Building a better understanding of adult social care

Informal caregiving and mental health: results from the Belgian health interview survey 2013 and 2018

BACKGROUND

Due to a globally ageing population, the demand for informal caregivers is increasing. This study investigates the socio-demographic profile of informal caregivers in Belgium and assesses the relationship between informal care (intensity and care recipients) and mental health, considering potential moderators like education, age, and gender.

METHODS

Using population-based data from the 2013 and 2018 waves of the Belgian Health Interview Survey (N = 14,661), we conducted multivariate (multinomial/ordinal) logistic and linear regression analyses to examine the socio-demographic profile of informal caregivers and their psychological distress, measured through the General Health Questionnaire (GHQ-12).

RESULTS

The prevalence of informal caregiving increased from 10.0% in 2013 to 13.0% in 2018. Informal caregivers were predominantly female, middle-aged, and often had no paid job. High-intensity caregivers (over 20 h/week) experienced significantly higher psychological distress compared to non-caregivers, whereas lower-intensity caregivers did not. Additionally, while gender, age, and education were significant predictors of who becomes a caregiver, they did not moderate the relationship between caregiving and mental health.

CONCLUSIONS

Our findings suggest that the stress of caregiving is more directly related to the nature and intensity of the caregiving tasks themselves rather than the demographic characteristics of the caregivers. Interventions aimed at reducing the adverse effects of caregiving might need to be universally applicable to all caregivers, focusing on reducing the intrinsic burdens of caregiving tasks rather than targeting demographic subgroups.

Does outsourcing enable the survival of good care homes? A longitudinal analysis of all care homes in England, 2011-2023

Background

It is unclear whether outsourcing has enabled the growth and survival of the best care homes, as intended. We aimed to test whether ownership (for-profit, public and third sector (non-profit)) influences determinants of closure among all care homes in England, 2011-2023.

Methods

We created a dataset of all care homes from 2011 to 2023 (29 548 care homes and 8346 closures) and Care Quality Commission inspections from 2014 to 2023 (n=65 726). Using logistic regression, we investigated determinants of care home closures including care home characteristics (eg, number of beds), service registrations (eg, dementia and nursing), quality (inspection ratings) and area deprivation. We then tested for interaction effects; specifically exploring (1) whether the determinants of closure vary by ownership and (2) whether quality differences between active and closed for-profit and third sector/public homes vary by area deprivation.

Results

The prevalence of for-profit care homes increased from 2011 to 2023. Ownership was a key determinant of care home closure; public and third sector care homes were almost twice as likely to close than for-profit providers (OR 1.8; 95% CI 1.44 to 2.24, p<0.001 and OR 1.6; 95% CI 1.37 to 1.76, p<0.001, respectively). Although care quality was also a significant determinant of closure, this association varied by care home ownership. For example, public and third sector homes rated 'good' were 7.6 percentage points (p<0.001) and 5.9 percentage points (p<0.001) more likely to close than for-profit homes with the same rating. Lastly, the quality of for-profit homes is heavily influenced by area deprivation, and the best active homes in deprived areas are operated by public and third sector providers.

Conclusion

Our findings suggest that outsourcing of care services has not promoted the survival of the best care homes and may have adverse effects on the equity and accessibility of care. This calls for a reassessment of current policies to ensure that vulnerable populations have continued access to adequate quality of care.

New horizons in systems engineering and thinking to improve health and social care for older people

Existing models for the safe, timely and effective delivery of health and social care are challenged by an ageing population. Services and care pathways are often optimised for single-disease management, while many older people are presenting with multiple long-term conditions and frailty. Systems engineering describes a holistic, interdisciplinary approach to change that is focused on people, system understanding, design and risk management. These principles are the basis of many established quality improvement (QI) tools in health and social care, but implementation has often been limited to single services or condition areas. Newer engineering techniques may help reshape more complex systems. Systems thinking is an essential component of this mindset to understand the underlying relationships and characteristics of a working system. It promotes the use of tools that map, measure and interrogate the dynamics of complex systems. In this New Horizons piece, we describe the evolution of systems approaches while noting the challenges of small-scale QI efforts that fail to address whole-system problems. The opportunities for novel soft-systems approaches are described, along with a recent update to the Systems Engineering Initiative for Patient Safety model, which includes human-centred design. Systems modelling and simulation techniques harness routine data to understand the functioning of complex health and social care systems. These tools could support better-informed system change by allowing comparison of simulated approaches before implementation, but better effectiveness evidence is required. Modern systems engineering and systems thinking techniques have potential to inform the redesign of services appropriate for the complex needs of older people.

Insights Into Informal Caregivers' Well-being: A Longitudinal Analysis of Care Intensity, Care Location, and Care Relationship

OBJECTIVES

This study investigates the psychological well-being of informal caregivers over time. It identifies the thresholds (or "tipping points") of caring intensity at which caregiving is associated with lower psychological well-being, and how this varies by care location and caregiver-care recipient relationships. It also examines how caring location and relationship are linked to informal caregivers' psychological well-being while controlling for caring intensity.

METHODS

Waves 1-18 (1991-2009) of the harmonized British Household Panel Survey and Waves 1-8 (2009-2017) of the U.K. Household Longitudinal Study were analyzed. Psychological well-being was measured using the General Health Questionnaire (GHQ)-12 score. Care intensity was measured by the weekly hours of care provided. Fixed-effects estimators were applied to the GHQ-12 score of caregivers across different care intensities, caring locations, and caring relationships.

RESULTS

All levels of informal care intensity are associated with lower psychological well-being among spousal caregivers. The thresholds to well-being are 5 hours per week when caring for a parent, and 50 hours per week when caring for a child (with a disability or long-term illness). Caring for "other relatives" or nonrelatives is not negatively associated with psychological well-being. The thresholds are 5 hours per week for both coresident and extraresident caregivers. Extraresident caregivers experience better psychological well-being compared to coresident caregivers, given relatively lower weekly care hours. Caring for primary kin (especially spouses) is linked to lower psychological well-being compared to other caregiving relationships, regardless of care intensity.

DISCUSSION

Policy and practice responses should pay particular attention to spousal caregivers' well-being. Caregiving relationship has a stronger association with the caregiver's well-being than care location.