1. Background
Technological innovation and economic wealth have resulted in a significant increase of individuals’ life expectancy. As individuals live longer, they are more likely to experience (long-term) functional impairments that limit their ability to live independently and undertake activities of daily living (OECD, 2023). Social care – defined as non-curative support or care provided to individuals in their own homes or community – supports individuals to live independently at home and participate in society despite their impairments (Wiles et al., Reference Wiles, Leibing, Guberman, Reeve and Allen2012; Equality and Human Rights Commission, 2009; Netten et al., Reference Netten, Burge, Malley, Potoglou, Towers, Brazier, Flynn, Forder and Wall2012; Hughes, Reference Hughes1993). Although the provision of social care varies across cultures depending on norms and values regarding familial responsibilities for caregiving, social care services may encompass practical support, eg. with cooking or cleaning, mobility aids, home adaptations and respite care for informal caregivers.
Social care services are financed in various ways across countries, reflecting different political, social, and cultural contexts. As described by Comas-Herrera et al. (Reference Comas-Herrera, Cyhlarova, Rajagopalan, Govia, Feng, Cyclus, Wharton, Carrino, Ilinca, Huber and Barber2025), financing mechanisms generally fall into two types of schemes: public and private. Public financing includes government-managed programs funded through taxation and social insurance schemes, while private financing encompasses out-of-pocket payments (sometimes means-tested), private insurance, or in-kind contributions from relatives (Comas-Herrera et al., Reference Comas-Herrera, Cyhlarova, Rajagopalan, Govia, Feng, Cyclus, Wharton, Carrino, Ilinca, Huber and Barber2025). In the Netherlands, for instance, social care is primarily publicly financed, consistent with its welfare state tradition (Bredewold, Reference Bredewold2025). Nonetheless, some services require co-payments (previously means-tested and likely to be again in the future) (Bakx et al., Reference Bakx, Schut and Wouterse2020). In contrast, in England, publicly financed social care is subject to both need and means testing and individuals are more often required to draw on private resources (Comas-Herrera et al., Reference Comas-Herrera, Cyhlarova, Rajagopalan, Govia, Feng, Cyclus, Wharton, Carrino, Ilinca, Huber and Barber2025).
The growing demand for social care renders decisions on the allocation of resources to social care inevitable, considering that not only public, but also private resources are scarce (Clarkson et al., Reference Clarkson, Davies, Hughes, Xie, Stewart, Clifford and Challis2018; Stewart et al., Reference Stewart, Hughes, Challis, Worden, Davies, Xie, Asthana and Gibson2021; Sussex et al., Reference Sussex, Burge, Lu, Exley and King2019). These decisions affect individuals’ access to social care, may have consequences for equitable access, and should therefore be evaluated in terms of fairness and justice. In decisions on the allocation of healthcare resources, the implications for equity and efficiency are typically evaluated (Asamani et al., Reference Asamani, Alugsi, Ismaila and Nabyonga-Orem2021; Culyer, Reference Culyer2015; Whitehead, Reference Whitehead1992) and inform decision-making. Several countries – including the Netherlands, England and Wales, Norway, Sweden and Denmark – introduced explicit decision-making frameworks to guide the allocation of healthcare resources on the national level (Reckers-Droog et al., Reference Reckers-Droog, Exel and Brouwer2018; Sabik and Lie, Reference Sabik and Lie2008). These frameworks typically consider effectiveness, efficiency, and necessity, while also incorporating the consequences of these decisions for solidarity, human dignity or social and geographical equity (Sabik and Lie, Reference Sabik and Lie2008).
In contrast, less is known about the consequences of resource allocation decisions in social care. Moreover, decisions on resource allocation in social care resources differ from those in healthcare as they are often made on national, local, and individual levels, in the absence of explicit decision-making frameworks. Our recent systematic review of the scientific literature on the underpinnings of such decisions highlights that decisions are guided by a broad range of norms and values, objectives, trade-offs, and strategies (Mos and Reckers-Droog, Reference Mos and Reckers-Droog2024). Importantly, these considerations may vary across decision-makers on the national, local, or individual levels. The findings of the systematic review underscore the inherent complexity of decisions on the allocation of social care resources, which introduces potential for inconsistency and variation (Mos and Reckers-Droog, Reference Mos and Reckers-Droog2024).
Variation in the provision of social care may result in disparities in health and well-being between (groups of) individuals. These disparities can be considered inequitable, particularly when these differences systematically put already disadvantaged individuals or groups at further disadvantage with respect to their health and well-being (Fleurbaey and Schokkaert, Reference Fleurbaey and Schokkaert2011; Anand, Reference Anand2002; Whitehead, Reference Whitehead1992). According to the principle of horizontal equity, individuals with similar levels of need should receive similar levels and types of support. According to the principle of vertical equity, differences in the level of support should reflect differences in individuals’ needs (Culyer, Reference Culyer2015). Infringement of these principles by resource allocation decision-makers, even when unintended, can be considered inequitable.
The aim of this study was to examine the consequences of decisions on the allocation of social care resources guided by the various underpinnings that were described in the ‘parent’ review of the theoretical and empirical literature (Mos and Reckers-Droog, Reference Mos and Reckers-Droog2024). To meet this aim, we conducted a secondary analysis of the articles included, extending the results of the parent review. By highlighting the potential consequences of decisions on the allocation of social care resources for different groups in society, we believe the results of this secondary analysis contribute to a better understanding of those consequences and supports decision-makers to consider these in future resource allocation decisions. At the same time, we seek to increase attention of scholars to the need for further research on the consequences of resource allocation in social care – an area that remains underexplored in comparison to healthcare, despite its growing relevance in view of demographic ageing.
2. Methods
2.1. Data sources and search strategy
This study consists of a secondary analysis of the articles included in a systematic review of the scientific literature on the theoretical and empirical underpinnings of decisions on the allocation of resources to social care (Mos and Reckers-Droog, Reference Mos and Reckers-Droog2024). We conducted the parent review following the Preferred Reported Items for Systematic Review and Meta-Analysis (PRISMA) framework (Liberati et al., Reference Liberati, Altman, Tetzlaff, Mulrow, Gøtzsche, Ioannidis, Clarke, Devereaux, Kleijnen and Moher2009). We did not register a systematic review protocol. With the help of an expert in search strategies for systematic reviews, we developed a search string including (synonyms and combinations of) the keywords ‘social care’, ‘resource allocation’, ‘right to health’ and ‘access’ (Bramer et al., Reference Bramer, de Jonge, Rethlefsen, Mast and Kleijnen2018). We assessed the relevance of the first 1000 results of the initial search string run on Embase. Subsequently, we made minor adjustments to the search string, resulting in the final search strategy (see Supplementary Material S1). We ran the search string on Embase, MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health Literature, International Bibliography of Social Sciences, Social Science Database, Applied Social Sciences Index and Abstracts, Social Services Abstracts and Sociology Database, and Google Scholar in February 2023. We updated the search in February 2024. Finally, we conducted a manual search of the reference lists of included articles to identify relevant studies that had not appeared in our primary search results.
2.2. Study selection
Before we screened the titles and abstracts of the identified articles, we assessed inter-rater agreement by calculating Cohen’s kappa coefficient based on the two authors’ independent title and abstract screening of a random selection of 35 records (McHugh, Reference McHugh2012). The results (K = 0.74) indicated a high level of agreement between the authors. Nonetheless, we further specified the eligibility criteria and raised the agreement to a very high level (K = 0.82) based on the independent screening of another 35 records.
We included articles that (1) were a primary study, review, letter, editorial, note, commentary, report or book chapter; (2) discussed any decision on the allocation of public resources to social care; (3) discussed any underpinnings (eg. decision criteria, norms and values, arguments, decision-criteria or trade-offs) of decisions on the allocation of resources to (different types of) social care; (4) are written in English; (5) are available in full-text. The two authors independently assessed the eligibility of the remaining records by screening their titles and abstracts, for which we used a standardised Excel workbook (VonHille, Reference VonHille2022). The first author screened all titles, and the second author screened the titles and abstracts of the excluded records to reduce the likelihood of any false negatives. The authors resolved any disagreements through discussion. The authors reviewed the full text of articles that passed the screening, articles that the authors could not agree on after discussion, and articles on which the abstract was unavailable. The first author individually assessed the full texts for eligibility and, in case of doubt, consulted the second author before deciding on the inclusion of the article together. Finally, the first author searched the reference lists of the included articles for any relevant articles that were not identified based on the database search. We included the articles that met all eligibility criteria in the parent review in this secondary analysis. To meet the aim of the current study, we selected articles that discussed the consequences of resource allocation decisions guided by the underpinnings described in the parent review.
2.3. Data extraction and analysis
We extracted data on the following characteristics of the included articles: author(s), year of publication, country of focus, type of study, and decision-making level. In the parent review, we systematically mapped the underpinnings of decisions on the allocation of resources to social care by applying the Framework Method in six steps (Ritchie et al., Reference Ritchie, Spencer, O’Connor, Ritchie and Lewis2003b; Reference Ritchie, Spencer and O’Connor2003a). First, the first author imported the articles into ATLAS.ti23. Second, the two authors independently and inductively coded a random selection of fourteen articles. Third, the first author developed a preliminary framework consisting of categories and themes based on that coding. Fourth, the two authors discussed this preliminary framework based on the second author’s independent coding of the same fourteen articles. Fifth, the third and fourth steps were repeated for the remaining articles. Finally, the first author further developed the framework until the authors agreed that no new categories and themes emerged from the data. The final framework encompassed six themes representing the underpinnings guiding decisions on the allocation of social care resources, described in detail in the parent review (Mos and Reckers-Droog, Reference Mos and Reckers-Droog2024).
In the current study, we systematically mapped the potential consequences of resource allocation decisions on social care through a secondary analysis of the articles included in the parent review. We conducted a thematic analysis to identify and describe the potential consequences of these decisions, how they manifest, and for whom. First, the first author inductively coded a random selection of one-fourth of the articles in ATLAS.ti23. Second, the first author developed a preliminary thematic framework in Microsoft Office Excel, consisting of initial categories that captured the different types of consequences (eg. arbitrariness, local variation, and intergenerational burden). Third, the two authors reviewed and discussed this framework, drawing on the second author’s independent coding of the same articles. The discussion helped to refine the framework by shifting the focus from abstract consequences to how different groups in society may be disproportionally affected by these consequences. This shift reflects an interpretive step where the data were re-examined through the lens of societal impact, rather than merely documenting consequences. The framework was iteratively refined throughout the analysis. As the coding continued, codes were merged, split, or redefined. For instance, we split the categories individuals with limited health literacy skills from socio-economically disadvantaged groups to better capture nuances across the dataset. Finally, the first author mapped the extracted data by entering coded excerpts from the articles into the framework. The final framework comprised five categories describing the groups in society that may be disproportionally affected by the consequences of resource allocation decisions on social care. Please note that these categories were not only descriptive but also interpretive, reflecting the analytical judgement of the authors about which societal groups were recurrently positioned as vulnerable or impacted across the reviewed literature, in line with the aim of this study.
3. Results
The parent’s review database search yielded 1588 records, of which 395 were identified as duplicates and removed. Screening the titles and abstracts of the remaining 1193 records resulted in the exclusion of another 804 articles, most often because they did not discuss any decision on the allocation of public resources to social care (n = 545). The full-text review of the 389 remaining records resulted in the exclusion of another 354 records, most often because they did not discuss any underpinnings of such decisions (n = 197). The 35 remaining articles were eligible for inclusion and subjected to scrutiny of the reference list. On that basis, we identified seven additional records that met the eligibility criteria, which resulted in a total of 42 articles included in the parent review. Of the 42 articles included in the parent review, 37 articles discussed the consequences of allocation decisions. Figure 1 presents an overview of the selection process.
Figure 1. Overview of the selection process.
Table 1 presents an overview of the 37 articles, as well as their year of publication, country of focus, type of study, decision-making level, and the consequences of resource allocation decisions on social care on which they focus. Of the 37 included articles, 16 articles focused on the consequences for long-term social care needs, 17 articles on the consequences for informal caregivers, 13 articles on the consequences for those with limited health literacy skills, as well as for individuals across different regions and 9 articles on the consequences for socio-economically disadvantaged groups. Based on these results, we identified five groups in society that may be disproportionally affected by the consequences of resource allocation decisions on social care: (1) individuals with long-term needs (2) informal caregivers, (3) socio-economically disadvantaged groups, (4) individuals with limited health literacy skills, and (5) individuals across different regions. Below follows the narrative summary of these categories. The framework is available in detail from: https://doi.org/10.34894/QMRWK3.
Table 1. Characteristics of the included studies
AU, Australia; BE, Belgium; CA, Canada; CN, China; DE, Germany; DK, Denmark; ES, Spain; FI, Finland; FR, France; IE, Ireland; IS, Iceland; IT, Italy; NL, the Netherlands; NO, Norway; NS, Not Specified; NZ, New Zealand; SE, Sweden; SG, Singapore; TW, Taiwan; UK, United Kingdom; USA, United States of America.
a Theoretical studies include qualitative research (eg. development and application of theories and frameworks); Empirical studies include qualitative research, quantitative research and mixed-method research to investigate underpinnings of resource allocation on social care.
b Decision-making level: Macro-level decisions concern the allocation of public resources from the national budget to social care relative to other types of care (eg. curative care) or other public goods and are typically made by the national (health) authority; Meso-level decisions concern the allocation of public social care resources to different types of social care; Micro level decisions concern the allocation of public social care resources to individual care packages.
3.1. Consequences for individuals with long-term social care needs
Both empirical and theoretical studies included in the review indicate the prioritisation of (post-)acute, often short-term, health care needs over long-term social care needs (Grenier and Guberman, Reference Grenier and Guberman2009; Forbes and Edge, Reference Forbes and Edge2009; Thorslund et al., Reference Thorslund, Bergmark and Parker1997; West, Reference West1999). Decision-makers on the macro and meso levels trade-off post-acute, and long-term support based on the perceived costs and benefits yielded by the two, and this has considerable consequences for individuals with long-term social care needs (West, Reference West1999; Thorslund et al., Reference Thorslund, Bergmark and Parker1997). Notably, decision-makers on the micro level appreciate social care for its capacity to simultaneously address social, psychological and physical needs (Dworkin, Reference Dworkin1997; Keogh et al., Reference Keogh, Pierse, O’Shea, Fitzgerald and Challis2020). While the objective comparison of the benefits and related costs of health- and social care services is complicated due to the distinct differences between the care types (Peasgood et al., Reference Peasgood, Carlton and Brazier2019; Kinghorn, Reference Kinghorn2019), healthcare services are generally considered to yield more significant or meaningful benefits as than social care services (Boxall et al., Reference Boxall, Dowson and Beresford2009; Hudson, Reference Hudson2010; Huxley et al., Reference Huxley, Evans, Munroe and Cestari2008; Peckham et al., Reference Peckham, Williams and Neysmith2014; Van Eenoo et al., Reference Eenoo, Declercq, Onder, Finne-Soveri, Garms-Homolová, Jónsson, Dix, Smit, Hout and Roest2016). One of the reasons for this could be that healthcare services are believed to restore a particular health state rather than maintain it and that this is more valuable than preventing deterioration (West, Reference West1999). Another reason could be that there is relatively more evidence available on the effects of healthcare services compared to social care services (Peasgood et al., Reference Peasgood, Carlton and Brazier2019).
Moreover, resource scarcity and the trend to discharge patients from healthcare services early when they are still unwell, compel decision-makers to divide limited resources between individuals with (post-)acute needs and those with long-term needs. Based on the included articles, social care services are increasingly targeted at meeting (post-)acute needs, and few resources remain to serve those with long-term needs (Forbes and Edge, Reference Forbes and Edge2009). The use of eligibility criteria designed to meet the needs of those that are worse-off typically sustains this trade-off, which may result in long-term care needs – being perceived as not urgent enough – not being met (Equality and Human Rights Commission, 2009; Durocher et al., Reference Durocher, Wang, Bickenbach, Schreiber and Wilson2019; Cambridge and Ernst, Reference Cambridge and Ernst2006). Although the needs of individuals with long-term needs may not be considered the most urgent by decision-makers, their ability to live a ‘normal’ life in their own homes and to engage in meaningful social activities, such as employment or education, significantly depends on social care support (Equality and Human Rights Commission, 2009). As such, the inclination towards allocating resources to meet (post-)acute needs makes individuals with long-term needs vulnerable to social exclusion (Grenier and Guberman, Reference Grenier and Guberman2009), which some consider to be unfair (West, Reference West1999). Furthermore, a lack of adequate support may deprive individuals of the human right to privacy and family life (Morris, Reference Morris2004; Boyle, Reference Boyle2010) and increase the burden on informal caregivers (Thorslund et al., Reference Thorslund, Bergmark and Parker1997).
3.2. Consequences for informal caregivers
The allocation of insufficient resources to meet demand for social care may compel individuals in demand of such care to seek more support from informal caregivers (Keefe & Rajnovich, Reference Keefe and Rajnovich2007). Decision-makers, who are often responsible for adhering to a fixed budget, may perceive informal care as a cheaper and, hence, appealing substitute for formal care (Boyle, Reference Boyle2010; Keefe & Rajnovich, Reference Keefe and Rajnovich2007; Netten et al., Reference Netten, Burge, Malley, Potoglou, Towers, Brazier, Flynn, Forder and Wall2012; Equality and Human Rights Commission, 2009). Nonetheless, this may create a cycle where decision-makers are allocating fewer resources to formal social care services, placing an increasing and potentially unsustainable burden on informal caregivers.
Seeking and providing informal care does not always stem from limited access to social care. Rather, this may be rooted in certain cultural traditions of familial responsibility (Tan, Reference Tan2013; Wong & Leung, Reference Wong and Leung2012; Yeh, Reference Yeh2020; Cambridge & Ernst, Reference Cambridge and Ernst2006). For example, in China, Taiwan, Italy and Spain, caring for relatives across generations and for extended periods is generally perceived as the norm (Cambridge et al., Reference Cambridge and Ernst2006). However, in the Netherlands, Sweden, Finland, Denmark, Norway, and the United Kingdom (UK) this type of support is typically perceived as a public responsibility rather than a private one (Thorslund et al., Reference Thorslund, Bergmark and Parker1997; Szebehely & Meagher, Reference Szebehely and Meagher2018; Cambridge et al., Reference Cambridge and Ernst2006). Common to these societies are unigenerational households and high employment rates among women. In the Canadian context, Peckham et al. (Reference Peckham, Williams and Neysmith2014) found that neither unilateral households nor increased employment rates among women facilitate informal caregiving. Indeed, the provision of informal care often demands adaptations from caregivers that significantly affect their lives (Equality and Human Rights Commission, 2009).
An empirical study included in the review indicated a relationship between an increase in the provision of informal care (following a decrease in resources allocated to social care) and a decline in the employment rate of middle-aged women (Szebehely & Meagher, Reference Szebehely and Meagher2018). Informal caregiving may indeed force individuals to temporarily or permanently leave their employment, leading to both short- and long-term financial losses due to lost productivity and diminished career opportunities. This can put considerable stress on the caregiver’s household and increase their risk of burnout (Keogh et al., Reference Keogh, Pierse, Challis and O’Shea2021; Netten et al., Reference Netten and Davies1990; Peasgood et al., Reference Peasgood, Carlton and Brazier2019; Keogh et al., Reference Keogh, Pierse, O’Shea, Fitzgerald and Challis2020; Peckham et al., Reference Peckham, Williams and Neysmith2014; Rand et al., Reference Rand and Malley2014; Van Eenoo et al., Reference Eenoo, Declercq, Onder, Finne-Soveri, Garms-Homolová, Jónsson, Dix, Smit, Hout and Roest2016). Notably, the responsibility of informal caregiving, and consequently the related impacts, still primarily fall onto female members of society (Peckham et al., Reference Peckham, Williams and Neysmith2014; Szebehely & Meagher, Reference Szebehely and Meagher2018).
To compensate for the effects of providing informal care, informal caregivers may receive some form of compensation for their time and labour. Such compensation may be direct, eg. financial remuneration, or indirect, eg. tax reliefs or respite care (Keefe et al., Reference Keefe and Rajnovich2007; Rand et al., Reference Rand and Malley2014). Financial support policies help compensate informal caregivers for the loss of income, maintain their economic independence, and recognise the value of their work done. Nonetheless, financial compensation for informal caregiving may encourage women to leave the workforce, perpetuating the traditional gendered division of labour where men are the primary breadwinners and women take on the role of caregivers (Keefe et al., Reference Keefe and Rajnovich2007).
3.3. Consequences for socio-economically disadvantaged groups
Resource allocation decisions on social care may create or sustain existing differences in access to social care between more and less advantaged individuals in society. (Wu, Reference Wu2022; Tseng et al., Reference Tseng and Wu2021). Austerity measures such as the introduction of co-payments, decreasing levels of service provision, the introduction of waiting lists, and declining service quality may impact individuals with a lower income more severely. Based on the included articles, individuals with a smaller budget may forgo medication or other essential expenses to afford co-payments or privately purchased care (Grenier et al., Reference Grenier and Guberman2009; Livadiotakis et al., Reference Livadiotakis, Gutman and Hollander2003). Alternatively, they rely on relatives to provide support (Equality and Human Rights Commission, 2009). Indeed, articles included in the review indicate that access to and usage of social care is lower among individuals with a lower socio-economic status, even though their need for social care may, on average, be greater (Wu, Reference Wu2022; Tseng et al., Reference Tseng and Wu2021).
Differences between socio-economic groups may further be exacerbated by the finding that individuals with a higher socio-economic status are generally better able to obtain support. eg. because they have better access to information, stronger social networks, or are better able to navigate institutional systems (Szebehely & Meagher, Reference Szebehely and Meagher2018; Equality and Human Rights Commission, 2009). As such, those individuals and their relatives are less likely to suffer the negative consequences of lower levels of service provision (Szebehely & Meagher, Reference Szebehely and Meagher2018; Livadiotakis et al., Reference Livadiotakis, Gutman and Hollander2003). Wealthier individuals may also be better able to afford private support if access through the public social care system is deemed insufficient (Szebehely & Meagher, Reference Szebehely and Meagher2018). Indeed, they may less frequently have to trade-off between fundamental needs such as medication or food, and support than others in society. Waiting lists and decreasing satisfaction with the quality of public social care services may further incentivise wealthier individuals to opt for private care, as this may be quickly available to them and superior in quality (Szebehely & Meagher, Reference Szebehely and Meagher2018). Private care providers provide a wide variety of additional services to those who can afford them (Thorslund et al., Reference Thorslund, Bergmark and Parker1997; Grenier et al., Reference Grenier and Guberman2009).
While some articles argue that means-testing is de-universalising (Szebehely & Meagher, Reference Szebehely and Meagher2018), others believe that, to avoid de-universalisation of access to good quality social care and ensure that less advantaged individuals in society have access to the social care they need, eligibility criteria related to the income of care recipients may become relevant in resource allocation decisions. eg. access to some types of social care, such as mobility aids, can be means-tested (Van Eenoo et al., Reference Eenoo, Declercq, Onder, Finne-Soveri, Garms-Homolová, Jónsson, Dix, Smit, Hout and Roest2016; Durocher et al., Reference Durocher, Wang, Bickenbach, Schreiber and Wilson2019). Based on the included articles, the rationale behind such criteria is ‘to provide something to everyone, but the greatest help to those with the fewest resources’ (Equality and Human Rights Commission, 2009). It should be noted that reducing related inequalities by applying income-related eligibility criteria may benefit those with the fewest resources but may disadvantage those whose incomes are just above the eligibility threshold (Durocher et al., Reference Durocher, Wang, Bickenbach, Schreiber and Wilson2019). In the UK, where publicly funded social care is only available for individuals with high needs and few private resources, approximately 70 per cent of low earners are likely to be ineligible for any state funding for social care services, yet their incomes are insufficiently high to afford private care (Equality and Human Rights Commission, 2009).
3.4. Consequences for individuals with limited health literacy skills
To foster individuals’ autonomy, decision-makers are placing increasing emphasis on personal choices and preferences of care recipients by allocating public resources through individual budgets or direct payments (Boyle, Reference Boyle2010; Lymbery, Reference Lymbery2010). This assumes that care recipients are capable of making informed decisions about their care. However, not all individuals possess the skills to behave as ‘responsible consumers’, nor do all individuals wish to take on this role (Clarke, Reference Clarke2006). Differences in health literacy skills – the ability to access, understand, and use information to make decisions about social care – can affect individuals’ capacity to navigate social care systems to obtain the support they need. The reliance on personal agency, together with the lack of explicit decision-making frameworks and decision rules in social care systems, can disrupt the consistent allocation of public resources to individuals based on formal needs-assessments (eg. by a case manager) rather than individuals’ health literacy skills (Keogh et al., Reference Keogh, Pierse, O’Shea, Fitzgerald and Challis2020; Reference Keogh, Pierse, Challis and O’Shea2021; Morris, Reference Morris2004; Peckham et al., Reference Peckham, Williams and Neysmith2014).
Furthermore, the competition over resources in health and social care systems may encourage strategies to shift the responsibility for resource allocation from the macro level to the meso level (Peckham et al., Reference Peckham, Morton-Chang, Williams and Miller2018; Rand et al., Reference Rand and Malley2014). On the meso level, local authorities may safeguard the available budget and curb demand for social care services by (over-)complicating the procedures that need to be followed to obtain access to these services (Rand et al., Reference Rand and Malley2014). Such strategies, whether or not intentional, pose significant challenges for those in need of social care as individuals must possess the health literacy skills to navigate complex procedures and advocate for their needs, as well as have sufficient time to do so (Szebehely & Meagher, Reference Szebehely and Meagher2018; Equality and Human Rights Commission, 2009). As such, differences in the uptake of social care may arise, based on individuals’ ability to process information, navigate institutional systems, and advocate for one’s needs (Clarke, Reference Clarke2006).
The articles included in the review indicate that processing information, navigating procedures and institutional systems, and making responsible choices with regard to obtaining access to social care services may also be more challenging for those who are older, are part of a minority group, or those whose cultural background or mother tongue differs from those dominant in society (Lymbery, Reference Lymbery2010; Szebehely & Meagher, Reference Szebehely and Meagher2018; Clarke, Reference Clarke2006; Campbell, Reference Campbell1987; Durocher et al., Reference Durocher, Wang, Bickenbach, Schreiber and Wilson2019; Brannelly et al., Reference Brannelly and Matthews2010).
3.5. Consequences for individuals across different regions
The discretion of decision-makers responsible for allocating resources to social care is determined by the legal and budgetary boundaries formulated on the national level. In centralised social care systems – where social care policy is formulated on the national level and implemented by local authorities – it may be expected that individuals with similar needs receive the same level of support, regardless of exactly where they live within a country. However, the implementation of national policy that follows the principle of horizontal equity may be hampered by local circumstances, resource constraints, or differing interpretations of national policy (Turvey et al., Reference Turvey and Fine1996; Cambridge et al., Reference Cambridge and Ernst2006; Van Eenoo et al., Reference Eenoo, Declercq, Onder, Finne-Soveri, Garms-Homolová, Jónsson, Dix, Smit, Hout and Roest2016; Peckham et al., Reference Peckham, Morton-Chang, Williams and Miller2018; Reference Peckham, Williams and Neysmith2014; Morris, Reference Morris2004; Hirdes et al., Reference Hirdes, Poss and Curtin-Telegdi2008). Locally implemented austerity measures may, consequently, result in local variation (eg. between municipalities in a country) that cannot be justified on the basis of variation in individuals’ needs for social care (Wong et al., Reference Wong and Leung2012; Turvey et al., Reference Turvey and Fine1996; Peckham et al., Reference Peckham, Williams and Neysmith2014). Such differences in social care provision may not only be unjustified but also create uncertainty about whether an individual will receive the same level (and type) of support elsewhere, even if their needs remain unchanged. This, in turn, restricts individuals’ freedom of movement (Equality and Human Rights Commission, 2009; Morris, Reference Morris2004).
In more decentralised social care systems – where regional or local authorities enjoy policy discretion to provide social care in view of local needs – variations in the provision of social care are more likely and may be justified by differences in local needs and priorities (Cambridge et al., Reference Cambridge and Ernst2006; Wiles et al., Reference Wiles, Leibing, Guberman, Reeve and Allen2012). Although decentralised social care systems provide decision-makers on the meso level considerable policy discretion to foster efficiency, as well as local accountability, transparency, and scope for innovation (Cambridge et al., Reference Cambridge and Ernst2006), decentralisation does not preclude the existence of any nationally formulated policy on the allocation of social care resources. Moreover, while the discretion of decision-makers on the regional or local levels may justify local variation in social care provision based on local differences in need (Thorslund et al., Reference Thorslund, Bergmark and Parker1997; Szebehely & Meagher, Reference Szebehely and Meagher2018), some studies included in the review describe significant local differences in social care provision in Norway and Sweden that cannot be justified on these grounds, raising concerns about ‘geographical equality and fairness’ (Forbes et al., Reference Forbes and Edge2009; Thorslund et al., Reference Thorslund, Bergmark and Parker1997; Szebehely & Meagher, Reference Szebehely and Meagher2018).
Furthermore, variation in social care provision may also occur on the micro level, depending on the time individuals apply for social care and on the professional assigned to manage the applications. To adequately respond to individual needs, social care professionals enjoy at least some allocative discretion (Peckham et al., Reference Peckham, Williams and Neysmith2014). Based on the included articles, allocation decisions may be informed by subjective interpretations of need and other subjective perceptions, such as expectations of informal caregivers and preferences of the care recipient (Peckham et al., Reference Peckham, Williams and Neysmith2014; Equality and Human Rights Commission, 2009; Peckham et al., Reference Peckham, Morton-Chang, Williams and Miller2018; Morris, Reference Morris2004; Keogh et al., Reference Keogh, Pierse, O’Shea, Fitzgerald and Challis2020; Reference Keogh, Pierse, Challis and O’Shea2021).
4. Discussion
The objective of this study was to examine the consequences for equitable access to social care of decisions on the allocation of social care resources. Thirty-seven articles reported on the consequences for individuals with long-term social care needs, informal caregivers, socio-economically disadvantaged groups, individuals with limited health literacy skills, and individuals across different regions, on which we reported in sections 3.1 to 3.5. Our findings indicate that resource allocation decisions can potentially result in inequitable access to social care.
Our main findings suggest that individuals with long-term needs may face reduced access to social care compared to individuals with short-term or post-acute needs. Our main findings also indicate that the shift of responsibility for social care to informal caregivers in response to resource constraints and growing demand for social care may disproportionally affect women, undermining efforts to reduce gender inequalities in society. This consequence may be compounded by our finding that those in society who are less advantaged (ie. those with a lower socio-economic status or with limited health literacy skills) may be disproportionally affected by the consequences of resource allocation decisions. Evidence suggests that these groups depend more heavily on informal care (Broese van Groenou et al., Reference Broese van Groenou, Glaser, Tomassini and Jacobs2006; Mackenbach, Reference Mackenbach2019). As a result, the caregiving burden may be disproportionately high among less advantaged groups in society, and the related social and financial consequences of caregiver burden may sustain existing disadvantages. Further quantitative research is needed to examine the severity and long-term impact of these consequences for specific individuals or groups in society.
These findings suggest that access to social care services may, all else equal, differ between more or less advantaged individuals in society, and conflict with the principle of horizontal equity. Moreover, our finding that consequences of decisions on the allocation of resources to social care may affect some more than other stand in contrast with values upheld by citizens as regards the provision of social care. Based on evidence from the UK, citizens value equity and universality in social care provision (Involve and House of Commons, 2018). Individuals struggle to save for future social care needs and may prefer to pay more taxes to finance a public social care system that guarantees universal access to services (Dixon et al., Reference Dixon, Trathen, Wittenberg, Mays, Wistow and Knapp2019; Sussex et al., Reference Sussex, Burge, Lu, Exley and King2019). Combined with our findings, these findings suggests a disconnect between public preferences and resource allocation in social care, which highlight the need for decision-makers to consider the consequences for equitable access in the allocation of scarce public resources to social care.
Moreover, our findings that the provision of social care services to individuals may depend on the decision-maker assigned to manage the applications, and the local interpretation and implementation of social care policy also suggest potential for horizontal inequity. Together with our finding that complex decision-making processes affect less advantaged individuals more severely as these individuals struggle to navigate complex application and appeal procedures, this underscores the importance of the provision of information to foster equitable access to social care. Such differences between more and less advantaged groups in society have also been described with respect to access to (curative) healthcare services (Paasche-Orlow & Wolf, Reference Paasche-Orlow and Wolf2007; Mackenbach, Reference Mackenbach2019). Further research is warranted to determine whether and to what extent decision-makers are aware of the consequences of resource allocation on social care.
Finally, local variation in the interpretation and implementation of social care policy may create disparities in access to social care across regions. Although in decentralised social care systems, local variation in the provision of social care services to individuals with similar needs may be considered democratic and legally permissible, such variation can create legal uncertainty to those in need for support and hamper effective access to social care. In 2012, the European Committee of Social Rights judged that significant local differences violate individuals’ social rights as protected by the Revised European Social Charter (Council of Europe, 1961; EUROPEAN COMMITTEE OF SOCIAL RIGHTS, 2012). More recently, the Committee on the Rights of Persons with Disabilities concluded that in the Netherlands, the lack of harmonisation in implementation across all levels of government resulted in inconsistencies and highly uneven support for persons with disabilities (Committee on the Rights of Persons with Disabilities, 2024). This echoes the need to consider the potentially discriminatory consequences of policies and decisions on the allocation of social care resources.
As regards this study, we want to highlight two limitations. First, the search string used was developed to gain broad insight into the underpinnings of decisions on the allocation of resources to social care and did not specifically include ‘consequences’ or ‘outcomes’. While inductively analysing the data, we observed that the consequences of these decisions were frequently described in relation to the underpinnings of these decisions. As such, we captured the consequences of these decisions in a stand-alone theme which we presented here. However, we may not have captured consequences of decisions made based on underpinnings other than those identified in the systematic review. Indeed, there may be other consequences that warrant further research and attention. Second, while none of the included articles provide a clear definition of what constitutes equitable access to social care, the original authors may have held some implicit notion of equity that have influenced our results.
5. Conclusions
This study provides insight into the consequences of decisions on the allocation of social care resources. Our findings signal that the consequences of such decisions, such as increased reliance on informal caregiving and private means, may put already disadvantaged groups in society – such as women, those from socio-economically disadvantaged groups and with limited health literacy – at a disadvantage with respect to their health and well-being. Furthermore, inconsistencies between national policy and local implementation introduce potential for local variation in the provision of social care services to individuals with similar needs. Further quantitative research is needed to examine the magnitude and distribution of the identified consequences of resource allocation decisions for different groups in society. For example, future studies could use quantitative methods such as surveys or administrative data analysis to assess the impact on lower-income groups, informal carers, and older adults with limited support networks. Additionally, qualitative research could further explore how individuals experience these consequences and how national financing schemes may mitigate them. Nonetheless, our findings illustrate the importance for decision-makers of considering these consequences. Equitable access to social care may further contribute to the sustainability of publicly funded social care systems, as timely and adequate access prevents deterioration of individual’s health or well-being.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1744133125100327
Data availability statement
The datasets generated and/or analysed during the current study are available in the Dataverse data repository, https://doi.org/10.34894/QMRWK3.
Financial support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Open access funding provided by Erasmus University Rotterdam.
Competing interests
The authors declare that they have no competing interests.
Ethical standards
Not applicable.
Consent for publication
Not applicable.
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