Spain's 2007 long-term care reform gave older people with care needs access to cash subsidies and publicly funded home help. Joan Costa-Font, Sergi Jiménez-Martín and Cristina Vilaplana-Prieto show this produced benefits that in many cases were more cost-effective than equivalent investments in heal…
Spain's 2007 long-term care reform gave older people with care needs access to cash subsidies and publicly funded home help. Joan Costa-Font, Sergi Jiménez-Martín and Cristina Vilaplana-Prieto show this produced benefits that in many cases were more cost-effective than equivalent investments in health care. Health care and social care are usually funded, evaluated and argued about as if they belong to separate worlds. Health programmes have to prove their worth. In England, the National Institute for Health and Care Excellence (NICE) applies a cost-effectiveness threshold of roughly £20,000–30,000 per Quality-Adjusted Life Year (QALY) gained. Social care faces no such test. We therefore know surprisingly little about what governments get, in health terms, for the money they spend helping older people with washing, dressing, cooking or getting about. This is particularly important in the UK given Andy Burnham has announced plans to create a new National Care Service. Spain's System for Autonomy and Care for Dependent People Spain offers a rare opportunity to see the value of investing in social care. Before 2007, publicly funded long-term care in Spain was scarce and means-tested. It was essentially reserved for people with very high levels of need. The unspoken expectation was that families, above all women, would cope. This changed in 2007 when a new system – the System for Autonomy and Care for Dependent People (SAAD) – established access based on assessed need, regardless of a person's age. After an assessment, each person receives an individual care plan. This may include publicly funded home help, day centres, telecare or residential care. It may also include a cash subsidy for families who provide care at home. The rollout was gradual. In 2007 only people with the highest level of dependency were covered. Those with severe needs were added from around 2011 and moderate needs from 2015. Access also varied across Spain as regions assess people and deliver services. Austerity then intervened. In 2012, at the height of the Eurozone crisis, caregiving subsidies in Spain were cut by 15%, co-payments rose and hours of home help fell. This staggered, uneven expansion, followed by a retrenchment, resulted in significant variation in who received care and when. Measuring the benefits of social care Using the Spanish sample of the Survey of Health, Ageing and Retirement in Europe (SHARE), we compared people in Spain who received SAAD social care benefits with similar people who did not, before and after the SAAD system was introduced. We matched them on age, sex, marital status, education, income and chronic conditions, controlling for region and year effects. Our four outcomes are life satisfaction (0–10), loneliness (a 3–9 scale), depressive symptoms and survival between survey waves.
Spain shows investing in social care can be better value than funding health care - LSE European Politics
Access to care improves both well-being and survival. Among recipients of caregiving subsidies, life satisfaction rises by 0.24 points on the 0–10 scale. Among home help recipients it rises by 0.50, twice as much. Loneliness falls by about 0.6 points for subsidies and 0.5 for home help. The probability of surviving to the next survey wave rises by 3 percentage points for subsidies and 2.6 for home help. We also find fewer depressive symptoms. However, the two types of support work slightly differently. Home help has the larger effect on life satisfaction, which is consistent with regular professional assistance and company. Subsidies have larger effects on survival and on loneliness and depression, perhaps because they allow families to arrange flexible care.
The benefits are not evenly spread. They are larger for women, for people living alone and in rural areas, as well as for the oldest people. Among people aged 80 and over, subsidies are associated with a 5.6 percentage point increase in survival. What lies behind these gains? We cannot prove a single channel, but the pattern is consistent with the practical effects of care. Recipients report better diets, have stronger grip strength relative to non-recipients, feel more in control of their lives and have fewer hip and other fractures.
The 2012–2017 austerity years are also informative. The cuts offset a substantial part of SAAD's benefits, with loneliness and depression rising and life satisfaction and survival falling relative to the counterfactual. Retreating care is not free: the costs show up in health and well-being. Investing in social care is good value for money
Spain shows investing in social care can be better value than funding health care - LSE European Politics
We estimate that caregiving subsidies cost around €6,200 per Quality-Adjusted Life Year (QALY) gained and home help around €9,200. Cost-effectiveness thresholds across Europe typically range from €20,000 to €50,000 per QALY, and NICE's range is higher than our estimates. Even for the least cost-effective groups we identify, such as women aged 55–59 receiving home help, the estimate is about €17,500 per QALY. That is still below the usual thresholds for health care. In other words, on these estimates, the average euro spent on long-term care buys health gains at a price that compares favourably with the health programmes that systems already fund.
Our estimates for the average recipient of long-term care in Spain are of the same order or lower, although currencies and price years differ and subgroups vary. This suggests that in the UK social care could be financed by replacing NHS programmes that fall short on cost-effectiveness with social care programmes that deliver more health per pound. What they do indicate is that health returns from home help and carer support are real and they can be at least as large per pound as the returns to many things the NHS buys.
A social care service that is evaluated on the same terms as health care and funded in part by reallocating from less cost-effective health programmes would be a better use of limited resources. For policymakers, the implication is that long-term care should be routinely assessed with the same health-economic tools as medical interventions, including measures of loneliness, depression and life satisfaction.
