Dr. Jean Long:

I thank the committee for inviting me to make a presentation of our findings. On behalf of the Department of Health, the HRB commissioned an evidence review titled Approaches to Regulation and Financing of Home Care Services in Four European Countries. The countries examined were Germany, the Netherlands, Sweden and Scotland. It was published in April 2017 and covered two topics.

The first topic was the regulation of formal home care services. All four countries have explicit national legislation and policy covering formal home care services. The national government controls the vision for home care, but regional governments oversee the selection of home care services that will be publicly funded. Support to keep people living in their own homes is the main principle underpinning home care policy in all four countries. There is a long tradition of regulated formal home care in the Netherlands and Scotland, whereas regulated formal home care was introduced later in Sweden and Germany.

Excepting Sweden, three of the four countries have national a set of quality standards for home care services that are guided by legislative acts. In addition, the three countries have an independent inspectorate to assess quality standards. Quality standards have been determined by the regulator with input from patient representatives in Germany, the Netherlands and Scotland. To achieve accreditation, home care service providers in Germany and the Netherlands are expected to operate using an in-house quality management system, and are also responsible for ensuring that staff are properly qualified and suitably remunerated. Annual quality audits are carried out by external bodies in Germany and the Netherlands, and accreditation is awarded if the audit results meet the standards. Scotland operates a national annual compulsory registration scheme, and registration is determined on the basis of meeting basic standard requirements. Germany, the Netherlands and Scotland have common national minimum training criteria for home care workers.

In Germany and Scotland, random inspections are carried out on home care providers annually to ensure standards are adhered to. In addition, specific complaints are investigated separately. The Netherlands monitors home care services via annual surveys, and inspections are only carried out in response to specific complaints.

In Sweden, regular inspections, surveys and responses to specific complaints are completed. Germany, the Netherlands and Sweden publish results of home care service quality inspections on publicly accessible websites. Germany, the Netherlands, and Scotland operate sanctions if quality standards are not adhered to. In each country, regulatory bodies are or appear to be partly funded through contributions made by long-term care insurances, or by registration fees paid by care providers.

On approaches to assessing and financing home care services, need rather than the ability to pay for home care services is an underlying principle of formal home care provision in all four countries. Germany and the Netherlands have long-established long-term care insurance schemes which facilitated the provision of formal home care services and these have recently been subject to reforms, which included revised needs assessments and eligibility entitlements alongside the introduction of increased or additional co-payments. Scotland and Sweden have a long-standing rights-oriented home care services sector funded through taxation, which are increasingly being rationed by stricter eligibility criteria and the introduction of fixed fee services and co-payments.

All four countries have formal needs assessment which contain documented eligibility criteria that allows a fair and comparative assessment as to the need for formal home care and the level of requirements. All four countries encourage some level of informal care by close relatives to help fill the home care requirement. All four countries have an element of user choice as to how services are provided to address formal home care requirements, with services typically offered in kind or via personal budgets. The basket of formal home care services in the four countries include personal care and help with household tasks. Nursing care is included in the basket of services in Germany, the Netherlands and Scotland and is provided through a separate assessment process in Sweden.

Generally, the literature on the four countries reported that the supply of formal home care could meet the demand, but their actions indicate that countries have taken interventions to either restrict formal home care supply or fund additional demand. For example, Germany has increased the long-term insurance premium for childless people, increased co-payments to 30% of the total formal home care costs, tightened the criteria for how much home care people can receive, and expects families to provide informal care where the formal care service cannot meet the demand. The Netherlands has waiting lists and has reduced its needs-based service allocation by tightening access criteria. Scotland has increased the budget allocated to home care and asked citizens who earn over £16,000 to pay for household tasks. Sweden has also tightened criteria entitling its citizens to home care. Small co-payments are required for all services in Sweden. Tax free credits are available to taxpayers who buy private home care for their elderly relatives.