Empowering care users

For many years now a narrative of empowering care users has featured heavily in international and national policy debates about improving the quality of long-term care. The argument for empowering care users is rooted in an understanding of autonomy as critical to a person’s quality of life and therefore to successful ageing (Clark, Reference Clark1988). The idea of increasing the autonomy of users of long-term care services has been implemented in various ways in many countries, for example Israel, Japan, the United States, many European countries and Taiwan, China (Moilanen et al., Reference Moilanen, Kangasniemi, Papinaho, Mynttinen, Siipi and Suominen2021). Initiatives to empower older people have been closely associated with the consumer movement of the last century and marketisation reforms. They have frequently emerged as a reaction against paternalistic services that tend to overwhelm individual preferences and expressions of control, as captured by the concepts of ‘total’ institutions or ‘one-size-fits-all’ services. In many countries, initiatives to develop more modern services that give people greater autonomy have coalesced around the concept of ‘personalisation’ or ‘person-centredness’, which broadly require that people can direct decisions about their care and services are designed around the person (McCormack et al., Reference McCormack, Roberts, Meyer, Morgan and Boscart2012).

To give older people greater autonomy over their care, the most significant policy has been cash for care schemes (Lundsgaard, Reference Lundsgaard2005). Under these schemes people are given cash payments in lieu of services. The rationale is that care meeting the older person’s preferences can best be met through giving them the money to choose the care they want. In addition to the positive effect of this increase in autonomy on their quality of life, through exerting their choice in markets it is argued that older people will drive quality improvements in care. Although such schemes are found in many countries (e.g., the Netherlands, Germany, the United Kingdom and Taiwan, China) there is substantial variation in how cash for care schemes operate and the rules around how cash can be spent. Differences tend to reflect the reason for offering cash benefits, such as encouraging informal care provision, and range from having choice over the type of services or care provider to being able to hire and supervise care staff (personal assistants) (e.g., England) or employ family members (e.g., the Netherlands) (Zigante, Reference Zigante2018; da Roit & Gori, Reference da Roit and Gori2019).

Despite the growth of cash for care schemes internationally there is limited evidence about their impact on the quality of long-term care. In one of the few literature reviews, Low et al. (Reference Low, Yap and Brodaty2011) found that cash for care schemes improve satisfaction with care and community service use but had little effect on care outcomes. The review includes findings from an evaluation of the Individual Budgets programme in England (a form of cash for care), which showed that individual budgets made users feel more in control of their care but an impact on other aspects of quality of life was not identified. Given the current era of austerity, there are also concerns about how well cash for care schemes work in practice (Pearson & Ridley, Reference Pearson and Ridley2017). Issues are reported around the level of the cash payments (da Roit & le Bihan, Reference da Roit and le Bihan2010) and this has given rise to concerns over whether they are large enough to cover the care package the older person needs (let alone wants) and equally, whether there is a workforce in the local area willing and able to take up the work. Some argue that in European countries, cash for care schemes have ‘de facto converted into policies supporting either informal care, low-paid market care, or both’ (da Roit & Gori, Reference da Roit and Gori2019: 518), with consequences for quality (see discussion around professionalisation below).

Cash for care schemes focus largely on giving older people greater choice over their care, but empowering older people is not simply about offering them choice (Kane & Kane, Reference Kane2001). For older people to be empowered with respect to long-term care, there is a need to address wider structures within society and long-term care systems that influence how older people are seen and treated, especially around attitudes towards safety and protection that can unnecessarily limit what people can do, with impacts on their quality of life (Kane & Kane, Reference Kane2001; Clarke, Reference Clarke2007). There is also a need for a more nuanced debate around how autonomy can be realised in practice. Research illustrates that many older people can be reluctant to take control of decisions about their care (Baxter et al., Reference Baxter, Rabiee and Glendinning2013; Ottmann et al., Reference Ottmann, Allen and Feldman2013). Greater attention needs to be given to how older people can be enabled to strike a balance between being independent and receiving support as they age, including enabling them to make informed choices. Public reporting of quality information, discussed later in this chapter, is an important aspect of this.

Professionalisation of care work and investment into the workforce

For many countries, professionalising the workforce is a key strategy for improving the quality of long-term care. With respect to improving quality, the aim of professionalisation is to ensure that workers have the right skills, experience and up-to-date knowledge to deliver high-quality and safe care. Professionalisation includes a number of strategies such as: registration and regulation of the workforce; education, training and continuing professional development; and improving pay, progression and working terms and conditions (OECD, 2020; Hemmings et al., Reference Hemmings, Oung and Schlepper2022). Countries take different approaches to professionalisation, mixing strategies within these three broad areas, but much of the evidence examines the effects of professionalisation on recruitment and retention of workers as opposed to long-term care quality. This is because these strategies are also, even if not primarily, motivated by attracting and retaining workers to address the challenges almost all countries face of finding enough care workers to meet the demand from an ageing population (OECD, 2020), as discussed in chapter 2 of this volume.

Educational and training requirements for long-term care workers are generally low across OECD countries, and in many countries no qualification is required to become a care worker (OECD, 2020). It is increasingly recognised that this is problematic: as older people are living longer with multiple long-term conditions their needs have become increasingly complex and care work is becoming an increasingly skilled job. This makes upskilling through training and continuing professional development more important for quality. Countries have tried different approaches including mandatory training requirements, granting workers rights to training, integrating training with the health sector through placement rotations and training in health interventions, and training targeted at underrepresented groups, such as men and younger people (OECD, 2020; Hemmings et al., Reference Hemmings, Oung and Schlepper2022). While there is not evidence for the impact of all of these approaches, the evidence does show that quality of care is influenced by the skills and expertise of staff as well as the environment and culture in care facilities (Haunch et al., Reference Haunch, Thompson, Arthur, Edwards, Goodman and Hanratty2021), and that quality, as measured by clinical outcomes such as pressure ulcers and urinary tract infections, is better in nursing homes with higher levels of more qualified staff (Clemens et al., Reference Clemens, Wodchis, McGilton, McGrail and McMahon2021). Indeed, Clemens et al. (Reference Clemens, Wodchis, McGilton, McGrail and McMahon2021) argue their review suggests that as the complexity of older people’s needs increases, replacing more qualified staff with less qualified staff risks negatively affecting the quality of care.

Too strong a focus on professionalisation of the workforce also poses risks with respect to quality. A highly professionalised workforce is likely to be a more expensive workforce. Long-term care is already seen as unaffordable by many and governments have not shown a willingness to spend proportionately more public money on funding long-term care. Without sufficient funding and with strict enforcement of professional staffing requirements, there is a danger that workloads increase or more expensive workers, such as nurses, may be displaced by less expensive or unqualified workers, undermining the goal of professionalisation. Therefore, any steps to professionalise the workforce need to be planned carefully so as not to adversely affect retention or increase the unqualified workforce (Hemmings et al., Reference Hemmings, Oung and Schlepper2022). However, as discussed in chapter 8, improvements in workforce training, and consequently in the quality of the long-term care provided, can boost economic growth as it can induce family caregivers to remain in jobs and/or choose more productive careers, because those they provide care to will instead receive care from trained aides.

The unqualified workforce is already significant in most countries given the heavy reliance on what is known as informal, or unpaid, care (provided by family members, neighbours and friends) (OECD, 2020). Given the importance of informal carers to long-term care, it is argued that governments should also aim to enhance the quality of care they provide (Schneider et al., Reference Schneider, Sundström, Johannson, Tortosa and Gori2015). Some countries, including Sweden, Germany, the Netherlands, Spain and England, have invested in training and support schemes for informal carers to support quality, but this approach is patchy and often dependent on local provision (see Zigante, Reference Zigante2018 for an overview).

Arguably more problematic with respect to long-term care quality, forms of temporary contracts are common in the long-term care sector (e.g., Japan, Spain, France, United Kingdom) and undeclared employment by migrant workers is a concern (OECD, 2020). The latter is found particularly in countries with policies that support the private hire of personal assistants in the home (e.g., cash for care, substantial co-payments for home care services and an undersupply of home care services). In Western European countries with access to relatively cheap labour in Central and Eastern European countries, these workers are often migrant carers who live in private households (Schwiter et al., Reference Schwiter, Strauss and England2018). There is evidence of substandard care and poor working conditions among this workforce (Simmons et al., Reference Simmons, Rodrigues and Szebehely2022). Although some countries (e.g., Austria) have taken steps to regularise these workers, the lack of oversight and regulation of this workforce in other countries (e.g., Italy) raises ongoing concerns about the quality and safety of care for older people as well as precarity of employment for the care workers (da Roit & Moreno-Fuentes, Reference da Roit and Moreno-Fuentes2019).

Ageing in place

Formal care systems have traditionally been focused on residential care forms of care, such as nursing homes, but for many years there has been a drive towards ‘ageing in place’. This has been defined as ‘the ability of older people to live in their own homes and communities safely, autonomously, and comfortably, regardless of age, income, or functional limitations’ (Low et al., Reference Low, von Humboldt, Kalfoss, Wilson, Leal, Gu and Dupre2021:1). It is argued that more personalised (i.e. better-quality) care can be provided in the older person’s own home and that it can help people to maintain connections with family and friends (i.e. better outcomes) (Wiles et al., Reference Wiles, Leibing, Guberman, Reeve and Allen2012; Stones & Gullifer, Reference Stones and Gullifer2016; Low et al., Reference Low, von Humboldt, Kalfoss, Wilson, Leal, Gu and Dupre2021). The evidence suggests that older people prefer to remain in their own home and communities as they age, at least until such time as they perceive that their care needs are too great (Lehnert et al., Reference Lehnert, Heuchert, Hussain and König2019). Yet, it is very difficult to find evidence in favour of ageing in place over institutional long-term care on grounds of quality, since an unbiased comparative evaluation of these alternatives is extremely difficult.

While ageing in place is a valuable ambition for long-term care systems, it is clear that it is not a panacea. Importantly, it brings new challenges for quality. The neighbourhoods in which people live can become more hostile and challenging as people age; in particular urban environments across the world have been found to lead to exclusion and loneliness (Judd et al., Reference Judd, Tanoue and Liu2020; Lewis & Buffel, Reference Lewis and Buffel2020). Ageing in place is generally considered to be cheaper than the equivalent care in an institution, but it can become more expensive (Bakx et al., Reference Bakx, Wouterse, van Doorslaer and Wong2020), especially where people have very complex needs and live in poorly designed inaccessible housing, which is unfortunately the majority of housing in many high-income countries (Smith et al., Reference Smith, Lehning and Kim2018; Judd et al., Reference Judd, Tanoue and Liu2020; Mulliner et al., Reference Mulliner, Riley and Maliene2020). Indeed poorly designed housing can precipitate care needs, for example where there are many steps, or where people are no longer able to maintain their properties causing them to become hazardous (Braubach & Power, Reference Braubach and Power2011). There may also be safety concerns around people being left without supervision, for example if they have dementia, or without access to support when needed, for example for toileting or when thirsty. These factors limit the potential of ageing in place for people who live alone. As we discuss later in this section, innovative solutions are emerging to manage some of these problems (e.g., technologies to support people’s independence), but many of the problems identified require massive, long-term investment and major infrastructure improvements, for example building lifetime homes, renovating the housing stock and making cities and places ‘dementia-friendly’ and ‘age-friendly’. Hence, while it may be possible to improve the balance of care in favour of home-based care, institutional forms of care seem likely to remain a part of the long-term care mix in all countries for the foreseeable future.

A further challenge to ageing in place is dissatisfaction with home care, which has been the cornerstone of most countries’ strategies for ageing in place (Genet et al., Reference Genet, Boerma, Kringos, Bouman, Francke and Fagerström2011). Home care services typically involve visits from care workers to older people’s homes to help them with ADLs such as getting up, getting dressed, washing and mealtimes. Older people report that the timing of visits is frequently unsuitable, for example being put to bed at six in the evening, and that the tasks care workers can and will do are not always those that users would like them to do, with support for socialising, odd jobs, activities and outings being frequently mentioned as lacking in the United Kingdom context (Tarricone & Tsouros, Reference Tarricone and Tsouros2008; Genet et al., Reference Genet, Boerma, Kringos, Bouman, Francke and Fagerström2011). These concerns over home care relate to challenges in managing busy times of the day and rigid contracting practices. In recent years new forms of home care have developed, such as examples based on the Buurtzorg model of self-managing neighbourhood teams from the Netherlands, that deliver a more flexible and holistic service. The evidence suggests that these bring increased staff satisfaction, benefits to users’ wellbeing and a reduction in costs, but most studies are of low quality and it has not been easy to translate this approach to other countries with different long-term care systems (Hegedüs et al., Reference Hegedüs, Schürch and Bischofberger2022).

Changing the culture of residential care

In recent years new models of congregate living have been promoted that are designed to overcome some of the more depersonalising aspects of care homes. The culture change movement aims to make institutions more home-like and person-directed. It is particularly strong in the United States, where a network exists to promote it, and it includes a range of models, such as Green Houses and the Eden Alternative (Koren, Reference Koren2010). The movement has spread to a number of countries (Brownie, Reference Brownie2011), and similar types of models have emerged elsewhere, such as My Home Life in the United Kingdom (Owen, Reference Owen2013). In Europe, initiatives associated with the movement are sometimes referred to as the household or home model of care, reflecting the preference for specially-designed, small-scale, home-like environments where a small number of people live together (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009; Ahmed et al., Reference Ahmed, Ormandy and Seekles2019). Many of these household models have been developed specifically for people with dementia, including concepts such as group homes, Cantou and more recently the Green Care Farms in the Netherlands (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009; de Boer et al., Reference de Boer, Hamers, Zwakhalen, Tan, Beerens and Verbeek2017).

There are difficulties determining the impact of culture change and household models as there are many variants and what is implemented can also vary considerably (Brownie & Nancarrow, Reference Brownie and Nancarrow2013; Ausserhofer et al., Reference Ausserhofer, Deschodt, de Geest, van Achterberg, Meyer and Verbeek2016). Despite these challenges, the evidence suggests they are generally popular with their users. A systematic review found that these programmes are associated with positive impacts on staff outcomes, improvements in the psychological status of residents, and reduced levels of agitation in residents with dementia. These benefits, however, may come at the expense of an increased risk of falls (Brownie & Nancarrow, Reference Brownie and Nancarrow2013). Additionally, implementing culture change is far from straightforward, since it depends on existing homes adopting the measures. A key barrier is the cost of introducing environmental improvements. Among other challenges it can be difficult to meet quality regulations (especially around the management of health and safety) while staying true to the model (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009; Miller et al., Reference Miller, Miller, Jung, Sterns, Clark and Mor2010; Kapp, Reference Kapp2013; Corazzini et al., Reference Corazzini, Twersky, White, Buhr, McConnell and Weiner2015). As a consequence of these challenges, although awareness and uptake of these models is growing, they remain on the periphery of provision (Miller et al., Reference Miller, Miller, Jung, Sterns, Clark and Mor2010).

Technology to enhance and improve care settings

TechnologyFootnote ¹ also has a role to play in making services safer and more productive and enabling people to age in place. It has risen in prominence in recent years and particularly so during the Covid-19 pandemic, as people sought ways to keep people safe and connected while minimising face-to-face contact (Chu et al., Reference Chu, Ronquillo, Khan, Hung, Boscart and Miller2021). There are numerous technologies that can help organisations to deliver better and safer long-term care and help older people to age in place, but evidence of the impacts of these solutions on the quality of care is variable and generally fairly limited (for a recent review see Zigante, Reference Zigante2020). There are also well-known problems with adoption and routinisation of technologies in care settings, including the need for staff training especially if their digital literacy is limited, and acceptability for staff and older people (Greenhalgh et al., Reference Greenhalgh, Wherton, Papoutsi, Lynch, Hughes and A’Court2017). There is a vast array of technologies that can support ageing in place, and we highlight as examples a few for which there is a more substantial evidence base (for reviews see Carretero, Reference Carretero2014, Reference Carretero2015; Czaja, Reference Czaja2016). While our focus here is on how technology can enhance quality, the role of technology in improving efficiency and access to long-term care is also discussed in chapter 4 of this volume.

‘Smart home’ technology is increasingly researched as a means to enhance the quality of long-term care for people ageing in place. This includes technologies that contain a degree of artificial intelligence, such as wearable devices and other sensors, communication devices or connected devices for remote control operation. Marikyan et al. (Reference Marikyan, Papagiannidis and Alamanos2019) identified the core functions of smart home technology as offering comfort, access to care and improving users’ safety. Smart homes can provide monitoring and disease management and enable care staff to monitor health remotely and detect life threatening changes early, as well as provide medical care when necessary. Smart home applications can also support virtual medical ‘visits’, meaning older people do not have to make tiring and potentially difficult trips to clinics and hospitals (Czaja, Reference Czaja2016). There is evidence that smart homes can improve socialisation and help users overcome the feeling of isolation (Marikyan et al., Reference Marikyan, Papagiannidis and Alamanos2019). There is also evidence that smart home solutions help older people carry out everyday activities, improve physical safety and social communication. Older people reported that smart homes improved their sense of security, quality of daily life and activities, and provided them with information about the care they could receive (Turjamaa et al., Reference Turjamaa, Pehkonen and Kangasniemi2019).

Another type of technology that supports ageing in place is ICT. A systematic review found that these technologies have a positive, yet short-term, impact on social support, social connectedness and social isolation among older people living independently, although the results for loneliness were inconclusive (Chen & Schulz, Reference Chen and Schulz2016). Examples of ICT included in the review were the use of communication tools (landline phones, smartphones, tablet computers, email and online chat rooms or forums) and high-technology apps (Wii, television gaming systems and GeriJoy, a virtual pet companion) which consistently reported a positive effect. Although noting a dearth of rigorous research, the review concluded that older people can benefit from ICT interventions and will use them frequently after proper training (Chen & Schulz, Reference Chen and Schulz2016). There is also evidence that ICT can be supportive of high-quality dementia care in care homes (see Goh et al., Reference Goh, Loi, Westphal and Lautenschlager2017) and social interaction in care homes, although more evidence is needed (Macdonald et al., Reference Macdonald, Yu, Weeks, Moody, Wilson and Almukhaini2021).

Management of quality

A key tool for organisations to improve quality is active quality management. Quality management rose to prominence as the quality movement gained momentum, introducing and adapting techniques for quality control from manufacturing to service industries and the public sector. Quality management systems provide organisations with a framework for measuring and monitoring quality and acting on the results. The focus of quality management systems is on achieving continuous quality improvement, and in this way they are different from quality standards and accreditation, which are tools used by governments to control the behaviour of organisations and provide a minimum level of quality. There are numerous examples of systems (e.g., ISO, EFQM, E-Qalin) which have been taken up to different extents by organisations in different countries (for reviews see Nies et al., Reference Nies, Leichsenring, Holdsworth, van der Veen, Rodrigues and Gobet2010; Cès & Coster, Reference Cès and Coster2019). Some quality management systems include third-party certification linked to the use of internal quality management and self-assessment of quality, resembling voluntary accreditation schemes.

Reviews suggest that quality management systems are widely used by provider organisations across countries (Nies et al., Reference Nies, Leichsenring, Holdsworth, van der Veen, Rodrigues and Gobet2010; OECD/European Commission, 2013). In some countries, such as England, adoption is high because the care standards require providers to have quality management systems in place. There does seem to be a willingness among providers to adopt these systems and participate in voluntary accreditation schemes because they are seen to signal quality in a competitive market. Their adoption in countries with less competitive markets suggests that this may be as much about attracting older people as it is about attracting and retaining staff (Malley et al., Reference Malley, Trukeschitz, Trigg and Gori2015).

Importantly, digital technology also has a place in supporting quality management. To date it has been used more widely for surveillance, such as monitoring the timeliness and duration of visits by home care staff (Moore & Hayes, Reference Moore, Hayes and Moore2018). Increasingly, however, as organisations introduce digital systems for care records, medicines management and other forms of monitoring (e.g., of vital signs or sleep) the data collected can be used to support audits and spot patterns in behaviours that can be targeted for quality improvement activities (Kruse et al., Reference Kruse, Mileski, Vijaykumar, Viswanathan, Suskandla and Chidambaram2017). At present, however, most provider organisations lack the capacity and skills to analyse the data collected and use it to full effect (Ko et al., Reference Ko, Wagner and Spetz2018). More broadly there is relatively little evidence of care homes developing quality improvement expertise (Chadborn et al., Reference Chadborn, Devi, Hinsliff-Smith, Banerjee and Gordon2021).

Markets for long-term care

As already mentioned, most countries operate quasi-markets for long-term care provision. This generally refers to a situation where state-funded services are provided by a plurality of independent providers who compete for business from state-appointed purchasers (i.e. commissioners/procurers of long-term care) or directly from users. In many cases quasi-markets were introduced as part of the wave of New Public Management reforms that swept across many countries towards the end of the last century (European Social Network, 2021). The rationale tended to be to promote choice for users, improve quality and reduce costs by subjecting providers to competitive forces (Lundsgaard, Reference Lundsgaard2005). The characteristics of quasi-markets vary substantially across countries in terms of how financing works, how and when independent providers are allowed to engage in the market, as well as the regulations that govern the markets. For example, in Sweden certain municipalities allow independent providers while others operate a combination of public and private providers (Zigante & King, Reference Zigante and King2019). Whether these reforms have produced the desired effects is debated and the evidence around this (which comes largely from studies of the United States nursing homes market) is mixed with respect to its impact on quality. It depends on the methods used, the country (with some positive effects on quality from United States studies and negative from United Kingdom studies) and the presence of certain institutional features, such as public reporting of quality information, meaning it is important to understand the country context. The most consistent finding across studies is that competition depresses prices (for reviews see Forder & Allan, Reference Forder and Allan2011; Yang et al., Reference Yang, Yong and Scott2022).

There are many reasons why long-term care markets may not deliver good quality care. These include individual-level factors such as lack of, or difficulties assessing, information about quality of services a priori, reluctance on the part of users and families to switch providers (in particular care homes) and a distorted relationship between price and quality due to co-payments by the user and the local government/the state. There are also structural factors including the market power of public purchasers potentially leading to unsustainable prices, the cost of withdrawing contracts for publicly funded care (even when quality is poor), and market behaviours including private providers cream-skimming (selecting people who are easier to care for) and locating in densely populated wealthier areas (for a wider discussion of market failures, see Corlet Walker et al., Reference Corlet Walker, Druckman and Jackson2022, and chapter 5 of this volume. Consequently, it is argued that a range of conditions must be addressed in order to realise the benefits from marketised long-term care provision and that it is crucial for governments to regulate long-term care markets to ensure at least a minimum level of quality. Key mechanisms for influencing the quality of long-term care markets are oversight and public reporting of information which we address next.

Oversight for quality

The goal of quality oversight is to address the problem of ‘bad apples’ by imposing external regulatory controls to ensure a minimum standard of quality and safety across care providers. Oversight systems for quality assurance tend to consist of three elements: a method for setting standards or directions, a method of surveillance for detecting compliance with the directions, and a method for enforcing compliance, should instances of noncompliance be detected (Hood et al., Reference Hood, Scott, James, Jones and Travers1999). Responsibility for regulating the entry of providers, inspection and enforcement actions may be held by a single national regulator or multiple regulators, often at arms-length from government, or by a patchwork of regional organisations (Nies et al., Reference Nies, Leichsenring, Holdsworth, van der Veen, Rodrigues and Gobet2010; Cès & Coster, Reference Cès and Coster2019). Countries also vary considerably in how they implement these elements, but often combine a mechanism for regulating entry of new providers to the market (i.e. accreditation, registration, certification) with a form of inspection to ensure providers continue to meet minimum standards while they are in operation (Mor et al., Reference Mor, Leone and Maresso2014; for a discussion and examples see Cès & Coster, Reference Cès and Coster2019; Zigante & King, Reference Zigante and King2019). There is often a close relationship between the system for oversight and other mechanisms for quality improvement. For example, in some countries quality management systems are mandated through standards and there is often a relationship with public procurement of long-term care, for example with accreditation/authorisation a pre-requisite for access to public funds (European Social Network, 2021).

As a strategy to improve quality, oversight is often seen as expensive and its effectiveness is debated. Key challenges relate to: the degree of alignment between the standards and the goals of the system, especially in countries that rely solely on structural indicators of quality (e.g., single rooms, staff ratios); how standards can be adequately and appropriately measured; and the costs of surveillance and inconsistencies in measurement, especially for process and outcomes based standards, which rely on assessment by inspectors. In promoting or enforcing compliance, there is a further challenge involved in achieving a balance between strong sanctions and deterrence to identify ‘knaves’ on the one hand, and persuasion and education to ensure the system does not crowd out ‘knightly’ motivations on the other (for a more detailed discussion and description of approaches in countries see Mor et al., Reference Mor, Leone and Maresso2014; Malley et al., Reference Malley, Trukeschitz, Trigg and Gori2015; Cès & Coster, Reference Cès and Coster2019; Zigante & King, Reference Zigante and King2019).

Public reporting of quality information

One reason long-term care markets fail is that they are subject to imperfect and asymmetric information. Older people are unable to assess the quality of care options with certainty prior to purchase due to a lack of easily searchable or comparable information about aspects of quality that matter, such as outcomes and experiential information (for a discussion see Konetzka et al., Reference Konetzka, Yan and Werner2021). The purpose of public reporting is to correct this information problem by providing older people with information about quality that will inform their choice of provider and increase the probability of going to a high-quality provider. It is also argued that providers will be incentivised to improve their performance, to bolster their reputation and ensure they do not lose market share (Berwick et al., Reference Berwick, James and Coye2003).

Much of the academic research around the effects of public reporting comes from the United States where information about the quality of nursing homes has been available for over two decades now via the website Nursing Home Compare (now Care Compare). In a wide-ranging review Konetzka and colleagues (Reference Konetzka, Yan and Werner2021) report evidence for a modest but meaningful change in provider behaviour and older people’s choice behaviour, but note that this was only apparent after the (simpler) five-star ratings system for providers was introduced. More negatively, there was also evidence of providers gaming the system, focusing only on improving aspects of quality that were measured, and some indications that the policy is exacerbating disparities by race, ethnicity and income. There is much less evidence of the impact of public reporting schemes from other countries, which differ in terms of the range and format of quality information reported (Rodrigues et al., Reference Rodrigues, Leichsenring and Winkelmann2014). However, the evidence presents similar challenges to those found in the United States around the use of information by older people to choose providers. This suggests that the impact of public reporting is not likely to be substantially different in other countries, although it may be tempered by the degree of competition in markets and other features of the long-term care systems.

Notably in countries where public reporting occurs there appears to be fairly low awareness of the quality information that is made available. Questions are also raised about whether the publicly reported information covers the kind of experiential information people want and the ability of older people to play the role of the empowered consumer who actively seeks out detailed quality information. Most older people choosing care (and especially care homes) make this decision at a time of considerable stress, and evidence suggests that they require support to access the information and make use of it. In chapter 3 in this volume, other scholars have discussed how even eligibility rules to public long-term care benefits can be characterised by very different degrees of transparency and ease of access. Mistrust in the information available undermines its use, highlighting the importance of users having confidence in its reliability. Additionally, for most people quality is also not the only consideration – location and availability of places are more important. The general conclusion from the accumulated evidence is that public reporting is a part of the solution to improving quality, but more effort is required to improve the information, raise awareness and support older people to make use of it (Rodrigues et al., Reference Rodrigues, Leichsenring and Winkelmann2014; Trigg et al., Reference Trigg, Kumpunen, Holder, Maarse, Solé Juvés and Gil2018; Konetzka et al., Reference Konetzka, Yan and Werner2021).

Standardisation of care practices

Drawing inspiration from the evidence-based practice movement, a further mechanism for improving quality is standardisation of care practice. The aim is to ensure that care everywhere aligns with what is evaluated to be best practice. This strategy differs from standard setting associated with oversight in that it intends to move organisations away from a focus on delivering minimum standards towards a focus on delivering the best standards (OECD/European Commission, 2013). To facilitate the standardisation of care practice, however, an infrastructure is needed for generating evidence of good care practice, evaluating the evidence collected and synthesising it into guidelines. These guidelines then need to be adopted by organisations if they are to lead to the standardisation of care practice across organisations; all the evidence suggests that this requires as much investment and effort in the long-term care arena as it does in others (Diehl et al., Reference Diehl, Graverholt, Espehaug and Lund2016).

While there is a tradition of developing and using clinical guidelines in medical care, to date there has been much less attention given to developing and using guidelines to standardise the nursing and social care provided by long-term care workers and organisations. One area of care practice that has received more attention is the process for measuring and assessing needs, where standardisation is lacking (this is discussed in chapter 3 in this volume). All OECD countries use some form of needs assessment to assess the degree of disability and allocate benefits to older people, and in a growing number of countries standardised instruments are mandated (e.g., United States, France, Canada). A popular instrument is the interRAI (resident assessment instrument), which supports the assessment of needs, care planning, resource allocation and the monitoring of changes in needs over time. A major challenge with these tools is that they may not be sensitive enough to the varying needs of such a diverse group of people and can inhibit the tailoring and personalisation of care, hence some countries allow greater discretion in how the tools are applied in practice (for an extended discussion see OECD/European Commission, 2013).

A number of countries (e.g., Australia, Canada, France, Germany, United Kingdom) have developed guidelines for other areas of care practice. While there are guidelines for topics such as social work practice for adults with complex needs and safeguarding of adults in care homes in England, the implementation of these guidelines has not been studied (Bauer et al., Reference Bauer, Tinelli, Weatherly, Anderson, Li and Naidoo2021). The available evidence focuses almost exclusively on the management of aspects of clinical practice (e.g., oral health, medication review, pain protocols, pressure ulcer prevention) within nursing homes (Möhler & Meyer, Reference Möhler and Meyer2015; Diehl et al., Reference Diehl, Graverholt, Espehaug and Lund2016). The accumulated evidence argues for the importance of having implementation strategies specific to the nursing home setting, identifying particular differences in the skills mix of staff, availability of resources and complexity of needs of residents compared to other settings (McArthur et al., Reference McArthur, Bai, Hewston, Giangregorio, Straus and Papaioannou2021). These studies conclude that greater rigour is needed in the development of guidelines and their implementation within long-term care organisations (Möhler & Meyer, Reference Möhler and Meyer2015; Diehl et al., Reference Diehl, Graverholt, Espehaug and Lund2016; Bauer et al., Reference Bauer, Tinelli, Weatherly, Anderson, Li and Naidoo2021).

Procurement of quality services

Many countries have some degree of public procurement of long-term care services, which we understand as the purchasing and contracting of long-term care by public authorities from for-profit or not-for-profit care providers. Procurement of services generally takes place at the local/regional level, except in very small countries where this may be managed at the national level. Procurement is common even in countries where long-term care benefits are provided via cash payments or have a substantial self-funder market as in the United Kingdom (European Social Network, 2021). Public procurement is generally highly regulated, and in the EU specific directives apply, but these allow public authorities to consider quality (and other factors) alongside cost in awarding contracts. In theory, the public authority can use public procurement to increase competition on quality by putting a higher weight on quality criteria and asking providers to compete on both price and quality, or by setting the price and output quantity (e.g., care hours provided) and asking providers to compete on quality criteria only (for examples see Malley et al., Reference Malley, Trukeschitz, Trigg and Gori2015).

In a review of public procurement practices in European countries, countries report a number of challenges affecting their ability to procure high-quality services. These include the bureaucracy of tendering procedures, difficulties ensuring the quality of service delivery and problems with the continuity of provision that affects the ability of providers to create good quality secure jobs (European Social Network, 2021). Given the experiential nature of care quality, public authorities find it particularly challenging to assess and select providers based on quality, so despite the fact most respondents in the review report using quality criteria for procurement it is unclear how informative this information is and the degree to which it (rather than cost) influences decisions (European Social Network, 2021). In England, experience has also been that the often inflexible nature of contracts, which can be highly prescriptive around tasks, may not be working in the best interests of care users (Lewis & West, Reference Lewis and West2014).

Countries have tried a range of mechanisms to improve public procurement practices to ensure that they support and encourage high-quality long-term care. Firstly, some countries (e.g., United Kingdom and examples in Finland) seat procurement within the context of strategic commissioning, which is generally understood as a strategic process of specifying, purchasing and monitoring services to meet the local population’s needs, drawing on analysis and evidence of needs and other market insight (for a discussion see Newman et al., Reference Newman, Bangpan, Kalra, Mays, Kwan and Roberts2012). Central to strategic commissioning is the intention that the decision to purchase services is made based on evidence about whether more value will be gained by purchasing services as opposed to delivering them in-house.

Secondly, and relatedly, there are examples in some countries of public authorities trying to establish greater dialogue and more of a partnership approach with providers, with examples of public authorities accompanying contract monitoring with support to improve and involving providers in the design and development of contracts, which seem to build trust and establish a positive approach to quality improvement (Malley et al., Reference Malley, Zigante and Jones2019; European Social Network, 2021).

Thirdly, in some countries public authorities seek to further incentivise quality, through tying the level of payments to the achievement of quality criteria (i.e. payments for performance), which can include the achievement of specified user outcomes (i.e. outcomes based commissioning) (Malley et al., Reference Malley, Zigante and Jones2019; European Social Network, 2021). As with any incentive scheme there are concerns that it may induce providers to behave in ways that maximise their profit but are not in the spirit of the scheme, including through gaming measures and cream-skimming. In recent years more evidence about the impact of these programmes has started to emerge, largely from the United States. Studies present a mixed picture of the effect of pay-for-performance schemes on the quality of long-term care, with some showing a modest impact. The technical design of schemes with respect to quality measurement is critical. It is also important to get the target and size of the incentives right, as targets that are too distant will disincentivise actors to improve, while too easy a target can perversely reduce quality on targeted measures as good providers reduce their efforts (Norton, Reference Norton2018; Li & Norton, Reference Li and Norton2019).