At the national level, profound changes are taking place in relation to social and health care and interventions to support people who are not self-sufficient. In recent months, some reports have been published that allow you to take stock of the resources dedicated to ongoing care in our country.
The main evidence is presented:
- of the State General Accountancy Report (RGS) "The medium to long-term trends in the pension and socio-health system" that captures public resource trends for the LTC;
- Istat statistics "The system of accounts for health" that reconstructs, even in an intertemporal key, the health expenditure for the different functions.
The State General Accountancy Report allows us to observe the time trend of LTC expenditure relative to GDP, i.e. the public resources invested to assist the elderly and disabled who are not self-sufficient in relation to national resources (gross domestic product).
The service expense is the sum of three items:
- the accompanying allowance provided by the central system
- health benefits for the LTC
- social welfare interventions for people who are not self-sufficient (mainly in-kind interventions and provided by local authorities)
A comparison of the results for 2017 and those of previous editions shows a decrease in LTC compared to GDP in the last five years (from 1.74% to 1.7%).
In 2017 (last available) the most significant component of expenditure was the allowance (0.79%), followed by health expenditure (0.68%) and finally other benefits (0.23%). It is only this last item that shows growth over the five-year period, in spite of the other two voices experiencing major contractions, in particular the expenditure on allowances (Figure 1, continuous lines).
As regards health expenditure as a whole, it should be noted that the medium-term trend is that of contraction with respect to GDP. In this scenario of reducing the investment of national resources in health protection, health care for LTC has also experienced a setback. Of course, the backlog on acute health has been more pronounced than the decrease experienced in health for the LTC, but it is striking that health spending on ongoing care, one of the components on which the health service has the greatest delays and in many regions inadequate, is also decreasing compared to GDP in a society where the need for non-self-sufficiency is increasing.
If, compared to the expenditure on LTC for the entire population, the expenditure for the over-65s alone is isolated, it is an absorption of national resources of 1.24% in 2017: as already observed for the entire population, the accompanying allowance is the most important component, followed by health expenditure. Unfortunately, for this aggregate it is not possible to compare evenly with the expenditure of previous years, due to a revision of the accounting criteria. As a result, the overall expenditure on the LTC of the elderly is not possible.
The trend for the accompanying allowance for the elderly is clearly a reduction in the absorption of national resources: from 0.65% in 2013 to 0.61% in 2017. Over the same period, for the population as a whole, there was a loss of 0.5 percentage points, almost entirely focused on the elderly. If this seems obvious, given the fact that it is the overriding target of these monetary benefits, it should be noted, however, that this very type of need seems to be the one most affected by the return of the allowance. This phenomenon is difficult to justify by epidemiological improvements that could make it increasingly difficult for older people to access monetary benefits in favour of non-self-sufficiency.
The other benefits, mainly represented by spending on local welfare, have achieved a good hold compared to GDP, both for the whole of the non-self-sufficient and for the elderly only. In more recent times, the restoration of the National Non-Self-Sufficiency Fund and the removal of some constraints may have contributed to the resumption of local welfare for those who are not self-sufficient. It should be pointed out, however, that this strengthening is not confirmed in the data on social expenditure collected by Istat, according to which, in absolute terms, municipal expenditure for the elderly would have decreased by 7.7% between 2012 and 2016.
How is health spending and its role of the LTC changing?
To better understand the evolution of the health component, it is useful to show the overall picture of nhs resources and their relative allocative choices among the various functions that the NHS is called upon to ensure. This type of analysis is possible thanks to some statistics that Istat has recently made available; these are results built with the same SHA methodology on which the Accountancy report is based. In addition to the LTC, the other functions of health are prevention, care for care and rehabilitation, pharmaceuticals, while an additional category is that of spending on governance-administration services.
How has health spending on various functions changed over time?
Over the last five years, the growth in public health expenditure, in absolute terms, has been fairly subdued, with behaviour differentiated according to the various functions: in the medium term the component that has strengthened the most is pharmaceuticals, followed by long distance from LTC and prevention. On the other hand, resources for support services are reduced, while for care and rehabilitation activities (the most important component that includes hospital and outpatient care) there is substantial stability.
How has the weight of various health services changed?
Spending on long-term health care (LTC), considered a good proxy for health care spending, has slightly strengthened its importance compared to overall health spending. In any case, the component that has gained the most weight is pharmaceutical/therapeutic equipment expenditure, the item to which health policies have given higher priority (e.g. supplementary funding for new cancer drugs).
How is the LTC component changing? What are the main features?
Spending on long-term health care is provided in various settings (residential/day/day/outpatient/home). The Istat report shows that residential is the most important, with an increase in importance compared to 2012. The importance of resources for LTC care at home appears to be being strengthened, while the absorption of health expenditure for day centres, a service that is struggling to take off, is being reduced in both absolute and relative terms.
It is worth considering, in addition to the expenditure financed by public resources, that of families. Health accounts published by Istat show that with an increase in health expenditure for LTC paid for by the public system of 0.9% on average annually between 2012 and 2017, household funding increased by 2.8% over the same period. It therefore seems that the slight strengthening of public resources for LTC-type health care is failing to keep pace with the increase in the health needs of people who are not self-sufficient, resulting in a shift in burdens on families.
The Istat report allows some comparisons between health spending by function of the various European countries, with results related to the total sources of funding (public and private resources).