1. Integration and efficiency in complex and long- term care ….. Prof. Dr. Guus Schrijvers Denmark, januari 2010

2. I want to present to you:  We carried out a preliminary study on the accessibility, care allocation, and assessment of long term care in seven European countries.  What are the theme’s in the public debate in those countries, we asked ourselves en what can we learn from their practices?  In this presentation I present to you some observations with the emphasis on the financial sustainability of the LTC.

3. Development of the systems.  50 years ago, long term care was everywhere generally a private responsibility. A responsibility of the family, the local community and as a matter of last resort, of charity.  Long term care is now everywhere, direct or indirect a mayor public responsibility.  They are the product of the political en social history of the seven countries. In the Netherlands from 0% in 1945 tot 3.4 % of BNP in 2008.

4. AWBZ: % of GNP

5. Themes in the countries surveyed. 1) The financial sustainability of long term care. 2 How to integrate care, social participation and welfare. 3) Strengthening of the autonomy and empowerment people in need for longtime care. 4) Accessibility of care, care assessment and care providing.

6. Accessibility of care, care assessment and care providing. In all of the seven countries the accessibility to LTC is an important theme in the public debate. We see a tendency to introduce elements of a demand driven system in all seven countries.

7. Accessibility of care, care assessment and care providing. Access to information Bureau- cracy Distri - bution Waiting lists Quality control Multiple counters No legally defined rights Postcode problem Netherlands√√√√ France√√√√ England√√√√√√√*√ Sweden√√√*√ Switzerland√√√√*√*√ Belgium√√√√√*√*√ Germany√√√√√*√

8. Accessibility of care, care assessment and care providing. Supply drivenDemand driven LimitationsAvailable care supplyAvailable individual budget Assessment criteria Urgency and riskInsurance or budget claim Legal positionDependent of civil servants. Legally defined rights and written procedures Assessment methods Professional discretion.Algorithms, based on legally defined rights ResponsibilityPrimarily publicPrimarily private Care supplyPublic fundingEffective demand

9. Strengthening of the autonomy and empowerment. In all countries we see initiatives and debates aimed to empower the position and strengthen the autonomy of people in need of LTC. We see the public function gradually changing from a supply orientated and care providing role to a more supporting role, whereby people are enabled and supported to solve their problems in their own way and to their own preferences.

10. Strengthening of the autonomy and empowerment.

11. Growths of positive care assessments in the Netherlands. Bron: CIZ trendrapportages 2008

12. Number of positive assessments. Relative increase 2005-2008 Total: 33% supplies standard care 28% personal budget 116% SSC + PB 112%

13. How to integrate care, social participation and welfare. Chronisch zieke moet kunnen meedoen Door in te zetten op een ketenzorg voor chronisch zieken streeft het kabinet naar winst voor individu en arbeidsmarkt, schrijven de ministers Piet Hein Donner en Ab Klink. Now there are 4.5 million people with chronically diseases, in 15 year 30% more:

14. How to integrate care, social participation and welfare. Integration promoting developments: Demand driven systems and initiatives. Integrated Personal Budgets (France, England, Germany). Diagnoses Related Groups DRG (Netherlands and Germany ). Integrated assessment and Integrated decision making. (Switzerland en France, pilots in England, Belgium and the Netherlands). Integrating budgets is one integrated budget. (France CNSA). Case management, personal assistant, (Sweden, Belgium, pilot Netherlands). All initiatives are limited to people under the age of 60, with a handicap or chronic disease.

15. The financial sustainability of long-term care. A decreasing proportion of the population, has to meet the rising costs of an aging population. Productivity growth in care lags behind other sectors. The level of expectation of care quality rises with the general welfare level. One cannot rely on family support and informal care anymore. Financing long term care is expected to be a growing problem in all these countries, causes including:

16. The financial sustainability of long term care. Solutions to the financing problems: Increasing threshold levels (England, Sweden, Netherlands). Diverting the cost to the local government by inflating the national or insurance contribution to the local government (Sweden, England, Switzerland, Netherlands). Reduction (of growth of) care supply. (Sweden, England, Switzerland, Sweden, Belgium). Increasing the costs of the people in need of care by raising the private contribution or inflating the public contribution (Switzerland, France, Germany). Reducing the claim rights (Netherlands, Sweden)

17. The financial sustainability of long-term care. Public financed systems Supply driven : Reduce the availability of care, or raise tax or premium. Growing waiting lists. Reduced quality and quantity. Reduced the service level. Increase of threshold. Prioritize on urgency and risk. Demand driven: Reduce the budget or raise tax or premium. Inflating individual budged, or insurance contribution to the cost of care. Increase of threshold levels.

18. Development of a three tier system. 1.People in need of care (and/or their social environment) organize and finance their own care. 2.People receive forfeiture means, like allowances, tax reductions, insurance means in order to keep their lives going tot their own preferences. for some people this will not be sufficient therefore: 3.They make a plan of their future with element as education, work, transport, income and care and they receive a integrated budget, with enables them to carry out that plan. (France, pilots in Germany and England).

19. A three tier system. Private responsibility Public support for private responsibility Comprehensive public support

20. I thank you for your attention!! Guus Schrijvers http://www.integratedcare.eu/integratedcare_ned/downloads/090905laatste-30-juli.pdf