Towards the Development of a Predictive Model of Long-Term Care Demand For Northern Ireland and the Republic of Ireland

Dr Maev-Ann Wren, Economic and Social Research InstituteApril 19th 2013

Outline Definitions, method, data, systems

Population and disability

Care - utilisation and projected utilisation

Model performance

North-South comparisons

Policy questions

What is long-term care? Residential care:

Residential care homes & nursing care homesSheltered housing? Intermediate care facilities?

Hospitals for older people? Delayed discharge from acute hospitals?

Home/community care:

Home helps & personal care assistantsMeals on wheels? Day centres?

Informal care:

Spouse, partner, adult child, adult child’s partner, sibling, friend/neighbour

Methodology Population + disability -> need

2 projection scenarios:

pure population increase vs declining disability

2006 utilisation -> 2007-2021 projected utilisation

Cell-based macro-simulation – adapts PSSRU methodology

Not prediction of balance between care settings

Individual-level data required

Model projection methodology

Number of people in projection year

Disability Rate in projection year

Utilisation Rate in 2006 base year

X X =

Number of users in projection year

By single year of age and gender to 100+

By age cohort By genderBy disability definition By care type:

ResidentialFormal home careInformal home careCombinations of care

By single year of age and gender orBy age cohort

Pure population scenario omits second step

Data sourcesDemographics RoI: Census, Morgenroth

NI: NISRA, GAD

Need/disability RoI: Census, NDS

NI: NISALD, CHS

Care/nursing homes

RoI: DoH/INHO/HSE

NI: DHSSPS/BSA/RQIA

Domiciliary RoI: NDS/HSE/TILDA

NI: NISALD

Unmet RoI: NDS

NI: NISALD

Systems of careAssessment NI Care management for residential +

nursing homes + domiciliary care

RoI Residential care needs assessment only

Entitlement NI Residential: nursing care free; personal + hotel costs means-tested, family home incl.Domiciliary: means-test for home helps, free aged 75+

RoI Residential: means-tested co-payment, family home % incl. after death; Domiciliary: no legal entitlement, patchy provision, erratic co-payments; 11% people aged 75+ with ADL paid

Demographics - Republic

Aged 65+: 11% in 2006 to 15%+ in 2021 468,000 to 792,000 – nearly 70% increase

Outward migration potential carers

Rising female labour force participation

Convergence in male and female life expectancies

Late to population ageing; care infrastructure under-developed

Demographic change

0

50,000

100,000

150,000

200,000

250,000

Numbers aged 74-84 157,000 248,000

Numbers aged 85+ 48,000 106,000

2006 2021

Source: Morgenroth (2009)

But with less disability? Longer periods, deferred disability; shorter periods,

divergent trends

Studies using ADL measures show decline

Evidence of declining disability for older people in RoI & NI

Preferred scenario assumes cohort effect converges to long-run trend of declining disability

Prevalence ADL difficulty aged 65+ reduces by 7-8% RoI and NI

Rate reduces, numbers with ADL difficulty up

Disability, RoI 2002-2006Percentage at each age with reported disability

0%10%20%30%40%50%60%70%80%

70 y

ears

72 y

ears

74 y

ears

76 y

ears

78 y

ears

80 y

ears

82 y

ears

84 y

ears

86 y

ears

88 y

ears

90 ye

ars a

nd o

ver

Alldisabilities2002

Alldisabilities2006

Source: Census 2002 and 2006

Utilisation patterns, Republic Alternative estimates

Of people aged 65+ in 2006 base year:

4.4% to 4.8% in residential LTC 8.9% to 10.5% receive formal home help 8.8% have ADL difficulty and receive intense all-day

or daily informal care; 28% receive some informal care

Gender differences and unmet need

Utilisation of care in all settings - proportions

0%

5%

10%

15%

20%

25%

2006 2021

With severe disability

With ADL difficulty

In residential LTC (low)

In residential LTC (high)

Receiving home help (low)

Receiving home help (high)

All day/daily informal care

Utilisation of care in all settings - numbers

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

2006 2021

With severe disability

With ADL difficulty

In residential LTC (low)

In residential LTC (high)

Receiving home help (low)

Receiving home help (high)

All day/daily informal care

Utilisation of care in all settings – 2006 NDS

Men aged 65-74

13.2%

58.6%

3.1%

10.9%

0.0%14.2%

Women aged 65-74

11.2%

46.7%

20.9%

15.4%

5.5%

0.3%

Men aged 75 and over

36.7%

0.5%

24.9%

1.0%

25.3%

11.6%

Women aged 75 and over

26.9%2.5%

30.3%

32.3%

7.8% 0.1%

 Communal establishment

 Informal help only  

 Both informal and formal help

  Formal help only  

  No help    

  Only PHN/ other

Utilisation projections, RoI & NI

Annual average increase

2006 2021

Residential

RoI 967 22,491 36,993

NI 285 9,585 13,858

Home RoI 1,866 49,179 77,164

NI 280 11,315 15,512

Informal RoI 1,565 41,018 64,500

NI 734 42,821 53,827

NB: Definitions of categories differ in RoI and NI

Who will care? Republic2006 2021

Nos give all day/daily care to cohabiting family aged 65+ with ADL difficulty

32,017 50,470

Intense cohabiting caregivers as % population aged 65+

6.8% 6.4%

Nos give all day/daily care to non-cohabiting family aged 65+ with ADL difficulty

15,717 24,681

Intense non-cohabiting caregivers as % women aged 35-54

2.8% 3.2%

Intense non-cohabiting caregivers as % women aged 35-54 not in labour force

10.8%

How well does model perform? Republic

Residential care: Projection: extra 550-756 places p.a. 2006-2011 Private nursing homes: 590 residents p.a. 2006-early 2010 Count public bed numbers changed but evidence increase to

2009 Within projection range to 2009/2010

Formal home care: Projection: extra 1,050-1,240 recipients p.a. 2006-2011; Public home help recipients: 415 p.a. 2006-Sept 2011 Home care package recipients: 957 p.a. Overlap & private unknown, close to/within projection

Unlikely to have met unmet care need, reduced public provision

Ageing North & South

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2006-2011 2011-2016 2016-2021

RoINI

Increase in numbers of people aged 65 and over

Residential LTC North & South

Percentage of people aged 65 & over in residential long-term care

3.6%

3.8%

4.0%

4.2%

4.4%

4.6%

4.8%

2006 2021

RoI: low

RoI: high

RoI: excl ltd stay

NI: publiclyfunded care

NI: incl elderlycare hospitalbeds

0%

2%

4%

6%

8%

10%

12%

2006 2021

RoI: low HSE

RoI: high incl.privatepayment

NI: publicstatutoryprovider, ADLrecipient

Home care North & SouthPercentage of people aged 65 & over receiving formal home care

Men aged 65-74Women aged 65-74

Women aged 75-84Men aged 75-84

Men aged 85+Women aged 85+

Men aged 65-74

Women aged 65-74

Men aged 75 and over

Women aged 75 and over

Unmet need, North and South ADL

difficulty and no help

North

South

‘No help’ pie slice on same basis, for other pie slices definitions differ & North-South not comparable.

Policy questions How and where to meet need?

How to design our systems: availability, entitlement?

Does NI system of care management provide a safety net?

Does NI free home help for over-75s achieve better outcomes?

How to fund care?

Is disability the best measure of need?

How improve our modelling?