It is an urgent search. Right now about 80 % of the long-term care is provided in an informal, ad-hoc and rather disorganised manner. 'Typically it is women, it is a family relative or a migrant worker who is willing to work for very low wages,' explains Kai Leichsenring, coordinator of the European Interlinks project and senior researcher with the European Centre for Social Welfare Policy and Research. The project studies health systems and long-term care for older people in Europe, and aims at modelling the interfaces and links between prevention, rehabilitation, quality of services and informal care. One early result of the project is that the informal model dependent on relatives or migrant labour will be hardly sustainable in the future. It will be inadequate to meet the expected demand and not as effective as it will need to be. 'We are living longer and if nothing is done now then demand could overwhelm healthcare systems in the future,' Dr Leichsenring warns. Governments are very aware of the challenge but this is uncharted territory. Reliable, effective policy options are not obvious, or clearly defined. 'We are really doing basic research, because everybody is talking about long-term care systems but nobody has actually got one. No country has an integrated long-term care system in place,' he believes. He says right now countries deal with people who need long-term care in a wide variety of ways. Some countries deliver LTC, such as it is, through the healthcare system. Others deliver service primarily through the social welfare system, while some are a mixture of both. 'But only a few emerging examples follow an integrated plan to manage long-term care efficiently, throughout the care chain,' Dr Leichsenring emphasises. Once possible policy options are known, policy-makers can stretch that LTC chain to very early preventative measures, deployed well before long-term care is required. For example, loss of mobility, depression and social isolation are early warning signals that indicate who will need LTC in the future. 'We all know people who are 90, who need no long-term care, they are still mobile and independent,' notes Dr Leichsenring. 'And we know that people who have a lot of social links, friends and family, who are active and take care of their health, these people will need, as a group, much less long-term care, if any,' he notes. 'On the other hand, if you’re living alone, in the countryside and you never married, then it is more likely that you will need more help as you get older.' By encouraging social, active people and targeting early measures at the less active, isolated people, policy-makers can go a long way towards preventing the need for LTC altogether. But once long-term care is needed there are simple, effective and cheap ways to reduce those problems. Rather than accessing expensive hospital care, activities and services need to be further developed to maintain people in their usual surrounding, and to support family carers in coping with ever increasing strain - by intermediate care facilities, information about alternatives, respite care or professional care counselling. It is by the simple act of contrasting two outcomes from two different social situations that Interlinks provides highly cost-effective insights. Qualitative insights The EU-funded Interlinks project believes by looking at care systems across Europe, it can study all the possible, applicable elements of an effective, efficient LTC system. 'We are taking an inventory of what is there right now,' explains Dr Leichsenring. This type of research, qualitative insight backed up by quantitative sampling, will offer policy-makers new, evidence-based options for the design of long-term care systems. Work has progressed at a brisk pace. The project has produced four major reports, looking at prevention and rehabilitation systems across Europe, quality assurance and management (QA/QM), and informal care. It has also produced a case study examining migrant carers in Italy. 'Prevention and rehabilitation is a huge focus for us because we believe that organisational innovation and equal access of older people to rehabilitation can ensure a decent quality of care,' stresses Dr Leichsenring. Prevention can follow the example above, but it can also be as simple as minimising unnecessary hospital visits, for instance. Elderly people tend to be more susceptible to infection and visiting hospital increases the risk of getting one. Prevention can also focus on integrated care pathways around common procedures. For example, after a hip-replacement the patient will need rehabilitation, physical therapy, and home help in the short term. This ensures the patient gains mobility and independence quickly. But if an LTC system misses any of those steps in the care pathway, if physical therapy does not follow seamlessly after surgery, then the benefit can be lost. In this situation a fragmented care system is detrimental to individual health and safety, and will produce unnecessary costs in a mid-term perspective. Dr Leichsenring notes that the research team has seen some fairly impressive schemes for managing LTC at the local level, but improvements can be seen also on the regional and national levels. For instance, the health centre in Skaevinge (Denmark) is getting impressive results by combining home care, outreach and part-time care. Regulatory systems can also have an enormous influence, too. In Sweden, municipalities are responsible for LTC, but if there is nothing available then the municipality must pay for a hospital stay for any citizens who require LTC. This is a strong incentive to develop local services. In the UK, too, the National Health Service has started to make interesting steps towards integrated funding of LTC by using primary care trusts or PCTs. Gathering these examples has been hard work. 'There are different countries involved, and many contributors working within different systems and using different data to quantify their systems,' remarks Dr Leichsenring, 'It is like herding cats, so it can be quite challenging.' Still, Dr Leichsenring believes it is a worthwhile effort. 'It will lead to a European state-of-the-art model for describing and analysing long-term care provision and offer an analytical toolbox,' he explains. 'It will develop a range of reform policy options applicable to any stage of a national LTC system's development. The project outcome will guide policy analysis and design, permit comparison and will substantially broaden the scientific base that supports Member States' efforts to organise their health and LTC systems.' That toolbox will be offered as an interactive, online policy engine, where policy-makers can take certain steps to see how it affects the overall system. The model will also ensure all links in the LTC chain are considered. 'We will have that model completed by March 2011, when it will be tested internally, and then released to the public in April or May,' Dr Leichsenring states. For now, that will mark the end of Interlinks funded work and will contribute to the emergence of integrated LTC systems in Europe. The Interlinks project received funding from the Health programme of the EU's Seventh Framework Programme (FP7) for research.