Formal and informal resources in meeting old age-related care needs: A European comparison Anneli Anttonen Professor University of Tampere Dept. of Social Policy and Social Work Presentation at RECWOWE DOCTORAL WORKSHOP Work, care and well-being: public and private arrangements Helsinki, Stakes, September 16-17, 2008

Elder care and social policy Elder care coming more important. Societies are greying, old people are living alone more often than before, and working age population is expected to retire later than now. Consequently, care needs are increasing at the same time when informal care resources are diminishing. In addition, the public service provision have met its limits of growth at least in countries, which have been so called social services states or caring states (Anttonen 2005; Szebehely 2004).

Elder care: less modern part of the welfare state In many countries, elder care service provision is even today organised locally (and sometimes) without national legislation and regulation. It might carry some features of poor law tradition, for instance, in the form of extensive means-testing. Yet, it is becoming more modern.

Elder care as a social investment Until these days, elder care has lacked the high social valuation typical to health care, education or childcare. Elder care is not seen as a social investment needed for the economic success of the society. Yet, social policy commentators within the EU (Feasibility…2003) and OECD (2005) are increasingly paying attention to elder care.

Welfare state change – welfare state redesign To what direction? What is the dynamic of change? Degree of change? Object of change? Outcome of change? Impact of change? To what direction? What is the dynamic of change? Degree of change? Object of change? Outcome of change? Impact of change? What should be studied? Paradigms? Discourses? Institutions? Policies? Outcomes? What should be studied? Paradigms? Discourses? Institutions? Policies? Outcomes? Jørgen Goul Andersen (2007)

Elder or adult care policies in transition: old and new directions Comparision of 12 European countries (Anttonen & Sointu 2006) Comparision of 12 European countries (Anttonen & Sointu 2006) Increase in public responsibility in some countries or in some policy fields (payments of care schemes). Increase in public responsibility in some countries or in some policy fields (payments of care schemes). Formal/semi-formal/informal care arrangements (Geissler & Pfau- Effinger). Formal/semi-formal/informal care arrangements (Geissler & Pfau- Effinger). From services to money (care insurance, personal care budget, cash for care schemes). From services to money (care insurance, personal care budget, cash for care schemes). New hybrid forms of ‘work’ and ‘care’ emerging (Ungerson 2004). New hybrid forms of ‘work’ and ‘care’ emerging (Ungerson 2004). Commercialisation/economisation of care: private solutions. Commercialisation/economisation of care: private solutions. Social responsibility of firms (mainly childcare). Social responsibility of firms (mainly childcare).

Nordic care policies in transition Finland and Sweden have met the limits of public service provision (e.g. home care services for adults; institutional care). Finland and Sweden have met the limits of public service provision (e.g. home care services for adults; institutional care). From universalism toward targeting: de- universalisation (Gilbert 2001) From universalism toward targeting: de- universalisation (Gilbert 2001) Informalisation of care (Szebehely 2004). Informalisation of care (Szebehely 2004). Marketisation and commercialisation of care. Marketisation and commercialisation of care.

Privatisation of public care provision Privatisation of financing: increased fees for service users; Privatisation of financing: increased fees for service users; Privatisation of service provision: increased presence of private providers (contracting out, vouchers); Privatisation of service provision: increased presence of private providers (contracting out, vouchers); Privatisation of the work organisation: NPM, new wage systems. Privatisation of the work organisation: NPM, new wage systems. (Szebehely 2004).

From old to new politics of elder care The old politics of the elder care bases on strong centralised institutions, universal treatment of ‘clients’ or ‘patients’ and professional needs-interpretation. In the new politics of the elder care the figure of client/patient becomes replaced by the figure of ‘consumer’ (Clarke 2006; Kremer 2006) making ‘free choices’ on the emerging social care market. Since the early 1990s, the transition from the ‘old’ to the new market-related politics of the welfare state has taken place in a number of countries. Since the early 1990s, the transition from the ‘old’ to the new market-related politics of the welfare state has taken place in a number of countries.

How to solve the care puzzle Care puzzle (Marta Szebehely): increasing care needs and decreasing informal care resources. Care puzzle (Marta Szebehely): increasing care needs and decreasing informal care resources. Is the development of formal care resources following the change in needs (for instance the ageing of population)? Is the development of formal care resources following the change in needs (for instance the ageing of population)? Increase in formal care resources and decrease of informal care resources. Increase in formal care resources and decrease of informal care resources.

Who will be future informal carers? The overall share of women aged in paid employment has risen between 1980/1991 and 2003, except in Eastern Europe. The overall share of women aged in paid employment has risen between 1980/1991 and 2003, except in Eastern Europe. Maternal employment has rapidly increased, rapid change in some countries (e.g. Ireland and Spain). Maternal employment has rapidly increased, rapid change in some countries (e.g. Ireland and Spain). The employment rate among women in the age group of years increased from 29 to 39 percent (by 24 percent) in the group of 14 West European countries (no data from Austria, Italy and Switzerland). Most of the increase occurred between 1998 and The employment rate among women in the age group of years increased from 29 to 39 percent (by 24 percent) in the group of 14 West European countries (no data from Austria, Italy and Switzerland). Most of the increase occurred between 1998 and Feminisation of labour market › decrease in informal care resources. Feminisation of labour market › decrease in informal care resources.

Ageing of societies In 2004, the highest proportion of elderly population was found in Italy (19.2 percent), and lowest in Ireland (11.1 %). In 2004, the highest proportion of elderly population was found in Italy (19.2 percent), and lowest in Ireland (11.1 %). We simply can assume that at age of 80 the need for help starts to increase. We simply can assume that at age of 80 the need for help starts to increase. There is an increase also of population over 80. There is an increase also of population over 80.

Meeting care needs of older people: cash benefits (share of GDP) Cash related benefits: over the period of EU Norway and Switzerland: share of cash benefits of GDP increased by 10 % when counted as a difference of 17 countries’ means. Cash related benefits: over the period of EU Norway and Switzerland: share of cash benefits of GDP increased by 10 % when counted as a difference of 17 countries’ means. Growth was fastest in Portugal (78 %), some reduction in Luxembourgh and Ireland, smaller in the NL and Norway. Growth was fastest in Portugal (78 %), some reduction in Luxembourgh and Ireland, smaller in the NL and Norway. In the new member states ( ) the expenditure of old age related cash benefits fell to some extent. In the new member states ( ) the expenditure of old age related cash benefits fell to some extent. All in all, related to ageing of popultation there seems to be a minor decrease in these expenses. All in all, related to ageing of popultation there seems to be a minor decrease in these expenses. Cash benefits: a resource to be used for care. Cash benefits: a resource to be used for care.

Social care services Social expenditure on old age benefits in kind presented as Euros (PPP) per inhabitant. Social expenditure on old age benefits in kind presented as Euros (PPP) per inhabitant. Large country variation. Large country variation. Although the expenditure in kind has on average increased, there has happened some relative decrease in the expenses related to persons over 80 and the growth of GDP. Although the expenditure in kind has on average increased, there has happened some relative decrease in the expenses related to persons over 80 and the growth of GDP.

Results There was a slight decrease (related to GDP) in money spent to cash benefits per person over 65+. There was a slight decrease (related to GDP) in money spent to cash benefits per person over 65+. There was no real increase in the public expenditure spent to servcies per person 65+. There was no real increase in the public expenditure spent to servcies per person 65+. The expenditure of the benefits in kind accounted only 4 percent of total expenditure on old age; all the rest was expenditure on various cash benefits. The expenditure of the benefits in kind accounted only 4 percent of total expenditure on old age; all the rest was expenditure on various cash benefits. Moreover, the number of long-term care hospital beds has fallen dramatically. Moreover, the number of long-term care hospital beds has fallen dramatically. However, the lack of reliable data makes it difficult to evaluate public policy for older people in any detail. However, the lack of reliable data makes it difficult to evaluate public policy for older people in any detail. Previous research findings give us evidence that there really is a great variation in service provision for older people in Europe (Bettio & Plantenga 2004, Rostgaard 2002). Previous research findings give us evidence that there really is a great variation in service provision for older people in Europe (Bettio & Plantenga 2004, Rostgaard 2002).

Support for informal carers Anttonen & Sointu (2006): public policy of care in 12 European countries. Anttonen & Sointu (2006): public policy of care in 12 European countries. Support for informal care at home Support for informal care at home –Cash benefit to care giver –Cash benefit to care receiver –Care leave to care giver –Services supporting informal care at home

Payments for informal care: some conclusions 12 countries have slighlty different policy alternatives to support informal care 12 countries have slighlty different policy alternatives to support informal care 8 countries paid cash payments for care receivers (+ 2 tax redcutions) 8 countries paid cash payments for care receivers (+ 2 tax redcutions) 8 countries offered care leaves often accompanied by financial remuneration 8 countries offered care leaves often accompanied by financial remuneration 6 countries paid cash payments for care givers 6 countries paid cash payments for care givers 3 of studied countries offered a wide range of support (the NL, Norway and Sweden) following by Germany, Italy and the UK 3 of studied countries offered a wide range of support (the NL, Norway and Sweden) following by Germany, Italy and the UK France: nearly all support to care receivers France: nearly all support to care receivers Denmark: nearly all support to care givers Denmark: nearly all support to care givers Large country variations Large country variations

Summary: formal and informal resources Social spending on pensions and other cash benefits (a remarkable share of GDP) meaning that changes in this spending have a great impact on resources older people have in use. Social spending on pensions and other cash benefits (a remarkable share of GDP) meaning that changes in this spending have a great impact on resources older people have in use. Social spending on services in kind is still marginal, more difficult to estimate outcomes and impact on resources in situation of changes. Social spending on services in kind is still marginal, more difficult to estimate outcomes and impact on resources in situation of changes. More public money spent on supporting informal care at home: motivating informal carers to do their work or strengthenin autonomy of older people. More public money spent on supporting informal care at home: motivating informal carers to do their work or strengthenin autonomy of older people. There is no European social care strategy or policy. There is no European social care strategy or policy.

Whose choice? Money instead of services In Austria and Italy (same in Germany): money received is not used to good quality care or medical aid by low income households. In Austria and Italy (same in Germany): money received is not used to good quality care or medical aid by low income households. Empowerment of users by choice: exit of low income families and difficult/vulnerable users (family takes over care; immigrant workers are used). Empowerment of users by choice: exit of low income families and difficult/vulnerable users (family takes over care; immigrant workers are used). Marianne Egger de Campo: Exit and Voice. An Investigation of Care Service Users in Austria, Belgium, Italy and Northern Ireland (2007) Marianne Egger de Campo: Exit and Voice. An Investigation of Care Service Users in Austria, Belgium, Italy and Northern Ireland (2007)

Is choice the answer for good care? Personal budget: empowerment of consumers (through money). Personal budget: empowerment of consumers (through money). Managing own money leads to independence of those need in care. Voice and choice. Yes. Managing own money leads to independence of those need in care. Voice and choice. Yes. Disempowerment of professionals. Disempowerment of professionals. From monopoly of professionals to monopoly of clients. From monopoly of professionals to monopoly of clients. Family members in first instance. Stronger sense of responsibility. Family members in first instance. Stronger sense of responsibility. Intimate relations are changing. Intimate relations are changing. Monique Kremer (2006) Monique Kremer (2006)

Care inequalities Access to formal care (services): differences between individuals/households; Access to formal care (services): differences between individuals/households; Informal care resources: huge variation depending on life situation; Informal care resources: huge variation depending on life situation; Care rich and care poor individuals households; Care rich and care poor individuals households; Right to receive good care? Right to give care/not to give care? Right to receive good care? Right to give care/not to give care?

What is the future of care work? Who are informal carers in the future societies, and in what terms? Who are informal carers in the future societies, and in what terms? How to compensate losses in informal care resources? How to compensate losses in informal care resources? Nor the family, state or market alone cannot meet all care needs. Nor the family, state or market alone cannot meet all care needs. Exit, voice and choice – but on what terms and to whom? Exit, voice and choice – but on what terms and to whom?

Thank you!