Reframing long-term care policy: from services to social determinants

The organisation and financing of services dominate long-term care policy and research. This article argues for reorientation towards the social determinants of long-term care and the inequalities they generate. Building on Dahlgren and Whitehead’s influential equivalent for health, the article offers a framework for understanding how inequalities in long-term care need, access and experience are shaped by social networks, living and working conditions, services and policies, social norms, and political, economic and environmental conditions. International evidence on inequalities in need, access and experience is reviewed, and new analysis is presented for England, based on analysis of the Health Survey for England and the Adult Social Care Survey. Socio-economic inequalities are associated with steep gradients in need. Combined with unequal access to formal services, this results in more unmet need among disadvantaged people and a greater weight of responsibility on their family and friends. The final section explores the implications of a social determinants’ perspective for long-term care: addressing ‘upstream’ drivers of need (including social protection, housing and neighbourhood regeneration); inclusion and empowerment agendas; and ensuring that services effectively compensate for, rather than re-enforce, inequalities.