National Care Service - national systems of social care in Nordic and Scandinavian countries: learning and evidence review

3. Findings

A total of 1,507 records were identified by our search strategy (1,202 from peer-reviewed databases and 305 from the grey literature). After screening, 86 studies were included in the review - 46 from the peer reviewed literature and 40 from the grey literature.

3.1 User Experience

3.1.1 User involvement

User involvement in care planning was found to be an important facilitator to positive user experiences as it increases choices and improves the experience for users. Five papers were identified, four of which considered care for older people^{1 2 3 4}and one that considered support services for people with severe mental illness in community care.⁵ Evidence suggests that user involvement should be facilitated by professionals, to ensure a balance between the preferences of users and professional expertise.⁶ Matschek et al (2020) found that for patients with severe mental health issues, developing simple user-led plans with a professional led to improvements and support in daily living.⁵ However, three studies considering care for older adults^{3 6 7} found that in practice it can be difficult for providers to make user preferences a priority when care planning as they may struggle to find a balance between designing care plans based on their own knowledge and considering the preferences of users. Further, systems must ensure that when encouraging empowerment of users in their care planning, attention is paid to individuals who may have limited ability to make decisions about their care or have limited knowledge on options available.^{6 7}

3.1.2 Person-Centred

Services which support older people to live the life they choose were found to be important for users' emotional and physical wellbeing.^{2 6} Support services included assisting socialisation and integration into society, support in the home environment and support to deal with unplanned or urgent situations. These were delivered in various ways including through home adaptions, knowledge and information sharing and professional assistance.

One study addressed the transition out of care for young people with learning disabilities.⁸ It reported young people do not want services only to consider what professionals think they need but want to be listened to and have the ability to express their needs as well.

3.1.3 Joined up

Four papers highlighted that collaboration, respect and communication between care professionals, unpaid carers and users supported a successful system. ^{1 6 9 10} This joined-up working facilitated the alignment of user preferences and appropriate support for individual need. The evidence also suggested that difficulties in communication between groups was damaging to user experience. This included communication between professionals, unpaid carers and users. There was less evidence on how good collaboration and communication can be embedded in the system. Methods mentioned in the literature included improved support for users and carers to navigate the health and care system (especially when care spans across different providers and sectors),¹ support for the implementation of integration from managers, primary care physicians and frontline staff,^{1 2} reduced fragmentation of the system by using co-location of services and a continuity of care staff,⁹ prioritising person-centredness⁶ and ensuring there is easy and accessible information sharing.⁶ User perspectives should be considered when evaluating and improving services.²

Integrated health and social care services provide a broad range of care needs including physical, cognitive, psychological, and social services.⁶ This allows care services to support users with more complex needs. It is important that users receive this care with continuity as fragmentation can lead to poorer user experiences.^{1 9}

Roberts et al. (2018)⁸ identified that young people transitioning out of care have a range of both personal and professional needs such as relationships, employment, and education. Access to health services, accommodation, and finance, as well as the transition to adult services, are seen as challenging without appropriate support.

3.1.4 Equality

Equality in access and quality of older people's care is crucial for a positive user experience.^{2 11} The Danish system focuses on care service provision and high geographical coverage, which aims to reduce inequalities in access to formal care regardless of where a user lives.¹² This is especially important for access to specialised services which can be unequally distributed across an area making them more difficult for individuals in certain geographies to utilise.¹¹

One study found inequalities in the continuity of care across patients with chronic care needs.¹⁰ Some users reported a fragmentation of service delivery which included being examined by multiple healthcare professionals for the same problem; and a high turnover of social workers, making it more difficult for users to navigate the system and develop relationships with professionals.

Schultz et al. (2019)¹⁰ found that service users perceived differing levels of respect from health and social care workers, with some users feeling that there was a lack of understanding and empathy from professionals towards their condition, while others had the opposite experience.

Finally, levels of unmet need were found to vary amongst older adults with disabilities in Europe, suggesting that not all adults have access to services which adequately support them.

3.2. Learning from key informants

3.2.1. Governance

Eighteen of the papers that considered evidence from key informants specifically discussed the role of high-level governance in the design and implementation of integrated social care. Views were based on experiences from Sweden,^{14 15 16 17 18 19 2021} Norway,^{11 19 21 22 23 24} Denmark ^{21 22 23 25} Finland ^{21 26 27} and three multi-country studies.^{28 29 30} Important themes that arose were the role of legislation, the degree of centralisation and formal organisational integration, and the importance of regulation and monitoring.

3.2.1.1. Legislation

Findings from eleven of these studies highlighted the need for appropriate and consistent national legislation to support the aims of social care services.^{15 16 17 18 19 20 21 23 24 25} These discussed the degree to which national legislation can and should dictate standards and means of service provision. For example, in Sweden existing legislation was flexible enough to allow the design and implementation of the integrated Norrtaelje model without the need for new legislation to be enacted. However, the subsequent implementation of the Act on System of Choice in the Public Sector was viewed as presenting challenges to the model, with its emphasis on competition and marketisation, which then had negative effects on integration and the collaboration between health and social care.^{15 16 18}

The Swedish example also suggests how even high-level framework legislation can limit local autonomy when it is used in conjunction with parallel national policies to implement rules and incentives that local social care commissioners and providers are required to follow.¹⁷ One study, reporting the views of strategic and political stakeholders involved in the care of older people in Sweden, showed that legislation designed to facilitate increased coordination and collaboration could not overcome mistrust between regional and local authorities.²⁰

In Norway sectoral reform has been underpinned by legislation that places the responsibility for clinical care, public health and rehabilitation on local municipalities, with the relationships between the organisations involved defined by legislation and monitored service agreements.^{19 24}

Two studies highlight Denmark as an example where national legislation can provide a framework that helps ensure services are user focused. In this example, national legislation defines the right of service users to participate in decision-making about their care.^{23 25}

From the findings of the studies that considered legislation, an important facilitator in the provision of integrated social care is to be clear about the vision for the service and only define in law those elements that are critical, while leaving flexibility for negotiation at the local level.

Legislative barriers include inconsistent and changing legislation that results in power imbalance and national laws that prevent the free flow of information.²¹

3.2.1.2. Centralisation and localism

Another key theme was the extent to which governance and regulation should be centralised in a formal organisation. Eleven studies highlighted the importance of getting the balance right between top-down governance to ensure standardisation and quality of services versus bottom-up flexibility to allow for local context and to meet service user needs. ^{14 16 20 24 25 26 29 30}

There are many examples of both approaches with neither one more preferable than the other. ^{16 24 30} One study which examined the historical perspective in Finland, identified a cycle of decentralisation and recentralisation with pros and cons for both models.²⁶ Recent calls for recentralisation have been driven by the impact of local autonomy on care inequalities at the regional level. A study reporting the views of senior care services stakeholders in Sweden identified opposing stakeholder views: one view supported more centralisation and a single government body responsible for all care of older people; the other placed more emphasis on collaboration based on mutual agreements and networking to ensure services were relevant for the local population.²⁰ The evidence suggests that decentralisation can be both a barrier and a facilitator to integrated systems. Decentralised systems can lead to fragmentation if there are divisions in health and social care between different institutional levels.^{11 16} However, decentralised governance can be seen as an enabler as is the case in Denmark, where national legislation provides a clear broad framework for service provision within which municipalities retain responsibility for social care policies.²⁵

Studies of the Norrtaelje model in Sweden illustrate that a fully integrated model does not necessarily ensure better clinical care coordination.^{14 15 16} Evidence from a multi-country review suggested that it may be important to focus less on formal organisational structures, and more on relationships with an emphasis on networks rather than hierarchies.²⁹ In the highly decentralised Danish example, the evidence highlights three key instruments of regulation relating to the content, completion and monitoring of care agreements. In Denmark these are determined by the national government and the regions/municipalities are required to follow them. ^{23 25} One study identified that most often bottom-up initiatives were developed by empowering local organisations to work together and be creative, and therefore policy makers should consider a hybrid top-down and bottom-up approach to support integrated care.³⁰

An important regulatory facilitator is to have the right balance between formal centralisation and local autonomy. Cultural factors including historical relationships and mistrust can be a key barrier.²⁰ A facilitator in the Norrtaelje model is the existence of a single decision-making and financing body encouraging agreement with all the providers. This enables delivery of social care, home health care and rehabilitation for the same person in a coordinated manner.¹⁶ Formal governance structures can support systems by providing consistent strategic advice.³⁰

3.2.1.3. Regulation

A final theme highlighted the importance of clear regulatory roles and responsibilities to ensure effective regulation and monitoring.

Two studies that examined the systems in Denmark, Norway and Sweden highlighted the fact that central monitoring, standards and control of service provision had the potential to reduce local autonomy with implications for service quality. They noted the importance of having governance structures and national monitoring standards that clearly defined responsibilities and boundaries.^{17 22.}

Evidence from Denmark and Norway also suggests that coordination and monitoring of complex care services is particularly important in a marketised system with both public and private provision.²³ Two studies looking at multiple country examples stressed the fact that marketisation has implications for quality in social care and therefore there needs to be consistent ways of measuring quality^[6] across different care settings to ensure protection of the most vulnerable.^{19 28}

Monitoring systems can facilitate social care integration by including user outcomes, not just process outcomes. One study suggested that policy makers should direct policy development at the individual and local levels, then create mechanisms to support negotiations to achieve the desired outcomes of making care user centred and shifting care from hospital to community settings.²⁴ Coordination and monitoring barriers include occupational cultures, work boundaries, autonomy, lack of coordination and communication, and data recording.¹⁴

3.2.2. Funding

Approaches to achieve financial integration varied, as highlighted by one study which looked at international literature for integrated resource mechanisms across health and social care; but could include grants, cross charging, aligned budgets, lead commissioning, pooled funds and integrated management with or without pooled funds.³¹ Evidence relating to funding of national social care systems has been grouped into the following categories: pan-European learning, horizontal financial integration (e.g. across different parts of a social care system), vertical integration (e.g. between central and local structures) and marketisation.

3.2.2.1. Pan-European learning

Funding of social care is variable across Europe, with it centrally funded in half of the EU states and the other half mostly sharing funding responsibilities between central and regional/local level.³² To achieve sustainable, high-quality integrated social care requires long-term commitments and investment in social care organisations, alongside robust evaluation.³³ Learning from European health systems suggests improving financing by prioritising the cost-effectiveness of services, better procurement, developing new models of remuneration (giving incentives to provide a balance between quality and amount of services) and adapting financing to prioritise equal service access especially for vulnerable and rural populations where waiting times and workforce shortages can be an issue.³⁴

3.2.2.2. Horizontal financial integration

Key facilitators of horizontal financial integration can include all stakeholders having a clear shared vision, financial and non-financial incentives and organisational processes may help to align aims of integrated resource mechanisms (e.g. funding, management and/or provision) with actions among stakeholders, and avoiding a one-size-fits-all approach;³¹ as well as pooled resources/unified structure as noted in the Swedish system.²¹ Coordinated funding was considered a strength of the Norrtaelje model, and initial difficulties in financial coordination in Sweden were mitigated using local associations.²⁹ By contrast, multiple sources of funding in Norway were considered to be a weakness.²⁹

Implementation of horizontal financial integration is noted as challenging,^{15 21 35} often despite statutory and regulatory support.³⁵ Specific challenges were implementing a shared funding system due to differences in payment structures and difficulty transferring cost savings to different parts of the system in the Norrtaelje model,¹⁵ and separate budgets and the flow of funds between municipalities as seen in the Norwegian system.^{21 29}

The effect of financial integration on cost, health and service use outcomes was assessed in three studies.^{14 31 35} The evidence for cost and service use outcomes was mixed. One international literature review of social care systems from nine countries noted that there was weak evidence that integration resource frameworks could achieve cost savings.³¹ In another international review of 38 schemes from eight countries comparing the effects of 'integrated financing plus integrated care' relative to usual care, 34 schemes (in studies published in or since 1999) looked at secondary care costs and/or utilisation. This review found approximately a third of schemes had no significant effect on hospital costs or utilisation, three reported a significant reduction in secondary care use versus usual care; in the remaining schemes, the evidence was unclear. This review also noted that integrated care with integrated financing had the potential to enable health and social care to be shifted into the community, reduce admissions for some groups and improve access to care.³⁵

The impact of integrated funding on health outcomes was reported to be lacking or not significant in two studies.^{31 35} An analysis of developments in the Norrtaelje model was not able to establish the link with better user- (or cost) outcomes; however, it did find structural and process changes which increase the likelihood of improved outcomes.¹⁴

3.2.2.3. Vertical financial integration

Universality of care is a feature of Nordic countries.^{14 22 25 36 37} The literature highlights some challenges: it is expensive to provide,³⁶ requires a high-level of dedicated funding,²⁵ and there is potential tension between central government and local government bodies, with the latter concerned that the system is no longer affordable for an ageing population.¹⁷

Conversely, decentralisation of funding can result in a situation where wealthier local government bodies can choose to invest more in care services,¹⁷ particularly home care service provision.²² Fragmentation of funding can result in gaps in service provision when budgets are tight and service users can be passed around from one funding body to another.¹⁷

Austerity and inadequate public resource provision are important cross-cutting funding issues. Although the severity of austerity and consequences of constrained public funding varied among Denmark, England and Norway in one study, austerity measures can result in a gap between what needs to be delivered and what can be, forcing rationing decisions by care workers or local municipalities and potentially reinforcing inequalities in provision based on geographical differences.²²

3.2.2.4. Marketisation

Marketisation in the provision of health and social care can include a number of approaches, such as competition, private provision and economic incentives. The literature highlights several potential advantages. For example, it may benefit users by offering increased choice. ^{37 38}

A case study highlights the implementation of a unique form of public‐private partnership in Finland that is a one-stop shop home care service for older users (known as Kotitori); it supports access to private services for those who can pay for it, but also supports access to public services for those that need it and cannot afford it.³⁸ Positive dynamics of competition and user choice may support integration and drives up quality as well as being a powerful lever for making delivery of services more efficient.³⁹

However, a number of shortcomings to marketisation were also reported. It challenges universalism in Nordic and Scandinavian countries, particularly for services for the older users,^{22 37} and paying for additional services may challenge equality of access.²² Providing user choice in the form of cash for care can challenge integrated care provision, lead to uncertainty of funding for care providers and can also lead to fragmentation of service provision. ⁴⁰ Increased competition has increased instability in the market of home care for the elderly and increased costs for local areas.

A comparative analysis suggests that in Denmark competition is expensive, has not increased efficiency, and separation between regional and municipal services has led to fragmentation. ³⁹ While new cash-for-care schemes could enable greater choice and control for users, it is unclear whether they are effective in terms of cost and quality.⁴¹ When considering cash for care options, it is important to be clear about eligibility rules and the mix of paid and unpaid care which can be complicated and a barrier to accessing the funding.⁴¹

3.2.3. Service integration

A large number of papers focused on how services can work together to provide seamless care for those requiring it. Findings tend to be from pan-European or international studies looking at ways to provide better-integrated care. Key themes emerging include person centeredness, mechanisms for integration, collaboration and trust and a shared vision.

3.2.3.1. User involvement

Delivery of services with the person at the centre have been used in Sweden and Norway to involve users, family and carers in developing and providing integrated care for patients with mental health and addiction problems,^{42 43} and for adolescents and young adults with complex mental health issues.⁴⁴ Similarly, in a large pan-European⁴⁵ and Finnish⁴⁶ study looking at integrated care for older adults with multimorbidity, person centred care was seen as a key factor in providing care. Older users were viewed as needing to be seen at the centre of service delivery at a national level (individuality, autonomy, choice) but this needs to be balanced with costs and availability.⁴⁷

Several implementation barriers to involving users have been identified. Social workers and care staff report mixed benefits due to tension between what professionals can provide, and what users want and the unsystematic use of individual care plans across services,⁴³ administration and bureaucracy, lack of resources, user involvement, time and unclear responsibility.⁴⁴

Facilitators to user involvement mainly focused on leadership style and context, ensuring individual plans were agreed with users, as well as being a supportive manager.⁴⁴ Agreement needs to be reached between unpaid carers and service users on what their needs are and how it should be delivered in the home or care setting.⁴⁵ In Finland, an integrated and responsive system, service availability and accessibility, guidance, leadership, resources, and the effective use of technology were seen as facilitators.⁴⁶

Professionals delivering services for older users need appropriate training, organisational support and specific competencies.

Few studies looked specifically at social care services for the disabled. One model of social care provision for people with a long-term disability is that established in Stockholm, Sweden.⁴⁸ This is based on a cooperative model (collective support) which provides services to allow independent living, providing choice of services and different ways of delivery/funding such as via direct payments. Discussions of barriers to providing disability services through cooperatives⁴⁸ focused on understanding how cooperatives function, especially in the social care market, their small size and population coverages, competitiveness and how sustainable long-term funding can be secured.

Inter-organisational co-operation can also be a problem due to welfare agencies having different legislative mandates, budgets, and areas of responsibility. This can result in individuals with a disability being redirected to different organisations without getting the services they need.⁴⁹

3.2.3.2. Organisational integration

There is no one model for integrated care.⁵⁰ Analysis of case studies from seven OECD countries identified that integration evolves over time and should be built from the bottom up using a model already designed to improve care. Developing integrated care requires transparency in funding, data management systems, leadership and collaboration, roles and responsibilities, care planning and user involvement.

Key mechanisms for service integration have been identified from several studies including European health systems (e.g. the To-REACH project⁵¹ and the pan-European (SELFIE) project on older people with multi morbidity).⁵² These identify the need for person- and population-centeredness and supporting mechanisms to improve efficiency such as the workforce, digital health, measuring and improving quality, financing and governance; as well as integration with other sectors such as education and employment.^{51 53} Implementation of digital health technology is integral to providing joined up care across organisations and improving communication and data collection. ^{21 34 36 54 55 56} A system needs to be designed to enable shared access across different organisations, but still protect patient confidentiality where required.⁵⁷

The key mechanisms to support implementation of integrated care have been reported for frail older people and fall under four main themes: service delivery, leadership and governance, workforce, and financing. ^{21 52} Barriers include developing shared information systems, fragmented funding, cultural resistance, and opposing political party views.⁵²

Provision of palliative care^{58 59} and rehabilitation⁶⁰ varies across Europe and internationally. Palliative care can be regulated at different levels as well as having different funding sources including charitable, public and private sources. Delivery of palliative care needs to ensure early access to health care, health and social care input, be community-based for user access, provide equitable access, and be sustainable.^{58 59} Rehabilitation service requires high-level coordination to provide services⁶⁰ as well as equality of services, workforce health and wellbeing, and less provider competition.

Having a clear vision and commitment to deliver an agreed model of care is important, as there is considerable variation across the EU, Norway and Iceland and other countries. How integrated care is defined and delivered in different countries varies considerably. ^{21 40 61} Facilitators of these integrated care initiatives include a commitment to the vision of integrated care, good communication and leadership, trusted and familiar systems providing universal and professional care, a skilled workforce and flexibility and coordination between different levels of service delivery. A commitment to and an understanding of the model of care is important.⁶² Barriers include a lack of cooperation between organisations, teams or professions, organisational culture and separate IT systems.

3.2.3.3. Professional Integration

The majority of studies which focus on working together to provide integrated care report the need for better people skills such as collaboration, communication, cooperation and trust.

People skills, such as communication and cooperation, are key for integration of services amongst different client populations. Personal characteristics of leaders of integrated care such as personality, ability, knowledge, experience on the ground, and person skills are also viewed as important. ^{45 57 63 64}

This includes collaboration and cooperation both vertically and horizontally between multidisciplinary teams. Integration outcomes rarely focus on health impacts but rather on improving coordination, increasing knowledge and staff and client satisfaction.⁶⁴ Health and social care reforms in Finland have required novel ways for cooperation and agreement in establishing service provision⁶⁵ including high level ministerial collaboration to overcome functional and cultural boundaries and to reduce hierarchy and create stability.^{24 39}

Trust is important both within multidisciplinary teams as well as across different sectors. This includes the health and social services as well as employment and education.^{39 53} Trust is also required at different political, strategic and inter-professional levels.²⁰

Trusting relationships were also found to be a key facilitator^{45 57} including collaboration between care professionals in different parts of the system as well as responsibility and accountability. Successful leaders were important in championing change and promoting integrated services.⁵⁷ Power imbalance and breakdown in trust and failed attempts to collaborate and cooperate between agencies were noted as barriers at all levels.²⁰

Country and region-specific population factors should also be considered as a one-size fits all approach may not be appropriate.⁵⁷ The Norrtaelje system in Sweden found that there was cultural resistance to the model, as consideration was not paid to different cultures in professional groups from different localities – this was partially mitigated by recruiting local health care staff.^{29 57}

3.2.4. Workforce

Eight studies considered the impact of work force factors on integrated care systems. Four of these studied integrated health and social care systems for adults,^{21 25 57 66} two focused on integrated care for older adults,^{64 67} one compared paid and unpaid care,⁶⁸ and one considered multiple areas of care including long term, hospital, primary and mental health.⁵¹

Evidence from Sweden suggests that staff training and continuous personal development should be considered as part of the integration strategy.⁶⁴ In Denmark, education for staff and professionalisation of the role of care providers was found to be an important facilitator for successful teams and systems.²¹

Linked to this is ensuring that there is an appropriate supply of care staff – shortages of social care professionals continues to be an issue in several countries.^{25 66 67} In Sweden, the availability of a skilled workforce is crucial to the system's success.⁶⁸ It is also important that health professionals are trained in a variety of skills and that there is a balance of roles across regions, to ensure access to appropriate care services regardless of location.³⁴

In the Norrtaelje model, strong leadership with clear goals and organisational culture supported team collaboration and successful implementation. ^{15 62} It developed joint integration activities to encourage managers to get on board.¹⁵ However, this system was set up in a small community and this may be more difficult in larger or more open settings where more time and flexibility is required.

Staff needs should be considered when developing an integrated care system. Barriers to integration included issues with employment such as shift patterns, contract types (for example, non-permanent contracts) and hours worked.²¹ Berglund et al.⁶⁴ found that job satisfaction is an important factor in an integration strategy.

In Sweden, social work has recently undergone reform both in terms of structure and how services are delivered.^{69 70 71} Professionals' roles were seen as being eroded with less focus on professional management. This included undertaking new duties such as delivering on budgets, securing private services and administrative duties.⁶⁹ How services are organised is still under debate. Some professionals see services as specialized (e.g. in depth knowledge of specific areas) whereas others see them as being generic (holistic generalist view).^{70 71}

In addition, there has been an Evidence Based Practice (EBP) approach in Swedish social service practice to succeed the New Public Management (NPM) system.⁷² However, little progress has been made over the past 15 years. Reasons for lack of progress include delivery using a top-down approach, difficult and complex to understand, unclear goals and it is not recognised as policy (seen as new methods). The lack of progress is also due to the interpretation of governance and power relations in terms of who has implementation responsibility at national, regional and local level.

3.3. Population health outcomes

Much of the population health outcomes evidence identified for social care draws on the pan-European Survey of Health Ageing and Retirement in Europe (SHARE) study. Five SHARE studies looked at inequalities in social care provision in relation to need. ^{73 74 75 76 77} These studies highlight inequality issues across selected European countries such as those in greatest need and with lowest socio-economic position having less access to social care. Of these five studies, four made inequality comparisons between countries,^{73 75 76 77} including Denmark and Sweden. All studies found inequalities in care, particularly between users with different socio-economic position. The evidence suggested only Denmark and the Netherlands successfully targeted home care services at poorer individuals.⁷⁵ Further, Armjios-Bravo⁷³ suggested that there was an inequitable distribution of use of paid and unpaid home care, with those from higher income households more likely to benefit from paid care. Differences were highlighted between levels of unmet need, with those from the lowest socio-economic position most likely to have unmet care needs.^{76 77}

An additional SHARE study investigated the consequences of private out-of-pocket expenditure to access social care.⁷⁸ Out of pocket costs were found to affect most older people in the included European countries, with a small percentage of older people incurring catastrophic financial costs. These were more likely to be the poorest and most vulnerable older people. The authors suggest action around availability and affordability of social care, increasing equity of financing of social care, and wider strengthening of social protections.

A final SHARE study investigated the impact of home-based social care on the quality of life of care-giving adult children in Sweden and Denmark.⁷⁹ The timing of cutbacks to social care provision indicate that social care coverage affects the quality of life of care-giving adult children. This was the only SHARE study that explicitly investigated changes in social care coverage and a health outcome rather than just describing a cross-sectional association.

Evidence from other quantitative research studies on the impact of integrated health and social care on population health outcomes was mixed with regards to access to services and service use outcomes.

3.3.1. Access to care services

High target efficiency of social care was found in Sweden, meaning that few people who need public social care services did not receive them.⁸⁰ The authors suggested that this could be due to support given to unpaid carers, high geographical coverage of services or appropriate targeting of services. While the perception that many older users in Sweden do not receive the social care they need was not supported by the findings, the authors caution this could change over time and monitoring of key indicators is recommended to ensure that finite resources are matched to need in the most efficient way possible.

A study in two Finnish cities provides information on the reasons for using public or private social care services.⁸¹ It found that while choice can help needs of some users, it may also widen inequalities in access, as choice may not be available to those in greatest need.

A descriptive study looking at social care trends in Sweden between 1993 and 2006 highlights that universalism and localism are inherently in tension and that their relationship may change in complex ways over time.⁸² For example, during this period universalism has weakened in terms of social protection but increased in terms of reduced local variation.

3.3.2. Service use outcomes

Studies that investigated the impact of social care integration on service use outcomes reported mixed findings. The integrated HSC programme in the Norrtaelje area of Sweden was linked to a fall in emergency department visits for over 65-year-olds while overall emergency department visits have remained higher than the rest of Stockholm.⁸³ Similarly, in Norway, integrated care may have led to the prevention of unplanned medical admissions amongst the oldest in the population,⁸⁵ while a weak negative association was found between integrated social care provision and days in hospital (though this was neither clinically nor statistically significant). Overall, unplanned medical visits varied very little with levels of social care, suggesting that just providing more social care might not have much impact on unplanned admissions other than for the oldest age groups.⁸⁵ After the introduction of integrated care in Finland, levels of healthcare use decreased (after a short-term increase), with the biggest changes being seen in primary health care nurses' appointments.⁸⁶