Personal assistants (PAs) have become an increasingly important element of long-term care (LTC) in England since the introduction of Direct Payments in 1996 and the Care Act 2014 legislation. The PAs, who are directly employed by social care users, can perform a number of support tasks including vital assistance in activities of daily living (ADL). Internationally these roles would be classed as domestic care work, including the employment of migrant care workers, e.g. in Germany and Austria. High turnover rates and work absenteeism in this market can cause disruption of these important daily activities, causing LTC users to potentially suffer neglect and poorer quality of life. Although there is research on turnover and absenteeism in nursing workforce in hospitals and LTC workers in nursing homes, little attention has been given to reasons for turnover of PAs and even less for absenteeism, which often precedes turnover, in a workforce of over 100,000 people in England. This research aims to fill this gap in knowledge by analyzing the reasons behind the absenteeism of PAs using quantitative methods. We used survey data of PAs in England, exploring the factors associated to one form of absenteeism — sick leave from work. After controlling for a number of factors ranging from job characteristics such as number of hours worked and type of contract, socio-economic characteristics from the PA and their employer, and supply and demand factors at local government region, the findings suggest a number of factors that significantly influenced sick leave, including distances traveled to work and number of PAs employed. Following the analysis, two people with life experience of LTC discuss the findings of the study and how they compare to their experiences of the market for PAs, providing a unique perspective from the people who could benefit the most from improving PA retention and reducing absenteeism.

Hypertension (HTN) affects approximately 25% of the UK population and is a leading cause of mortality. Associated annual health care costs run into billions. National treatment guidance includes initial lifestyle advice, followed by anti-hypertensive medication if blood pressure (BP) remains high. However, adoption and adherence to recommended exercise guidelines, dietary advice and anti-hypertensive medication is poor. Four short bouts of isometric exercise (IE) performed 3 days per week (d/wk) at home elicits clinically significant reductions in BP in those with normal to high-normal BP. This study will determine the feasibility of delivering personalised IE to patients with stage 1 hypertension for whom lifestyle changes would be recommended before medication within NHS primary care.

Long-term care (LTC) is one of the largest financial risks faced by the elderly. Yet, it remainslargely uninsured. This paper explores the relationship between cognitive abilities and private voluntary or supplementary long-term care insurance (LTCI) ownership as another possible factor contributing to the small size of the market. We used data from a European panel survey, which collects detailed information on both private insurance coverage and three indicators of cognitive abilities: numeracy, verbal fluency and memory skills. We find that memory, but not numeracy or verbal fluency, has a positive and statistically significant effect on the probability of owning private LTCI above and beyond other characteristics such as general education, family, risk factors, income and wealth. Fixed effects estimates show that a one-standard deviation increase in the recall measure score is associated with a 0.5 percentage-point increase of the probability of holding insurance for the baseline sample and a 1 percentage-point increase among the younger cohort. The findings suggest that cognitive limitations in LTCI decision-making are likely to be linked to information processing skills and can be an important factor affecting the expansion of the market that need to be taken into consideration in policy design.

Objectives: This study estimates the prevalence of unmet social care needs of people over 50 living in England with cancer and the effect of cancer on unmet needs. Methods: We used data from the English Longitudinal Study of Ageing. We estimated the mean, standard deviation and 95% CI of the prevalence of unmet social care needs among people with cancer. Logistic regression analysis with individual random effects was used to estimate the effect of cancer on unmet needs controlling for other determinants. Pain measures were included stepwise in the regression to estimate their mediating effect. Results: The prevalence rate of unmet social care needs among people living with cancer is 9% (SD=0.29; 95% CI: 8.3-10) compared to 6% (SD=0.24; 95% CI: 6.1-6.5) among people without cancer. People with cancer have significantly higher odds of having unmet needs by a factor of 1.44 (95% CI: 1.20-1.72), after controlling for the effect of other characteristics. Adding pain measures reduces the effect of cancer to a factor of 1.36 (95% CI: 1.14-1.64) in the odds of unmet needs but still remains statistically significant. Conclusions: A more integrated approach to cancer care is more likely to address the high level of unmet needs and consequent adverse implications.

Young people are facing challenges in transitioning to housing autonomy because of changes in labour market conditions in recent years. This article explores the effects of youth unemployment and non-standard employment on the likelihood of leaving the parental home. We adopt a dynamic modelling approach, and use data from a large longitudinal British survey covering the years 2009-2014. We find that unemployment and part-time work, but not the duration of the contract, have a negative effect on the likelihood of obtaining housing autonomy. We also find that past as well as anticipated unemployment have significant negative effects, which suggests that the decision about whether to move out depends on the individual's longer-term labour market trajectory. The analysis also reveals gender differences in part-time work, but not in unemployment once we take into account unobserved time-invariant heterogeneity.

This work quantitatively assesses the potential reasons behind the difference in prices paid by care home residents in England. Evidence suggests that the price paid by private payers is higher than that paid for publicly-supported residents, and this is often attributed to the market power wielded by local authorities as the dominant purchaser in local markets. Estimations of private prices at local authority level are used to assess the difference in price paid between private and public prices, the fees gap, using data from 2008 to 2010. Controlling for local area and average care home characteristics, the results indicate that both care home and local authority market power play a role in the price determination of the market.

Background: Obesity is a known predictor of disability and functional limitations, and, in turn, of health care use. In this study, we aim to explore whether obesity is also a significant risk factor for future long-term care use, overall and by type of care. Methods: We use multinomial logistic regression analysis on data from the English Longitudinal Study of Ageing (ELSA) for individuals aged 65 and older between 2002 and 2011. Selection issues are tackled using the rich set of control variables, exploiting the data's longitudinal structure and accounting for loss to follow-up (including death). Control factors include health-related behaviours (physical activity, alcohol and tobacco consumption), functional limitations (related to ADLs, iADLs and mobility) and specific existing health conditions, notably diabetes, high blood pressure and cardio-vascular diseases. Results: We find that obese older people are 25% (p < 0.01) more likely to receive informal or privately-paid care in the future, but this does not hold for formal care. This is an additional direct effect after controlling for a wide range of health conditions and functional limitations. We document some evidence that this effect is due to the development of new functional limitations. Sensitivity analyses suggest that the results are robust to controlling for prediabetes, subjective health, depression, or unobserved heterogeneity. Conclusions: This study provides new evidence of a positive direct effect of obesity on the future use of long-term care services. Accordingly, it adds evidence of further economic benefits to any overall evaluation of policies to promote a healthy weight in the population, particularly in the older population.

Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper we study the interdependencies between the long-term (home care) services and eqpuwnvcvkqpu"ykvj"c"rtkoct{"ectg"fqevqt."cu"wugf"d{"rgqrng"qxgt"970"Uvctvkpi"ykvj"c"oqfgn"qh"kpfkxkfwcnÓu"fgocpf" for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the British Household Panel Study for 1991-2009. To address potential concerns about endogeneity we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.

In terms of its societal impact, the global financial crisis of 2008 was considered to be the most significant crisis since the Great Depression in 1929 (Rollero and Tartaglia, 2009), and it is often referred to as the Great Recession. Ever since, Europeans, and particularly young Europeans, have been facing a threatening work situation because unemployment rates have increased substantially in most European countries (Chung et al, 2012; Eurostat, 2014). At the same time, temporary employment has followed suit, albeit at a lower speed, but affecting mostly young people. , Empirical evidence suggests that unemployment and job insecurity have detrimental effects on individuals' well-being, and not only in the general population (for reviews see Sverke et al, 2002; De Witte, 2005; Cheng and Chan, 2008; see McKee-Ryan et al, 2005, for a meta-analysis) but also among young people (see Voßemer and Eunicke, 2015). Hence, it is important to investigate the outcomes of unfavourable labour market conditions for young people in Europe, because employment opportunities mark young individuals' transition to adulthood (Bynner and Parsons, 2002). Any attempt to fully understand the conditions under which young people facing unemployment and job insecurity are particularly vulnerable must also account for the role of macrolevel moderators, given the large variations in social policies and economic growth observed across the different European countries (Voßemer et al, 2018). Although it is plausible to think that the strength of the individual-level effects of unemployment and job insecurity on well-being may vary between poorer and richer countries, few studies have looked at potential cross-country differences and the role of macrolevel moderators in understanding this relationship (for example Eichhorn, 2013; Wulfgramm, 2014). Most of these studies focused on the moderating role of labour market policies or the countries' economic conditions, often measuring either GDP per capita or the country-level unemployment rate (UR). However, these two measures may have a completely different meaning when examined as moderators, and they should not be viewed as being interchangeable. First, GDP and UR do not substitute each other, because some countries often experience jobless growth, whereas others may experience a decrease in UR due to a concerted effort by the government without any increase in GDP per capita. Second, conceptually, GDP and UR underline different phenomena. Thus, when they are investigated simultaneously, different mechanisms are being discerned and tested. GDP per capita reflects the level of resources per citizen available in the country such as employment-related (for example, unemployment benefits) or health-related (including health expenditure) resources. The present analysis focuses on GDP as an overall measure that captures all kinds of societal support and the capacity of the government to provide such support. In this way, it captures the broader context in contrast to previous empirical attempts that looked at specific policy measures (Voßemer et al, 2018). Based on conservation of resources (COR) theory (Hobfoll, 1989), it is argued that higher levels of GDP may buffer the detrimental effects on well-being of unemployment and job insecurity, because in countries with a higher GDP, people have access to more resources when they face difficult times – irrespective of that country's UR. When the level of resources (as measured by the GDP) is held constant, there are two potential mechanisms to consider regarding the moderating role of UR. On the one hand, based on the principle of social comparison or the norm (see Clark, 2003), unemployment is likely to hurt less when there are more unemployed people around, because it is attributed externally and not to one's own, personal failure. On the other hand, from the standard economics perspective, higher UR means fewer prospects of finding a job for those currently unemployed – hence, strengthening the unfavourable effect of own unemployment. In reality though, both mechanisms are likely to be in place, and one can determine only empirically which of the two effects prevails. The current analysis investigates the moderating role of both GDP per capita and UR simultaneously as moderators of the relationship between unemployment/job insecurity and well-being. This attempts to distinguish the economic (that is, resource) effect from the social norm effect. The GDP per capita is expected to represent mostly an economic resource. Even though the UR is likely to combine both economic and social norm considerations, this study expects that the effect of UR will mainly capture the social norm effect when simultaneously controlling for GDP. Furthermore, the study also distinguishes between the moderating role of long-term trajectories and business cycle fluctuations, given their different nature with respect to the formation of individual expectations. Macroeconomics has long been preoccupied with the separation of long-term trends in key indicators from short-term business cycle fluctuations. There are two reasons to think that such a separation is relevant when analysing the moderating effect of macroeconomic conditions on the relationship between employment status and well-being. If one considers the resource availability argument (Hobfoll, 1989), the underlying reason for the separation of the long-term trend from the business cycle fluctuation lies within the state budgeting process. The budget is set annually, based on historic information and future spending forecasts. Therefore, it is more likely that short-term fluctuations will send a weaker signal to individuals with regards to resource availability compared to that from the long-term GDP trajectory. A similar mechanism is likely to be in place with regards to UR: a long-term unemployment trajectory should send a stronger signal to individuals with regards to social comparison than the business cycle fluctuation.

Although there is some recent evidence around the effects of obesity on health care utilisation and costs, not much is known about the relationship between obesity and long-term care utilisation (Public Health England, 2013). Few studies from the USA find that obesity increases the risk of nursing home admissions and use of personal care assistance (Elkins et al. 2006, Ziza et al. 2002, Resnik et al. 2005, Yang and Zhang 2014). Nizalova, Gousia and Forder (2017) show that obesity leads to higher use of informal care but find no effect on other types of long-term care. In this study we explore whether the effect on various types of care differs depending on the degree of obesity among older people in England and whether the findings are sensitive to the incorporation of information on long-term care use prior to death. We find that in addition to the obesity at the level of BMI between 25 and 45 representing a risk for future use of informal care, (super) obesity at the level of BMI at 45 and greater represents a significant risk for all types of care use, including social care and nursing home/residential care.

Obesity and physical activity rates are known to be strong predictors of disability and functional limitations, and in turn use of health care. In this study we aim to explore whether obesity and physical activity are also significant risk factors for future long-term care need (both informal and formal care). We use regression analysis of data from the English Longitudinal Study of Ageing (ELSA) between 2002 to 2011 to addres this aim. Selection issues are tackled using the rich set of control variables in ELSA; exploiting the longitudinal structure of the data; and accounting for loss to follow-up (including death). Control factors include: impairment (ADLs) and specific existing health conditions – notably diabetes, high blood pressure, and CVD. We find that obese older people are 25% more likely to be in receipt of informal or privately paid care in two year's time, but this does not hold for formal care. People who are physically active are 38% less likely to be using any care two years later, with the strongest effect for formal care use. Sensitivity analysis suggests that the results are not driven by either prediabetes, or a link between obesity and subjective health and depression, or unobserved factors.

We conducted a review of the literature on primary care physician (Eg family doctor, general practitioner or other generalist working in a community setting) payment, methods and their impacts on physician behaviour. A comprehensive search of databases identified a large number of studies, of which thirty six were included in the final review. Although we were interested in looking at a wide range of outcomes, the majority of the evidence related to activity volume, referrals, supplier-induced demand, patient pre selection and prevention. Our review therefore focused on the evidence around the effects of the three main remuneration methods (fee-for-service (FFS), capitation and salary) on these outcomes. We also considered mixed systems of the main methods. The studies included in the review spanned qualitative, quantitative, mixed method research and RCTs.

Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper we study the interdependencies between the long-term (home care) services and consultations with a primary care doctor, as used by people over 75. Starting with a model of individual's demand for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the BHPS for years 1991-2009. To address potential concerns about endogeneity we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.