Priorities for long-term care resource allocation in England: Actual allocation versus the views of Directors of Service and older citizens

Abstract

Context: Decisions about resource allocation in long-term care are a perennial issue. The basis for deciding between different needs in prioritising allocation is contested. In England, this debate has crystallised with the advent of self-directed support, where individuals’ expressed preferences drive resources. Objectives: To compare perceptions of the priority given to needs for resource allocation in long-term care of older people by two stakeholder groups, compared with actual resource allocation. Methods: Survey data, eliciting perspectives of senior service managers and older citizens, were used to rank the perceived importance of eight needs-related outcomes. Actual resource allocation from 17 local authorities was also modelled against these outcomes. A variable importance metric was used to rank the importance of these outcomes in determining actual resource allocation. Findings from each data collection were compared. Findings: Differences in prioritisation of needs emerged between stakeholders compared with actual allocation. Older citizens and actual allocation prioritised basic and instrumental activities of daily living (ADLs). Directors’ rankings were more distinct, still prioritising basic ADLs, but ranking psychological well-being higher and instrumental ADLs lower. Limitations: The model of actual allocation could not account for political and bureaucratic factors influencing resource allocation, nor the complexity of certain needs that might incur greater resources. Implications: Discretion continues to influence resource allocation, which remains a contested area. Directors must account for overall spend and other extrinsic factors to maintain sustainability, whereas older citizens prioritise instrumental ADLs, despite these being considered lower priority in eligibility decisions. Overall, ADLs remain important drivers of allocation.