Population ageing has been rapidly increasing in most of the developed world. However, healthy life expectancy has not been growing at a similar pace, resulting in an expansion in the number of years older people live with health and care needs. Long-term care (LTC) provision is diverse across Europe and more economically developed countries with input from different actors and agencies ranging from informal family carers, the state, and, increasingly, migrant workers. Nevertheless, the ethos of LTC policies in the UK, Europe, Australasia and North America are informed by person-centeredness, independence, and inclusion philosophies (OECD, 2020). One of the core concepts in LTC policies revolves around ‘ageing in place’ and the importance of people growing older within their homes and communities for as long as possible. However, the role of care homes remains essential for certain groups of older people with multiple and complex care needs. While concepts of dignity, independence and choice are evident in many LTC policy documents, funding pressures, escalating demands, and an expansion in the diversity of needs have led to a reliance on marketisation and, in many cases, on inadequate care provision. At the same time, other state policies on migration, social housing, employment regulation, and the nature of work in social care shape the practices of LTC service delivery. Shifts in population structures are also influenced by other important historical and current dynamics, including migration and mobilities and their interplay with LTC supply and demand. For example, past generations of migrants are now growing older in host countries with a growing demand for culturally sensitive care. Simultaneously, the shortage of LTC workers across many countries in the Organisation of Economic cooperation Countreis (OECD) requires special policy attention to improved conditions of work and equality across a number of dimensions, including gender, racial and age diversity, to ensure workers from all backgrounds can be attracted to and retained in the LTC sector. The practices of LTC service delivery also draw on and reflect national, often ageist, discourses around older people, the gendered nature and value of LTC and, increasingly, the ethnicity of service users and workers in LTC.
The Covid-19 pandemic has thrown an intense light on the LTC sector for all the wrong reasons: from high infection levels and death rates in care settings, mainly residential care (OECD, 2020), to evidence of failure to protect the LTC workforce with fragmented and contradictory guidelines and delays in or inadequate supplies of personal protection equipment and training (Reed etal., Reference Reed, Murmann, Hsu, Turnpenny, Van Houtven, Laberge, Low, Hussein and Allinforthcoming). The significant effects of Covid-19 combined with a long-standing multiplicity of challenges – including many related to funding, ensuring diverse and adequate services, and resourcing a well-trained and supported workforce – call to understand the granularities of the different facets of LTC provision. In this themed section, we bring together a selection of articles from leading authors in LTC research from the UK and Europe. We aim to explore the paradoxical position of LTC between an official ethos of dignity, quality and inclusivity, and the realities and pressures of providing inclusive, person-centred and sustainable LTC within polices of cost containment and refamilarisation (Da Roit and Le Bihan, Reference Da Roit and Le Bihan2019). These pressures and realities include an increased financial burden on the state and individuals; commissioning practices; meeting the needs of specific groups, including people with learning disabilities and culturally diverse populations; the role of social housing as a critical component of LTC provision within the ageing in place paradigm; and addressing workforce issues, including decent working conditions, workplace inclusivity and equality of employment outcomes.
This themed section brings several prominent scholars in LTC research from different disciplines, including health economics, sociology, demography, social policy, organisational studies and health and care policy. The contributors employ diverse methodological approaches, ranging from reviews and policy analysis to in-depth qualitative and quantitative methods. They also bring a diversity of perspectives and vantage points in their assessments of how the delivery of LTC is shaped ‘on the ground’, extending from cross-national comparisons of LTC and other policy settings to how workers, particularly those from minority groups, experience the day-to-day work of LTC.
Roland and colleagues, in their state-of-the-art article, consider the different LTC funding and delivery models across Europe and other OECD countries. They assess the range of models used from LTC insurance schemes, reliance on general taxations, to ‘safety-net’ models that leave most of the financial burden on individuals and their families. The one clear, typical, pattern across the diverse group of countries that emerges from this analysis is that all countries are faced with escalating LTC costs associated with population ageing. They highlight a range of strategies employed by various countries in the face of such challenges, from well-designed, but small, incremental changes in social insurance premiums (e.g. Germany, Japan and France) to broader LTC reforms in an attempt to improve efficiency in resource utilisation (e.g. the Netherlands and Finland). They emphasise that whatever the direction of policy reform undertaken in different countries, the pathway to reforms also varies, such as through centralised or devolved reforms. Furthermore, there also remain considerable challenges in implementation. Finally, Roland and colleagues highlight that the role of, and reliance on, informal care, whether implicit or explicit in national LTC policies continues to be essential. Familiarisation remains a significant element in the way countries seek to constrain LTC funding, with policies being explicitly developed in some countries to encourage support from family and friends.
Lindblom and Torres consider the broader context within which LTC policy and delivery is located. Inspired by Pickering (Reference Pickering2001), they analyse news articles in the two largest national daily newspapers in Sweden between 1995 and 2017, focusing on how language is used to locate and identify the ‘others’, in this case where migration and elderly care intersect. Lindblom and Torres analyse the role of media in segmenting and othering minorities with adverse effects on the inclusivity and equality of the provision and quality of LTC. They draw attention to the rhetorical practices used to other migrant and minority groups both as service users and workers in various ways. They argue that such process and rhetorical representation may appear as viable mechanisms to recognise minority groups within the parameters of care receiving and delivery. However, they conclude that while public discourse and media representation are used as tools for recognising these groups, they are also used as tools of misrepresentation. Within the context of migration and care, this is because neither the public discourse nor the media tackle issues of inclusivity or injustice.
Darton examines an area of research that is relatively neglected in the LTC research and literature, which has to do with the role of housing. This is a crucial topic especially within the context of the shift of ageing policies towards personalised care and the role of home as a place for achieving both independence and receiving adequate care. Darton investigates the policy and practice development of the provision of extra care housing and how it can facilitate achieving the policy aspirations of ageing in place. He focuses on its impact on residents, mainly frail older people, including during the Covid-19 pandemic. Darton provides an overview of the rationale and development of this specific type of housing in the UK context where local authorities have commissioned extra housing to support people outside traditional residential care. However, a range of pressures has led to changes in the balance of care and indeed to greater inflexibilities in providing social care and support. He discusses the need for further research to explore the implications for the future development of this form of provision. In particular, Darton identifies the need for further cost-benefit analyses to consider the alignment of policies on housing with other forms of LTC provisions.
Focusing on service delivery of LTC in England, Allan and Darton show how ensuring enough and adequate LTC supply, mainly that provided in people’s own homes, has been challenging for many countries. This is due to the fast pace of increased demand and workforce shortages coupled with the complexity of arrangements between state and privately funded services. Using two local authorities in England as case studies, they analysed three components related to LTC supply: staffing, demand and stakeholder relationships. Engaging with national and local policies to highlight features for the sustainability of LTC provision, Allan and Darton examine the incentives and deterrents of ensuring adequate workforce supply to match the growing needs of older adults. They emphasise the ways in which the UK mixed funding model, and reductions in public spending on LTC, challenge the capacity of providers to provide adequate remuneration and working conditions to the social care workforce with direct implications for service quality.
Finally, Hussein examines racial inequalities in the UK’s health and social care work outcomes, including recruitment, work experience, and rewards. She also investigates the differential experiences of racialised health and social care workers during the Covid-19 pandemic. Employing a rapid review methodology, she identifies fifty-one outputs published since 2017 that examine the UK’s differential experience of minority ethnic health and social care workers. The findings are analysed within a framework of intersectionality to understand the effects of gender, race, faith and migration status when examining the ways inequalities are manifested within health and social care work settings. The review provides evidence of the significant contribution of racialised workers to the health and social care sectors and identifies common challenges faced by all low-paid workers in these sectors. However, Hussein also identifies individual and structural factors adversely affecting workers from minority groups, especially those with intersectional visible markers (such as black Muslim men), who are positioned at the lowest hierarchy of outcomes, including mistreatment and lack of in-work support.
Hussein’s analysis highlights the broad relevance of the findings by Lindbloom and Torres on media representations of older adults, particularly of migrant groups, both as services users and workers in Sweden. While such representations shape the community perceptions about people and sectors they know little about, they also shape the experiences of migrant groups within LTC. The ways in which gender and racial inequalities are manifested within LTC settings are reflected in, and amplified by, media representations and public discourse. These representations and discourses draw on historical and national norms of institutionalised racism and discrimination. Hussein’s rapid review demonstrates the very tangible impact of this othering of the non-normative worker in the UK context in the creation of niches or ghettos within the health social care sector for racialised workers and in creating power hierarchies within the workplace.
The article by Roland and colleagues takes a cross national perspective on the key features of LTC policy development and innovation across a range of countries. Within that comparative analysis, the UK stands as an outlier, even with the general shift to various cost containment mechanisms in the countries studied. This is seen in local authorities taking on more responsibility for meeting shortfalls in government funding, and an increased reliance on informal care. Allen and Darton’s detailed analysis of the incentives and deterrents to the supply of LTC in England provide a vivid illustration of how such national polices are enacted at the local level, and the consequent strategies employed by local authorities to mitigate the impact of these policy and funding settings, particularly on staffing. Importantly, their findings also point to the market-shaping role of actors at the local level in incentivising or deterring both providers and staff. Their analysis points to within country variations suggesting that the implementation of national policies should not be assumed to be uniform across a particular national setting.
This themed section engages with the complexities of implementing LTC policies that aim to achieve person-centred and inclusive services situated within broader sets of constraints. In some cases, these challenges are part of system constraints, such as funding challenges and tight resource allocation that shape the ability of the state to adequately fund LTC service. These constraints in turn create direct and indirect pressures on LTC providers, LTC workers, and informal carers. In other cases, constraints in providing good quality LTC are the product of hostile public discourses fostered by institutional and structural racism, othering certain groups and creating hierarchies among them, and, in particular, adversely affecting LTC workers and older people from minority groups.
