Costs needs and outcomes in residential and community-based care of the elderly: towards the quantification of optimal targeting criteria

<p>Starting from the conventional theoretical formulation for modal choice and achieving the optimal balance of care, Part 1 first describes the elaborations made within that framework and presents estimates. It then discusses evidence about the costs of outcomes of importance in their own right in the evaluation of system performance. Part 2 discusses the feasibility of shifting the balance to community based care with a budget increasing little faster than the population at risk.

<p><p><p>Part 1 commences with a summary of the traditional theoretical framework for choosing care modes and achieving the optimal balance of care (Diagram 1.1). The framework focuses on the relationships between costs and dependency.

<p><p><p>Section 1.1 describes the elaborations of that framework and presents estimates.

<p><p><p>(i) "Dependency", a vaguely defined concept, was replaced by "functional incapacity". Estimates for British residential homes suggest that the relationships betwen costs and disability do not depart substantially from the monotonicity assumed by the original theoretical argument (Table 1.1). However the relationships are not monotonic for recipients of community based social care having substantial informal support (Table 1.2).

<p><p><p>(ii) Costs have been studied in greater detail: the range has widened; costs accounts compiled for interest groups; economists' opportunity cost principles applied; and more attention paid to the constituents of costs. Table 1.3 illustrates how the opportunity costs of residential care provided by local authorities differ with the scale and targeting criteria chosen between each of twelve authorities.

<p><p><p>Section 1.2 discusses evidence about the costs of outcomes of ultimate evaluative significance. This question has been raised by technical advances in research methods and changes in service demand and supply. Again the theoretical argument is focussed on what patterns might be expected in an equitable and efficient system (Diagram 1.2). The comparison of actual and these ideal patterns help to pinpoint faults in the present system. Table 1.4 compares the costs of morale and quality of care outcomes in the Thanet community care project and its comparison group. It suggests that an optimising allocation process would indeed result in patterns like those in Diagram 1.2), but that standard services do not yield these patterns.

<p><p><p>Part 2 discusses the feasibility of meeting the increase in need adequately and equitably by the provision of more community©based rather than residential based care, assuming that the expenditure of public funds will rise no more quickly than the number of persons in the age groups most at risk.

<p><p><p>Prepared for the conference "Les Institutions Sanitaires et Sociales Face au Vieillissement" at the "National School of Public Health", Rennes, France, September 1988