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Additional file 1: Table 1. Results from the iterative Rasch analyses from the current study in 1211 participants. Table 2. Fit Indices for Each Item in 1211 participants.

In this study, we examine the relationship between formal care provision and informal care receipt from within and outside the household for people over 75 years old using data from the British Household Panel Survey between 1991 and 2009. To address potential concerns about endogeneity of formal care we use a set of instrumental variables including a novel care eligibility variable. We find a negative and statistically significant effect of formal care on informal care from within the household, suggesting a substantial degree of substitutability between these two modes of care. With regards to informal care provided from outside the household, although the effect is still negative, the degree of substitutability is substantially smaller and mostly not statistically significant. These findings support current discussions and policies towards the implementation of an integrated care system, providing grounds for estimates of savings in the cost of informal care enabled by spending on formal care.

Although there is some recent evidence around the effects of obesity on health care utilisation and costs, not much is known about the relationship between obesity and long-term care utilisation (Public Health England, 2013). Few studies from the USA find that obesity increases the risk of nursing home admissions and use of personal care assistance (Elkins et al. 2006, Ziza et al. 2002, Resnik et al. 2005, Yang and Zhang 2014). Nizalova, Gousia and Forder (2017) show that obesity leads to higher use of informal care but find no effect on other types of long-term care. In this study we explore whether the effect on various types of care differs depending on the degree of obesity among older people in England and whether the findings are sensitive to the incorporation of information on long-term care use prior to death. We find that in addition to the obesity at the level of BMI between 25 and 45 representing a risk for future use of informal care, (super) obesity at the level of BMI at 45 and greater represents a significant risk for all types of care use, including social care and nursing home/residential care.

Personal health budgets (PHBs) in England have been viewed as a vehicle for developing a personalised patient‐based strategy within the substance misuse care pathway. In 2009, the Department of Health announced a 3‐year pilot programme of PHBs to explore opportunities offered by this new initiative across a number of long‐term health conditions, and commissioned an independent evaluation to run alongside as well as a separate study involving two pilot sites that were implementing PHBs within the substance misuse service. The study included a quantitative and qualitative strand. The qualitative strand involved 20 semi‐structured interviews among organisational representatives at two time points (10 at each time point) between 2011 and 2012 which are the focus for this current paper. Overall, organisational representatives believed that PHBs had a positive impact on budget‐holders with a drug and/or alcohol misuse problem, their families and the health and social care system. However, a number of concerns were discussed, many of which seemed to stem from the initial change management process during the early implementation stage of the pilot programme. This study provides guidance on how to implement and offer PHBs within the substance misuse care pathway: individuals potentially would benefit from receiving their PHB post‐detox rather than at a crisis point; PHBs have the potential to improve the link to after‐care services, and direct payments can provide greater choice and control, but sufficient protocols are required.

We investigate how other high-income countries have thought about and implemented changes to their funding systems for health and social care to better meet the challenges ahead. This paper is part of a broader project funded by the Health Foundation, which aims to identify a range of feasible options for the future funding of health and social care in the four countries of the UK, and assess the relative (un-)attractiveness of different funding approaches to the general public. The research reported here examines trends and innovations in health and social care funding in a selection of high-income countries. We focus on where the money to pay for care comes from, not on how it is then spent.\ud Drawing on a review of the literature and interviews with 30 key informants in a range of high-income countries, we explore current thinking on the options for funding health care and social care. Our aim is to add to the evidence base and improve the quality of the debate, rather than make recommendations. Specifically, we:\ud • provide examples of funding configurations for health and social care, as well as changes that have been implemented, or are being considered, in a range of high income countries\ud • explore the drivers of recent or planned health and social care funding changes and reforms and the contexts within which decisions around funding were taken\ud • highlight key points that can inform the range of conceivable options for funding health care and social care in the four countries of the UK.\ud Overall we find that:\ud • most reviewed countries fund health care primarily from public sources, such as taxation and mandatory health insurance, while social care often relies to a comparatively greater extent on individuals paying privately\ud • health and social care funding reforms tend to be incremental rather than radical, are path-dependent, and are catalysed by changes in economic conditions rather than by rising demand for care\ud • high-income countries have taken diverse approaches to tackling the need to increase health and social care funding and there is no single optimal, or commonly preferred, solution to achieving sustainable revenues.

Obesity and physical activity rates are known to be strong predictors of disability and functional limitations, and in turn use of health care. In this study we aim to explore whether obesity and physical activity are also significant risk factors for future long-term care need (both informal and formal care). We use regression analysis of data from the English Longitudinal Study of Ageing (ELSA) between 2002 to 2011 to addres this aim. Selection issues are tackled using the rich set of control variables in ELSA; exploiting the longitudinal structure of the data; and accounting for loss to follow-up (including death). Control factors include: impairment (ADLs) and specific existing health conditions – notably diabetes, high blood pressure, and CVD. We find that obese older people are 25% more likely to be in receipt of informal or privately paid care in two year’s time, but this does not hold for formal care. People who are physically active are 38% less likely to be using any care two years later, with the strongest effect for formal care use. Sensitivity analysis suggests that the results are not driven by either prediabetes, or a link between obesity and subjective health and depression, or unobserved factors.

In many countries, public responsibility over the funding and provision of long-term care services is held at the local level. In such systems, long-term care provision is often characterised by significant local variability. Using a panel dataset of local authorities over the period 2002–2012, the paper investigates the underlying causes of variation in gross social care expenditure for older people in England. The analysis distinguishes between factors outside the direct control of policy makers, local preferences and local policy spillovers. The results indicate that local demand and supply factors, and to a much lesser extent local political preferences and spatial policy spillovers, explain a large majority of the observed variation in expenditure.

The Maximising the value of survey data in adult social care (MAX) project aims to develop toolkits, with local authority (LA) staff where possible, to encourage and support LAs to make more use of data drawn from the ASCS and PSS SACE1 to inform local policy and practice. The initial fact-finding phase (MAX Phase 1) activities aimed to:learn more about how LAs currently use ASCS and PSS SACE data, including identifying local practices and barriers; identify potential uses of the data to inform local decision-making; and inform the development of a toolkit to support LAs to make better local use of the data. \ud \ud Along with two analysis and interpretation consultation panel workshops conducted early in the second phase of the project, 139 staff from 95 LAs have so far taken part in MAX. In summary, the findings from these activities demonstrate that LAs generally seem to value the ASCS and PSS SACE and, to some extent, are using the views of service users and carers to inform local service planning and delivery. However, there were several challenges. One of these, identified by just over half of the LAs, concerned analysing the survey data and interpreting the findings to address local questions. A number of barriers seem to underlie this challenge, including difficulties with: identifying local information needs; managing and analysing ASCS and PSS SACE data; and being allocated sufficient time to conduct further analysis.\ud \ud While some LAs find analysing ASCS and PSS SACE data challenging, others are carrying out local statistical analysis, over and above those required for national (ASCOF) reporting. The case studies reported here describe how three local authorities have used and analysed the ASCS and PSS SACE data to support local decision-making. In turn, the case studies will be used to inform the development of ‘how to’ guides and tools to help LAs analyse and interpret survey data, as well as report and interpret analysis findings

Executive summary of the MAX working paper - How can MAX help local authorities to use social care data to inform local policy? Maximising the value of survey data in adult social care [MAX] project

The promotion of wellbeing is the newly-stated guiding principle for the long-term care (social care) system in England. It signals a shift away from a focus on care need ‘deficits’ approach. Such a change in perspective has the potential to substantially alter how public care systems operate. The practical challenges are significant, both in the interpretation of wellbeing goals and in determining how the care system might be configured to achieve them.\ud The main aim of this paper is to contrast a needs-led resource allocation system with one using a maximising wellbeing approach; that is, one based on: measuring the wellbeing consequences of using services and applying the principles of cost-effectiveness and opportunity cost. As a precursor, the paper also describes how a maximising wellbeing approach might be applied in the case of long-term care.\ud We argue that in theory a maximising wellbeing approach with full information will produce greater total wellbeing improvement for the same budget than a needs-based system. In practice, the comparison will depend on: (a) whether we can actually measure wellbeing in a way that is consistent with the policy goals; (b) the availability of cost-effectiveness information; and (c) the decision rules used to implement a maximising wellbeing approach.

Previous literature shows that Body Mass Index (obesity status) is a strong predictor of the\ud disability and functional limitations. Relying on the data from the English Longitudinal Survey of\ud Ageing over the period from 2002 to 2011, we find that obesity status is also a significant risk\ud factor in determining future informal care needs but not formal care use, even after controlling for\ud ADLs and IADLS and for specific existing health conditions, including diabetes, high blood pressure,\ud and CVD. Obese elderly are 1.7-1.8 times more likely to use informal care and privately paid care,\ud but not formal care, in two-year’s time. Sensitivity analysis on a restricted sample shows that this\ud result is not driven by prediabetes. We also find that physical activity is associated with a\ud significantly lower likelihood of using any mode of care in the future, with the strongest effect for\ud formal care use. Moreover, the effect of obesity on informal care use is larger for females, but the\ud protective effect of physical activity is stronger for males.