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Despite international consensus on the need to transition to community-based social services, the perception that only institutions can produce the economies of scale required for care to be affordable is still hampering this transition. Doubts about the economic viability of community care were identified as one of the major challenges for deinstitutionalisation in our 2011 report ‘Developing Community Care.’

A recent survey of European Social Network members showed that these doubts persist: 22% of the respondents said that in their country institutional care is still seen as more viable economically. At our 2023 Seminar ‘Social Services Leading Care in the Community,’ which took place in Barcelona in Spain on 9-10 October, we discussed with international researchers and social services managers how those economic concerns can be addressed.

Addressing doubts on economic sustainability

Joanna Lizut, Vice-rector, Janusz Korczak Pedagogical University in Warsaw, Poland, presented a study on progress of the Polish deinstitutionalisation strategy. One of the main outcomes was that providers, relatives and persons drawing on care need to be taken on board in the preparation process, including better information about its financial consequences. “Many persons mentioned they did not feel well informed about what costs to expect. Families and persons drawing on care were worried about the potential of increasing co-payments. People working in institutions feared the reform was a pretext to cut social care expenditure, rather than to improve people’s quality of life”, explained Ms Lizut.

Collecting evidence on the economic case

Invited to present the newest evidence on the economic case for community care, Adelina Comas-Herrera, Researcher at the Care Policy and Evaluation Centre, London School of Economics and Political Science (LSE) referred to an LSE review of the economic consequences of deinstitutionalisation of mental health services. Ms Comas said: “Community-based models of care are not inherently more costly than institutions once the needs of individuals and the quality of care are taken into account.” Ricarda Milstein, Health Policy Analyst at the Organisation for Economic Co-operation and Development (OECD) explained that long-term care provided in the community is likely more cost-effective and appropriate for low to moderate long-term care needs, with positive effects on indicators such as hospital (re)admissions.

Špela Režun, Director of a public social welfare centre in Slovenia’s Upper Sava Valley that provides daycare, home care and residential care for people with disabilities, explained that care costs for people with low and medium care dependency were indeed lower in independent and family living settings than in residential care. She warned though that, community-care provided just by informal carers could create non-intentional effects: “We have many clients who live with their families. Although they are adults and would like to live on their own, the care allowances received by their families create economic dependence, so their families don’t let them live by themselves.”

Giving the right economic incentives

There needs to be investment in housing and new care services so that people can stay in their homes. Nordic countries have adapted their funding systems to incentivise home care for people with low and medium dependencies. In England this has led to a reduction of care home beds over the past ten years, despite the trend of an ageing population. Consequently, Ms Comas explained that “the profile of people living in care homes is changing: the share of care home residents with severe dependency has increased in England and Wales from 63% to 87% since 1992.”

The recently finalised Rural Care project implemented in Castilla y Leon, Spain, to support older people to remain in their own homes, is an example that shows how investment in such services can lead to a reduction of costs. Those taking part in the project needed on average to pay 72 EUR of co-payments per month, whereas their peers living in care homes faced monthly costs of 889 EUR. As OECD countries are increasingly looking into community-based solutions, the up-scaling of such projects to the national level is a crucial task for governments, suggested Ricarda Milstein.

Alfonso Lara Montero, ESN CEO concluded: “If we aim for the fulfilment of the person’s needs as the main outcome of care, investing in community-based services is more cost-effective. This economic argument is key, not only to win people’s hearts but also their minds when they take decisions on how to design the care systems of the future.”