding methods included public, tax-based systems (45%), social insurance (22%), private insurance (20.5%), and out-of-pocket payments (12.5%). The main advantages of LTC financing, which varied between options, included equity, reliability and predictability, flexibility, sustainability, and choice. Their disadvantages were extended waiting periods (private plans), limited financial base and rigid benefits formula (social insurance), opacity in resource allocation and intergenerational burden (public, tax-based systems), and inefficiency (out-of-pocket payments).
Introduction
Background to the Research
Over the past few years, the elderly demographic in industrialised nations has grown significantly, resulting in a constrictive population pyramid. The high number of people in the senior cohort (>65 years) is attributable to accessible, quality healthcare and lower fertility levels (Young & Tinker, 2017). Another reason is demographic (baby-Boomer) ageing trends, which describes the post-WWII spike in fertility rate in developed countries. Currently, in the UK, just like in other European nations, the demography reflects a fast ageing population society. The nation has about 8.3 million people aged 48-57 years, raising concerns over later life health needs (Young & Tinker, 2017). Those in the 65+ age group constitute 16.4% of the population (Young & Tinker, 2017). Further, loneliness in old age in this cohort is likely to be high because of instances of single households and childlessness.
A fundamental implication of the ageing population for public health is increased demand for long-term care (LTC). Projections indicate that expenditures on LTC in Europe will increase twofold over the next few years (European Commission, 2012). Further, it is estimated that “70 percent of seniors aged 65 years or older” require LTC support to “meet health or personal care needs” (U.S. Department of Health and Human Services [DHHS], 2015, para. 6). The drivers of this demand include higher life expectancy, increased disability and morbidity rates, and changing household composition, among others (Wittenberg, 2014). LTC assistance encompasses diverse, supportive services meant to enable seniors to lead healthy and meaningful lives. It includes activities of daily living or ADLs aimed at assisting a person to age at home or a supportive retirement centre. In most cases, relatives or children provide LTC services freely. However, given the social realities in the UK – spikes in divorce rates and childlessness – unpaid LTC assistance is diminishing, raising the demand for formal plans, e.g., senior centres. This scenario calls for comprehensive LTC financing programs to reduce the burden on caregivers and achieve better elderly health outcomes.
Statement of the Problem
While multiple models for institutional and home-based LTC exist, it is essential to determine their pros and cons, cost-effectiveness, and long-term sustainability. The financing of LTC is an issue of economics. The rising per capita costs of these services constitute a significant problem emerging from the social risk of ageing. It is projected that the global prevalence of disability is likely to rise, increasing spending on LTC in the years to come (Stone, 2000). Furthermore, limited low-cost coverage options leave a large number of the elderly with a heavy financial burden. LTC costs will continue increasing because individual plans and government programs are inadequate. For instance, in the US, Medicare and Medicaid cater for 63 percent of long-term care financing at 40 and 23 percent, respectively (Reaves & Musumeci, 2015). However, LTC insurance accounts for only 9 percent of the costs, which leaves a significant population uncovered. Self-insurance may not be an option, as it requires an individual to save throughout his/her work years to insure himself or herself.
The only viable alternative left for most families is to care for their elderly loved ones at home or community settings. However, home-based care is impracticable in cases where the family caregivers all work or do not live with their senior relatives. Furthermore, the decrease in higher divorce rates and childlessness constrains the availability of unpaid carers at home. Forcing working family members to leave employment and provide LTC care may affect their earning capacity (Manton, Lamb & Gu, 2007). As a result, the number of informal care providers is low. Manton, Lamb, and Gu (2007) report that the elderly care ratio will drop from seven caregivers per person (>80 years) to as low as four carers per person in 2030. These challenges call for adequate and sustainable public financing arrangements to expand social protection systems. The availability of affordable but sustainable programmes can help address increasing elderly long-term care needs in the developed world.
Rationale for Doing the Study
Affordable, universal coverage enhances the equity and accessibility of LTC to senior citizens. The primary methods of financing LTC include out-of-pocket payments, private insurance, tax-based public systems, and social insurance (Costa-Font & Courbage, 2011). These financing options have different advantages and disadvantages. A study examining the pros and cons of these measures is necessary to establish the best option for addressing supply and demand challenges and ensuring optimal LTC care. For example, in France, private providers grapple with high costs because users do not pay for all LTC services and a comprehensive coverage encourages family caregivers to opt for the expensive formal care or nursing homes (Chevreul & Brigham, 2013). This moral hazard results in an inefficient LTC sector, whereby the provider costs even out the profits. Consequently, private insurance often does not cover all LTC needs.
The direct beneficiaries of this study include the government/policy makers, private LTC providers, family caregivers, and elderly persons. Public spending on LTC is a controversial issue in the developed world due to the rising elderly population and potential impacts on national budgets. Public expenditure measures can help manage the moral hazard related to LTC coverage. Demand-side strategies can incentivise insurers and promote private insurance uptake (Wolff & Kasper, 2006). Therefore, an appraisal of LTC financing options would give the best program in terms of outcomes and cost-effectiveness. The assessment criteria may include elements of “fairness, cost efficiency and effectiveness, long-term sustainability and acceptability, and choice”, among others (Wanless et al., 2006, p. 11). Therefore, the findings of this research will contribute to improved understanding of the efficiency of financing measures – whether demand-side or supply-side. It will also establish the drawbacks (disadvantages) of these interventions in relation to LTC access or equity.
The findings of this research will highlight the importance of demand-side financing strategies in improving LTC outcomes. The study will show the causal relationships between the current LTC financing strategies and their consequences to inform policy actions. Knowledge of these correlations will be useful in designing efficient demand-side programs that can be implemented to curb high costs and stimulate private LTC insurance uptake. Further, understanding the benefits of financing long-term formal care over informal, unpaid care by family caregivers could provide a business case for governments to intervene.
Overall Aim and Research Objectives
The primary aim of this study is to gain insights into the advantages and disadvantages of financing LTC by appraising current options, programs, and methods used to meet LTC needs in the UK. The specific research objectives guiding this study are:
- To describe the types of home-based and institutional LTC services used by elderly recipients in the UK and related funding methods
- To determine the advantages of LTC financing for existing public and private insurance options
- To assess the disadvantages of financing approaches used to meet LTC needs of the elderly
Overall Research Approach
This study evaluates LTC financing options for the elderly population using appraisal criteria of fairness, choice, long-term sustainability, cost-efficiency, and effectiveness. A qualitative approach that includes a cross-sectional design was used to collect data through telephone interviews. Qualitative data analysis was done using thematic analysis of the responses to identify general themes.
Sampling Approach
The sample included children, relatives, and other caregivers of home-based and institutional LTC services to elderly persons. Elderly care homes in Scotland were contacted and requested to appoint a respondent – family member – to participate in this study. Thus, a purposive sampling approach was used. To analyse the pros and cons of LTC financing data collected from each respondent included the reason for choosing a particular option, capacity to pay for LCT services, and his/her rating of the program using the criteria of equity, cost efficiency, choice, and sustainability. Demographic information was also collected using a web-based questionnaire.
Potential Limitations of the Study
Potential participant bias related to the purposive sampling strategy may occur. The respondents from Scottish senior centres are aware of financing options for LTC services. They may favour a particular program available in a given home over another one implemented in a different institution. The English-language interviews may also limit the diversity of the respondents. However, a sample that exhibits cultural, economic, and linguistic diversity could help overcome these limitations.
Dissertation Structure
The rest of this dissertation is divided into four chapters: literature review, research methods, data description and analysis, and conclusions and recommendations. Each of these sections covers different aspects of the research. Chapter 2, i.e., literature review, gives a background discussion of history, concepts, models, and theories on LTC financing and explains how the current research fits in with scholarly findings. Chapter 3 is the research methods section. It includes the research questions of the study, data collection procedure and method (interviewing), key variables and measures, sample size, sampling approach, validity and reliability assessment, and data analysis. Chapter 4 covers data description and analysis. The results and findings of this research are presented in this section using charts, graphs, and tables, among others. Finally, chapter 5 gives the study’s principal conclusions based on the research objectives, practical implications, and recommendations for future scholarly work in this area.
Literature Review
Introduction
This chapter gives a review of fundamental concepts, theories, models, and frameworks related to the financing of long-term care (LTC) for the elderly. First, a description of the array of LTC services and settings is provided. Next, an in-depth review of the current long-term care financing models and frameworks is given. The characteristics of funding approaches are described in the subsequent section. Finally, a discussion of how the study fits in with the body of literature is given in the summary section followed by research questions.
Long-term Care Services
LTC refers to “medical, social, or personal care” given to elderly persons or individuals with functional independence over an extended period to promote independent living (OECD, 2017, p. 1). Most LTC providers are informal caregivers who often include family members, relatives, or friends. Typically, LTC encompasses a variety of supportive services meant to help a person live as independently as possible (Stone, 2006). Ageing, as a natural process, is accompanied by functional deterioration that limits an individual’s ability to care for himself or herself (OECD, 2017). However, not all elderly require the same kind of services, which explains the multiplicity of LTC settings – hospices, care homes, and assisted living facilities, among others. As they age, the elderly require different levels of support, ranging from help with activities of daily living, e.g., bathing, dining, and toileting (Stone, 2006). They may also need assistance with tasks like cooking, medication management, and financial administration. Therefore, LTC services – whether formal or informal – are meant to support the elderly to lead healthy lives at home or in senior centres.
LTC also includes social and medical care for persons with disabilities (Stone, 2006). Historically, LTC involved basic forms of assistance, such as providing walkers to those unable to walk. However, with time, the range and variety of LCT services have grown, allowing smooth transitional care into community facilities (Stone, 2006). In the UK, the central government develops policy and funds the social services budget, while local authorities determine community LTC needs (Wittenberg, 2014). The government also manages social security benefits for the disabled. In this view, the primary funding mechanisms for LTC include public and private insurance plans that involve different levels of coverage to the elderly.
Disabled persons of all ages require LTC services (Stone, 2006). In this category are those with chronic illness, mental disorders, or physical challenges. Another group that consumes LTC services is the elderly population, i.e., people aged >65 years. The number of adults requiring LTC is projected to increase because the proportion of this cohort in the general population is growing (Manton et al., 2007). As the demand for LTC rises, the consumers will face a multiplicity of options with different benefits and limitations. As such, the most desirable financing solution would be one that is cost-effective and comprehensive enough to cater for future increases in the elderly population.
LTC Settings
Elderly and disabled persons receive long-term support in a variety of environments. In most cases, the primary caregivers in home settings are children, relatives, or friends (Stone, 2006). However, as older adults become frail, they require more specialised care, which the untrained family members may not offer. As a result, they seek help from nursing homes or assisted living centres, which, in addition to home-based carers, are the leading LTC providers for the elderly in most countries. Decisions to move to an LTC facility are dependent on individual preferences, level of independence, cost, additional support from relatives, and the reimbursement model used (Stone, 2006). The three main settings for institutional LTC are residential care homes, assisted living institutions, and hospices. These systems differ in the type and array of services offered and the independence level of those admitted.
Nursing homes provide LTC care to the elderly with physical or cognitive impairments (Stone, 2006). They differ from residential care homes, which target active older adults. According to the Office for National Statistics [ONS] (2014) census, in 2011, about 291,000 older persons (>65 years) lived in English and Welsh residential care homes, representing a 0.3% growth from the 2001 figure. The elderly share among the three UK countries is different. They were distributed as follows: England had 376,250 pensioners in its 10,330 care homes, Northern Ireland had 9,455 elderly residents in its 464 senior centres, and Scotland had 27,700 places in its 1,160 facilities (ONS, 2014). Indeed, residential care homes are the main LTC settings for the ageing UK population. In 2011, persons aged ≥85 years comprised 59.2% of the elderly living in these facilities (ONS, 2014). In contrast, 56.5% of pensioners in this age bracket sought residential care in 2001. Thus, it can be concluded that care home placement for the elderly rises with longevity.
Older residents have diverse and complex medical and social needs. Most of them require assistance to walk, bathe, and dress as routine ADLs (Voisine et al., 2009). Additionally, in care homes, they have unrestricted access to medical care to manage health complications. Most residents are those without a family or have relatives who are unable to provide informal LTC services (Voisine et al., 2009). The most preferred setting for LTC is one’s residence, which means that care homes are the last resort. The principal funders of care home stays are informal carers and the National Health Service (NHS), which owns about 1% of these facilities (British Geriatrics Society, 2011). Another financing option is out-of-pocket payments for residential care.
Assisted living facilities (ALFs) offer a broader array of services than nursing homes. They provide home management, medical, and support services to the elderly (Voisine et al., 2009). ALFs seek to give a homely environment complete with private apartment units to residents (Stone, 2006). They first sprang up in the US private sector in the 1980s to offer the elderly a choice in a market dominated by care homes (Stone, 2006). They provide custodial care but limited medical services. In most cases, the residents have to pay for the LTC services through private insurance or out-of-pocket payments because NHS coverage for AFLs is limited (Rodrigues & Schmidt, 2010). Older people with debilitating illnesses such as cancer can move to hospices. These facilities offer long-term care for terminally ill patients who cannot be cared for in AFLs or care homes (Rodrigues & Schmidt, 2010). Therefore, the choice of institutional care would depend on the physical or cognitive wellness of the elderly, costs, and personal preferences, among others.
Long-term Care Financing Models
On average, most elderly persons (>65 years) utilise long-term care for 3.5 years before death (Kemper, Komisar, & Alecxih, 2005). Additionally, LTC is costly; care homes charge about $82,000 annually, making LTC unaffordable to most families (Kemper et al., 2005). Several LTC financing alternatives exist, ranging from federal plans to private insurance options; however, none of these approaches can singly meet all LTC needs. While some cover for custodial care only, others limit those eligible for coverage based on health status or age (Tell, 2013). The LTC financing models and frameworks in different jurisdictions are discussed below.
Informal care
Unpaid care is the primary LTC option for most elderly persons. It involves family members, relatives, or friends, providing informal care or emotional support to their frail loved one (Tell, 2013). However, family care is declining in the UK for several reasons. According to Hoff (2015), informal carers are diminishing due to increasing female employment (two-thirds of British women are working), higher divorce rates, childlessness, lower fertility, and improved longevity. These factors imply that informal care accounts for a fraction of LTC services. However, the economic impact of providing care by about 5.8 million family members is considerable (ONS, 2014). Lifetime expenses for LTC for the elderly are estimated to be £30,000 (Curtis & Burns, 2017).
In the UK, the annual expenditure on LTC for dementia is estimated to be £26.3 billion, with £11.5bn attributed to family caregivers (Curtis & Burns, 2017). They shoulder this burden through forfeiting job opportunities and medical costs for the elderly. Additional charges may come from buying private health services and LTC premiums. Moreover, family members caring for their elderly loved one at home may suffer psychological distress, notably when support for debilitating conditions is lacking (Hoff, 2015). Thus, the socioeconomic impact to informal caregivers is significant. For this reason, informal care seems unsustainable to cope with the growing demand for LTC.
Private Insurance
Individuals with resources pay for LTC from their income or savings (Hoff, 2015). However, this approach seems inefficient, as LTC needs differ between persons. As such, very few of them can make enough savings to meet LTC costs. Consequently, risk pooling appears to be a cost-efficient model for redistributing resources based on LTC needs of the individual. Private long-term care insurance (LTCI) plans involve individual plans or employer benefits packages (Stone, 2000). In other models, a firm pays part or entire premiums for its staff.
Many LTCI options related to LTC care products exist in the market. They can be classified into three main categories: facility-only, home healthcare programs, and comprehensive plans (Beam, Morith, & O’Hare, 2006). These policies differ with the type of services covered. Facility-only insurance pays for institutional care provided in ALFs, hospices, and care homes, while home health care plans cover home-based LTC services (Beam et al., 2006). On the other hand, comprehensive policies cater for institutional and home-based care.
Despite the multiplicity of LTCI options, fewer seniors purchase these plans due to problems inherent in private LTCI. Issues of claims denial, changing dependency rates, user awareness, and affordability reduce uptake levels (Wittenberg & Malley, 2007). Interventions that address these problems include co-payments, limited coverage, and increased premiums (Witten & Malley, 2007). However, these strategies make LTCI policies unattractive and expensive to the majority. Age is another consideration providers use to determine premiums. Thus, the costly coverage plans for older adults make LTCI a cost-inefficient option for them.
International Public Insurance Systems
Funding arrangements across countries can be distinguished based on the extent to which LTC care is a state or private responsibility. Public models often involve a risk pooling mechanism, collective funding of LTC, or redistribution of care resources based on LTC needs (Forder & Fernandez, 2011). Of a particular significance is the foundation for coverage. While some public systems cater for the risk of all citizens in need of care, i.e., social insurance, others focus on the most vulnerable groups through a safety net (Forder & Fernandez, 2011). In some countries, contributions to the national insurance scheme are mandatory, while in others they are voluntary, i.e., tax-based. Other publicly funded models require co-payments at the point-of-need.
The rationale for a public insurance system is primarily to realise efficiency and equity goals (Forder & Fernandez, 2011). An efficient and equitable scheme is achieved through risk pooling and redistribution, respectively. It may be a safety net like in the US and UK, full social insurance, e.g., the German scheme, or a combination of the two, e.g., the Japanese model (Forder & Fernandez, 2011). In Japan, the public LTCI system is mandatory, and it covers all citizens aged ≥40 years (Forder & Fernandez, 2011). It is tax-based (half of the costs) and includes age-related premiums or co-payments. In contrast, Germany’s universal scheme involves payments (1.95% of earnings) co-shared by employers and staff (Forder & Fernandez, 2011). However, retirees and students pay lower rates. It is based on the social risk of ageing, which requires collective contributions to reduce the socioeconomic impacts of LTC.
France has the ‘Allocation Personnaliseed Autonomie’ (APA), which is a universal scheme financed through taxation (Chevreul & Brigham, 2013). Like the German and Japanese systems, the French model is universal; however, in France, the level of LTC care received depends on one’s needs and socioeconomic status. As such, the elderly receive APA support, which ranges from “90% to 10% of the assessed care costs” (Chevreul & Brigham, 2013, p. 13). Australia implements a means-tested scheme. In this model, high-income groups receive less public support than those of low financial means (Forder & Fernandez, 2011). Thus, wealthier individuals would pay for most of their LTC needs or utilise private plans. In the USA, the primary public financing mechanism for LTC is Medicaid (Stone, 2006). It involves joint funding efforts of the central and state governments, and it is designed to support vulnerable groups (Stone, 2006). It covers nursing home services and a range of medical care costs.
The international funding systems fall into two broad categories: tax-based scheme and social insurance. They differ in the hypothecation of contributions, i.e., the quantity of resources committed to LTC, eligibility criteria, and the incorporation of a means-tested model. In the UK, the debate on funding reforms revolves around introducing free personal care with non-means-test component, as it is the case in Scotland, or retaining the present means-tested model with some limitations (Wanless et al., 2006). The Scottish scheme entails a non-means-tested coverage for home-based care and fixed payments for care home services (Wanless et al., 2006). However, unpaid personal care provision has not translated into a move to institutional care in Scotland. Instead, it has led to an increase in costs due to demographic ageing and improved home ownership that tend to favour informal, home-based care (Wanless et al., 2006). The different funding schemes should be reviewed in the context of LTC objectives, demographic pressures, and cost-care tradeoffs.
Characteristics of a Long-term Care Financing System
The viability of LTC financing system is dependent on their attributes. This section reviews criteria for evaluating funding models to determine their advantages and disadvantages of available plans. The systems are appraised based on “fairness, economic efficiency, choice, affordability, and sustainability or acceptability” (Wanless et al., 2006, p. 11).
The equity of a scheme refers to the fairness in resource mobilisation and allocation. It entails equitable access to services based on needs to ensure improved outcomes for all (Wanless et al., 2006). Horizontal equity is an essential attribute of a good financing solution, as it provides adequate care for seniors with different needs. An important aspect of fairness is that LTC care should not be withheld because the individual cannot pay for those services (Szebehely & Trydegard, 2012). Therefore, public schemes must address inequalities in LTC access by different demographic groups.
In some cases, pro-poor systems may not live up to the principle of equity, as they involve less support to middle-income groups (Hancock, Wittenberg, Hu, Morciano, & Comas-Herrera, 2013). Another aspect of fairness relates to whether the elderly with family caregivers should receive less public support. Intergenerational equity is a big issue in risk pooling systems. Working-age adults are the main contributors to social insurance funds (Hancock et al., 2013). They do so in the hope that they will be supported in old age. However, economic prosperity varies between generations. Moreover, the high dependency ratio in the developed world poses a burden to the younger generation. In an equitable scheme, adults should contribute to a social fund that will care for their generation’s LTC needs.
Efficiency and effectiveness evaluate the economic impact of a public financing scheme. They measure service quality and output against costs. Effectiveness is the realisation of a program’s goals, while efficiency entails the attainment of optimal outcomes from the investment (Hancock et al., 2013). In the context of LTC, an efficient system delivers quality services that are consistent with resource costs. As such, resources should be allocated where they would provide maximum benefits. Public systems reduce under-insurance by covering the uninsured against cost risks (Hancock et al., 2013). However, they can lead to inefficiency when there are inherent information problems. They may not be aware of people’s needs, resulting in inefficient resource allocation. As a result, a moral hazard emerges where there is over-consumption of LTC services and a non-profitable sector (Chevreul & Brigham, 2013).
‘Choice’ is a core objective of community-based care. The funding model should not limit people’s preferences, cause stigma, or exclude others (Rothgang, 2010). However, most financing schemes discussed involve safety nets for the poor but not the wealthier, regardless of their LTC needs. Affordability is a critical criterion for appraising approaches to funding. A good scheme must include cost control mechanisms to protect low-income users from premium spikes. It must also be acceptable and economically sustainable. It should remain solvent and involve wider acceptability by the public. For such a system to be acceptable, it must be affordable and fair to increase people’s willingness to pay for coverage (Rothgang, 2010). A sustainable scheme must be adaptable to the changing economic realities of a country. The evaluation criteria discussed in this section is used to appraise approaches to LTC funding in the UK to determine their advantages and disadvantages.
How the Study Fits in with the Literature
The study aims to determine the advantages and disadvantages of current LTC funding systems in the UK. Approaches to the financing of LTC are increasingly becoming a debated issue due to the growing elderly share in the population. From the literature review, while LTC services can be offered in different settings, home-based care delivered by family or relatives is the most preferred option. Further, factors such as demographic changes, childlessness, and increasing divorce rates have increased the demand for institutional care. Older adults pay for LTC through private or public financing schemes. The most common ones include self-insurance (out-of-pocket payments), facility-only, home healthcare, and comprehensive plans. Public insurance systems differ between countries, ranging from full social insurance in Germany to safety nets in the UK and US – Medicaid and Medicare.
While the public financing systems for institutional care are known, their pros and cons in the context of LTC are less understood. Since the demand for LTC services is bound to increase, as the baby-Boomer generation nears retirement, it is crucial to identify optimal financing solutions that would offer maximum benefits to users. Various criteria exist for appraising these schemes exist in scholarly works. This study adds to this growing body of literature by evaluating the advantages and disadvantages of programs and plans for LTC financing in the UK against the goals of efficiency, fairness, and sustainability, among others.
Research Methods
This study aims to explore the advantages and disadvantages of long-term financing plans or programs in the UK. The research questions for this research focus on the attributes of current approaches to LTC funding and their advantages and disadvantages from the perspective of caregivers/payers and elderly users. A qualitative, cross-sectional design is used to investigate these phenomena. This chapter addresses the study’s research questions, sample size and sampling approach, data collection time and place, key variables and measures, and analysis methods.
Research Questions
The following research questions guide this study. Primary data on LTC financing will be used to answer these questions.
- What are the forms of home-based and institutional LTC services that are utilised by elderly recipients in the UK and how are they funded?
- What are the advantages of LTC financing to caregivers and users?
- What are the limitations of the approaches to funding LTC care from the perspective of consumers or their families?
Study Design and Method
This research involved a qualitative, cross-sectional design. According to Zheng (2015), a cross-sectional survey entails gathering data to derive inferences about the target population at a specific time. Since the current study seeks to determine the pros and cons of the current LTC financing approaches from the perspective of caregivers, a cross-sectional design was deemed appropriate.
Data Collection Procedure
Data were collected between 7th January 2018 to 7th February 2018 at different locations. Respondents were recruited from three care homes in Edinburgh – St. Margaret’s, Colinton, and Braid Hills. The researcher contacted and requested the administrators of these centres to nominate participants. They included caregivers or family members of elderly persons who were using LTC services and providers. The administrators availed the phone contacts of the participants.
The nominated participants were contacted to assess their eligibility before data collection. The inclusion criteria were that one had to be related to an old adult using LTC services for at least six months and a payer of home-based or institutional nursing care. Before interviewing the participants, focus groups were held with the caregivers and providers to fine-tune the interview questions. Through this approach, current LTC financing systems and their strengths and weaknesses were identified for inclusion in the actual interview.
They were required to read and sign a mailed participant information sheet describing the purpose of the research. Additionally, each participant had to sign a consent form indicating his/her understanding of the study aims and willingness to take part in it before the interviews. The document also expressly stated that participation was voluntary and one can withdraw at any time. Further, it indicated that their identities would not be revealed. After signing the consent form, each participant was interviewed in a session lasting about 30-45 minutes. The recorded responses were transcribed verbatim for data analysis. A questionnaire was also administered after the interviews to obtain demographic information of the participants.
Sample Size and Sampling Approach
The study used a non-probabilistic method to recruit participants (n=40). According to Bryman and Bell (2011), a non-probability approach to sampling is convenient, fast, and inexpensive. Using a purposive sampling technique enabled the researcher to draw the study sample from only the nominated family members during data collection. The sample frame was the accessible population of elderly persons (N=136) using LTC services in three care homes in Edinburg area. The facility administrators nominated 45 participants, 15 from each care home. However, five family members opted out of the study at the screening stage.
Instruments
The format of the interview questions was semi-structured. The aim was to elicit specific answers and probe them further for open-ended responses. The first set of questions focused on general financing methods that participants used to pay for LTC services for their elderly loved ones. The agencies, services, and insurance plans the family members used were also sought. The researcher also asked questions that are more specific about the types of LTC received from care homes, payment methods their elderly qualify for, and satisfaction with LTC care.
The second set of questions centred on the advantages and disadvantages of LTC financing choices they have used before. The participants were asked to name the key strengths and weaknesses of LTC financing – whether public or private insurance schemes. They were also asked economic questions related to equity, sustainability, efficiency and effectiveness, and affordability of the LTC funding option they are using. In addition to the interviews, participants also completed a web-based demographic questionnaire. It sought information about age, gender, income bracket, and level of education. The aim was to understand the participants’ background and ability to pay for LTC services provided by care homes.
Ethical Issues
Research ethics require the protection of participants’ rights, sensitivity to social or cultural issues, and respect for anonymity (Miller, 2015). In this study, the dignity of the respondents was protected in two ways. First, family member participation was voluntary. The participant information sheet notified the interviewees about the nature of the study, while informed consent stated their rights in this research and freedom to withdraw at any point in the study. Second, participant confidentiality was guaranteed by not revealing their identities or addresses even after completing the research. Additionally, demographic questions focused on age, gender, and level of education. Sensitivity to socio-cultural differences was achieved by asking questions respectfully and accurately. The interviews were conducted in English, which was the first language of the participants.
Study Validity, Reliability, and Generalisability
Qualitative studies raise questions of reliability and validity of the results, which can be addressed using different techniques (Creswell, 2007). Various strategies were used to ensure that the study is valid, reliable, and generalisable. The first one was peer debriefing, which allowed other students to interrogate the researcher on the choice of research methods and interpretations (Creswell, 2007). The investigator noted and addressed the concerns and issues raised during these sessions. The second technique involved piloting the interview questions in focus groups involving students caring for seniors in their homes. The results indicated that family members preferred a simple format. As a result, the interview protocol was refined to reflect these preferences and guarantee content validity.
Researcher bias during sampling, data collection, and interpretation constitutes a threat to external validity that should be addressed from the start (Creswell, 2007). The investigator used telephone interviews to limit contact with the interviewees and help minimise the influence of personal preconceptions. Further, the administrators nominated eligible participants, which eliminated sampling bias. The views of an experienced qualitative researcher on a preliminary coding framework were sought to enhance the reliability of data analysis. One anticipated problem at the data collection stage included scheduling the telephone interviews in a way that does not inconvenience the participants.
Data Analysis
The exploration of the qualitative data involved thematic analysis, which entails identifying dominant themes in the dataset to explain a particular phenomenon (Creswell, 2007). Participant comments as written down during the telephone interview were examined for accuracy and completeness. Coding of narrative data was done by reading interview transcriptions (Gibbs, 2007). Abstract subcategories were generated from the labels or codes. The sub-themes were collapsed to form general themes to help explain the advantages and disadvantages of LTC financing from the perspective of users or their families.
Data Description
This chapter describes the response rate and demographic characteristics of the participants. The information is summarised in percentages and descriptive statistics such as the mean. The presentation involves tables, charts, and graphs.
Response Rate
The research used interviews of 40 participants sampled from three LTC facilities in Edinburg. The initial number of people targeted was 45. However, five family members declined to participate in the study when they were contacted. The study achieved a higher response rate (88.9%) through planning, follow-ups, and flexible interview schedules spread over four weeks. The researcher could pose an interview session and continue it later based on the availability of the interviewee. The telephone-interviewing format also contributed to a higher response rate, as the participants could be interviewed remotely.
Demographic Information
The demographic characteristics of the participants are summarised in Table 4.2.1 below.
Table 4.2.1 – A Summary of the Demographic Characteristics
From Table 4.2.1, of the 40 participants, 23 were female and 17 were male, representing 57.5% and 42.5% of the sample, respectively. Thus, a slightly higher number of caregivers are women despite the increasing female employment in the UK (ONS, 2014). It is expected that female carers would be more than male ones in the general population. The types of relationships with the older adults included children, grandchildren, and siblings. Twenty-five of the participants were kids of the old adult, ten were granddaughters, three were grandsons, and two were sisters of the LTC recipient, as indicated in Figure 4.1 below. Their ages ranged from 29 to 46 years with the mean age being 38. The family caregivers’ average number of years of education was 11.2. Twenty-nine of them were employed in distant locations, eight worked from home, and three were retired. The number of work hours for those commuting to their workstations was between 12 and 50 weekly.
Most participants had decent resources (n=23 or 57.5%), 27.5% of them had less than sufficient wealth, and 15% of the interviewees indicated that their assets were more than adequate. Of the 40 respondents, only 28 had an income. The categories of annual earnings were less than £25,000 (37.5%), £25,000-50,000 (52.5%), and over £50,000 (10%). Since a majority of respondents were wealthy, it is expected that they would use private insurance schemes to pay for LTC care for their elderly loved ones. Data on marital status showed that 77.5% of the participants were married, 12.5% were separated, and 10% were single.
The older adults utilising LTC services and being cared for by the participants were aged between 65 and 94 years (mean age = 71.2). Most of them were senior women (72.5%). Most of the participants had given care to the elderly persons for a period of six months to five years (mean = 4.8 years). Figure 4.2 below illustrates the methods that the seniors used to finance their LTC needs.
From Figure 4.2.2, of the 40 interviewees, 18 or 45% indicated that they use public insurance (non-means-tested) to pay for LTC for their elderly loved one. Another 20.5% used private coverage plans, 22% utilised social insurance, and 12.5% relied on out-of-pocket payments or personal savings
Discussion and Analysis
This chapter discusses the perspectives of 40 family caregivers of an elderly relative utilising LTC services available in three care homes in Edinburg. Data were collected through telephone interviews of eligible participants nominated by the administrators of these facilities. Their responses were analysed to give insights into the pros and cons of the current schemes used to fund LTC services. Three financing approaches were investigated, namely, out-of-pocket payments, private insurance, tax-based public systems. The discussion of the study’s results for each research question includes excerpts from the interviews.
Research Question
This section examines LTC services and funding methods commonly used by the elderly in Scotland based on the responses of the interviewees. The participants were all relatives of elderly persons utilising care home services to meet their LTC needs that ranged from ADLs to health complications like dementia. From the analysis of the interview responses, the LTC requirements of the seniors were diverse. The old adults requiring minimal LTC support were those with no complex medical needs that necessitate formal care and medical attention to improve elderly outcomes. Their length of stay in the care homes was minimal, as most of them preferred family assistance with ADLs, payment of care, and medication management. Therefore, home-based care was popular with elderly persons without chronic conditions.
On the other hand, old adults with complex needs required more LTC support from the care homes. The respondents indicated that they paid for services such as community health nursing, physiotherapy, grooming, and adult day care, among others, at these facilities. A summary of the LTC services received, as mentioned by the respondents, is given in Table 5.1 below.
Table 5.1.1 – Common LTC Services Used
From Table 5.1.1, the most utilised home-based care for the elderly was that offered by home health aides with 21 of the participants (52.5%) indicating that they use it. Coming in second was physiotherapy. Eleven of those interviewed (27.5%) revealed that their elderly relatives were receiving physical therapy at home. A further six (15%) stated that the old adults were using care home services, while two of the participants (5%) paid for adult day care and ALF support for their parents. The use of home health aides reflects the preference of the elderly to age in their homes (Voisine et al., 2009).
Participants were also asked about the funding sources for the LTC services. Thematic analysis revealed four major themes. First, institutional LTC from the care homes was paid for through tax-based public systems or NHS and private insurance plans. Similarly, hospice care and medical costs were financed through the two methods. Out-of-pocket payments funded home-based care involving community health nurses and aides. Additionally, expenses related to ADLs were paid from personal or family sources. Those using out-of-pocket payments constituted 12.5% of the sample. Local organisations for the elderly also funded some of institutional or home-based LTC services. Only two participants indicated that they helped support the LTC care. However, most of them paid for household supplies used by the older adult.
Typically, the recipients relied on more than one approach to fund their LTC needs. The different financing schemes mentioned could be grouped into three categories: – private, public, out-of-pocket payments. Table 5.2 shows the preferred approaches to LTC financing based on the responses of the family caregivers.
Table 5.1.2 – Methods Used to Fund LTC Services
Table 5.1.2 indicates that public schemes or the NHS pays for most of the LTC services, followed by private insurance plans. The least used source of funding was out-of-pocket payments. Thus, public and private insurance schemes dominate LTC funding in the UK. Tax-based systems and safety nets bring on board those who cannot afford private coverage plans. Additionally, it is clear from the results that no single funding method was adequate or comprehensive to cover all the LTC services the elderly persons were receiving.
Research Question
This section explores the themes gleaned from the participants’ views about the advantages of LTC financing for elderly consumers. It includes verbatim quotes to paint a picture of the respondents’ opinions and experiences. The major themes included equity, reliability and predictability, flexibility, sustainability, and choice attributes of the four funding methods: public, tax-based systems, social insurance, private plans, and out-of-pocket payments.
Equity
When asked about how fair one thinks LTC funding methods are to consumers, most participants considered social protection as the most equitable model compared to tax-based systems, private plans, or out-of-pocket payments. Of the 40 participants, 31 considered this financing method to be fair due to guaranteed entitlement to benefits. Notably, they stated that social LTC insurance has greater allocation transparency than the other three systems. The redistribution of resources based on a predefined formula as opposed to linking it to resource availability was mentioned as a vital strength of this approach. Additionally, it makes LTC a social right for all elderly. A remark from one participant illustrates this line of thought: “the harmonisation of benefits and evaluation can enhance access and reduce regional inequalities”.
The participants also considered non-means-tested, tax-based systems to be fair. Of the 40 interviewees, 19 felt that although universal healthcare ensures equity in access to LTC, it disadvantages high-income groups who pay more taxes. One participant noted, “Such a social program supports the vulnerable elderly who may not afford expensive private insurance plans”. However, another noted that since tax payable depends on earnings, it is unfair to provide similar benefits across all income groups. In this context, private insurance was considered fair because the payment of premiums entitles one to LTC coverage. Participants also noted that social justice might not be guaranteed through out-of-pocket payments. As one interviewee remarked, “With this system, only the wealthy can afford care services, limiting LTC access by the poor”.
Reliability and Predictability
LTC financing was considered reliable and predictable. In particular, the participants viewed social insurance as the most financially transparent system among the four models. The following statement from one of the participants exemplifies the public support this model enjoys: “my dad is guaranteed care whenever he needs it since it is funded through salary deductions. We also pay more to receive dementia care”. The social contributions create a funding stream that can be depended upon to cater for particular risks.
Public health insurance was also considered dependable to some extent. Some respondents indicated that mandatory and universal systems ensure that those who need essential LTC services access them. Since public health insurance is tax-based, i.e., paid for from federal or regional budget, they have a broader tax base. The participants felt that this form of financing is reliable and predictable. Further, this approach to funding is not limited by one’s income or deductions, as it is the case with social insurance. The following response to a question about the reliability and predictability of public LTC insurance illustrates this point: “the government will always allocate funds to healthcare; therefore, all citizens will receive basic care regardless of their employment status”.
The participants consider private insurance is predictable and reliable to a limited degree. Unpredictable risks related to care inflation result in premium fluctuations that affect LTC access. From their responses, older people are unaware of how the issues of adverse selection and uncertainties about future LTC needs influence the cost of the policies. They point out the unpredictability of the rates. This view is exemplified in the following response: “some people pay more than others for the same services, and sometimes premiums can shoot up within a short time”. Most people are not aware of the effect of factors, such as care inflation and age-adjusted contribution and risks, on contribution rates. In contrast, the out-of-pocket payment approach was considered reliable, especially when the older adult had savings that allow him or her to pay for LTC services.
Flexibility
Some LTC financing methods were considered advantageous because they involve flexible benefits schemes that are not tied to individual income. One participant whose elderly parent utilises public insurance demonstrated this point. He said, “With a universal cover, we are not worried about future costs. I do not know how else we would afford assisted living, medical care, and drugs without government support”. Another one indicated that public financing systems are not fixed; they evolve with the changing LTC needs and government policy priorities. Further, since they depend on taxes, they are likely to involve expanded safety nets for the poor.
Social insurance and private plans were also associated with enhanced adaptability and flexibility. Among the participants, a number of them indicated that these two financing approaches could be changed easily to suit LTC needs. This belief was based on the view that the social contribution rate and premiums are not fixed; they can be adjusted upwards or downscaled to reflect demand realities. One participant stated that moving to a new scheme or policy is possible in private insurance plan. Another one indicated that paying for old age LTC during working years guarantees one flexible social insurance benefits, including claims. Participants also felt that personal savings represent a flexible mode of paying for LTC services. This approach allows one to purchase any LTC care product as long as he/she can afford it.
Sustainability
Another recurring theme was the economic sustainability of LTC financing. Several interviewees felt that some funding approaches are more sustainable than others are. In particular, they felt that social insurance could be sustained for a more extended period because it depends on payroll taxes and not federal expenditures. They noted that this model allows additional contributions to be made to cover other risks, such as dementia. The increased willingness to contribute lends social sustainability to this financing approach. According to one participant, “if I know I would receive comprehensive LTC benefits, then why shouldn’t pay more for the service”. Therefore, the sustainability of social insurance lies in its broader acceptability.
Public insurance was also considered sustainable in the long-term as long as the government separates LTC funding from other federal healthcare expenditures. Respondents felt that the demographic pressures of ageing and the opposition for risk sharing could be minimised through a ring-fenced financing stream for LTC. On the other hand, private insurance and out-of-pocket payments have limited economic sustainability in the long-term. Issues of adverse selection and cost fluctuations have noted the factors affecting the economic performance of these two funding arrangements, making them unsustainable.
Choice
Providing a range of options to the elderly was considered a major advantage of any LTC financing plan. Funding models that offer multiple packages for formal LTC care in different institutions or formal-informal linkages were preferred to those with limited choices. They allocate resources to home-based care, including non-medical services, and allow users to choose LTC institutions. Most respondents indicated that public insurance restricts the choice of providers. However, they indicated that social insurance and private plans involve wider provider choices and reimbursable informal care alternatives.
Research Question
This section discusses the limitations of LTC financing as highlighted by the participants. From their responses to semi-structured questions, the disadvantages of LTC funding differed between approaches. The following discussion summarises the weaknesses and flaws of private insurance, social insurance, public LTC systems, and out-of-pocket payments based on the participants’ views.
Private Insurance
Most participants identified ‘extended waiting period’ as a key disadvantage of private LTC plans. They noted that the requirement that premiums be paid during working years to qualify for LTC benefits is a flawed premise. Some labelled the model as inequitable since it is difficult to assess risks or LTC needs. One participant said, “LTC needs vary between elders, and thus, care costs may not be uniform. Therefore, paying premiums only to receive limited coverage in old age is unfair”. Further, if it were not mandatory, a majority of younger people would not purchase it, though they might need LTC when they reach >65 years.
Social Insurance
Participants indicated that social insurance involves a rigid coverage scheme. They reckoned that this funding approach allocates benefits using a pre-determined formula that makes LTC plans highly standardised and inflexible. A participant caring for her elderly mother remarked, “There are no cash payments for informal care not covered in the package”. Another disadvantage gleaned from the responses is the limited financial base of social insurance systems. The participants stated that the dependence on payroll tax reduces their net earnings, which hurts their living standards in times of high living costs. They also associated these systems with a debt burden to future generations, especially in the wake of rising baby-Boomer ageing.
Public LTC Systems
Participants identified limited allocation transparency as the main limitation of this method. It was not clear to them how benefits are linked to GDP. However, some noted that the available budget determined how much expenditure went into LTC. Further, the lack of predefined eligibility criteria means that local authorities are the ones that decide which services or providers an elderly person can use. This aspect leads to limited choices and aggravates inequalities. Respondents also indicated that universal systems posed a burden to high-income groups and younger generations that do not use LTC.
Out-of-pocket Payments
Private savings were considered inexpedient due to the high LTC costs. Further, participants reasoned that out-of-pocket payments might be costly for some demographic groups that require more LTC support, e.g., women, dementia patients, etc.
Summary
Overall, the results of this study are consistent with scholarly findings in literature on the pros and cons of LTC funding. For instance, Wanless et al. (2006) identify equity as the hallmark of a good LTC financing solution. The approach should be fair in resource mobilisation and redistribution. In this study, a key advantage of social insurance and tax-based systems (universal cover) was the reduction inequalities through allocation efficiency and risk pooling. Other advantages of LTC financing modes defined in literature and confirmed in this research include choice and sustainability. Barr (2010) observes that an optimal LTC system is the one that gives users options, alternative packages, or a wider provider selection. Similarly, in this study, the strength of social insurance was found to lie in its provision of broader choices of institutions and reimbursable informal care. Sustainability in literature implies that a financing solution must be acceptable, adaptable, and economically viable (Fernandez & Forder, 2012). Similarly, in this study, funding methods with wider acceptability and public/political support, e.g., social insurance, were considered advantageous because they are socially sustainable.
Additional beneficial aspects of LTC funding systems uncovered through this study include the flexibility of the model to accommodate changing LTC needs and reliability and predictability. This research also adds to literature by identifying the disadvantages of these schemes in the context of long-term care provision. Extended pre-funding waiting periods, risk assessment difficulties, adverse selection, rigid benefits allocation formula, limited transparency, and intergenerational debt burden are some of the limitations of these funding approaches determined through this study.
Conclusions and Recommendations
The overall aim of this research was to evaluate the advantages and disadvantages of financing LTC in the UK. The specific objectives were to describe the types of home-based and institutional LTC care and funding methods used by old adults, determine the advantages of the financing systems, and assess the disadvantages of the schemes used to fund LTC needs for the elderly. Understanding the pros and cons of the approaches to long-term care is critical in the provision of adequate, equitable, and sustainable institutional and home-based care for pensioners. The UK is grabbling with demographic pressures related to a higher elderly share in the general population. Optimal LTC solutions can only be developed by understanding the weaknesses and strengths of current schemes from the perspective of users or their families.
This research used a qualitative, cross-sectional design to explore the views of a purposive sample of 40 family caregivers drawn from three care homes in Edinburg. Data were collected using the interviewing method and a demographic questionnaire. The analysis of the qualitative information involved descriptive statistics and thematic analysis to help identify emergent themes describing the advantages and disadvantages of current LTC funding options. Purposive sampling was deemed fast, inexpensive, and adequate for an exploratory study. The use of interviews allowed the researcher to explore the subjective views and positions of the participants and draw specific inferences.
A Summary of the Main Findings
The study sought to answer three research questions on the types of LTC services elderly recipients use in the UK and how they are funded, the advantages of LTC financing options, and the disadvantages of these approaches. The findings of this research indicate that the elderly utilise (in decreasing order) the services of home health aides (52.5%), physiotherapy (27.5%), care home support (15%), and adult care and assisted living assistance (5%). They used four significant approaches to finance LTC services: public or tax-based systems (45%), social insurance (22%), private plans (20.5%), and out-of-pocket payments (12.5%).
The advantages of LTC financing gleaned from the participants’ responses varied depending on the scheme. Overall, social insurance emerged as the most beneficial approach to users and the economy. It was associated with equity (allocation transparency), reliability and predictability, flexibility and adaptability, sustainability, and choice. The other three systems were also found to offer these advantages, though to a smaller degree. Each LTC financing method had some inherent flaws that limited its widespread acceptability or support among the family caregivers interviewed. From their responses, the disadvantages of private insurance include risk assessment issues, long pre-funding periods before claiming benefits, and adverse selection impacts.
In contrast, the flaws of social insurance were the rigidity of the benefits scheme, intergenerational debt burden, and leaner financial bases. Public LTC systems, including non-means-tested schemes (universal) schemes, were associated with the disadvantages of limited resource allocation transparency, the absence of clear eligibility criteria, and intergenerational care burden, while out-of-pocket payments were considered financially inexpedient and costly to populations with higher LTC needs.
Practical Implications of the Findings
Long-term care funding has been a challenge to policymakers in the UK due to the potential flaws inherent in each model. The findings of this research have implications for designing an optimal LTC financing approach that would address the current problems of inequity, sustainability, economic efficiency, and demographic ageing pressures, among others. In particular, the demand for LTC is likely to increase as the baby-Boomer generation nears retirement (Young & Tinker, 2017). As such, policymakers should prioritise funding schemes that address the most required services. From the findings of this study, these benefits may include home health aides, physiotherapy, care home support, and adult care and assisted living. The caregivers interviewed indicated that these services are in demand in Edinburg. The most preferred funding approach should be one that provides these benefits.
The finding that old adults mainly utilise tax-based systems, social insurance, and private plans to pay for their LTC needs implies that risk pooling helps lower costs. Incentives to private providers and subsidies to LTC institutions could lead to lower premiums or social contributions and more old adults taking insurance cover. Further, from the study, out-of-pocket payments constitute the least preferred method; researchers consider this approach costly because it is inefficient and lacks a risk pooling mechanism (Glendinning, Davies, Pickard, & Comas-Herrera, 2004). Therefore, increased federal efforts through subsidies and tax concessions are needed to expand social and private insurance schemes.
In this study, most of the current funding schemes were associated with the advantages of equity, reliability and predictability, flexibility and adaptability, and choice. In particular, from the responses, social insurance exemplified all these attributes. Efforts by policymakers to make social contributions more predictable would make this system more acceptable to the elderly population. Further, the disadvantages of private LTC financing, such as limited resource base and adverse selection can be minimised through government support public-private partnerships to promote uptake. Therefore, policies geared towards greater cooperation, allocation transparency, and inclusivity are required to bolster Scotland’s non-means-tested model.
Limitations of the Study
The smaller sample size of 40, though adequate for an exploratory study, may have reduced the reliability of the results due to low statistical power. Further, potential bias in sampling and data collection could have limited the external validity of the research’s findings. Non-random selection (purposive sampling) was used to draw a homogeneous sample (culture and language). As such, the results of this study may not be generalised to carers from other cultural groups within the UK or countries. However, participant bias was reduced through telephone interviews, which minimised researcher contact with the interviewee.
Suggestions for Future Research
This study used a homogeneous sample of family caregivers, which may have limited the generalisability of the results. Future research in this area should involve a random, heterogeneous sample to produce data that can be generalised to other settings. The interviewing method used in this study was not appropriate for measuring the pros and cons of LTC financing. Future researchers should use quantitative methods to determine the extent to which LTC financing has been beneficial to users. Further, the sample should include formal caregivers in care homes who are familiar with the LTC funding systems.
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