Public and private nursing homes in Norway and Sweden: what do we know about ownership and quality? Conference May 14, 2014, Bergen. Marta Szebehely Professor of Social Work Stockholm University

Presentation based on work carried out within Normacare New report: Marketisation in Nordic eldercare Contributions by 17 scholars from 7 countries Download or purchase (125 SEK):

Marketisation in a Nordic context of universalism 1980: Publicly funded and provided services for all; some non-profit; no for-profit – a trust based system; very little regulation and control 1990: importation of market ideas – ”competition will improve quality and cut costs” Based on economic theory, ideology and economic interests – rather than on older people’s demands Today: –Sweden: 18% for-profit; 3% non-profit –Norway: 4% for-profit; 5% non-profit Large municipal variation

Much larger for-profit sector in Sweden (and Finland) than in Norway (and Denmark) Timing matters (recession)? Resistance matters? Competetive tendering favours large corporations Sweden: ½ of private nursing homes (10% of all ‘beds’) run by the two largest corporations (Attendo and Carema), owned by private equity companies, each with 15,000 employees in the Nordic countries Higher concentration than in most countries – an attractive market Large actors have loud voices – affect policy makers

Consequences of marketisation – what is known about quality? Structure : Lower staffing, lower training and fewer permanently employed in for-profit – lowest in largest corporations Process: For-profit report more assessment of risk for falls, pressure ulcers et – most in largest corporations Outcomes: –No data on actual falls, pressure ulcers etc –No difference in ’user satisfaction’. Unintended (?) outcomes: Stricter regulation & control

Consequences of marketisation : contested issues Economists: –Competition  higher efficiency: better process quality and equally satisfied users with fewer resources –Improved quality by user choice in homecare and by better tenders and stricter control in nursing homes Care researchers: –Time, continuity and flexibility crucial for users  High staffing ratios and permament employment important quality indicators –Stricter regulation and control  negatively affect flexibility –Care services not like other services –Users to frail to act as customers

Consequences for universalism: the distribution of welfare Very little Nordic research Non-profit actors need protection Winners and losers in choice models? Increased private financing (topping up)? A threat to universalism? Rebecca Blank: ”The more one cares about enforcing universalism in the provision of services, the stronger the argument for government provision”

Thanks for listening!