conceptual report on long-term care -...

CONCEPTUALREPORTONLONG-TERMCARE

Dr.Alexandralopes(Ed.),UniversityofPorto

SocialProtectionInvestmentinLong-TermCareHORIZON2020-GrantAgreementNo649565

D.2.1ConceptualReportonLong-TermCare 1

ExecutiveSummary

Deliverable 2.1 describes the general theoretical framework related to social investment in thecontextoflong-termcare(LTC)thatwillbefollowedinSPRINT.ThepaperpresentsanaccountofsocialinvestmentasapolicyparadigmandexploressocialinvestmentasaconceptinthecontextofitsapplicationinLTC.ThisdeliverableincludesthedefinitionofsocialinvestmentappliedtoLTCasitisunderstoodwithinSPRINT.

Thefundamentalpillarsofsocial investmentasapolicyparadigminvolveasignificantchange inthe core elements of the policy making process inherited from the post-war welfare models,moving from a focus on “repairing” the unforeseen damage caused by events to a focus on“preparing” individuals and families to address life chances and deal with disruptive events,preventingthedamagetheycancause.Thephilosophyunderpinningsocialinvestmentfocusesonthreemain social policy functions: i) the creation of capacities, which involves a shift in policyanalysis from an exclusive focus on present costs to a focus on current and future impacts; ii)addressingsocialriskswithinlife-coursedynamics,whichinvolvesamovefromaclearcutdividebetweenthosewhopayandthosewhoarerecipientsofwelfareprovisiontoamoredynamicandbetter adjusted vision of contemporary social reality where individuals have different status indifferentphasesoftheirlives;iii)thereconciliationofworkandfamilylife,notonlyrespondingtoideologiesofgenderthatpressuretowardsgenderequalitybutalsoasapre-requisitetodealwiththe consequences of demographic ageing and the need to secure economic and fiscalsustainability.

SPRINT aims to apply a social policy analysis to a specific domain of policy design andimplementation - that of long-term care (LTC). Social investment applied to LTC involves theidentification of good value investments in LTC that create the conditions for the realization ofpoliciesthatcontributetothemostefficientuseandallocationofresourcesoverthelifecourseinsupport of high levels of participation in the labour market, while enhancing and maintainingcapacitiesandindependentlivingofolderpeopleandsimultaneouslypromotingefficiency,equityandqualityoflife.

Social investmentwithinLTCwill thusbeunderstoodaswelfareexpenditureandpoliciesthatgenerateequitableaccesstocaretomeettheneedsofageingpopulations, improvequalityofcare and quality of life, increase capacities to participate in society and the economy, andpromotesustainableandefficientresourceallocation.

In terms of its broad goals, from a social investment perspective SPRINTwill be looking at LTCarrangementsintheircapacityto:i)usesocialbudgetsefficientlyandeffectivelyinsolutionsthatareadequateandsustainable;ii)strengthenpeople’scapacitiesandopportunitiestoparticipateinsociety and in the labour market; iii) use prevention and rehabilitation to reduce current andfutureneedsforassistance;iv)coordinatehealthandsocialcarearrangementstoachievelasting



positivesocial impactsandavoid institutionalfragmentation;v)fosterqualityofcare,well-beingandequity;vi)promoteindependentlife.

So far impactsof investment inLTChavenotbeeneasilymeasuredandquantified.LTC ismoreoftenportrayedasacost rather thanpartof social capitalandsocial cohesion inpursuitof theEuropeansocialmodel.ThebroadambitionofSPRINTistocomeupwithamodelofsocialmetricsthat can be used to measure the social impacts and economic returns of different LTCarrangementswiththeviewtoidentifyingthemostpromisingalternativestorealisetheambitionofthesocialinvestmentpolicyparadigm.

SPRINT will use an adapted Social Return on Investment (SROI) approach to measure andunderstandtheimpactsofLTCarrangements.SROIisaprinciplesbasedmethodformeasuringthesocialvalueofanactivityrelativetotheresourcesinvestedinit.Itmovesfromassessingoutcomestomeasuringtheimpactoftheactivity.SROIaimsatmeasuringoutcomesinmonetarytermsandat using theoretically and empirically justified values in valuing inputs and outcomes. It placesemphasis on stakeholders’ views and tries to put financial ‘proxy’ values on all the impactsidentifiedbystakeholdersthatdonottypicallyhavemarketvalues.LTCisafieldofpolicydesignandimplementationwheremanydifferentcostsandbenefitsneedtobeconsideredandwhereaplurality of stakeholders play a part. The aspiration of SPRINT is to disentangle the impactmechanisms of LTC provision with a view to identifying good value investments in that field,developing innovative assessment tools that can genuinely bring a fresh approach to theconsiderationofthesocialvalueofLTCandhelpincomparingoptionsintermsoftheirexpectedreturns.

K e y m e s s a g e s

• Thework to be developed through SPRINT takes as a starting point that in the context ofdemographic ageing, while the role of families in providing informal care will remainimportant,Statesneedtofindadequateandsustainablewaystotacklecareneedsbymeansof formal LTCschemesor services.Failure todosomight involve in the longer termhighercosts for individuals and for society as a whole than if comprehensive public support wasprovidedthroughcapacitatingservices.ThebroadambitionofSPRINTistoprovideinnovativeanddifferentwaystolookatLTCcostsandbenefitsanddevelopinvestmentmodelsthatcanassist decision-makers in the allocation of resources andwhen choosing between differentservicesandschemes.

• SPRINT aims to develop amodel of socialmetrics that can be used tomeasure the socialimpactsandeconomic returnsofdifferent LTCarrangementswitha view to identifying themostpromisingalternativestorealisetheambitionofthesocialinvestmentpolicyparadigm.SPRINTintendstoanalyseaselectedsampleofLTCarrangementsintermsoftheircapacitytomakepositivecontributionsto:1)useofsocialbudgetsefficientlyandeffectivelyinsolutionsthatareadequateandsustainable;2)strengtheningofpeople’scapacitiesandopportunities



to participate in society and in the labour market, taking account of gender equality; 3)emphasisingpreventionandrehabilitationtoreducecurrentandfutureneedsforassistance;4) coordination of care arrangements to achieve lasting positive social impacts and avoidinstitutionalfragmentation;5)fosteringofquality,well-beingandequityincareprovision.

• SIwithinLTCwillbeunderstoodaswelfareexpenditureandpoliciesthatgenerateequitableaccesstocaretomeettheneedsofageingpopulations,improvequalityofcareandqualityoflife, increase capacities to participate in society and the economy, andpromote sustainableandefficientresourceallocation.

• Concepts developed in this deliverablewill be further operationalised in terms of variablesandindicatorsforspecificapplicationswithinsubsequentworkpackages.



T a b l e o f C o n t e n t s

ExecutiveSummary...................................................................................................................1

AcronymsandAbbreviations.....................................................................................................5

1 Introduction.......................................................................................................................6

1.1 Background.......................................................................................................................6

1.2 Objectives.........................................................................................................................6

2 Methodology.....................................................................................................................7

3 ThePolicyAnalysisofSocialInvestmentasaWelfareParadigm.........................................7

3.1 TheSocialInvestmentApproachasanEmergingAnalyticalFramework.........................8

3.2 AnalysingtheWelfareFunctionsfromaSIPolicyPerspective.......................................10

4 SocialInvestmentinLong-TermCare...............................................................................11

4.1 TheReasonsforApproachingLTCfromaSIPolicyPerspective.....................................11

4.2 TheSocialImpactsofLTCfromaSIPerspective:SomeTentativeDimensionsofAnalysis.......................................................................................................................................14

5 AddressingSocialValueofLong-TermCare......................................................................16

5 Conclusions......................................................................................................................19

6 References.......................................................................................................................21

7 AnnexI:UnderstandingofSIinSPRINTPartnerCountries................................................23



AcronymsandAbbreviations

CBA Cost-benefitanalysis

EC EuropeanCommission

LTC Long-termcare

OECD OrganizationforEconomicCo-operationandDevelopment

SI Socialinvestment

SIP Socialinvestmentpackage

SROI Socialreturnoninvestment

WP Workpackage


D.2.1ConceptualReportonLong-TermCare

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1 Introduction

1.1 Background

In February 2013 the European Commission launched its ‘Social Investment Package’ (SIP)(EuropeanCommission2013).This isofferedasan innovativeperspectiveonsocialpolicy inthecontextofdemographicchangeandeconomicpressuresacrossEurope.Atthesametime,aspartof the SIP, a Commission StaffWorking Documentwas published on ‘Long-term care in ageingsocieties–Challengesandpolicyoptions’(EuropeanCommissionSWD2013),callingfora ‘socialinvestment-orientedstrategy’toaddressthespecificpolicychallengesoflong-termcareforolderpeople.

The EC has commissioned the SPRINT project to investigate and develop the concept of socialinvestmentinthecontextoflong-termcare.

1.2 Objectives

ThispaperformsthefirstdeliverableofSPRINTWorkPackage(WP)2andprovidesaconceptualreportonlong-termcare(LTC)fromtheperspectiveofsocialinvestment.ItisaimedatprovidingaconceptualframeofreferencetoguidesubsequentworkinSPRINTand,inparticular,answerthefollowingquestions:

1. WhatinterpretationsofSocialInvestment(SI)havebeendebatedintheliterature?2. HowcanSIbeappliedinthecontextofLong-TermCare(LTC)?3. WhatdimensionsofimpactcanbeconsideredwhenapplyingaSIperspectivetoLTC?4. HowtotheoreticallyapproachthemeasurementofsocialandeconomicimpactsinLTC?

The contents of this paper are intended for partners in the SPRINT project and also to beaccessibletostakeholders.

Deliverable 2.1 describes the general theoretical framework on social investment that will befollowedinSPRINT.ThepaperincludesapresentationofthevariousdefinitionsofSIasaconceptandasapolicyparadigm,settingthebackgroundfortheanalysisofhowapplicableitistoLTC.Itmoves then to the definition of Social Investment applied to long-term care within SPRINT,followingadiscussionabout thesocial impactsofLTC.Fromthisdefinition, thepapermoves tosome general considerations on how tomeasure LTC impacts, highlighting some dimensions ofanalysisofLTCthatneedtobetakenintoconsiderationwhendoingasocialvalueanalysis.



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2 Methodology

Thispaperisaconceptualpaperandassuchitfollowedamethodologythatinvolvedprimarilytheconsiderationofdifferentstreamsofliteraturerelatedtosocialinvestmentincludingresearchonmeasuring performance and literature on social impact models. A comparative analysis ofdifferent approaches to key concepts was carried out with a critical review of avenues andshortcomingsbroughtaboutbydifferentauthors.

The systematic literature reviewwas carriedout in phases andwith inputs fromall consortiummembers.DuringthefirstphaseofliteraturesearchwehaveresortedtogeneralsearchenginessuchasGoogleAcademicaswellastoseveralacademicrepositoriessuchasAcademicSearch,B-On,IngentaConnect,ISIWebofScience,PubList,SCOPUSandSocialCareOnline.Searcheswereinitially carried out based on broad search terms: social investment and social return oninvestment,combinedwithwelfarestateandwithLong-TermCare.

Inasecondphase,wehavenarroweddownthedatabasesforoursearchesandhavebrowsedinmoredetailsomeacademicjournalsnamelythosefocusingonsocialpolicyanalysisandonageingpolicies. Some examples are the European Journal of Social Policy, Policy and Administration,JournalofSocialPolicy,amongothers.AdetailedlistofreferencesthatwerecollectedduringtheworkcarriedoutunderWP2isavailableontheSPRINTwebsiteasrelevantbackgroundliteraturefortheresearchproject1.

Deskwork research has also included the review of policy documents emanating from theEuropean Commission and affiliated organisations, and from other supranational organisationssuch as the OECD or ILO. Search engines used to collect relevant documents include: ECLAS –EuropeanCommissionLibrariesCatalogue,EuropeanLibrary,EUR-Lex,CORDISandILODatabases.

SPRINT project partners provided a summary of understanding of social investment in theircountries(seeAnnexI).

3 ThePolicyAnalysisofSocialInvestmentasaWelfareParadigm

InthissectionwereviewtheintellectualrootsofSocialInvestmentwithafocusonthescholarlydebatethathasbeendevelopinginEuropearoundthatconcept.ThemainargumentsputforwardbothinfavourandagainstSIasapolicyparadigmarerevisitedandageneralframeworkforpolicyanalysisfromaSIperspectiveisoutlined.

1http://sprint-project.eu/wp-content/uploads/2015/11/SPRINT_-literature-core.pdf



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3.1 TheSocialInvestmentApproachasanEmergingAnalyticalFramework

The social investment approach relates back to the earlier concept of social protection as aproductive factor which in itself implied investment – social protection yielded a return(Söderstöm2008).Itisalsorelatedtoproductivistviewsofsocialpolicy,anapproachtowhichtheOECD,atleastimplicitly,subscribes(OECD2006).Italsoopensavenuesforinnovationinfundingapproachessuchassocial investmentbonds (Mulganetal.2010). It isapolysemicconceptthathas been experiencing remarkable diffusion across the globe but that has been worked andreworked by different stakeholders and in different policy communities in a variety of policydirections.

SomeoftheleadingEuropeanscholarsthathavebeenadvocatingforSocialInvestmentasanewsocialpolicyparadigmincludeFerreraetal.(2000),Esping-Andersenetal.(2002),VandenbrouckeandVleminckx(2011),KersbergenandHemerijck(2012),Moreletal.(2012),Dodová(2013)andBonoli(2013).Toalargeextent,theworkofthesescholarsemergedalongsidetherecognitionofthecross-roadsEuropewasfacingattheturnofthenewmillennium,confrontedwithaseriesofchallengestothestructuralpillarsofthewelfarestatearrangementsinplace.Deindustrialization,changes in traditionaldynamicsof family formation, ageingof thepopulation, are just a fewofthese challenges. Associated with these were a series of consequences that would be termed«new social risks» (Vanderbroucke and Vlemincx 2011): long-term and youth unemployment,distributional distortions in income generated by work and in-work poverty, obsolescence ofqualifications and skills of older workers, difficulties and tensions in work-care conciliation aresomeofthemostquotedintheliterature.WhenEsping-Andersenetal.published,in2002,Whywe Need a New Welfare State, they were trying to address precisely the policy challenge ofovercoming the inefficiencies of themale-breadwinner employment-basedwelfare statemodelwhile keeping the legacy of the European socialmodel and the normative aspirations of socialjustice.Intheirworktheauthorsintroduceashift inthetraditionalanalysisofwelfarefunctionsfocused on redistribution and costs of provision and move to a focus on the results of theprovision and on the intrinsic sustainability of social policies that create future social andeconomicvalue(Hemerijck2015,p.5).

The fundamental pillars of SI as a policy paradigm, as discussed byHemerijck (idem), involve asignificant change in the core elements of the policy making process moving from a focus on“repairing” theunforeseendamagescausedbyevents toa focuson“preparing” individualsandfamiliestoaddresslifechancesanddealwithdisruptiveevents,preventingthedamagestheycancause. Thephilosophyunderpinning SI involves advocating threemain social policy functions: i)the creation of capacities, which involves a shift in policy analysis from an exclusive focus onpresentcoststoafocusoncurrentandfutureimpacts;ii)addressingsocialriskswithinlife-coursedynamics,whichinvolvesamovefromaclearcutdividebetweenthosethatpayandthosewho



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arerecipientsofwelfareprovisiontoamoredynamicandbetteradjustedvisionofcontemporarysocial reality where individuals change status in different phases of their lives; iii) thereconciliationofworkand family life,notonly responding to ideologiesofgender thatpressuretowardsgenderequalitybutalsoasapre-requisitetodealwiththeconsequencesofdemographicageing and the need to secure economic and fiscal sustainability by means of enlargedparticipationinthelabourmarket.

The academic debate on SI, although recent, already includes serious tensions and is far frombeingconsensual.Therearenumerouscritics fromdifferentstreamsof thoughtquestioningtheassumptionsofSIandchallengingwhatareconsideredtheexcessivepromisesandexpectationsofearlySImanifestos.SomecriticsfocusontheultimateinefficiencyofSIifwordsdonottranslateintoaction,highlighting the relative shallownessof theelegant rhetoricofSI (JensonandSaint-Martin,2003)orthewayanydiscretioninpolicydecisionmakingwillultimatelybeovertakenbyausterity reforms in thecomingyears (StreeckandMertens2011).Somevoicesamong feministscholars denounce the instrumental use of gender equality policies by SI approaches seen asmotivatedbytheneedtohavefemalesinthelabourmarket(Saraceno2015).OtherauthorsdrawuponthefoundationalsociologicalcritiqueofMertonontheaccumulationofadvantages(Merton1968)andhighlightthe“MatthewEffect”ofSIpolicies.Cantillon(2011)warnsaboutthebiasesofSItowardstheinterestsofthemiddle-classes(eg.education,childcare,life-longlearning)attheexpensesofthelowerclasses,whileNolan(2013)referstothedangersofhavingpoliciestacklingnew social risks and activation principles crowding out the policy agenda on redistribution andminimumguarantees.

SPRINTstarts fromthescholarlydebatesandpolicydevelopmentsthathavebeendeveloping inEuropeoverthelasttwodecadesandthathaveconvergedintothepublicationbytheEuropeanCommission,onthe20thofFebruary2013,oftheSocialInvestmentPackageforGrowthandSocialCohesion. This document summarizes a series of policy goals and guidelines that had beenmaturingforsometimeandthatformthepolicyparadigmthathasbeenunfoldingacrossEuropein a discrete but firm manner as an alternative to the inefficiencies of the Keynesian male-breadwinner fullemploymentmodel,butalsoasanalternativetotheneoliberalbelief that it isnotpossible to reconcilegenerouswelfareprovisionandeconomicgrowth.Social Investment isheredefinedasinvestmentinpeople:

Social investment involves strengthening people’s current and future capacities. In otherwords, as well as having immediate effects, social policies also have lasting impacts byofferingeconomicandsocialreturnsovertime,notablyintermsofemploymentprospectsorlabour incomes. In particular, social investment helps to 'prepare' people to confront life'srisks, rather than simply 'repairing' the consequences. Modernisation of social policiesrequires systematic introduction of ex-ante result orientation in financing decisions and a



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systematic approach of the role social policies play in the different stages in life: fromeducationviawork/unemploymenttosicknessandold-age(COM2013,p.3).

3.2 AnalysingtheWelfareFunctionsfromaSIPolicyPerspective

SIoffersaninnovativeanalyticalframeworkforthinkingaboutsocialpolicy,inparticularbecauseit: i) involves making a distinction between forms of social spending that can be regarded asinvestment and others that cannot; ii) starts from the notion that it is possible to reconcileeconomic and social goals when analysing the impacts of policies going back to the notion of‘productive socialpolicy’ asput forwardbyMyrdals in the1930’s in Sweden;and iii) involvesadifferent approach to time and impact assessment in the analysis of policy cycles and policyoutcomes,movingawayfromafocusonpastandpresenttoafocusonthefuture.

Inhisworkonhowtoanalysethewelfarefunctionsofsocialinvestmentpolicies,HemerijckarguesthatthewelfarefunctionsoftheSIparadigmarenotnecessarilyindependentfromeachotherandinpolicypracticetheyareoftenoverlapping(Hemerijck2014).Thefirstwelfarefunctionconcernsfacilitating the functioning of the labour market and life course transitions. The goals to beachieved are mostly subordinated to the primacy of labour market participation, by means ofcapacitationof thoseexcludedor struggling toparticipate in the labourmarketorbymeansofassisting thosewhoexperiencedifficulties in reconcilingparticipation in the labourmarketwithother,primarilyfamily,responsibilities.Someadditionalgoalsunderthisfirstwelfarefunctionaretheparticipationofwomeninthelabourmarketandtheparticipationofolderworkersintermsofpostponingretirement.

Thesecondwelfarefunctionisrelatedtoenhancingfutureproductivityandiscloselyassociatedwith the enhancement and the maintenance of inputs into the labour market across the lifetrajectory inageingsocieties.The focushere isonpreparing individuals,bymeansofeducationandqualifications,undertheassumptionthatifonestartsstrongonewillbemorelikelytoremainstrongandbemorecapableofupgrading in later life. Issuessuchaseducationand trainingarecriticalaspectsunderthissecondwelfarefunction,butsoareallpoliciesthatincreasecapacitiesand strengthen what Hemerijck labels the “stock” (Hemerijck 2015, p.7), such has disabilitypreventionandindependentlivingpolicies.

The third welfare function, which Hemerijck refers to as “buffer”, and sees as a surreptitiousKeynesianism (idem, ibidem), concerns incomeprotection and distribution as pre-conditions foreffectiveSIpolicies.Itisunderthisthirdwelfarefunctionthatthetopicsofequityandqualityareintroducedasmechanismstoinducestabilityofarrangementsandasenseoffairnessandsocialjustice.



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SPRINTissetondevelopingasocialinvestmentpolicyanalysistoaspecificdomainofpolicydesignandimplementation,thatofLong-TermCare(LTC).SIappliedtoLTCinvolvesasastartingpointthe consideration that LTC policies can contribute to themost efficient use and allocation oflabour resources over the life course in support of high levels of participation in the labourmarket,whileenhancingandmaintainingcapacitiesandindependentlivingofolderpeopleandsimultaneouslyguaranteeingequity,well-beingandqualityoflife.

Responding to the challenges put forward by the EC in the StaffWorking Document on LTC inageingsocietiesthataccompaniesSIP(SWD2013),SPRINTaimstodemonstratethateveninlaterstagesof lifeandwhen thereareconditions limiting functionalandcognitivecapacities there isstillanargumentforasocialinvestmentperspectiveonsocialprotection.

4 SocialInvestmentinLong-TermCare

In this section we move to the analysis of the current policy debates about LTC to set thebackgroundfortheapplicationofaSIperspectivetotheanalysisofpolicyoptionsinthatfield.Wemake a case for the relevance of using a SI inspired policy analysis framework to consider theimpacts of different LTC arrangements and policies. This part of the paper paves the way inconceptualtermsfortheworkinsubsequentworkpackagesaddressingthedimensionsofimpactofLTCandthecorrespondingcriteria tomeasurecostsandbenefitsandtocomputereturnsoninvestmentassocialvalue.

4.1 TheReasonsforApproachingLTCfromaSIPolicyPerspective

LTCwithinSPRINTonlyincludeslong-termcareforolderpeopleandreferstoarangeofservicesandassistanceforpersonswho,overanextendedperiodoftime,aredependentonhelpwithbasicactivitiesofdaily living (ADL’s)and/or instrumentalactivitiesofdaily living (IADL’s) (SWD2013,p.3).

ThereisageneralconsensusabouthowdemographicageingischallengingcountriesaroundtheglobeincreasinglyconfrontedwithgrowingLTCneedsfromolderpersons.OrganizationssuchastheOECDortheEChavepublishedmultiplereportswithforecastsandpolicyrecommendationstotacklewhatmanyconsiderthemostpressingissueofthe21stcentury(seeSWD2013orColomboet al. 2011). Despite this visibility of LTC needs in the international debate, it attracts differentlevelsof interestatthenationalpolicy level,withmanycountriesstillrankingitquitelowinthe



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policyprioritieslist.OneofthemostvisiblefacetsofthisneglectisthecontinuinglackofreliabledataoncoverageandaccesstoLTCbenefitsandservicesinmanyEuropeancountries.

Eventhoughmanyandvariedeffortsaredirectedtoextendingandrestoringpeople’sautonomyandindependence,theneedforcareisexpectedtoincrease,especiallytheneedforformalcare.Thisisnotjusttheconsequenceofrisinglifeexpectancyleadingtoincreasingnumbersofpeoplereachingtheagewhensomeformofhelp isrequired indaily lifebutalsoaconsequenceofthedecline in the supplyof informal (unpaid), familybased care.Patternsof family formationhavebeen changing over the last decades, with people having fewer children, often in trajectoriesleadingtopatchworkfamiliesandwithasubstantialincreaseingeographicmobilityofindividualsmoving around looking for work (Liefbroer 1999, Oinonen 2009). These factors converge toproduce a substantial decrease in the availability of informal care. However, only a few EUcountries provide extensive, publically financed care for older people. Inmany countries,mostcareisstillprovidedonanunpaid,informalbasisbyfamilymembers,mostofwhomarewomen(seealsodeliverableD2.4).

Although there is considerable certainty about future ageing scenarios, it has been increasinglydifficult to “sell” the idea of expanding welfare and social services to national governmentsstruggling to provide the very basic coverage, especially in times of budgetary constraints andpressure towards a focus on financial sustainability. So far, impacts of investments in LTC inEuropehavenotbeeneasilymeasuredandquantified. Indeed,LTCismoreoftenportrayedasacost rather than a contribution to social capital and social cohesion in pursuit of the Europeansocialmodel.

SPRINTaimstogivemeaningtotheconceptofsocial investmentasappliedtoLTCprovision. Itsobjectivesincludecreatingameansofassessingthesocialcostsandbenefitsofdifferentwaysofproviding LTC,and showinghowprovisioncanachieve socialbenefits that canbe seenasgoodvalueforthemoneyspentonprovision.ThebroadambitionofSPRINTistodevelopamodelofsocialmetricsthatcanbeusedtomeasurethesocialimpactsandeconomicreturnsofdifferentLTCservicesandschemeswithaviewtoidentifyingthemostpromisingalternativestorealisetheambitionofthesocialinvestmentpolicyparadigm.

LTCisagoodexampleofafieldofpolicydesignwhereavarietyofcostsandbenefitsneedtobetakenintoaccount.ThispresentsamajorchallengefortheSPRINTproject.Forexample,onecanthinkthatreducingpublicprovisionmayreducecostsmeasuredaspublicsocialexpenditure,butitmay have impacts in other areas that may actually represent even higher costs. It may, forexample,preventthosethattakeupcareresponsibilitiesfromparticipatinginthelabourmarket,andthereforefromcontributingtotheeconomythroughtaxesandothersocialcontributions.TheaspirationofSPRINT istodisentangletheoftencomplex impactmechanismsofLTCprovisiontoidentifyinvestmentsthatdelivergoodvalueinthatfield.



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TheanalysisSPRINTofferstakesasastartingpointthatinthecontextofdemographicageing,andalthoughtheroleoffamiliesinprovidinginformalcarewillremainimportant,statesmightneedtofind adequate and sustainable ways to tackle care needs by means of formal LTC schemes orsystems. Failure to do somight involve in the longer term higher costs for individuals and forsociety as a whole than if comprehensive public support was provided through capacitatingservices.

LookingatLTCfromaSIperspective involves lookingatthebroadersocialpicture inwhichcarearrangements unfold and considering all social actors affected by the decisions that are takenregarding those arrangements. It involves moving away from an exclusive focus on costs, aperspectivethatfeedsthefearthatLTCwillincurextremelyhighpublicexpenditure,andinsteadembracingapolicyanalysisapproach thatplacesLTC inageingsocietiesat the intersectionofaseriesofchallenges thatneed tobe tackled for sustainablegrowthandacompetitiveEuropeaneconomy.Figure1belowsummarisestheelementswithinthescopeofSPRINTandhowitaimstolookatLTCfocusingonthesocialreturnoninvestments.

Figure1:KeyelementstoapproachLTCfromaSIperspective

Investors Investment Returns

Thoseallocatingresources

-varietyofagents:public/private;formal/informal;commercial/notforprofitactingwithininstitutionalandregulatoryframeworks-varietyofresources:monetary;time;effort;infrastructures

LTCprovision

-tacklingdifferenttypesofneeds:health/socialcare;ADL’s/IADL’s;dementia;needsofcarers-focusingondifferentapproachestoneeds:prevention;rehabilitation;assistance;palliative;hospicecare

ResultsofLTC:costsandbenefits

-maybeexperiencedaspositiveornegative;maybeofamaterialorofanon-materialnature;maybeexperiencedindividuallyorcollectively;mayhavedifferentimpactsalongtime-varietyofcosts:fiscal;socialexpenditure;privateexpenditure;socialcosts;opportunitycosts;preventivecosts-varietyofbenefits:wellbeing;economicbenefits;efficiency;opportunities;quality



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SPRINTisnotattemptingtocarryoutaremappingofLTCprovisionwithinEurope.Rather,itseeksto take account of different approaches, ranging from universal to minimal provision and allgradationsbetween,tryingtoidentifyandexplainwhatresourcesareemployedandtoevaluatethecostsandbenefitsofeachapproach.Asshownunderfigure1,thisinvolvestheidentificationof the current landscapeoforganizationand resourcingof LTC, the stakeholders, the resourcesand the dimensions of impact of different LTC arrangements. It also involves setting out theinstitutional and regulatory frameworks which provide the context for LTC provision. For aselected sample of care services and schemes, SPRINT will consider the criteria that make aninvestmentagoodvaluefromasocialinvestmentperspective,afterconsiderationofallcostsandallbenefitsforavarietyofstakeholders.Indoingso,SPRINTwillnotonlyidentifysomecommonground fordebateona topic that isoftenchallenging for cross-country comparisonsandpolicyreplication, but also develop amodel of investment in LTC that can assist decisionmakers andintroduceinthepolicy-decisionprocessinnovativewaysoflookingatcostsandreturns.

4.2 TheSocial ImpactsofLTCfromaSIPerspective:SomeTentativeDimensionsofAnalysis

Thequestionarises:WhatistheambitionofthesocialpolicyparadigminthefieldofLTC?Inotherwords, what are the social impacts of LTC policies that can be viewed from a SI approach?Ultimately,howdoestheframeworkofSIfitLTC?

Oneofthefirstpointsof intersectionofLTCwiththebroadSIambitionconcernsthe impactofprovision of care services as a capacitating policy in terms of increasing the participation ofworkersinthelabourmarket.Theexpecteddecreaseintheavailabilityoffamilycaregiversduetodemographicageing isexpectedtoputadditionalpressuresonfamilies intheirendeavourtotackle their older members’ needs for LTC. This pressure is particularly felt by women whotraditionally absorb more responsibilities in care provision, with a detrimental impact in theirabilitytoparticipateinthelabourmarket(seeGabrielleetal.2011).Oneofthepolicyprioritiesofthe SI agenda isdecreasing thegender gap in labourmarketparticipationwithanemphasisonwomen that aremothers of young children andwomen aged 50 plus, the two groups that aremoreaffectedbythedifficultiesofreconcilingworkandfamilylifeduetocaringresponsibilities.Thegroupofolder femaleworkers is themaingroupsupplying informalcare toolder relatives,oftenspousesbutalsoolderparents(Ferrantetal.2014).ThelackofformalLTCprovisionislikelytoaffectdisproportionallythisgroupofthepopulationthatwillnotonlysuffertheconsequencesoflossofpaidemploymentaffectingcurrentincome,butalsobenefitsandretirementsavingsthatcouldresult.LTCservicesascapacitatingservicescanthereforebethoughtofasdeliveringpoliciesthat increase the flow of workers into the labour market while decreasing the future costs of



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income protection of individuals that are deprived of normal and complete trajectories in thelabour market. Additionally, these become active contributors, paying taxes and socialcontributions.

Another important element of intersection of LTC with the SI policy paradigm concerns theprevention approach. This can be looked at from different angles. In a sense,provision of LTCservicescanbevaluedasakeypolicymechanismtosupportautonomyandindependentliving,postponingtheneedforinstitutional(typicallymoreexpensive)care(seeColomboetal.2011).Social investment in LTC, for older people, is thus about helping individuals to maintain anindependent lifestyle, continuing to live in their own homeswherever possible and interactingsocially within a supportive community. Prevention and rehabilitation as principles of LTCprovisionthushavethepotentialtosecurehumancapitalpreventingfurthererosionofhealthandwellbeing.Healthandwellbeingthereforebecomeassetsthathaveasocialnatureandnotsimplydimensionsofindividualutility.

ThisanalysiscanbeexpandedtoconsidertheimportanceofLTCservicesprovisionintermsofinitspotentialtodecreaseequityproblemsinsocietyandinincreasecapacitytoinduceefficiencyintheuseofresources,actingasabufferinsecuringincomestabilityandfinancialsustainability.Failure to provide affordable LTC services is likely to affect disproportionally the lower incomegroupsandexposethemiddleclasses toahigherriskof impoverishment ifconfrontedwiththeneed to secure out-of-pocket payments for care. LTC costs often have a detrimental financialeffectonspouses/partnersandonchildrenofthepersonneedingcare.Householdassetsmaybespentdowntoprovidecareforthefirstpersonneedingcareandthesurvivor(s)maybeleftwithlittleornoassetstocoverfortheirownneeds,increasinginequity(seeBajtelsmitandRappaport2014). Provision of affordable LTC services may have thus a protecting effect on householdfinances and assets, relieving them for use in other domains, such as consumption, acting as apreventivemechanism for impoverishment and correcting the structural dimensionsof inequitythathindertherealisationoftheEuropeansocialmodel.

Furthermore,provisionofLTCservicescanbelookedatinitscapacitytoenhancethewellbeingof peoplewith caring responsibilities,notonlyby removing tensionsbetweenworkand familyresponsibilities or improving their social inclusion through participation in work, but also bypreventing the deterioration of their physical and mental health and the opportunity costs ofengaging in informal care provision diverting them from other activities such as looking afterchildrenorvolunteerwork(seePinquartandSörensen2003).

Morebroadly,wecanconsiderthesocialimpactsofLTCasexternalitiesandlookathowsocietyasawholewillfeelbetterorworsedependingonhowtheiroldercitizensarelookedafter.Thesefeelingsarenotsimplyrootedinsomesortofsocialaltruism,wherebypeoplewillfeelgoodiftheyknow older frail people are being properly looked after, but it also relates in a sense to anintergenerationalpactthatmakesindividualsfeelmoreorlesscomfortableabouttheirprospects



16

in the futurewhen they themselvesbecomeold and frail by looking athow society tackles theneeds of older people today. Regular monitoring of attitudes and expectations of EuropeancitizenssuggestsagrowingconcernaboutLTCanda low levelofsatisfactionwiththequalityofcare and the affordability of care currently being provided in many national states (SeeEurobarometer378ReportonActiveAgeingbyDGCOMM2012).

TheambitionofSPRINT is todevelopanoperationalpolicyanalysis framework that identifieskeyareasofimpactofLTCprovisionintermsoftheirpotentialtogenerateeconomicandsocialreturns and considering all the stakeholders that are touched by the different approaches toprovision.

5 AddressingSocialValueofLong-TermCare

Following the broaddiscussion on the features of a SI policy analysis and how it intersects thedimensionsofsocial impactofLTC,wecannowdefineSocialInvestmentinthecontextofLong-TermCareas

Welfareexpenditureandpolicies thatgenerateequitableaccess tocare tomeet theneedsofageingpopulations,improvequalityofcareandqualityoflife,increasecapacitiestoparticipateinsocietyandtheeconomy,andpromotesustainableandefficientresourceallocation.

FromaSIperspectiveLTCarrangementscanbeviewedintermsoftheircapacityto:i)usesocialbudgets efficiently andeffectively in solutions that are adequateand sustainable; ii) strengthenpeople’s capacities andopportunities toparticipate in society and in the labourmarket; iii) useprevention and rehabilitation to reduce current and future needs for assistance; iv) coordinatehealth and social care arrangements to achieve lasting positive social impacts and avoidinstitutional fragmentation; v) foster quality of care, well-being and equity; vi) promoteindependentlife,forexamplethroughtheuseofmoderntechnologies.

SPRINTwillinvestigatethecriteriathatshouldbefulfilledbyaLTCserviceorschemeinordertoqualify itassocial investmentproducingpositivesocial impactalongsomeorall thedimensionslistedabove.

Subsequently, under WP4 and WP5, SPRINT will be addressing the relationship betweeninputs/costsandoutputs/benefitsofLTCservicesandschemeswiththeaimofdevelopingatoolthat can be used to ensure that LTC investments deliver a demonstrable social impact whileremainingeconomicallyandsociallyviable.



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SPRINTwilldevelopaSocialReturnon Investment (SROI)approach tomeasureandunderstandtheimpactsofLTCarrangements.SROIisaprinciplesbasedmethodformeasuringthesocialvalueofanactivityrelativetotheresourcesinvestedinit.ItisnotdramaticallydifferentfromstandardCost-Benefit Analysis (CBA) whereby one is investigating whether an action (an investment) isjustifiedintermsoftheextenttowhichitimproveswellbeinggiventhecostthatisincurred.SROI,similartoCBA,aimsatmeasuringoutcomesinmonetarytermsandatusingtheoreticallyjustifiedvalues in valuing inputs andoutcomes,while adopting a broadperspective on value created. Itplacesagreatdealofemphasisonstakeholders’viewsandtendstoputfinancial‘proxy’valuesonalltheimpactsidentifiedbystakeholdersthatdonottypicallyhavemarketvalues(Arvidsonetal.2010).

OneofthemainchallengesthatSPRINTwillfaceconcernstheoperationalizationoftheLTCflow,depictedunderFigure1,asSIwithaviewtoestablishingthelogicsandthemetricsoftheimpactmechanism.LTCisafieldofpolicydesignwhereavarietyofcostsandbenefitsneedtobetakenintoaccount.Moreover,whatsomeexperienceasbenefitsothersmayexperienceascosts(interaliaasaconsequenceofinstitutionalfragmentation).Addingtothis,notallcostsandbenefitswillbeimmediatelyexpressibleinmonetaryterms(althoughsomemightbe,andforsomeavaluewillhave to be constructed). Both fiscal costs and benefits and social costs and benefits areconsidered.Additionally,opportunitycostsmayneed tobe includedgivenmoneyspentononeareacannotbespentonotherareaswhichinvolvestheneedforqualificationoftheoutcomeofdifferent investments. Attribution plays an important part in the analysis (were otheractivities/interventionsalsogeneratingsomeoftheoutcomes),andthisisrelatedtotheconceptofdeadweight.Durationofbenefitsisalsoimportantasthesemightbeexpectedtodeclineovertime(attrition).TheaspirationofSPRINTistodisentangletheimpactmechanismsofLTCprovisiontoidentifyinvestmentsthataregoodvalueinthatfieldanddevelopinnovativeassessmenttoolsthatcanactuallybringafreshapproachtotheconsiderationofthesocialvalueofLTCandhelpcomparingoptionsinviewoftheirexpectedreturns.

The information requirements to undertake this exercise are very demanding and a substantialefforttoidentifyandassessavailabledatawillbecarriedoutunderWP5withaviewtoidentifyingin themost precisemanner possible the resources that are pooled into LTC provision and theactors involved inLTCprovisionso that the total costsofprovidingcare for thedifferentactorsandthe impacts(positiveandnegative)ofdifferentarrangementsfordifferentstakeholderscanbecomputed.

ReferringtothecontentsofFigure1andtheabovestatements,and inanattempttoprovideaconceptual starting point for the identification of costs and benefits of LTC to differentstakeholdersandfromaSIperspective,Table1belowsummarizessomekeyissuestobetakenupinsubsequentdeliverables.



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Table1:DimensionsofimpactofLTCfromaSIperspective:elementsofcostsandbenefitsfordifferentstakeholdersStakeholders Costs Benefits

State

Fiscal costs / Public expenditures /SocialExpenditure;Cash benefits / fees for LTC homes /costs of domiciliary care services /adaptationcosts;Costsof“respitecare”;Taxreliefs

Greatertaxandsocialcontributionsifmorepeoplearefreetoparticipateinthe labourmarket, relieved of caringresponsibilities,Freeingpotentialcarerstoparticipatein the labourmarket thus avoiding adepreciation of the human capital ofsuch people while enhancing laboursupply, and so reducing inflationarypressures

Users

Outofpocketcosts;Insuranceexcesses(includingexcessesof public LTC insurance) andexpenditures that means-tested orneedstestedsystemsdonotcover;Adaptationcosts

Meeting needs in an affordable waycan be argued as a benefit in itselfpromotingequity.ImprovedhealthandqualityoflifeAgeinginplace:apreferencebutalsoamoreaffordablewaytoprovidecarecomparedtoinstitutionalcareIndependentlivingandautonomy

Informal/Familycarers

Social costs: Lower quality of life,stressLoss of present and future income ifpreventedfromtakingpaidworkOpportunity costs associated withinability to participate in otheractivities: looking after children;voluntary work; leisure activities;educationandtraining

Feelings of satisfaction for lookingafter a loved one (intergenerationalsolidarity;spousesolidarity)Participation in labour marketsecuringpresentandfuture income–improvedgenderequalitySatisfaction with reconciliation offamilyandworkSatisfaction from knowing olderperson is receiving good andaffordablecare

Formalcarers

Costs of operations for theorganizationprovidingcareCostsforworkers:Health andwellbeing of careworkerscan deteriorate if: excess in workinghours; insufficient number of carers;insufficienttrainingLow job satisfaction due to badworking conditions and low wages incaresector

Ideologiesofcare:e.g.incharitiestheprovision of a care service as thematerializationofamissionGeneratesemploymentHigher productivity of care provisionbyuseofprofessionaltrainedworkersandinnovativetechnologies



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Deliverables D2.3 and D2.4 will be identifying the current landscape or LTC organization andresourcingaswell as thepublic andprivate stakeholders involved in LTC. The jointworkof thedeliverablesunderWP2willdirectlyfeedtheanalysiscarriedoutunderWP4andWP5wherethefundamentals of the SROImethodology will be introduced and adapted tomeasure social andeconomic returns of investments in LTC. Thiswill involve a detailed discussion on the differentmethodstomonetizeinputsandoutcomesofLTCinviewofestablishingthecriteriaofSIandthemeasurementofsocialvalue.Beforehand,andsincetheprovisionofLTCtakesplace innationalsettingsframedbyinstitutionsandregulations,aswellasbyinternationalguidelinesandnorms,underWP3weshallbelookingattheinternationalandnationalapplicablelegislationandsoft-lawwhich shape entitlements to LTC and distribution of roles among stakeholders. The goal is toexamine how these institutional and regulatory frameworks interact with social investmentmodelsofprovision.

5 Conclusions

Europeneedstoprepareforasteepincreaseinthenumberofpeopleintheagegroupmostlikelytoneed long-termcare.At the same timeEuropealsoneeds to find innovativeand sustainableways to organize and finance long-term care. Not many countries offer publicly fundedcomprehensivecareservicesandeventhesehavebeenmovingtowardstheintroductionofneedsassessmentandmeans-testedpolicieswitha view to containingexpansionof serviceprovision.Formanycountriesfamilyself-servicingremainsthemostcommonwayofdeliveringcare.SPRINTstartsfromtherealizationthatthecurrentmodesofrespondingtoolderpeople’slong-termcareneeds are not sustainable in view of projected demographic changes coupled with changes inlabour market dynamics, models of family formation and also normative orientations andexpectationsofEuropeans.Althoughtherearepressurestowardsfiscaldisciplineandbudgetarycontainment,notdevelopingefficientwaysofdeliveringcaremayresultinhighercoststhanthoseinvolvedinactualprovision.

ThispaperprovidesatheoreticalanalysisofhowthesocialinvestmentapproachcanbeappliedinthecontextofLTC.StartingfromthebroadscholarlydebatearoundtheconceptofSI,thepaperhasofferedadefinitionofSI inthecontextofLTCthatwillbedevelopedbytheSPRINTproject:welfareexpenditureandpolicies thatgenerateequitableaccess to care tomeet theneedsofageingpopulations,improvequalityofcareandqualityoflife,increasecapacitiestoparticipateinsocietyandtheeconomy,andpromotesustainableandefficientresourceallocation.

The paper also identifies dimensions of social impact of LTCwith a view to demonstrating theconceptualfeasibilityoflookingatLTCassocialinvestment.MovingawayfromtheconsiderationofLTCaspurelycost,thepaperhasrevealedsomedimensionsofreturnthatmayberelevantto



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considerandeventually lead toqualifying some investments in LTCasgoodvaluebasedon thebenefitstheybringnotonlytoindividualsbutforsocietyasawhole.Thishasincludedthelistingof importantdimensionsof analysisof LTC servicesand schemes thatneed tobe considered inordertoconfirmthataspecificserviceorschemehasdeliveredademonstrablesocialimpact.



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6 References

Arvidson,M.,F.Lyon,S.McKayandD.Moro.2010.TheambitionsandchallengesofSROI.

Bajtelsmit, V. and Anna Pappaport. 2014. The impact of Long-Term Care costs on retirementwealthneeds.SocietyofActuaries.

Bonoli, G. 2013. The origins of active social policy. Labour market and childcare policies incomparativeperspective.Oxford:OxfordUniversityPress.

Cantillon,B.2011.Theparadoxofthesocialinvestmentstate:growth,employmentandpovertyintheLisbonera.JournalofEuropeanSocialPolicyNetwork(ESPN).Brussels:EuropeanCommission.

Colombo,F.,A.Llena-Nozal,J.mercierandF.Tjadens.2011.Helpwanted?Providingandpayingforlong-termcare.Paris:OECDPublishing.

COM 2013. Towards Social Investment for Growth and Cohesion – including implementing theEuropean Social Fund 2014-2020. Communication from the Commission to the EuropeanParliament,theCouncil,theEuropeanEconomicandSocialCommitteeandtheCommitteeoftheRegions.Brussels,20.2.2013COM(2013)83final.

EuropeanCommission 2012. Special Eurobarometer 378:ActiveAgeing.DGEmployment, SocialAffairsandInclusion.

Dodová, I. 2013. Social investment as a new paradigm of social policy. DANUBE: Law andEconomicsReview,4(3):231-42.

Esping-Andersen,G.,D.Gallie,A.HemerijckandJ.Myles.2002.Whyweneedanewwelfarestate.Oxford:OxfordUniversityPress.

Ferrant,G.,M.P.LucaandK.Nowacka.2014.Unpaidcarework:themissinglinkintheanalysisofgendergapsinlabouroutcomes.OECDDevelopmentCenter.

Ferrera,M.,A.HemerijckandM.Rhodes.2000.The futureof socialEurope: recastingworkandwelfare in the new economy. Report prepared for the Portuguese Presidency of the EuropeanUnion.Oeiras:CeltaEditora.

Gabrielle, S., P. Tanda and F. Tediosi. 2011. The impact of Long-Term Care on caregivers’participationinthelabourmarket.ENEPRIResearchReport98,ANCIEN,ENEPRI.

Hemerijck,A.2014.Socialinvestment2Stocks”,“flows”and“buffers”.PoliticheSociali,1(1):9-26.

Hemerijck,A.2015.Thequietparadigmrevolutionofsocialinvestment.SocialPolitics22(2):242-256.



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Jenson,J.andDenisSaint-Martin.2003.Newroutestosocialcohesion?Citizenshipandthesocialinvestmentstate.TheCanadianJournalofSociology,28(1):77-99.

Kersdbergen,K.andA.Hemerijck.2012.TwodecadesofchangeinEurope:theemergenceofthesocialinvestmentstate.JournalofSocialPolicy,41(3):475-92.

Liefbroer,A.1999.Fromyouthtoadulthood:understandingchangingpatternsoffamilyformationfromalifecourseperspective.PopulationIssues.SpringerNetherlands:53-85.

Merton,R.1968.TheMatheweffectinscience.Science,159(3810):56-63.

Morel,N.,B.Palierand J.Palme (eds.).2012.Towardsa social investmentwelfare state? Ideas,policies,challenges.Bristol:PolicyPress.

Mulgan,G.,N.Reeder,M.AylottandL.Bo’Sher.2010.Socialimpactinvestment:thechallengeandopportunityofsocialimpactbonds.YoungFoundation.

Nolan,B.2013.Whatuseis“socialinvestment”?JournalofEuropeanSocialPolicy,23:459-68.

OECD.2006.Promotingpro-poorgrowth:keymessages.Paris:OECD.

Oinonen, E. 2009. Starting the first family. Changes in patterns of family formationanddemographictrendsinFinlandandSpain.EuropeanSocieties,6(3):319-346.

Pinquart, M. and S. Sörensen. 2003. Differences between caregivers and noncaregivers inpsychologicalhealthandphysicalhealth:Ameta-analysis.PsychologyandAgeing,18(2):250-67.

Saraceno, C. 2015. A critical look to the social investment approach from gender perspective.SocialPolitics,22(2):257-69.

Söderström,L.2008.Theeconomicsofsocialprotection.Cheltenham:EdwardElgarPublishing.

Streeck, W. and D. Mertens. 2011. Fiscal austerity and public investment. Is the possible theenemyofthenecessary?MPIfGDiscussionPaper,11/12.

SWD 2013. COMMISSION STAFF WORKING DOCUMENT Long-term care in ageing societies -Challengesandpolicyoptions.AccompanyingthedocumentCommunicationfromtheCommissiontotheEuropeanParliament, theCouncil, theEuropeanEconomicandSocialCommitteeandtheCommittee of the Regions Towards Social Investment for Growth and Cohesion – includingimplementingtheEuropeanSocialFund2014-2020.

Vandenbroucke,F.andK.Vleminckx.2011.Disappointingpovertytrends: issocial investmenttoblame?JournalofEuropeanSocialPolicy,21(5):450-71.



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7 AnnexI:UnderstandingofSIinSPRINTPartnerCountries

ThefollowingtablewaspreparedbyVasileiosBougioukoswhile working at LSE, and includes interpretations by Bernard Casey, for the SPRINTproject.

Country Partnercomments(including

interpretationsbyBHC)ESPN Thematic Report on SocialInvestment(countryreports)

CommentsonESPN

Joint SPC-EC report on Adequate socialprotection for long-term care needs inanageingsociety

Belgium The concept of Social Investment inBelgium is generally associated withsocial policy and is interpreted aspublic expenditure for welfarebenefits and allowances, social careservices, education, healthcare andactive employment policies. InBelgium there is a great tradition inwhatisregardedassocial investmentandthereisarathergeneroussystemofsocialbenefitsandcomplementarysocial services for disadvantaged andsociallyexcludedgroups.Atpolicy level,theapproachtosocialinvestmentby theBelgianauthoritiesis guided by the long-term objective

No specificreferenceto SI innarrowersense.No ref toSoc ImpactInvesting.No ref tosocialenterprise.

Nothing really, although mention ofinitiativesforbettercoordinationofhealthandsocialcareservicesDoes state that “Programmes forprevention, support for rehabilitationand schemes promoting independentliving are mostly found on the regionallevel”.



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to providewith adequate support allthose in need and to extend thecoverage of socialwelfare policies toalldisadvantagedpeople.[ButthetermislittleusedinBelgiumexcept by one or two academics –esp.FrankVandenbroucke]

Denmark The concept of social investment isnot used within long-term care inDenmark and other words such associal innovation and socialentrepreneurship is used in otherareas.

“The Danish approach to socialinvestment comes from a Nordictradition ofwelfare policies aimed atmaximising the realisation of humancapital of all citizens, particularlyenabling citizens to work and beautonomous, whilst taking care ofthose who cannot take care ofthemselvesand/orcannottakepartintheordinarylabourmarket.”NoreferencetoLTC

No specificreferencetoSIin narrowersense.No ref toSoc ImpactInvesting.No ref tosocialenterprise.

Across political parties, municipalitiesand interestgroupsthere’san increasedfocus on preventive health care andrehabilitation for older people. Theoverarching recommendation from theHome Care Commission is to make aparadigmatic shift in Danish LTC policyfrom a primary focus on serviceprovision to a combination of emphasison a) prevention for older peoplewithout functional limitations, b) re-enablement for thebig groupof elderlywith few tomoderate limitationsandc)more compensatory and nursing caremeasures for persons with large andcomplexcareneeds.An example: The Fredericia Modeloperates a programme of home-basedrehabilitation. Fredericia’s programme



25

hasoperatedsince2008,and isentitled"As long as possible in one's own life".Within two days of being dischargedfromhospital,olderpeopleareregisteredandattachedtoanoccupationaltherapistorphysiotherapist, who assesses theirneedsandpreparesarehabilitationplandesigned toenable themtoundertake -andtogaintheconfidencetoundertake- the normal activities of dressing,cooking,shoppingetc.Theaimistoenableolderpeople to look after themselves andenhancetheirqualityoflife.

Finland IthinkthatSIasatermisquitenewinthe context of the Finnish elderlycare. Decision-makers inmunicipalities and government dothink in terms of social cost-benefitand cost-effectiveness analyses andunderstand these approaches, but IwouldthinkthattheideaofSIisnewtoFinnishdecisionmakers.Itisnotheardinthepublicdiscussionaroundelderlycare.

“The importance of the socialinvestment paradigm varies frompolicy to policy. Sometimes the verysamepolicydomainhasexplicitsocialinvestment goals, but simultaneouslyit may include elements thatcontradict the EU idea of socialinvestment.”“All these measures have a socialinvestmentperspective,butwhileitismore clearly spelled out in somemeasures, it is hidden in thebackgroundofothers.Theproblemis

No ref toSoc ImpactInvestingNo ref tosocialenterprise

Therearenospecificnationalpoliciesorprogrammes for prevention andrehabilitationofolderpeople.



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not the number of options and theirunderpinnings, the problem is theinsufficient coordination of variousactorsinthefield.Bettercoordinationofmeasuresandactorswouldleadtobetterresults.Furthermore,whereasthetimehorizoninsocialinvestmentsexpands to several decades, thehorizoninausteritymeasuresismuchmore limited.” Brief reference topoliciesforLTCincsupportforcarers.

Germany ThetermSIisnotwidelyusedinGermany. However, KfW (domesticdevelopmentbank)hasusedthetermto describe investments in “socialinfrastructure”asprovidedbynot-for-profit organisations. Here, the termoverlapswithsocialenterprise”.The Bertelsmann Foundation hasbeen interested in “financing socialchange” and with “social impactinvesting”. Here the emphasis hasbeen on “social impact bonds”. Theinfluence of the UZKI-led SocialImpactInvestmentTaskforce(SIITF)isclear.]There is [also] an agency (FASE) forfinancing social enterprise that talks

A better reconciliation of work andlong-term care is therefore a keyelement in a social investmentapproach; the cost increase in long-termcare insurance,especially in thesectorofinpatientnursinghomes,canbe limited and the objective ofextending people’s working life ispromoted

No ref toSocImpactInvesting.No ref tosocialenterprise.

As an example of “better carecoordination” - in Germany mainlynurses, act as “case managers”responsible for informing and advisingolder people and their families aboutappropriate health and long-term careandotherservices.HI funds may feel that there is notenough economic incentive to offerrehabilitation measures, even thoughthey are by law obliged to do so. Therecent reform puts more pressure oninsurance funds/companies. Since 2013,every new applicant for benefits fromLTCIhastoreceiverecommendationsforpotentialrehabilitationmeasures.



27

ofSI. Last there isaCentre forSocialInvestment and Innovation at theUniversity of Heidelberg that hasresearchedSIinthenarrowaswellasthebroadersensed.

Greece SocialinvestmentinGreeceisnotaconcept which is either used orrecognised.

Caseswhere SI could be inferred areearly childhood development (wherecrèchesetcarejustifiedasameanstoincrease female labour participation,thoughwithout apparent concern ontheinfantsthemselves).

No ref toSocImpactInvesting.No ref tosocialenterprise

Prevention measures and promotion ofindependentlivingamongtheelderlyareratherneglectedpolicyareas(asarealsopublichealthandhealthpromotion).

Hungary Ourgovernmenthasnotbeenfamousfor investing in vulnerable groups tillnow (rather the opposite) orsupporting such investments (theywanted to strengthen the middleclass;atleastthiswaswhattheysaid).There are some initiatives from thecivilsector:socialenterprises.Andthegovernmental agencies take part:mainly in conferences, where theyemphasizehow important this is,butifweexaminetheirpolicy,thereisnochange.Sothereisasmallgroupwhotalkaboutit.

“Social investment is not a centralthemeinmostHungariansocialpolicyand has not been adopted as anexplicit social policy approach.”“Social investment is not a centraltheme in most Hungarian socialpolicy; the term itself is hardly everused.However, some policies can besaidtobeofasocialinvestmenttype.Inparticular,a focusonchildpovertyand on early intervention generallycanbe said topoint in thisdirection.However, even since 2013, socialinvestment has not been adopted asan explicit social policy approach.”Long-term care (LTC) is generally

No specificreferencetoSIin narrowersense.No ref toSoc ImpactInvesting.No ref tosocialenterprise.



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treatedasamarginalareainHungary,which is also indicated by the lowshare of related social protectionexpenditure.

Italy Social investment, innovation,efficiency are keywords that havebeen at the centre of the Italiandebate during the 70s - ‘80s. Thepolicy debatewas oriented toward ademocratic planning system able tointroduce and support the neededinstitutional, economic and socialreforms.Some reference to social impactinvesting.But“aclearsocialinvestmentstrategyis lacking and Italy does notincorporate the protection of therights of the people experiencingpoverty and social exclusion into itspolicypillars".

When compared to most WesternEuropean countries, the mainfeatures of the Italian LTC publicsystem are the following (mostly atodds with an SI approach): i) verystrong prevalence of cash-benefitprogrammes over services; ii) arelatively weak investment inresidential care; iii) a mediuminvestment in home care, althoughthis type of service is fundamentallyand informally supported by migrantcareworkers(workingandbeingpaiddirectlybyfamilies).

No ref toSoc ImpactInvesting.No real refto socialenterprise.

In general the LTC system is stillunderdeveloped with significantvariation among regions. It ischaracterized by a high degree offragmentationamonginstitutionsaswellas sources of funding and governance,withmanagementresponsibilitiesspreadover local (municipalities) and regionalauthorities, according to differentmodalitiesinrelationtotheinstitutionalmodelsofeachregion.Preventive measures are not verywidespreadinItaly.

Lithuania TheconceptofSIisnotdiscussedwidelyorrecognisedinLithuaniansocialpolicy.Social investment would probably beunderstood (by broader public orpolicy makers) as some kind ofinvestment related to social causes

No ref toSocImpactInvesting.No ref tosocialenterprise.

ImplementationoftheIntegralDevelopmentAssistanceProgrammefinancedfromthefundsoftheEuropeanSocialFundaimedathighqualityintegralassistance (nursing and social services)fordisabledpersons,elderlypeopleandconsultancysupportforfamilymembers



29

(mostlikelyasnot-forprofit)andthatwouldprovidesomereturn indistantfuture (mostly related tochild/family/youth support/rightspolicies).

taking care of such persons wascommenced.Increasedavailabilityandqualityofoutpatientrehabilitationisoneofthegoals in the strategic health policydocuments.

Poland Socialinvestmentisknownamongcolleagues who are interested in theEU ideas but there is no seriousresearch or even publicationsavailable. I have written some timeago on social investment and thearticle will be published soon. Theconcept of social economy waspopularsometimeago.Therewereeveninstitutionsbasedonthis concept,Theassessmentof theirresultswasnotsatisfactory.Might be understood as socialenterprise – e.g. enterprises that aremore "social" and less for profit. Ahotel employing people withintellectual disability will be oneexample.

“Poland does not have a separatesocial investment policy agenda butmanyideasoftheSIParereflectedin the NRPs (National ReformProgrammes) and medium-termstrategic documents adopted in2013”.Does have a section on LTC,describingpolicies/intentions,butnotasSI.

NospecificreferencetoSIinnarrowersense.NoreftoSocImpactInvesting.Noreftosocialenterprise.

Portugal The discourse on Social Investmenthasbeenverymuchassociatedtothatof the role of Third Sectororganizations intheoverallsystemof

“Thegeneralisedlackofsocial impactassessmentofthereformsintroducedmakes it difficult to monitor theiroutcomes and therefore their

No ref toSocImpactInvesting.



30

welfare provision and to the need offinding funding alternatives to publicfinancing. A Social Investment Lab(SIL)hasbeenestablished.ItisaNGOthat operates as a sort ofadvisory/consulting agent for socialentrepreneurs and third sectororganizations as well as to potentialinvestors.Sofar,theactivityhasbeenfollowing more the advocacyapproach because it is felt to becritical to introduce the concept andthe vocabulary of SI in the socialsector and among organizationsoperating in the social sector. Theapproach of the SIL has beenrevolvingsofarverymucharoundtheargument that social entrepreneursandthirdsectororganizationsneedtodiversify their sources of funding,moving away from the traditionaldependence from state funding, andSIshowsasaninnovativeapproachtoattract funding from the privatesector. Soon after the SIL waslaunched,agovernmentalagencywascreated, Social Innovation Portugal,with a mandate to foster over the

contribution to implementation of asocialinvestmentapproach.”Brief mention of LTC, but not inrelationtoSI.

No ref tosocialEnterprise.



31

nextfiveyearstheecosystemofsocialinvestment. For that purpose it wasallocated €150m under the Portugal2020Horizonprogramme.Thismoneyis part of the European structuralfundsthecountryhasreceivedunderthe EU framework 2014-2020. TheagencymaingoalofSIP is tosupportSocial Innovation andEntrepreneurshipinPortugal.

UK The government has embraced thesocialinvestmentrhetoric.Thereisaspecial site for it on the UKgovernment website. Much of thediscussion overlaps with discussionabout social innovation, socialentrepreneurship and social impactbonds and also social enterprise. Butthetermdoesappearinitsownright.There is awholepaper entitled2010to2015governmentpolicy: social investment, issuedunder the coalition government in2015. This describes SI as “animportant tool in public serviceprovision. It can help finance newways of tackling social problems.”According to the original “vision”,

“Socialinvestmentisnotyetacentralor explicit theme in most UK socialpolicy. Nevertheless, some policiespursued since 2010 (and before) canbe said to be of a social investmenttype.” “The social protection systemhas become more concerned withrelief than with prevention andprotection.”“Policies within the smaller nationsand some local authorities havevaried in the extent to which theyadopt a social investmentperspective.” Very brief mention ofLTC.

Brief(critical)referencetoSIBs.Noreftosocialenterprise.

Anexample:LinkAgePlus60programme,aschemeworth£10millionto improvethe wellbeing of older people throughpromoting stronger partnership, betterinformation and access to services, andputting older people at the forefront ofservicedesignanddelivery.TheLinkAgePlus principles can be replicated in avariety of contexts. Case studiesdemonstrate the potential of theapproach and a business case has beendeveloped.Takingfallsasanexample,onaverage,a fall resulting inahip fracturecosts around £20 000 to the taxpayer.Evidence suggests that 15 weeks ofbalanceclassesreducesthelikelihoodofa participant falling by around 50 percent. An example: Scotland new



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there was e a Proposal from SocialFinance:SocialImpactBondinhealth.The opportunity: to invest in thedevelopment of Social Impact Bondsinhealthandsocialcareservices.Thestructure of the fund is designed toreduce the risk of productdevelopment while enablingrepayment where possible. There issupposedly an SIB initiative -Markettrends: new retail investmentproducts Threadneedle Investmentsand Big Issue Invest have formed asocialinvestmentpartnershiptobringthe first daily liquid, FCA registereddiversifiedSocialBondFundtotheUKmarket. Big Society Capital provided£10m of seed investment to helplaunchthefund,withThreadneedle,aleading investment house thatmanages assets of nearly £85 billion,contributingafurther£5million.Both retail and institutional investorsare able to invest at least £2,000 inthe fund which will invest incompanies,associations,charitiesandtrusts in areas including affordablehousing, employment and training,

legislation is close to adoption whichmergesthehealthandsocialbudgetanddelivery into a single structure in orderto further increase the quality andefficiency of health and social careservices, which are increasinglyinterdependent due to the growingproportion of older people in need ofLTC.Systematic prevention, rehabilitationand independent living policies forelderlypeoplewithlong-termcareneedsare underdeveloped in the UnitedKingdom.



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and health and social care. On theother hand Carers UK themain NGOrepresenting carers’ interests doesn’tmention SI. Age UK (the main NGO)and Big society Capital (a socialimpact investor sponsored by thegovernment)commissionedastudyin2014to lookatthecontributionofSIto LTC. This looked at examples(including some that were socialenterprises) and also gave someattentiontoSIBs.

TheSPRINTProjecthasreceivedfundingfromtheEuropeanUnion'sHorizon2020researchandinnovationprogrammeunderGrantAgreementNo649565

conceptual report on long-term care -...

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