A Comparison of the Long-Term Care Systems in Norway and England

Abstract

Background

In a context of rapid population ageing, most countries face major challenges to prepare their long-term care systems to meet rising demands. It is vital that research examines how systems can adapt to these demographic changes. International comparisons between long-term care systems can support the identification of shared lessons on the advantages and disadvantages of different systems and associated outcomes.

Objective

To analyse and compare the long-term care systems in Norway and in England and identify lessons from this comparison.

Method

Using Donabedian’s structure-process-outcome framework, this comparative overview analysed the commonalities and differences between the two systems. Data were identified from Government websites, relevant publications, and websites from key national sector organisations from the time period in which the study was conducted (2021-2025).

Results

The Norwegian and English systems exhibit more similarities than differences. The most notable differences emerged in the structure component, particularly in terms of funding mechanisms and the degree of care integration. Differences were also evident in the outcome component, where national outcome measures are less systematically embedded in the Norwegian system. In contrast, the process component revealed that both countries have implemented similar initiatives to address shared challenges within their services.

Conclusion

We argue that to build a system fit for the future, we need to confront elements currently unaddressed and to understand the interdependence within the triad of care (care recipient-informal carer-workforce), as well as its gendered nature.

Introduction

Long-term care (LTC) can be defined as care that is provided for an extended period of time to support people with their basic activities of daily living. It includes a wide range of personal, social, and medical care services aiming to prevent, reduce, or rehabilitate functional decline. ¹ Worldwide, there is an apparent demographic trend of rapid population ageing. The proportion of the global population aged 65 years and over is projected to rise from 10% in 2022 to 16% in 2050. ² This has significant implications for the delivery and system organisation of LTC, and most countries face major challenges to ensure their LTC systems are prepared and equipped to meet rising demands. ³ The United Nations recommend investment in the development and adaptation of care systems and policies to ensure alignment with demographic changes. ² Making international comparisons between LTC systems and policy contexts can support the identification of shared lessons on the advantages and disadvantages of different LTC systems and associated outcomes. ⁴ Even though comparing LTC systems is complicated by various factors including differences in 1) terminology, 2) complexity of systems, and 3) organisational structures, ⁵ such comparisons are useful to better understand the association between system type and outcomes for people drawing on care. Several studies have compared care outcomes across OECD (Organisation for Economic Co-operation and Development) countries, and these have, for example, looked at effects of prioritisation, informal carer support and expenditure on service quality, equity, and care outcomes.^6-8

The last two decades have seen an increasing recognition in care policy of the importance of measuring outcomes in LTC to understand how well systems are meeting individuals’ needs.^9,10 Though not as well-developed as outcome measures in health care, there has been a growth in reliable LTC outcome measures, to improve the systematic comparison of care outcomes across services and across countries. Two of the most widely used and psychometrically validated measures are the ICEpop CAPability measure for Older people (ICECAP-O) ¹¹ and the Adult Social Care Outcomes Toolkit (ASCOT).^12-14 In contrast to health care specific outcome measures, these measures focus on, in the case of ICECAP, the wellbeing of older people, and in the case of ASCOT, on social care-related quality of life (SCRQoL) relevant to LTC provision. Both measures have been validated for use with older care recipients^15,16 but recent research in the UK indicates that they capture different constructs of quality of life, with only the ASCOT significantly associated with care quality and effectiveness. ¹⁷ ASCOT has been translated and applied in different LTC settings ¹⁸ and is currently used by central government to benchmark outcomes between local authorities in England ¹⁹ and by care providers in England, Australia and Sweden as part of routine care planning. ²⁰ International utilisation of common outcome measures, like ASCOT, allows for meaningful comparisons of LTC quality and outcomes across different countries.

This paper is part of a larger programme of work, the QUALCARE project, which aimed to translate and validate a Norwegian version of ASCOT and collect ASCOT data from LTC settings in three municipalities in Norway. The current paper presents a comparative overview of the LTC systems in England and Norway, their current strategic directions, and emerging evidence around quality of life outcomes, providing important context to the wider study. The selection of these specific countries was pragmatically guided as the wider project was an England-Norway collaboration, However, these two countries also present interesting differences as welfare states with evolving LTC systems. Both countries have taken steps to use ASCOT as an outcome measure within their LTC systems, but England is further ahead in this process. When it comes to LTC, England has already integrated outcome measurement into policy frameworks, whereas Norway is only at the starting point of this process. In this paper, we will describe and compare the unique LTC contexts in Norway and in England using Donabedian’s model, ²¹ explained in more detail below. This comparative overview will answer the following research question: How do the LTC systems in Norway and England compare and what can we learn from this comparison?

Method

Ethics

As this study exclusively includes secondary data, ethical approval was not required.

Data Search

This study was a comparative overview, rather than a systematic review. We mapped key LTC documents in Norway and England to compare their LTC systems, current strategic directions, and emerging evidence around quality of life outcomes. The research team consisted of researchers from Norway and England. To collect data on the relevant statistics and policies of each LTC, we searched Government websites as well as websites from key national sector organisations (e.g. Carers UK) in each country, and made use of relevant publications. As the available data about Norway is published in Norwegian, the Norwegian researchers gathered and translated data on the Norwegian system, whereas the English research team members searched for data on the English system. Searches were undertaken between May 2024 and May 2025. The time period of the search was January 2021-May 2025, as this was the time period in which the wider programme of work on outcome measurement was conducted. Since this paper is a comparative overview providing context to the wider study, this time period was viewed as appropriate. Decisions on what data to include were guided by regular discussions within the multidisciplinary team, which included experts from health and social care research from both countries. With reference to government documents, we included a variety of data covering legislation, strategies, and frameworks that were relevant to the Donabedian framework (i.e. provided information on the context, structure, process or outcomes of the LTC systems). We also included data from key LTC sector organisations, such as workforce support organisations, care recipients’ advocacy organisations, and think tanks. Selection of these were similarly guided by relevance to the Donabedian framework. We focused on national level data, and excluded documents concerning regional or local data. We included documents that considered long-term care at a macro level, and excluded documents focusing on more specific LTC concerns.

Synthesis and Comparison Framework

To synthesise and compare data from the two countries, we made use of Donabedian’s structure-process-outcome model. This model has been predominantly used in research measuring quality of care in health services but has also been successfully used in published work comparing social care systems ²² and in work considering care quality, and how it is measured.^14,23 The model proposes that quality of care (systems) can be studied based on three causally connected components, namely structure, process, and outcome. The structure of a care system (e.g. resources, organisation) affects the processes, or how care is delivered (e.g. person-centred, in the community), which in turn affects outcomes for people receiving care (e.g. quality of life, patient satisfaction, mortality, morbidity). Later research has added context as a component to account for the contextual impact of government policies.^22,24 This model provides a useful framework to describe the LTC systems in England and Norway, and, similar to Aulja and colleagues’ ²² paper, helped us identify on which level (structure, process or outcome) differences and similarities lie.

Results

The results section will describe and compare the LTC systems following Donabedian’s context-structure-process-outcome model.

Context

Context pertains to the policies and legal frameworks that affect the structure, process and outcomes of a LTC system. ²² We have also included contextual information about the countries’ demographics.

England has an estimated population of 57.1 million with a population density of 438 people per squared kilometre. The median age is 40.5 years. ²⁵ The latest data suggest that 81.7% of the population is white, followed by Asian (9.3%), Black (4.0%), mixed race (2.9%) and other (2.1%). ²⁶ Norway has a much smaller population of 5.6 million with a population density of 15 people per squared kilometre. The median age is 39.8. Norway does not hold data on ethnicity, however current numbers show that 17.3 % of the population are immigrants. ²⁷ Both countries can be classed as welfare states, although they differ in their conceptualisation and practical implementation. The Norwegian welfare state can be considered social democratic, whereas the English welfare state follows a more liberal model.^28,29

In England, the Care Act ¹⁰ provides statutory guidance on the responsibilities of local authorities in relation to LTC. It acts as a legal framework that protects adults at risk from abuse and neglect, and assigns local authorities the responsibility for the promotion of quality of life. Key principles of the Act include the promotion of care recipients’ wellbeing, preventing or delaying the need for care, health and social care integration, safeguarding, individual choice and control, carers’ rights, and national eligibility criteria for care and support.

In Norway, the Health and Care Services Act ³⁰ regulates the provision of health and care services. It ensures that all residents have access to necessary and high-quality LTC services. The Act outlines the scope of services, including preventative care, treatment, rehabilitation, and LTC, and emphasizes principles such as user involvement, quality assurance, and coordination across service levels. Several other laws provide complementary regulations, including the Patient and User Rights Act, ³¹ promoting informed decision-making, the Health Personnel Act, ³² with a focus on safeguarding and care quality, and the Public Health Act, ³³ promoting coordination and collaboration across sectors.

Both governments regularly publish policy papers in relation to the funding and reform of LTC. In England, as a response to the COVID pandemic, the Build Back Better plan was released in 2021, ³⁴ setting out new plans for LTC reform. In the same year, the People at the Heart of Care white paper ³⁵ presented a 10-year vision to strengthen how integrated care and support is delivered. Early in 2022, the policy paper ‘Health and Social Care Integration’ focused on improving the joint coordination and delivery of health and care services with a particular emphasis on place-based integration. ³⁶ Later in 2022, the Plan for Digital Health and Social Care ³⁷ outlined plans for digital transformation. Early in 2025, the UK government set out three strategic shifts to move care from: 1) hospital to community, 2) sickness to prevention, and 3) analogue to digital. ³⁸ These strategic shifts aim to cut waiting times, reduce the amount of time spent in ill health, tackle health inequalities, reduce mortality caused by cancer, cardiovascular disease and suicide, and improve the sustainability of LTC system.

In Norway, Coordination Reform ³⁹ in 2012 signaled a change in LTC by significantly strengthening local authorities’ responsibility in LTC. The more recent National Health and Coordination plan ⁴⁰ focuses on three main challenges: lack of qualified personnel, poor coordination, and unequal access to services. To create a more resilient, coordinated, and equitable LTC system, the plan proposes better recruitment and retention, revised funding models, and new organisational approaches. Furthermore, a dedicated Age Reform ⁴¹ was launched in 2022, facilitating older adults to live independently and safely at home for as long as possible. The strategy focuses on four areas: strengthening local communities to reduce loneliness, improving housing planning and adaptation, ensuring a skilled and motivated workforce, and providing better support for informal caregivers. More recently, the Department of Health published a white paper, ⁴² elaborating on resource, severity and benefit as guiding principles for priority setting in Norwegian LTC.

Taken together, the context of LTC in England and Norway is not dissimilar. Both countries have health and care acts regulating service provision that emphasise wellbeing, safeguarding, user involvement, and high-quality care. Recent government strategies appear to include similar priorities: community-based support, digital innovation, and prevention. The largest differences can be found in population size and density. Table 1 provides an overview of the key commonalities and differences with regards to context.

Table 1.

Key Commonalities and Differences in Context

​	Commonalities	Differences
		England	Norway
Context	1. Government Acts regulating LTC service provision.	1. Population size of 57.1 million.	1. Population size of 5.6 million.
		2. Population density of 438/km2.	2. Population density of 15/km2.
	2. Recent strategic shifts including community-based support, digital innovation, and prevention.	3. Liberal welfare state.	3. Social democratic welfare state.

Structure

The Norwegian and English LTC systems are structured within the legal and policy context described above. Structure refers to the overall organisation, financing, and resources of care. ²¹

Organisation

English LTC is organised in a decentralised manner, with 152 local authorities each having responsibility for commissioning and monitoring social care in their locality. Social care comprises a wide range of different services including, but not limited to, residential care and nursing homes, rehabilitation services, domiciliary care, post-discharge services, intermediate care services, and informal carer support.

Norway’s LTC system is similarly decentralised. However, unlike England, the responsibility for primary health and care services is distributed to the 357 local authorities (municipalities), leaving care to be organised and delivered through much smaller administrative units. Norwegian local authorities have the freedom to arrange their services according to local needs, giving rise to local variation. ⁴³ The scope of local services is broader than in England and includes primary healthcare, such as general practitioners (GPs), emergency medical services, and physiotherapy. Local authorities are also responsible for supporting informal caregivers through respite care and counselling.

Unlike health care in England, which is provided by The National Health Service (NHS), social care is not free at the point of use and requires a needs assessment and means test. ⁴⁴ If someone’s needs are deemed eligible, a care plan is developed, and a means test (financial assessment) is carried out to determine how much someone must pay towards their care. The more wealth someone has, the more they will be expected to pay. ⁴⁵ Any person with assets over £23,250 must cover all social care costs themselves; they are referred to as self-funders. What counts as assets varies between community and residential care settings. When assets are between £23,250 and £14,250, financial contributions are provided on a sliding scale. ⁴⁴ People with assets below £14,250 are eligible to have their care fully covered by the government, depending on their weekly earnings.

If an individual is assessed as needing full-time care, the local authority can refer the person for a Continuing Health Care assessment, which will determine whether there is a ‘primary health care need’. ⁴⁶ Under these circumstances, the NHS will fund 100% of the cost of social care. Where an individual is deemed ineligible, the NHS will meet the health needs but the local authority (or individual) will pay for the social care. ⁴⁷ There is inconsistency, nationally, around how eligibility criteria are applied and disputes between health and social care services over who is responsible for a person’s package of care are common and can take a long time to resolve. ⁴⁸ By contrast, LTC in Norway is based on universal access. ⁴³ The allocation of services is dependent on needs assessments and guided by principles of benefit, resource efficiency, and severity of needs, which aim to ensure that services are distributed fairly and in accordance with clinical and ethical priorities. ⁴⁹ Approximately 1.5% of requests for home care, and 7% for residential care are rejected. ⁵⁰ User co-payments are applied to certain services, such as physiotherapy or residential stays, although these are regulated to ensure affordability and protect vulnerable groups.

In Norway, when individuals require LTC, their needs are assessed, and both health and social care services are typically organised—and most often delivered—by the municipality. This is in contrast to the English mixed economy of care, in which care is provided by a range of sources, dominated by for profit provision. In Norway, significant efforts have also been made to strengthen the integration between hospital services and municipal health care. One key initiative in this regard was the introduction of the Coordination Reform ³⁹ in 2012, which aimed to enhance collaboration between health and social care services. The reform established legal frameworks and introduced financial incentives to promote integration and continuity of care. This effort to integrate care is continued in the National Health and Care coordination plan, ⁴⁰ which emphasises digital solutions to support information sharing and integrated care. Despite the fact that integration of health and care services has been a long-standing policy priority in England, there is limited evidence of progress that makes a difference to care recipients and staff. The UK Government encourages the NHS and local authorities to increase integration, and to pool resources across health and social care to minimise delays in the discharge process ⁵¹ ; for example, through the Better Care Fund, ⁵² introduced in 2015 to encourage pooled budget arrangements. There is some research evidence that suggests the Better Care Fund successfully reduces discharge delays, ⁵³ but major barriers to successful integration remain. ⁵⁴

The Care Quality Commission ⁵⁵ (CQC) is the national, independent regulator of the adult social care sector in England that monitors, inspects, and regulates care services. Services receive a rating of outstanding, good, requires improvement, or inadequate. Local authorities have an important role in ensuring a high-quality care market for their local population. They support services they commission to improve after poor CQC ratings. Similarly, the Norwegian Board of Health Supervision is the independent authority responsible for the overall supervision of health and care services. Their supervision activities include system audits, case-based investigations, and nationwide thematic inspections. Findings are used to promote quality development in services. ⁵⁶

Financing

In England, social care is funded by a combination of local revenue raising processes, such as council tax, and central government funding. However, in the last year before emergency COVID funding was introduced, government grants accounted for only 22% of revenue ⁵⁷ allocated using a Relative Needs Formula, which considers population size, age distribution, and indicators of social and health-related needs.^58,59 Local NHS trusts are also required to contribute a set amount via the Better Care Fund.^58,60 In 2023/24, total expenditure for adult social care (ASC) in England was £32 billion, which was approximately 1.1% of UK GDP. ⁶¹ Approximately half of the total expenditure was spent on working-age adults and the other half on adults aged 65 and over. ⁶² In 2023/2024, the total number of requests for support was over 2.1 million; approximately 859,000 people received publicly funded social care, ⁶³ which is 1.5% of the population. It is estimated that £8.3 billion is spent on privately funded social care. ⁶⁴ Despite reforms and repeating promises by the government to reform the sector and allocate sufficient funding,^34,65 it is characterised by austerity and pressures are expected to increase due to an ageing population, who are living longer with more complex care needs. ⁶⁶ The King’s Fund predicts that funding for social care requires an increase of 3.4% per year on average between 2021/22 and 2032/33 to meet the rising demand. ⁶⁷

Funding in Norway primarily comes from governmental block grants allocated according to a formula considering factors such as population size, age distribution, and indicators of social and health-related needs. Local authorities also generate revenue through local taxes, providing a degree of financial autonomy. The state also provides earmarked grants for specific initiatives or reforms, such as the development of dementia care services or the expansion of GP coverage. In 2024, the total expenditure on LTC was 0.2 billion NOK, which constitutes 4.3 % of Norway’s GDP. ⁶⁸ Between 30-40% of the expenditure was spent on younger users under the age of 65. In total, 399 000 people in Norway received LTC services, counting for 7% of Norway’s 5.6 million inhabitants. ⁶⁹ Despite the relatively high expenditure on LTC services, Norwegian local authorities are also experiencing austerity and face similar challenges of meeting the needs of an ageing population.

Resources

It is estimated that 1.705 million people work in the English adult social care sector, representing around 4.7% of the workforce. Most (76%) provide direct care, in roles such as (senior) care worker, personal assistant, and ancillary staff. The workforce is predominantly female (79%). Twenty-five percent of staff have been recruited internationally. The workforce is employed within local authorities, the independent sector, and by people receiving direct payments. The number of full-time equivalent (FTE) filled posts was estimated at 1.27 million. There are approximately 18,500 adult social care organisations, operating in 40,000 establishments, of which 50% provide residential services. Nearly 80% of the workforce is employed by independent sector employers. In 2023/2024, the contribution of the adult social care workforce to the English economy was £68.1 billion. ⁷⁰

LTC in Norway represents one of the largest employment sectors, accounting for approximately 15–20% of the national workforce. As of 2024, the sector employed around 230,000 individuals, corresponding to 160,779 FTEs. This marks a 9.4% increase in FTEs since 2019, with a 2.4% growth from 2023 to 2024 alone.^68,71 The workforce is distributed across various service areas. Health services (e.g., GPs, physiotherapists, and public health nurses) employed approximately 23,359 FTEs, while the care services (e.g., nursing homes and home-based care) accounted for 157,075 FTEs. The growth in FTEs has outpaced the growth in the number of employed individuals, indicating a trend toward larger positions and potentially more stable employment. ⁷¹ Most FTEs are hired in the public sector, however around 10% are employed in private sector.

Both countries are facing a serious recruitment and retention crisis. In England, there are currently 131,000 vacant posts (vacancy rate of 8.3%) with a turnover rate of 24.8%. Job roles with the highest vacancy rates include personal assistants (11%) and social workers (10.5%). ⁷⁰ Reasons for the English workforce crisis include high stress and pressure on staff, sub-optimal pay and job conditions, a lack of Government funding, and difficulties recruiting internationally. ⁷² Furthermore, the workforce is fragmented and not well integrated with health services, leading to inefficient processes and a lack of transparency. ⁷³ Recognising this workforce crisis, the Department of Health and Social Care commissioned a Workforce Survey, which included the development of a new measure of care-work related quality of life (CWRQoL) of the workforce. ⁷⁴ Findings revealed inequalities in CWRQoL. One third of those surveyed said they would leave their employer as soon as they could find another job. Addressing the workforce crisis and attracting people into the sector is a priority for central government (see the Made with Care campaign ⁷⁵ ).

In 2024, the estimated shortfall in the Norwegian LTC workforce was 13,800 (∼6 % vacancy rate) with a turnover rate of 28%. ⁷¹ The most critical shortages are among registered nurses and healthcare assistants. Recruitment is complicated by competition from other sectors and international demand. Local authorities also face growing pressures to adapt their services to meet the needs of an increasingly frail and care-dependent population. ⁷⁶ The situation is particularly acute in rural and sparsely populated areas. In response, national strategies such as Competence Enhancement ⁷⁷ and the Live Safely at Home Reform ⁴¹ have been launched to strengthen local capacity. Other initiatives include improving working conditions, and developing new roles such as interdisciplinary care coordinators.

The increased challenge to formally support people puts increasing pressure on informal carers. In England, approximately 5 million people provide unpaid care to a friend of family member. This informal support was valued at £193 billion a year, exceeding the value of the NHS. ⁷⁸ There are 1.7 million people providing 9 hours or less unpaid care a week, and 1.4 million people providing 50 or more hours unpaid care a week. ⁷⁹ Data from 2015-19 suggests that 48.6% of unpaid carers experience at least one adverse health effect from providing unpaid care. ⁸⁰

In Norway, a national survey from 2014 showed that 22 % of the population provided care on a regular basis. A survey by the Norwegian Association for Next of Kin ⁸¹ suggests that approximately half of informal caregivers spend more than 10 hours per week on care. On average, informal carers provided 10 hours of support a week, while people contributing to personal care (e.g. dressing and toileting) provided 18 hours a week on average. ⁸² As the pressure on the health and care services increases, the burden on informal caregivers is expected to rise. ⁸³

In summary, both countries have a decentralised LTC system, in which local authorities have a degree of freedom to arrange services. In addition, both countries experience recruitment and retention challenges. In both systems, an independent regulator inspects the quality of care services. There are, however, notable differences in structure. In England, social care, means tested, and health care, free at the point of use, are two distinct structures. In the Norwegian system, municipalities are responsible for the organisation of both social care and health care, operating on the basis of a universal access model. The Norwegian LTC care system seems to encompass stronger and better integration between health and social care.^49,84 In England, integration has been a longstanding policy priority, however, there is limited evidence that successful progress has been made. ⁵⁴ In Norway, LTC is based on universal access, whereas in England access to funded care is means-tested. Furthermore, Norway spends a much larger proportion of its GDP on LTC compared to England. Despite these differences, both countries report similar challenges of austerity, and concerns about the projected number of unmet needs. Both systems experience similar pressures from an ageing population with more complex needs. Table 2 provides an overview of the key commonalities and differences in structure.

Table 2.

Key Commonalities and Differences in Structure

​	Commonalities	Differences
		England	Norway
Structure	1. Decentralised LTC system.	1. Local authorities are responsible for LTC; the NHS is responsible for health care. Integration is less well-developed.	1. Local authorities are responsible for both health and LTC, which are well integrated.
	2. Workforce recruitment and retention challenges.	2. Access to funded LTC is means-tested.	2. LTC access is based on universal access.
	3. Independent regulator assesses service quality.	3. Primary LTC funding source is local revenue raising.	3. Primary LTC funding source is government block grants.
	4. Austerity experienced by local authorities.	4. Mixed economy of formal care delivery (dominated by for profit provision).	4. Formal care delivery predominantly provided by the state.
	5. Approximately 1 in 5 people provide informal care.	5. 1.1% of GDP is spent on LTC.	5. 4.3% of GDP is spent on LTC.

Process

Process concerns the interpersonal principles of care; how care is delivered. ²¹

In England, there is a strong emphasis on person-centred care, described as placing the individual at the heart of their care and support, ensuring their needs, preferences, and wishes are central in the care process. ¹⁰ Its importance is highlighted in the People at the Heart of Care policy paper, ³⁵ and endorsed and supported by numerous key social care stakeholder organisations and the sector regulator.^85-90 What person-centred care constitutes in practical terms is dependent on individual circumstances; it is a philosophy of care that follows principles of dignity, compassion, choice, and respect.

In Norway, person-centered care is also implemented to put the individual’s needs, values, and life story at the heart of service delivery. However, the golden standard of person-centered care seems hard to achieve within the institutional frameworks that govern LTCs and available resources.^91,92 Whilst both countries recognise the importance of individual choice and personal preference, person-centred care appears better developed in England, and its importance is emphasised in national policy. Nevertheless, it is unclear how well this translates into choice for care recipients in reality, especially given the current funding model, recruitment shortages and waiting times.

A further focal point in both countries is community-based care, which is designed to support individuals in and close to their own homes. ³⁸ In England, a supported ‘Home First’ approach is encouraged, ⁹³ with going home after hospital discharge seen as the default pathway. Norway has also seen a significant expansion of home-based LTC services. In response to both user preferences and policy goals, local authorities have increasingly prioritised enabling individuals to live at home for as long as possible. ⁹⁴

In both countries, digital transformation is being harnessed to support community-based care and enable individuals to live independently for longer. There have been significant investments in digital health technologies such as electronic care records, remote monitoring, wearable fall detection systems, telehealth and memory aids, particularly in rural areas where access to services can be limited.^76,95,96 Technology holds great potential for efficient community-based care, but its current use is still fragmented. ⁹⁷ It is also important to note that not all individuals are digitally confident. ⁹⁵ Coupled with person-centred approaches, digital innovation can enable care recipients to be more in control of their needs, but this will require investment, system integration, and co-production.

Person-centred, community-based, digitally enabled care plays an essential role in preventing and delaying care needs, which is another important area of focus in both countries. In England, prevention has been a prominent theme in governmental policies to address rising concerns around system pressures.^10,34,38 However, there is a lack of conclusive evidence on the impact of current preventative adult social care services. ⁹⁸ Local commissioners and practitioners must have a shared understanding of prevention, but currently, a consistent approach across local authorities remains elusive. Similarly, in Norway, there has been a growing emphasis on preventative health and early intervention.^49,99 As a result, local authorities have taken on greater responsibility for follow-up care after hospital discharge and for managing complex, long-term conditions in the community. ⁸⁴

Taken together, England and Norway predominantly show commonalities when it comes to care processes. Both countries prioritise community-based care pathways and home-based care, supporting people to live independently for longer. Additionally, both emphasise the importance of prevention and digital transformation. A minor difference relates to the emphasis on person-centred care. Whilst both countries recognise the importance of individual choice and personal preference, person-centred care appears better developed in England, its importance emphasised in national policy. Table 3 provides an overview of the key commonalities and differences relating to the process of care.

Table 3.

Key Commonalities and Differences in Process

​	Commonalities	Differences
		England	Norway
Process	1. Emphasis on prevention of care needs.	1. A commitment to person-centred care is reflected in national policy and endorsed by key care stakeholder organisations.	1. Person-centred care is viewed as important, but less well embedded in policy.
	2. Development of digital technology to support (community-based) care.
	3. Increased home-based care provision.

Outcomes

Outcomes reflect the impact of the received care on the recipient. ²¹ Several English policy documents highlight the importance of outcomes in LTC.^10,34 In 2012, the government published the Adult Social Care Outcomes Framework ⁹ to enhance transparency of outcome measurement in LTC. ASCOT has been used for several key indicators in the framework to evaluate quality of life outcomes. Indicators are populated by data collected in the annual Adult Social Care Survey, which is administered by NHS England to a sample of publicly funded social care users. ¹⁹ Despite positive developments in annual data collection on LTC outcomes, there is limited evidence of routine use of outcome measures in LTC practice, which may be affected by implementation barriers such as limited resources.^18,100

Data from the latest iteration of the Adult Social Care Survey show that 65.4% of care recipients were very or extremely satisfied with the care and support they received, whilst 2.2% were very or extremely dissatisfied. ¹⁰¹ Further, 91.3% of care recipients felt that the services they received helped improve their quality of life, and 32.1% of care recipients indicated their quality of life was so good it could not be better. Additionally, 66.2% reported that they have enough choice over the care and support they receive, and 34.4% recorded they have as much control over their daily life as they want. Fifty-six point eight percent indicated they feel clean and able to present themselves as they wish, 63.4% felt they can access all the food and drink they like when they want to, and 71.1% of care recipients recorded feeling as safe as they want. Forty-five point six percent indicated they have as much social interaction as they want with the people they like, and 38.9% felt able to spend their time as they want, doing things they enjoy.

In Norway, none of the national quality indicators are represented in outcome measures. Local authorities conduct user satisfaction surveys, but these differ geographically in form and content, and results are often not publicly available. Initiatives to develop a national survey have thus far not been implemented. To facilitate the availability of a quality of life outcome measure the current QUALCARE project included creating a Norwegian translation of ASCOT. As part of this project, a study was conducted to measure the care-related quality of life of 471 LTC recipients in three local authorities in Norway. Findings demonstrated a high total score for current quality of life. ¹⁰² The study also showed that services helped improve quality of life. Respondents in home care settings reported slighter higher quality of life than people in sheltered housing and nursing homes. In home care, 82% indicated they could access all the food and drink they like when they want, 73 % said they feel clean and able to present themselves as they wish, 56% mentioned their accommodation is as clean and comfortable as they would like, and 60% reported feeling as safe as they want. Furthermore, 41% reported they have as much social interaction as they want with the people they like, 39% felt able to spend their time as they want, doing things they enjoy, and 38% reported they have as much control over their daily life as they want.

Summarising, whilst both countries report similar findings in terms of quality of life in LTC recipients, significant differences lie in the extent to which outcome measurement has been prioritised and adopted by the LTC systems. The English LTC system has a much more developed outcome measurement infrastructure compared to Norway. The current project has played a key role by conducting foundational work to realise the collection and availability of Norwegian outcome data. Whilst England is further along in outcome measurement, this is not yet routinely embedded within care practice. This is an essential next step to ensure that LTC services are meeting individuals’ needs. Appropriate and effective outcome measurement structures have the potential to generate good quality data that can support the achievement of strategic priorities. Table 4 provides an overview of the key commonalities and differences relating to outcomes.

Table 4.

Key Commonalities and Difference in Outcomes

​	Commonalities	Differences
		England	Norway
Outcomes	1. Similar findings in relation to quality of life of care recipients.	1. Routine outcome measurement is strongly embedded in policy.	1. Routine outcome measurement supported by government is in early development.
	2. Quality of life measurement not routinely embedded in practice.

Discussion

Lessons

This paper described and analysed the differences and commonalities between the Norwegian and English LTC systems using Donadedian’s structure-process-outcome model. We predominantly found similarities between the two countries, with the most significant differences identified in structure (access to care, provision of care, and integration of health and social care), and outcome (routine outcome measurement embedded in policy). Both countries are welfare states, however, the Norwegian welfare state is considered more universal. Despite these differences, the two countries contend with the same major challenges when it comes to LTC provision; meeting the needs of an ageing population with increasingly complex needs, workforce recruitment and retention, and austerity, as is the case for most developed welfare states.^103,104 This aligns with convergence theory which states that in response to similar pressures, LTC systems in different countries become increasingly similar. ¹⁰⁵ What is needed to address these challenges and how outcome measurement might play a role, remains a key question. What can we therefore learn from this comparison?

Our analysis suggests that both systems attempt to address challenges in relation to care recipients, the care workforce, and informal carers (the triad of care) but they do this in relative isolation, disregarding their potential interconnectedness. Research in the English context, for example, shows the interdependence of quality of life for care recipients and informal carers, and highlight the importance of examining the wider impact of LTC policy and practice on care dyads, and the key role of rigorous outcome measurement to realise this.^18,106

We argue that to build a LTC system fit for the future, we need to go even further and better understand the interdependence within the triad of care (care recipient-informal carer-workforce), as well as its gendered nature. Women are disproportionately represented in both informal and formal caregiving roles, a pattern that reflects and reinforces traditional gender norms. ¹⁰⁷ Informal care remains largely unpaid and undervalued, limiting women’s participation in the labour market and contributing to cumulative economic disadvantages, including lower lifetime earnings and reduced pension entitlements. ¹⁰⁸ Similarly, the formal care workforce is predominantly female and frequently characterised by low wages, limited career progression, and precarious working conditions. ¹⁰⁹ These structural inequalities contribute to high staff turnover and burnout, undermining the quality and continuity of care provision. These dynamics intersect with other axes of inequality, as women from marginalised or migrant backgrounds are overrepresented in the most vulnerable segments of the care labour market. ¹¹⁰ At the same time, older women constitute a significant proportion of care recipients, often with limited financial resources due to a lifetime of unpaid caregiving. ¹¹¹ Collectively, these patterns illustrate how gendered expectations underpin the LTC system, producing intergenerational and intersectional inequities that demand comprehensive, gender-sensitive policy responses.

A healthy and skilled workforce are considered an essential component of care quality in the Donabedian model. They are a fundamental part of the structure and experience of care, especially in LTC, which is inherently relational in nature. The workforce are also citizens within the LTC system and members of local communities, many of whom may be managing their own health and care needs, as well as those of their social networks. Supporting and valuing a healthy LTC workforce is therefore essential when considering how to improve the health of a nation. The suite of ASCOT tools has the potential to support this more holistic approach to outcome measurement. As well as considering the outcomes of care recipients, we can use these validated measures with informal carers and the care workforce.^12,74,112

Future research should incorporate robust and holistic outcome measurement to aid the advancement of LTC systems to make them better fit for the future. It is also essential that future studies consider the triad of care to capture the interconnectedness of the workforce, carers, and care recipients, and how LTC systems affect them, rather than studying these in isolation. Lessons drawn from research can support improvements to the equity and sustainability of LTC systems for all elements of the triad.

Strengths and Limitations

A strength of this paper is the comprehensive outline of the English and Norwegian LTC systems following the components described in Donabedian’s ²¹ framework. This allowed for a careful comparison of systems, providing useful findings about where differences and similarities lie and what can be learned from this. The comparison was carried out by a team consisting of English and Norwegian researchers, ensuring that respective policy documents and information about the LTC system were presented with an understanding of their relative context.

One limitation of this paper is that we predominantly focused on documentation relevant during the timeframe of the study (2021-2025). An extended timeline may have resulted in a more comprehensive overview of (the development of) the differences and commonalities between England and Norway. Furthermore, we may have omitted certain elements of the LTC system that are not accounted for in Donabedian’s model. There are also limitations to the selected comparative overview approach that may have resulted in omissions. A systematic policy review may increase rigour.

Conclusion

Taken together, the LTC systems in England and Norway exhibit more similarities than differences and the Donabedian model proved to be a valuable framework for presenting and comparing the two. The most notable differences emerged in the structure component, particularly in terms of funding mechanisms and the degree of care integration. Differences were also evident in the outcome component, where national outcome measures are less systematically embedded in the Norwegian system. In contrast, the process component revealed that both countries have implemented similar initiatives to address shared challenges within their services. However, none of these initiatives fully confront the broader complexities of care provision—particularly the interdependencies in the triad of care and the gendered nature of the sector. The persistent female dominance in caregiving roles remains largely unaddressed, and sustainable, innovative solutions to this issue are still lacking.

ORCID iD

Jolie R. Keemink https://orcid.org/0000-0002-4153-4530