Exploring the impact of austerity-driven policy reforms on the quality of the long-term care provision for older people in Belgium and the Netherlands

How regulatory frameworks drive differences in home-care agencies: Results from a national multicenter cross-sectional study in Switzerland

INTRODUCTION

The sustainability and rising costs of the health-care system are of concern. Although health-care reforms impact various areas of care, there is only limited evidence on how regulations affect home-care agencies and health-care delivery.

OBJECTIVES

The primary aim was to explore different financial and regulatory mechanisms and how they drive differences in the organizational structures, processes, and work environment of home-care agencies.

DESIGN AND METHODS

We used data from a national multicenter cross-sectional study of Swiss home care that included a random sample of 88 home-care agencies with a total of 3223 employees. Data was collected in 2021 through agency and personnel questionnaires including geographic characteristics, financial and regulatory mechanisms, service provision, financing, work environment, resources and time allocation, and personnel recruitment. We first conducted a cluster analysis to build agency groups with similar financial and regulatory mechanisms. We then performed Fisher's exact, ANOVA, and Kruskal-Wallis tests to determine group differences in organizational structures, processes, and work environments. Finally, we performed a lasso regression to determine which variables were predictive for the groups.

RESULTS

Four agency groups were built, differing in view of financial and regulatory mechanisms and we found differences in the range and amount of services provided, with regard to employment conditions and cost structures.

DISCUSSION

The most prominent differences were found between agency groups with versus agency groups without a service obligation. Financial incentives must be well aligned with the goal of achieving and maintaining financially sustainable, accessible, and high-quality home care.

How does long-term care impact the psychological wellbeing of older adults in different care policy contexts in the Netherlands?: A comparison of 1998, 2008 and 2018: A comparison of 1998, 2008 and 2018

Receipt of long-term care (LTC) is generally associated with worse psychological wellbeing for community-dwelling older adults. In addition to objective features of care use (e.g. formal vs. informal care), the subjective evaluation of care provision in terms of perceived sufficiency might be particularly predictive of one's wellbeing but is seldomly considered in the literature. Substantial changes in the availability of long-term care in past decades raise the question to what extent these effects, if present, are consistent over historic time. The present study, therefore, aims at better understanding the associations between types of LTC use and perceived care sufficiency on psychological wellbeing in a changing LTC context in the Netherlands. Data from the Longitudinal Aging Study Amsterdam (LASA) were used from three points in time: 1998 (N = 582), 2008 (N = 459) and 2018 (N = 415). At each wave, participants were between 75 and 85 years of age and living independently. The results show that after adjusting for age, gender, education and health, using formal LTC had a negative effect on depressive symptoms only in 2018, but that this effect was not significantly worse compared to previous cohorts. Perceived care sufficiency was consistently negatively associated with depressive symptoms in all three points in time. This suggests that despite a less generous Dutch LTC system, psychological wellbeing among LTC users remains stable. Perceiving care provision as sufficient, however, can help older adults maintain psychological wellbeing and should be considered by researchers and policymakers that aim to improve care recipients' wellbeing.

Trends in long-term care use among Dutch older men and women between 1995 and 2016: is the gender gap changing?

This study examines whether the gender gap in long-term care use in the Netherlands has changed between 1995 and 2016. Previous research has shown that women use more formal care services than men, while men use more informal care. In the past decades, there have been changes in the individual determinants of care use, such as health and social resources, and care provision. This raises the question of whether gender differences in care use have also changed over time. The Longitudinal Aging Study Amsterdam (LASA) involved respondents aged 70–88 in seven waves: 1995/96, 1998/99, 2002/03, 2005/06, 2008/09, 2011/12 and 2015/16 (N = 6,527 observations). Generalised estimating equations (GEE) were used to analyse changes in the impact of gender on the use of informal and formal home care, residential care and private home care, and the non-use of care. Men used more informal care provided by a partner than women, but women used other sources of care more than men. Individual social resources explained the gender gap in informal and formal home care use, and health and social resources explained the gap in residential care. In the non-use of care and, to some extent, in residential care use, the gender gap widened over the years to the disadvantage of men and was not explained by health and social resources. The persistent and even increasing gender gap in the non-use of care over time warrants an exploration of the role of gender in seeking care and access to care, and a closer examination of the role of long-term care policies in maintaining this gap.

Generalist-Specialist Collaboration in Primary Care for Frail Older Persons: A Promising Model for the Future

OBJECTIVES

The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success.

DESIGN

A qualitative multiple case study with semistructured interviews.

SETTING AND PARTICIPANTS

A selection of 22 participants from 7 "established collaboration practices" within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice.

METHODS

Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes.

RESULTS

Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration's urgency by organizations and national policy makers).

CONCLUSIONS AND IMPLICATIONS

For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons.

Socio-economic inequality in long-term care: a comparison of three time periods in the Netherlands

As a result of the rapid ageing of societies, meeting the demands for long-term care has become increasingly difficult. In the Netherlands, informal care is recognised as a key element to compensate for cut-backs in formal care provision. Formal, informal and privately paid long-term care services, however, are not used equally across socio-economic status (SES) groups and whether these inequalities have been reduced or exacerbated over time has not been researched. This study investigates to what extent educational and income inequalities in the use of formal, informal and privately paid care have changed over time. Data from the Longitudinal Aging Study Amsterdam (LASA) was used from three points in time: 1995 (N = 787), 2005 (N = 550) and 2015 (N = 473). Participants were between 75 and 85 years of age and living independently. The results indicate that lower SES groups are consistently more likely to use formal and informal care, and less likely to use privately paid care compared to higher SES groups. An increase in inequality was only found in the use of informal care; while informal care use is stable among lower SES groups, it decreases steeply among higher SES groups. These findings highlight the importance of education for explaining variation and changes over time in care use. Governmental efforts to mobilise informal care-givers might be outweighed by trends towards less long-term care.

Working towards health equity for ethnic minority elders: spanning the boundaries of neighbourhood governance

PURPOSE

This paper analyses how neighbourhood governance of social care affects the scope for frontline workers to address health inequities of older ethnic minorities. We critically discuss how an area-based, generic approach to service provision limits and enables frontline workers' efforts to reach out to ethnic minority elders, using a relational approach to place. This approach emphasises social and cultural distances to social care and understands efforts to bridge these distances as "relational work".

DESIGN/METHODOLOGY/APPROACH

The authors conducted a two-year multiple case study of the cities of Nijmegen and The Hague, the Netherlands, following the development of policies and practices relevant to ethnic minority elders. They conducted 44 semi-structured interviews with managers, policy officers and frontline workers as well as 295 h of participant observation at network events and meeting activities.

FINDINGS

Relational work was open-ended and consisted of a continuous reorientation of goals and means. In some cases, frontline workers spanned neighbourhood boundaries to connect with professional networks, key figures and places meaningful to ethnic minority elders. While neighbourhood governance is attuned to equality, relational work practice fosters possibilities for achieving equity.

RESEARCH LIMITATIONS/IMPLICATIONS

Further research on achieving equity in relational work practice and more explicit policy support of relational work is needed.

ORIGINALITY/VALUE

The paper contributes empirical knowledge about how neighbourhood governance of social care affects ethnic minority elders. It translates a relational view of place into a "situational" social justice approach.

On the characteristics of reporting ADL limitations and formal LTC usage across Europe

The increase in the proportion of elderly people in most industrialized countries triggers higher demand for long-term care (LTC) associated with limitations in activities of daily living (ADL). The aim of this research is to derive the drivers affecting the probability of reporting limitations in ADL and the probability of demanding formal LTC, e.g., personal care and services in domestic tasks. By using the most recent wave of a cross-national European survey on individuals aged over 50 years (SHARE, wave 6), we develop econometric models for identifying the effect of demographic, social and medical factors on ADL limitations and formal LTC along five conjectures. On the one hand, we analyze functional limitations and we find that characteristics such as the age, the gender, the wealth status and the education level influence the probability to report limitations. Further, while we find that pathologies significantly increase the probability to become dependent in general, the effect of cancer is lower. On the other hand, we find again an influence of the demographic and social factors on the probability to use formal LTC. We emphasize on the decrease in the probability due to the presence of the partner in the household, in particular for housekeeping tasks. This is less the case for help related with personal care. In addition, we note that pathologies such as cancer have no influence on the probability to report formal LTC while others like mental and Parkinson diseases highly increase it. We find that elderly living in countries with LTC family care schemes report less formal care than in others. This indicates the importance of LTC policies. Finally, we validate the robustness of our results by applying the models to data from earlier waves of the survey. Our findings give insights for the underwriting standards to be used in future LTC insurance products and for the design of LTC policy environments across Europe.

The involvement of volunteers in palliative care and their collaboration with healthcare professionals: A cross-sectional volunteer survey across the Flemish healthcare system (Belgium)

Volunteers occupy a specific space in the delivery of palliative care (PC), addressing specific aspects of care and providing a link between professional healthcare providers and informal care. Engaging and empowering these volunteers can be an important strategy to deliver more integrated and comprehensive PC. Insights into current actual volunteer involvement and collaboration across different healthcare services providing generalist and specialist PC is lacking. This study aims to describe volunteers' involvement in the organisation of PC, collaboration with professionals and how they evaluate this. A cross-sectional postal survey of volunteers was conducted between June and November 2018 using a written questionnaire. A two-step disproportionately stratified cluster randomised sample of 2,273 registered volunteers was taken from different strata of healthcare organisations providing care for people with serious illnesses in the Flemish healthcare system (Belgium). Overall response was 35% (15%-60% for individual strata). About 67% of volunteers were often to always informed about the organisation of patient care and 48% felt the organisation often to always takes their opinion into account, while a minority report having decision rights (18%) or autonomy (24%). For some, their organisation failed to inform (17%), consult (27%), take into account their opinion (21%), give them decision rights (20%) or autonomy (16%) over certain aspects of patient care provision often enough. Overall, volunteer-professional collaboration was low, and mostly limited to information sharing. Dedicated PC volunteers collaborated extensively with nurses, often involving task coordination (46%). Ambiguity regarding tasks, agreements and/or rules (15%) and lack of information exchange (14%) were the most cited barriers to volunteer-professional collaboration. Many volunteers were open to stronger involvement in the organisation of care in PC services. Collaboration with professionals seemed lacking in width and depth. Particularly, nursing home volunteers indicated a desire and large potential for more involved and collaborative roles in PC provision.

Looking for traces of the Troika's intervention in European road safety

The recent economic crisis has required the bailout of some European States by the so-called Troika, with capital injections accompanied by financial austerity. This paper analyzes econometrically the impact of this support programme on road safety for an original panel data (1995-2015). The findings also corroborate the Kuznets curve hypothesis for traffic accidents in the long term. Regarding the impact of intervention in the short term, despite reductions in safety policy budgets due to austerity, financial support, and related austerity measures might have led to an improvement in road safety, reducing both the number of accidents and fatalities. Therefore, it seems that our result is more linked to the austerity measures than to the financial support given by the Troika.

Empathy and Efficiency in Healthcare at Times of Austerity

Efficiency is an important value for all publicly funded healthcare systems. Limited resources need to be used prudently and wisely in order to ensure best possible outcomes and waste avoidance. Since 2010, the drive for efficiency, in the UK, has acquired a new impetus, as the country embarked on an ‘age of austerity’ purportedly to balance its books and reduce national deficit. Although the NHS did not suffer any direct budget cuts, the austerity policies imposed on the welfare system, including social and mental healthcare, have had a direct and detrimental impact on the healthcare service. This paper draws from a qualitative study conducted in three A&E Departments in England to explore the effects of austerity policies on the everyday experiences of doctors and nurses working in Emergency Departments. It discusses the operationalisation of efficiency in A&E, in a climate of austerity, and its effects on the experiences and practices of healthcare professionals. It uses the empirical data as a springboard to highlight the role of structures and regulations, in this case targets and protocols, in how core healthcare ethical values, such as empathy, are exercised in practice. It provides an analysis of the normative role structures and regulations can play on the perception and practice of professional duties and obligations in healthcare.

Evolution of Job Satisfaction and Burnout Levels of Emergency Department Professionals during a Period of Economic Recession

Satisfaction at work has been found to be a predictive factor of permanency. On the other hand, burnout has been associated with financial loss. The purpose of this study was to analyse the levels of satisfaction and burnout of professionals in a hospital emergency department and make a comparison with results from the same service during the economic recession in 2012. An analytical, cross-sectional and descriptive study was undertaken during two time periods into the levels of satisfaction and burnout of the professionals of an emergency department. Consequently, 146 replies were received. The percentage of professionals who considered their salary to be unsatisfactory in 2012 diminished in comparison with 2018 (p = 0.034), while job stability was considered more satisfactory in 2018 (p = 0.039) and the timetable in 2018 as more unsatisfactory (p = 0.009). With regards to burnout, it was observed that in 2018 the score for depersonalisation had fallen (p = 0.029) in comparison with 2012. An improvement in the level of satisfaction is observed in 2018, and more positive scores have also been found in the depersonalisation subscale in 2018. An inverse association was observed between depersonalisation in 2018 and overall satisfaction.

Use of out-of-hours primary care in affluent and deprived neighbourhoods during reforms in long-term care: an observational study from 2013 to 2016

OBJECTIVES

Major long-term care (LTC) reforms in the Netherlands in 2015 may specifically have disadvantaged socioeconomically deprived groups to acquire LTC, possibly impacting the use of acute care. We aimed to demonstrate whether LTC reforms coincided with changes in the use of out-of-hours (OOH) primary care services (PCSs), and to compare changes between deprived versus affluent neighbourhoods.

DESIGN

Ecological observational retrospective study using routinely recorded electronic health records data from 2013 to 2016 and population registry data.

SETTING

Data from 15 OOH PCSs participating in the Nivel Primary Care Database (covering approximately 6.5 million inhabitants) in the Netherlands. PCS utilisation data on neighbourhood level were matched with sociodemographic characteristics, including neighbourhood socioeconomic status (SES).

PARTICIPANTS

Electronic health records from 6 120 384 OOH PCS contacts in 2013-2016, aggregated to neighbourhood level.

OUTCOME MEASURES AND ANALYSES

Number of contacts per 1000 inhabitants/year (total, high/low-urgency, night/evening-weekend-holidays, telephone consultations/consultations/home visits).Multilevel linear regression models included neighbourhood (first level), nested within PCS catchment area (second level), to account for between-PCS variation, adjusted for neighbourhood characteristics (for instance: % men/women). Difference-in-difference in time-trends according to neighbourhood SES was assessed with addition of an interaction term to the analysis (year×neighbourhood SES).

RESULTS

Between 2013 and 2016, overall OOH PCS use increased by 6%. Significant increases were observed for high-urgency contacts and contacts during the night. The largest change was observed for the most deprived neighbourhoods (10% compared with 4%-6% in the other neighbourhoods; difference not statistically significant). The increasing trend in OOH PCS use developed practically similar for deprived and affluent neighbourhoods. A a stable gradient reflected more OOH PCS use for each lower stratum of SES.

CONCLUSIONS

LTC reforms coincided with an overall increase in OOH PCS use, with nearly similar trends for deprived and affluent neighbourhoods. The results suggest a generalised spill over to OOH PCS following LTC reforms.

Volunteer involvement in the organisation of palliative care: A survey study of the healthcare system in Flanders and Dutch-speaking Brussels, Belgium

Ageing populations increasingly face chronic and terminal illnesses, emphasising the importance of palliative care and quality of life for terminally ill people. Facing resource constraints in professional healthcare, some governments expect informal caregivers like volunteers to assume a greater share of care provision. We know volunteers are present in palliative care and perform many roles, ranging from administration to providing companionship. However, we do not know how involved they are in the organisation of care and how healthcare organisations appraise their involvement. To address this, we provide an extensive description of the involvement of volunteers who provide direct patient palliative care across the Flemish healthcare system in Belgium. We conducted a cross-sectional postal survey of 342 healthcare organisations in Flanders and Brussels in 2016, including full-population samples of palliative care units, palliative day care centres, palliative home-care teams, medical oncology departments, sitting services, community home-care services, and a random sample of nursing homes. Volunteer involvement was measured using Sallnow and Paul's power-sharing model, which describes five hierarchical levels of engagement, ranging from being informed about the organisation of care to autonomy over certain aspects of care provision. Response was obtained for 254 (79%) organisations. Volunteers were often informed about and consulted regarding the organisation of care, but healthcare organisations did not wish for more autonomous forms of volunteer involvement. Three clusters of volunteer involvement were found: "strong involvement" (31.5%), "restricted involvement" (44%), and "uninvolved" (24.5%). Degree of involvement was found to be positively associated with volunteer training (p < 0.001) and performance of practical (p < 0.001) and psychosocial care tasks (p < 0.001). Dedicated palliative care services displayed a strong degree of volunteer involvement, contrary to generalist palliative care services, suggesting volunteers have a more important position in dedicated palliative care services. A link is found between volunteer involvement, training, and task performance.

Austerity measures and the transforming role of A&E professionals in a weakening welfare system

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called "age of austerity" for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients-altering the meaning of A&E from 'Accidents and Emergencies' to the Department for 'Anything and Everything'. The second section in this study's findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS-in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E.

Changing long-term care provision at the local level in times of austerity – a qualitative study

In the first decade of the century, long-term care (LTC) policies for dependent older people in Italy were improved with respect to both the availability of public funds and the quality of services. At the turn of the decade, however, cost-containment and austerity measures were imposed as an overall priority for the public sector and this goal also affected the LTC sector. This article explores the effects produced by cost-containment policies, which widened the gap between care needs and available public funding, on the provision of LTC services at the local level in Italy during the economic crisis. The study is based on 34 semi-structured interviews with services managers employed in Italy's publicly funded LTC system. Data were analysed with the framework analysis method and six cross-cutting thematic categories were identified that depict, according to the interviewees, the main transformations that occurred in the provision of LTC at the local level as a consequence of cost-containment policies. ‘Uncertainty’ refers to the inability to predict what direction the LTC system is going to take in the foreseeable future. ‘Short-termism’ illustrates the pressure to focus excessively on day-to-day service delivery at the expense of a medium- to long-term view of their future. ‘Endangering quality’ describes the risk of not being able to maintain the level of quality of care achieved so far. ‘Allocative tensions’ refers to the tensions due to the increasing requirement to ration the provision of public LTC services. ‘Unequal re-familiarisation’ represents the very different impacts of the trend of re-familiarisation depending on families’ financial situation. ‘Inappropriate care’ depicts the rising number of older people receiving public care interventions that are not appropriate to meet their needs.

Facilitating aging in place: A qualitative study of practical problems preventing people with dementia from living at home

Although the majority of people with dementia wish to age in place, they are particularly susceptible to nursing home admission. Nurses can play an important role in detecting practical problems people with dementia and their informal caregivers are facing and in advising them on various ways to manage these problems at home. Six focus group interviews (n = 43) with formal and informal caregivers and experts in the field of assistive technology were conducted to gain insight into the most important practical problems preventing people with dementia from living at home. Problems within three domains were consistently described as most important: informal caregiver/social network-related problems (e.g. high load of care responsibility), safety-related problems (e.g. fall risk, wandering), and decreased self-reliance (e.g. problems regarding self-care, lack of day structure). To facilitate aging in place and/or to delay institutionalization, nurses in community-based dementia care should focus on assessing problems within those three domains and offer potential solutions.