1. 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 marta.szebehely@socarb.su.se

2. 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): www.normacare.net www.normacare.net

3. 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

4. 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

5. 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

6. 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

7. 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”

8. Thanks for listening!